Introduction:Stereotactic radiosurgery (SRS) provides excellent tumor control in small and medium vestibular schwannomas (VS), but its impact on the vestibular system remains uncertain. This study examines the effects of SRS on subjective vestibular symptoms, vestibular function, and potential predictors of symptom worsening. Materials and methods:A retrospective analysis was conducted on adult VS patients treated with SRS over eight years. Vestibular symptoms were graded at baseline and six months post-SRS. The vestibular sensory organs (VSO) were defined as the combined volume of the saccule, utricle, and ampullae. Vestibular function was assessed with bithermal, bilateral caloric testing, video head impulse testing, and vestibular evoked myogenic potentials. Two illustrative treatment plans were generated to assess feasibility of vestibular dose reduction without compromising planning target volume (PTV) or cochlear constraints. Results:Among 45 VS patients (median age 61.4 years), 14 (31 %) reported worsened vestibular symptoms at six months. These patients had higher Dosemean to VSO (6.45 Gy vs 2.92 Gy, p < 0.0001). A Dosemean > 4 Gy was strongly associated with symptom worsening (OR = 27.3, 95 % CI [3.4-301.8], p = 0.0002). Similar associations were observed for Dosemax, with an 8 Gy threshold. Higher Dosemean to the lateral ampulla was correlated with a greater percentage change in caloric weakness (slope = 7.77, R2 = 0.38, p = 0.04). In two illustrative plans, VSO optimisation lowered vestibular dose without compromising PTV coverage or cochlear dose. Conclusion:Higher vestibular radiation dose is strongly associated with worsened vestibular symptoms and possibly with functional decline. Dose reduction to vestibular subunits is feasible without compromising the tumor dose, helping mitigate these effects.

Chronic subjective tinnitus is the most common form of tinnitus and refers to an internal persistent phantom auditory perception. Evidence from neuroimaging studies has established tinnitus and its associated distress as a brain network disorder, with multiple brain regions displaying dysregulated activity or connectivity extending way beyond the auditory pathway. Hyperactivity in the auditory cortex has been associated with perceived tinnitus loudness, and somatosensory-auditory interactions have recently been involved in promising treatment avenues through their disruption using non-invasive or bimodal neuromodulation techniques, albeit with low mechanistic evidence. In this study, we evaluated the neural effects of prolonged downregulation of bilateral auditory cortex activity mediated by real-time fMRI neurofeedback in individuals with moderate to severe (Tinnitus Handicap Inventory [THI] scores ≥ 48) chronic tinnitus. Twenty-one participants (aged 49 ± 11.4 years old, 16 males, 5 females) completed 15 fMRI neurofeedback sessions over 3-4 months each, as part of a randomized clinical trial (ClinicalTrials.gov: NCT05737888) comparing neurofeedback interventions over the current standard of care, cognitive behavioral therapy (CBT). We performed whole-brain general linear modeling analyses to delineate regulated brain areas, accounting for age, gender, and THI scores at baseline. Task-modulated functional connectivity analyses were carried out using psychophysiological interactions to unveil associated connectivity patterns emerging during cognitively demanding tinnitus defocalization. Most participants succeeded at reducing the average activity of their auditory cortex throughout the training. Whole brain analyses additionally revealed a strong downregulation of parietal operculum 3 (OP3), a region previously reported to be activated in the right hemisphere during experimentally induced transient phantom percepts. In accordance with the hypothesis that OP3 may mediate the integration of multisensory inputs in tinnitus, we have shown that both left and right auditory cortices decrease their connectivity with OP3 during closed-loop auditory downregulation. Moreover, we observed a reduced connectivity of bilateral OP3 with a functional multisensory integration network that was previously found to be engaged by the primary and secondary auditory cortices during audio-tactile integration. These findings support the hypothesis of OP3 having a key role in multisensory integration stemming from altered somatosensory-auditory crosstalk in chronic tinnitus. Targeted neuromodulation to desynchronize the connectivity between OP3 and the auditory cortex could further inform our understanding of the mechanisms behind recent successful bimodal interventions for reducing tinnitus.

Stereotactic radiosurgery is now a reference treatment for small-to-medium-sized vestibular schwannomas. It provides excellent tumor control with low associated morbidity. The preservation of auditory and vestibular function remains a major concern and largely depends on dosimetric optimization, particularly the reduction of the dose delivered to the cochlea and vestibular system. Recent advances in understanding the radiobiological tolerance of these structures, coupled with technological innovations (high-resolution imaging, modern radiosurgery platforms, and artificial intelligence tools), allow for more precise and personalized treatment planning. Together, these innovations enhance therapeutic efficacy while minimizing toxicity.

Stereotactic radiosurgery (SRS) is a standard treatment for vestibular schwannoma but is associated with a substantial risk of progressive and irreversible hearing loss. NADPH oxidase 3 (NOX3), an enzyme predominantly expressed in the inner ear, has been identified as a key source of oxidative stress underlying cochlear injury. Using a mouse model of SRS-induced hearing loss, we found that genetic deletion of Nox3 preserved auditory function and protected cochlear structures, including hair cells, synaptic ribbons, and spiral ganglion neurons. Complementary experiments using local delivery of a small interfering RNA directed against Nox3 confirmed that transient inhibition markedly reduced hearing loss and tissue damage compared with scrambled controls. In addition, Nox3 inhibition attenuated radiation-induced lipid peroxidation and macrophage infiltration within the cochlea. These findings identify NOX3-derived oxidative stress as an important upstream mediator of SRS-induced ototoxicity and demonstrate that its inhibition confers significant functional and structural protection. Given the predictable timing of SRS in clinical settings, a NOX3-targeted intervention may offer a feasible and selective strategy to prevent hearing loss as an adjunct to tumor-directed treatment.

BackgroundStereotactic radiosurgery (SRS) is widely used to treat vestibular schwannomas but may cause irreversible hearing loss due to cochlear toxicity. The underlying mechanisms are not fully understood, and no effective otoprotective therapies exist. We aimed to establish a mouse model that replicates the clinical pattern of radiation-induced hearing loss.MethodsC57BL/6J mice (n = 31) received 8 Gy (n = 3), 16 Gy (n = 5), 24 Gy (n = 8), or 32 Gy (n = 15) using the Leksell Gamma Knife ICON system. Targeting was based on the built-in cone-beam CT, co-registered with MRI and CT-based mouse atlases, to guide unilateral cochlea targeting. A single isocenter was placed lateral to the right cochlea, with the 80% isodose line traversing its medial edge. Auditory brainstem response (ABR) was measured at baseline and at 1 and 4 weeks post-SRS. A 32 Gy subgroup (n = 7) was evaluated at 16 weeks. Histological analysis of cochleae was performed at 4 weeks in all groups and at 16 weeks in the long-term 32 Gy group.ResultsSRS was well tolerated, and the contralateral cochlea received a very low radiation dose. No ABR shifts were observed at 8 or 16 Gy, with only minimal histological changes. At 32 Gy, ABR threshold shifts at 22.6 and 32 kHz were evident by week 1 and worsened by week 4. Similar but milder effects occurred at 24 Gy. In the 32 Gy long-term subgroup, hearing loss progressed across all frequencies, most severely at high frequencies, alongside a sustained wave I amplitude decline. At 32 Gy, outer hair cells were reduced by 14 and 44% at 32 and 45.2 kHz, respectively, at 4 weeks, and by 38 and 80% at 16 weeks. Ribbon synapses were mildly reduced at 4 weeks and more markedly at 16 weeks in corresponding high-frequency regions. Spiral ganglion neuron density was mildly reduced at the basal and middle turns. All reported changes were statistically significant when compared to the contralateral ear.ConclusionThis new model reproduces key features of SRS-induced cochlear toxicity, including unilateral, dose-dependent, and progressive hearing loss. It thus provides a valuable platform for investigating mechanisms and testing otoprotective strategies.

Lightning strikes can cause diverse neuro-otologic injuries. Tympanic membrane rupture is common, whereas bilateral profound sensorineural hearing loss with vestibular dysfunction and perilymphatic fistula is rare. Cochlear implantation for lightning-induced deafness has been reported only once. A farm worker struck by lightning sustained second-degree burns and intracranial hemorrhages requiring emergency neurosurgical management and cervical wound closure. During intensive care, clear left-sided otorrhea prompted ENT evaluation, revealing bilateral tympanic membrane perforations. Beta-trace testing confirmed cerebrospinal fluid leakage. Temporal bone CT demonstrated left ossicular chain dislocation and stapes footplate fracture with perilymphatic fistula, managed by exploratory tympanotomy with fistula closure and tympanic reconstruction. The patient remained with bilateral profound sensorineural hearing loss and left vestibular hypofunction. Six months after injury, right-sided cochlear implantation with a MED-EL Synchrony Flex 28 electrode array was performed. Four months post-implantation, aided thresholds averaged 30 dB HL with 30

PURPOSE:To assess the efficacy, safety, and tolerance of drainage under local anesthesia compared to immediate tonsillectomy to treat uncomplicated unilateral peritonsillar abscess (PTA) in adults. METHODS:A randomized clinical trial was conducted in a tertiary care university hospital. Adults with PTA radiologically confirmed as ≥1 cm and uncomplicated were randomly assigned to two groups using block randomization. They immediately underwent either tonsillectomy under general anesthesia or drainage under local anesthesia. The primary outcome was treatment success at 48 h, defined as a reduction in swelling and restoration of swallowing function, allowing hospital discharge. Secondary outcomes included pain and anxiety levels, along with postoperative bleeding. RESULTS:A total of 41 patients were included (66 % male; age range 18-77 years). Twenty-one patients underwent tonsillectomy, while 20 underwent drainage. The success rate was higher in the tonsillectomy group (100 %) than in the drainage group (75 %, p = 0.02). Pain and anxiety levels were significantly higher in the drainage group (p < 0.01). Postoperative bleeding occurred in 33 % of the tonsillectomy group, while no bleeding was reported in the drainage group (p < 0.01). CONCLUSION:Immediate tonsillectomy for treating PTA offers definitive management with high efficacy, albeit with an increased risk of postoperative bleeding. Drainage under local anesthesia is associated with a higher failure rate and increased patient discomfort but demonstrates a better safety profile. Treatment decisions should be tailored based on patient preferences, clinical presentation, and available resources. TRIAL REGISTRATION:ClinicalTrial.gov protocol record NCT04543708.

The clinical need for minimally invasive inner ear diagnostics and therapeutics has grown rapidly in recent years, particularly with the development of gene therapies for treating hearing and balance disorders. These therapies often require delivery of large injectate volumes that can cause hearing damage. In response to this challenge, dual-lumen microneedles, with two separate fluidic pathways controlled independently by micropumps, were designed for simultaneous aspiration and delivery to the inner ear across the round window membrane (RWM) and were fabricated using 2-photon polymerization (2PP). To assess the proof of concept of the dual-lumen microneedle device, simultaneous injection of 5 µL of adeno-associated virus (AAV) expressing green fluorescent protein (GFP) and aspiration of 5 µL of perilymph was performed in guinea pigs in vivo. Hearing thresholds were measured using auditory brainstem response (ABR) at time points before and 1 week after the procedure. Confocal imaging of the cochlea, the utricle, and the contralateral inner ear was employed to quantify and characterize the spatial distribution of hair cells with AAV transduction. Dual-lumen microneedle devices were found to be functional in the surgical setting. There was hearing loss limited to higher frequencies of 24 kHz and 28 kHz with ABR mean threshold shifts of 13 dB sound pressure level (SPL) (p = 0.03) and 23 dB SPL (p < 0.01), respectively. Furthermore, cochlear AAV transduction with a stereotypical basoapical gradient was observed in all animals (n = 5). Thus, dual-lumen microneedles can facilitate delivery of large volumes of therapeutic material into the inner ear, overcoming the limitations of single-lumen microneedles.

Chronic otitis media (COM) significantly impacts the quality of life of patients, yet existing assessment tools may not fully capture its multidimensional effects. The Zurich Chronic Middle Ear Inventory (ZCMEI-21) has emerged as a comprehensive and internationally recognized measure for evaluating health-related quality of life (HRQoL) in COM patients. However, a validated French version of the ZCMEI-21 is lacking, necessitating translation and validation to facilitate its use in French-speaking populations. A prospective multicentre study was conducted to translate and validate the ZCMEI-21 into French (ZCMEI-21-Fr). The translation process followed established guidelines, including professional translation, cognitive debriefing, and back-translation. The validation process involved administering the ZCMEI-21-Fr together with the generic EQ-5D questionnaire to French-speaking COM patients across multiple centers. Internal consistency, reliability, and validity were assessed using psychometric statistical methods. A total of 102 French-speaking COM patients were included in the study. The ZCMEI-21-Fr demonstrated excellent internal consistency (Cronbach’s α = 0.89) and reliability across all subscales. Total ZCMEI-21-Fr scores correlated strongly with a question directly assessing HRQoL (r = 0.59, p < 0.0001). Moderate correlations were observed with the EQ-5D (r = 0.41, p < 0.0001). The ZCMEI-21-Fr offers a valuable tool for assessing the psychosocial impact of COM in French-speaking patients. Its comprehensive coverage of HRQoL dimensions, including psychological effects, distinguishes it from existing instruments. The availability of a validated French version enhances the standardization of HRQoL assessment in COM patients on an international scale.

Otosclerosis is characterized by pathological remodeling of the bone of the otic capsule. Classically, foci of pathological bone leads to progressive fixation of the stapes, resulting in conductive hearing loss. Involvement can be uni- or bilateral. Otoscopy is normal. -Hypoacusis generally appears between the age of 30 to 50, regularly with tinnitus. Sometimes, the inner ear is also affected, with sensori-neural hearing loss or vestibular impairment (vertigo). Successful hearing rehabilitation can be achieved with hearing aids or stapes surgery (stapedotomy). Cochlear implantation is considered in cases of severe or profound sensorineural hearing loss. High resolution CT-scan or Cone Beam CT confirm the diagnosis and optimal planning of surgical treatment.

Objective To investigate the impact of cerebellopontine angle (CPA) masses on subjective and measured taste function. Study Design Retrospective cross-sectional study. Setting Tertiary referral center. Patients Consecutive adult patients with untreated CPA masses. Interventions Gustatory function was psychophysically measured with Taste Strips (range, 0–16) on both sides of the tongue. Subjective taste complaints were assessed using a questionnaire. Main Outcome Measures Half-sided taste impairment (hemi-ageusia) was defined as side-to-side asymmetry ≥4 points with <9 points on the side of the CPA mass. We used the Koos classification for vestibular schwannomas (VS) and, in the case of facial nerve palsy, the House–Brackmann grading system. Results We included 135 patients (mean [standard deviation (SD)] age, 55.3 ± 14.1 yr; 62 males). The most common CPA mass was VS (77%). Overall, the measured taste function was lower on the affected compared with the healthy side of the tongue (mean score, 9.8 ± 3.3 versus 11 ± 2.9; p < 0.0001). Looking for clinically relevant one-sided taste impairment revealed 18 (13.3%) patients with hemi-ageusia, but only 4 (30.8%) of those subjectively complained of taste dysfunction. Regarding VS, Koos IV masses presented the lowest score on the affected side (mean score, 7.5 ± 3.7). Six patients presented with facial palsy. Having facial palsy did not result in a lower Taste Strips score (p = 0.23). Conclusion Before any CPA mass treatment, a measurable ipsilateral decrease in gustatory function is present in many patients. Most patients do not notice this preexisting taste impairment. From a medicolegal standpoint, this warrants consideration. To avoid postoperative claims regarding taste function, a preoperative assessment may be considered.

Purpose: To investigate the impact of 3D-printed temporal bone models with two different material transparencies on trainees' mastoidectomy performance. Methods: Eleven ORL residents performed two anatomical mastoidectomies with posterior tympanotomy on two 3D-printed models with different transparency and VR simulation training. Participants where divided into two groups based on their experience. Within each group participants were randomized to start with the model printed in a completely opaque material or in a material featuring some degree of transparency. After drilling on 3D-printed models, the participants performed two similar mastoidectomies on human cadavers: one on the left side of one cadaver and one on the right side of another cadaver. After drilling 3D-printed models and cadavers, the final-product performances were evaluated by two experienced raters using the 26-item modified Welling Scale. Participants also evaluated the models using a questionnaire. Results: Overall, the participants performed 25 % better on the 3D-printed models featuring transparency compared to the opaque models (18.6 points vs 14.9 points, mean difference = 3.7, 95 % CI 2.0-5.3, P < 0.001)). This difference in performance was independent of which material the participants had drilled first. In addition, the residents also subjectively rated the transparent model to be closer to cadaver dissection. The experienced group starting with the 3D-printed models scored 21.5 points (95 % CI 20.0-23.1), while the group starting with VR simulation training score 18.4 points (95 % CI 16.6-20.3). Conclusion: We propose that material used for 3D-printing temporal bone models should feature some degree of transparency, like natural bone, for trainees to learn and exploit key visual cues during drilling.

Objective Assessment is key in modern surgical education to monitor progress and document sufficient skills. Virtual reality (VR) temporal bone simulators allow automated tracking of basic metrics such as time, volume removed, and collisions. However, adequate performance assessment further includes compound rating of the stepwise bony excavation, and exposure and preservation of soft tissue structures. Such complex assessment requires further development of automated assessment routines in the VR simulation environment. In this study, we present the integration of automated mastoidectomy final-product assessment with validation against manual rating. Methods At two international temporal bone courses, 33 ORL trainees performed anatomical mastoidectomies in the Visible Ear (VR) Simulator with automatic performance assessment using a newly implemented rating routine based on the modified Welling Scale. Automated assessment was compared with manual ratings by experts using absolute agreement, intraclass correlation, and generalizability analysis to establish validity and reliability. Results The overall average agreement between manual and automatic assessment was 83.9% compared with the inter-rater agreement of 88.9%. A majority of items (15 out of 26) showed high agreement between automated and manual rating (>85%). Intraclass correlation coefficients were found to be high. Generalizability analysis with D-studies found that five repetitions per participant are needed for a G coefficient >0.8, which is considered necessary for high-stakes assessments. Conclusion We have demonstrated the feasibility, validity, and reliability of an automatic assessment system integrated into a VR temporal bone simulator. This can prove to be an important tool for future self-directed training with skills certification.

BACKGROUND:Although most patients with post-traumatic olfactory dysfunction (PTOD) undergo MRI, there is no consensus about its diagnostic or prognostic value. The aims were: 1) to classify the extent of post-traumatic neurodegeneration; 2) to determine its relationship with chemosensory dysfunction (smell, taste, trigeminal); and 3) to establish whether MRI can predict olfactory improvement.METHODOLOGY:We conducted a retrospective cohort study based on a series of 56 patients with PTOD. All patients underwent validated psychophysical tests of their smell, taste, and trigeminal functions, otorhinolaryngologic evaluation, and MRI. An experienced radiologist blinded to patient data evaluated 40 chemosensory-relevant brain regions according to a four-point scale (0=no lesion to 3=large lesion). Follow up data after 4 years (on average) were available in 46 patients.RESULTS:The cluster analysis showed 4 brain lesion patterns that differed in lesion localization and severity. They are associated with diagnostic categories: anosmia, hyposmia and normosmia. Two clusters were highly specific for anosmia (100% specificity)and could accurately predict this condition (100% positive predictive value). No clusters were associated with trigeminal or taste dysfunction. Regarding improvement, 72.7% of patients in the cluster with mild lesions experienced subjective and measurable olfactory improvement whereas this was only the case in 21.7-37.5% of patients with larger lesions. The odds of subjective smell improvement were 5.9 times higher in patients within the milder cluster compared to larger ones.CONCLUSIONS:The analysis of brain lesions in PTOD allows corroboration of smell test results and prediction of subjective and measurable improvement.

Purpose: The purpose of this study was to analyze the prevalence of and complications resulting from temporal bone fractures in adult and pediatric patients evaluated for cranio-facial trauma in an emergency setting. Methods: A retrospective blinded analysis of CT scans of a series of 294 consecutive adult and pediatric patients with cranio-facial trauma investigated in the emergency setting was conducted. Findings were compared between the two populations. Preliminary reports made by on-call residents were compared with the retrospective analysis, which was performed in consensus by two experienced readers and served as reference standard. Results: CT revealed 126 fractures in 116/294 (39.5%) patients, although fractures were clinically suspected only in 70/294 (23.8%); p < 0.05. Fractures were longitudinal, transverse and mixed in 69.5%, 10.3% and 19.8% of cases, respectively. Most fractures were otic-sparing fractures (95.2%). Involvement of the external auditory canal, ossicular chain and the osseous structures surrounding the facial nerve was present in 72.2%, 8.7% and 6.3% of cases, respectively. Temporal bone fractures extended into the venous sinuses/jugular foramen and carotid canal in 18.3% and 17.5% of cases, respectively. Vascular injuries (carotid dissection and venous thrombosis) were more common in children than in adults (13.6% versus 5.3%); however, the observed difference did not reach statistical significance. 79.5% of patients with temporal bone fractures had both brain injuries and fractures of the facial bones and cranial vault. Brain injuries were more common in adults (90.4%) than in children (63.6%), p = 0.001. Although on-call residents reliably detected temporal bone fractures (sensitivity = 92.8%), they often missed trauma-associated ossicular dislocation (sensitivity = 27.3%). Conclusions: Temporal bone fractures and related complications are common in patients with cranio-facial trauma and need to be thoroughly looked for; the pattern of associated injuries is slightly different in children and in adults.

Background: Cognitive behavioral therapy (CBT) is the current standard treatment for chronic severe tinnitus; however, preliminary evidence suggests that real-time functional MRI (fMRI) neurofeedback therapy may be more effective. Purpose: To compare the efficacy of real-time fMRI neurofeedback against CBT for reducing chronic tinnitus distress. Materials and Methods: In this prospective controlled trial, participants with chronic severe tinnitus were randomized from December 2017 to December 2021 to receive either CBT (CBT group) for 10 weekly group sessions or real-time fMRI neurofeedback (fMRI group) individually during 15 weekly sessions. Change in the Tinnitus Handicap Inventory (THI) score (range, 0-100) from baseline to 6 or 12 months was assessed. Secondary outcomes included four quality -of -life questionnaires (Beck Depression Inventory, Pittsburgh Sleep Quality Index, State -Trait Anxiety Inventory, and World Health Organization Disability Assessment Schedule). Questionnaire scores between treatment groups and between time points were assessed using repeated measures analysis of variance and the nonparametric Wilcoxon signed rank test. Results: The fMRI group included 21 participants (mean age, 49 years +/- 11.4 [SD]; 16 male participants) and the CBT group included 22 participants (mean age, 53.6 years +/- 8.8; 16 male participants). The fMRI group showed a greater reduction in THI scores compared with the CBT group at both 6 months (mean score change, -28.21 points +/- 18.66 vs -12.09 points +/- 18.86; P = .005) and 12 months (mean score change, -30 points +/- 25.44 vs -4 points +/- 17.2; P = .01). Compared with baseline, the fMRI group showed improved sleep (mean score, 8.62 points +/- 4.59 vs 7.25 points +/- 3.61; P = .006) and trait anxiety (mean score, 44 points +/- 11.5 vs 39.84 points +/- 10.5; P = .02) at 1 month and improved depression (mean score, 13.71 points +/- 9.27 vs 6.53 points +/- 5.17; P = .01) and general functioning (mean score, 24.91 points +/- 17.05 vs 13.06 points +/- 10.1; P = .01) at 6 months. No difference in these metrics over time was observed for the CBT group ( P value range, .14 to >.99). Conclusion: Real-time fMRI neurofeedback therapy led to a greater reduction in tinnitus distress than the current standard treatment of CBT.