Hearing Preservation Outcomes With Standard Length Electrodes in Adult Cochlear Implantation and the Uptake of Electroacoustic Stimulation Background: Cochlear implantation with preservation of residual low-frequency hearing enables patients to utilize acoustic and electrical stimulation. It is widely accepted that preservation of residual low-frequency hearing is beneficial in both background noise and for music appreciation. The extent to which patients may benefit is not fully understood, but the importance of these concepts is reflected in electrode design developments and also refinement of surgical technique. Greater understanding is needed around factors that may affect hearing preservation. This study reports experience in adults using standard length cochlear implant arrays. Objective: The study reviews hearing preservation outcomes using the HEARRING GROUP method for factors such as gender, electrode type, insertion depth, laterality, preoperative hearing level, and time between surgery and audiogram. Furthermore, the study reviews rates of electroacoustic stimulation use in those with postoperative functional residual low-frequency hearing. Methodology: Retrospective case series. Inclusion criteria: preoperative ≤ 85 dB HL at 250 Hz and aged ≥ 18 years. The hearing preservation percentages were calculated using the HEARRING group formula S=[1 − ((PTApost − PTApre)/(PTAmax − PTApre))*100]%. . Preservation of > 75% was considered complete, 25 to 75% partial, and 1 to 25% minimal. Standardized operative technique with facial recess approach, posterior tympanotomy, and minimally traumatic round window insertion was performed for each implant. Results: Fifty-three implantations in 52 patients met the inclusion criteria. The mean age at implantation was 55.5 years. The average time since the last audiogram was 10 months. The mean average total pre and postoperative pure-tone averages were 92.4 dB, 99.2 dB, respectively, using minimum reporting standards for adult cochlear Implant (CI). Thirty percent demonstrated complete hearing preservation, 35.8% partial hearing preservation, and 20.8% minimal hearing preservation. Overall, mean hearing preservation was 52.9%. Sex, age at implantation, insertion depth, lateral versus perimodiolar electrode, and preoperative hearing level did not statistically significantly affect rates of hearing preservation in our study. There was a statistically significant deterioration in hearing preservation outcomes difference at 3 months compared with 12 months postoperatively. Only two patients within our study out of 17 with functional postoperative hearing went on to use electroacoustic stimulation. Conclusion: Hearing preservation varies between patients and postoperative outcomes are difficult to predict. This study adds to existing literature in terms of likelihood of hearing preservation following cochlear implantation. In turn, this improves our ability to counsel patients as to the chances of preserving residual low-frequency hearing postoperatively and their ability to use electroacoustic stimulation. Address correspondence and reprint requests to Laura Harrison, F.R.C.S., B.M.B.S., B.Medsci., UCL Ear Institute, 332 Gray's Inn Road, London WC1X 8DA, UK; E-mail: lauraharrison707@gmail.com The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Structural Analysis of Tympanic Compartments of the Middle Ear in Patients With Down's Syndrome: A Temporal Bone Study Hypothesis: There may be findings peculiar to the temporal bones of children with Down's syndrome (DS). The purpose of this study is to investigate the temporal bone histopathology of the children with DS. Background: Otitis media with effusion is a highly prevalent condition with DS. Knowledge of the volume of the tympanic compartments and the area of the tympanic isthmus might be important to find out the pathogenesis of highly prevalent otitis media with effusion in those patients. Methods: We compared the volume of the epitympanum, mesotympanum, and the areas of the tympanic isthmus and tympanic orifice of eustachian tube in temporal bones from patients with DS. We also investigated the eustachian tube histopathologically. Results: The mean volume of the epitympanum and the mesotympanum was significantly smaller in the DS group than the control group. We found no significant difference in the mean diameter of the protympanic opening and tympanic orifice between the two groups. The mean narrowest area of the aerated and bony tympanic isthmus also was not significantly different between the two groups. An immature development of eustachian tube and cartilage was seen. We found mesenchyme remaining at the epitympanum and/or mesotympanum in all specimens in the DS group, and in five specimens in the control group. Conclusion: In the presence of the small middle ear, poorly developed eustachian tube, and tensor muscle, a vicious circle occurs, making otitis media with effusion difficult to resolve. Address correspondence and reprint requests to Sebahattin Cureoglu, M.D., Ph.D., Department of Otolaryngology—Head and Neck Surgery, University of Minnesota, Lions Research Building, Room 210, Mayo Mail Code 2873, 2001 6th Street SE, Minneapolis, MN 55455; E-mail: cureo003@umn.edu This project was funded by the International Hearing Foundation; the 5 M Lions International; and the Starkey Foundation. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Insertion Depth for Optimized Positioning of Precurved Cochlear Implant Electrodes Hypothesis: Generic guidelines for insertion depth of precurved electrodes are suboptimal for many individuals. Background: Insertion depths that are too shallow result in decreased cochlear coverage, and ones that are too deep lift electrodes away from the modiolus and degrade the electro-neural interface. Guidelines for insertion depth are generically applied to all individuals using insertion depth markers on the array that can be referenced against anatomical landmarks. Methods: To normalize our measurements, we determined the optimal position and insertion vector where a precurved array best fits the cochlea for each patient in an IRB-approved, N = 131 subject CT database. The distances from the most basal electrode on an optimally placed array to anatomical landmarks, including the round window (RW) and facial recess (FR), was measured for all patients. Results: The standard deviations of the distance from the most basal electrode to the FR and RW are 0.65 mm and 0.26 mm, respectively. Owing to the high variability in FR distance, using the FR as a landmark to determine insertion depth results in >0.5 mm difference with ideal depth in 44% of cases. Alignment of either of the two most proximal RW markers with the RW would result in over-insertion failures for >80% of cases, whereas the use of the third, most medial marker would result in under-insertion in only 19% of cases. Conclusions: Normalized measurements using the optimized insertion vector show low variance in distance from the basal electrode position to the RW, thereby suggesting it as a better landmark for determining insertion depth than the FR. Address correspondence and reprint requests to Rueben A. Banalagay, 2301 Vanderbilt Pl., VU Station B #351679, Nashville, TN 37235; E-mail: rueben.a.banalagay@vanderbilt.edu The content is solely the responsibility of the authors and does not necessarily represent the official views of this institute. R.F.L. is a consultant with Advanced Bionics, Johnson&Johnson, Ototronix, and Medel. This research was supported in part by grants R01DC014037, R01DC008408, and R01DC014462 from the National Institute on Deafness and Other Communication Disorders. IRB approval number 090155. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Potential Ototopical Antiseptics for the Treatment of Active Chronic Otitis Media: An In-Vitro Evaluation Objectives: Primary: to compare, in vitro, the antimicrobial activity of different antiseptic agents versus quinolone drops, against the common organisms of chronic otitis media. Secondary: to examine the possible role of pH on the antimicrobial activity of the antiseptic solutions. Methods: Three antiseptic powders (boric acid; iodine; and a 1:1 combination of these two) and four solutions (2% boric acid; 2% acetic acid; 3.25% aluminum acetate; and 5% povidone iodine) were tested against five bacteria and two fungi common in chronic otitis media, using both agar plates and the modified broth dilution method. These results were compared with the antimicrobial activity of quinolone drops. The potential role of pH of solutions was tested by reducing the acidity of the agents and repeating the broth dilution. Results: Of the powders, iodine, and iodine/boric acid combined, are very effective against all organisms. Boric acid powder showed moderate effectiveness against all organisms. All solutions performed poorly on the agar plates. 5% povidone iodine has good effectivity when tested with the broth dilution method. 3.25% aluminum acetate had the best activity against Pseudomonas aeruginosa. Conclusion: Boric acid powder and 5% povidone iodine solution show promise for clinical use. Boric acid powder has proven clinical effectiveness. 5% povidone iodine requires further clinical research. Although very effective in vitro, iodine powder is toxic to tissues and cannot be recommended for clinical use. The pH of solutions does not seem to play a significant role in their antimicrobial activity in vitro. Address correspondence and reprint requests to Andries Francois van Straten, F.C.O.R.L. (SA), Faculty of Medicine and Health Sciences, Room 5054, Clinical Building, Building 91, Francie van Zijl Drive, Tygerberg, 7505 Cape Town, South Africa; E-mail: vanstraten.andre@gmail.com Address for reprints: Same as for correspondence. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Current Management of CPAP After Otologic and Neurotologic Surgery Background: Obstructive sleep apnea is a highly prevalent disorder often treated with continuous positive airway pressure (CPAP). CPAP transmits high pressures through the Eustachian tube, and has significant implications for patients undergoing surgery of the middle ear, inner ear, and lateral skull base. In such patients, nothing is known regarding the likelihood of surgical complications with CPAP use, or medical complications with its cessation. No consensus or guidelines exist for postoperative management of this vitally important but potentially hazardous therapy. Objective: To gain an understanding of the current state of practice with regards to postoperative CPAP management in patients undergoing middle ear, stapes, cochlear implant, and lateral skull base surgeries. Methods: An electronic survey was sent to all members of the American Neurotology Society via email. Results: The survey was completed by 54 neurotologists. Duration of postoperative CPAP limitation had similar distribution for surgery of the middle ear, stapes, and skull base: fewer surgeons recommend immediate use, with more advising ≤1 week and ≥2 week abstinence. For cochlear implantation, immediate use is most commonly advocated. The rationale for restricting postoperative CPAP use varied by surgery type. Subgroup analysis showed no variations by region; however, surgeons with >15 years of experience tend to advocate for earlier return to CPAP than those with less experience. Conclusion: Current neurotology practice varies widely concerning CPAP management after otologic and neurotologic surgeries, both with regard to duration of CPAP abstinence and in rationale for its limitation. Address correspondence and reprint requests to Nathan D. Cass, M.D., University of Michigan Medical School, Ann Arbor, MI 48109; E-mail: ncass@med.umich.edu No sources of funding were received for this study. S.C.B. received research funding from Oticon Medical and Cochlear Corporation, honorarium from Acclarent. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Quality of Otology and Neurotology Research in Otolaryngology Journals Objective: To identify trends in the quality of otology studies published in general otolaryngology journals over a 20-year period. Study Design: Retrospective analysis. Methods: Otologic and neurotologic papers from 1997, 2007, and 2017 were identified in the three general otolaryngology journals with the highest Eigenfactor scores: the Laryngoscope, European Archives of Otorhinolaryngology, and Otolaryngology–Head and Neck Surgery. The studies were reviewed and assigned level of evidence (LoE) based on standards set by the Centres for Evidence Based Medicine (CEBM). One-way analysis of variance were calculated with a 95% bootstrap sensitivity analysis performed. Results: A total of 786 otology articles were reviewed for level of evidence, of which 557 (70.8%) were original, clinical research, eligible for LoE assignation. Total publications increased for each year in all three journals. Both the absolute number and proportion of high evidence studies (level of evidence 1 and 2) increased with respect to time in all three journals. Lower evidence studies (level of evidence 3, 4, or 5) made up 66.8% of total publications in 2017. There was a reduction in average level of evidence (towards higher quality evidence) by 0.431 units from 1997 to 2017 (Diff = –0.431 between 1997 and 2017, p < 0.001). There was no significant difference in rate of change of level of evidence between 1997 and 2007 and 2007 and 2017 (0.033, p = 0.864). Conclusion: Over a 20-year period the number of total publications increased with time. The majority of otology publications in 2017 were lower evidence studies, though significant increases in the number and proportion of high evidence studies in general otolaryngology journals were observed throughout the study period. Address correspondence and reprint requests to Daniel H. Coelho, M.D., Otolaryngology–Head & Neck Surgery, Virginia Commonwealth University School of Medicine, PO Box 980146, Richmond, VA 23298-0146; E-mail: daniel.coelho@vcuhealth.org Funding: Statistical analysis was supported by the Biostatistics Consulting Laboratory, which is partially supported by Award No. UL1TR002649 from the National Institutes of Health's National Center for Advancing Translational Science. Financial Disclosures: None. The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The National Landscape of Acute Mastoiditis: Analysis of the Nationwide Readmissions Database 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. Address correspondence and reprint requests to Zachary G. Schwam, M.D., Mount Sinai Department of Otolaryngology—Head and Neck Surgery, 1 Gustave L. Levy Place, Box 1189, New York, NY 10029; E-mail: zachary.schwam@mountsinai.org G.B.W. is on the surgical advisory board for Oticon and Med-El. He consults for Med-El, cochlear, and Advanced Bionics. M.K.C. has received travel grants from Med-El, Cochlear, Stryker, educational research grants from Advanced Bionics, and has done clinical research with Advanced Bionics, Cochlear, and Otonomy. The abstract for this manuscript was selected as a poster presentation at the 2019 American Otological Society Meeting in Austin, Texas, May 3 to 5, 2019. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Position Paper on Systematic and Meta-Analysis Reviews No abstract available

Association of Speech Recognition Thresholds With Brain Volumes and White Matter Microstructure: The Rotterdam Study Objectives: Brain volumetric declines may underlie the association between hearing loss and dementia. While much is known about the peripheral auditory function and brain volumetric declines, poorer central auditory speech processing may also be associated with decreases in brain volumes. Methods: Central auditory speech processing, measured by the speech recognition threshold (SRT) from the Digits-in-Noise task, and neuroimaging assessments (structural magnetic resonance imaging [MRI] and fractional anisotropy and mean diffusivity from diffusion tensor imaging), were assessed cross-sectionally in 2,368 Rotterdam Study participants aged 51.8 to 97.8 years. SRTs were defined continuously and categorically by degrees of auditory performance (normal, insufficient, and poor). Brain volumes from structural MRI were assessed on a global and lobar level, as well as for specific dementia-related structures (hippocampus, entorhinal cortex, parahippocampal gyrus). Multivariable linear regression models adjusted by age, age-squared, sex, educational level, alcohol consumption, intracranial volume (MRI only), cardiovascular risk factors (hypertension, diabetes, obesity, current smoking), and pure-tone average were used to determine associations between SRT and brain structure. Results: Poorer central auditory speech processing was associated with larger parietal lobe volume (difference in mL per dB increase= 0.24, 95% CI: 0.05, 0.42), but not with diffusion tensor imaging measures. Degrees of auditory performance were not associated with brain volumes and white matter microstructure. Conclusions: Central auditory speech processing in the presence of both vascular burden and pure-tone average may not be related to brain volumes and white matter microstructure. Longitudinal follow-up is needed to explore these relationships thoroughly. Address correspondence and reprint requests to André Goedegebure, Ph.D., Department of Otorhinolaryngology, Head and Neck Surgery, Erasmus MC, P.O. Box 2040, 3000 CA Rotterdam, the Netherlands; E-mail: a.goedegebure@erasmusmc.nl N.M.A. wrote the manuscript and analyzed the data. All authors discussed the results and implications and commented on the manuscript at all stages, and they were responsible for the study design. The Rotterdam Study is supported by the Erasmus Medical Center and Erasmus University, Rotterdam, The Netherlands; the Organization for Scientific Research; the Netherlands Organization for Health Research and Development; the Research Institute for Diseases in the Elderly; the Netherlands Genomics Initiative; the Ministry of Education, Culture, and Science; the Ministry of Health, Welfare, and Sports; the European Commission (DG XII); and the Municipality of Rotterdam. Hearing-related research within the Rotterdam Study is partly funded by The Heinsius Houbolt Foundation. Separately, N.M.A. is supported by the Intramural Research Program at the National Institute on Aging, Baltimore, Maryland (N.M.A. received funding). F.R.L., A.G., and P.H.C. report funding by Cochlear Ltd. The authors disclose no conflicts of interest. Supplemental digital content is available in the text. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (http://journals.lww.com/otology-neurotology). Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Effect of Vestibular Schwannoma Size and Nerve of Origin on Posterior External Auditory Canal Sensation: A Prospective Observational Study Objective: Posterior external auditory canal (EAC) hypesthesia (Hitselberger's sign) has been previously described to occur in all vestibular schwannomas (1966) but has not been studied since. We hypothesized that sensory loss may be related to tumor size and sought to determine if this clinical sign could predict preoperative characteristics of vestibular schwannomas, intraoperative findings, and/or surgical outcomes. Study Design: Prospective observational study. Setting: Tertiary referral center. Patients: Twenty-five consecutive patients who underwent surgery for vestibular schwannoma. Intervention: Patients were tested for the presence of EAC hypesthesia or anesthesia. Main Outcome Measures: Preoperative, intraoperative, and postoperative findings were recorded, including facial nerve function, hearing function, tumor size, tumor nerve of origin, and extent of resection. Results: Twelve patients (48%) demonstrated either posterior EAC hypesthesia (11 patients) or anesthesia (1 patient). Sensory loss was a significant predictor of size (tumor maximal diameter) (p = 0.004). Median tumor diameter was 1.7 cm in the cohort with intact sensation versus 2.9 cm in the cohort with sensory loss. Patients with sensory loss were also significantly more likely to be associated with a superior vestibular nerve origin tumor (p = 0.01). Preoperative sensory loss did not significantly predict postoperative facial outcome (p = 0.10). Conclusion: Neurological exam findings may be overlooked in the workup of brain tumors. Posterior EAC hypesthesia is a predictor of tumor size and superior vestibular nerve origin. These findings may have implications for patient selection, particularly with the middle cranial fossa approach. Furthermore, given this relationship with tumor size, this clinical biomarker should be studied as a potential predictor of tumor growth. Address correspondence and reprint requests to Gautam U. Mehta, M.D., Division of Neurosurgery, House Institute, 2100 West 3rd Street, Ste 111, Los Angeles, CA 90057; E-mail: gmehta39@gmail.com The authors disclose no conflicts of interest. Copyright © 2020 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company