Publications by authors named "George B Wanna"

122 Publications

Does Auditory Environment Predict Speech Perception Outcomes in Elderly Cochlear Implant Patients?

Audiol Neurootol 2021 May 5:1-9. Epub 2021 May 5.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine, Ear Institute, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA.

Introduction: Cochlear implantation (CI) is a reliable and safe means by which sensorineural hearing loss can be ameliorated in the elderly population. However, a high degree of variation exists in postimplantation hearing outcomes for which some modifiable factors of the daily natural auditory environment may be contributory. In this study, we analyze the relationship between cochlear implant patient age, natural auditory environment, and postimplantation speech perception among older adults.

Methods: Data log from automatic environment classification enabled sound processors of postlingually deafened CI recipients ≥50 years old (n = 115) were obtained retrospectively and analyzed for time spent (hours per day) in listening environment and loudness (SPL dB). Speech perception testing was assessed in a subset of patients (n = 27) using open-set word recognition in quiet Consonant-Nucleus-Consonant in the short and intermediate postoperative period.

Results: The mean subject age was 70 years (range, 53-99 years). Average daily implant use was 10.8 h and was not significantly correlated with age (p = 0.23, Spearman's rho). Age was positively correlated with the percentage of hours spent at <40 and 40-50 dB and negatively correlated to proportional CI use at higher volume (60-70, 70-80, and >80 dB; rs = 0.21, 0.20, -0.20, -0.35, -0.43; p = 0.021, 0.036, 0.033, <0.001, <0.001, respectively). Age was positively correlated with CI use in the quiet scene (rs = 0.26, p = 0.006) and negatively correlated with scenes containing speech and noise (rs = -0.19, -0.25; p = 0.046, 0.007). Total hours of device use and time spent at <40, 40-50 dB, and quiet environments were significantly correlated with improved CNC word scores (rs = 0.48, 0.48, 0.51; p = 0.01, 0.01, <0.01, Spearman's rho). While all speech (speech in noise + speech) was not significantly correlated to improvements in speech perception, a medium effect size was observed (rs = 0.37, p = 0.057).

Discussion/conclusion: This study supports a relationship between auditory environment and age, with older CI recipients spending a greater proportion of time in quiet. Older CI users demonstrated greater improvements in speech perception with longer daily device use. Additional examination of the relationship between auditory environment and speech perception is necessary to conclusively guide future auditory rehabilitation efforts.
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http://dx.doi.org/10.1159/000513637DOI Listing
May 2021

The Price of Otologic Procedures: Variation in Markup by Surgical Procedure and Geography in the United States.

Otol Neurotol 2021 Mar 26. Epub 2021 Mar 26.

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai Department of Otolaryngology, New York Eye and Ear Infirmary of Mount Sinai, New York, New York.

Objective: To characterize and analyze variation in price markup of seven common otologic surgeries by procedure and geographic region.

Study Design: Retrospective Analysis of the Centers for Medicare and Medicaid Services database of 2017 Medicare Provider Utilization and Payment Public File.

Setting: Inpatient and outpatient centers delivering Medicare-reimbursed services.

Patients: Full sample of patients undergoing procedures with Medicare fee-for-service final action claims during 2017.

Interventions: Seven procedures (myringotomy, tympanoplasty, mastoidectomy, tympanomastoidectomy stapedotomy/stapedectomy, cochlear implant, bone-anchored hearing aid).

Main Outcome Measures: Markup ratio (MUR) is defined as the ratio of total charges to Medicare-allowable-costs; Variation in MUR was measured using coefficient of variation (CoV).

Results: Among all providers, the median MUR was 2.4 (interquartile range: 1.9-3.1). MUR varied significantly by procedure, from 2.3 for myringotomy to 8.7 for mastoidectomy (p < 0.01). MUR also varied significantly within procedure, with the least variation found in myringotomy (CoV = 0.46), and the greatest in cochlear implants (CoV = 0.92). Using the national average as baseline, MUR varied 71% between states, ranging from 1.75 to 6.24. Within the same state, significant variation was also noted, varying by 4% (CoV = 0.04) in Montana compared with 138% (CoV = 1.38) in Pennsylvania. MUR was not significantly correlated with patient comorbidity or Centers for Medicare and Medicaid Services risk scores.

Conclusions: There was significant variation in the price of otologic surgery across geographic regions and procedures. The MUR for otology is lower or comparable to that reported in other surgical fields.
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http://dx.doi.org/10.1097/MAO.0000000000003151DOI Listing
March 2021

Burkitt lymphoma of the nasopharynx causing life-threatening airway obstruction: A case report.

Am J Otolaryngol 2021 Feb 16;42(4):102977. Epub 2021 Feb 16.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, NY, New York, USA; Department of Otolaryngology-Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, NY, New York, USA.

Objective: To describe a case of Burkitt lymphoma (BL) in a child manifesting with acute airway obstruction. To review available literature on the clinical features and characteristic presentation of this disease.

Methods: Case report with literature review.

Results: We present the case of an 8-year-old boy with nasopharyngeal BL manifesting initially as sore throat, nasal congestion, and snoring that progressed to dyspnea and, ultimately, acute airway obstruction requiring emergent tracheostomy. The child was treated with intensive chemotherapy and achieved complete response.

Conclusion: This case highlights the importance of maintaining high clinical suspicion when evaluating common otolaryngologic symptoms and emphasizes the potential for Burkitt lymphoma to cause rapid patient deterioration.
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http://dx.doi.org/10.1016/j.amjoto.2021.102977DOI Listing
February 2021

The utility of augmented reality in lateral skull base surgery: A preliminary report.

Am J Otolaryngol 2021 Jan 29;42(4):102942. Epub 2021 Jan 29.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America.

Objective: To discuss the utility of augmented reality in lateral skull base surgery.

Patients: Those undergoing lateral skull base surgery at our institution.

Intervention(s): Cerebellopontine angle tumor resection using an augmented reality interface.

Main Outcome Measure(s): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery.

Results: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy.

Conclusions: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.
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http://dx.doi.org/10.1016/j.amjoto.2021.102942DOI Listing
January 2021

Surgical Outcomes With Cochlear Implantation in Patients With Enlarged Cochlear Aperture: A Systematic Review.

Otol Neurotol 2021 Jun;42(5):638-645

Department of Otolaryngology, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: Evaluate surgical outcomes in patients with enlarged cochlear aperture (ECA) after cochlear implantation.

Databases Reviewed: PubMed, EMBASE, and Scopus.

Methods: A systematic review was performed using standardized methodology. Studies were included if they included subjects with ECA who underwent cochlear implantation. Exclusion criteria included non-English articles, abstracts, letters/commentaries, case reports, and reviews. Bias was assessed using the Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool.

Results: Out of 1,688 identified articles, 7 articles representing 23 subjects with ECA were included. Publication rates increased between the period of study from 2009 to 2018. Four studies were level 4 evidence and three studies were level 3 evidence. In total, 20 subjects underwent cochlear implantation. Cerebrospinal fluid gushers were encountered in the majority of cases that reported complications (16/17, 94.1%); one patient developed postoperative meningitis, and another experienced postimplantation facial nerve stimulation. No study provided measurements on cochlear aperture size or defined size criteria used to identify ECA. Four studies recognized X-linked deafness to be associated with ECA, and the most common mutation was in POU3F4 gene.

Conclusion: An association exists between ECA and cerebrospinal fluid gusher, underscoring the importance of reviewing preoperative imaging. Size criteria are not well defined, and there is a paucity of data with respect to normative measurements. Many cases of ECA may give a genetic link. Although level of evidence of current studies remains modest, ECA reports have increased and will likely continue to expand with advancements in imaging and genetic testing.
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http://dx.doi.org/10.1097/MAO.0000000000003021DOI Listing
June 2021

Cochlear Implantation in Meniere's Disease: A Systematic Review and Meta-Analysis.

Laryngoscope 2021 Jan 19. Epub 2021 Jan 19.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives/hypothesis: Meniere's disease (MD) is a debilitating condition characterized by hearing loss, vertigo, and tinnitus. The objective of this study was to systematically investigate outcomes in MD after cochlear implantation (CoI), with and without labyrinthectomy.

Study Design: Systematic review and meta-analysis.

Methods: A systematic review of articles in Medline and Embase was performed to identify all studies of patients with MD who underwent CoI. This analysis evaluates outcomes of speech recognition, pure tone audiometry, vertigo, tinnitus, and quality of life.

Results: Of 321 studies identified, 37 were included, involving 216 patients. Mean age at implantation was 61.4 years (range 27-85 years) with average length of follow-up at 1.7 years (range 0-9 years). Forty-four (20.4%) patients underwent labyrinthectomy. Meta-analysis demonstrated significant improvements in audiometric outcomes following CoI. There was a statistically significant improvement in Hearing in Noise Test performance, with a mean difference improvement of 44.7 (95% confidence interval [CI] [8.8, 80.6]) at 6 months and 60.1 (95% CI [35.3, 85.0]) at 12 months. The Freiburger Monosyllabic Test (FMT) and Consonant-Nucleus-Consonant (CNC) also improved significantly, with mean difference improvements of 46.2 (95% CI [30.0, 62.4]) for FMT and 19.3 (95% CI [8.1, 30.4]) for CNC. There was a statistically significant decrease in tinnitus, as measured by a mean difference reduction of 48.1 (95% CI [1.0, 95.2]) in the Tinnitus Handicap Index.

Conclusions: CoI with and without simultaneous labyrinthectomy is a viable treatment option for patients with MD, yielding high rates of tinnitus suppression and vertigo control. Post-CoI MD patients demonstrate similar postoperative speech perception outcomes to non-MD implant recipients. Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29393DOI Listing
January 2021

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part I, Trainees.

Otolaryngol Head Neck Surg 2021 May 29;164(5):1019-1029. Epub 2020 Sep 29.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Objective: To assess the prevalence of distress and burnout in otolaryngology trainees, including associations with relevant sociodemographic and professional factors, and to compare these results with those of attending otolaryngologists.

Study Design: A cross-sectional survey of trainees and attending physicians.

Setting: Twelve academic otolaryngology programs.

Methods: Distress and burnout were measured with the Expanded Physician Well-being Index and the 2-item Maslach Burnout Inventory. The Patient Health Questionnaire-2 and Generalized Anxiety Disorder-2 were used to screen for depressive disorders and anxiety disorders, respectively. Associations with sociodemographic and professional characteristics were assessed.

Results: Of the 613 surveys administered to trainees and attending physicians, 340 were completed (56%). Among 154 trainees, distress was present in 49%, professional burnout in 35%, positive depressive disorder screening in 5%, and positive anxiety disorder screening in 16%. In univariable analysis, female gender, hours worked in a typical week (HW), and nights on call in a typical week (NOC) were significantly associated with distress. In multivariable analysis, female gender (odds ratio, 3.91; = .001) and HW (odds ratio for each 10 HW, 1.89; = .003) remained significantly associated with distress. Female gender, HW, and NOC were significantly associated with burnout univariably, although only HW (odds ratio for each 10 HW, 1.92; = .003) remained significantly associated with burnout in a multivariable setting. Attending physicians had less distress than trainees ( = .02) and felt less callous and less emotionally hardened than trainees ( < .001).

Conclusion: Otolaryngology trainees experience significant work-place distress (49%) and burnout (35%). Gender, HW, and NOC had the strongest associations with distress and burnout.
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http://dx.doi.org/10.1177/0194599820959273DOI Listing
May 2021

Prevalence of and Associations With Distress and Professional Burnout Among Otolaryngologists: Part II, Attending Physicians.

Otolaryngol Head Neck Surg 2021 May 29;164(5):1030-1039. Epub 2020 Sep 29.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Objective: To ascertain the prevalence of and associations with distress and professional burnout among academic otolaryngology attending physicians.

Study Design: Cross-sectional survey.

Setting: Twelve US academic otolaryngology programs.

Methods: A questionnaire was administered that encompassed sociodemographic and professional features, the Expanded Physician Well-being Index for distress, the 2-item Maslach Burnout Inventory for professional burnout, the Patient Health Questionnaire-2 screen for major depressive disorder, and the Generalized Anxiety Disorder-2 screen for generalized anxiety disorder.

Results: The survey response rate was 56% and included 186 attending physicians. The average respondent age was 47 years; 72% were men; 93% were married or partnered; and 86% had children. Distress was present in 40%, professional burnout in 26%, positive depression screening in 8%, and positive anxiety screening in 11%. In a univariable setting, age, hours worked in a typical week, nights on call in a typical week, and years of practice were significantly associated with distress, although in a multivariable setting, only hours worked in a typical week remained significantly associated with a positive Expanded Physician Well-being Index screen (odds ratio for each 10-hour increase, 2.61; 95% CI, 1.73-3.93; < .001). In a univariable setting, hours worked in a typical week was significantly associated with a positive Maslach Burnout Inventory screen.

Conclusion: Distress or professional burnout occurs in more than a quarter of academic otolaryngology attending physicians, whereas the prevalence of depression or anxiety is approximately 10%. The number of hours worked per week had the strongest association with distress and burnout. These findings may be used to develop and implement programs to promote physician well-being and mitigate professional burnout.
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http://dx.doi.org/10.1177/0194599820959279DOI Listing
May 2021

Microdrill in endoscopic stapes surgery: Is it safe?

Am J Otolaryngol 2020 Nov - Dec;41(6):102666. Epub 2020 Aug 12.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

Purpose: To assess the safety of using a microdrill in endoscopic vs microscopic stapes surgery.

Materials And Methods: A retrospective review of 29 adult ears with otosclerosis who underwent either an endoscopic or microscopic approach to microdrill stapedotomy.

Primary Outcome: Determine if transcanal endoscopic stapes surgery with the microdrill is as safe as microscopic stapes surgery. Secondary outcome: Bone and air pure-tone averages, air-bone gap, speech discrimination, overall surgical cost, and operative time were measured and analyzed. Complications such as post-operative dysgeusia, vertigo, readmission, revision and hearing loss were noted.

Results: 29 patients with otosclerosis were retrospectively reviewed, in total 14 endoscopic and 15 microscopic approaches were included, all performed over one-year period. None of the endoscopic surgeries require conversion to the microscope. No statistically significant audiometric differences between the endoscopic vs microscopic approaches in air pure-tone averages and air-bone gap. There were 82.8% air-bone gap closure to <15 dB with no significant difference in the percent of such closures between the endoscopic (85.7%) and microscopic groups (80%, P = .68). Three prostheses were used: 4.25 mm (17.2%), 4.5 mm (58.6%) and the 4.75 mm (24.1%) smart/eclipse. Endoscopic median operative time was 51 min vs 42 min for microscopic approach (P =.004).

Conclusions: The endoscopic with microdrill approach is criticized to lack depth perception, especially when using a microdrill to perform in stapedotomies. Our study showcases that using the microdrill use produces minimal differences in outcomes, cost, and is a safe modality to stapes surgery in both approaches.
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http://dx.doi.org/10.1016/j.amjoto.2020.102666DOI Listing
December 2020

Displacement of a Total Ossicular Replacement Prosthesis Following Ossicular Chain Reconstruction.

Ann Otol Rhinol Laryngol 2021 Apr 20;130(4):420-423. Epub 2020 Aug 20.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, USA.

Objective: Herein we describe the diagnosis and management of total ossicular replacement prosthesis (TORP) displacement following tympanoplasty with ossicular chain reconstruction (OCR).

Methods: Case report with literature review.

Results/case: A 40-year-old male with otorrhea and tympanic membrane perforation underwent a right revision tympanoplasty with OCR using a TORP with a tragal chondroperichondrial graft. On postoperative day (POD) 4, he developed vertigo and profound right-sided hearing loss. Temporal bone computed tomography showed the prosthesis in the vestibule. After a steroid taper with mild improvement in symptoms, the TORP was removed two weeks later and the patient continued to improve.

Conclusion: TORP displacement into the vestibule is a very rare complication following OCR. Conservative management with high dose steroids may improve symptoms, however further middle ear exploration and surgical management may be warranted depending on the depth of displacement into the inner ear as well as symptom severity.
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http://dx.doi.org/10.1177/0003489420953587DOI Listing
April 2021

Enlarged Cochlear Aperture as a Risk Factor for Cerebrospinal Fluid Gusher During Cochlear Implant Surgery.

Ear Nose Throat J 2020 Aug 13:145561320947631. Epub 2020 Aug 13.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.

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http://dx.doi.org/10.1177/0145561320947631DOI Listing
August 2020

Staying ahead of the curve: Early lessons from a New York City Otolaryngology Department's organizational response to the coronavirus pandemic.

Laryngoscope Investig Otolaryngol 2020 Jun 19;5(3):401-403. Epub 2020 May 19.

Department of Otolaryngology-Head and Neck Surgery Icahn School of Medicine at Mount Sinai New York New York USA.

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http://dx.doi.org/10.1002/lio2.400DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7276712PMC
June 2020

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database.

Otol Neurotol 2020 09;41(8):1084-1093

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai.

Objective: To determine risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility in patients with acute mastoiditis. Trends in treatment and complication rates were also examined.

Study Design: Retrospective cohort study.

Setting: Nationwide Readmissions Database (2013, 2014).

Patients: Pediatric and adult patients in the Nationwide Readmissions Database with a primary diagnosis of acute mastoiditis.

Interventions: Medical treatment, surgical intervention.

Outcome Measures: Rates of and risk factors for readmission, prolonged length of stay, and discharge to a rehabilitation facility. Procedure and complication rates were also examined.

Results: Four thousand two hundred ninety-five pediatric and adult admissions for acute mastoiditis were analyzed. The overall rates of readmission, prolonged length of stay, and discharge to a rehabilitation facility were 17.0, 10.4, and 10.2%, respectively. Children 4 to 17 years of age had the highest rates of intracranial complications, and children ≤3 years were most likely to undergo operative intervention. Any procedure was performed in 31.2% of cases, and undergoing myringotomy or mastoidectomy was associated with lower rates of readmission but higher rates of prolonged length of stay. Those with intracranial complications and subperiosteal abscesses had the highest surgical intervention rates.

Conclusions: Readmission, prolonged length of stay, and discharge to a rehabilitation facility are common in patients with acute mastoiditis with various sociodemographic and disease-related risk factors. While once a primarily surgical disease, a minority of patients in our cohort underwent procedures. Undergoing a surgical procedure was protective against readmission but a risk factor for prolonged length of stay.
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http://dx.doi.org/10.1097/MAO.0000000000002745DOI Listing
September 2020

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

Am J Otolaryngol 2020 Sep - Oct;41(5):102562. Epub 2020 May 27.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States of America.

Objective: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience.

Patients/intervention: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon.

Main Outcome Measures: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane.

Results: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences.

Conclusions: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.
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http://dx.doi.org/10.1016/j.amjoto.2020.102562DOI Listing
November 2020

COVID-19 sampling from the middle ear and mastoid: A case report.

Am J Otolaryngol 2020 Sep - Oct;41(5):102577. Epub 2020 Jun 2.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America.

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http://dx.doi.org/10.1016/j.amjoto.2020.102577DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7264918PMC
September 2020

Temporal Bone Encephaloceles: Utility of Preoperative Imaging.

Otolaryngol Head Neck Surg 2020 09 28;163(3):577-581. Epub 2020 Apr 28.

Department of Otolaryngology and Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA.

Objective: To determine the diagnostic efficacy and clinical value of preoperative computed tomography (CT) and magnetic resonance imaging (MRI) among patients with suspected temporal bone encephaloceles (TBE).

Study Design: Retrospective chart review from 2006 to 2018.

Setting: Tertiary referral center.

Subjects And Methods: The subjects underwent surgery for a clinically suspected TBE or cerebrospinal fluid (CSF) leak. Preoperative imaging test characteristics of CT and MRI, including sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV), were calculated for TBE scans and compared with intraoperative findings.

Results: Fifty-seven subjects with otorrhea, middle ear effusion, hearing loss, and/or meningitis with suspected TBE or CSF leak were identified. All had preoperative CT scans, and 61% (35/57) had preoperative MRI scans. Intraoperatively, 37 of 57 patients (65%) were found to have a TBE. CT scans (17% sensitivity, 100% specificity, 100% PPV, 46% NPV) were less sensitive than MRI (58% sensitivity, 100% specificity, 100% PPV, 24% NPV) for detecting TBEs. Furthermore, the time from initial scan to operative repair was significantly longer in those who had a CT followed by MRI scan compared with CT alone or a fused CT-MRI scan (mean = 68 vs 15 days, respectively; = .004).

Conclusion: CT and MRI provide complementary information that may aid surgical planning. However, imaging cannot always rule out TBE. In cases with high clinical suspicion, surgical confirmation is often required for definitive diagnosis and treatment. The cost of an additional preoperative study should be considered before its use.
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http://dx.doi.org/10.1177/0194599820918566DOI Listing
September 2020

Repair of a Temporal Bone Encephalocele With the Surgical Exoscope.

Otol Neurotol 2020 04;41(4):561

Department of Otolaryngology Head and Neck Surgery, New York Eye and Ear Infirmary of Mount Sinai.

Objective: We describe our experience using the extracorporeal video microscope, the "exoscope" for repair of a temporal bone encephalocele.

Method: The patient is a 69-year-old male with a right temporal lobe encephalocele herniating through a tegmen defect. He underwent definitive tegmen defect repair and bipolar cauterization of the encephalocele. The authors elected for a combined transmastoid and transtemporal approach in order to isolate the tegmen defect and provide watertight repair. The Synaptive robotic BrightMatter (Toronto, ON) drive video exoscope monitor system was used for the entirety of the case including both the transmastoid approach and transtemporal craniotomy.

Results: No intraoperative complications were encountered during either the transmastoid (mastoidectomy) or transtemporal craniotomy. The authors were able to complete the entire case without abandonment of the exoscope in favor of the traditional binocular microscope. Advantages of this technology in clinical practice includes high-resolution three-dimensional visualization, increased degrees of freedom for exoscope adjustment, and reduced surgeon fatigue in a fixed, unnatural posture. Limitations include decreased depth perception and increased operative time.

Conclusion: The exoscope system is a safe and effective alternative or adjunct to the existing binocular operating microscope for lateral skull based procedures. The exoscope provides the surgeon with a comfortable, high-resolution visualization without compromising surgical exposure and patient safety.SDC video link: http://links.lww.com/MAO/A837.
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http://dx.doi.org/10.1097/MAO.0000000000002433DOI Listing
April 2020

Thirty-Day Readmission and Prolonged Length of Stay in Malignant Otitis Externa.

Laryngoscope 2020 09 22;130(9):2220-2228. Epub 2019 Nov 22.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

Objectives: To determine independent risk factors for 30-day readmission, prolonged length of stay (PLOS), and discharge to a rehabilitation facility for those with malignant otitis externa.

Methods: Retrospective cohort study of patients hospitalized with malignant otitis externa (International Classification of Diseases, 9th edition, code 380.14) in the Nationwide Readmissions Database (2013-2014). Overall and disease-specific complication and mortality data were analyzed using chi-squared and multivariate analysis.

Results: There were 1267 cases of malignant otitis externa extracted. A PLOS of ≥8 days (90th percentile) was found in 14.2% (n = 180) of patients, and 13.7% (n = 174) were discharged to a facility. Patients were readmitted within 30 days at a rate of 12.5% (n = 159). The overall rates of uncomplicated and complicated diabetes were found to be 42.1% and 17.8%, respectively. Factors independently associated with PLOS included undergoing a surgical procedure (odds ratio [OR] 2.08, P < .001), and having central nervous system complications (OR 3.21, P < .001). Independent risk factors for disposition to a facility included nutritional deficiency (OR 1.91, P = .029), PLOS (OR 4.61, P < .001), and age 65-79 years (OR 6.57, P = .001). Readmission was independently linked to PLOS (OR 3.14, P < .001). Diabetes was not an independent risk factor for any outcome.

Conclusions: Thirty-day readmission, PLOS, and ultimate discharge to a rehabilitation facility were common and closely intertwined. Despite the classic association between diabetes and malignant otitis externa, diabetes was not an independent risk factor for any of our outcomes.

Level Of Evidence: 4 Laryngoscope, 130:2220-2228, 2020.
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http://dx.doi.org/10.1002/lary.28409DOI Listing
September 2020

Accuracy of a Modern Intraoperative Navigation System for Temporal Bone Surgery in a Cadaveric Model.

Otolaryngol Head Neck Surg 2019 11 24;161(5):842-845. Epub 2019 Sep 24.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.

Objectives: To determine the accuracy of a modern navigation system in temporal bone surgery. While routine in other specialties, navigation has had limited use in the temporal bone due to issues of accuracy, perceived impracticality, and value.

Study Design: Prospective observational study.

Setting: Temporal bone laboratory.

Subjects And Methods: Eighteen cadaveric specimens were dissected after rigid fiducials were implanted and computed tomography scans were obtained. Target registration and target localization errors were then measured at various points.

Results: The mean overall target registration error was 0.48 ± 0.29 mm. The mean target localization error was 0.54 mm at the sinodural angle, 0.48 mm at the lateral semicircular canal, 0.55 mm at the round window, 0.39 mm at the oval window, and 0.52 mm at the second genu of the facial nerve.

Conclusion: A modern navigation system demonstrated submillimeter accuracy for all points of interest. Its use in clinical as well as training settings has yet to be fully elucidated.
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http://dx.doi.org/10.1177/0194599819864292DOI Listing
November 2019

National 30-day readmission and prolonged length of stay after vestibular schwannoma surgery: Analysis of the Nationwide Readmissions Database.

Am J Otolaryngol 2019 Nov - Dec;40(6):102290. Epub 2019 Sep 10.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America; Audiology, Hearing, and Balance Center, Mount Sinai Health System, United States of America; Ear Institute, Mount Sinai Health System, United States of America. Electronic address:

Purpose: To determine the risk factors for unanticipated readmission, prolonged index admission, and discharge to a facility after vestibular schwannoma surgery.

Materials And Methods: Retrospective cohort study of those undergoing surgery for vestibular schwannoma in the Nationwide Readmissions Database (2013-2014). Main outcome measures included readmission rate, length of stay, discharge destination.

Results: There were 4585 cases identified. The overall unanticipated readmission rate was 8.1%, and 9.1% had a prolonged length of stay (PLOS) of ≥7 days. Mean and median LOS were 4.63 and 4.00 days, respectively, and >90% of patients were discharged after 7 days. Disposition to a facility occurred in 6.7% of cases. Teaching hospitals were protective against unintended readmission (odds ratio [OR] 0.44, p < .001). Major functional loss was associated with PLOS (OR 12.55, p < .001). High volume centers were associated with decreased risk of PLOS (OR 0.46, p < .001) and facility discharge (OR 0.68, p < .001). The most common readmission diagnoses included "other nervous system complications" (n = 128), cerebrospinal fluid leak (n = 71), "other postoperative infection" (n = 61), and meningitis (n = 59).

Conclusions: Unanticipated readmission and prolonged LOS following vestibular schwannoma surgery are common, with varied sociodemographic, hospital, and patient factors independently associated with each. Further studies are needed to investigate targeted interventions aimed at minimizing readmission and prolonged LOS using the factors outlined above.
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http://dx.doi.org/10.1016/j.amjoto.2019.102290DOI Listing
April 2020

The utility of intraoperative navigation of the temporal bone for otolaryngology resident training.

Laryngoscope 2020 05 5;130(5):E368-E371. Epub 2019 Aug 5.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York, U.S.A.

Objectives: To determine whether image guidance improves dissection quality among residents in the temporal bone lab and to gauge their reactions to its use.

Methods: Prospective cohort study of nine otolaryngology residents who dissected cadaveric temporal bones with and without image guidance in the temporal bone laboratory. Quality of dissection was measured with the Welling scale. A survey was administered assessing their interactions with the navigation system.

Results: There was no significant difference in quality of dissection for the majority of structures or number of major errors with use of image guidance. Dissection quality of the tegmen (4.67 vs. 5.67, P = .034) and sinodural angle (0.83 vs. 1.56, P = .005) was superior in the non-navigation specimens. The majority of residents reported increased confidence with locating several critical anatomic structures and found the system intuitive to use. Nearly all thought it would be helpful in revision cases or for aural atresia.

Conclusion: Image guidance did not improve quality of temporal bone dissection or number of major errors in this cohort of residents, but the majority found it intuitive and increased confidence in finding several structures. Navigation systems may play an important adjunctive role in resident education and further work is required to determine its optimal use.

Level Of Evidence: NA Laryngoscope, 130:E368-E371, 2020.
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http://dx.doi.org/10.1002/lary.28219DOI Listing
May 2020

Endoscopic Versus Microscopic Middle Ear Surgery: A Meta-analysis of Outcomes Following Tympanoplasty and Stapes Surgery.

Otol Neurotol 2019 09;40(8):983-993

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York.

Objective: This meta-analysis compares the efficacy and safety of endoscopic and microscopic approaches to tympanoplasty and stapes surgery, two common middle ear procedures.

Data Sources: A comprehensive electronic search of PubMed/MEDLINE, Scopus, Web of Science, and Cochrane Library was conducted for studies published from the year 1960 through June 2018. Article selection and screening proceeded according to the strategies outlined in the standard Preferred Reporting Items for Systematic Reviews and Meta-analysis statement.

Methods: Studies were assessed for quality using the Newcastle-Ottawa Scale and the Jadad scale depending on the presence of randomization. Bias was analyzed using funnel plots. For each outcome measure, a forest plot was generated and a pooled relative risk or risk difference was calculated to assess significance.

Results: Twenty-one studies met the inclusion criteria, 16 tympanoplasty (1,323 ears) and 5 stapes surgery (283 ears). The nonrandomized studies scored moderately well but the randomized studies were of low quality with respect to the Newcastle-Ottawa Scale and the Jadad Scale, respectively. With respect to tympanoplasty, statistical analysis demonstrated that the endoscopic approach had significantly lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Furthermore, endoscopic compared to microscopic methods were similar in terms of audiological outcome, graft success rate, and complication rate. Among stapes surgeries, the endoscopic approach demonstrated a significantly decreased incidence of postoperative pain and chorda tympani injury but was similar to the microscopic approach with respect to audiological outcome, postoperative dizziness, and operative time.

Conclusions: Though the merits of endoscopic techniques are becoming more well known, there are still concerns regarding their efficacy and safety. An analysis of the current literature suggests that audiological, functional, and safety outcomes are similar, if not superior, for the endoscopic approach to both tympanoplasty and stapes surgery compared to the microscopic approach. With respect to tympanoplasty, patients undergoing the endoscopic approach had lower canalplasty rates, better cosmetic outcomes, and shorter operative times. Among stapes surgeries, patients in the endoscopic group had a lower incidence of postoperative pain and injury to the chorda tympani. This meta-analysis of the current evidence supports the use of endoscopic techniques for tympanoplasty and stapes surgery.
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http://dx.doi.org/10.1097/MAO.0000000000002353DOI Listing
September 2019

Standardization of the Punch Technique for the Implantation of Bone Anchored Auditory Devices: Evaluation of the MIPS Surgical Set.

Otol Neurotol 2019 07;40(6):e631-e635

Texas Ear Center, Houston, Texas.

Objective: To describe and assess intraoperative and postoperative outcomes in the insertion of osseointegrated auditory implants with a newly designed surgical instrumentation set through a punch type technique.

Study Design: Retrospective case series.

Methods: Patients who underwent bone anchored auditory implant surgery using the Minimally Invasive Ponto Surgery (Oticon Medical, Somerset, NJ) surgical set through a punch technique at nine neurotology tertiary referral based practices were identified. Demographic data, skin thickness at implant site, implant used, duration of surgery, adverse intraoperative events, and postoperative outcomes were recorded.

Results: Seventy-five patients comprised the study cohort (32 males, 43 females). Most patients (57. 3%) were aged 51 to 75 years while 30.7% of the cohort comprised those aged 18 to 50 years and 12% were over 75 years. All but two patients received 4 mm fixtured implants and 68% received the Oticon Medical BioHelix implant. Two patients received 3 mm fixture implants and 32% received the Oticon Medical Wide Ponto implant. Mean surgical time was 12.2 minutes (6-45 min, standard deviation of 6.88 min). In three instances, surgery was converted to a linear incision to control brisk bleeding. Skin condition was Holgers 0 to 1 in 91.8%, while 5.5% had Holgers 2, and 2.7% had Holgers 3 at the first postoperative visit. At second postoperative visit, 94.3% had Holgers 0 to 1, 4.3% had Holgers 2, and 1.4% had Holgers 3. All instances of adverse skin reactions were treated with topical or systemic antibiotics and/or local debridement. There were no instances of implant loss. One patient had his implant traumatically displaced to a 45-degree angle necessitating implant replacement at a second site.

Conclusion: Punch technique placement of osseointegrated auditory implants using the Minimally Invasive Ponto Surgery surgical set represents a safe technique that further simplifies a progressively minimally invasive surgery.
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http://dx.doi.org/10.1097/MAO.0000000000002291DOI Listing
July 2019

Hearing Outcomes Following Type 3 Tympanoplasty With Stapes Columella Grafting in Canal Wall Down Mastoidectomy.

Ann Otol Rhinol Laryngol 2019 Aug 2;128(8):736-741. Epub 2019 Apr 2.

4 New York Eye and Ear Infirmary of Mount Sinai, New York, New York, USA.

Objectives: To analyze hearing outcomes following Type 3 tympanoplasty with stapes columella grafting after canal wall down mastoidectomy and determine disease recurrence rates in patients undergoing this procedure.

Methods: This retrospective cohort analysis examines patients undergoing Type 3 tympanoplasty with stapes columella grafting following canal wall down mastoidectomy for cholesteatoma at a tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if they were found to have undergone the aforementioned procedure. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 6 months and 1 year postoperatively.

Results: Nineteen patients met criteria for this study. Erosion of the otic capsule, posterior fossa plate, or tegmen was noted in 37% of cases, highlighting disease severity. Eighteen (95%) had undergone prior otologic surgery. Mean time to short-term follow-up was 6 ± 3 months. The average short-term ABG was 26 ± 11 dB HL; 26% achieved an ABG <20 dB, and 58% achieved an ABG <30 dB. Fifteen had follow-up at least 1 year postoperatively (mean = 33 ± 16 months). At longer-term follow-up, mean ABG was 25 ± 10 dB HL; 33% achieved an ABG <20 dB, while 66% achieved an ABG <30 dB. Hearing remained stable over time ( = .52). At date of last clinical follow-up, only 1 (5%) patient had undergone revision for recurrent disease.

Conclusion: In some patients undergoing canal wall down mastoidectomy for advanced or recurrent cholesteatoma, Type 3 tympanoplasty with stapes columella grafting yields marginal hearing benefit. This type of reconstruction is a viable option in this challenging patient cohort, particularly as it is associated with low rates of revision surgery.
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http://dx.doi.org/10.1177/0003489419841400DOI Listing
August 2019

Angiolymphoid hyperplasia with eosinophilia of the external ear.

Am J Otolaryngol 2019 May - Jun;40(3):453-455. Epub 2019 Mar 12.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, USA; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, USA; Audiology, Hearing, and Balance Center, Mount Sinai Health System, USA; Ear Institute, Mount Sinai Health System, USA.

Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.
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http://dx.doi.org/10.1016/j.amjoto.2019.03.007DOI Listing
October 2019

Purely intracranial vagal schwannoma: A case report of a rare lesion.

Am J Otolaryngol 2019 May - Jun;40(3):443-444. Epub 2019 Feb 18.

Icahn School of Medicine at Mount Sinai, Department of Otolaryngology-Head and Neck Surgery, United States of America; New York Eye and Ear Infirmary of Mount Sinai, Department of Otolaryngology, United States of America; Audiology, Hearing, and Balance Center, Mount Sinai Health System, United States of America; Ear Institute, Mount Sinai Health System, United States of America. Electronic address:

We present a rare intracranial vagal schwannoma along with its preoperative, intraoperative, and postoperative course.
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http://dx.doi.org/10.1016/j.amjoto.2019.02.011DOI Listing
October 2019

Long-Term Hearing Outcomes following Total Ossicular Reconstruction with Titanium Prostheses.

Otolaryngol Head Neck Surg 2019 07 19;161(1):123-129. Epub 2019 Feb 19.

4 New York Eye and Ear Infirmary at Mount Sinai, New York, New York, USA.

Objective: (1) Characterize a large cohort of patients undergoing total ossicular chain reconstruction with titanium prosthesis. (2) Analyze long-term hearing outcomes of the same cohort.

Study Design: Case series with chart review.

Setting: Tertiary care center.

Subject And Methods: This study reviews patients who underwent total ossicular chain reconstruction (OCR) with titanium prostheses (TORPs) at a single tertiary care center from 2005 to 2015. Patient charts were reviewed for demographic data, diagnosis, and operative details. Patients were included in statistical analysis if length of follow-up was 2 years or more. Evaluation of hearing improvement was made by comparing preoperative air-bone gap (ABG) and ABG at follow-up at 2 years.

Results: In total, 153 patients were identified who met inclusion criteria. The mean age of included patients was 40 years (range, 6-89 years). Sixty patients (39%) had a history of OCR, and 120 patients (78%) had a diagnosis of cholesteatoma at the time of OCR. Preoperatively, the mean ABG was 36 ± 12, whereas the mean ABG at 2-year follow-up improved to 26 ± 13. This was statistically significant ( < .0001) using a Wilcoxon matched-pairs signed rank test. Twelve patients (8%) required revision OCR. Two revisions were performed due to prosthesis extrusion (<1%).

Conclusion: Titanium prostheses lead to significant improvement in hearing over long periods. The results are sustained as far out as 5 years following surgery. In addition, rates of revision surgery with titanium TORPs are low. Based on this series, there are no readily identifiable predictors for outcomes following total OCR.
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http://dx.doi.org/10.1177/0194599819831284DOI Listing
July 2019

Endoscopic resection of a chorda tympani schwannoma: A novel approach for an exceedingly rare entity.

Laryngoscope 2019 05 12;129(5):1188-1190. Epub 2018 Sep 12.

Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, U.S.A.

We present a novel approach for a rare chorda tympani schwannoma. A case report as well as special considerations in all phases of care are reviewed. Laryngoscope, 129:1188-1190, 2019.
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http://dx.doi.org/10.1002/lary.27482DOI Listing
May 2019

Superior Canal Dehiscence Involving the Superior Petrosal Sinus: A Novel Classification Scheme.

Otol Neurotol 2018 10;39(9):e849-e855

Department of Otolaryngology-Head and Neck Surgery.

Objectives: To highlight superior semicircular canal dehiscence (SSCD) involving the superior petrosal sinus (SPS), and to propose a novel classification system for SPS associated SSCD with potential surgical implications.

Study Design: Multicenter retrospective review.

Setting: Three tertiary referral centers.

Patients: All patients diagnosed with SPS associated SSCD (1/2000 to 8/2016). Radiographic findings and clinical symptoms were analyzed.

Intervention: Surgical repair or observation.

Main Outcome Measure: Radiographic findings and clinical symptoms were analyzed.

Results: Thirty-three dehiscences (30 patients) involving the SPS were identified. The average age at the time of presentation was 52.5 years (median, 56.9; range, 4.9-75.3 yr), and 53.3% of patients were men. Three patients had bilateral SPS associated SSCD. The most common associated symptoms at presentation were episodic vertigo (63.6%), subjective hearing loss (60.6%), and aural fullness (57.6%). Four distinct types of dehiscence were identified: class Ia. SSCD involving a single dehiscence into an otherwise normal appearing SPS; class Ib. SSCD involving a single dehiscence into an apparent venous anomaly of the SPS; class IIa. SSCD involving two distinct dehiscences into the middle cranial fossa and the SPS; class IIb. SSCD involving a single confluent dehiscence into the middle cranial fossa and the SPS.

Conclusions: SSCD involving the SPS represents a small but distinct subset of SSCD cases. This scenario can create a unique set of symptoms and surgical challenges when intervention is sought. Clinical findings and considerations for surgical intervention are provided to facilitate effective diagnosis and management.
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http://dx.doi.org/10.1097/MAO.0000000000001965DOI Listing
October 2018

The importance of electrode location in cochlear implantation.

Laryngoscope Investig Otolaryngol 2016 12 29;1(6):169-174. Epub 2016 Nov 29.

Department of Otolaryngology-Head and Neck Surgery Vanderbilt University Medical Center Nashville Tennessee U.S.A.

Objectives: As indications for cochlear implantation have expanded to include patients with more residual hearing, increasing emphasis has been placed on minimally traumatic electrode insertion. Histopathologic evaluation remains the gold standard for evaluation of cochlear trauma, but advances in imaging techniques have allowed clinicians to determine scalar electrode location . This review will examine the relationship between scalar location of electrode arrays and audiologic outcomes. In addition, the impact that surgical approach, electrode design, and insertion depth have on scalar location will be evaluated. : PubMed literature review : A review of the current literature was conducted to analyze the relationship between scalar location of cochlear implant electrode arrays and speech perception outcomes. Further, data were reviewed to determine the impact that surgical variables have on scalar electrode location.

Results: Electrode insertions into the scala tympani are associated with superior speech perception and higher rates of hearing preservation. Lateral wall electrodes, and round window/extended round window approaches appear to maximize the likelihood of a scala tympani insertion. It does not appear that deeper insertions are associated with higher rates of scalar translocation.

Conclusion: Superior audiologic outcomes are observed for electrode arrays inserted entirely within the scala tympani. The majority of clinical data demonstrate that lateral wall design and a round window approach increase the likelihood of a scala tympani insertion.

Level Of Evidence: N/A.
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http://dx.doi.org/10.1002/lio2.42DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5510268PMC
December 2016