Hemodynamic Changes in the Sigmoid Sinus of Patients With Pulsatile Tinnitus Induced by Sigmoid Sinus Wall Anomalies Objective: This study is to investigate the hemodynamic changes of pulsatile tinnitus (PT) patients induced by sigmoid sinus wall anomalies (SSWA). Study Design: Prospective study. Setting: Tertiary referral university hospital. Patients: Fifteen unilateral PT patients with SSWA identified on computed tomography images and surgery and 15 age-, sex-, and body mass index-matched healthy volunteers underwent velocity-encoded, cine magnetic resonance imaging. Intervention: Hemodynamic data in sigmoid sinus were obtained from velocity-encoded, cine magnetic resonance imaging, and compared between PT patients and controls. Main Outcome Measures: Heart rate was recorded. Cross-sectional area (CSA), peak positive velocity (PPV), average positive flow volume per beat (APFV/beat), average flow volume per beat (AFV/beat), peak negative velocity (PNV), and average negative flow volume per beat (ANFV/beat) were measured. Average flow volume per minute (AFV/min), average positive flow volume per minute (APFV/min), average negative flow volume per minute (ANFV/min), average positive velocity (APV), average negative velocity (ANV), and regurgitation fraction (RF) were calculated. Results: APV at PT side of patients was 13.4 ± 3.3 cm/s, which was significantly slower than that at corresponding side of controls (15.8 ± 2.6 cm/s). PNV and RF at PT side of patients were 21.0 ± 15.4 cm/s and 2.4% respectively, which were significantly higher than those values at corresponding side of controls (both of them were 0). HR, CSA, PPV, APFV/beat, APFV/min, AFV/beat, AFV/min, ANV, ANFV/beat, and ANFV/min were 69.8 ± 9.4 beat/min, 48.4 ± 17 mm2, 31.4 ± 5.9 cm/s, 5.4 ± 1.8 ml/beat, 373.9 ± 117.7 ml/min, 5.1 ± 2.0 ml/beat, 352.0 ± 134.6 ml/min, 2 (0–4.9) cm/s, 1 (0–2.7) ml/beat, and 4.1 (0–141.3) ml/min at PT side of patients, and 67.4 ± 7.8 beat/min, 38.2 ± 18 mm2, 29.9 ± 3.9 cm/s, 5.3 ± 2.0 ml/beat, 350.3 ± 125.3 ml/min, 5.1 ± 1.9 ml/beat, 340.5 ± 117.9 ml/min, 0 (0–2.1) cm/s, 0 (0–0.8) ml/beat, and 0 (0–55.4) ml/min at corresponding side of controls. These hemodynamics were not significantly different between groups. Conclusion: APV, PNV, and RF changes take place in SSWA patients, which may be associated with the occurrence of PT and have the potential value to improve accurate etiological diagnosis and predict treatment success. Address correspondence and reprint requests to Zhaohui Liu, M.D., Department of Radiology, Capital Medical University, Beijing Tongren Hospital, No 1 Dong Jiao Min Street, Dongcheng District, Beijing 100730, China; E-mail: lzhtrhos@163.com X.H., R.D., G.W., S.G., Z.W. are co-authors. This work was supported by the grant (81371545) from the National Natural Science Foundation of China, the grant (Z161100004916041) from Beijing Nova Program Interdisciplinary Studies Cooperative Projects, and the grant (2015-3-016) from Beijing Health System High-level Health Technical Personnel Training Program. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The Management of Tympanic Membrane Perforation With Endoscopic Type I Tympanoplasty Objective: The objective of this study is to describe what we consider to be the state-of-the-art procedure for the treatment of tympanic membrane perforations, and to present the results attained in our institution. Study Design: A retrospective cohort study, using data of Verona University Hospital, Italy. This medical record includes the data of 98 patients who underwent 100 transcanal endoscopic type I tympanoplasties from November 2014 to October 2017. Setting: Tertiary referral center University Hospital of Verona, Italy. Patients: Were enrolled 109 patients, that underwent endoscopic type I tympanoplasty in the period considered. Out of the selected patients, 11 (10.1%) were lost to long-term follow-up, and were therefore excluded from our study. Other exclusion criteria were surgical approaches that included other procedures. Patients whose follow-up was shorter than 6 months were excluded from this study. Intervention: The technique is based on an endoscopic placement of underlay graft of temporal fascia or tragal cartilage. We consider the data of four surgeons from Verona University ENT department. Main Outcome Measure: In the study we considered the reduction of the Air Bone Gap as functional outcome and the integrity of the reconstruction as anatomical outcome of success. Results: No major intraoperative complications were observed. The closure rate was 86%. The mean surgery time was 48.6 minutes. The air bone gap was improved within 20 DB HL in 89% of patient. Only 8% of patients needed revision surgery, and none needed a third surgical evaluation. Conclusion: Endoscopic ear surgery is by now a reality that has replaced in many cases exclusive microscopic ear surgery. Transcanal endoscopic type I tympanoplasty can be considered nowadays as an alternative technique for tympanic membrane perforations. Address correspondence and reprint requests to Dr Flavia Di Maro, M.D., Otolaryngology—Head and Neck Surgery Department, University Hospital of Verona, Piazzale Aristide Stefani, 1 37126 Verona, Italy; E-mail: fldm22@gmail.com All of the authors have participated in the planning writing or revising the manuscript. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

A Simple, Objective, and Mathematical Grading Scale for the Assessment of Facial Nerve Palsy Objectives: It is imperative to acquire a simple, objective, and mathematical method for the assessment of facial nerve palsy which can be universally accepted and implemented. A grading scale which is convenient, continuous and economical was attempted for the first time for global and region-specific assessment of facial nerve palsy. Study Design: Hospital-based observational study. Setting: Medical college hospital. Patients: Ten normal subjects and 51 patients with facial paralysis. Interventions: Patients with facial nerve palsy were graded according to the revised version of House–Brackmann grading system (HBGS-2) and a newly proposed grading system. Main Outcome Measures: The results of the present study were compared with the HBGS-2. Data were analyzed using SPSS-17 (IBM Corporation, New York) for descriptive statistics, normality test, Wilcoxon signed-rank test, and Mann–Whitney U test. Results: The mean time spent on recording measurements was 288 seconds. For the new method and HBGS-2, the modes were graded 3 and 4, corresponding to incomplete facial paralysis. The Kolmogorov–Smirnov normality and Wilcoxon signed rank tests were found significant. In Mann–Whitney U test, probability value indicated that grades of new scale were similar to grades of HBGS-2. Conclusion: The proposed simple, objective and mathematical (SOM) method of grading facial nerve palsy is convenient and provides global and regional continuous percentage that can monitor the progress and classify the patients with facial paralysis into six-point grades based on severity. This system was having substantial compatibility with HBGS-2 grading. For further validity, multi-center study with a larger sample of patients would be required. Address correspondence and reprint requests to Mohan Bansal, M.S., Ph.D., F.I.C.S., F.A.C.S., GPO Road, Near Old ST Stand, Anand, Gujarat, 388001, India; E-mail: mohanbansal@yahoo.com There are no financial interests, relationship, and affiliations relevant to the subject of the manuscript including employment, consultancies, honoraria, stock ownership, etc. No financial or personal relationships with other people or organizations that could inappropriately influence (bias) the authors’ actions. 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 © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Communication Mode and Speech and Language Outcomes of Young Cochlear Implant Recipients: A Comparison of Auditory-Verbal, Oral Communication, and Total Communication Objective: To evaluate the effect of communication mode on the spoken language outcomes of children who received a cochlear implant. Study Design: Retrospective analysis of postoperative speech and language and reading scores for children who received a cochlear implant and used three different modes of communication: auditory-verbal (AV) (n = 39), oral communication (OC) (n = 107), and total communication (TC) (n = 57). Setting: A single tertiary cochlear implant clinic. Patients: All children received their cochlear implant before the age of 5 years, had no known cochlear anomaly or cognitive delay that would affect their outcome with the CI, and had established consistent use of their respective communication methodology. Intervention: Rehabilitation varied depending on the selected communication methodology. Data were collected during routine postoperative speech and language evaluations. Main Outcome Measures: Receptive and expressive language, reading comprehension, and speech intelligibility scores obtained up to 7 years post-activation of a cochlear implant. Results: All groups showed improvements over time. Linear mixed model analyses indicated scores obtained by children in the AV group were significantly higher than mean scores obtained by children in the other groups on most test measures at most post-implant intervals. Significantly greater numbers of children in the AV group obtained standard scores within normal limits than children in the OC and TC groups. Conclusions: These findings support the use of the auditory-verbal communication approach to facilitate development of age-appropriate speech and language and literacy skills in profoundly deaf children. Address correspondence and reprint requests to Ellen S. Thomas, M.A., University of Michigan Cochlear Implant Program, 475 Market Place, Building 1 Suite A, Ann Arbor, MI 48108; E-mail: Ellent@med.umich.edu Source of Funding: No source of funding was received for this project. Ellen Thomas: None. Teresa A. Zwolan has received honoraria and grant funding from Cochlear Americas. However, no monies were received related to this project. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Temporomandibular Joint Herniation: Review of the Literature Objective: To define clear clinical characteristics and management strategies of herniation of temporomandibular joint (TMJ) into the external auditory canal (EAC). Data Source: MEDLINE, PubMed, and EMBASE databases. Study Selection: A search was conducted using the keywords “temporomandibular joint” and “herniation” with all of their synonyms. Literature selection criteria included articles published in English, and articles dating back no further than 1970. Results: Forty articles regarding 51 cases were eligible for critical appraisal. According to the previously published papers, TMJ herniation has following characteristics; symptoms are nonspecific, but a distinguishable feature is a protruding mass into the EAC that can be seen to appear and disappear as the mouth opens and closes. High-resolution computed tomography scans are sensitive to the bony defect and are helpful in diagnosing TMJ herniation. In the surgical treatment of TMJ herniation, wall reconstruction rather than simple mass excision could be a safe and long-lasting strategy. Conclusions: Herniation of TMJ into the EAC is a rare condition, but can be encountered in the clinic at any time. This literature review could be helpful in the diagnosis and treatment of TMJ herniation into the EAC. Address correspondence and reprint requests to Jeon Mi Lee, M.D., Ph.D., Department of Otorhinolaryngology, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, South Korea; E-mail: entmeowmiya@gmail.com Funding: This work was supported by the National Research Foundation of Korea (NRF) grant funded by the Korea government (MSIT) (No. 2019R1C1C1006341) to J.M.L. The authors declare that there are no conflicts of interest in regard to this work. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Role of Autophagy in Acquired Cholesteatoma Hypothesis: Autophagy and its enhancement may have a role in the pathogenesis of acquired cholesteatoma. Background: The etiopathogenesis of acquired cholesteatoma remains unclear. Some clinical features of cholesteatoma are similar to those of cancer. The study of autophagy in cancer has indicated that enhanced autophagy enables tumor cell survival and growth. Methods: Cholesteatoma epithelium and normal external auditory canal (EAC) epithelium were obtained from patients with acquired cholesteatoma, and marginal epithelium of the tympanic membrane perforation was obtained from patients with chronic otitis media (COM). Immunohistochemistry (IHC) was performed to detect the expression of light chain 3 (LC3) in cholesteatoma and EAC epithelium. Western blotting (WB) was performed to detect the expression of LC3, Beclin-1, or the PI3K/AKT pathway in cholesteatoma, EAC, and COM epithelium. Results: LC3 staining of IHC was stronger in cholesteatoma epithelium compared with normal EAC epithelium. The ratios of LC3-II/I and Beclin-1 expression on WB were significantly higher in cholesteatoma epithelium compared with EAC epithelium or COM epithelium, and there was a significantly higher ratio of p-PI3K/PI3K and p-AKT/AKT in cholesteatoma epithelium compared with EAC epithelium. Conclusions: Enhanced autophagy might play a role in the pathogenesis of acquired cholesteatoma. PI3Ks might have different regulatory functions on autophagy in the cholesteatoma epithelium. Address correspondence and reprint requests to Shuihong Zhou, M.D., Department of Otolaryngology–Head and Neck Surgery, First Affiliated Hospital, College of Medicine, Zhejiang University, 79 Qingchun Road, Hangzhou City 310003, Zhejiang Province, China; E-mail: 1190051@zju.edu.cn Funding: This research was supported by Science and Technology Department of Zhejiang Province, China (No. 2018KY373). The authors declare no conflicts of interest in this research. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Bilateral Persistent Stapedial Arteries Associated With Abnormal Lower Extremity Bone Growth No abstract available

The Role of Sex on Early Cochlear Implant Outcomes Objective: To determine the presence of sex differences in cochlear implant outcomes. Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: Adult patients having undergone cochlear implantation from 2009 to 2017. Intervention(s): Standard electrode length cochlear implantation. Main Outcome Measure(s): AzBio scores in quiet of the implanted ear at the 1 to 3 months and 6 to 9 months postoperative time points. Results: Of 55 patients with complete demographic and speech recognition testing, 36.4% (n = 20) were men. The mean age at time of surgery was 59.81 ± 16.54 years and the mean duration of hearing loss was 26.33 ± 18.54 years; there was no significant difference between men and women. The mean preoperative AzBio score was 11 ± 15.86% and there was no difference between men and women. Through 2 (sex) × 3 (time point) analysis of covariance (ANCOVA), there was no main effect of sex (F[1, 48] = 0.74, p = 0.39, η2 = 0.02) on postoperative AzBio scores, but there was a significant sex by time point interaction, (F[1.77, 85.03] = 4.23, p = 0.02, η2 = 0.08). At the 1 to 3 months postoperative time point, women exhibited higher relative improvement in AzBio scores than men (67 ± 27% versus 55 ± 31%). Further, this relative improvement increased and remained significant at the 6 to 9 months postoperative time point (women: 71 ± 22% versus 58 ± 30%). Conclusions: Sex may play a role in early speech recognition outcomes after adult cochlear implantation. Address correspondence and reprint requests to Esther X. Vivas, M.D., Department of Otolaryngology, Emory University Hospital Midtown, Medical Office Tower, 11th Floor, Suite 1135, 550 Peachtree St NE, Atlanta, GA 30308; E-mail: evivas@emory.edu The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Cochlear Enhancement May Precede Cochlear Obliteration After Vestibular Schwannoma Excision Objective: Cochlear obliteration after vestibular schwannoma excision has been noted, with implications on cochlear implantation. Early postoperative cochlear enhancement with gadolinium on magnetic resonance imaging (MRI) has also been observed. Timing of enhancement and association with obliteration is described here. Study Design: Retrospective case review. Setting: Tertiary referral center, ambulatory. Patients: Patients receiving vestibular schwannoma excision surgery by the senior author performed at one institution between January 2015 and July 2017 with postoperative MRIs Intervention: Diagnostic. Main Outcome Measure(s): The imaging characteristics on postoperative MRIs examined were loss of fluid signal on postoperative T2 images and cochlear enhancement on gadolinium enhanced T1 images. In the patients receiving labyrinthine sparing procedures, presence of postoperative hearing was evaluated. Results: Of the 42 patients evaluated, 24 received the translabyrinthine approach and 18 received a labyrinth sparing surgery. Twenty-nine had evidence of cochlear enhancement on T1 with gadolinium contrast, and 27 had evidence of cochlear obliteration on T2 images. The odds ratio of patients with cochlear enhancement having obliteration was 30.0:1 (p < 0.0001). Intense cochlear enhancement (n = 21) appeared a median of 163 days after surgery, and complete or near complete obliteration (n = 18) appeared a median of 480 days after surgery, a statistically significant difference (p < 0.001). Within the labyrinth sparing group, there was no statistically significant association between hearing loss and cochlear obliteration or enhancement. Conclusions: Cochlear enhancement is correlated with cochlear obliteration and may precede it. Address correspondence and reprint requests to Moises A. Arriaga, M.D., Hennessy Blvd., Ste 709 Baton Rouge, LA 70808; E-mail: Maa@neurotologic.com There are no conflicts of interest to disclose Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Intraoperative Recording of Auditory Brainstem Responses for Monitoring of Floating Mass Transducer Coupling Efficacy During Revision Surgery—Proof of Concept Objective: The objective of the study was to measure auditory brainstem responses elicited by stimulation via a semi-implantable active middle ear implant with an electromagnetically driven floating mass transducer to quantify the coupling efficacy (=vibroplasty in situ thresholds – bone conduction thresholds) in a patient during a revision surgery. Patients: One patient, reimplanted with an active middle ear implant in a revision surgery. Intervention(s): Diagnostic. Main Outcome Measure(s): Intraoperative auditory brainstem responses evoked by stimulation via an active middle ear implant in a calibrated set-up directly indicating the coupling efficacy magnitude (auditory brainstem response threshold = coupling efficacy), as well as pre- and postoperative bone conduction and vibroplasty in situ thresholds. Results: The intraoperative auditory brainstem response threshold was detected at 0 dB nHL, i.e., the magnitude of coupling efficacy was determined intraoperatively to be 0 dB. The actual postoperative coupling efficacy (=postoperative vibroplasty in situ – postoperative bone conduction thresholds) was –2.5 dB. Conclusions: The coupling efficacy determined intraoperatively was consistent with the postoperative coupling efficacy. The described method seems to be a promising tool to objectively quantify the magnitude of coupling efficacy in active middle ear implant surgeries. Address correspondence and reprint requests to Laura Fröhlich, M.Sc., Department of Otorhinolaryngology, Head & Neck Surgery, Martin Luther University Halle-Wittenberg, University Medicine Halle (Saale), Ernst-Grube-Str. 40, 06120 Halle (Saale), Germany; E-mail: laura.froehlich@uk-halle.dewww.medizin.uni-halle.de/hno This work was performed by intramural funding. Material support was provided by MED-EL in the form of the audio processor. The authors have no conflict of interest related to this work. Some of the devices discussed in this study may not report and may not be approved in all countries. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company