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Review
Peer-Review Record

Subtotal Petrosectomy (SP) in Cochlear Implantation (CI): A Report of 92 Cases

Audiol. Res. 2022, 12(2), 113-125; https://doi.org/10.3390/audiolres12020014
by Ignacio Arístegui 1, Gracia Aranguez 2, José Carlos Casqueiro 3, Manuel Gutiérrez-Triguero 4, Almudena del Pozo 4 and Miguel Arístegui 5,*
Reviewer 1: Anonymous
Reviewer 2: Anonymous
Audiol. Res. 2022, 12(2), 113-125; https://doi.org/10.3390/audiolres12020014
Submission received: 7 December 2021 / Revised: 13 February 2022 / Accepted: 17 February 2022 / Published: 25 February 2022
(This article belongs to the Special Issue Advances in Cochlear Implantation)

Round 1

Reviewer 1 Report

The Authors report an impressive series of cases of cochlear implantation performed through a subtotal petrosectomy. The paper is worth to be published; however the following points should be explained before publications:

130: The Authors do not specify the radiological investigations adopted for their follow-up and the time interval at which some investigations have been performed. Because of the risk of entrapped cholesteatoma (or cholesterol granuloma) this is a critical point when evaluating the SP complications

356: "When labyrinthectomy has to be associated ...... SP is preferred". Labyrinthectomy is commonly performed through a standard mastoidectomy because not all the Meniere cases show a contracted mastoid. It is not clear why the Authors prefer the combination with SP in these cases. 

371: "Gusher may be anticipated in case of EVA......" Intraoperative finding in case of isolated EVA is usually a peri-lymphatic oozing, because there is no connection between the peri-lymphatic and the subarachnoid space. As a consequence SP for this indication is probably not necessary. In case of a real gusher the surgeon may also intraoperatively switch from the standard transmastoid technique to the SP

Author Response

The issue on imaging follow up is answered in 135-140.

356 Added to the phrase, explains why using SP in all cases of labyrinthectomy with narrow space.

371 For us perilymphatic gusher also increases the risk of meningitis if ME infection occurs. A comment is included. 

Author Response File: Author Response.docx

Reviewer 2 Report

This paper represents one of the biggest series available in the literature regarding CI and SP. It is not the largest, as mentioned in the abstract. The text should be generally revised in the English form; there are many typos and verbs are both in the present and past forms. Also, abbreviations are not reported or sometimes repeated (i.e see lines 40, 44,45). I think you should need the help of an academic professional writer.

Then, section 2 has to be rewritten. Sections 2.1....could be shifted into the discussion (as done, so this could represent a repetition) or directly removed. 

Cases where a more extensive skull base procedure has been perfomed (i.e cases of petrous bone cholesteatoma, acoustic neuroma) have to be revomed; they do not represent a SP. You can consider them in a different paper. You may do this also for meniere's cases, in which also a standard technique can be safely performed.

Cases of choelsteatoma could represent a topic to be discussed. If small cholesteatoma can be safely treated with SP + CI, more extensive cases can represent a problem in terms of follow up. You correctly cited the possibility of a radiological follow up with CT or MRI scans, but also a staged procedure putting a dummy electrode in the first stage could be a choice, delaying the CI after an initial follow up. Considering that in many of your cases a single stage was performed, cite the follow up (min-max-median).  

 

Author Response

That assertion (the largest series) has been changed (one of the largest series)

English has been reviewed by an English accademic professional.

Section 2 includes the basis for indications. Although it may look repetitive on discussion, the first is the leitmotiv for inclusion of patients in each group in materials and methods. An then, discussion is referred to each group of conditions mentioned in results. We would prefer to keep it as it is. But thank you for your suggestion.

Vestibular Schwannoma, petrous bone cholesteatoma are complex skull base procedures and outcomes may be influenced by this surgical complexity, but when you eliminate the middle ear, you proceed with all the steps of a SP and could be included, in our opinion, in this work. Looking after residuals, repneumatization, local infection, leakage or extrusion, could be evaluated although understandably with a higher risk in those indications. 

Meniere´s disease is not a common indication for SP and we are not always using it, but, as stated in the work (we have partial changed a statement to make it more clear), when the anatomy is narrow and specially if there is a previous perforation or grommet, we do prefer a SP approach. 

We have include in materials and methods the methodology for follow up in all patients, with or without cholesteatoma. 

We agree, and have included a comment, that when PBC is extensive, the surgeon should balance between the need for hearing rehabilitation and the risk of residual. Although electrode dummies  are not always allowed by CI companies, it could clearly be an option in selected cases. 

 

Author Response File: Author Response.docx

Round 2

Reviewer 2 Report

Thanks for the improvements added, especially in the English form.

Again, both acoustic neuroma, meniere Disease and petrous bone cholesteatoma cases have to be revomed.

A translabyrinthine approach with closure of the external auditory canal is not a subtotal pectrosectomy, even if the closure of the EAC and removal of the ME content are shared surgical steps.

Furthermore, both with acoustic tumor and meniere disease cases there is no need on closing the EAC (the risk of CSF leak in case of acoustic neuroma is the same of a SP if the attic and posterior tympanotomy are correctly packed with periosteum). These cases represent a different topic to be discussed, so the relative sub-chapters have to be removed. 

Author Response

Thank you again for your comments and suggestions. 

But unfortunately, I do not agree with the reviewer.

Cases of VS, PBC and MD in our opinion make sense to be included and is justified to include them in the work. 

Not all MD patients are implanted with a SP approach. But when the anatomy is limited, and especially when an active  perforation after intratympanic management is present, it has been used. 

In the case of VS, I agree that it can be done with an approach through the attic, and it may work. But it is a different opinion and we can discuss it, but for us it also makes sense. We have done it and justified it, and will not remove it.

If for the reviewer is a major problem to keep VS, PBC and MD, I am really sorry, but then I will consider sending the work to a different journal.

 

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