Hearing outcomes of cochlear implant recipients with pre-operatively identified cochlear dead regions

Objectives: To determine how patients who did not meet UK TA166 NICE criteria for cochlear implantation (CI) but were subsequently found to have cochlear dead regions (DRs) performed with CI.Methods: A retrospective review of medical records was performed on CI recipients: 152 controls and 40 in the DR group. Of these, 34 pairs were matched by pre-operative Bamford-Kowal-Bench (BKB) scores and compared.Results: The forty DR patients had a median age at implantation of 56 years. Their mean pre-operative BKB score of 23% increased to 78% after CI. Thirty-seven experienced improvements in BKB scores. In matched case-control analysis, the improvement in mean BKB score with CI was no different (p = 0.19) between the DR group and control group; a similar proportion of patients benefitted in each group.Discussion: This study is the largestreport to date of performance of patients with DRs, before and after CI. The DR group gain similar benefit as the controls.Conclusion: Patients with DRs, who did not meet TA166 NICE criteria, received the same benefit as those who did. TEN testing to detect DRs should be included in routine CI work-up where standard criteria are not met.

The Cambridge Otology Quality of Life Questionnaire: an otology-specific patient-recorded outcome measure. A paper describing the instrument design and a report of preliminary reliability and validity

OBJECTIVE

The Cambridge Otology Quality of Life Questionnaire (COQOL) is a patient-recorded outcome measurement (PROM) designed to quantify the quality of life of patients attending otology clinics.

DESIGN

Item-reduction model. A systematically designed long-form version (74 items) was tested with patient focus groups before being presented to adult otology patients (n. 137). Preliminary item analysis tested reliability, reducing the COQOL to 24 questions. This was then presented in conjunction with the SF-36 (V1) questionnaire to a total of 203 patients. Subsequently, these were re-presented at T + 3 months, and patients recorded whether they felt their condition had improved, deteriorated or remained the same. Non-responders were contacted by post. A correlation between COQOL scores and patient perception of change was examined to analyse content validity.

SETTING

Teaching hospital and university psychology department.

PARTICIPANTS

Adult patients attending otology clinics with a wide range of otological conditions.

MAIN OUTCOME MEASUREMENTS

Item reliability measured by item–total correlation, internal consistency and test– retest reliability. Validity measured by correlation between COQOL scores and patient-reported symptom change.

RESULTS

Reliability: the COQOL showed excellent internal consistency at both initial presentation (a = 0.90) and 3 months later (a = 0.93). Validity: One-way analysis of variance showed a significant difference between groups reporting change and those reporting no change in quality of life (F(2, 80) = 5.866, P < 0.01).

CONCLUSIONS

The COQOL is the first otology-specific PROM. Initial studies demonstrate excellent reliability and encouraging preliminary criterion validity: further studies will allow a deeper validation of the instrument.

Outcome of translabyrinthine surgery for vestibular schwannoma in neurofibromatosis type 2

OBJECTIVES

To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). RESEARCH TYPE: Retrospective cohort study.

SETTING

Two tertiary referral NF2 units.

PATIENTS

One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients.

RESULTS

Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House-Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1-3 in 83.2% and HB 4-6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the cases, 14 facial nerves were lost during surgery and repaired using direct anastomosis or grafting. There was no tinnitus present preoperatively in 27% of the cases, and 22% of patients developed tinnitus postoperatively. In patients with preoperative tinnitus, 61% remained the same, 17% got it resolved and only in 21% it worsened. The preoperative hydrocephalus rate was 26%, and among 15% of the cases five ventriculo-peritoneal (VP) shunts were performed. The cerebrospinal fluid leak rate was 2.5%. Fifty-six patients underwent auditory brainstem implantation (ABI) and two patients had cochlear implant (CI) sleepers inserted.

CONCLUSIONS

The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load. There is still an argument for the management by observation until the neurological compromise dictates interventional treatment particularly with the option of hearing rehabilitation with ABI or CI. The translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.

Electric acoustic stimulation of the auditory system: experience and results of ten patients using MED-EL's M and FlexEAS electrodes

OBJECTIVE

To evaluate the hearing preservation rate and speech perception scores in patients with profound high frequency hearing loss and acoustically aidable low frequency hearing, managed with the MED-EL electric acoustic stimulation system referenced to the insertion depth of the electrode array.

STUDY DESIGN

Retrospective data analysis.

PARTICIPANTS AND SETTING

Ten patients implanted at the Auditory Implant Centre, Guy's and St Thomas's Hospital, London, UK.

MAIN OUTCOME MEASURES

Pure tone audiometry, speech perception tests and electrode insertion depth angle.

RESULTS

Postoperatively, functional hearing preservation allowing electric acoustic stimulation was achieved in eight patients and total preservation of residual hearing in five patients with follow-up periods of more than 12 months. Three of four (75%) patients with an insertion depth of >360 degrees had a threshold shift of >25 dB, and all four patients had a threshold shift of >10 dB. All patients with total hearing preservation had the electrode inserted up to 360 degrees at maximum. Overall, speech perception outcomes increased significantly and hearing impairment was significantly reduced after electric acoustic stimulation or electric stimulation alone as compared with the preoperative scores.

CONCLUSION

Electric acoustic stimulation provides significant benefit to individuals with profound high frequency hearing loss. Studies with larger number of patients are needed to establish the optimal electrode insertion angle as well as to further analyse the benefit of electric acoustic stimulation.

Improving prediction of malignancy of cytologically indeterminate thyroid nodules

Background

Fine-needle aspiration (FNA) is essential in the investigation of thyroid nodules. The British Thyroid Association guidelines recommend clarification of whether follicular nodules are probable follicular neoplasms that require surgical excision. This study assessed the value of the subclassification of cytologically indeterminate thyroid nodules into either follicular neoplasms or other pathology.

Methods

The cytology reports of all thyroid FNAs performed between November 2005 and December 2007 at a single institution reported as Thy 3 (follicular lesions) were reviewed. They were reclassified as Thy 3A (probable follicular neoplasm) or Thy 3B (probable non-neoplastic lesion), and subsequently correlated with final clinical outcome to determine the predictive value of this subclassification.

Results

Forty-nine specimens were categorized as Thy 3A and 55 as Thy 3B. Of excised lesions, 14 (29 per cent) of 48 Thy 3A and 4 (10 per cent) of 42 Thy 3B nodules were malignant. If Thy 3A were to predict malignancy and Thy 3B benign disease, the sensitivity of the classification was 88 per cent, with a specificity of 55 per cent and negative predictive value of 91 per cent.

Conclusion

Subclassification of Thy 3 nodules into Thy 3A and Thy 3B improves the assessment of risk for thyroid malignancy.

Sebaceous lymphadenoma of the parotid gland: report of two cases and review of the literature

Sebaceous lymphadenoma is an unusual salivary gland neoplasm which is rarely correctly diagnosed pre-operatively in the parotid gland. Two cases of sebaceous lymphadenoma are presented in which, in common with most cases reported in the literature, the correct pre-operative diagnosis was not made. Sebaceous lymphadenoma rarely transforms into a malignant tumour. Fine needle aspiration cytology identifies a benign process in the majority of patients who receive appropriate treatment on this basis. Although an uncommon tumour, it should be taken into consideration in the differential diagnosis of a solitary parotid mass.

A comparative study of patient satisfaction with day case and in-patient major ear surgery

Introduction: Major ear surgery can be safely performed on a day case basis (i.e. six hour stay). This study aimed to ascertain whether patients had the same level of satisfaction and speed of recovery following major ear surgery when it was performed as a day case compared with performance as an in-patient procedure.

Method: A cross-sectional survey, by postal questionnaire, of patient satisfaction with day case and in-patient major ear surgery was carried out with 158 patients. Comparisons were made between the responses of the two groups.

Results: The response rate was 71 per cent. Patients returned to work significantly sooner following day surgery (p < 0.025) but felt their operation to be of significantly more benefit following in-patient surgery (p < 0.05).

Conclusions: Patient satisfaction following day case major ear surgery is as good as that following in-patient surgery. This has supported the expansion of this service in our unit.

Myxoid liposarcoma metastatic to the thyroid gland: a case report and literature review

We present the second reported case of a myxoid liposarcoma metastatic to the thyroid gland in a 51-year-old gentleman with previous liposarcoma of the right thigh. Myxoid liposarcoma has a relatively good prognosis but tends to recur locally. Metastases affecting the thyroid gland are a rare entity and most commonly arise from the kidney, lung or breast. Clinical presentation, patterns of recurrence and prognosis of myxoid liposarcoma and metastases to the thyroid gland are discussed.

How we do it: ionomeric cement to attach the stapes prosthesis to the long process of the incus

Keypoints * The successful use of glass-ionomeric cement in primary stapes surgery for attachment of the wire loop of the stapes prosthesis to the long process of the incus is reported. * Early hearing outcomes were similar in patients where cement was used for stapes prosthesis attachment compared with those with standard wire crimping technique. * Use of glass-ionomeric cement to attach the stapes prosthesis to the incus may prevent stapes prosthesis displacement and loosening. * This technique may decrease rates of revision stapes surgery and allow the safe use of magnetic resonance image scanning.

Liver resection in a patient with concomitant thoraco-abdominal and cerebral aneurysms

BACKGROUND

Surgical resection remains the only curative procedure for liver metastases but even in expert hands it has appreciable morbidity and mortality rates. The presence of a concomitant aortic aneurysm greatly increases these risks.

CASE OUTLINE

A 66-year-old woman who was known to have large aneurysms of the thoraco-abdominal aorta and middle cerebral artery presented with colorectal liver metastases. After detailed preoperative assessment, she underwent resection of segments V and VI of the liver. The surgical procedure was uneventful. She made a good initial recovery, but on day 7 she suddenly became hypotensive and died from a cardiorespiratory arrest. Post-mortem examination revealed a ruptured thoracic portion of the thoraco-abdominal aortic aneurysm.

CONCLUSION

Despite careful control of perioperative blood pressure and the lack of abdominal complication, intrathoracic aneurysmal rupture on day 7 highlights the risk of major unrelated operations in patients with aneurysmal disease.