Early Magnetic Resonance Imaging for Patients With Idiopathic Sudden Sensorineural Hearing Loss in an Emergency Setting Objective: The role of magnetic resonance (MR) imaging in idiopathic sudden sensorineural hearing loss (ISSHL) is controversial due to the inhomogeneity of clinical and MR protocols. The aim of this work is to relate early MR findings obtained immediately after the admission, with the clinical presentation, the audiological findings, and the outcomes of treatment. Study Design: Prospective observational study. Setting: Tertiary referral university center. Patients: Forty-seven patients (22 M, 25 F; age: 54.4 ± 17.5 yr) consecutively referred to the Department of Emergency for ISSHL. Interventions: All patients underwent the diagnostic and therapeutic work-up for ISSHL, and MR imaging within 72 hours from the admission, independently of the symptoms onset. All patients received the same treatment (systemic steroid therapy, intratympanic steroid injection, and hyperbaric oxygen therapy). Main Outcome Measure(s): MR patterns, clinical, and laboratory findings. Results: MR imaging was positive in 25 of 47 cases (53%), with a perfect agreement between clinical and MR examinations (Cohen K = 1) upon the affected ear. Three different radiological patterns were observed: labyrinthine haemorrhage (n = 5), acute inflammatory process (n = 14), isolated blood–labyrinth barrier breakdown (n = 6). By binary logistic regression, only vertigo was associated with a positive MR imaging [B = 2.8; p = 0.011; OR = 9.5 (95% CI: 2.2–40.8)] and the latter was the only variable associated with an unfavorable outcome [(B = 2.8; p = 0.02 OR = 12.8 (95% CI: 2.9–56.7)]. Conclusion: Patients affected by ISSHL with associated vertigo show a higher likelihood of having a positive MR imaging, which, in turn, seems to predict an unfavorable outcome. Address correspondence and reprint requests to Diego Zanetti, M.D., Audiology Unit, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico Via Pace 2, 20122 Milan, Italy; E-mail: diego.zaneti.bs@gmail.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Reducing Artifacts in Intracochlear Pressure Measurements to Study Sound Transmission by Bone Conduction Stimulation in Humans Hypothesis: Intracochlear pressure (ICP) measurements during bone conduction (BC) stimulation may be affected by motion of the pressure sensor relative to the cochlear promontory bone, demonstrating the need to cement the sensor firmly to the cochlear bone. Background: ICP is a promising measurement tool for investigating the cochlear drive in BC transmission, but its use is not yet standardized. Previous ICP studies have reported artificially increased pressure due to motion of the sensor relative to the temporal bone. The artifact can be reduced by firmly cementing the sensor to the bone, but this is destructive for the sensor. Previous studies used a custom-made sensor; the use of commercially available sensors, however, is more generic, but also more challenging to combine with the cement. Therefore, the goals of the current study are: firstly, to evaluate a non-destructive cementing method suitable for a commercially available sensor, and secondly, to investigate ICP measurements during BC stimulation in more detail. Methods: To study the effect of sensor cementing, three fixation conditions were investigated on six fresh-frozen temporal bones: 1) alginate, 2) alginate and dental composite, 3) alginate and dental composite, released from micromanipulators. Pressures in scala tympani and vestibuli were measured simultaneously, while velocity measurements were performed on the cochlear promontory and sensor. The ratio between sensor and promontory bone velocity was computed to quantify the relative motion. Results: For air conduction stimulation, results were in line with those from previous ICP studies, indicating that baseline measurements were valid and could be used to interpret the results obtained with BC stimulation. Results showed that cementing the sensors and releasing them from the micromanipulators is crucial for valid ICP measurements. When the sensors were only sealed with alginate, the pressure was overestimated, especially at low and mid-frequencies. When the sensors were cemented and held in the micromanipulators, the pressure was underestimated. Compared with the scala tympani measurements, ICP measurements showed a lower scala vestibuli pressure below 1 kHz, and a higher pressure above 1 kHz. Conclusion: Dental composite is effective as a cement to attach commercially available sensors to the cochlear promontory bone. When sensors are firmly attached, valid ICP measurements can be obtained with BC stimulation. Address correspondence and reprint requests to Charlotte Borgers, M.Sc., Research Group Experimental Oto-rhino-laryngology (ExpORL), Department of Neurosciences, KU Leuven - University of Leuven, 3000, Leuven, Belgium; E-mail: charlotte.borgers@kuleuven.be Funding sources: This research work is carried out in the frame of IWT Research Project (155047). The last author, N.V. is supported by the Research Foundation Flanders as a senior clinical investigator. T.P. acknowledges support by FWO (12Y6919N). G.F. acknowledges support by VLAIO (HBC.2018.0184). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Long-term Implant Usage and Quality-of-Life in Sequential Bilateral Pediatric Cochlear Implantation Objectives: Our primary objective was to investigate the long-term usage of cochlear implants (CIs) in children who underwent sequential bilateral CI (SeqBCI), and to study factors that impact usage. Our secondary objective was to understand the difference in subjective benefit and educational/employment status, between users and non-users of the second CI (CI2). Study Design: Prospective case series. Setting: Tertiary academic centers. Patients: Sixty-eight young adults who underwent SeqBCI as children. Interventions: Pediatric SeqBCI. Main Outcome Measures: The main outcome measures were the current usage of the first CI (CI1) and CI2, factors that determine usage, current perceptions of their CIs, educational/employment status, and Speech, Spatial and Qualities of Hearing scale (SSQ12) scores. Results: Sixty five (95.6%) participants were using CI1 for over 8 h/d and the rest were using CI1 for 4 to 8 h/d. Fourty four (64.7%) participants used CI2 for at least 4 h/d, 10 (15%) indicated that they rarely used CI2 (<4 h/d) and 14 (21%) were not using CI2 at all. On multivariate analysis, the only independent predictor of long-term usage of CI2 was the inter-implant interval (odds ratio [OR] 0.78, standard deviation [SD] 0.65–0.91, p = 0.002). There was no significant difference in the SSQ12 scores of users and non-users of CI2. Conclusion: The finding of increasing rates of non-usage of CI2 with lengthening inter-implant interval is clinically relevant and critical to health-economic assessment. From a usage point of view, the evidence is sufficiently robust to recommend that in children with bilateral deafness, bilateral CI should be done simultaneously, and if not, soon after the first CI. In the context of a longer inter-implant interval, clinicians should weigh the marginal benefits of CI2 against the surgical risks vis-a-vis non-usage and bilateral vestibular hypofunction. Address correspondence and reprint requests to David Low, M.B.B.S., M.R.C.S., M.Med., Sunnybrook Health Sciences Centre, 2075 Bayview Ave., Room M1.102, Toronto, ON, M4N 3M5, Canada; E-mail: yongming@singnet.com.sg Funding: None. 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 (www.jcraniofacialsurgery.com). Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

High Dose of Intratympanic Steroids for Sudden Sensorineural Hearing Loss Salvage Objective: Intratympanic (IT) steroid administration for sudden sensorineural hearing loss is offered as salvage to patients who failed systemic steroid treatment. Our objective was to study the audiometric and clinical outcomes of patients given salvage therapy with high-dose IT steroids instilled via ventilation tube. Study Design: Retrospective case review. Setting: Academic secondary medical center. Patients: One hundred three patients >18 years of age with sudden sensorineural hearing loss who failed systemic steroids and received IT treatment between 2010 and 2018. Intervention: Following ventilation tube insertion, 1 ml of 10 mg/ml dexamethasone was instilled, twice daily, for 7 days. Outcome Measures: Hearing assessment immediately before and after treatment. Tinnitus and vertigo complaints and risk factors were also retrieved. Results: Tinnitus had improved in 53 (52%) patients, vertigo in 4 (4%), and aural fullness sensation in 56 (55%) (p < 0.001, p = 0.344, p < 0.001, respectively). The mean pure-tone threshold difference across frequencies following treatment was between 0 and 6 dB. A significant improvement was observed at 250, 500, 1000 Hz (p < 0.001 in all), and at 2000 Hz (p = 0.035). No significant difference was found at 4000 and 8000 Hz (p = 0.055, p = 0.983 respectively). Mean pure-tone average improvement of 4.5 dB was detected in 61 (59%) patients (p = 0.001). The mean speech discrimination score improved by 7% (p = 0.001). Four (22%) diabetic and nine (20%) hypertensive patients had pure-tone average ≥10 dB improvement (p = 0.759, p = 0.852 respectively). Conclusion: Although more than half of the patients improved clinically, the significance of the slight audiometric improvement should be weighed against the treatment protocol's complications. Address correspondence and reprint requests to Jacob Pitaro, M.D., M.Sc., Department of Otolaryngology—Head and Neck Surgery, Assaf Harofeh Medical Center, Zerifin 70300, Israel; E-mail: pitarojacob@gmail.com The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Assessment of Health Care Utilization for Dizziness in Ambulatory Care Settings in the United States Objective: Describe patient and physician characteristics, and physician recommendations for ambulatory care visits for dizziness in the US. Study Design: Cross-sectional analysis of visits for dizziness from the National Ambulatory Medical Care Survey (2013–2015). Setting: Ambulatory care clinics in the US. Patients: 20.6 million weighted adult visits [mean age 58.7 (1.0)] for dizziness, identified using ICD-9-CM codes (386.00–386.90, 780.40). Main Outcome Measures: Patient, clinical, and physician characteristics and physician diagnostic and treatment recommendations. Prevalence rates for benign paroxysmal positional vertigo (BPPV), unspecified dizziness, and other vestibular disorders were estimated, and descriptive statistics were used to characterize patients, physicians, and physicians’ recommendations. Results: The prevalence rate for dizziness visits was 8.8 per 1,000 (95% confidence interval [CI]: 7.5, 10.3). Most visits were for unspecified dizziness (75%), made by women (65%), whites (79%), and were insured by private insurance (50%). Visits for dizziness were to primary care physicians (51.9%), otolaryngologists (13.3%), and neurologists (9.6%). Imaging was ordered and medication prescription was provided in 5.5% and 20.1% of visits. Physical therapy (PT) was used for a higher percentage of BPPV visits (12.9%), than for other diagnoses (<1.0%). Physician treatment recommendations for vestibular diagnoses varied by physician specialty. Conclusions: A large percentage of visits had an unspecified diagnosis. A low number of visits for vestibular disorders were referred to PT. There are opportunities to improve care by using specific diagnoses and increasing the utilization of effective interventions for vestibular disorders. Address correspondence and reprint requests to Pamela M. Dunlap, D.P.T., Bridgeside Point 1, 100 Technology Drive Suite 210, Pittsburgh, PA 15219; E-mail: dunlappm@pitt.edu This work was supported, in part, by a grant awarded through the Health Resources and Services Administration of the US Department of Health and Human Services under Cooperative Agreement U81HP2649504-00, Health Workforce Research Centers Program to Dr. Freburger. The authors have no conflicts of interest to disclose. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

An Exploratory Study on the Use of Event-Related Potentials as an Objective Measure of Auditory Processing and Therapy Effect in Patients With Tinnitus: A Transcranial Direct Current Stimulation Study Objective: Treatment effect in tinnitus research is commonly evaluated by use of self-report questionnaires. As this is a solely subjective assessment method, the need for an objective measurement is paramount to genuinely evaluate the effects of therapeutic interventions. The current study explores the value of event-related potentials (ERPs) in the evaluation of high-definition transcranial direct current stimulation (HD-tDCS) for tinnitus treatment. Study Design: Prospective exploratory study. Setting: Tertiary referral center. Patients: Twenty-two chronic tinnitus patients. Intervention: HD-tDCS. Main Outcome Measures: ERPs. Results: The results show a significant shortening of the N1, P2, N2, and P3 latencies after HD-tDCS treatment. Moreover, the increased amplitude of the P2 and N2 peaks result in more salient and clear peaks, with the amplitude of N2 being significant larger after HD-tDCS. However, the ERP changes are not significantly correlated with the change in tinnitus functional index (TFI) total score. Conclusions: The current study was the first to explore ERPs as objective measure in a study with HD-tDCS in tinnitus patients. Adding ERPs to the outcome measures in tinnitus research may lead to a better understanding of the therapeutic effect in the future. The results showed a shortening of ERP latencies and an increased N2 amplitude, possibly reflecting more effective sound processing with higher recruitment of synchronized neurons in the auditory cortex. Future studies should elaborate on these results, by collecting control data and adding a sham group, to provide a better insight in the underlying mechanism of the ERP changes after tinnitus treatment. Address correspondence and reprint requests to Laure Jacquemin, Dienst NKO, Wilrijkstraat 10, 2650 Edegem, Belgium; E-mail: laure.jacquemin@uza.be The present research is financially supported by VLAIO (Agentschap Innoveren en Ondernemen) and a research grant from the FWO (Fonds voor Wetenschappelijk onderzoek Vlaanderen, Egmontstraat 5, 1000 Brussels) (T001916N). The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Glucocorticoid for Hearing Preservation After Cochlear Implantation: A Systemic Review and Meta-analysis of Animal Studies Objectives: To conduct systematic review and meta-analyses of preclinical studies describing the efficacy of glucocorticoids administered via different routes for hearing preservation after cochlear implantation. Data Sources: A literature search was performed in PubMed to identify peer-reviewed articles published before December 31, 2017, with no language restrictions. Search components were “Cochlear implant,” “Glucocorticoids,” and “Hearing preservation.” The results were specified for animal studies. Study Selection: Original studies in which glucocorticoids were administered before or during cochlear implantation in animal models and hearing threshold shifts were measured using auditory brainstem response. Data Extraction: Quality of included studies was assessed using the SYstematic Review Centre for Laboratory animal Experimentation protocol. Threshold Shift reduction between the “study” and “control” groups at 1-month postimplantation was the parameter used to evaluate hearing preservation. Data Synthesis: The random-effects models were used to combine the results of selected studies. Separate meta-analyses were performed for drug-eluting electrodes, systemic, and local administration. Conclusions: Administering either systemic or topical glucocorticosteroids had a significant effect on preserving low and high-frequency hearing. Topical administration was equally effective across a range of concentration levels and provided maximal hearing preservation when applied 120 minutes before implantation. The effect of systemic treatment was achieved with high doses, equivalent to 26 mg of dexamethasone per day in humans. No significant effect was found with the use of drug-eluting electrodes and more studies are needed to characterise the utility and efficacy of this administration method. Address correspondence and reprint requests to Prof. Stephen J. O’Leary, M.B.B.S., Otolaryngology, Department of Surgery, University of Melbourne, Level 5, PHW, RVEEH, 32 Gisborne Street, East Melbourne 3002, Australia; E-mail: sjoleary@unimelb.edu.au C.S. is supported by the Royal Victorian Eye and Ear Hospital, and the Gordon Darling Bequest to the University of Melbourne. S.J.O. is supported by a Practitioner Fellowship from the National Health and Medical Research Foundation (Australia). The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Neuropathological Findings of Dementia Associated With Subjective Hearing Loss Objective: The relationship between hearing loss and cognitive decline is of great importance with growing evidence of hearing loss as an independent modifiable risk factor for dementia. Our goal was to evaluate for differences in dementia neuropathology between subjective normal hearing and hearing loss subjects, as well as subjects who wore hearing aids. Study Design: Retrospective database. Setting: Tertiary academic center. Patients: Brain tissue analyzed from our Center on Aging. Demographics, subjective hearing status, hearing aid use, cognitive status, and dementia neuropathology documented. Interventions: Dementia neuropathology analyzed in brains of normal hearing and hearing loss subjects. Main Outcome Measures: Differences in dementia neuropathology between hearing groups. Groups were compared using logistic regression and analysis of covariance (ANCOVA). Results: Two-hundred and seventy-three subjects were included, 189 normal hearing and 84 subjective hearing loss subjects. No significant difference demonstrated in Alzheimer's disease neuropathology (p > 0.05) or pathologic stage (p = 0.2471). No significant difference observed in neuropathology of other major dementia types, specifically, presence of Lewy bodies (p > 0.05), Lewy body disease pathologic stage (p = 0.9778), or presence of micro-infarcts, macro-infarcts, or arteriosclerosis (p > 0.05). Hearing aid-wearing subjects had a lower prevalence of clinical dementia (39.1% versus 57.9%; p = 0.0208) with no significant difference in dementia neuropathology (p > 0.05). Conclusion: Subjective hearing loss was not found to be associated with significantly different dementia neuropathology, which counters hypotheses on hearing loss causing permanent neurodegeneration and cognitive decline. Hearing aid users were found to have a lower prevalence of dementia for similar levels of neurodegeneration, suggesting a potential neuroprotective effect of hearing aids. Address correspondence and reprint requests to Ryan M. Neff, M.D., 740 South Limestone, E300E, Lexington, KY 40536-0284; E-mail: ryan.neff1@uky.edu None of authors declare any conflicts of interest or additional sources of support or funding for this study. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Cognitive Performance in Chronic Tinnitus Patients: A Cross-Sectional Study Using the RBANS-H Objective: Many tinnitus patients report cognitive deficits such as concentration and attention difficulties. The aim of this study was to comprehensively assess cognitive functioning in tinnitus patients using a standardized test battery, the repeatable battery for the assessment of neuropsychological status adjusted for hearing impaired individuals (RBANS-H). Study Design: Cross-sectional study. Setting: Tertiary referral center. Participants: Twenty-eight chronic tinnitus patients and 28 control participants, matched for sex, age, hearing loss, and education level. Intervention: Diagnostic. Main Outcome Measures: All participants completed the RBANS-H, which includes subtests probing immediate and delayed memory, visuospatial capabilities, language, and attention. The tinnitus patients completed the tinnitus functional index (TFI), a visual analogue scale (VAS) measuring subjective mean tinnitus loudness and the hyperacusis questionnaire (HQ). Results: The total RBANS-H scores did not differ between tinnitus patients and controls. However, on the language subscale, mean scores of the tinnitus group (97.6 ± 11.0) were significantly lower than those of controls (104.4 ± 12.0), with correction for sex, age, hearing level, and education level (general linear model: p = 0.034). Post hoc t tests revealed a specific deficit concerning the semantic fluency subtest (tinnitus: 19.5 ± 6.2; control: 23.1 ± 5.9; p = 0.015). VAS scores for tinnitus loudness were negatively correlated to scores on the RBANS-H attention subscale (r = –0.48, p = 0.012). Conclusions: The current study successfully employed the RBANS-H to provide a broader view on cognitive functioning in tinnitus patients. The results showed a specific negative influence of tinnitus on verbal fluency, which could be related to a deficit in executive cognitive control. Moreover, patients experiencing louder tinnitus performed worse on specific subtests concerning attention. Address correspondence and reprint requests to Emilie Cardon, Dienst NKO Wilrijkstraat 10, 2650 Edegem, Belgium; E-mail: emilie.cardon@uantwerpen.be E.C. and L.J. have contributed equally to the work. The present research is financially supported by VLAIO (Agentschap Innoveren en Ondernemen) and two research grants from the FWO (Research Foundation - Flanders, Egmontstraat 5, 1000 Brussels, BELGIUM) (T001916N, T001618N). The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Intraoperative Monitoring of Auditory Function During Lateral Skull Base Surgery Objective: We present a unique case of a patient with a jugular foramen tumor with serviceable hearing. This study discusses the audiometric results and intraoperative electrocochleographic (ECochG) findings recorded during tumor removal to illustrate the potential utility of this technique in skull base surgery. Patients: A 22-year-old female patient presented with a jugular foramen schwannoma and associated symptoms of right-sided otalgia, mild hearing loss, and blurry vision. Interventions: Intraoperative ECochG responses during an infratemporal fossa approach: click and tone burst (1, 2, 4 kHz) stimuli were used and presented at 90 dB nHL. Main Outcome Measures: Intraoperative ECochG testing using frequency-specific tone bursts and clicks before and after tumor resection. Results: The compound action potential magnitudes, cochlear microphonic, and summation potential were recorded pre- and post-tumor removal. For statistical analysis, a paired t test with significance set at p < 0.05 was used. The compound action potential magnitudes increased at all test frequencies (p < 0.01) while the summation potential and cochlear microphonic remained relatively stable (p > 0.05). Audiometric testing demonstrated an improvement of the preoperative mild right-sided hearing loss after tumor resection (pure-tone average for 0.5, 1, 2, and 4 kHz of 30 dB HL preoperation and 7.5 dB HL after tumor resection). Conclusions: Intraoperative ECochG may allow for real-time monitoring during complex skull base surgery. Address correspondence and reprint requests to Eleonora M.C. Trecca, M.D., Division of Otology, Neurotology, and Cranial Base Surgery, 915 Olentangy River Road, Suite 4000, Columbus, OH 43212; E-mail: eleonoramc.trecca@gmail.com, eleonora.trecca@osumc.edu. Oliver F. Adunka, M.D., F.A.C.S., Professor and Vice Chairman for Clinical Operations, Director, Otology, Neurotology, and Cranial Base Surgery, 915 Olentangy River Road, Suite 4000, Columbus, OH 43212; E-mail: oliver.adunka@osumc.edu D.P. is consultant for Stryker, Medtronic and Integra. D.P. has royalties (KLS-Martin and Mizuho), and honorarium (Mizuho). O.F.A. is consultant for Advanced Bionics Corp, Med-El Corp, Cochlear Corporation, Spiral Therapeutics, and Advanced Genetics Technologies Corporation. O.F.A. has an ownership interest in Advanced Cochlear Diagnostics, LLC. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company