Residual Vestibular Schwannomas: Proposed Age-Tumor-Residual (ATR) Staging System to Predict Future Growth.

OBJECTIVE: To assess growth rates of residual vestibular schwannoma after subtotal and near-total surgical resection and establishing staging system for risk of residual tumor growth. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Patients with residual vestibular schwannoma after surgical resection from 2011 to 2023 identified on postoperative MRI defined as near-total resection (NTR, less than 5 mm of remaining tumor), subtotal resection (STR; 5-10 mm) and debulking (>10 mm). MAIN OUTCOME MEASURES: Tumor growth of 2 mm or more after subtotal or near-total surgical resection of vestibular schwannoma. RESULTS: A total of 56 patients (54% female; mean, standard deviation [SD] age 51 [17] yr) had residual tumor. Mean preoperative tumor size was 3.0 (1.1) cm, and residual tumors involved both sides with similar frequency (right: 52%). Quantitatively, 29% were NTR, 32% were STR, and 39% were debulking. With an average follow-up of 27 (SD 31) months, tumor growth occurred in 11 (20%), tumor shrinkage occurred in 16 (29%), and tumors were unchanged in 29 (51%) cases. Growing residual tumors were treated with radiation (7 patients) or a second surgical resection (4 patients). Multivariable analysis identified lower patient age, larger preoperative tumor size, and larger residual tumor size in risk of residual growth. A residual VS tumor staging system (Age, Tumor, Residual [ATR]) is proposed with most tumors in stage II (22, 42%) or stage III (23, 44%), whereas 7 (14%) tumors are stage I. CONCLUSIONS: Approximately 80% of residual VS are stable or shrink in size. Initial observation is advocated after incomplete resection and long-term follow up is needed. Patient age less than 55 years, larger preoperative tumor size, and larger postoperative residual tumor size appear predictive of residual tumor growth.Level of Evidence: 4.

Development of an Automated Triage System for Longstanding Dizzy Patients Using Artificial Intelligence.

Objective: To report the first steps of a project to automate and optimize scheduling of multidisciplinary consultations for patients with longstanding dizziness utilizing artificial intelligence. Study Design: Retrospective case review. Setting: Quaternary referral center. Methods: A previsit self-report questionnaire was developed to query patients about their complaints of longstanding dizziness. We convened an expert panel of clinicians to review diagnostic outcomes for 98 patients and used a consensus approach to retrospectively determine what would have been the ideal appointments based on the patient's final diagnoses. These results were then compared retrospectively to the actual patient schedules. From these data, a machine learning algorithm was trained and validated to automate the triage process. Results: Compared with the ideal itineraries determined retrospectively with our expert panel, visits scheduled by the triage clinicians showed a mean concordance of 70%, and our machine learning algorithm triage showed a mean concordance of 79%. Conclusion: Manual triage by clinicians for dizzy patients is a time-consuming and costly process. The formulated first-generation automated triage algorithm achieved similar results to clinicians when triaging dizzy patients using data obtained directly from an online previsit questionnaire.

Immediate CPAP Use after Skull Base Reconstruction with Hydroxyapatite Bone Cement.

OBJECTIVE: The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary academic medical center. PATIENTS: Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022. INTERVENTIONS: CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT). MAIN OUTCOME MEASURES: Postoperative skull base defects on CT, pneumocephalus, or intracranial complications. RESULTS: The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m 2 . Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively. CONCLUSION: Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.

Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research.

BACKGROUND: Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time. METHODS: This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials. RESULTS: Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01). CONCLUSIONS: In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials. PLAIN LANGUAGE SUMMARY: Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.

Cochlear Implantation in US Military Veterans: A Single Institution Study.

Objective: Military veterans have high rates of noise-induced hearing loss (NIHL) which is associated with more significant spiral ganglion neuronal loss. This study explores the relationship between NIHL and cochlear implant (CI) outcomes in veterans. Study Design: Retrospective case series of veterans who underwent CI between 2019 and 2021. Setting: Veterans Health Administration hospital. Methods: AzBio Sentence Test, Consonant-Nucleus-Consonant (CNC) scores, and Speech, Spatial, and Qualities of Hearing Scale (SSQ) were measured pre- and postoperatively. Linear regression assessed relationships between outcomes and noise exposure history, etiology of hearing loss, duration of hearing loss, and Self-Administered Gerocognitive Exam (SAGE) scores. Results: Fifty-two male veterans were implanted at an average (standard deviation) age of 75.0 (9.2) years without major complications. The average duration of hearing loss was 36.0 (18.4) years. The average time of hearing aid use was 21.2 (15.4) years. Noise exposure was reported in 51.3% of patients. Objectively, AzBio and CNC scores 6 months postoperatively showed significant improvement of 48% and 39%, respectively. Subjectively, average 6-month SSQ scores showed significant improvement by 34 points (p < .0001). Younger age, SAGE score ≥17, and shorter duration of amplification were associated with higher postoperative AzBio scores. Greater improvement in AzBio and CNC scores was associated with lower preoperative scores. Noise exposure was not associated with any difference in CI performance. Conclusion: Despite high levels of noise exposure and advanced age, veterans derive substantial benefits from cochlear implantation. SAGE score ≥17 may be predictive of overall CI outcomes. Noise exposure does not impact CI outcomes. Level of Evidence: Level 4.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion.

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Facial Nerve Preservation With Inferior Long-Axis Dissection of Large Vestibular Schwannomas.

OBJECTIVE: To describe a tumor resection using the inferior long-axis (ILA) technique for cisternal facial nerve dissection in large vestibular schwannomas (VS). STUDY DESIGN: Retrospective case series from 2018 to 2021. SETTING: Tertiary academic medical center. PATIENTS: Patients who underwent surgical resection with ILA facial nerve dissection of VS (>2.0 cm measured parallel to the petrous ridge) and had at least 3-month follow-up. INTERVENTIONS: Cisternal facial nerve dissection during retrosigmoid or translabyrinthine approach using standardized ILA technique developed by author R.N. MAIN OUTCOME MEASURES: Immediate postoperative and last follow-up facial nerve function with House-Brackmann scores of I to II defined as "good" facial nerve function and House-Brackmann scores III to VI defined as "poor" function. Extent of resection was also assessed. RESULTS: A total of 48 patients underwent large VS resection with ILA dissection of tumor off of the facial nerve from 2018 to 2021. Mean (standard deviation) tumor size was 3.11 (0.76) cm. Mean (standard deviation) follow-up was 9.2 (9.0) months. Gross-total resection or near-total resection were achieved in 75% (radiographic estimate) to 83% (surgeon estimate) of cases. End-of-case facial nerve stimulation at 0.05 mAmp with a response of at least 240 mV was achieved in 80.4% of patients. Good facial nerve function was observed in 72% immediately postoperatively, 70% 1-month postoperatively, and 82% of patients at last follow-up. CONCLUSIONS: The ILA technique is now the method of choice of the senior surgeon (R.N.) when performing microsurgical dissection of the cisternal facial nerve, with which he has achieved high rates of total or near-total resection with excellent facial nerve preservation.

Characterizing Cochlear Implant Magnet-Related MRI Artifact.

OBJECTIVE: To evaluate cochlear implant (CI) magnet-related MRI artifact shape and size, as well as imaging indications and clinical adequacy of scans. METHODS: A retrospective chart review was performed for patients undergoing CI and subsequent MRI head imaging from 2014 to 2020 at a single institution. Indications and adequacy of each scan was recorded, and interpretability compared by indication. Magnet-related artifact size was determined by performing ellipsoid modeling at axial slice of greatest signal loss. Artifact radius in centimeters was calculated for 5 sequence categories, and size compared between sequences, manufacturers, and by time from implantation. RESULTS: Twenty patients underwent 58 head MRI scans. Approximately 76% of MRIs (n = 44) for 70% of patients (n = 14) were performed for indications known of prior to implantation; the remainder were performed during workup of new issues. Desired structures were interpretable in 23 (52%) of known-indication MRIs and 8 (57%) of new-indication MRIs, without significant difference (P = .751). Magnet-related artifact magnitude, compared to the reference T1-weighted fast spin echo (FSE) (4.47 cm), was similar in T2 FSE (4.57 cm, P = .068) and T1 gradient echo (GRE) sequences (4.79 cm, P = .28), but significantly greater in T2 GRE (6.86, P < .0001) and DWI (7.56 cm, P < .0001) sequences. CONCLUSIONS: DWI and T2 GRE sequences are less useful in MRI evaluation of CI patients. With a more favorable artifact profile, T1 FSE, T2 FSE, and T1 GRE sequences more likely yield clinically useful information. The large proportion of scans performed for known pathology represents an opportunity to optimize for magnet location preoperatively.

TMPRSS3 expression is limited in spiral ganglion neurons: implication for successful cochlear implantation.

BACKGROUND: It is well established that biallelic mutations in transmembrane protease, serine 3 (TMPRSS3) cause hearing loss. Currently, there is controversy regarding the audiological outcomes after cochlear implantation (CI) for TMPRSS3-associated hearing loss. This controversy creates confusion among healthcare providers regarding the best treatment options for individuals with TMPRSS3-related hearing loss. METHODS: A literature review was performed to identify all published cases of patients with TMPRSS3-associated hearing loss who received a CI. CI outcomes of this cohort were compared with published adult CI cohorts using postoperative consonant-nucleus-consonant (CNC) word performance. TMPRSS3 expression in mouse cochlea and human auditory nerves (HAN) was determined by using hybridisation chain reaction and single-cell RNA-sequencing analysis. RESULTS: In aggregate, 27 patients (30 total CI ears) with TMPRSS3-associated hearing loss treated with CI, and 85% of patients reported favourable outcomes. Postoperative CNC word scores in patients with TMPRSS3-associated hearing loss were not significantly different than those seen in adult CI cohorts (8 studies). Robust Tmprss3 expression occurs throughout the mouse organ of Corti, the spindle and root cells of the lateral wall and faint staining within <5% of the HAN, representing type II spiral ganglion neurons. Adult HAN express negligible levels of TMPRSS3. CONCLUSION: The clinical features after CI and physiological expression of TMPRSS3 suggest against a major role of TMPRSS3 in auditory neurons.

Cochlear Implant Electrode Misplacement: A Case Series and Contemporary Review.

OBJECTIVE: To determine root causes leading to misplaced cochlear implant (CI) electrode arrays and discuss their management using a case series and contemporary literature review. STUDY DESIGN: Retrospective case review and contemporary literature review. SETTING: Single tertiary-referral center. PATIENTS: Adult and pediatric patients who were diagnosed with a misplaced CI electrode array, excluding tip-foldover. Literature review was performed via a MEDLINE database PubMed query. All articles that described at least one case of extracochlear electrode array misplacement were included; partial insertions and extrusions were excluded. MAIN OUTCOME MEASURE: Extracochlear misplacement. RESULTS: A total of 61 cases were reviewed, including 4 new cases and 57 cases from 29 previously published articles. We discuss management of CI arrays in the carotid canal, the vestibule, and the modiolus. The rate of CI misplacement is estimated to be 0.49%. The most frequent location of misplacement CI was the vestibular system (50.8%) followed by the internal carotid canal (11.5%). Normal cochlear anatomy was noted on preoperative computer tomography (CT) in 59.0% of patients; abnormalities were noted in 27.9%. The most common technical issue was misidentification or poor visualization of the round window. CONCLUSION: CI electrode misplacement is rare but can cause postoperative complications and may result in permanently diminished CI performance and hearing outcomes, even after revision surgery. Failure to identify the round window is the most common reason for CI misplacement, despite most patients having normal cochlear anatomy. Surgical strategies to localize the round window and basal turn are imperative for proper electrode placement. LEVEL OF EVIDENCE: 4.

Comparative Analysis of Recidivism After Endoscopic and Microscopic-Based Cholesteatoma Resection.

OBJECTIVES: 1) To analyze outcomes of cholesteatoma resection utilizing postauricular microscopic and endoscopic ear surgery (EES) approaches.2) To analyze predictors of residual and recurrent cholesteatoma. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Three hundred seventy-five adult and pediatric patients with cholesteatoma (2012-2017). INTERVENTIONS: Patients underwent surgical resection of cholesteatoma with EES (n = 122) and microscopic (n = 253) approach. MAIN OUTCOME MEASURES: Residual cholesteatoma, recurrent cholesteatoma, second-look procedures. RESULTS: The endoscopic cohort included significantly more pediatric cases (p = 0.0008). There was no difference in laterality, gender distribution, congenital or acquired cholesteatoma, and revision cases between the cohorts. Out of 122 EES cases, 16 (13%) developed residual disease and 9 (7%) developed recurrent disease. Of 253 microscopic cases 16 (6%) developed residual disease while 11 (4%) developed recurrent disease. Second look procedures were more commonly used in EES cohort (50 vs 18%). Single predictor analysis revealed 12 predictors for residual disease and 5 for recurrent disease. Multivariable model identified pediatric case distribution and higher disease stage to be significant predictors for both residual (p = 0.04, 0.007) and recurrent disease (p = 0.02, 0.01). EES approach was associated with a weak significance for residual disease (p = 0.049) but not recurrent disease (p = 0.34). CONCLUSIONS: EES approach for cholesteatoma resection seems to perform similarly to microscopic approach with no difference in rates of recurrent disease. However, it is associated with a higher rate of residual disease; this may be a reflection of a greater rate of second look procedures done in this group.

Speech Recognition Outcomes in Adults With Slim Straight and Slim Modiolar Cochlear Implant Electrode Arrays.

OBJECTIVE: To compare differences in audiologic outcomes between slim modiolar electrode (SME) CI532 and slim lateral wall electrode (SLW) CI522 cochlear implant recipients. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary academic hospital. METHODS: Comparison of postoperative AzBio sentence scores in quiet (percentage correct) in adult cochlear implant recipients with SME or SLW matched for preoperative AzBio sentence scores in quiet and aided and unaided pure tone average. RESULTS: Patients with SLW (n = 52) and patients with SME (n = 37) had a similar mean (SD) age (62.0 [18.2] vs 62.6 [14.6] years, respectively), mean preoperative aided pure tone average (55.9 [20.4] vs 58.1 [16.4] dB; P = .59), and mean AzBio score (percentage correct, 11.1% [13.3%] vs 8.0% [11.5%]; P = .25). At last follow-up (SLW vs SME, 9.0 [2.9] vs 9.9 [2.6] months), postoperative mean AzBio scores in quiet were not significantly different (percentage correct, 70.8% [21.3%] vs 65.6% [24.5%]; P = .29), and data log usage was similar (12.9 [4.0] vs 11.3 [4.1] hours; P = .07). In patients with preoperative AzBio <10% correct, the 6-month mean AzBio scores were significantly better with SLW than SME (percentage correct, 70.6% [22.9%] vs 53.9% [30.3%]; P = .02). The intraoperative tip rollover rate was 8% for SME and 0% for SLW. CONCLUSIONS: Cochlear implantation with SLW and SME provides comparable improvement in audiologic functioning. SME does not exhibit superior speech recognition outcomes when compared with SLW.

Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes.

OBJECTIVE: To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary medical center neurotology practice. METHODS: Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired t-tests. Single-predictor binary logistic regression was used to compare final reported symptoms between cohorts. Linear regression was performed to assess air-bone gap (ABG) changes postoperatively between cohorts. RESULTS: Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively (P < .001 for each). There was no significant difference in change in ABG between the 2 cohorts. On average, patient-reported symptoms and audiometrically-tested hearing improved postoperatively in both groups. CONCLUSION: While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.

Socioeconomic Influences on Short-term Postoperative Outcomes in Patients With Oral Cavity Cancer Undergoing Free Flap Reconstruction.

OBJECTIVE: To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer. STUDY DESIGN: Retrospective review (2000-2019). SETTING: Single-institution tertiary medical center. METHODS: MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation. RESULTS: The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (ß = 0.130, P = .022; ß = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]). CONCLUSION: MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.

Sinonasal Small Cell Carcinoma-Case Series of a Rare Malignancy.

Sinonasal small cell neuroendocrine carcinoma (SNEC) is an extremely rare and aggressive neoplasm that can arise in the sinonasal region. These tumors are associated with high morbidity and mortality, are difficult to diagnose, and are hard to treat. We describe 2 cases of this poorly understood malignancy and review imaging, pathology, and treatment decisions. A 41-year-old male and a 64-year-old female presented to a tertiary center in 2019 after developing nasal obstruction and were found to have sinonasal masses on imaging. Both biopsies showed strong expression of pancytokeratin with dot-like reactivity and expression of neuroendocrine markers chromogranin and synaptophysin. The findings were diagnostic of SNEC. Staging positron emission tomography/computed tomography and brain MRI were performed, and patients were discussed at a multidisciplinary tumor board. Neither had distant metastatic disease at presentation. One patient had no intracranial or orbital disease and underwent a subtotal endoscopic resection with adjuvant chemoradiation. The other patient demonstrated middle cranial fossa, dural, and orbital involvement as well as cranial nerve V palsy. This patient was treated with induction chemotherapy, followed by concurrent chemoradiation. Both patients are presently alive at 4 months follow-up, but one with persistent local disease and the other distant metastasis. Sinonasal small cell neuroendocrine carcinoma is a rare and poorly understood malignancy with an aggressive clinical course. Continued careful review of pathology and study of molecular features are needed for improved understanding of SNEC, and particularly for head and neck SNEC, to establish a staging system and better formulate treatment protocols.

Trends in Spontaneous Cerebrospinal Fluid Leak Repairs in the United States, 2009-2018.

Background: Rates of spontaneous cerebrospinal fluid leak (sCSF) repairs have increased in recent decades in line with increases in obesity rates. Objectives: To determine if the national rate of sCSF leak has continued to rise in recent years and to identify associated risk factors utilizing a comprehensive national database comprising most academic medical centers. Methods: A retrospective review from 2009 to 2018 was performed using the Vizient Clinical Database (CDB) of 105 leading academic medical centers in the United States. Patients who underwent CSF leak repair in the CDB database using ICD-9 and ICD-10 diagnostic and procedure codes. Patients with epidural hematomas over the same time frame were used as a control. National rates of craniotomy for sCSF leak repair each quarter were assessed and sCSF leak patient characteristics (age, gender, obesity, hypertension, diabetes) were calculated. Results: The rate of craniotomy for all sCSF leak repairs increased by 10.2% annually from 2009 to 2015 (P < 0.0001). There was no statistically significant change in the rate of epidural hematomas over the same period. The rate of lateral sCSF leak repair increased on average by 10.4% annually from 2009 (218 cases/year) to 2018 (457 cases/year) (P < 0.0001). A statistically significant increase was observed across all regions of the United States (P ≤ 0.005). sCSF leak patients had an average (standard deviation) age of 55.0 (13.2) years and 67.2% were female. Obesity was the only demographic factors that increased significantly over time. Likely due to comorbid factors, Black patients comprise a disproportionately large percentage of lateral sCSF leak repair patients. Conclusions: The rate of craniotomy for spontaneous CSF leaks continues to rise by approximately 10% annually.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy.

Objective To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting Set at the tertiary skull base center. Methods This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.