Electrode Array Type and Its Impact on Impedance Fluctuations and Loss of Residual Hearing in Cochlear Implantation Hypothesis/Objective: Determine variables associated with electrode impedance fluctuations and loss of residual hearing in cochlear implant (CI) recipients. Background: CI recipients with postoperative hearing preservation demonstrate superior speech perception with an electric-acoustic stimulation (EAS) device as compared with a CI-alone device. Maintaining superior speech perception over time relies on long-term hearing preservation; therefore, understanding variables that may contribute to loss of residual hearing is needed. Recent reports suggest a relationship between changes in electrode impedance and loss of residual hearing. The variables influencing this relationship have yet to be determined. Methods: Review of pediatric and adult CI cases from 2013 to 2016 who presented with preoperative residual hearing. Regression analysis was performed to evaluate effects of array type (lateral wall vs. perimodiolar), manufacturer, age at implantation, and preoperative hearing on impedance. The correlation between peak impedance change and change in low-frequency hearing was determined. Results: One hundred forty-six CI recipients presented with preoperative residual hearing. A multivariate regression analysis demonstrated a statistically significant association between preoperative hearing thresholds (p = 0.017), device manufacturer (p = 0.011), and array type (p = 0.038) on postoperative impedance changes. Hearing preservation rates and change in impedance differed by electrode array type. The association between peak impedance changes and loss of residual hearing differed between manufacturers (R2 = 0.208, p = 0.029 vs. R2 = 0.016, p = 0.609). Conclusion: Impedance fluctuation appears to be a marker for loss of residual hearing for specific electrode array types and manufacturers. Specific arrays may affect the cochlear microenvironment differently, with different effects on postoperative hearing preservation. Address correspondence and reprint requests to Kevin D. Brown, M.D., Ph.D., Associate Professor, Vice Chair of Outpatient Services, Chief of Division of Otology/Neurotology, Skull Base Surgery, Medical Director of Children's Cochlear Implant Center at UNC, 170 Manning Drive, CB#7070, Physicians Office Building, Rm G190A, University of North Carolina at Chapel Hill, Chapel Hill, NC 27599-7070; E-mail: kevin_d_brown@med.unc.edu; Nicholas J. Thompson, M.D., University of North Carolina, Chapel Hill, NC; E-mail: nicholas.thompson@unchealth.unc.edu M.T.D. and L.R.P. are supported by a research grant from MED-EL; H.C.P., B.O.C., and K.D.B. serve on the Surgical Advisory Board for MED-EL. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

The Importance of the Temporal Bone 3T MR Imaging in the Diagnosis of Menière's Disease Background: The aim of this study was to evaluate endolymphatic hydrops using the 3T temporal bone magnetic resonance imaging (MRI), performed according to the chosen protocol, and determine whether it could be applied as an objective diagnostic tool for Menière's disease. Methods: 105 participants diagnosed with probable (n = 50) and definite (n = 55) Menière's disease were included in this prospective study at Vilnius University Hospital, Santaros Clinics. Audiometry, vestibular function tests, videonystagmography, and computer posturography were performed before MRI. The 3T MRI with gadolinium contrast was performed to evaluate the endolymphatic hydrops. Imaging protocol consisted of 3D-FLAIR and 3D T2DRIVE sequences. Vestibular endolymphatic sac was interpreted as enlarged if occupied more than 50% of the vestibular area. Results: 78.1% of subjects had abnormal MRI findings other than hydrops, and it was more than 90% (50/55) of patients in the definite MD group (p < 0.001). Changes in caloric test were observed in 63.8% of subjects in general, and in 76.4% of patients with a definite Menière's disease. The side of the endolymphatic hydrops observed on MR imaging corresponded to the clinical diagnosis of the Menière's disease based on the results of audiometry (p < 0.001) and unilateral weakness (p < 0.001). Endolymphatic hydrops on MRI and directional preponderance in caloric test were two independent predictors of the definite Menière's disease. Conclusions: Temporal bone 3T MRI with gadolinium contrast is clinically superior to confirm the diagnosis of Menière's disease. Grade II endolymphatic hydrops on MRI, directional preponderance, and unilateral weakness on caloric test were independent predictors for the definite Menière's disease. Address correspondence and reprint requests to Aistė Paškonienė, Centre of Ear, Nose and Throat Diseases, Vilnius University Hospital Santaros Clinics, Santariskiu str. 2, LT08661, Vilnius, Lithuania; E-mail: aiste.paskoniene@santa.lt The authors received no specific funding for this work. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Comparison of Spontaneous Temporal Bone Cerebrospinal Fluid Leaks From the Middle and Posterior Fossa Objectives: To compare patients surgically managed for spontaneous cerebrospinal fluid (CSF) leaks of the temporal bone arising from the middle cranial fossa (MCF) and posterior cranial fossa (PCF) and to describe the surgical management of posterior fossa CSF leaks. Study Design: Retrospective case review. Setting: Academic tertiary center. Patients: Adult patients presenting with spontaneous temporal bone CSF leaks undergoing operative repair between January 2010 and August 2018. Patients with a history of trauma, previous mastoid surgery, and iatrogenic CSF leaks were excluded. Intervention: Transmastoid or MCF CSF leak repair. Main Outcome Measures: Patient demographics, body mass index (BMI), comorbidities, presenting features, and lumbar puncture opening pressures were compared between groups and the management of the PCF CSF leaks described. Results: Forty-six patients (26 women, 20 men) were included. The mean age at the time of repair was 58.0 ± 12.9 years (±SD). The origin of the CSF leak was from the PCF in three patients and MCF in 43 patients. All three patients with PCF leaks presented with an acute history of meningitis compared with only seven (16%) in the MCF group. This difference was statistically significant (p = 0.01, Fisher's exact test). There were no statistically significant differences in age, sex, BMI, or lumbar puncture opening pressures. The PCF leaks were repaired using a transmastoid approach with multilayer closure of the bony defect and fat graft obliteration of the mastoid. Conclusions: Spontaneous CSF leaks arising from the PCF are rare and may present more commonly with meningitis. Identification requires careful review of imaging. Address correspondence and reprint requests to Andrew A. McCall, M.D., Eye and Ear Institute, Suite 500, 203 Lothrop Street, Pittsburgh, PA 15213; E-mail: mccallaa@upmc.edu Accepted for poster presentation at the American Neurotology Society Meeting at the Combined Otolaryngology Spring Meeting in Austin, TX on May 3–4, 2019. This material has never been published and is not currently under evaluation in any other peer-reviewed publication. Source of funding: None. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Factors Associated With Facial Nerve Paresis Following Gamma Knife for Vestibular Schwannoma Objective: Evaluate the incidence of and potential contributory factors to facial nerve paresis and other cranial neuropathies (CN) following stereotactic radiosurgery with Gamma Knife (GK) for primary treatment of vestibular schwannoma (VS). Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: Charts were reviewed for all adult patients receiving primary GK treatment for unilateral VS between 2005 and 2013. Patients with NF2 or previous surgery were excluded from analysis. Intervention: GK radiosurgery. Main Outcome Measures: The incidence of new-onset facial nerve paresis after primary GK treatment of VS was evaluated. Secondary endpoints included other cranial neuropathies. Results: One hundred thirty-three patients with VS received primary GK therapy. Posttreatment CN developed in 33 patients (24.8%). Twelve patients (9.0%) experienced trigeminal paresthesia, 11 (8.3%) developed sudden sensorineural hearing loss (SSNHL) requiring steroids, and seven (5.3%) demonstrated facial paresis. The mean maximum cochlear dose was 15.49 Gy in patients with facial paresis compared with 12.42 Gy in subjects without facial paresis (p = 0.032). Subjects with facial paresis were more likely to have a lateral tumor without fundal fluid on magnetic resonance imaging (MRI) (71%) compared with subjects without facial paresis (43%). Conclusions: In the treatment of VS with primary GK, maximum cochlear dose was significantly associated with facial paresis. Laterally extending tumors without fundal fluid on MRI experienced higher rates of facial paresis. These factors should be considered during GK treatment planning for VS. Address correspondence and reprint requests to Michael J. Ruckenstein, M.D., Department of Otolaryngology–Head and Neck Surgery, University of Pennsylvania, 3400 Spruce Street, 5 Silverstein, Philadelphia, PA 19104; E-mail: Michael.ruckenstein@uphs.upenn.edu There are no financial disclosures to report. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Systematic Review and Network Meta-analysis of Cognitive and/or Behavioral Therapies (CBT) for Tinnitus Objective: To evaluate the efficacy of cognitive and/or behavioral therapies in improving health-related quality of life (HRQOL), depression, and anxiety associated with tinnitus. Data Sources: EMBASE, MEDLINE, PubMed, PsycINFO, and the Cochrane Registry were used to identify English studies from database inception until February 2018. Study Selection: Randomized controlled trials (RCTs) comparing cognitive and/or behavioral therapies to one another or to waitlist controls for the treatment of tinnitus were included. Data Extraction: Quality and risk were assessed using GRADE and Cochrane's Risk of Bias tool respectively. Data Synthesis: Pairwise meta-analysis (12 RCTs: 1,144 patients) compared psychological interventions to waitlist controls. Outcomes were measured using standardized mean differences (SMDs) and 95% confidence intervals (CI). I2 and subgroup analyses were used to assess heterogeneity. Network meta-analysis (NMA) (19 RCTS: 1,543 patients) compared psychological therapies head-to-head. Treatment effects were presented by network diagrams, interval plots, and ranking diagrams indicating SMDs with 95% CI. Direct and indirect results were further assessed by inconsistency plots. Conclusions: Results are consistent with previously published guidelines indicating that CBT is an effective therapy for tinnitus. While guided self-administered forms of CBT had larger effect sizes (SMD: 3.44; 95% CI: −0.022, 7.09; I2: 99%) on tinnitus HRQOL, only face-to-face CBT was shown to make statistically significant improvements (SMD: 0.75; 95% CI: 0.53, 0.97; I2: 0%). Guided self-administered CBT had the highest likelihood of being ranked first in improving tinnitus HRQOL (75%), depression (83%), and anxiety (87%), though statistically insignificant. This NMA is the first of its kind in this therapeutic area and provides new insights on the effects of different forms of cognitive and/or behavioral therapies for tinnitus. Address correspondence and reprint requests to Brian D. Westerberg, M.D., F.R.C.S.C., M.H.S.c., Department of Otolaryngology-Head and Neck Surgery, St. Paul's Hospital, BC Rotary Hearing & Balance Clinic, 1081 Burrard Street, Vancouver, BC, Canada V6Z 1Y6; E-mail: BWesterberg@providencehealth.bc.ca BDW and JL have paid travel expenses to attend cochlear implant conferences for educational and CME purposes from Med El, Cochlear, and Oticon. No financial support was received for the completion of this study. 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 © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Postoperative Healthcare Utilization of Elderly Adults After Cochlear Implantation Objective: To determine the association between geriatric age and postoperative healthcare utilization after cochlear implantation. Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: : Older adults (>59 yr) who underwent unilateral cochlear implantation from 2009 until 2016. Intervention(s): : Standard electrode length cochlear implantation. Main Outcome Measure(s): : Postoperative surgical and audiological visit rate after cochlear implantation for those aged 60 to 69, 70 to 79, and 80+ years. Results: : Fifty-nine older adult patients were included in the study with a mean age of 71.5 ± 6.9 years (range, 60–88 yr), mean duration of hearing loss of 25.4 ± 19.6 years (range, 0.25–67 yr), and mean length of follow up of 37 ± 24.6 months (range, 6–107 mo). There was no significant difference in the mean number of surgical and audiological visits over both the first and second postoperative years between those aged 60 to 69, 70 to 79, and 80+ years. Additionally, on one-way multivariate analysis of covariance (MANCOVA), there was no significant difference in cumulative postoperative healthcare utilization measures between each age group, when controlling for postoperative AzBio scores, estimated household income, and driving distance to the hospital. Conclusions: Older geriatric adults do not have higher rates of postoperative healthcare utilization after cochlear implantation than their younger, geriatric hearing impaired counterparts, despite presumed higher rates of frailty and comorbidity. Address correspondence and reprint requests to Esther X. Vivas, 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 Disclosures and Support: none. The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Risks of Intracochlear Pressures From Laser Stapedotomy Hypothesis: Surgical manipulations during laser stapedotomy can produce intracochlear pressure changes comparable to pressures created by high-intensity acoustic stimuli. Background: New-onset sensorineural hearing loss is a known risk of stapes surgery and may result from pressure changes from laser use or other surgical manipulations. Here, we test the hypothesis that high sound pressure levels are generated in the cochlea during laser stapedotomy. Methods: Human cadaveric heads underwent mastoidectomy. Fiber-optic sensors were placed in scala tympani and vestibuli to measure intracochlear pressures during key steps in stapedotomy surgery, including cutting stapedius tendon, lasering of stapedial crurae, crural downfracture, and lasering of the footplate. Results: Key steps in laser stapedotomy produced high-intensity pressures in the cochlea. Pressure transients were comparable to intracochlear pressures measured in response to high intensity impulsive acoustic stimuli. Conclusion: Our results demonstrate that surgical manipulations during laser stapedotomy can create significant pressure changes within the cochlea, suggesting laser application should be minimized and alternatives to mechanical downfracture should be investigated. Results from this investigation suggest that intracochlear pressure transients from stapedotomy may be of sufficient magnitude to cause damage to the sensory epithelium and affirm the importance of limiting surgical traumatic exposures. Address correspondence and reprint requests to Nathaniel T. Greene, Ph.D., Department of Otolaryngology, University of Colorado School of Medicine, 12631 E. 17th Ave., Mail Stop B205, Aurora, CO 80045; E-mail: Nathaniel.Greene@CUAnschutz.edu Author contribution statement: E.M., R.M.B.H., S.P.G., and N.T.G. designed and performed the experiments; E.M., R.M.B.H., S.P.G., and N.T.G. reviewed data and provided interpretive analysis; E.M., R.M.B.H., and N.T.G. analyzed data and wrote the paper. All authors discussed the results and implications and commented on the manuscript at all stages. S.G. receives grant support from the NIH/NIDCD for work unrelated to this project and is on the scientific advisory boards for Applied Genetic Technologies Corporation and Roche. He is also a consultant for Cochlear Corporation and Sirocco Therapeutics. In addition, he is on the advisory board for the Cystic Fibrosis Foundation and receives research support without personal financial remuneration from Med-El Corporation. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

On the Relationship Between Menière's Disease and Endolymphatic Hydrops 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. Address correspondence and reprint requests to Michael B. Gluth, M.D., Section of Otolaryngology–Head & Neck Surgery, The University of Chicago Medicine & Biological Sciences, 5841 S. Maryland Ave., Rm. E-103, MC 1035, Chicago, IL 60637; E-mail: mgluth1@surgery.bsd.uchicago.edu The authors disclose no conflicts of interest. Copyright © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

Long-Term Stability and Functional Outcome of an Active Middle Ear Implant Regarding Different Coupling Sites Objectives: Indication and implantation of active middle ear implants (AMEI) are well established. Choice of the coupling site depends from the individual anatomical situation. Long-term stability of different coupling sites in terms of functional outcome and complications are rare and were investigated in this study. Design: Retrospective analysis of 41 consecutive patients (45 ears) with coupling of the AMEI at the incus, stapes, and round window. Analysis of preoperative, postoperative, and long-term results of pure-tone average, speech discrimination in quiet at 65 dB (German language Freiburg Monosyllabic Test) and noise (German language Oldenburger Sentence Test), rate of revision surgeries as well as explantations and the novel parameter patient years (py). Results: Mean of follow-up was 3.0 ± 1.7 years resulting in a total of 135.6 py. Bone conduction was stable in all patients pre- to postoperatively as well as preoperatively to the long-term. Round window patients had the broadest air-bone gap (31.4 ± 19.4 dB HL) benefitting the most from the AMEI (functional gain = 39.0 ± 12.8 dB HL). Regarding speech discrimination, incus patients performed the best both in quiet (77.7 ± 22.8%) and noise (3.4 ± 2.9 dB SNR). In terms of revision surgery and explantations, round window patients exhibited the highest rates (20%). Conclusions: Regarding all coupling sites, satisfying long-term stability results and comparable complication rates were reported with best performance of coupling to the incus. Implementation of patient years might be a novel parameter for the comparison of revisions and explantations. Address correspondence and reprint requests to Jennifer L. Spiegel, M.D., Marchioninistr. 15, 81377 Munich, Germany; E-mail: jennifer.spiegel@med.uni-muenchen.de Author contributions: J.L.S. analyzed data, and wrote the paper; L.K. collected and analyzed data; M.J., B.G.W., and M.C. conceptualized the study and provided critical revision; F.I. designed the experiments, collected and analyzed data, and wrote the paper. All authors discussed the results and implications and commented on the manuscript at all stages. This work was supported by the German Federal Ministry of Education and Health (BMBF) in the context of the foundation of the German Center for Vertigo and Balance Disorders (DSGZ) (grant number 01 EO 0901). The authors did not receive payment or support in kind for any aspect of the submitted work. 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 © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company

3D-Printed Microneedles Create Precise Perforations in Human Round Window Membrane in Situ Hypothesis: Three-dimensional (3D)-printed microneedles can create precise holes on the scale of micrometers in the human round window membrane (HRWM). Background: An intact round window membrane is a barrier to delivery of therapeutic and diagnostic agents into the inner ear. Microperforation of the guinea pig round window membrane has been shown to overcome this barrier by enhancing diffusion 35-fold. In humans, the challenge is to design a microneedle that can precisely perforate the thicker HRWM without damage. Methods: Based on the thickness and mechanical properties of the HRWM, two microneedle designs were 3D-printed to perforate the HRWM from fresh frozen temporal bones in situ (n = 18 total perforations), simultaneously measuring force and displacement. Perforations were analyzed using confocal microscopy; microneedles were examined for deformity using scanning electron microscopy. Results: HRWM thickness was determined to be 60.1 ± 14.6 (SD) μm. Microneedles separated the collagen fibers and created slit-shaped perforations with the major axis equal to the microneedle shaft diameter. Microneedles needed to be displaced only minimally after making initial contact with the RWM to create a complete perforation, thus avoiding damage to intracochlear structures. The microneedles were durable and intact after use. Conclusion: 3D-printed microneedles can create precise perforations in the HRWM without damaging intracochlear structures. As such, they have many potential applications ranging from aspiration of cochlear fluids using a lumenized needle for diagnosis and creating portals for therapeutic delivery into the inner ear. Address correspondence and reprint requests to Anil K. Lalwani, M.D., Division of Otology, Neurotology, and Skull Base Surgery, Department of Otolaryngology—Head and Neck Surgery, Columbia University College of Physicians and Surgeons, 180 Fort Washington Avenue, Harkness Pavilion, 8th Floor, New York, NY 10032; E-mail: anil.lalwani@columbia.edu J.W.K. and A.K.L. are co-senior authors. Research was funded by the National Institutes of Health National Institute on Deafness and Other Communication Disorders with award number R01DC014547. Dr. A.K.L. is on the Medical Advisory Board of Advanced Bionics. 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 © 2019 by Otology & Neurotology, Inc. Image copyright © 2010 Wolters Kluwer Health/Anatomical Chart Company