Current Opinion in Otolaryngology & Head and Neck Surgery

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Editorial introductions

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Current imaging tools for vestibular schwannoma

imagePurpose of review
Of the tumors found in the cerebellopontine angle (CPA), vestibular schwannomas are by far the most common. Modern diagnostic imaging enables excellent visualization of the CPA and detection of very small tumors while optimizing patient comfort and time. This review addresses the current imaging tools available for diagnosis of vestibular schwannomas.
Recent findings
The current gold-standard imaging study for vestibular schwannomas is a gadolinium-enhanced T1-weighted MRI. The yield of this expensive study is only about 3–4% given the low incidence of vestibular schwannomas, thus there is utility in screening with noncontrast T2-weighted MRI, which is a quicker and more economical study.
Summary
Vestibular schwannomas are best evaluated with gadolinium-enhanced T1-weighted MRI, which can detect tumors as small as 2–3 mm. Recent studies have found that the reported sensitivity and specificity of noncontrast MRI is almost equivalent to that of gadolinium-enhanced T1-weighted MRI. As such, this modality is increasingly being adopted by institutions for both diagnosis and surveillance of vestibular schwannomas and shows promise for broader implementation. Newer protocols, such as FLAIR and DTI may provide additional information and further aid preoperative counseling and surgical planning in the future.

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Microtechnologies for inner ear drug delivery

imagePurpose of review
Treatment of auditory dysfunction is dependent on inner ear drug delivery, with microtechnologies playing an increasingly important role in cochlear access and pharmacokinetic profile control. This review examines recent developments in the field for clinical and animal research environments.
Recent findings
Micropump technologies are being developed for dynamic control of flow rates with refillable reservoirs enabling timed delivery of multiple agents for protection or regeneration therapies. These micropumps can be combined with cochlear implants with integral catheters or used independently with cochleostomy or round window membrane (RWM) delivery modalities for therapy development in animal models. Sustained release of steroids with coated cochlear implants remains an active research area with first-time-in-human demonstration of reduced electrode impedances. Advanced coatings containing neurotrophin producing cells have enhanced spiral ganglion neuron survival in animal models, and have proven safe in a human study. Microneedles have emerged for controlled microperforation of the RWM for significant enhancement in permeability, combinable with emerging matrix formulations that optimize biological interaction and drug release kinetics.
Summary
Microsystem technologies are providing enhanced and more controlled access to the inner ear for advanced drug delivery approaches, alone and in conjunction with cochlear implants.

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State of the art regeneration of the tympanic membrane

imagePurpose of review
One of the most common diseases of the tympanic membrane is a perforation, and tympanoplasty is one of the more common procedures in otolaryngology. Tympanic membrane regeneration and bioengineering aim to improve the success rate of the procedure, increase the availability of different scaffolds and provide innovative tools that will simplify the surgical technique and make it accessible for surgeons with varying expertise level. This review aims to raise awareness of current tissue engineering developments in tympanic membrane regeneration and how they may augment current clinical practices. We focus here on achievements in tympanic membrane cell cultures and on innovations in development of new scaffolds and growth factors that enhance regeneration of patient's native tympanic membranes.
Recent findings
In recent years, great achievements were reached in the field of tympanic membrane regeneration in the three hallmarks of bioengineering: cells, scaffolds and bioactive molecules. New techniques for modeling normal tympanic membrane proliferation were developed, as well as for isolation and expansion of normal tympanic membrane keratinocytes from miniature samples of scarred tissue. Ongoing clinical trials aim to seal the perforation by applying different scaffolds infiltrated by growth factors on the tympanic membrane.
Summary
Research efforts in tympanic membrane regeneration continue to seek the ideal single tissue-engineered substitute. Recent advances in tympanic membrane bioengineering include new types of scaffolds that may augment and provide a safe and effective alternative to the current gold-standard autograft. New bioactive molecules may simplify the surgical procedure and reduce surgical time by augmenting the native tympanic membrane regeneration. Several groups of bioengineering scientists and neurotologists are continuing to move forward and develop new strategies, seeking to create a fully functional tissue-engineered tympanic membrane.

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Current management of superior semicircular canal dehiscence syndrome

imagePurpose of review
The current article reviews literature on the contemporary management of superior semicircular canal dehiscence syndrome (SSCDS). Approaches to management and surgical techniques are compared along with a discussion of the use of more standardized, objective outcome measures.
Recent findings
Considerable debate still exists as to what approach and technique is most appropriate for patients with SSCDS and how to best measure postoperative outcomes. However, it is increasingly accepted that multiple factors account for outcomes in SSCDS, including presenting symptoms and presence of vestibular comorbidities. Therefore, surgical intervention is best tailored to each individual patient. Data on SSCDS outcomes is heterogenous, and increased emphasis is being placed on validated measures of outcome. Round window approaches remain controversial and their role is still undefined.
Summary
The treatment strategies for SSCDS continue to diversify. A patient-specific approach with systematic documentation of outcomes will continue to inform how these patients are best managed.

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Current opinions in otolaryngology and head and neck surgery: functional considerations in reconstruction after laryngectomy

imagePurpose of review
To review reconstruction techniques following total laryngectomy, partial laryngopharyngectomy, and total laryngopharyngectomy with an emphasis on long-term swallow and speech outcomes.
Recent findings
Recent literature has shown that the use of fasciocutaneous free flaps in the reconstruction of laryngectomy defects may lead to improved speech and swallow outcomes as compared with regional or free musculocutaneous flaps. Radial forearm and anterolateral thigh are the most often used fasciocutaneous free flaps, with similar speech and swallow outcomes. Primary closure with myofascial flap onlay yields similar speech and swallow results to fasciocutaneous flaps following laryngectomy that spares sufficient pharyngeal mucosa.
Summary
Whenever reconstructing a salvage laryngectomy defect or a primary laryngectomy defect with mucosal deficiency, current evidence suggests that a fasciocutaneous free flap used to augment pharyngeal volume both improves fistula rates as well as long-term speech and swallow outcomes. When sufficient pharyngeal mucosa is present, myofascial onlay can be considered as well.

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Optical coherence tomography: current and future clinical applications in otology

imagePurpose of review
This article reviews literature on the use of optical coherence tomography (OCT) in otology and provides the reader with a timely update on its current clinical and research applications. The discussion focuses on the principles of OCT, the use of the technology for the diagnosis of middle ear disease and for the delineation of in-vivo cochlear microarchitecture and function.
Recent findings
Recent advances in OCT include the measurement of structural and vibratory properties of the tympanic membrane, ossicles and inner ear in healthy and diseased states. Accurate, noninvasive diagnosis of middle ear disease, such as otosclerosis and acute otitis media using OCT, has been validated in clinical studies, whereas inner ear OCT imaging remains at the preclinical stage. The development of recent microscopic, otoscopic and endoscopic systems to address clinical and research problems is reviewed.
Summary
OCT is a real-time, noninvasive, nonionizing, point-of-care imaging modality capable of imaging ear structures in vivo. Although current clinical systems are mainly focused on middle ear imaging, OCT has also been shown to have the ability to identify inner ear disease, an exciting possibility that will become increasingly relevant with the advent of targeted inner ear therapies.

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