JOINT MEETING - IV CONSENSUS IN AUDITORY IMPLANTS & V EAONO INSTRUCTIONAL WORKSHOP

INSTRUCTIONAL COURSES ABSTRACTS

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WEDNESDAY, JUNE 16

9.30-10.30 Conference Room

MANAGEMENT OF GIANT CHOLESTEATOMAS
Armagan Incelesu (Ankara, Turkey)

11:00-13:00 (Conference Room)

ADVANCED INDICATIONS IN COCHLEAR IMPLANTS
Roland Laszig (Freiburg, Germany)

MASTOIDECTOMY IN MIDDLE EAR DISEASES
Giuseppe De Donato, Giuseppe Di Trapani (Piacenza and Rome, Italy)

17:30-18:30 (Rooms 1-8)

PEDIATRIC BILATERAL COCHLEAR IMPLANTATION. STATE OF THE ARTProf Angel Ramos-Macias, Prof. Manuel Manrique (Spain)

A NEW ANATOMO/FUNCTIONAL EVALUATION OF COCHLEAR IMPLANTS
SURGICAL OUTCOME
E. Cristofari, S. Burdo, A. Meli (varese, Italy)

TEMPORAL BONE DRILLING TECHNIQUES: HOW TO DRILL ANS HOW NOT TO!
Thomas Linder (Luzern, Switzerland)

THE MINOR’S DISEASE: HOW TO DIAGNOSE AND TREAT THE DEHISCENCE OF THE
ANTERIOR SEMICIRCULAR CANAL
Vincent Darrouzet (Bordeaux, France)

ACOUSTIC NEURINOMA
Gerald O’Donogue (Nottingham, United Kingdom)

The Obliterated Cochlea –Treatment Strategies
Benno Weber (Rosenheim, Germany)
Cochlear obliteration is mostly a result of infection ( meningitis, labyrinthitis etc.), trauma (fractures) osteo-fibrous lesion (like otosclerosis) or rare conditions like for example autoimmune disease. It can cause considerable problems during cochlear implantation preventing classical electrode insertion and resulting in significantly reduced clinical results. Numerous techniques for modified electrode insertion have been suggested by experienced implant surgeons in the last twenty five years (for example Cohen, Gantz., Balkany, Bredberg,
Lenarz et al.) Partial obliterations up to 10-12 mm in the basal turn can usually be overcome by clsiiical basal drill out procedures. In cases of more advanced obliteration second turn and retrograde insertions and modified drill out procedures have been suggested and performed. Modified electrode arrays like compressed arrays and double arrays are in use to address specific intraoperative situations. The instructional course will focus on the following issues: Radiological evaluation of obliteration Clinical conditions like meningitis and the general impact they have in various settings Surgical procedures and their advantages and disadvantages based on more than 60 personal cases The clinical challenges of unilateral obliteration Obliteration and reimplantation Specific implants and their clinical application (double array and compressed array) Borderline cases Clinical cases will be presented to illustrate the treatment strategies and the changes in approach since the early 90 ties.

MANAGEMENT OF PERIPHERAL FACIAL PARALYSIS
Prof. Dr. Yildirim A. Bayazit and Prof. Dr. Nebil Goksu (Ankara, Turkey)

DIFFICOULT STAPEDECTOMIES
Nuri Ozgirgin (Ankara, Turkey)

18:30-19:30 (Rooms 1-8)

BILATERAL COCHLEAR IMPLANTATION WITH SINGLE DEVICE - CONCEPT AND OUTCOMES
Luminita Radulescu, Sebastian Cozma, Oana Manolache, Cristian Martu, Dan Martu
University of Medicine and Pharmacy “Gr.T. Popa” Iasi, Romania
Bilateral cochlear implants have the potential to improve speech understanding and sound localization. Due to the limitation of the number of implants provided by our clinic, we decided to use bilateral implantation with a single device (single receptor-stimulator and single processor). The main aim of this study is to asses the bilateral vs unilateral benefit in postlingual deaf adults implanted with such devices. The second objective is to present briefly the device and to describe the surgical technique. We implanted three adults with bilateral severe to profound sensorineural hearing loss using a research developed cochlear implant with two electrodes array and a single receptor-stimulator.
There were no postoperative complications after binaural surgery. The outcomes were evaluated at three and six months after the first fitting. Sound direction identification is better with bilateral vs unilateral implant. Bilateral stimulation is significantly better than unilateral stimulation when noise is presented ipsilaterally. Overall the cochlear implant users perceive their own performance to be better with bilateral implant vs unilateral. Although results are
very promising and costs are lower than those for two cochlear implants, the validation of the bilateral cochlear implantation with single device will be available at the end of a multicentic study.

INDIVIDUALIZED TECHNIQUES IN CHOLESTEATOMA SURGERY
Fernando Mancini , Manuela Sacchi (Piacenza and Turin, Italy)

For many years at the Gruppo Otologico we have performed almost exclusively surgery on the middle ear, otoneurosurgery and skull-base surgery. We want to share our experience of several thousands cases operated on using various surgical techniques and various grafting materials either for reconstruction of the tympanic membrane or for ossiculoplasty. The skilled surgeon should be able to reduce the percentage of failures that, are mainly due to wrong selection of a surgical technique or to improper developement of the procedure selected. We emphasize that there is not a one uniquely perfect surgical technique. An attempt to better understand the causative pathology among various clinical pictures of chronic otitis media, with or without cholesteatoma, and to suggest a possible evolution of the disease as first seen in the clinic, will be helpful in adapting different techniques to the patient and to the pathologic conditions to be treated. We will present different pathological pictures shown as they have been recorded through endoscopic techniques. For each one we will explain the reason behind selection of a specific operation: an open- or closed-cavity tympanoplasty, a one- or two-staged procedure, performing or not performing a mastoidectomy. Sometimes we use old procedures, like the Bondy operation, modified to achieve better functional results. Helpful hints and pittfalls to avoid the most common failures will be demonstrated, with the help of intraoperative video-recordings.

SURGICAL ANATOMY OF THE MIDDLE EAR AND LATERAL SKULL BASE FOR BEGINNERS
Tarek Khrais (Irbid, Jordan)

PARTIAL OR TOTAL LABIRINTHECTOMY AND HEARING PRESERVATION IN OTOLOGY
AND NEUROTOLOGY
G. Magliulo (Rome, Italy)

MALIGNANT TUMORS OF THE TEMPORAL BONE
Roberto Pareschi (Legnano, Italy)
Malignancies of the temporal bone are rare and aggressive types of tumors. The squamous cell carcinoma (SCC) is the most frequent histologic type (80%), arising mainly in the auditory external canal. The incidence has been reported to be between one and six cases per million population years, which is less than 0.2% of all tumors of the head and neck. These tumors have been associated with chronic suppurative otitis media, exposure to chemicals or ultraviolet radiation, radiation-associated tumours. Most SCC of the temporal bone occur in the fifth and sixth decades of life. Otorrea is the primary symptom, otalgia, hearing loss and bleeding may be frequent as well. Diagnosis is usually delayed because symptoms are quite similar to other benign otologic conditions. Treatment is generally based on the combination of surgery and radio-therapy. Lateral temporal bone resection (LTBR) is, in many cases,
an adeguate surgical procedure for removal of most squamous cell cancers of the temporal bone. If the tumor does not involve the middle ear, the dura or cervical nodes, the cure rate is approximately 50%. If the tumor involve these structures the cure rate drops dramatically. Surgical cure for these tumors are difficult with any other kind of temporal bone resection (sub-total, total and enlarged LTBR.

COCHLEAR IMPLANTATION IN MEDICAL CHALLENGING CASES
John Xenelis (Athen, Greece)

MANAGEMENT OF THE PATULOUS EUSTACHIAN TUBE: A NEW APPROACH WITH THE SITTING CT AND THE PATULOUS EUSTACHIAN TUBE PLUG (PEP)
Toshimitsu Kobayashi, M.D.,
Department of Otolaryngology-Head and Neck Surgery, Tohoku University School of Medicine, Sendai, Japan
(Background) The diagnosis of the patulous Eustachian tube (PET) is not difficult in cases with typical symptoms. However, there are many cases in which symptoms are not so clear or the patient does not exhibit typical signs to confirm the diagnosis. In such cases a Eustachian tube (ET) function test apparatus, developed and being used in Japan for more than a decade, is very useful. However, its drawback is the inability of diagnosing the responsible
site for the abnormal ET function. In order to overcome this, the imaging of the ET has been attempted for many years and the recent advances in CT and MRI enabled us to visualize the ET and its surrounding structures. However, the fundamental drawback of the conventional imaging lies in that the examination is performed in the recumbent position where most patients lack their symptoms of PET. (Methods and Results) We have recently used a novel CT apparatus and developed a new imaging technique performed in the sitting position where the patients with PET exhibit the symptoms (Yoshida H, et al: Auris Nasus Larynx 30：135-140, 2003; Kikuchi T, et al: Otology&Neurotology 28:199-203, 2007) . Together with this imaging method (Sitting CT), we will show some simple but also novel methods
of diagnosing the PET using acoustical property of the ET (Hori Y, et al: Otology&Neurotology 27: 596-599, 2006). We will also introduce our original method of treating intractable PET in the outpatient basis by using a new silicone plug (Patulous Eustachian tube Plug: PEP) developed by us, being inserted transtympanically through the myringotomy under iontophoretic anesthesia of the tympanic membrane (Satou T, et al: Acta Otolaryngol 1158-
1163, 2005). This method is effective in more than 75% of the cases with PET refractory to the various conventional treatments. (Summary) 1. The authors developed new acoustical methods of diagnosing the PET. 2. Sitting CT is very useful in delineating the PET. 3. The silicone plug (PEP) developed by us is useful for more than 75% of the intractable PET cases in which other treatments had been ineffective. Publications related to PET from our group not cited in the text Kawase T, et al：Autophony in patients with patulous Eustachian tube: Experimental investigation using an artificial middle ear．Otology & Neurotology 27:600-603, 2006. Kawase T, et al：Patulous Eustachian tube associated with hemodialysis．Eur Arch Otorhinolaryngol 264：601-605, 2007)

ARGON LASER STAPEDECTOMY
Janez Rebol, PhD, MD (Maribor, Slovenia)
Abstract
Argon laser was first used for performing small fenestra stapedotomies 30 years ago. Studies performed at that time showed controversies over optimal type of laser that should be used in otosurgery. In comparison to CO2 laser the argon laser has an advantage to have a visible beam and smaller spot size. At that time some studies revealed a temperature increase resulting in thermal injury to the vestibule which suggested careful use of the argon laser. Its
beam passes through perilymph unimpeded. During time the fiberoptic argon laser system was developed which allowed the energy to be delivered more precisely to the exact location for intended use with less risk of thermal injury. Nowadays argon laser system is widely used and benefits of its use have been accepted. It is even possible to preserve portions of the stapes and stapes tendon during stapedotomy. The most important advantage of the
laser is the absence of mechanical trauma to the stapes. Fractured or a floating footplate and stapes luxation are highly unlikely. Reduced postoperative morbidity is also an advantage of the atraumatic technique which will be presented in the course.

THURSDAY, JUNE 17

8:00- 9:00 (Rooms 1-8)

TYMPANOPLASTY: SURGICAL TECHNIQUE STEP BY STEP
Onur Celik (Marisa, Turkey)

OTOLOGICS MIDDLE EAR TRANSDUCERS WITH CONTROLATERAL CONVENTIONAL
HEARING AID IN SEVERE SENSORINEURAL HEAR LOSS: EVOLUTION DURING THE
FIRST 24 MONTHS
Christian Dubreil (Lyon, France)

Tricks and Tips in Cochlear Implantations. The Different Devices
Paolo Solero
Audiology Institute, University of Turin, Turin, Italy
The four IC producers (Cochlear, Med-El, Advanced Bionics, Neurelec MXM) have modified their products in many ways due to the obvious technical evolution. The same happened to the surgical technique: the aim of the course is to give an idea of the different approaches related to the shape, material and details of the devices. From the electrodes bundle insertion to receiver fixation in various anatomical uncomfortable situations, relations between interior
antenna and processor , electrodes fixation in adults and children etc. are presented from the point of view of the healthcare practitioner, not as usual presented by “official” manuals and company’s brochures.

THE TRANSOTIC APPROACH: A REFERENCE APPROACH FOR PETROUS BONE CHOLESTEATOMA
Miguel Aristegui (Madrid, Spain)

MATERIAL AND TECHNIQUES IN MYRINGOPLASTY
M. Amadori (Padua, Italy)

Avoiding complications in Cochlear Implant Surgery
Pedro Clarós, MD PhD, Mª del Carmen Pujol Clínica Clarós.
C/ Los Vergós, 31. 08017 Barcelona (Spain) Tel. +34 932031212 Fax.+34 932803332 Email: clinica@clinicaclaros.com
Nowadays the Cochlear Implant is a usual technique in otology surgery. Currently is the treatment for the bilateral hearing loss. The age of implantation has been decreasing and more often implanted in younger ages. Given the growing popularity in the use of this device, there exists the risk of having complications due to a technique which does not fulfill all the security requirements. In our Cochlear Implant Centre, with an experience of 800 cochlear
implants intervened, we have a ratio of minimum complications. During the Instruction Course we will present the most frequent errors and the way to prevent them.

VBS SURGERY IN MIDDLE EAR AND MASTOID DISEASES
Millo Beltrame (Rovereto, Italy)

BIMODAL STIMULATION VS BILATERAL IMPLANTATION
Domenico Cuda (Piacenza, Italy)

9:00 - 10:00 (Rooms 1-8)

How to create a self-cleaning open mastoid cavity – Step by Step

Lehnerdt G & Jahnke K
As an introduction we will shortly discuss the indications for an open mastoid cavity in cholestoma surgery. Step by step we present the techniques how to achieve a small self-cleaning cavity. According to principles of the Tübingen middle ear school of Dietrich Plester, the crucial steps are to firstly drill down the posterior canal wall and the facial ridge. Secondly, we drill down the lateral bone to the level of the sigmoid sinus and in cases of a well pneumatized mastoid we can ground down the mastoid tip. Then we smoothen the bony rims with a diamond burr. Furthermore, the size of the cavity can be reduced by partial obliteration of the retrofacial space and the sinus-dura-angle using bone substitutes. In our hands cartilage chips have proven to be a good substitute, hydroxy apatite pellets or a musculoperiosteal flap according to Palva might be used alternatively. Our techniques to treat a labyrinthine fistula will be demonstrated. Measures to improve the epithelization of the cavity are discussed. Finally a wide auditory canal entrance has to be created by removal of cartilage and skin incisions and suturing the posterior part backwards. In a video some short examples will then elucidate the mentioned surgical steps, including some basic rules of ossicular chain reconstruction in open technique cases. After removal of the ear canal dressing an intensive aftercare including drying the cavity with a simple hair dryer will help to achieve the designated result of a fully epitheliazed cavity within weeks.

From the Middle and inner Ear biomechanic to the clinical application of a totally implantable hearing device
Jean-Marc Gerard*,** Koen Van den Heuvel** Marie-Paule Thill*** Michel Gersdorff**
*University Hospital Saint-Luc, Brussels, Belgium **Cochlear Technology Center, Mechelen, Belgium
***University Hospital Saint-Pierre, Brussels, Belgium
ABSTRACT 1.Middle ear and inner ear transfer function Introduction: Middle and inner ear transfer function can be measured using Laser Doppler Vibrometer (LDV) technology. Materials and methods: Fresh frozen heads are used.
A sine sweep is applied and velocity measurement is performed on the incus boby, stapes capitululm, posterior crus and round window. Results: Twelve sufficiently good ossicular chain and inner ear measurements were obtained. We extracted our normative velocity curve. Discussion and conclusion: Middle and inner ear transfer function variabilities are important. They have been described in temporal bones studies. We have decided to include ears that were marginally within the criterion range to be less restrictive. To improve measurement stability, dissection qualities need to be optimal (perfect exposure of anatomical structures and searching for best axis measurement). 2. Clinical application using Esteem middle ear hearing device Introduction: The Esteem middle ear implant is a totally implantable hearing system using the piezo-electric technology. The natural vibrations of the incus head are sensed by the Sensor. The Driver transfers the customized signal to the stapes head. Esteem requires no maintenance and restriction of activities and can be used 24/7 for a minimum of 4.5 years without recharging. Results: Between May 2008 and December 2009, Eleven patients were implanted for stable moderate sensori-neural hearing loss. The
best Pure Tone Average (PTA) gains were obtained at frequencies between 500 an 3000 Hz. The word recognition score gain at 50 dB HTL was 70±29%. The word recognition score in silence and with a signal-noise ration of +10, 0, -5 dB was 92.5, 84, 76 and 76.5% respectively. Discussion and conclusion: The esteem middle ear hearing device
is an excellent and promising exploitation of the middle ear biomechanic. It also opens doors to the development of future total middle ear implants.

COCHLEAR IMPLANTATION AND NEUROSTIMULATION FOR THE TREATMENT OF TTNNITUS: ON NEUROMODULATION, INDICATIONS AND OUTCOMES
By Paul Van de Heyning, Andrea Kleine Punte and Olivier Meeus (Antwerp, Belgium)

Petrous Apex Tumors. Differential Diagnosis and Surgical Approaches
Vittorio Achilli*, Alessandro De Stefano**, Vincenzo Pistorio* (*Lodi and **Chieti, Italy)
Deep to the middle and inner ear lies the Petrous Apex (PA) and it stretches further towards the central skull base. It has the shape of a three-sided pyramid with the apex pointing medially. It separates the clivus from the squama of the temporal bone and the greater wing of the sphenoid. Petrous apex is pneumatized in almost one third of the people and the air cell system is generally symmetric. In 4-7% of these cases only one petrous apex is aerated
(asymmetric pneumatization of the PA) and in the other side there is bone marrow, which has a bright signal on T1 weighted MR images and can mimic a pathologic condition. Lesions of the petrous apex are rare and often difficult to diagnose. These lesions represent a broad spectrum of abnormalities including congenital, inflammatory, neoplastic and infectious processes. Symptoms are often vague and non localizing in the early stages, but mayprogress to include hearing loss, headache, tinnitus, vestibular dynsfunction, facial nerve twitching or paralysis, multiple cranial neuropathies and sometimes otorrhea. Symptomatology varies depending on the type of pathology, its growth rate and involvement of adjacent structures like cranial nerves, eustachian tube, cochlea or dura. Successful tratment outcome depends on early and correct preoperative diagnosis. This warrants a high index of suspicion by the examining physician and the use of appropriate imaging modalities namely MR with Gadolinium contrast and thin section (1-1,5 mm) CT scan with bone details but without contrast enhancement. Both these studies are essential for adequate treatment as they both complement each other in providing a reliable differential diagnosis and in aiding
surgical planning. Occassionally, carotid arteriography is required in order to evaluate the vascular supply to the tumor, the relationship of the tumor with the internal carotid artery and the patency of this vessel. In hypervascularized tumors a preoperative embolization of the feeding vessels may be advised. The diagnosis is complete with routine auditory testing of patients. They often aids in assessing the degree to witch the inner ear and VIII cranial
nerve are affected by the lesion while ABR testing establish the potential for intra-operative hearing monitoring in selected cases. Petrous apex lesions pose several diagnostic and therapeutic dilemmas. The relative inaccessibility of this location associated with important surrounding neural and vascular structures poses a great surgical challenge. Surgical access to the petrous apex is decided based on several criteria such as : 1) preoperative ipsi and
controlateral hearing, 2) facial nerve function, 3) age of the patient, 4) suspected histology and 5) extent of the disease. Drainage procedures are indicated for some cystic lesions like cholesterol granulomas and arachnoid cysts. Congenital or acquired cholesteatomas require a more aggressive surgical approach in order o avoid recurrences. Asymptomatic PA effusion and asymmetric pneumatization of the PA are considered “leave me alone” conditions.
When preoperative diagnosis, based on well performed imaging studies is unclear, or a malignancy is suspected a
biopsy of the PA through an infralabyrithine, infracochlear or middle cranial fossa extradural approach, is needed. Solid tumors may require extensive exposure and a combined skull base approach for complete removal. Neurotologists and skull base surgeons must be aware of the multiple clinical and radiological features of PA lesions in order to avoid unnecessary surgery or to plan the most appropriate surgical approach. Over-Under Miringoplasty by Using

Perichondral-Cartilage Island Graft and Various Glass Ionomer Bone Cement applications in the Reconstruction of Ossicles
Prof.Dr.Burhan Dadas
Sisli Etfal Teaching Hospital İstanbul-Turkey
There have been many significant changes in the techniques used to repair the tympanic membrane. Of the two classical techniques of underlay and overlay, the former, in which the graft is placed completely medial to the remaining drum and the malleus, is used more commonly. The latter technique, on the other hand, is preferred in total perforations, anterior perforations or in failed underlay techniques. In this latter technique, the squamous layer on
the fibrous middle layer of the remaining membrane is entirely removed, and then the graft is placed lateral to the tympanic annulus.Each of these techniques has its advantages, yet neither is without pitfalls. The underlay technique has a high success rate in posterior perforations and is of considerable use in avoiding the risk of graft lateralization.
Overlay tympanoplasty provides better exposure in all perforations and is advantageous in that it minimizes the reduction of the middle ear space. This technique has a high success rate, particularly when employed in large, anterior perforations]. The main disadvantages of the underlay technique are as follows: there is inadequate exposure of the anterior middle ear, the middle ear space decreases and the success rate in large perforations is low.
On the other hand, a blunting anterior angle, graft lateralization, residual epithelium pearls and prolonged surgery in small perforations are some of the pitfalls of the overlay technique . A modified version of the two techniques mentioned above, over-under tympanoplasty is a recent method in which the graft is placed laterally to the malleus and under the remaining drum . This method is considered to minimize the disadvantages of both the classic
techniques of underlay and overlay. As the over-under technique is relatively new, it is not easy to find the results of large series in the literature ). The over-under tympanoplasty is a combination of the underlay and overlay techniques and has been developed with the aim of minimizing the disadvantages inherent in the other two techniques. This may explain why the over-under procedure is becoming widespread as a means of tympanic membrane repair
. There are a few studies on this relatively new technique in the literature. Stage and Bak-Pedersen , who supported the over-under procedure when used for perforations anterior to the handle of the malleus, reported a success rate of 91% in 39 ears. A similar success rate (90%) was attained by Kartush et al. in a series of 120 patients who underwent over-under tympanoplasty. The authors reported that the rate of late atelectasis in their series was 14%, and the lateralization of the grafted drum did not occur in any of the 120 patients. Kartush et al. Also reported that most of their patients had undergone mastoidectomy and ossiculoplasty. Cartilage is the grafting material of choice ,because of its rigidity and resistancy , in total perforations,tympanosclerosis, adhesive processes or recurrent perforations. However, there are controversies as to the audiologic aspect. the use of such a rigid material in tympanic membrane reconstruction .Cartilage has been proved to be well tolerated by the middle ear and to survive for long periods. Because increased mass and stiffness of the cartilage-reconstructed tympanic membrane might adversely affect its acoustic transfer characteristics, the acceptance of routine reconstruction of the tympanic membrane with cartilage has been hampered. On the other hand, hearing results after tympanic membrane reconstruction with cartilage have received less attention than its anatomic results. Adkins stated that cartilage-grafting the entire posterior portion of the tympanic membrane would cause a 5- to 10-dB conductive hearing loss. However, there exist reports, though not many, suggesting that hearing results of cartilage tympanoplasty are fairly good. Glasscock et
al reported that hearing did not appear to be adverselyaffected after cartilage tympanoplasty in cases with recurrent retraction pockets, although absolute hearing levels were lacking in their study. As for recurrent perforations and revision tympanoplasty, an air bone gap of less than 10 dB in 43.6% of cases and of less than 30 dB in 92.4% of cases was achieved in cartilage tympanoplasty by Milewski. Amadee et al reported complete closure of the perforation in 100% of cases, with a mean ABG of 4dB. Likewise, closure of ABG to within 10 dB in 65% of cases, and to within 20% in 86% of cases, was reported by Levinson.. In the retrospective study by Dornhoffer,the audiologic results of patients after cartilage-perichondrium grafting and after revision tympanoplasty with perichondrium were assessed. When the mean postoperative gain in ABG of 6.8 dB for the cartilage-perichondrium group was compared with that of 7.7 dB for the perichondrium group, no significant difference in hearing was shown. Gerber et al reported similar results in overall hearing improvement after cartilage tympanoplasty, which has been comparable to that after fascia grafting. Assuming that replacing a large portion of the tympanic membrane with cartilage would add stiffness or mass, which would affect individual frequencies rather than overall hearing level, the investigators also evaluated the frequency-specific data for the freq uencies 0.5, 1, 2, and 4 kHz. However, no sigificant difference at these frequencies was shown between the groups. Preoperative assessment of severity and prognosis of the middle ear disease by MERI and comparison of preoperative hearing levels showed that both groups of this study were statistically identical. It has been reported that cartilage island transplants are suitable for improving the sound transmission properties of the reconstructed tympanic membrane in comparison to 1-mm-thick cartilage plate in the study of Mürbe et al,. Those investigators have recommended creating a cartilage island reconstruction, when possible, because a suspension of the cartilage transplant in the osseous annular rim is likely to increase the
acoustic transfer loss of the reconstructed membrane. Perforations with adequate surrounding tympanic membrane remnants, as in subtotal perforations, are suitable for this technique. Kirazlı et al. reported an overall improvement in mean ABG of 11.9 dB after cartilage tympanoplasty was comparable to one of 11.5 dB after tympanoplasty with
temporalis muscle tympanoplasty. Glass ionomer bone cement (GIC) is an ionomer-based cement that forms a stable, waterproof junction with the adjacent bone during the setting and hardening process. After hardening, bone cement can be shaped by drilling. GIC is also used in reconstruction of the ear canal wall and obliteration of the mastoid cavity after canal wall down mastoidectomy. Successful repair of the ossicular chain with glass cement in cases of an inadequate incus after prior stapes surgery or incudostapedial joint discontinuity have been described (Bony defects of the mastoid or the ossicular chain can arise, especially after infections or middle ear surgery and can be repaired with ionomer bone cement . It was used for otological applications in Europe during the 1990s. Geyer and Helms and Babighian were the first otologists who reported on the use of glass ionomer cement in otological surgery. GIC material may unintentionally disperse through middle ear and contact with chorda tympani and facial nerve during middle ear surgeries. In order to prevent this condition, GIC material dispersing from surgical area should be removed by aspiration. There was not any neurotoxicity seen in our recent animal study .

SURGICAL APPROACHES TO THE SCALA TYMPANI IN COCHLEAR IMPLANT
SURGERY
Abdelkrim Lamrani (Annaba, Algerie)

LESSON LEARNED IN THE OPERATIVE TREATMENT OF CANCER INVOLVING THE
EXTERNAL EAR CANAL - THE OSLO EXPERIENCE
Ralph Doliner, Merie Bunne, Claude Laurent, Greg Eigner Jablonski (Oslo, Norway)

WORK-UP OF CONGENITAL HEARING LOSSES
Alessandro Martini (Ferrara, Italy)

16:00 - 17:00 (Rooms 1-8)

Fixation methods for Cochlear Implants
A. Aschendorff, S. Arndt, R. Beck, F. Hassepass, C. Schild, W. Maier, R. Laszig
Dept of Otorhinolaryngology and Implant Center Freiburg, University of Freiburg, Germany
Complications following Cochlear Implant surgery are rare. Most common complications include wound healing problems, flap necrosis, facial nerve damage and implant migration. A secured implant (receiver-stimulator) position is important to minimize later damage to electrode leads due to movement as well as to prevent anterior migration and problems in wearing the speech processor later. Nevertheless, the method of fixation or even no fixation is stilla point of discussion. Numerous different techniques are available for fixation of the reveiver-stimulator which will be discussed in detail.

CHOLESTEATOMA SURGERY: THE CWU BONY OBLITERATION TECHNIQUE
E. Offeciers, T. Somers (Antwerp, Belgium)

THE ENDOSCOPIC SURGERY OF THE EAR
Livio Presutti MD, Daniele Marchioni MD (Modena, Italy)
Until now, the middle ear surgery was based on the use of operating microscope. Until few years ago the use of the endoscope in otolaryngology was relegated to the skull base and paranasal sinus surgery. First experiences of endoscopic surgical approaches to the middle ear date back to the mid 90’s, when they appeared for the first time in literature, and since then has seen a slow but steady development of this approach, which nowadays is practiced
by some of main centers in Europe and in the world. The first experiences in our Otolaryngology department started in 2004, actually this kind of approach corresponds to the surgical treatment of some of the most frequent pathology of the middle ear, such as cholesteatoma. Incorporating the endoscope into surgical methods in otology contributes much to the concept of more conservative surgery, in fact the use of endoscope allows the surgeon to opt for a more conservative approach: the exclusively endoscopic approach is performed through the external ear canal, in this way there aren’t visible scars and the mastoidectomy is not necessary; compares to the traditional techniques the endoscopic approach provides clear advantages in term of preservation of the temporal bone, in
fact the endoscope offers the surgeon a less invasive option: with the endoscopic approach the removal of the ossicular chain is less frequent, instead the microsurgical approach needs a retroauricular incision, mastoidectomy and extensive dissection of tissue with frequent need to remove the ossicular chain. This conservative attitude results in less postoperative pain and a lower duration of hospital stay. Moreover the endoscope allows a better understanding
of cholesteatoma and a better eradication of residual disease from hidden areas such as the anterior epitympanic recess, retrotympanum, and hypotympanum, which are not yet controllable by an operating microscope. The introduction of the endoscope in this kind of surgery also gives the surgeon improved anatomical knowledge about these complex and changeable structures. Another field of application of endoscopic surgery is the otoneurosurgery, particularly for the removal of the intracanal portion of the vestibular schwannoma. Until few years ago this was subject of debate because the retrosigmoid approach, although less invasive than the translabirintic approach ,could expose to the risk of leaving residual tumor in the bottom of the internal auditory canal. The use of endoscope
in the ponto-cerebellar angle allows to solve this problem completely without resorting to major demolition of bone.

BASIC ANATOMY FOR EAR SURGERY
Asim ASLAN, MD, Department of ORL, Celal Bayar Univ. School of Medicine, Manisa - TURKEY
That the Temporal Bone has a complex anatomy makes the ear surgery difficult rendering surgical complications. Hence, having a good knowledge of its anatomy is the first step in a successful ear surgery. The main difficulty in learning the anatomy of the temporal bone is to understand three-dimentional relationships of the anatomical structures within the temporal bone. In this course, it has been aimed to solve this difficuly by demonstrating photos of
fine serial dissections in a cadaveric temporal bone.

Stapes surgery: pitfall and solution
Stefano Berrettini Associate Professor of Otolaryngology, Otology and Cochlear Implant Centre, University of Pisa, Italy
Abstract
Stapes surgery is considered as the main method for treatment of conductive hearing loss due to otosclerosis. About 90% of patients who underwent stapes surgery usually confirm hearing improvement. Although stapedectomy is a safe and effective procedure, pitfalls and complications can occur even if the operation is performed by an experienced surgeon. Many complications and pitfalls, in fact, may unexpectedly develop during the operation, leading to an extended surgical procedure with an increased risk of poor functional results. Therefore, the prevention of intraoperatory complications is of crucial importance. The complications and pitfalls reported in the stapes surgery typically refer to tympanic damages, chorda tympani injuries, malleus and/or incus problems, footplate problems, facial nerve prolapse, perilymphatic gusher, and bleeding. These problems have different relevance. While a perforation of the membrane tympani is generally easy to restore, a damage of the footplate, like floating, or breaking is conversely much harder to solve. Besides, malleus and/or incus problems like incus necrosis, ossicular fixation, and intraoperatory ossicular dislocation are not easy to achieve. This course is aimed at analyzing all the most significant pitfalls and complications of the stapes surgery. Specific solutions for each problem will be fully
explained and shown to the course attendants by means of surgical videos.

THE OUTCOME OF RADICAL SURGERY AND POST-OPERATIVE RADIOTHERAPY FOR
SQUAMOUS CARCINOMA OF THE TEMPORAL BONE
David A. Moffat Department of Neuro-otology and Skull Base Surgery, Addenbrooke’s, Cambridge University Hospital. UK
ABSTRACT Objective: A give a detailed of current opinion on the management of squamous cancer of the temporal bone and to analyse the clinical data and outcome of all the patients treated surgically for squamous carcinoma of the temporal bone in a tertiary referral skull base department over 25 years. Methods: Fifty four patients with squamous carcinoma of the temporal bone were analysed. The patients were staged according to the Pittsburgh system. The surgical technique, reconstruction of the surgical defect, pastoperative radiotherapeutic treatment, follow-up regimen and results are all described in detail. Results: Disease free survival of T2N0M0 tumours or stage II was 100%. The survival of stage III disease T3N0M0 was also 100%. Overall T3 tumours resulted in 50% survival since 50% had nodal involvement were stage IV disease and none of those survived. There was 100% mortality
where nodes were involved. There was a 54% survival for T4N0M0 tumours and 45% for T4 tumours overall.. The stage IV tumour survival was 42%. Conclusion: The overall disease free survival in the whole series was 52%. Node positive disease, poorly differentiated squamous cell histology, brain involvement and salvage surgery were associated with a poorer outcome. The improved survival (66%) of patients treated de novo in this series compared with
those treated as salvage (34%) suggests that early referral and aggressive primary surgical treatment with postoperative radiotherapy offers the greatest chance of cure.

PREVENTION OF RECURRENT CHOLESTEATOMA
A. Bacciu, E. Pasanisi, S. Bacciu (Parma, Italy)

BILATERAL COCHLEAR IMPLANTS INDICATIONS, MAPPING AND REHABILITATION
S. Burdo, A. Giuliani, L. Dalla Costa, L. Cucinotta (Varese, Italy)

FRIDAY, JUNE 17

8:00 - 9:00 (Rooms 1-8)

SURGICAL ANATOMY OF THE JUGULAR FORAMEN AND ITS IMPLICATIONS IN DECISION MAKING
Essam Saleh (Jedda, Saudi Arabia)

ELECTROACOUSTIC STIMULATION FOR THE MANAGEMENT OF SEVERE HEARING
LOSS.
Alain Uziel (Montpellier, France)

THE USE OF VASCULARIZED FLAPS IN MASTOID RECONSTRUCTION
Mattew Yung (Ipswich, United Kingdom)

STAPEDOTOMY WITH SELF RETAINING TITANIUM CLIP-PISTON
Daniel aWengen (Binningen, Switzerland)

Partial Deafness Treatment (PDT) :Surgical Treatment and Results
Skarżyoski H., Lorens A.,Zgoda M, Skarzynski P.H., (Nadarzyn, Poland)
Combined, electric and acoustic stimulation led to a rapid progress in cochlear implantation. Easing the criteria for qualifying patients benefited a new group of patients diagnosed with having residual hearing, thus being partially deaf. The pursuit for proving surgical aspects of the theory of conservation of residual hearing resulted in application of the so-called round window approach in cochlear implantation which was backed by data obtained in patients
treated since 1996. These promising and repeatable results inspired us to start a new program of treatment for those with so-called partial deafness. The concept proved to be an optimized form of treatment in patients, with good sound perception in low frequency tones and total deafness in the high frequency range, who received either electric stimulation alone or effective hybrid electric and acoustic stimulation. As a consequence, the proposed six step surgical “round window approach” has become a true answer to the challenging issue of reservation of residual hearing. Practical application of this method by Skarzynski since 2002, in treatment of so called “partial deafness” was proven in outstanding and stable post operative results in adult patients treated with this method. In 2004 the first in the world child with a diagnosed partial deafness was implanted and showed total preservation of residual hearing and then many children followed that unprecedented success. We present basic surgical steps and difficult situations that may be encountered during PDT, as well as rehabilitation strategy and long term results of a group of children and adults, treated in our Centre since introduction of the method. We would like to stress the great influence of the round window approach on cochlear implant surgery, especially in creating a new possibility
for preservation of residual hearing, which in return contributed to giving a new chance for better hearing to a large group of patients.

“SUPRAMEATAL APPROACH”. AN ALTERNATIVE IN COCHLEAR IMPLANTATION
Wilko Grolman (Utrecht, The Netherlands)

THE ROLE OF EUSTACHIAN TUBE IN CHRONIC OTITIS MEDIA
John Hamilton (Chelterham, United Kingdom)

Use of Cement in Ossiculoplasty
J.P. Souaid, M.D., F.R.C.S.C (Ottawa, Canada)
Objectives:
To know how to prepare, mix and apply the cement and the various indications and contraindications. Attendees will have the opportunity to use samples. Study Design: Retrospective case review and teaching using video demonstrations. Setting: tertiary referral center, hospital. Patients: Patients with ossicular abnormalities, cholesteatomatous and non-cholesteatomatous cases included. Intervention: Application of Otomimix cement during ossiculoplasty Main Outcome Measure: Hearing improvement according to AAOHNS reporting guidelines. Results: The hearing results for the various surgical situations will be presented and discussed. Conclusions: Attendees will learn how to use Otomimix cement and that it is a useful adjunct in ossiculoplasty with good hearing results.

9:00 - 10:00 (Rooms 1-8)

NEW PERSPECTIVES IN MANAGEMENT OF TEMPORAL BONE PARAGANGLIOMAS
Giovanni Danesi (Bergamo, Italy)

FACIAL NERVE, LANDMARK IN TEMPORAL BONE SURGERY
Jacques Magnan )Marseille, France)

VIBRANT SOUNDBRIDGE IN SENSORINEURAL, CONDUCTIVE AND MIXED HEARING
LOSS
Christian Streitberger (Meran, Italy)

REVISION SURGERY IN STAPEDECTOMY
Gregorio Babighian (Padova, Italy)

CONDUCTIVE HEARING LOSS WITH NORMAL TYMPANIC MEMBRANE: HOW TO PREVENT MISDIAGNOSIS AND UNPLEASANT SURGICAL SURPRISES
Erwin Dunnebier (Zaandams, The Netherlads)

VERSATILITY OF ENLARGED MIDDLE FOSSA APPROACH FOR SKULL BASE LESIONS
M. Gjiuric, (Zagreb, Croatia)

Retraction Pockets, when and how to act?
Ibrahim Hizalan, MD - Levent Olgun, MD (Bursa and Izmir, Turkey)
In this course some of the topics to be discussed will be: * Middle ear ventilation and formation of retractions * Classifications of retractions * Natural course (?) of retractions * Management of retractions: + retractions in pediatric patients + how to be aware ? + when retraction is a cholesteatoma ? + clinical evaluation of an ear with retraction + when to observe ? how ? + when to ventilate ? how ? + when to operate ? how ? * Discussion on management of different examples of retraction: + on different localisations (attic, anterior, postero-superior,.) + with hearing loss; or without + with clean pocket; or with debris + retraction only; or with invagination * Rules, hints and common errors

MANAGEMENT OF EXTERNAL AUDITORY CANAL IN MIDDLE EAR SURGERY
Alessandra Russo, Lorenzo Lauda (Piacenza and Rome, Italy)

10:00 - 11:00 (Rooms 1-8)

MANAGEMENT OF PARAGANGLIOMA TUMORS: OUR EXPERIENCE ON OVER 200 CASES
Mario Sanna (Piacenza and Rome, Italy)

UPDATE IN TINNITUS MANAGEMENT
M. Mazzoli, F. Trabalzini (Padova, Italy)

ON THE ORIGIN OF THE EAR - a conceptual approach
Rudi KUHWEIDE, MD Otologist and Chairman ENT-department, AZ St.Jan General & Teaching Hospital, Brugge, Belgium
The story of the ear starts by the cilium marking the origin of animal life. Mitochondria provided protozoa with the power to move a cilium. Choanoflagellate protozoa conglomerated to sponges. Next jellyfish are the first animals to acquire a mechanosensory organ. The hair cell in the jellyfish statocyst shows an astounding resemblance to the choanoflagellate tip comprising a cilium surrounded by a collar of microvilli. An evolutionary transition from a motor to a sensory function is suspected from the latest data on genetics of ciliated neuroectoderm. After the Cambrian explosion all new life forms were bilaterally symmetric, being divided into proto- and deuterostomes. In the latter, including echinoderms and vertebrates, a gene duplication separated the hair cell off the neuron, conferring it the autonomy to explore the entire spectrum of mechanosensation. The Pax 2 transcription factor guided the development of the otic placode throughout evolution of the larval deuterostome, resulting in the octavolateralis system in fish. Coupling to a cupula allowed the hair cells of the lateral line and semicircular canals to relay angular acceleration, initiating vibroception. Labyrinth segmentation as well as hair cell specialization into polarized high-speed particle
detectors extended vibroception into the high frequencies. However hearing beyond the near field necessitates the sensation of the pressure instead of the kinetic component of sound. This feature probably originated from an ambient pressure sensor to assist positioning in the low coastal waters. All terrestrial animals descend from lobefinned fish and they all commit to a sound pressure pathway paradigm. This consists in tapping a pressure sensor to drive the particle detectors in the endolymph, by inserting a volume to be displaced over a perilymphatic duct with the aid of a pressure release window. The tympanic cavity as most prevalent though not unique pressure sensor is a spin-off of the acute oxygen shortage that forced fish to go ashore and favored those with a spiracle as supplementary respiratory canal. The hyomandibula evolved from a controller of all three respiratory organs in lobe-finned
fish, over a strut preventing jaw collapse in basal reptiles, to a columella after quadrate bone withdrawal in reptiles and birds or else a stapes after mammals developed a seismic signal receiver at the lower jaw corner and the old reptilian articular-quadrate jaw changed into the malleoincudal joint. The peculiar mammalian ear did not improve on the acoustical transmission of the columella and there was no acoustical advantage in closing the Eustachian tube. Our hypothesis on the mammalian middle ear having developed as an adaptation to subterranean life is ever more sustained by the latest knowledge on how the diverse premammalian lineages survived the dinosaur dominance and asteroid impact. The duckbill as a living fossil already makes use of the prestin motor protein to launch active
tuning, although its cochlea still is comma-shaped and shows manifold rows of disorderly hair cells. As active tuning by the outer hair cells is similarly based on a particle detector relaying angular acceleration, basilar membrane displacement needs more power towards the higher frequencies. The resulting upward spread of masking is opposed by the coiled anatomy, that logarithmically propagates the lower frequencies towards the apex and was shaped to
advance discrimination and not because of size reduction.

Otogenetics: how to come to a molecular diagnosis
H. Kunst, Radboud University Nijmegen, The Netherlands
Nowadays, approximately 1 per 1000 new-borns are severely hearing impaired, i.e. with bilateral hearing thresholds of 80 dB or more. In at least half of these cases, the cause is inherited. The mode of inheritance can be autosomal recessive (70%-80%), autosomal dominant (20%-30%) and X-linked (1%-2%). Mitochondrial inherited sensorineural hearing impairment has also been described. In approximately 70% of the hereditary cases, no other stigmata related to sensorineural hearing impairment (SNHI) can be recognised; these types of hearing impairment are classified as non-syndromic. The above-mentioned data are mostly related to profound early childhood hearing impairment (prelingual phase). In the majority of the cases with autosomal dominantly inherited hearing impairment, the age of onset is after early childhood (postlingual phase). The prevalence of postlingual sensorineural hearing impairment, with an average hearing threshold of >25 dB, in western Europe is approximately 1% in young adults, about 10% up to the age of 60 and almost 50% at the age of 80. We do not know what the contribution of hereditary causes is, and what the prevalence is of the different modes of inheritance of hereditary postlingual hearing impairment. Agerelated
hearing impairment is considered to be multifactorial in which genetic as well as nvironmental factors are involved. Since 1992, considerable progress has been made in the field of molecular genetic studies on hereditary sensorineural hearing impairment due to improved and high-throughput methods, the human genome project and studies in mouse models. It has recently become possible to make genetic diagnoses based on molecular tests in an increasing number of otologic disorders. This is of high value because different genotypes might lie behind (strikingly) similar phenotypes. This is illustrated in autosomal dominant non-syndromic sensorineural hearing impairment for which until recently only eight types could be distinguished clinically according to Gorlin et al (1995), while nowadays about 57 different loci are known to be responsible for autosomal dominant non-syndromic hearing
impairment (genotypes). The locus on a chromosome, which harbours a gene that is involved in non-syndromic autosomal dominant hearing impairment, is specified by the prefix DFNA. Non-syndromic autosomal recessive hearing impairment carries the prefix DFNB. About 77 DFNB loci are known and 7 loci for X-linked forms of non-syndromic hearing impairment (DFN). Also two mitochondrial genes involved in non-syndromic mitochondrial hereditary hearing impairment are described. It is expected that the number of the various loci will show a considerable increase. About 141 loci causing non-syndromic SNHI are known, however, up to now only about 50 genes have been identified. Much of these data are available on-line via the Hereditary Hearing loss Homepage: http://webh01.ua.ac.be/ hhh/ For the most prevalent syndromes the genes have been identified, consequently mutation analysis is available for these patients. However, not all mutations within these genes have been identified or genes themselves are still unknown. In these cases a genetic diagnosis may not be established. Over 130 genes have been identified for the more than 400 genetic syndromes with hearing impairment. The most important recessively inherited syndromes with hearing impairment as a feature are: Usher syndrome (congenital hearing impairment, balance problems en
progressive pigmentary retinopathy), Pendred syndrome (hypothyroidism and progressive hearing impairment) and Jervell-Lange-Nielsen syndrome (congenital deafness and prolonged QT-interval). The most frequently seen dominantly inherited syndromes with hearing impairment are: Treacher Collins syndrome (craniofacial malformation like
coloboma of the lower eyelid, micrognathia, microtia, hypoplasia zygomatic arches and mandibula, inferior displacement of lateral canthi of the eyes,

COCHLEAR IMPLANT PROGRAMMING: FROM AUDIOLOGY TO ARTIFICIAL INTELLIGENCE
Paul Govaerts (Antwerp, Belgium)

UPDATES ON INTRATYMPANIC TREATMENT OF SUDDEN DEAFNESS
Diego Zanetti, MD, Stefan Plontke, MD (Brescia and Tuebingen, Italy and Germany)

Genetical aspects of ear diseases
Malou Hulcrantz (Stockholm, Sweden)
Objective: To give deeper knowledge in genetical hearing impairments. Syndromes including ear and hearing in not uncommon. 4-5000 diseases concerning hearing codes for only one gene (monogenic). One gene codes for one protein and one defect gene codes for one disease. 10% of the whole genom codes for proteins the rest (90%) is considered to be “junk”. Nonsyndromatic hearing loss (70%) is more common than the syndromatical ones (30%).
Many of the syndromatical disorders have today been cloned and the location on the chromosome have been mapped (like Alport, Jervell, Pendred, Treacher Collins, Waardenburg, Stickler, Usher). Inheritance of the diseases is usually divided into 4 different groups: dominant (Crouzon, Wardenburg, Osteogenesis Imperfecta, neurofibromatos)
recessive (Usher, Alport), x-linked (Hunter, Turner, albinism) and mithocondrial (Kearns-Sayre). The incidence is the same for both pre-lingual deafness and progressive hearing loss (1/1000). The only cure for these situations today is a cochlear implant. The pathology behind the ear problems are :Middle ear defects, morhogenetic inner ear defects, central auditory system defects, peripheral neural defects, neuroepithelial defects, cochleo-saccular defects and late onset hearing loss. The course will discuss the most common syndromatic and non-syndromatic hearing disorders and describe what is known about the location and pathology behind the hearing problems.
Keywords: Hearing loss, genetically impairment, syndromatical, non-syndromatical

Family Candidacy for Cochlear Implant
Mr. Omar Al-Sharif MA (Senior Speech Pathologist) and Ahmed J Jamal FRCSIr. FRCSEd .(Consultant ENT and CI surgeon), Manama, Kingdom of Bahrain
Objective: Family members play an important role in the success or failure of cochlear implanted children. This s emphasized in the role of the family in the process of cochlear implant children learning and interaction in their environment. Before implantation we need to ensure the role of the family in the believe that the child can overcome his deafness with their help, that the family understand all about cochlear implant and their readiness to be involved
actively in the hearing and speech rehabilitation process. This paper will present our views and experience on role of the family in: Understanding the ordeal of deafness and the function of Cochlear implant Understanding the importance of the rehabilitation and their role in this process Motivating the child to interact with everybody around him Helping the child to express himself freely and involve him in all family interactions. Being more supportive to
the child in his success as well as in failures. Conclusion: Surgery is not the only issue in the Cochlear implantation to restore hearing to the deaf. Attention to patient selection details and his/her family surroundings play major role in the success of our task to restore hearing. Family readiness and understanding of cochlear implantation function is the hidden factors behind a lot of problem and failures.
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Address for correspondence: Mr. Omar Al-Sharif MA
Senior Speech Language Pathologist
P.O. Box: 12 Manama, Kingdom of Bahrain
Tel.: mobile: + 973 39973371, Fax: +973 17795266 E-mail: oalsharif@yahoo.com
omarslp@batelco.com.bh
16:00 -17:00 (Room 1-8)

COCHLEAR IMPLANRS AND BACTERIAL MENINGITIS
Rubens Brito (Sao Paulo, Brazil)

BONE ANCHORED HEARING AIDS
C. Cenjor, C. Moreia (Madrid, Spain)

BPPV- Beyond unilateral posterior canal
Instructional course by Daniel Kaplan (Beer Sheva, Israel)
Positional vertigo lasting for seconds, while rolling in bed or looking up or down is usually caused by unilateral canalithiasis of the posterior semicircular canal. Less commonly, positional vertigo may be caused by either canalithiasis or cupulolithiasis of other organs in the labyrinth or may even originate from the brain. The objective of the course is to present unusual types of positional vertigo. The following entities will be discussed: Atypical posterior
canal BPPV, horizontal canal BPPV and bilateral posterior canal BPPV. Based on the literature and on the instructor’s clinical experience, these entities will be characterized in respect to pathophysiology, clinical presentation, management and prognosis. At the end of the course the participant is expected to recognize the characteristics of each one of these clinical entities and to be able differentiate them from unilateral posterior canal BPPV.

TOTALLY-IMPLANTABLE MIDDLE EAR DEVICE ESTEEM (ENVOY MEDICAL)
Maurizio Barbara
Neuroscience, Mental Health and Sensory Organs Department, Otorhinolaryngologic Unit, Sapienza University, II Medical School, Rome Italy
The Esteem ® middle ear device has recently been introduced for rehabilitation of sensorineural hearing loss of different degree. It takes advantage of piezoelectric principles ending up with direct stimulation of the stapes. Presently, it represents the only totally implantable system without implanted microphone. A first series of 22 patients,
operated on between July 2007 and March 2010, is presented. In all the patients, hearing thresholds were recorded at a better level than the pre-operative ones as well as compared to a previously-fitted hearing aid, when worn. A few complications were also occurring, regarding flap dehiscence (1), taste disturbance (3) and temporary delayed facial palsy (2). Results were also summarized by filling a specific questionnaire for a general satisfaction of the
whole rehabilitative procedure.

ACOUSTIC NEURINOMA: OUR EXPERIENCE ON OVER 2000 CASES
Abdelkader Taibah, Enrico Piccirillo (Piacenza and Rome, Italy)

Prelingual hearing impairment: benefit and guidelines for etiological and genetic investigation
Eva Orzan, MD
Pediatric Audiology Unit ORL and Pediatrics University Hospital of Padova, Italy
Approximately 2 in 1000 children present a permanent hearing impairment at birth or in early childhood. The cause of hearing impairment is mainly due to either environmental or genetic factors, but there are also individuals who are genetically predisposed to environmental damage (for example the mitochondrial mutation 1555 predisposes to aminoglycoside damage) and other individuals will probably be hearing impaired because of combination of
genetic and environmental factors The aetiology of hearing impairment has been studied by various Authors but in spite of significant advances in the understanding the specific causes of hearing loss, the relative contribution of the many aetiologies is only estimated. Moreover, identifying the precise cause in an individual remains difficult in up to 20-30% of the cases. Roughly, environmental causes account for 20-30% in industrialized countries and
include prematurity, prenatal or postnatal infection, arachnoid hemorrage, pharmacological ototoxicity and others. On the other hand, genetic causes account for at least 50%-70% of prelingual hearing impairment and have proved to be extremely heterogeneous with more than 80 genes mapped or cloned. In view of the complex structure of the inner ear and the mechanisms of normal hearing, it is not surprising that changes in hundreds of different
genes can result in hearing loss. Hereditary hearing impairment can be broadly defined as either syndromic or non syndromic. Syndromic hearing impairment is defined as such when one or more abnormalities are associated with the hearing problem and are coinherited. Over 400 clinical descriptions of syndromic hearing impairment have been described in the literature and reviewed by Gorlin. In the majority of patients the hearing impairment is seen in isolation, unassociated with other abnormalities. This type of non syndromic hearing impairment is thought to represent up to 60% of all cases of childhood sensorineural hearing loss. The course will propose a clinical approach to the aetiological investigation of individuals with hearing loss 210 consecutive children affected by permanent prelingual hearing loss will be presented. Subjects are classified by their medical record (including ophthalmology review and neuroimaging of petrous temporal bone) and by audiometric and molecular genetic features, in an effort to use all available phenotypic and clinical clues for etiological diagnosis. The purpose is to highlight important issues in developing diagnostic and molecular-genetic services for preverbal hearing loss and to form the basis of a diagnostic testing program. This information may ameliorate timing and quality of intervention of this frequent pathology.

THE USE OF CARTILAGE IN TYMPANOPLASTY
Philippe Romanet (Dijon, France)

CLASSIFICATION AND MANAGEMENT OF INNER EAR MALFORMATIONS
Levent Sennaroglu (Ankara, Turkey)

17:30 - 18:30 (Rooms 1-8)

Preoperative imaging in cochlear implantation
Paul Merkus, MD PhD (p.merkus@vumc.nl)
Amsterdam- VU University Medical Center the Netherlands
Objective: Preoperative imaging is helpful in most otologic cases and essential in all cochlear implant cases. Planning of the operation, avoidance of complications and increasing the success rate of the implantation are the main reasons to perform thorough pre-operative imaging. Good practical skills to interpret the scans as a surgeon are essential. (A good radiologist is also very helpful, but is beside the topic of this workshop). This workshop will hopefully help the otologist: ordering the right scan for the right indication, recognizing pathology, and assist in (pre-) operative decision making. Topics The focus of this workshop will be preoperative imaging in cochlear implant candidates. In this workshop we will discuss the imaging techniques, imaging of relevant anatomy, imaging of frequent encountered pathology (like meningitis, otosclerosis and malformations) and some special cases are presented. Consequences of the images for decision making and operation technique will be discussed. Perioperative imaging and post-operative imaging will only briefly be mentioned Audience Level of expertise to benefit from this workshop is: -last year resident to ear surgeon and early stage implant surgeons-. Interactive session whenever possible.
Address Correspondence: Paul Merkus, MD PhD Dept of Otorhinolaryngology - Head and Neck surgery Cochlear Implant team VUMC Amsterdam VU University Medical Center
Amsterdam, PO BOX 7057 1007 MB Amsterdam, The Netherlands p.merkus@vumc.nl

BAHA: INDICATIONS AND TECHNIQUES FOR THE BEGINNER
Claudio Cola, Antonio Caruso (Rimini and Piacenza, Italy)

Vestibular Evaluation made Simple for the Otologist: a Surgeon’s Perspective
Badr Edin Mostafa (Cairo, Egypt)
All surgeons are faced by patients with vertigo and dizziness. We are more accustomed to audiological and radiological tests. However the other function of the ear namely the vestibular function should be tested. Vestibular testing has traditionally been a complicated uninformative venture and usually neglected by surgeons. In this workshop I will try to outline the main clinical vestibular tests, their interpretation and their clinical impact on the decision making in the management of patients with vertigo. A stepwise approach will be adopted from simple history-taking to office examination to the routinely-performed tests. An integrated decision tree will be drawn in a trial to get as accurately as possible, a site of lesion and if possible a type-of- lesion result in order to tailor the most adequate therapeutic strategy for each individual.

MANAGEMENT OF AURAL ATRESIA: AURICLE RECONSTRUCTION AND HEARING RESTORATION
H. Haijri*, A. Russo**, A. Caruso** (*Tunis, Tunisia and **Piacenza, Italy)

The Esteem middle ear implant
Marie-Paule Thil (Brusselles, Belgium)
The Esteem , a fully implantable hearing device, which uses the tympanic membrane as microphone, got the CE agreement in 2006, and is now accepted by FDA since December 2009. There are up to now about 250 persons implanted . We would like to share the Belgian experience of the system. First we present the characteristics of the device, discuss the indications and give the results of our first 10 implanted patients. The global gain by pure tone
audiometry is 27 dB, the comprehension improved up to 70% at 50 dB HTL. The global satisfaction of the patients established by different questionnaires is excellent as all of them agree to make the operation again.

COCHLEAR IMPLANTATION IN INNER EAR MALFORMATIONS
Nicolò Frau (Rovereto, Italy)

Management of Jugular Foramen Paraganglioma’s
Speaker: R. Mark Wiet, MD,
Ear Institute of Chicago, Assistant Professor, Department of Otolaryngology, Rush University
Medical Center, 11 Salt Creek Lane, Suite 101, Hinsdale, Il 60521, rmwiet@hotmail.com
Purpose: To provide an overview of the management jugular foramen paragangliomas from diagnosis to follow up. Summary: The management of jugular foramen paragangliomas is a challenging and requires multidisciplinary input to maximize patient outcomes. Topics reviewed in this instructional course will include diagnosis of paragangliomas, their genetics, preoperative preparation, review of various approaches for resection from the jugular foramen, and the role of various stereotactic radiosurgery instruments in their management. Illustrative cases will be presented for discussion.

18:30 -19:30 (ROOMS 1-8)

The Role of Imaging in Cochlear Implantation Surgery
Professor Hassan Wahba Professor of OtoRhinoLaryngology Ain Shams University Cairo Egypt
Introduction: With the recent and continuous advances in surgery for sensorineural hearing loss, it is proved every day that proper visualization of the structure of the temporal bone by CT scan and the inner ear and internal auditory canal by MRI is gaining more and more importance in aiding otologic surgeons during their path within the ear to improve the prospects and results for cochlear implantation surgery by whatever device from whichever company. Objectives: It is the purpose of this instructional course to lay the foundations for proper understanding of the imaging anatomy of the temporal bone which is considered by many difficult and complicated, in other words, imaging anatomy of the temporal bone made easy. This can only be achieved by understanding the three dimensional relations of the various anatomical structures in the temporal bone and then applying that to a sectional view in the axial coronal and sagittal planes. After actually laying the foundations of understanding the anatomy in the CT scan a second application of the newly understood format will be applied to the MRI, thus gaining a full CT and MRI imaging understanding that will be the foundation for diagnosis of pathologies whether congenital or acquired, as well as acquiring a rapid surgical map for the otologic surgeon that guides him or her during the otologic procedure of cochlear implantation with precision and no surprises. Instructional Course details: The course will show the various images obtained from the work of the author as a surgeon at the cochlear implantation center Ain Shams University Specialized Hospital during the period 1993-2009 a period of 16 years in which 190 implant surgeries were carried out and around 3000 patients were evaluated for the possibility of implantation. The following details will be covered: Cochlear patency: every cochlear implant surgeon desires a patent cochlea to achieve the optimum implantation of enough electrodes of the cochlear implant that would achieve the best hearing results. Cochlear patency has long been an issue and has prompted surgeons to find alternate surgical methods to bring the electrode array as lose as possible to the cochlear modiolous. The course will show the differences between partial and complete cochlear obliteration by ossification in particular post meningitic and the importance of evaluating both CT scan and MRI. Also, emphasis will be laid on how to early detect ossification and thus hasten the procedure of implantation. Other causes of obliteration will be also discussed as post otosclerotic and post traumatic. Cochlear development: with the presentation of many patients with prelingual profound sensorineural hearing loss to cochlear
implant centers; imaging of the ears discovered numbers of these patients who were previously prescribed a hearing aid but had a inner ear anomaly the so-called inner ear dysplasia or sometimes called Mondini dysplasia. A renewed interest in these patients became obvious with nomenclatures and classification. It is the intention of this course to expose the various inner ear malformations according to the basis that they are a result of arrest of fetal development leading to the various forms. It is also the purpose of this course to carry out an evaluation of each anomaly to help the surgeon chose the patient that would give the optimum result after implantation. Cochlear nerve bundle: MRI has further increased our interest and opened new frontiers in the examination of the vestibulocochlear nerve bundle within the internal auditory canal. Also, the fact that a cochlear nerve aplasia may be present although the inner ear is fully developed has raised the alarm that the cochlear nerve must be visualized and assessed by MRI and CT scan in order to discover an aplasia or hypoplasia of the nerve in order not to implant a device in the cochlea with no results and instead to use a brainstem implant with its benefits although still minimal at this stage of this developing technology. Surgical issues: any and every otologic surgeon desires a map for the temporal bone prior to otologic surgical procedures especially cochlear implantation. The course will cover the entire surgical route from the mastoidectomy, posterior tympanotomy , identification of the facial nerve, identification of the labyrinthine windows, location of the internal jugular bulb and internal carotid canals, understanding the internal anatomy of the cochlea with special emphasis on the hook area scala tympani and scala vestibule, assessment of cochlear length and size and assessment of skull bone thickness for creating the seat for the device. Postoperative assessment: the surgery for cochlear implantation is never complete without a postoperative image by X-ray or CT scan to assure the surgeon that the electrode array is in good position with an acceptable insertion of enough electrodes into the cochlear lumen. The actual introduction of the electrode array through a cochleostomy into a non-visualized area carries many risks and hazards for possible incomplete or extracochlear insertions especially in cases with partial ossification. Proper assessment of postoperative images also help the programmer of the device in addition to neural response telemetry to properly program the device. Conclusion: Finally it is the intention of this instructional
course to help otologic surgeons acquire the necessary skills and understanding to facilitate the diagnosis of profound sensorineural hearing loss as well as to geographically assist in their cochlear implantation procedure.

BAHA: STATE OF THE ART
Emmanuel Mylanus (Nijmegen, The Netherlands)

CLINICAL EXAMINATION OF THE DIZZY PATIENT
D. Nuti (Siena, Italy)

Active Middle Ear Implants in 2009 in Europe and in USA: Further developments and new indications.
Arnaud Devèze, MD Department of Otolaryngology, University La Méditerranée, Assistance Publique Hôpitaux de Marseille, Marseille, France.
Stéphane Tringali, MD University Claude Bernard Lyon 1, CNRS, UMR5020 Neurosciences sensorielles, Comportement, Cognition, F-69366, Lyon, France.
Herman A. Jenkins, MD Department of Otolaryngology, University of Colorado Denver, School of Medicine, Aurora, CO, USA.
Conventional hearing aids have advanced tremendously throughout the last decade with miniaturization and improvements in digital signal processing. However, conventional hearing aid technology suffers from drawbacks, such as unsatisfactory sound quality (limited frequency range, undesired distortion), occlusion of the external ear canal, acoustic feedback with high amplification, and social stigma. Recently, active middle ear implants have been developed to overcome these issues. The Middle Ear TransducerTM (MET, Otologics, Boulder, CO, USA) is available in both a semi-and fully implantable active middle ear implant commercially available for treatment of moderate to severe sensorineural and mixed hearing loss in adults (available in Europe since 2000, undergoing clinical trials in United States). The semi-implantable is composed of an external part containing the microphone, the battery and
the sound processor, and of an internal part implanted in the middle ear in which the transducer is connected to the body of the incus. The fully implantable system (Carina) has all components implanted under the skin as a unit. In this instructional course, the surgical techniques, problems and results with these active middle ear implants in sensorineural and mixed hearing losses will be presented. These include: 1) Authors’ experiences in conductive
and mixed hearing losses, using semi- and fully implantable devices, and 2) update of US clinical trials of the fully implantable Carina system. Numerous results have been reported so far in the literature. Although this appears to be a reliable solution, achieving success requires significant attention to details. Discussions of candidate selection, specifics on placement and coupling of the transducer to the ossicular chain or round window, and limitations of the
device will provide information to be used as a guide for surgeons in implantation.

SURGICAL AND RADIOLOGICAL ANATOMY OF THE TEMPORAL BONE
M. Falcioni, A. Giannuzzi (Piacenza and Rome, Italy)

MANAGEMENT OF MAJIOR EAR MALFORMATIONS
Thomas Somers (Antwerp, Belgium)

Indications and techniques for staged cholesteatoma surgery
Auhtors: Amir Minovi, MD, Stefan Dazert, MD (Bochum, Germany)
In this instructional course our strategy of staged cholesteatoma surgery is presented. In our department we usuallyuse the inside-outside technique for the removal of cholesteatomas. By drilling the lateral attic the cholesteatoma is exposed and followed until its posterior region can be visualized. Depending on the removed portions of the attic, either it is reconstructed or a canal wall down procedure with an open mastoid cavity is performed. In special cases
such as an involvement of the foot plate or an infiltration of the facial nerve a second look surgery is mandatory. The indications and techniques for a staged cholesteatoma surgery are further discussed.

Auditory Brainstem Implantation in Prelingual Deaf Children with Severe Inner Ear Malformations
Atas A (1), Sennaroglu G (1), Sevinc S (1), Yucel E (1) , Sennaroglu L (1), Sarac S (1), Ziyal I (2). (1)
Hacettepe University Department of Otolaryngology - Audiology and Speech Pathology; (2) Hacettepe University Department of, Neurosurgery, Ankara – Turkey.
Introduction: Auditory Brainstem Implant (ABI) has been aplied in children who are born deaf due to cochlear nerve aplasia or with severe degree of inner ear dysplasia and for whom a cochlear implant is not an option. Application of ABI is more complicated than Cochlear Implant. ABI electrodes have been placed in Cochlear Nucleus that is so near to some important Cranial Nerves and electrically stimulation of Cochlear Nucleus has some risk of side effects. Fitting of ABI is also so important to decide which electrodes have effective auditory stimulation and which electrodes have side effects that must be closed. The children with cochlear nerve aplasia or with inner ear dysplasia also have risks of some limitations in Cochlear Nucleus as size and shape. These are increased the risk of side effects. We have no much more information about effects of long term electrically stimulation on cochlear
nucleus in children. Materials and Method: ABI was applied in 20 children (1 - 5 years old) with cochlear nerve aplasia and severe degree of cochlear malformations. 19 Nucleus ABI-24 and 1 Medel Pulsar CI 100 ABI were used. Intaoperative EABR measurments were done in all children. Initial stimulation was carried out 6-8 weeks after the implantation in intensive care unit. The electrodes that caused side effects and nonauditory sensations were closed. Language and auditory development of children were evaluated in every three months Results and discussion:The children that have been implanted with ABIs, were followed up every two weeks during the first three months and every three months later. Intraoperative EABR measurements indicated important tips for fitting. Fitting parameters and stimulation parameters were observed and found some changing. Numbers of open electrodes were increased and some electrodes that had nonauditory sensations were found to have auditory sensation. The numbers of electrodes had side effects were decreased during the following up. The results of ABI’s in prelingual children show the good improvements in auditory plasticity and language development. Especially changing some fitting parameters cause some extra improvement in children. Auditory sensations have been happened in lateral
electrodes were thought plastisty or the growth of cochlear nucleus after the stimulation. Improvement in language and auditory developments were found in all children. We believe that careful surgery, intra and post-operative EABR measurments, fitting and rehabilitation will increase the benefits of ABI applications in children. E-mail: atas@hacettepe.edu.tr

SATURDAY, JUNE 19

8:00 - 9:00 (Rooms 1-8)

ROUND WINDOW APPLICATION OF ELECTROMAGNETIC MIDDLE EAR IMPLANTS
Levent Olgun (Izmir, Turkey)
SUMMARY:Some chronic diseases of external or middle ear leads to considerable conductive or mixed hearing losses,and if the pathology can not be medically or surgically corrected a hearing aid may be a solution.But some patients can not use or tolerate their hearing aids’ either due to anatomical or medical reasons or because of acoustic problems.Middle ear implants originally developed for sensorineural hearing losses may be a solution for some
of these patients.Since first used on 2005 by Colletti .application of middle ear implants onto the round window has gained popularity and have been used on patients with radical mastoidectomy cavities,chronic external ear diseases or congenital aural atresia cases.In this course , various middle ear implants would be rewieved,basic principles of round window stimulation with electromagnetic implants would be discussed , application of elctromagmetic
implants onto the round window would be presented with video clips’ and audiological results would be evaluated. During presentation details would be interactively discussed with the audiance.

Current Status of Local Drug Delivery to the Inner Ear
Prof. Dr. med. Stefan K. Plontke - Dept. of Otolaryngology - Head and Neck Surgery Elfriede-Aulhorn-Str. 5, D- 72076 Tübingen, Germany Stefan.Plontke@uni-tuebingen.de
There is an increasing interest in the treatment of human inner ear disorders by local drug delivery to the inner ear in stead of systemic therapy. The objective of this presentation is to review the current state of preclinical and clinical knowledge on treatment of inner ear disorders by local drug delivery. Since rational local pharmacotherapy of the inner ear requires an understanding on how drugs move in the inner ear, principles of drug dispersal within the inner ear fluids after topical administration are demonstrated and relevant pharmacokinetic studies are reviewed. Clinically, the focus will be on the treatment of sudden sensorineural hearing loss through intratympanic drug administration by providing an overview over the available clinical studies. As more candidate substances for the treatment of inner ear disorders are being discovered, it is equally important to develop appropriate drug delivery strategies. For local drug delivery to the inner ear, a variety of drug delivery systems exist ranging from intratympanic injections of fluids to the use of pumps, and biodegradable biopolymers. The currently available drug delivery strategies are reviewed with a focus on controlled drug delivery systems and their safety-benefit aspects. Finally, an outlook is given on future developments in local drug delivery to the inner ear including intracochlear drug administration in combination with auditory prosthesis.

ACOUSTIC NEUROMA SURGERY: OTOLARYNGOLOGICAL OR NEUROSURGICAL ISSUE?
Franco Trabalzini (Padua, Italy)

CHOLESTEATOMA SURGERY: RESULTS, INFLUENCTIAL FACTORS AND FOLLOW-UP
Milan Stankovic (Nis Serbia)

VBS SURGERY FOR OTOSCLEROSIS
Georg Sprinzl (Innsbruck, Austria)

OSSICULAR CHAIN MALFORMATIONS
V. Vincenti, F. Di Lella, E. Pasanisi (Parma, Italy)

Tympanomastoid Surgery for the General Otorhinolaryngologist
A. Sismanis (Athens, Greece)
Course Abstract: In this course “stay out of trouble” and simplified tympanoplasty and mastoidectomy techniques will be presented based upon the instructor’s 30 years experience. In particular, the use of cartilage “shield” grafts for repair of tympanic membrane perforations and type III ossicular reconstruction in atelectatic ears will be described. In the presenter’s experience this is a very stable grafting material, easy to handle, with excellent take and satisfactory hearing results even in revision cases and atelectatic middle ears (25 dB or less in 79 % of cases). A reliable mastoidectomy by using the mastoid dural tegmen as landmark for entering the mastoid antrum, especially in poorly pneumatized temporal bones, will also be presented. Performing a posterior tympanotomy in similar situations is often not feasible by identifying the vertical segment of the facial nerve. A simple posterior tympanotomy for such
cases by identifying the fossa incudis, horizontal semicircular canal, and horizontal facial nerve as landmarks will be presented will be presented as well Slides and many intra-operative video clips will be used to accomplish these goals. Educational Objectives: Learn a reliable mastoidectomy technique by using the mastoid dural tegmen as landmark, a posterior tympanotomy by identifying the fossa incudis, horizontal semicircular canal, and horizontal
facial nerve. Understand an effective and practical tympanoplasty and type III ossicular reconstruction by using cartilage “shield” grafts as well other grafting materials and prostheses. Course Relevance and Purpose: This course is mainly for the general Otolaryngologists who wish to learn reliable, safe and practical techniques for mastoidectomy
in poorly pneumatized temporal bones and cartilage “shield” and other grafting materials in tympanoplasty. Key Points: Techniques will be presented based upon the instructor’s 30 years experience. In particular, the use of cartilage “shield” grafts for repair of tympanic membrane perforations and type III ossicular reconstruction in atelectatic ears will be described. In the presenter’s experience this is a very stable grafting material, easy to handle, with excellent take and satisfactory hearing results even in revision cases and atelectatic middle ears (25 dB or less in 79 % of cases). A reliable mastoidectomy by using the mastoid dural tegmen as landmark for entering the mastoid antrum, especially in poorly pneumatized temporal bones, will also be presented. Performing a posterior tympanotomy in similar situations is often not feasible by identifying the vertical segment of the facial nerve. A simple posterior tympanotomy for such cases by identifying the fossa incudis, horizontal semicircular canal, and horizontal facial nerve as landmarks will be presented will be presented as well.
References: Aidonis I, Robertson TC, Sismanis A.Cartilage shield tympanoplasty: a reliable technique. Otol Neurotol. 2005 Sep;26(5):838-41. Kyrodimos E, Sismanis A, Santos D.: Type III cartilage “shield” tympanoplasty: an effective procedure for hearing improvement. Otolaryngol Head Neck Surg. 2007 Jun;136(6):982-5. 9:00 - 10:00 (Rooms 1-8)

Total implantable middle ear prosthesis (Otologics Carina) for sensorineural and mixed
hearing loss
Luca Bruschini Medical Assistant, Otology and Cochlear Implant Centre, University of Pisa, Italy
Abstract Purpose: The purpose of this report is to show our experience with the fully implantable Carina™ in ten adult patients, eight with moderate to severe sensorineural hearing loss (SNHL) and two with mixed hearing loss. Materials and methods: Ten adult patients, eight with moderate to severe SNHL and two with mixed hearing loss (one due to tympanosclerosis and the other to otosclerosis) were implanted between November 2007 and October 2009 in the ENT Unit of the University of Pisa. The mean follow-up was 16 months of device use (range 3-25 months). Results: In all the patients we recorded neither surgical relevant complications, nor significative postoperative variations in hearing thresholds, including air conduction and bone conduction, thus indicating the absence of surgical damage to the cochlea. With the device functioning, all the patients demonstrated improvements in hearing thresholds in free field and in speech perception abilities; moreover they reported subjective benefits. With regard to the post-operative adverse effects, we experienced problems of feedback noise, which could be solved in nine cases using minor fitting adjustments. In one patient a second surgery was needed to change the microphone position.
We additionally had single-cases of minimal extrusion of the microphone cable that required a revision surgery; one device failure that required its substitution; and ask for explantation of the device for psychological problems experienced by another patient. Conclusions: Our results attest that the Otologics MET Carina™ is a viable treatment for moderate to severe sensorineural hearing loss and for cases of mixed hearing loss. Moreover, in selected
cases it could represent an alternative to conventional hearing aids.

VESTIBULAR FUNCTION ASSESSMENT
Antonio Denia Lafuente - Unidad de Sordera y Vértigo, Madrid, SPAIN
Conventional tests for the study of vestibular function include the basic electronystagmography (ENG)/videonystagmography (VNG) battery (visualoculomotor, positional and bithermal caloric tests) and rotational tests around the vertical axis. Advances in video techniques have contributed to the development of more accurate and accessible
video-oculography (VOG) systems, making this the preferred method for both the qualitative clinical examination and recording of ocular movements using “video Frenzels”, as well as for quantitative testing using conventional vestibular studies through the use of two-dimensional VOG systems (2D VOG). Conventional tests have been very useful in providing the majority of our basic clinical and physiological understanding of vestibular function even though they are primarily focused on the study of the vestibuloocular reflex as it relates to the horizontal semicircular canal, without providing us with any information on the otolith organs or the vertical canals. Fortunately, several recent discoveries related to the clinical and laboratory study of patients with dizziness have led to the ability to make a more accurate diagnosis of vestibular conditions. Some otolith function tests related to the saccule have been incorporated into the routine laboratory study of vestibular function, while other more sophisticated tests related to utricle function are gradually being incorporated into some clinics that are specialized in the study of patients with dizziness. Additionally, tests have been developed to study vertical semicircular canal function using three-dimensional (3D) techniques to record and analyze ocular movements. These tests are beginning to be used
in some vestibular testing laboratories. The combination of conventional and modern vestibular tests broadens the study of vestibular function to the majority of peripheral vestibular organs, making the tests more complete. This instructional course reviews and summarizes the use and clinical applications of conventional and modern clinical and laboratory vestibular function tests, emphasizing their advantages and limitations.

COCHLEAR IMPLANTS IN VERY YOUNG CHILDREN: INDICATIONS AND SURGICAL
TECHNIQUES
A. Della Volpe (Napoli, Italy)

ACOUSTIC NEUROMA
Shakeel Saeed (London, United Kingdom)

Management of middle ear cholesteatoma with fistula or invasion of the labyrinth. The-
Parma experience.
Piazza F., Zini C. ENT Department, Otology & Neurotology – Parma (Italy)
The surgeon should always be prepared for the possibility of a labyrinthine involvement in cholesteatoma surgery (incidence is about 10%). In 1998 we presented the Zini-Piazza classification which makes a clear distinction among erosions, fistulae and invasions of the labyrinth. Intraoperative management of labyrinthine involvement starts by opening the cholesteatoma sac. The medial wall of the sac is inspected and palpated to detect any bony defect. Once a fistula or an invasion is found, matrix is left over the bony defect while the surrounding disease is removed. If removal of the matrix is planned, it should be the last maneuver performed prior to completing the surgical procedure. We found that the intraoperative topical application of sodium 2-mercaptoethanesulphonate (mesna) facilitates
the dissection of the matrix. In the so called “chemically assisted dissection” (CADISS) of the matrix we use the common mechanical instruments opportunely modified in order to deliver the 10% mesna solution directly on the tip of the instruments. In closed techniques, the matrix is detached from the periphery to the center of the FISTULA and the area of the bony defect is sealed with bone pate which is glued to the surrounding bone. In case of INVASION
of the labyrinth, drilling of the canal(s) is usually necessary to expose the bottom of the “cul de sac” which is later on removed. The interrupted canal is then sealed with small bone wax spheres and the area of the canal(s) is closed with bone pate. Results will be described in detail. Chemically assisted dissection of the matrix allowed us to increase the number of closed techniques, removing the cholesteatoma matrix, not only in case of large fistula,
but also in case of invasion of the semicircular canals.

STAPES SURGERY: OTOSCLEROSIS, PRIMARY AND REVISION SURGERY AND CONGENITAL MALFORMATIONS. RULES AND HINTS
Robert Vincent (Colombieres, France)

SURGICAL APPROACHES TO THE COCHLEA FOR THE TREATMENT OF HEARING LOSS WITH IMPLANTABLE DEVICES
Manuel Manrique (Pamplona, Spain)

FACIAL NERVE REHABILITATION
Marco Fontana (Padua, Italy)

10:00 - 11:00 (Rooms 1-8)

Rehabilitation of complete auricular atresia by Middle Ear Implants
Eric TRUY, MD, Professor of Otolaryngology Edouard Herriot University Hospital and Claude Bernard University (Lyon, France)
Complete Auricular Atresia (CAA) is one of the major challenging disease an ENT has to face. Questions from parents are about esthetics and audition. It is important to give them as soon as possible a clear agenda regarding pinna reconstruction and means to restore a usefull audition. Both projects are to be exposed, and interference between them are to be explained to parents. Reconstruction of outer ear canal, tympanic membrane and ossicles
is very difficult; results are not constant and some complications can occur. So alternative methods using bone conduction have been developped: bone conduction on head set are more recently on soft band, waiting for a cortical bone thick enough to propose a Bone Anchored Hearing Aid (BAHA). More recently Middle Ear Implants (MEI) have been used in some patients with CAA. Objectives of this course are: 1. to remind how audition is in unilateral and bilateral CAA. 2. to expose briefly the principles and the agenda for pinna reconstruction with special emphasis to interference with all possible functional surgeries. 3. to expose alternative functional means of auditory rehabilitation (external bone conduction, functional surgery, BAHA, MEI). 4. to propose an agenda for patients suffering from CAA. 5. to expose surgery of MIE applied to CAA, and to report results of our experience.

Working up the dizzy patient
Giorgio Guidetti Servizio di Audio-Vestibologia e Rieducazione Vestibolare Azienda USL di Modena g.guidetti@ausl.mo.it
Clinical tests are more important than the classical instrumental methods in identifying lesions of both peripheral vestibular system and the entire balance system. We have a lot of clinical tests. In the field of static and dynamic balance control, the bedside examination (Romberg standing test, Unterberger stepping test , past point test, forefinger- nose indication test) is interesting but do not have much sensitivity or specificity. In the field of oculomotor pathologies the function of cranial nerves III, IV and VI is first evaluated. The vestibular oculomotor reflex is the most accessible gauge of vestibular function. Nystagmus is the typical sign of vestibular damage. Nystagmus is traditionally divided into 2 types: pendular and jerk nystagmus. Pendular nystagmus is characterised by equal speed in either direction, and jerk nystagmus has 2 phases. In jerk nystagmus, the speed is faster in one direction than in the other. True pendular nystagmus is sinusoidal, whereas jerk nystagmus has a slow phase and a fast saccadic phase. The localising significance of nystagmus is often a mere indication of dysfunction somewhere in the posterior fossa but certain nystagmus patterns are quite specific and permit reasonably accurate neuroanatomic diagnosis. The different kinds of central and peripheral nystagmus (congenital, spontaneous, evoked by ocular movements, by positions of the head, by positioning movements or provoked by stimulations such as head movements, visual inputs and particular devices) and the different posture and gait pathologies will be shown.

OPERATING ROOM SET-UP IN MIDDLE EAR AND LATERAL SKULL BASE COURSE FOR BEGINNERS
Hiroshi Sunose (Sendai, Japan)

HOW TO AVOID CSF LEAK IN LATERAL SKULL BASE SURGERY
Jeff Mulder, Paul Merkus, Paolo Fois (The Netherlands, Italy)

Management of complications of chronic otitis media
N. Quaranta, A. Quaranta
Otolaryngology “G. Lugli”, Otologic and Neurotologic Surgery, University of Bari
Chronic otitis media can lead to extracranial and intracranial complications. The presence of an extracranial or intracranial complication is evident before surgery, however a labyrinthine fistula or a dehiscence of the facial nerve may be found only during surgery. An ear surgeon has to know the possible complication of a chronic otitis media and has to be prepared to manage these complications. During the course the pathogenesis and the management
of such complications will be discussed and clinical cases will be shown.

Experiences with different self-crimping prostheses in stapes surgery
J. Hornung MD - Department of Otorhinolaryngology, Head & Neck Surgery University Erlangen-Nuremberg, Germany
Introduction: Prostheses currently used in stapes surgery differ in form, the diameter of the piston, the length of the implant, and also in weight. Apart from ease of handling during surgery, the most important requirements for stapes prostheses are good biocompatibility and adequate transmission of sound. Stable fixation of the prosthesis on the long process of the incus is particularly relevant to this last requirement to achieve the main objective of stapes
surgery: to provide a reliable and persistent improvement in hearing. The fixation necessary for most prostheses, referred to as crimping, is certainly one of the most difficult and, at the same time, most important steps for the quality of hearing after stapes surgery. This step is affected by a range of factors, making the accurate prediction of the audiometric results nearly impossible. To avoid the problems of manual crimping, various further modifications
have been made to the prostheses. Course description: The main goal of this course is to show the benefits of using self-crimping stapes prostheses and how this could help to standardize stapes surgery. In form of a presentation with included videos four self-crimping prostheses will be presented. The presentation contains the explanation of the different fixation mechanism, including video demonstration of the intra operative handling and discussion of the advantages and disadvantages from each prosthesis. The course further includes also pearls and pitfalls to encourage the participants in testing self-crimping stapes prostheses by themselves. A major point is to demonstrate the short and long term hearing results obtained with these prostheses compared to manual crimping ones like a Fisch or Richards piston. In the last 6 years we gained a lot of experience with different self-crimping prostheses. Before this time we used mainly manual crimping prosthesis with a platinum or stainless steel wire loop. Especially for beginners in stapes surgery this makes crimping a very difficult surgical step. The use of the self-crimping prostheses led to a simplification and standardization and helped us to save time during surgery in our department. The influence of the experience of the surgeon was reduced. The hearing results we got with these new prostheses were similar to the results with manual crimping prostheses. Based on these experiences we exclusively use one of the presented self-crimping stapes prosthesis.

CHOLESTEATOMA AND MIDDLE EAR UNDERAERATION DISEASES - FROM PATHOPHYSIOLOGY VIA SURGICAL TECHNIQUES
Michal Lunz (Haifa, Israel)

Neuro-otological features of benign paroxismal vertigo and benign paroxismal positional vertigo in children: a follow up study
V. Marcelli, F. Piazza (Naples and Parma, Italy)
BACKGROUND: Causes of benign episodic vertigo in paediatric age include benign paroxismal vertigo of childhood (BPV) and benign paroxismal positional vertigo BPPV). OBJECTIVE: The aim of this presentation is to review the the clinical, audiological and vestibular findings in a cohort of children with BPV and in a group of children with
BPPV and to highlight the differences useful to formulating a differential diagnosis. METHODS: Eighteen children, aged 4-9 years, consecutively examined between January 2002 and December 2002 entered our study. The clinical characteristics of vertigo, presence of triggering factors, family history of migraine, presence of motion sickness, migraine and
other accompanying symptoms were considered. Neurological, ophtalmologic, vestibular and auditory functions were assessed. RESULTS: Eight children suffered from BPPV and ten from BPV. In the BPPV group, the vestibular examination was normal except for the Dix- Hallpike maneuver. Liberatory maneuvers were immediately effective in all patients and all remained symptom-free during the follow up. In the BPV group, the vestibular examination was positive in 3 patients, but none had positive Dix-Hallpike maneuver. All patients with BPV have a positive family history of migraine and seven had a history of motion sickness. In all, migraine was present one year before the vertigo symptoms, with a frequency of at least two migraine episodes a month. CONCLUSION: BPV differs from BPPV in terms of family history, clinical symptoms, otoneurological signs, and must be treated with liberatory maneuvers: neither medical therapy nor strict follow-up is needed

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JOINT MEETING - IV CONSENSUS IN AUDITORY IMPLANTS &
V EAONO INSTRUCTIONAL WORKSHOP - Parma June 16-19, 2010

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