Identifying Slim Modiolar Electrode Tip Fold-Over With Intracochlear Electrocochleography.

The aim of this study is to report on our preliminary experience with Transimpedance Matrix (TIM)-measurement for the detection of cochlear implant electrode tip foldovers compared with intraoperative imaging in patients implanted with the slim modiolar electrode (SME). Proof of concept study. Tertiary university referral center. Twenty five ears (in 22 patients) implanted consecutively with the SME. Following cochlear implantation, intraoperative TIM-measurement and fluoroscopy were performed. One week postoperatively, the electrode position was evaluated using Computed Tomography (CT)-imaging. Electrode array tip foldover. Electrode array tip foldover occurred in three of the 25 cochlear implantations performed (12%). In each case, the foldover was detected by both TIM and fluoroscopy, leading to reposition and correct intracochlear placement of the array. TIM-measurement is a promising method for the intraoperative detection of an electrode array tip foldover. The TIM-tool with intuitive heatmap display is easy to use, fast, and readily available to clinics using TIM-software in the operating theatre.

ObjectiveCharacterize the sensitivity and specificity of TransImpedance Matrix (TIM) recordings compared with x-rays in detecting cochlear implant tip foldovers.Study DesignRetrospective.SettingMulti-institutional, academic and private surgery centers.PatientsPatients 6 months and older undergoing cochlear implantation.InterventionsAfter cochlear implant array insertion, intraoperative TIM recordings and x-rays were conducted to confirm appropriate placement. If a foldover was identified, repeat insertion, followed by TIM and x-ray, was performed.Main Outcome MeasuresPresence of tip foldovers as determined by TIM recordings and x-rays.ResultsThere were 13 tip foldovers out of 484 insertions, yielding a 2.7% tip foldover rate. Using x-rays as the “gold standard,” TIM recordings showed 100% sensitivity, 99.6% specificity, 84.6% positive predictive value (PPV), and 100% negative predicative value in detecting tip foldovers. The x-ray images for two TIM-identified tip foldovers were interpreted as normal intraoperatively (apparent false positives), but then were interpreted as foldovers when presented to the operating surgeon postoperatively in a blinded fashion. If these false positives had been reclassified as true positives, TIM specificity and PPV would both improve to 100%.ConclusionsThese results provide further support regarding the utility of TIM recordings to evaluate appropriate cochlear implant electrode array position. Despite the low tip foldover rate reported across the literature and within this study, this multicenter patient group provided a large sample size to calculate the sensitivity and specificity of TIM recordings in identifying tip foldovers. Compared with the reference-standard, x-ray imaging, TIM recordings show equivalent, and in some cases superior, performance in identification of tip foldovers. Thus, use of TIM can potentially preclude the need for routine intraoperative x-rays without compromising patient care.

Recent advancements toward minimizing surgical trauma and preserving residual hearing during cochlear implantation have promoted the use of intracochlear electrocochleography (ECochG) for intraoperative surveillance. However, variations in the distribution of response generators throughout the cochlea complicate the interpretation of signal changes during electrode array insertion. This exploratory study aimed to investigate whether simultaneous recordings from 2 locations within the cochlea could address this issue. This was done by (1) comparing recordings acquired simultaneously from an apical and a more basal electrode contact during atraumatic electrode array insertions; and (2) comparing these response patterns with preoperative pure-tone audiograms. In 10 standard CI recipients, ECochG recordings were obtained during stepwise insertion of a short-temporary electrode array. Simultaneous intracochlear recordings were acquired from 2 contacts separated by 4.2mm in response to 500Hz tone bursts. For both electrode contacts, the differences between responses to alternating-polarity stimuli, hereafter named "ECochG responses," were derived. After completion of the recordings, the temporary electrode array was removed and a standard CI electrode array inserted. In 6 of 10 participants, ECochG response amplitude decreases of ≥3dB were recorded at the more basal electrode contact. In 4 cases, these amplitude drops were preceded by amplitude drops recorded at the apical electrode contact, with both occurring no more than 1.7mm apart along the cochlear duct. Trauma would be expected to produce a simultaneous amplitude drop-at different recording locations-for both electrodes. In contrast, a drop at the basal electrode that is preceded by a drop in the ECochG recording at the apical electrode, with both drops occurring at approximately the same location, is likely atraumatic. These atraumatic drops may also be associated with large phase shifts. Overall, the ECochG response tracks recorded at the apical and more basal contact were similar, while the ECochG response patterns and audiogram did not show a strong resemblance. The proposed approach could facilitate the detection of ECochG response changes relevant for predicting hearing preservation during cochlear implantation. By distinguishing between simultaneous and sequential amplitude drops, this method could provide additional insights into the atraumatic nature of certain ECochG response changes.

This study aimed to evaluate the effectiveness of the SmartNav in detecting tip fold-over during cochlear implantation and to compare angular insertion depth measurements obtained via SmartNav and transorbital X-ray imaging. This retrospective multicentre study included patients with normal cochlear anatomy, comprising 163 individuals and 213 ears who underwent cochlear implantation using Nucleus CI522 and CI622 systems at Gazi University Faculty of Medicine and Gaziantep City Hospital. Of the 213 cochlear implantations, tip fold-over was detected in 4 implantations (1.88 per cent) intra-operatively with SmartNav. One case (0.47 per cent) of tip fold-over was not detected by SmartNav and identified post-operatively through X-ray imaging. SmartNav showed a sensitivity of 80 per cent, specificity of 100 per cent. A strong correlation was found between SmartNav and X-ray angular insertion depth measurements (p < 0.001). The SmartNav is a reliable tool for the intra-operative detection of tip fold-overand the assessment of angular insertion depth in patients with normal cochlear anatomy.

Plain Language SummaryCochlear implants are medical devices that can restore hearing in people with severe or complete hearing loss. These devices use thin wires called electrode arrays that are placed inside the inner ear (the cochlea) to send electrical signals to the hearing nerve. There are different types of electrode arrays, and they may work differently depending on their shape and how they are positioned in the ear. This study looked at two types of electrode arrays that are both curved to fit the shape of the cochlea. One is called the Contour Advance (CA), and the other is called the Slim Modiolar Electrode (SME). We examined how these two types performed in 70 adults who received a cochlear implant. We measured the strength of the electrical signal needed to activate the hearing nerve, the level of stimulation needed for the sound to be comfortable for the user, and how long the battery lasted in daily use. We found that the two electrode types worked differently. The CA array showed more stable results and a clearer relationship between the measured signal strength and the user’s comfortable hearing level. The SME needed stronger signals in some parts of the cochlea and showed more variation across users. Battery use was also related to different factors for each array type. This study shows that the choice of electrode array can affect how the implant works and how it should be programmed. This information may help improve hearing outcomes for people using cochlear implants.

Utility of Intraoperative Radiographs in Pediatric Cochlear Implant Surgery.

A cochlear implant (CI) is a hearing device introduced in the 1980s for profoundly deaf subjects who gained little or no benefit from powerful hearing aids. This device comprises an electrode array inserted in the cochlea, connected to an internal receiver, and an externally worn speech processor. The CI transforms acoustic signals into electrical currents which directly stimulate the auditory nerve. Since the early 1990s, cochlear implantation in children has been developing rapidly. Although it is still difficult to predict how a child will perform with a cochlear implant, the success of cochlear implantation can no longer be denied. In this paper, some recent papers and reports, and the results of the various Nijmegen cochlear implant studies, are reviewed. Issues about selection, examinations, surgery and the outcome are discussed. Overall, our results were comparable with those of other authors. It can be concluded that cochlear implantation is an effective treatment for postlingually deaf as well as prelingually (congenital or acquired) deaf children with profound bilateral sensorineural deafness.

Surgical Outcomes of Simultaneous Cochlear Implantation and Intracochlear Schwannoma Removal.

Intracochlear electrocochleography findings in cochlear implant recipients with auditory neuropathy spectrum disorder.

The round window insertion (RWI) and cochleostomy approaches are the 2 most common surgical techniques used in cochlear implantation (CI). However, there is no consensus on which approach is ideal for electrode array insertion, in part because visualization of intracochlear electrode position is challenging, so postoperative assessment of intracochlear electrode contact is lacking. To measure and compare electrode array position between RWI and cochleostomy approaches for CI insertion. Retrospective case-comparison study of 17 CI users with Med-El standard-length electrode arrays who underwent flat-panel computed tomography scans after CI surgery at a tertiary referral center. The data was analyzed in October 2015. Flat-panel computed tomography scans were collected between January 1 and August 31, 2013, for 22 electrode arrays. The surgical technique was identified by a combination of operative notes and imaging. Eight cochleae underwent RWI and 14 cochleae underwent cochleostomy approaches anterior and inferior to the round window. Interscalar electrode position and electrode centroid distance to the osseous spiral lamina, lateral bony wall, and central axis of the modiolus. Nine participants were men, and 8, women; the mean age was 54.4 (range, 21-64) years. Electrode position was significantly closer to cochlear neural elements with RWI than cochleostomy approaches. Between the 2 surgical approaches, the RWI technique produced shorter distances between the electrode and the modiolus (mean difference, -0.33 [95% CI, -0.29 to -0.39] mm in the apical electrode; -1.42 [95% CI, -1.24 to -1.57] mm in the basal electrode). This difference, which was most prominent in the first third and latter third of the basal turn, decreased after the basal turn. The RWI approach was associated with an increased likelihood of perimodiolar placement. Opting to use RWI over cochleostomy approaches in CI candidates may position electrodes closer to cochlear neural substrates and minimize current spread. These findings need to be interpreted in light of the increased potential for osseous spiral lamina trauma with reduced distances between the electrode array and modiolus.

Objectives: The aim of this discussion paper and literature review was to estimate the incidence of a variety of complications associated with the surgical placement of cochlear implant (CI) electrode arrays and to discuss the implications and management of sub-optimal electrode placement. Results: A review of the peer-reviewed literature suggests that the incidence of incomplete electrode insertion and kinking is more prevalent in straight arrays and not more than about 2% in CI recipients with normal cochlear anatomy/patency. Incidence of tip fold-over is greater with perimodiolar arrays but also occurs with straight arrays and is typically less than 5%. Conversely, electrode migration is more common with straight arrays, and high rates (up to 46%) have been reported in some studies. Scalar translocations have also been reported for both perimodiolar and straight arrays. Higher rates have been reported for stylet-based perimodiolar electrodes inserted via cochleostomy (up to 56%), but with much lower rates (<10%) with both sheath-based perimodiolar arrays and lateral wall arrays. Electrode positioning complications represent a significant proportion of perioperative CI complications and compromise the level of benefit from the device. Careful surgical planning and appropriate pre- and intraoperative imaging can reduce the likelihood and impact of electrode positioning complications. There is also evidence that newer array designs are less prone to certain complications, particularly scalar translocation. Conclusions: It is important that implanting surgeons are aware of the impact of sub-optimal electrode placement and the steps that can be taken to avoid, identify and manage such complications.

Cochlear implantation is currently regarded as a safe and minimally invasive procedure. However, cochlear implantation can have an impact on vestibular function, despite the lack of correlation between patient symptomatology and damage in vestibular tests. Thus, the present study aims to analyze the presence of hydrops and histological reactions at the level of the vestibule after cochlear implantation with dexamethasone pump delivery in Macaca fascicularis (Mf). A detailed histological study was conducted on a total of 11 Mf. All 11 Mf were divided into three groups: 5 Mf were implanted with an electrode array HL-14 connected to a pump delivering FITC-dextran for 24 h (Group A); 4 Mf were implanted with a CI electrode array attached to a pump for FITC-dextran delivery for 7 days (Group B); and 2 Mf were considered the control group, without any kind of cochlear device implantation (Group C). After drug deliver, the selected macaques were euthanized to collect tissue samples for histological analysis. An experienced observer, focusing on the utricle and saccule areas, conducted a blinded inner ear histology analysis. Surgical procedures were successfully performed in all cases. No signs of cochlear reaction to the device were observed, including neither collapse nor fibrosis. Endolymphatic sinus dilatation was observed in Mf4A and Mf3B, while cochlear hydrops was observed in Mf3A. The mean areas of the utricle and saccule exhibited some statistically significant differences, specifically, in the saccule between groups C and both groups A (p = 0.028) and B (p = 0.029); however, no significant differences were observed between groups A and B or among comparisons of the utricle. A significant concern relates to the safety of cochlear implantation with regard to vestibular preservation and hearing. New advancements in electrode arrays, such as CI devices coupled with delivery pumps, pose a challenge in maintaining minimally traumatic surgical concept-based procedures without affecting the inner ear homeostasis. The implantation of this device may cause vestibular hydrops in the saccule, indicating that the longer the time of substance release, the greater the grade of hydrops evidenced at the saccular level. Apart from this finding, the risk of histological damage to the vestibule is low.

By estimating the length of the cochlear duct, commercial software algorithms intend to support CI teams by the selection of the suitable electrode array length prior to cochlear implant (CI) surgery. In the present study center, predominantly 31.5 mm flexible electrode arrays are used for patients with radiologically regular cochleae. Routinely performed postoperative Stenvers x-ray detects complete insertion in all cases. The aim of this study was to test the accuracy of the commercial software algorithm in predicting the angular insertion depths for this specific CI group with deeply inserted electrodes. Retrospective cohort study. University medical center, tertiary academic referral center. Patients undergoing a cochlear implant surgery MED-EL FLEXsoft electrode array (Synchrony2, MED-EL, Innsbruck, Austria) between January 2019 and December 2022. Preoperative CT images for 72 CI ears with 31.5 mm flexible electrode arrays were examined using OTOPLAN, and the maximum insertion depth (maxAID) was estimated. Postoperatively, the actual maxAID was determined through Stenvers x-ray images. The preoperatively estimated maxAID demonstrated a correlation with the postoperatively measured maxAID (R = 0.45, p < 0.001) but deviated by 44.8° ± 8.4°. There is a systematic overestimation by OTOPLAN of the insertion depths for estimated values exceeding 720°. To address this, an optimal offset of 2.4 mm is identified when considering this parameter in estimating maxAID for depths exceeding 720°. OTOPLAN predicts AID outcomes in CI patients but may deviate in small cochleae (CDL < 35 mm).

Speech recognition outcomes with a cochlear implant (CI) are highly variable. One factor suggested to correlate with CI-aided speech recognition is frequency-to-place mismatch, or the discrepancy between the natural tonotopic organization of the cochlea and the electric frequency allocation of the CI electrodes within the patient's cochlea. To evaluate the association between frequency-to-place mismatch and speech recognition outcomes in a large cohort of postlingually deafened adult CI users, while controlling for various clinical factors known to be associated with those outcomes. This retrospective cohort study used data from a CI program at a tertiary medical center and included CIs from postlingually deafened adult CI users. After excluding patients whose data were not logged, patients with implantations occurring between 2016 and 2023 were included in the analysis. The data were extracted in November 2023. Results of the Consonant-Nucleus-Consonant (CNC) monosyllabic word recognition test measured in the CI-aided alone condition 1 month, 3 months, 6 months, and 12 months after activation served as the main outcome. The independent variables included frequency-to-place mismatch, electrode array type, mean modiolar distance, electrode position, age at implantation, biological sex, contralateral hearing abilities, time since CI activation (test interval), and daily device use. In 498 CIs from 447 postlingually deafened adults (mean [SD] age, 63.1 [17.1] years; 271 [54.4%] CIs with male users), frequency-to-place mismatch was negatively correlated with CI-aided speech recognition outcomes, but the association was only significant for precurved electrode arrays and not straight electrode arrays. In the linear mixed effects model for straight electrode arrays, only test interval (β = 1.14 [95% CI, 0.90-1.38]) and daily device use (β = 0.90 [95% CI, 0.42-1.38]) were correlated with the improvement of word recognition over the first year of device use. In the model for precurved electrode arrays, mismatch at 1500 Hz (β = -0.011 [95% CI, -0.011 to -0.006]), scalar location (β = 16.37 [95% CI, 9.01 to 23.74]), test interval (β = 1.18 [95% CI, 1.18-1.41]) and daily device use (β = 1.65 [95% CI, 1.15-2.14]) all were significantly associated with the improvement of word recognition over the first year of device use. In this cohort study of postlingually deafened adult CI users, including both straight and precurved electrode arrays, daily device use and time since CI activation were found to be significantly associated with improved CI-aided speech recognition outcomes. Frequency-to-place mismatch at 1500 Hz and scalar location were associated with word recognition only for precurved arrays. These findings suggest that, for patients with straight arrays, any interference produced by frequency-to-place mismatch may be overcome by adaptation, which could be supported by daily device use. However, for patients with precurved arrays, daily device use may not be sufficient to completely overcome electrode placement factors, including scalar location and mismatch.

EDITORS' INTRODUCTION In the early years of its publication, the American Journal of Otology published articles featuring some of the most notable otology and neurotology programs in the country and the world. Over the years that journal has grown, changed names, and developed a second (fully open access) journal. At the same time, the subspecialties of Otology and Neurotology have changed and grown. With the advent of more formal certification and the need for an increasing number of specialty trained surgeons as well as other hearing, balance, and skull base professionals, the number of notable programs has dramatically increased both inside and outside the United States. Each of these programs is dedicated to providing quality patient care, performing cutting edge research, and training the next generation of both surgeons and scientists that will help lead our specialty in the future. As we launch the newest addition to the family of journals that started with the American Journal of Otology, we wanted to revive the tradition that started with the American Journal of Otology. The Journal's editorial board has formed a special group of individuals to consider which programs to highlight with each issue of the journal. Programs can be featured for a variety of achievements in the past or in the present and can be self-nominated or nominated by the committee. As we launch this series, the obvious first choice was to start where this all started, and it is our pleasure to begin this series with a look at the birthplace of the American Journal of Otology. We hope our readers find these historical looks insightful but also utilize these historical profiles as a method to help our current and future programs to evolve into even better institutions for future generations. HISTORY The Otology Group was founded in a small building in Nashville, TN, on State Street (Fig. 1), as a private practice by Michael E. Glasscock III, M.D. (1933–2018) in 1970. Nearly 51 years later, The Otology Group at Vanderbilt celebrates its anniversary as one of the largest, most innovative centers for skull base surgery, speech and hearing sciences, and neurotologic education. The historic reputation of The Otology Group of Vanderbilt transcends generations of fellows and faculty members and the group remains deeply rooted in the same fundamentals and principles from which it was founded.FIG. 1.: The small building of which The Otology Group was founded on State Street, Nashville, TN, by Dr Michael E. Glasscock III, M.D., in 1970.Michael E. Glasscock III, M.D. (Fig. 2) was a world-renowned clinician dedicated to patient and physician education (1). In 1980, He founded the American Journal of Otology, now known as Otology and Neurotology. He also founded the nonprofit organization, the EAR Foundation, dedicated to educating patients and physicians on ear and hearing disorders. In his career, he published nearly 250 peer-reviewed articles and was the editor of Surgery of the Ear. In conjunction with his partner, C. Gary Jackson, M.D., they possessed a passion for educating fellows and this passion continues to resonate within the fellowship and will do so for years to come. Dr Glasscock had sincere respect for his patients and strived to provide them with unrivaled state-of-the-art care. He was known for "doing things my way," and such mentality (and bravado) paved the way for center that exists today.FIG. 2.: Michael E. Glasscock III, M.D. (1933–2018).The Vanderbilt Bill Wilkerson Center (Fig. 3) was founded in 1951 by Dr Wesley Wilkerson, and named in honor of his son, Bill Wilkerson who was killed in Germany in 1945 during WWII. Wesley Wilkerson was an otolaryngologist in Nashville with a passion for pediatric hearing loss and chartered the Tennessee Hearing and Speech Foundation. In 1997, the Bill Wilkerson Center merged with Vanderbilt University Medical Center (VUMC). The Center was under the leadership for many years by Freeman O'Connell, Ph.D., then Fred Bess, Ph.D. (1978–2009) and is now under the leadership of Anne Marie Tharpe, Ph.D. (2009–current). Partnered with the Vanderbilt Department of Otolaryngology, the combined departments are now known as the Vanderbilt Bill Wilkerson Center for Otolaryngology and Communication Sciences. The Department of Otolaryngology, Head and Neck Surgery was reorganized in1985 and was led by Robert H. Ossoff, M.D. (1985–2009), Roland Eavey, M.D. (2000–2021) and is now under the leadership of Eben Rosenthal, M.D. (2021–present). The Department is ranked highly by external rankings nationwide and holds a strong reputation in both clinical care, research, and resident/fellow training (2). In 2004, the private practice which Mike Glasscock founded, The Otology Group, merged with the Vanderbilt Department of Otolaryngology, forming what is now known as The Otology Group of Vanderbilt. Within the Center is housed, in addition to The Otology Group of Vanderbilt, the Departments of Otolaryngology and Hearing and Speech Sciences, The Mama Lere Hearing School, The Pi Beta Phi Rehabilitative Institute, The Temporal Bone Lab, The Cochlear Implant Research Lab, The Balance Disorders Clinic, and The National Center for Childhood Deafness and Family Communication.FIG. 3.: The Vanderbilt Bill Wilkerson Center as it exists today and the home of The Otology Group at Vanderbilt, The Departments of Otolaryngology and Hearing and Speech Sciences, The Mama Lere Hearing School, The Pi Beta Phi Rehabilitation Institute, Cochlear Implant Research Laboratory, The Temporal Bone Lab, The Balance Disorders Lab, and National Center for Childhood Deafness and Family Communications.CLINICAL ENTERPRISE Under Dr Glasscock III, M.D.'s guidance, The Otology Group evolved into one of the world's most preeminent centers for skull base, cochlear implants, and ear disorders. The group is now led by David S. Haynes, M.D., M.M.H.C., a direct trainee of Glasscock III, M.D. The group is composed of 5 additional faculty and 2 nurse practitioners, including Robert Labadie, M.D., Ph.D., Marc Bennett, M.D., M.M.H.C., Matthew O'Malley, M.D., Kareem Tawfik, M.D., Elizabeth Perkins, M.D., Ken Watford, D.N.P., A.P.R.N., and Emily Brignola, D.N.P., A.P.R.N., F.N.P.-C. As one of the oldest and largest neurotology practices in the country, the clinicians strive to provide innovate, evidence-based, and honorable patient care. The Otology Group at Vanderbilt clinical practice involves a wide range of surgical approaches and techniques aimed at providing care for the most complex tumors and ear-related disorders. This includes advanced approaches to the skull base, cochlear implantation, otologic surgery, repair of cerebrospinal fluid leaks, and surgical treatment of balance disorders including superior canal dehiscence and Meniere disease. VUMC was one of the first centers to adopt endoscopic ear surgery (led by Alejandro Rivas, M.D., now at Case Western Reserve University) and to begin an annual endoscopic ear course, educating our residents, fellows, and other otolaryngologists on the new techniques of endoscopic ear surgery. The Otology Group at Vanderbilt encompasses the renowned Skull Base Center and Hearing Implant Program, a premiere destination for patients from all over the world. The Skull Base Center upholds a strong and collaborative relationship with The Department of Neurological Surgery including neurosurgeons, Reid C. Thompson, M.D. (Chair), Lola B. Chambless, M.D., and Peter J. Morone, M.D., M.S.C.I. The Skull Base Center and Hearing Implant Programs provide multidisciplinary, coordinated care, allowing for a large number of patient visits and surgical procedures, while providing the highest quality patient care. We also have a monthly multidisciplinary aural atresia clinic attended by audiology, neurotology, facial plastics, and other specialists. In addition, we have multidisciplinary teams that care for Neurofibromatosis Type II, and pediatric hearing loss, led by Kareem Tawfik, M.D. and Elizabeth L. Perkins, M.D., respectively. In 2020, The Otology Group of Vanderbilt performed over 400 skull base consultations and 140 skull base procedures despite the challenges brought by a global pandemic. Nearly 1500 patients were evaluated in the Balance Disorders Lab in 2020. In addition, 300 patients underwent cochlear implantation both in 2019 and in 2020, making VUMC the largest cochlear implant center in the United States and one of the largest in the world. RESEARCH The Cochlear Implant Research Laboratory includes principal investigators René Gifford, Ph.D. and Robert Labadie, M.D., Ph.D., and other investigators who continue to lead in international cochlear implant research. Research at VUMC ranges from reports on clinical and surgical effectiveness and quality outcomes reviews, to randomized controlled trials, such as the impact of image-guided cochlear implant programming on pediatric speech development. Research is supported from departmental resources, industry sponsored trials, and extramural funding (3–6). Our departments are ranked no. 2 in the nation in National Institute of Health (NIH) research and recent recipients of a $3.1 million NIH grant. Our recent NIH funding includes analysis of pre- and postinsertion computed tomography scanning to accurately estimate the electrode position which is used in preoperative planning and postoperative cochlear implant mapping (Fig. 4A, B) (7,8).FIG. 4.: Computed tomography (CT) scan analysis of electrode array placement following cochlear implantation. A, CT scan analysis with a perimodiolar electrode array including the cochlear, vestibule, and semicircular canals. B, Closer visualization of the electrode array and cochlea allows for assessment of the electrode array position with the modiolus (yellow) and scala tympani (blue) and scala vestibuli (green).A highly integrated, multidisciplinary team consisting of audiologists, speech language pathologists, hearing scientists, computer science engineers, and surgeons has been facilitated by institutional resources. VUMC sits on the same campus as Vanderbilt University, allowing close collaboration with other departments primarily Department of Speech and Hearing Sciences, Electrical Engineering and Computer Sciences. Vanderbilt Institute for Surgery and Engineering arose from these collaborations and continues to develop innovative solutions for surgical procedures including skull base and cochlear implant procedures. Our colocation of services has also allowed for extensive optimization of clinical delivery that includes same-day work up and surgery for cochlear implants and bundled pricing for cochlear implant services, the first in the world (9). This collaborative environment motivates basic discoveries which can then be clinically translated to improve individual outcomes. Efforts to use our electronic medical record and artificial intelligence to better coordinate clinical care and discovery is being explored by Matthew O'Malley, M.D., and will help to define our future. EDUCATION The Vanderbilt Bill Wilkerson Center is not only home to the Otology Group of Vanderbilt clinical practice but also houses our Temporal Bone lab (Fig. 5) and our research facilities. The Otology Group of Vanderbilt accepts 1 fellow per year into the neurotology program for a complement of 2 who join the neurotology service with 3 otolaryngology residents. Through the generous support of Michael E. Glasscock III, M.D. and Mr Herbert O. Christopher, the fellowship is enabled to pursue educational, academic, and research endeavors that will improve patient outcomes. Keeping with the theme of physician education, the first temporal bone lab was built in 1970 by Michael E. Glasscock III, M.D., with Jack Urban. The Otology Group of Vanderbilt continues to host multiple workshops and continuing medical education (CME) courses. This includes the annual temporal bone course, with the 85th version being held in the Fall of 2021 and the 7th annual Endoscopic Ear Course held next spring. In addition, an annual CME Otolaryngology course is held in Vail, CO, providing neurotologic education to neurotologists, otolaryngologists, and resident trainees. We also host an in-house resident/fellow temporal bone and endoscopic courses spanning 6 weeks led by Marc Bennett, M.D.FIG. 5.: The VUMC temporal bone lab resides in the Bill Wilkerson Center. The group hosts an annual temporal bone course, with nearly 300 participants in the virtual course in Fall 2020. VUMC indicates Vanderbilt University Medical Center.Fellow and resident education is ubiquitous, with weekly grand rounds on Friday mornings and weekly dedicated neurotology lectures on Thursday mornings led by prominent speakers within the field. Stepping beyond medical education, a leadership course is instituted throughout the year covering topics such as operations, cost accounting, organizational structure, strategy, and leadership (10). Multidisciplinary care is executed through many conferences for both skull base and cochlear implant recipients. The cochlear implant conference is held monthly and attended by audiologists, speech language pathologists, surgeons, social workers, administrative team members, implant research team members, and the cochlear implant coordinator. The monthly skull base conference is attended by neurotology faculty and fellows, neurosurgeons, radiologists, radiation oncologists, skull base coordinators, and research team members. Keeping with the Glasscock scholarly mission, The Otology Group at Vanderbilt takes considerable pride in the education of fellows and residents. This education begins with otologic surgery but transcends into every aspect of being a clinician and a leader. Fellows are "raised" to emulate the Glasscock mentality of prioritizing patient care and practicing with honor and integrity. Previous graduates and current fellows are customarily found at the podium at national and international conferences (Fig. 6) with nearly 30 to 34 peer-reviewed publications per year and over 90 scientific presentations at meetings, courses, and workshops annually. Prior fellows have held leadership positions in multiple international organizations including the American Neurotologic Society, the American Otologic Society, Triological Society, The Collegium Oto-Rhino-Laryngologicum Amicitiae Sacrum, the American Cochlear Implant Alliance, and many others. The fellows graduate with extensive operative and clinical experience, moving on to flourish within the field as division directors and chairpersons, academic deans, successful private practitioners, and academic leaders. This year, the Otology Group at Vanderbilt will proudly graduate its 73rd fellow in neurotology. Built on the legacy of Michael E. Glasscock III, M.D., the Otology Group at Vanderbilt will continue to strive for excellence in research, education, leadership training, and constantly seek innovation and improvement in patient care.FIG. 6.: The Otology Group will graduate its 73rd fellow in the upcoming year, as shown in this group composite. In the center of the composite proudly pictures the faculty mentors and Michael E. Glasscock III, M.D.As a rapidly growing department, The Otology Group at Vanderbilt is committed to providing care for all populations and modeling diversity. Such vision is facilitated through expanding care to remote populations involving telehealth, expedited and personalized care, and physician outreach. The group fosters diversity and equality through onboarding international faculty and fellows who reflect the increasingly diverse society we serve. CONCLUSION The Otology Group at Vanderbilt has strived from its inception to provide the highest quality patient care and to train the best neurotologic surgeons to become leaders in our field. We aspire to discover and provide novel and innovative treatments that will improve the lives of our patients. Education of patients, practicing physicians, and physicians in training remains an essential component of our group. As we celebrate our 51st year, our values remain stronger than ever.