Publications by authors named "Michael B Gluth"

42 Publications

Frequency-Specific Analysis of Hearing Outcomes Associated with Ossiculoplasty Versus Stapedotomy.

Ann Otol Rhinol Laryngol 2021 Sep 29;130(9):1010-1015. Epub 2021 Jan 29.

Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, IL, USA.

Objective: Surgery on the ossicular chain may impact its underlying mechanical properties. This study aims to investigate comparative differences in frequency-specific hearing outcomes for ossiculoplasty versus stapedotomy.

Methods: A retrospective chart review was conducted on subjects who underwent ossiculoplasty with partial ossicular replacement prosthesis (PORP) or laser stapedotomy with self-crimping nitinol/fluoroplastic piston, and achieved closure of postoperative pure tone average air-bone gap (PTA-ABG) ≤ 15 dB. 45 PORP and 38 stapedotomy cases were included, with mean length of follow-up of 7.6 months.

Results: The mean change in PTA-ABG was similar for the 2 procedures (-17.9 dB vs -18.1 dB,  = .98). Postoperative ABG closure for stapedotomy was superior at 1000 Hz (8.9 dB vs 13.9 dB,  = .0003) and 4000 Hz (11.8 dB vs 18.0 dB,  = .0073). Both procedures also had improved postoperative bone conduction (BC) thresholds at nearly all frequencies, but there was no statistical difference in the change in BC at any particular frequency between the 2 procedures.

Conclusion: Both procedures achieved a similar mean change in PTA-ABG. Stapedotomy was superior to PORP at ABG closure at 1000 Hz and at 4000 Hz, with 1000 Hz the most discrepant. The exact mechanism responsible for these changes is unclear, but the specific frequencies affected suggest that differences in each procedure's respective impact on the native resonant frequency and mass load of the system could be implicated.
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http://dx.doi.org/10.1177/0003489421990164DOI Listing
September 2021

The Utility of Numeric Grading Scales of Middle Ear Risk in Predicting Ossiculoplasty Hearing Outcomes.

Otol Neurotol 2020 12;41(10):1369-1378

Section of Otolaryngology-Head & Neck Surgery, The University of Chicago, Chicago, Illinois.

Objective: To assess the usefulness of numeric grading scales of middle ear risk in predicting ossiculoplasty hearing outcomes.

Study Design: Retrospective review.

Setting: Tertiary care, academic medical center.

Patients: Adults and children undergoing ossiculoplasty between May 2013 and May 2019 including: synthetic ossicular replacement prosthesis, autograft interposition, bone cement repair, and mobilization of lateral chain fixation.

Intervention: Cases were scored via middle ear risk index (MERI), surgical prosthetic infection tissue eustachian tube (SPITE) method, and ossiculoplasty outcome scoring parameter (OOPS) scale. Preoperative and postoperative hearing outcomes were recorded.

Main Outcome Measure: Statistical correlation between risk score and postoperative pure-tone average air-bone gap (PTA-ABG).

Results: The 179 included cases had average pre and postoperative PTA-ABGs of 30.3dB (standard deviation [SD] 12.7) and 20.3dB (SD 11.1), respectively. Mean MERI, SPITE, and OOPS scores were 4.5 (SD 2.3), 2.8 (SD 1.7), and 3.1 (SD 1.8), respectively. Statistically significant correlations with hearing outcome were noted for all three methods (MERI r = 0.22, p = 0.003; OOPS r = 0.19, p = 0.012; SPITE r = 0.27, p < 0.001). No scale predicted poor (PTA-ABG > 30dB) outcomes; only low SPITE scores predicted excellent (PTA-ABG < 10dB) outcomes (odds ratio [OR] 0.74 [Confidence Interval: 0.57 - 0.97], p = 0.032).

Conclusions: Significant weak correlations between each middle ear risk score and hearing outcomes were encountered. Although only the SPITE method predicted postoperative PTA-ABG, it was not overwhelmingly superior. Current grading scale selection may be justified by familiarity or ease of use.
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http://dx.doi.org/10.1097/MAO.0000000000002776DOI Listing
December 2020

Ipsilateral Cochlear Implantation in the Presence of Observed and Irradiated Vestibular Schwannomas.

Ann Otol Rhinol Laryngol 2020 Dec 18;129(12):1229-1238. Epub 2020 Jun 18.

Department of Otorhinolaryngology-Head and Neck Surgery, Rush University Medical Center, Chicago, IL, USA.

Objectives: Historically, eventual loss of cochlear nerve function has limited patients with neurofibromatosis type 2 (NF2) to auditory brainstem implants (ABI), which in general are less effective than modern cochlear implants (CI). Our objective is to evaluate hearing outcomes following ipsilateral cochlear implantation in patients with NF2 and irradiated vestibular schwannomas (VS), and sporadic VS that have been irradiated or observed.

Methods: Multi-center retrospective analysis of ipsilateral cochlear implantation in the presence of observed and irradiated VS. MESH search in NCBI PubMed database between 1992 and 2019 for reported cases of cochlear implantation with unresected vestibular schwannoma.

Results: Seven patients underwent ipsilateral cochlear implantation in the presence of observed or irradiated vestibular schwannomas. Four patients had sporadic tumors with severe-profound contralateral hearing loss caused by presbycusis/hereditary sensorineural hearing loss, and three patients with NF2 lost contralateral hearing after prior surgical resection. Prior to implantation, one VS was observed without growth for a period of 7 years and the others were treated with radiotherapy. Mean post-operative sentence score was 63.9% (range 48-91) at an average of 28 (range 2-84) months follow up. All patients in this cohort obtained open set speech perception. While analysis of the literature is limited by heterogenous data reporting, 85% of implants with observed schwannomas achieved some open set perception, and 67% of patients previously radiated schwannomas. Furthermore, blending literature outcomes for post implantation sentence testing in quiet without lip-reading show 59.0 ± 35% for patients with CI and observed tumors and 55.7 ± 35% for patients with radiated tumors, with both groups ranging 0 to 100%.

Conclusion: This retrospective series and literature review highlight that hearing outcomes with CI for VS patients are superior to those achieved with ABI. However, important considerations including imaging, delayed hearing loss, and observation time cannot be ignored in this population.
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http://dx.doi.org/10.1177/0003489420935482DOI Listing
December 2020

Histology of the Cochlear Outer Sulcus Cells in Normal Human Ears, Presbycusis, and Menière's Disease.

Otol Neurotol 2020 04;41(4):e507-e515

Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois, USA.

Hypothesis: Outer sulcus cell features and distribution are hypothesized to differ throughout regions of the human cochlea and between diseased and normal specimens.

Background: Outer sulcus cells play a role in inner ear fluid homeostasis. However, their anatomy and distribution in the human are not well described.

Methods: Temporal bone specimens with normal hearing (n = 10), Menière's disease (n = 10), presbycusis with flat audiograms (n = 4), and presbycusis with sloping audiograms (n = 5) were examined by light microscopy. Outer sulcus cells were assessed quantitatively and qualitatively in each cochlear turn. One specimen was stained for tubulin immunofluorescence and imaged using confocal microscopy.

Results: Outer sulcus cells interface with endolymph throughout the cochlea, with greatest contact in the apical turn. Mean outer sulcus cell counts in the upper apical turn (8.82) were generally smaller (all p < 0.05) than those of the upper basal (17.71), lower middle (18.99) upper middle (18.23), and lower apical (16.42) turns. Mean outer sulcus cell counts were higher (p < 0.05) in normal controls (20.1) than in diseased specimens (15.29). There was a significant correlation between mean cell counts and tonotopically expected hearing thresholds in the upper basal (r = -0.662, p = 0.0001), lower middle (r = -0.565, p = 0.0017), and upper middle (r = -0.507, p = 0.0136) regions. Other differences in cell morphology, distribution, or relationship with Claudius cells were not appreciated between normal and diseased specimens. Menière's specimens had no apparent unique features in the cochlear apex. Immunofluorescence staining demonstrated outer sulcus cells extending into the spiral ligament in bundles forming tapering processes which differed between the cochlear turns in morphology.

Conclusion: Outer sulcus cells vary throughout the cochlear turns and correlate with hearing status, but not in a manner specific to the underlying diagnoses of Menière's disease or presbycusis.
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http://dx.doi.org/10.1097/MAO.0000000000002535DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7275934PMC
April 2020

On the Relationship Between Menière's Disease and Endolymphatic Hydrops.

Authors:
Michael B Gluth

Otol Neurotol 2020 02;41(2):242-249

Section of Otolaryngology-Head & Neck Surgery, The University of Chicago Medicine & Biological Sciences, Chicago, Illinois.

: The relationship between Menière's disease and endolymphatic hydrops is ambiguous. On the one hand, the existence of cases of endolymphatic hydrops lacking the classic symptoms of Menière's disease has prompted the assertion that endolymphatic hydrops alone is insufficient to cause symptoms and drives the hypothesis that endolymphatic hydrops is a mere epiphenomenon. Yet, on the other hand, there is considerable evidence suggesting a relationship between the mechanical pressure effects of endolymphatic hydrops and resultant disordered auditory physiology and symptomatology. A critical appraisal of this topic is undertaken, including a review of key histopathologic data chiefly responsible for the epiphenomenon hypothesis. Overall, a case is made that A) the preponderance of available evidence suggests endolymphatic hydrops is likely responsible for some of the auditory symptoms of Menière's disease, particularly those that can be modulated by mechanical manipulation of the basilar membrane and cochlear microphonic; B) Menière's disease can be reasonably considered part of a larger spectrum of hydropic inner ear disease that also includes some cases that lack vertigo. C) The relationship with endolymphatic hydrops sufficiently robust to consider its presence a hallmark defining feature of Menière's disease and a sensible target for diagnostic detection.
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http://dx.doi.org/10.1097/MAO.0000000000002502DOI Listing
February 2020

Delineation of the intratemporal facial nerve in a cadaveric specimen on diffusion tensor imaging using a 9.4 T magnetic resonance imaging scanner: a technical note.

Radiol Phys Technol 2019 Sep 29;12(3):357-361. Epub 2019 Jul 29.

Department of Surgery, Section of Otolaryngology, University of Chicago, Pritzker School of Medicine, Chicago, IL, USA.

The purpose of this study was to determine whether the intratemporal facial nerve could be delineated on 9.4 T magnetic resonance imaging (MRI) using T2-weighted and diffusion tensor imaging (DTI). DTI using a b value of 3000 and an isotropic resolution of 0.4 mm on a 9.4 T MRI scanner was performed on a whole-block celloidin-embedded cadaveric temporal bone specimen of a 1-year-old infant with normal temporal bones. The labyrinthine, tympanic, and mastoid segments of the facial nerve and the chorda tympani nerve were readily depicted on DTI. Therefore, DTI performed using a high b value on a high-field strength MRI scanner could help evaluate the intratemporal facial nerve in whole temporal bone ex vivo specimens.
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http://dx.doi.org/10.1007/s12194-019-00528-4DOI Listing
September 2019

Giant Cell Tumor of the Pinna.

Otol Neurotol 2019 08;40(7):e758-e760

Bloom Temporal Bone Laboratory, Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago, Chicago.

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http://dx.doi.org/10.1097/MAO.0000000000002301DOI Listing
August 2019

Impact of cochlear tonotopy on electrically evoked compound action potentials (ECAPs).

Acta Otolaryngol 2019 Jan 17;139(1):22-26. Epub 2019 Jan 17.

a Department of ENT , Universitatsklinikum Essen , Essen , Germany.

Background: A wide range of cochlear implant electrode designs exists. Lateral wall electrodes may be favored for their potential to preserve residual hearing by virtue of being thin and delicate; whereas perimodiolar electrodes may have advantages in case of profound hearing loss, due to electrode positioning in close proximity to the auditory nerve fibers.

Aim: The aim of this study was to investigate the impact of these two array designs on the interaction between electrodes and the auditory nerve in different tonotopic regions of the cochlea.

Patients And Methods: A retrospective study of both adult and pediatric cochlear implant recipients (CI24RE/CI512 or CI422, Cochlear®) was undertaken. The differences of threshold Neural Response Telemetry (tNRT) acquired 12 months after surgery were analyzed with respect to the tonotopic location.

Results: The results of 168 implants showed that perimodiolar arrays had lowest thresholds in the basal region whereas straight arrays had lowest thresholds in the apex. Highest thresholds for both array types were encountered in the medial parts.

Conclusions And Significance: tNRTs differ depending on electrode type and location inside the cochlea. This should be considered pre implantation when choosing the electrode array type and post-implantation when mapping the CI program.
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http://dx.doi.org/10.1080/00016489.2018.1533993DOI Listing
January 2019

Histopathology of the Mucosa of Eustachian Tube Orifice at the Middle Ear in Chronic Otitis Media With Effusion: Possible Insight Into Tuboplasty Failure.

Ann Otol Rhinol Laryngol 2018 Nov 6;127(11):817-822. Epub 2018 Sep 6.

2 University of Chicago, Section of Otolaryngology-Head & Neck Surgery and Bloom Otopathology Laboratory, Chicago, Illinois, USA.

Introduction: Balloon dilation of the cartilaginous segment of the Eustachian tube has emerged as a means to directly augment tubal dilatory function, and this has been applied as a potential treatment for otitis media with effusion (OME). Although results of clinical studies involving this modality appear promising, there are still a moderate number of ears affected by OME that do not respond. The purpose of this study was to investigate the status of mucosa of the Eustachian tube at the middle ear orifice in OME as it may relate to some cases of tuboplasty failure.

Methods: Twenty-three temporal bone specimens with OME were identified within an institutional archived collection. Each specimen was inspected for the presence of a fixed obstruction at the level of the Eustachian tube orifice at the protympanum. In addition, the mucosa at the tubal orifice was graded on a 4-point scale.

Results: Overall, 3 cases (13%) were normal (Grade 1), 6 cases (26%) were mildly thickened (Grade 2), 11 (48%) were severely thickened (Grade 3), and 3 (13%) were severely thickened with polypoid degeneration (Grade 4). A single case was noted to have a complete fixed obstruction in the form of a mucosal web.

Conclusion: In ears affected by OME, the mucosa of the Eustachian tubal orifice at the middle ear is most often severely thickened. Normal mucosa, mucosa with severe polypoid changes, or a complete fixed obstruction are possible but uncommon. The majority of specimens studied had sufficiently diseased mucosa to raise questions regarding whether thickened mucosa in the tubal orifice may act as a barrier to middle ear ventilation that would not be directly addressed by cartilaginous Eustachian tube balloon dilation.
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http://dx.doi.org/10.1177/0003489418796648DOI Listing
November 2018

Combined petrosal approach.

Curr Opin Otolaryngol Head Neck Surg 2018 Oct;26(5):293-301

Section of Otolaryngology - Head & Neck Surgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois, USA.

Purpose Of Review: The combined petrosal approach to the lateral skull base merges a retrolabyrinthine-presigmoid posterior fossa craniotomy with an adjacent middle fossa craniotomy, which are rendered continuous by division of the tentorium. This is a hearing-preserving approach that affords wide access to the lateral aspect of the clivus, the prepontine space, and the cerebellopontine angle.

Recent Findings: This article details the historical development of the combined petrosal approach alongside a description. In particular, the critically relevant anatomy is reviewed, including the course of the vein of Labbé, with a view toward avoiding the known complications associated with this approach. Outcomes for application of this approach as applied for various lesions are also reviewed as portrayed by the current literature.

Summary: The combined petrosal approach affords wide access to the lateral skull base in the middle and posterior fossa. The approach and the lesions addressed by this approach involve delicate and sensitive anatomy. We review the evolution of this approach and highlight advancements that have allowed the combined petrosal approach to be a safe addition to the surgeon's armamentarium.
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http://dx.doi.org/10.1097/MOO.0000000000000480DOI Listing
October 2018

Human Superior Olivary Nucleus Neuron Populations in Subjects With Normal Hearing and Presbycusis.

Ann Otol Rhinol Laryngol 2018 Aug 4;127(8):527-535. Epub 2018 Jun 4.

3 University of Chicago, Section of Otolaryngology-Head & Neck Surgery and Bloom Otopathology Laboratory, Chicago, Illinois, USA.

Introduction: Normative data on superior olivary nucleus neuron counts derived from human specimens are sparse, and little is known about their coherence with structure and function of the cochlea. The purpose of this study was to quantify the neuron populations of the divisions of the superior olivary nucleus in human subjects with normal hearing and presbycusis and investigate potential relationships between these findings and histopathology in the cochlea and hearing phenotype Methods: Histopathologic examination of temporal bone and brainstem specimens from 13 subjects having normal hearing or presbycusis was undertaken. The following was determined for each: number and density of superior olivary nucleus and cochlear nucleus neurons, inner and outer hair cell counts, spiral ganglion cell counts, and pure tone audiometry.

Results: The results demonstrate a significant relationship between cells within structures of the cochlear nucleus and the number of neurons of the medial superior olivary nucleus. No relationship between superior olivary nucleus neuron counts/density and cochlear histopathology or hearing phenotype was encountered.

Conclusion: Normative data for superior olivary nucleus neuron populations are further established in the data presented in this study that includes subjects with normal hearing and also presbycusis.
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http://dx.doi.org/10.1177/0003489418779405DOI Listing
August 2018

Newly Diagnosed Meniere's Disease: Clinical Course With Initiation of Noninvasive Treatment Including an Accounting of Vestibular Migraine.

Ann Otol Rhinol Laryngol 2018 May 16;127(5):331-337. Epub 2018 Mar 16.

3 Section of Otolaryngology-Head & Neck Surgery and Bloom Otopathology Laboratory, University of Chicago, Chicago, Illinois, USA.

Objective: To describe the course of Meniere's disease with noninvasive treatment during the first few years after initial diagnosis.

Methods: A retrospective review of consecutive patients with newly diagnosed definite Meniere's disease between 2013 and 2016 and a minimum follow-up of 1 year. Patients received a written plan for low sodium, water therapy, and treatment with a diuretic and/or betahistine. Subjects were screened and treated for vestibular migraine as needed. Vertigo control and hearing status at most recent follow-up were assessed.

Results: Forty-four subjects had an average follow up of 24.3 months. Thirty-four percent had Meniere's disease and vestibular migraine, and 84% had unilateral Meniere's disease. Seventy-five percent had vertigo well controlled at most recent follow-up, with only noninvasive treatments. Age, gender, body mass index, presence of vestibular migraine, bilateral disease, and duration of follow-up did not predict noninvasive treatment failure. Worse hearing threshold at 250 Hz and lower pure tone average (PTA) at the time of diagnosis did predict failure. Fifty-two percent of ears had improved PTA at most recent visit, 20% had no change, and 28% were worse Conclusions: Encountering excellent vertigo control and stable hearing after a new diagnosis of Meniere's disease is possible with noninvasive treatments. Worse hearing status at diagnosis predicted treatment failure.
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http://dx.doi.org/10.1177/0003489418763224DOI Listing
May 2018

In Vitro Susceptibility of Ciprofloxacin-Resistant Methicillin-Resistant Staphylococcus aureus to Ototopical Therapy.

Otolaryngol Head Neck Surg 2018 05 13;158(5):923-929. Epub 2018 Mar 13.

1 Section of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Chicago Medical Center, Chicago, Illinois, USA.

Objective Despite the rising incidence of methicillin-resistant Staphylococcus aureus (MRSA) otologic infections, choice of treatment remains controversial. Only fluoroquinolone-containing ototopical preparations are approved by the US Food and Drug Administration for middle ear application. Furthermore, American Academy of Otolaryngology-Head and Neck Surgery Foundation guidelines advocate ototopical monotherapy for both tympanostomy tube otorrhea and acute otitis externa. Unfortunately, MRSA may be ciprofloxacin resistant. This causes confusion regarding antibiotic selection, because susceptibility profiles reflect a minimum inhibitory concentration (MIC), referenced against systemic, not ototopical, drug delivery dosing. The goal of this study is to determine the ciprofloxacin MIC for ciprofloxacin-resistant MRSA isolates from otologic infections and compare that value to the expected drug concentration achieved by fluoroquinolone ear drops and determine MRSA genotype for each isolate. Study Design In vitro assay with retrospective medical record review. Setting Tertiary care university hospital. Subjects and Methods Thirty otologically sourced ciprofloxacin-resistant MRSA isolates collected from adult and pediatric patients. MICs were calculated by broth dilution method. Isolates underwent multilocus sequence typing and polymerase chain reaction for arcA and Panton-Valentine leukocidin to establish the genotype. Results MICs ranged from 16 to 1025 µg/mL. There was a relationship between MIC and genotype; of the 7 isolates with an MIC value greater than 512 µg/mL, 6 were sequence type (ST)8. Conclusion These findings support the practice of ototopical monotherapy for patients with uncomplicated ciprofloxacin-resistant MRSA otitis externa. However, they raise concern that ototopical therapy may not be adequate to treat highly resistant strains of MRSA infecting the middle ear space.
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http://dx.doi.org/10.1177/0194599818762382DOI Listing
May 2018

Advantages and Complications of Fisch Partial Mastoidotympanectomy for Tumors of the Retromandibular Fossa and Poststyloid Space.

J Neurol Surg B Skull Base 2017 Oct 26;78(5):380-384. Epub 2017 Apr 26.

Section of Otolaryngology-Head and Neck Surgery, University of Chicago, Chicago, Illinois, United States.

 This study aims to characterize a single surgeon's experience with resection of tumors of the retromandibular fossa and poststyloid space utilizing the Fisch partial mastoidotympanectomy (FPMT) technique of partial temporal bone resection.  Retrospective review.  Academic medical center.  Seven patients who underwent tumor resection with FPMT.  Complications.  Six males and one female underwent FPMT, with ages ranging from 44 to 79 years. The facial nerve was sacrificed in six cases, no cases were converted to more extensive temporal bone resection procedures, and no postoperative hearing loss occurred. The only intraoperative complication experienced was a violation of the external auditory canal in four cases, which resulted in postoperative wound healing issues in two cases.  FPMT allows for the release of tumors of the poststyloid space and retromandibular fossa without compromise of hearing status. Preservation of external auditory canal soft tissues is challenging, and the violation is experienced relatively frequently due to shearing forces during soft tissue retraction. When encountered, robust repair of defects is encouraged to prevent further wound healing complications.
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http://dx.doi.org/10.1055/s-0037-1602701DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5582968PMC
October 2017

Age-Related Change in Vestibular Ganglion Cell Populations in Individuals With Presbycusis and Normal Hearing.

Otol Neurotol 2017 04;38(4):540-546

Bloom Otopathology Lab, Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medicine & Biological Sciences, Chicago, Illinois.

Hypothesis: We sought to establish that the decline of vestibular ganglion cell counts uniquely correlates with spiral ganglion cell counts, cochlear hair cell counts, and hearing phenotype in individuals with presbycusis.

Background: The relationship between aging in the vestibular system and aging in the cochlea is a topic of ongoing investigation. Histopathologic age-related changes the vestibular system may mirror what is seen in the cochlea, but correlations with hearing phenotype and the impact of presbycusis are not well understood.

Methods: Vestibular ganglion cells, spiral ganglion cells, and cochlear hair cells were counted in specimens from individuals with presbycusis and normal hearing. These were taken from within a large collection of processed human temporal bones. Correlations between histopathology and hearing phenotype were investigated.

Results: Vestibular ganglion cell counts were positively correlated with spiral ganglion cell counts and cochlear hair cell counts and were negatively correlated with hearing phenotype. There was no statistical evidence on linear regression to suggest that the relationship between age and cell populations differed significantly according to whether presbycusis was present or not. Superior vestibular ganglion cells were more negatively correlated with age than inferior ganglion cells. No difference in vestibular ganglion cells was noted based on sex.

Conclusion: Vestibular ganglion cell counts progressively deteriorate with age, and this loss correlates closely with changes in the cochlea, as well as hearing phenotype. However, these correlations do not appear to be unique in individuals with presbycusis as compared with those with normal hearing.
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http://dx.doi.org/10.1097/MAO.0000000000001325DOI Listing
April 2017

Guidelines for Tinnitus-Reply.

JAMA 2016 Sep;316(11):1215

University of Chicago, Chicago, Illinois.

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http://dx.doi.org/10.1001/jama.2016.11908DOI Listing
September 2016

Tinnitus.

JAMA 2016 May 24-31;315(20):2221-2

Section of Otolaryngology-Head and Neck Surgery, Division of Surgery, University of Chicago, Chicago, Illinois.

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http://dx.doi.org/10.1001/jama.2016.5209DOI Listing
May 2016

Anatomic basis of the middle temporal artery periosteal rotational flap in otologic surgery.

Laryngoscope 2016 06 15;126(6):1426-32. Epub 2015 Sep 15.

Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medical Center, Chicago, Illinois.

Objectives/hypothesis: To describe the elements critical to successful middle temporal artery periosteal rotational flap harvest and utilization based on the anatomic features of the middle temporal artery.

Study Design: Description of anatomy based on cadaver dissection.

Methods: Seventy temporal fossa dissections were performed on 35 adult human cadavers.

Results: Sixty-nine of 70 dissections had an identifiable middle temporal artery muscular branch pedicle in the periosteum deep to the temporalis muscle. Pedicle length was at least 7 cm in 32 of 38 (84%) male cadavers and in 20 of 31 (65%) female cadavers (P = 0.054), whereas the average length required to reach the digastric ridge from the pedicle base to the digastric ridge in a mastoidectomy cavity was 5.2 cm. The pedicle sharply transitions from a posterior to a posterior-superior course 0.93 cm superior (range: 0.5-1.9 cm) and 0.04 cm posterior (range: 1.4 cm posterior-0.7 cm anterior) to the spine of Henle. Branching occurred in 26 of 69 pedicles (38%), and 20 of 31 (65%) branches were oriented posteriorly. If temporalis muscle fibers are not incorporated into the flap, the thickness is roughly three times that of a standard temporalis fascia graft.

Conclusion: The muscular branch of the middle temporal artery is reliably identified in the periosteum deep to the posterior aspect of the temporalis muscle, and this vessel is sufficiently robust to provide axial blood supply to a rotational periosteal flap that has sufficient thickness and length to allow a variety of applications in otologic surgery.

Level Of Evidence: NA. Laryngoscope, 126:1426-1432, 2016.
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http://dx.doi.org/10.1002/lary.25635DOI Listing
June 2016

Rhabdomyosarcoma and other pediatric temporal bone malignancies.

Authors:
Michael B Gluth

Otolaryngol Clin North Am 2015 Apr 31;48(2):375-90. Epub 2015 Jan 31.

Bloom Otopathology Laboratory, Section of Otolaryngology-Head & Neck Surgery, Comprehensive Ear & Hearing Center, University of Chicago Medicine & Biological Sciences, MC 1035, 5841 South Maryland Avenue, Chicago, IL 60637, USA. Electronic address:

This article outlines the nature of temporal bone malignancy in children, particularly from the viewpoint of a surgeon. This article includes a synopsis of the presentation, workup, and management options for children affected by these uncommon tumors. Particular attention is given to rhabdomyosarcoma, including an update of modern staging, risk classification, and prognosis; however, a concise review of other forms of pediatric temporal bone cancer and an overview of surgical approaches available for treatment is undertaken as well.
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http://dx.doi.org/10.1016/j.otc.2014.12.010DOI Listing
April 2015

Immunotargeted photodynamic therapy for cholesteatoma: in vitro results with anti-EGFR-coated indocyanine green nanocapsules.

Otol Neurotol 2015 Jan;36(1):76-81

*Section of Otolaryngology-Head and Neck Surgery, University of Chicago Medicine and Biological Sciences, Chicago, Illinois; and †Departments of Surgery and ‡Otolaryngology-Head and Neck Surgery, and §Phillips Classic Laser and Nanomedicine Laboratory, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.

Hypothesis: The objective was to test the hypothesis that immunotargeted photodynamic therapy (IT-PDT) using anti-epithelial growth factor receptor (EGFR)-coated indocyanine green (ICG) nanocapsules would selectively kill cholesteatoma-derived keratinocytes while sparing middle ear-derived mucosa cells in vitro.

Background: Rates of residual cholesteatoma caused by incomplete microsurgical removal are unacceptably high; thus, development of an adjuvant therapy to safely destroy undetected residual cholesteatoma cells would be desirable. IT-PDT is a possible means to achieve this end.

Methods: ICG nanocapsules coated with anti-EGFR were synthesized and applied to cholesteatoma-derived keratinocytes and middle ear mucosa cells in vitro. Selective binding to keratinocytes was evaluated by fluorescence microscopy. Activation of ICG was undertaken by applying near-infrared light (810 nm) at an applied energy dose of 1,080 J/cm. Cell death was evaluated 2 hours after treatment with trypan blue staining.

Results: Selective and robust nanocapsule binding to keratinocytes, but not mucosa cells, was confirmed by preapplication and postapplication fluorescence measurements. A keratinocyte cell death rate of 70.12% ± 2.50% was achieved, whereas negligible mucosa cell death was observed. Negligible cell death was also observed for both cell types with application of the nanocapsules alone or with application of near-infrared light alone.

Conclusion: Anti-EGFR ICG nanocapsules applied topically and activated as part of an IT-PDT scheme results in a high rate of cholesteatoma-derived keratinocyte cell death while negligibly affecting middle ear mucosal cells in vitro. These preliminary findings suggest that this is a feasible concept and that further investigation is warranted.
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http://dx.doi.org/10.1097/MAO.0000000000000590DOI Listing
January 2015

Vascularized reconstruction of partial external auditory canal wall defects using the middle temporal artery flap.

Otol Neurotol 2014 Jan;35(1):e31-5

Division of Otology and Neurotology, Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.

Objective: To review indications and surgical outcomes for partial canal wall defect reconstruction using the middle temporal artery (MTA) rotational flap.

Study Design: Retrospective review.

Setting: Academic tertiary referral center.

Patient: Adults that underwent attempted reconstruction of various partial canal wall defects with the MTA flap by a single surgeon.

Intervention(s): Review of demographic data, defect etiology and location, operative technique, subject wound healing risk factors, and time/success of canal wall healing.

Main Outcome Measure(s): Rate of complete canal wall healing/epithelialization by 8 weeks postoperation.

Results: Eighteen cases were reviewed. Underlying canal wall pathology included the following: cholesteatoma, penetrating trauma, malignancy, osteonecrosis, and canal-mastoid fistula. In all cases, the canal wall was completely healed and epithelialized by 8 weeks postoperation, and there were no flap-related complications. Many cases (56%) involved previous intact-canal wall mastoidectomy surgery in the past with apparent degeneration of thinned canal wall bone. In 2 cases, the MTA pedicle had been violated by previous surgery; however, a smaller vascularized flap based on remnant blood supply was successfully used in each instance.

Conclusion: The MTA flap is useful as a thin, pliable flap that can be applied for reconstruction of various partial canal wall defects. This technique may be particularly useful in the settings of osteonecrosis and chronic infection where introduction of vascularized canal wall lining is particularly desirable. Although short-term outcomes are encouraging, the long-term outcomes of this technique are unknown.
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http://dx.doi.org/10.1097/MAO.0000000000000182DOI Listing
January 2014

Cochlear implant failure, revision, and reimplantation.

Otol Neurotol 2013 Dec;34(9):1670-4

*Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences; †Department of Audiology, Arkansas Children's Hospital; and ‡Department of Biostatistics, University of Arkansas for Medical Sciences, Little Rock, Arkansas, U.S.A.

Objective: To evaluate the long-term adverse cochlear implant (CI) outcomes resulting in revision surgery including CI reimplantation (CIR).

Patients: Pediatric and adult patients requiring revision procedures after CI placement.

Intervention(s): Revision surgery on cochlear implant patients.

Main Outcome Measures: Device type, length of total device follow-up, time to device failure, cause for failure, peak pre-CIR and post-CIR audiometric performance, rate of surgical site complications, and operative findings.

Results: A total of 317 patients, receiving 439 CIs between January 2000 and April 2012, met inclusion criteria for this series. For the patients implanted at our institution, the revision surgery rate was 4.1%, with a CIR rate of 3.0%. The CIR rates among the pediatric and adult populations were 5.0% and 1.3%, respectively (p = 0.0336). The rate of revision procedures because of failed fixation or device extrusion was 0.9%. Device failure was experienced in 8 patients in our series, with 75% occurring with the CI24R (CS) device.

Conclusion: All reimplanted patients with available data had good audiometric outcomes, with the exception of those reimplanted for soft failure who had poor immediate auditory function. Using the manufacturers' recommended surgical technique, including drilling a bony recess with suture fixation, very low surgical revision rates were achieved. Pediatric patients experienced significantly higher complications requiring CIR. All hard failures in this series occurred in the pediatric group and in a single device. Continued follow-up will be needed to determine if additional devices will succumb to this mode of failure.
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http://dx.doi.org/10.1097/MAO.0000000000000079DOI Listing
December 2013

Determining benchmarks in hearing preservation surgery for vestibular schwannoma.

J Neurol Surg B Skull Base 2012 Aug;73(4):273-80

Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States.

Objectives The objectives of this study were to determine minimal benchmarks of success in vestibular schwannoma hearing preservation surgery, wherein the likelihood of having preserved hearing in a single patient is at least as likely as having created a poor facial nerve outcome for a single patient. Design This is a statistical analysis of published literature. Setting Academic Tertiary Medical Center. Main Outcome Measures Based on published natural history data, the number needed to treat (NNT) equation was used to calculate the minimally acceptable hearing preservation rates within various hearing classification schemes. Results Given good facial nerve outcome rates of 85, 90, and 95%, the corresponding hearing preservation rates at 4.7 years that are likely to preserve classes A and B hearing (American Academy of Otolaryngology-Head and Neck Surgery classification) in a single patient as to cause a poor facial nerve outcome are 70, 65, and 60%, respectively. If surgery is limited exclusively to intracanalicular tumors, these rates drop to 62, 57, and 52%, respectively. If the word recognition scoring classification is used, required hearing preservation rates are higher. Conclusion It is possible to use the NNT equation alongside projected facial nerve outcomes to estimate benchmarks of minimally acceptable hearing preservation rates.
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http://dx.doi.org/10.1055/s-0032-1312710DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424036PMC
August 2012

Management of acquired cholesteatoma in the pediatric population.

Curr Opin Otolaryngol Head Neck Surg 2013 Oct;21(5):440-5

Department of Otolaryngology/Head and Neck Surgery, University of Arkansas for Medical Sciences, Arkansas Children's Hospital, Little Rock, Arkansas 72205, USA.

Purpose Of Review: This review focuses on the most recent literature pertaining to pediatric acquired cholesteatoma and aims to integrate findings into a comprehensive management approach.

Recent Findings: Pediatric acquired cholesteatoma has been shown to differ from the adult variety secondary to anatomy and physiologic factors. Whereas the goals of therapeutic management are ultimately similar in adult and pediatric patients, special considerations must be taken into account when deciding on a treatment plan for a child. Although avoidance of an unstable mastoid cavity is an important consideration in this population, successful management has been reported with canal wall-up, canal wall-down, and hybrid techniques. Second-look procedures are also important when concern of recurrence exists. Newer innovations include endoscopic ear surgery and diffusion-weighted imaging.

Summary: The principal goal of pediatric cholesteatoma management is eradication of disease. An individualized approach is paramount in yielding superior results in these patients. Special consideration should be given to anatomical and social factors.
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http://dx.doi.org/10.1097/MOO.0b013e32836464bdDOI Listing
October 2013

Risk analysis of unilateral severe-to-profound sensorineural hearing loss in children.

Int J Pediatr Otorhinolaryngol 2013 Jul 20;77(7):1128-31. Epub 2013 May 20.

Department of Otolaryngology/Head and Neck Surgery, University of Arkansas for Medical Sciences, 4301 West Markham, Little Rock, AR 72205, USA.

Objective: To explore the etiology of pediatric unilateral severe-to-profound sensorineural hearing loss (USPSNHL) and the risk of hearing loss in the contralateral ear.

Methods: Pediatric patients with USPSNHL referred to a tertiary children's hospital for unilateral bone-anchored hearing aid implantation were identified for study. Clinical charts, audiograms, and radiographic imaging of the temporal bones were reviewed.

Results: Eighty-four children with USPSNHL were reviewed (40 male, 44 female). The etiology of USPSNHL could be identified in 35 patients (41.7%), with perinatal events (16.2%) and family history of hearing loss (10.0%) being the most common identifiable risk factors. Forty percent of children with available newborn hearing screens passed in both ears but later developed USPSNHL. Progressive unilateral hearing loss leading to USPSNHL was found in 21% percent of patients. No patient experienced worsening hearing in the contralateral ear (mean follow-up=31.9 months). Of the 49 temporal bone scans available for review, 40.8% demonstrated aberrant inner ear anatomy, including semicircular canal dysplasia (10.2%), cochlear aperture stenosis (10.2%), hypoplastic cochlea (8.1%), enlarged vestibular aqueduct (14.3%), incomplete partition I/II (6.1%), and anomalous internal auditory canal (2.0%).

Conclusion: Pediatric USPSNHL can be attributed to a variety of sources with a cause identifiable in approximately 40% of patients. Temporal bone CT scan acquisition appears to be relatively high yield in this patient population, but only rarely do results have clinical implications. Early follow-up suggests that this population of children with USPSNHL does not appear to have a significantly increased risk for hearing loss in the contralateral ear.
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http://dx.doi.org/10.1016/j.ijporl.2013.04.016DOI Listing
July 2013

Osseointegrated hearing device placement in congenital lamellar ichthyosis.

Otol Neurotol 2013 Jun;34(4):723-5

Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences and Arkansas Children's Hospital, Little Rock, Arkansas 72205, USA.

Objective: To present a case of osseointegrated hearing device placement in a child with conductive hearing loss related to manifestations of congenital lamellar ichthyosis.

Patient: A 5-year-old female patient with congenital lamellar ichthyosis resulting in conductive hearing loss because of bilateral external auditory canal stenosis and tympanic membrane blunting.

Intervention: Unilateral osseointegrated hearing device placement using a traditional skin flap technique.

Main Outcome Measures: Frequency and severity of adverse skin reactions, device usage, and audiometric testing.

Results: After 51 months of follow-up postoperatively, the patient has only required 2 treatments for minor skin reactions (Holgers Grade I). Aided speech reception threshold was 15 dB hearing level (HL) compared to 35 dB HL unaided. The subject has used the device continuously with parental report of improvement in school performance.

Conclusion: Osseointegrated hearing device placement may be a viable option in patients with congenital lamellar ichthyosis despite the skin-related comorbidities known to be associated with this disease condition.
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http://dx.doi.org/10.1097/MAO.0b013e3182908c44DOI Listing
June 2013

Hearing aid tolerance after revision and obliteration of canal wall down mastoidectomy cavities.

Otol Neurotol 2013 Jun;34(4):711-4

Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.

Objective: To review the tolerance of hearing aid use after revision and obliteration of a previously unstable canal wall down mastoidectomy cavity.

Study Design: Retrospective case series.

Setting: Academic tertiary referral center.

Patients: Adults and children who underwent the described surgical procedure followed by attempted hearing aid use.

Intervention(s): Surgical revision and obliteration of a chronically unstable canal wall down mastoidectomy cavity and subsequent attempted use of a conventional, ear-level hearing aid.

Main Outcome Measure(s): Stability of mastoid cavity after starting conventional hearing aid usage.

Results: From a review of 87 consecutive mastoid obliteration procedures performed on previously unstable open cavities, 20 ears in 19 subjects were identified for study inclusion. The indication for hearing aid use was mixed hearing loss in the majority of subjects (85%). Among included ears, 7 (35%) had at least one documented temporary period of hearing aid nonuse because of otorrhea; however, permanent discontinuation of hearing aid use in favor of bone-anchored hearing implant placement only occurred in 3 ears (15%). The mean follow-up from the start of hearing aid use was 49 months.

Conclusion: Although failures do exist, attempted use of a hearing aid after revision of an unstable canal wall down mastoidectomy cavity seems feasible and generally well tolerated. However, the exact likelihood of achieving this result is yet uncertain, and hearing performance was not assessed in this study.
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June 2013

Outcomes of cartilage tympanoplasty in the pediatric population.

Otolaryngol Head Neck Surg 2013 Feb 7;148(2):297-301. Epub 2012 Dec 7.

Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.

Objective: To justify the successful use of a patient selection algorithm based on age for primary cartilage tympanoplasty.

Study Design: Case series with chart review.

Setting: Tertiary care pediatric hospital.

Subjects And Methods: We performed a retrospective chart review of patients between ages 4 and 13 years who underwent cartilage tympanoplasty for tympanic membrane perforations from August 2005 to November 2011. Demographics, complication data, and auditory outcomes were collected.

Results: Patients were subdivided into 3 age groups. Group 1 consisted of patients younger than 7 years (n = 43); group 2, ages 7 to 10 years (n = 40); and group 3, ages 10 to 13 years (n = 36). Mean follow-up was 595 days (range, 48-1742). Complication rates respective to the 3 groups were as follows: remnant perforation (6.97%, 5.00%, 2.78%), revision tympanoplasty (2.33%, 2.50%, 0%), and need for tympanostomy tubes (4.65%, 2.50%, 0%). Logistic regression models were used to evaluate complication rates between groups. No significant differences were found (remnant perforation, P = .710; repeat tympanoplasty, P = .998; tympanostomy tubes, P = .875). No significance was found among audiological outcomes between the 3 groups.

Conclusion: These data suggest cartilage tympanoplasty can be performed effectively in young children when appropriate conditions exist.
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http://dx.doi.org/10.1177/0194599812470434DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4118686PMC
February 2013

Facial and lower cranial neuropathies after preoperative embolization of jugular foramen lesions with ethylene vinyl alcohol.

Otol Neurotol 2012 Sep;33(7):1270-5

Department of Surgery, Division of Otolaryngology-Head and Neck Surgery, University of Wisconsin-Madison, Madison, Wisconsin 53792-7375, USA.

Objective: To report 3 unique cases of cranial neuropathy after super-selective arterial embolization of jugular foramen vascular tumors with ethylene vinyl alcohol.

Study Design: Clinical capsule report.

Setting: Three tertiary academic referral hospitals.

Patients: Three patients who underwent superselective arterial embolization (SSE) of head and neck paragangliomas with ethylene vinyl alcohol are described. One individual was treated with primary SSE, whereas the remaining tumors were treated with preoperative SSE followed by surgical extirpation within 72 hours. All patients were found to have new cranial nerve deficits after SSE.

Results: One patient with isolated complete cranial nerve VII palsy demonstrated partial return of function at 8 months. One individual experienced cranial nerve VII, X, and XII palsies and demonstrated partial recovery of function of the involved facial nerve after 19 months. One subject experienced ipsilateral cranial nerve X and XI palsies after SSE and recovered full function of the spinal accessory nerve within 1 week but failed to demonstrate mobility of the ipsilateral true vocal fold.

Conclusion: We present the first report documenting facial and lower cranial neuropathies after super-selective embolization of head and neck paragangliomas with EVA. Although it is difficult to draw conclusions from this small number of cases, it is plausible that the use of ethylene vinyl alcohol during SSE may result in a higher risk of permanent cranial neuropathy than the use of other well-established and more temporary agents. Knowledge of the arterial supply to the cranial nerves can help the clinician to choose the embolization agent that will provide maximal occlusion while minimizing the risk of complications.
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http://dx.doi.org/10.1097/MAO.0b013e31825f2365DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3581607PMC
September 2012

Method and reproducibility of a standardized ossiculoplasty technique.

Otol Neurotol 2012 Sep;33(7):1207-12

Department of Otolaryngology-Head and Neck Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas 72205, USA.

Objective: To describe a standardized ossiculoplasty technique and to evaluate its reproducibility.

Study Design: Retrospective review.

Setting: Academic tertiary referral center.

Patients: The first 35 consecutive patients (adults and children) that underwent ossiculoplasty between 2009 and 2010 using a standardized technique that was newly adopted by a surgeon that had previous experience only using other ossiculoplasty techniques.

Intervention: Standardized technique consisted of the following: 1) reconstruction from the stapes to the malleus neck, 2) usage of standard length prostheses (2-mm partial ossicular replacement prosthesis and 4-mm total ossicular replacement prosthesis) in nearly all cases, 3) bending the prosthesis head 15 to 30 degrees according to the contour of the malleus, 4) freestanding reconstruction without packing, 5) usage of a large cartilage graft over the prosthesis head, 6) usage of a footplate stabilization prosthesis for total ossicular replacement prosthesis cases, and 7) tympanoplasty at the same stage as ossiculoplasty. The predicted postoperative air-bone (A-B) gap was calculated according to middle ear risk factors based on a scoring system developed using this technique, which was compared with the actual average postoperative A-B gap.

Main Outcome Measure: Predicted versus actual postoperative A-B gap.

Results: Thirty cases had audiometric data available for review. The average postoperative A-B gap was 15.3 dB (range, 1-31 dB), which was not different (p = 0.9060) than the predicted value. This also was statistically better (p < 0.0001) than the preoperative A-B gap of 27.8 dB.

Conclusion: Short-term data suggest that this standardized technique of ossiculoplasty leads to predictable hearing outcomes and seems to be reproducible by an experienced otologist with only limited specific instruction.
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September 2012
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