Outcomes of Minority COVID-19 patients managed with ECMO: A single-center experience.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has significantly burdened the global healthcare system since December 2019. Minority populations are found to have a higher incidence of hospitalization and higher mortality when compared to Caucasians. Extracorporeal membrane oxygenation (ECMO) is reserved for COVID-19 patients who develop respiratory failure refractory to conventional management. To our knowledge, no data has been reported on outcome differences between Minority COVID-19 patients and Caucasian COVID-19 patients managed with ECMO. We aimed to investigate the outcome differences between these two groups. METHODS: Our retrospective cohort study had 23 adults (aged 18 and older) diagnosed with COVID-19 by polymerase chain reaction. All patients developed acute respiratory distress syndrome (ARDS), refractory to conventional treatment, and were managed on ECMO support. The primary outcome of interest was mortality; the secondary outcome was the rate of ECMO-related complications. RESULTS: The overall mortality rate of our study was higher (70%) than other reports of the COVID-19 population on ECMO. Caucasians in our study had more severe respiratory acidosis with carbon dioxide retention and appeared to have a higher mortality rate of 85.7% compared to Minorities (62.5%). No differences in complication rates between these two groups were identified. CONCLUSIONS: Our cohort revealed a high overall mortality rate of COVID-19 patients on ECMO support. The Caucasian group was observed to have higher mortality than the Minority group. The high overall mortality was likely attributed to the Caucasian group, which had more severe respiratory acidosis before ECMO initiation, a known predictor of poor prognosis in ARDS patients. Our cohort's ethnic composition may also partially explain the high mortality rate since COVID-19 Minorities are reported to have worse outcomes than Caucasians. Larger and randomized studies are needed to investigate further the mortality and complication differences between Minority and Caucasian patients diagnosed with COVID-19 and managed by ECMO.

Microglial activation occurs in the absence of anxiety-like behavior following microembolic stroke in female, but not male, rats.

BACKGROUND: The incidence of depression and anxiety disorders is twice as high in women than men; however, females exhibit less neuronal damage following an equivalent ischemic event. Microembolic stroke increases anxiety- and depressive-like behaviors in male rats but the behavioral repercussions in females are unknown. FINDINGS: Given the relative neuronal protection from stroke in ovary-intact females, female rats exposed to microembolic stroke may be behaviorally protected as compared to males. The data presented demonstrate that anxiety-like behavior is increased in males despite a comparable increase in microglial activation following microembolic stroke in both males and females. CONCLUSIONS: These data suggest that males may be more behaviorally susceptible to the effects of microembolic stroke and further illustrate a dissociation between neuroinflammation and behavior in females.

Evaluating Mixed Reality as a Tool for Patient Education of Facial Fractures.

Background: Patients may be educated about facial fractures using two-dimensional computed tomography (2DCT); however, three-dimensional mixed reality (3DMR) goggles may improve patient education by delivering content in an immersive environment. Objective: To compare the effectiveness of 2DCT and 3DMR formats used for patient education on facial fractures, as measured by surveys. Methods: In this prospective, randomized, crossover study, video tutorials intended for facial fracture informed consent were created in 2DCT and 3DMR formats from a single CT data set of a zygomaticomaxillary complex (ZMC) fracture. Subjects were randomly assigned into two groups. Group 1 (n = 25) viewed the 2DCT tutorial, answered self-assessment and information recall surveys, viewed the 3DMR tutorial, repeated the prior surveys as well as a comparison survey. Group 2 (n = 25) followed the same sequence but viewed the 3DMR tutorial and then the 2DCT tutorial. Results: Participants (n = 50) had no differences in age (group 1-51.9 years/standard deviation [SD] 20.9; group 2-44.7 years/SD 17.6 years; p = 0.223), gender (group 1-10 male/15 female; group 2-11 male/14 female; p = 0.999), college education level (group 1-25 yes; group 2-25 yes; p = 0.844), or prior 2DCT or 3DMR experience (group 1-9 yes/16 no; group 2-13 yes/12 no; p = 0.393). The 3DMR format was preferred over 2DCT (p < 0.05), and it was reported to enhance understanding as compared to 2DCT (p < 0.05). No differences for information recall were noted (p = 0.753). Conclusion: In this study, participants preferred 3DMR goggles over 2DCT for a simulated ZMC fracture-informed consent.

Pulmonary hypertension in hereditary hemorrhagic telangiectasia: A clinical review.

Hereditary hemorrhagic telangiectasia (HHT) is a rare autosomal dominant hereditary disorder characterized by recurrent spontaneous epistaxis, mucocutaneous telangiectasias, and solid organ arteriovenous malformations (AVMs). Pulmonary hypertension (PH) is an increasingly recognized complication in patients with HHT, most often precipitated by high-output heart failure in the presence of hepatic AVMs as well as pulmonary arterial hypertension in the form of a proliferative vasculopathy. The presence of PH in patients with HHT is associated with significant elevations in rates of morbidity and mortality. Additionally, there is growing recognition of a thromboembolic propensity in this population that increases the risk of chronic thromboembolic PH, posing unique clinical considerations regarding the use of anticoagulation. Patients with HHT are also at risk of PH due to disorders commonly seen in the general population, including left-sided heart and lung disease. The etiology of PH in HHT is multifaceted and complex; the diagnostic approach and treatment strategies must consider the underlying pathophysiology of HHT. This comprehensive review summarizes current knowledge of PH in HHT, detailing the pathogenesis of known etiologies, diagnostic evaluation, and suggested treatment modalities as well as emerging therapies that may be of future interest.

Acute Esophageal Necrosis Following Acetaminophen Overdose: An Unreported Cause of Black Esophagus.

Description Acute esophageal necrosis (AEN), also known as "black esophagus" or Gurvits syndrome, is an uncommon finding with an unclear etiology and pathogenesis. This condition often presents as an upper gastrointestinal bleed in older men with multiple comorbidities. AEN is characterized by circumferential black, necrotic mucosa in the esophagus. We present a case of AEN following acetaminophen overdose. The patient was ultimately discharged from the hospital with oral omeprazole twice daily, a clear liquid diet, and a recommendation for follow-up in the outpatient setting for repeat EGD in 4 to 6 weeks. Acetaminophen overdose, although a rare cause, must be considered as a possible etiology of AEN.

Surgeon education through a surgical cost feedback system reduces supply cost in endoscopic skull base surgery.

OBJECTIVE: A large proportion of healthcare expense is operating room (OR) costs. As a means of cost mitigation, several institutions have implemented surgeon education programs to bring awareness about supply costs. This study evaluates the impact of a surgical cost feedback system (surgical receipt) on the supply costs of endoscopic skull base surgery (ESBS) procedures. METHODS: The supply costs of each ESBS surgical case were prospectively collected and analyzed before and after the implementation of a nonincentivized, automated, and itemized weekly surgical receipt system between January 2017 and December 2019. Supply cost data collected 15 months prior to intervention were compared with cost data 21 months after implementation of the surgical receipt system. Demographics, surgical details, and OR time were collected retrospectively. RESULTS: Of 105 ESBS procedures analyzed, 36 preceded and 69 followed implementation of cost feedback. There were no significant differences in patient age (p = 0.064), sex (p = 0.489), surgical indication (p = 0.389), or OR anesthesia time (p = 0.51) for patients treated before and after implementation. The mean surgical supply cost decreased from $3824.41 to $3010.35 (p = 0.002) after implementation of receipt feedback. Usage of dural sealants (p = 0.043), microfibrillar collagen hemostat (p = 0.007), and oxidized regenerated cellulose hemostat (p < 0.0001) and reconstructive technique (p = 0.031) significantly affected cost. Mediation analysis confirmed that the overall cost reduction was predominantly driven by reduced use of dural sealant; this cost saving exceeded the incremental cost of greater use of packing materials such as microfibrillar collagen hemostat. CONCLUSIONS: Education of surgeons regarding surgical supply costs by a surgical receipt feedback system can reduce the supply cost per case of ESBS operations.

The Hurricane Lung: A Case of Hydrocarbon Pneumonitis With Abscess Formation Following Fuel Siphoning.

Fuel siphoning is a widespread practice worldwide, but infrequently observed in the United States. Some reports suggest greater incidence of fuel siphoning during the hurricane season. Fuel siphoning is associated with a high risk of hydrocarbon toxicity, often leading to the development of hydrocarbon pneumonitis. This form of exogenous lipoid pneumonia can present acutely with chest pain and dyspnea. While most cases of hydrocarbon pneumonitis resolve spontaneously with supportive care, rarely patients develop life-threatening complications. We present the case of a 56-year-old man who developed hydrocarbon pneumonitis complicated by abscess formation after attempting to siphon fuel from a gasoline tank in preparation for a hurricane.

Response to pegylated interferon in a COVID-19-positive elderly woman with primary myelofibrosis treated with ruxolitinib.

An 83-year-old female had asymptomatic SARS-CoV-2 infection while taking ruxolitinib. She remained RT-PCR positive for viral RNA for >120 days, and Pegylated interferon for 4 weeks led to viral RNA clearance. The observations support combination therapy of ruxolitinib + interferon for COVID-19.

Surgeon cost feedback through a surgical receipt program reduces cost in sinonasal surgery.

BACKGROUND: Operating room (OR) costs are a large portion of healthcare expenses. This study evaluates the impact of a surgeon-targeted surgical receipt cost feedback system on OR supply costs in sinonasal surgery and individual components contributing to procedural cost. METHODS: Itemized weekly surgical receipts detailing individual case supply costs were analyzed before and after the implementation of a non-incentivized surgeon cost feedback system between January 2017 and June 2019. Supply cost data collected 15 months prior to intervention was compared to cost data 15 months after implementation of the weekly automated receipt dissemination to surgeons. Chi square test was used for categorical data and the Wilcoxon test was used to compare change in cost. Univariate and mediation analyses were performed to assess variables impacting cost. RESULTS: Of 502 sinonasal procedures analyzed, 239 were before and 264 after cost feedback implementation. There were no significant differences in age/gender, or indication for surgery. The median OR supply cost decreased from $1229.64 to $1097.22 (p = 0.02) after receipt implementation. There were effects of procedure type (p = 0.02), circulating nurse specialization (p < 0.001), steroid eluting stent (p = 0.002), and sinus drill (p < 0.001) on cost. Mediation analysis confirmed full mediation by decreasing use of steroid-eluting stents. CONCLUSION: Surgeon cost feedback in the form of individualized OR surgical receipts is an effective model to reduce supply cost per case in sinonasal surgery.

The Role of Thrombolytic Therapy for Patients with a Submassive Pulmonary Embolism.

A pulmonary embolism (PE) is an acute life-threatening respiratory event that results in upwards of 200,000 deaths per year in the United States. While anticoagulation is currently the standard of treatment for PEs, there is increasing evidence to suggest that in certain cases anticoagulation in combination with thrombolytic therapy may improve patient outcomes and reduce mortality. This article aims to compare the effects of combined intervention with thrombolytic therapy and anticoagulation to the effects of anticoagulation alone in patients with submassive PEs in terms of various outcome measures, including but not limited to: mortality, hemodynamic status, length of hospital stay, and safety. The methodology consisted of the critical appraisal of the primary literature articles pertaining to intervention with thrombolytic agents in cases of a submassive or intermediate risk PE, including a discussion of each study's strengths and limitations. Ultimately, this review found that the use of thrombolytic agents in conjunction with anticoagulants has been associated with decreased hemodynamic decompensation and decreased length of hospital stay, with no change in mortality outcomes, at a cost of increased rate of bleeding and stroke. The use of thrombolytic agents with anticoagulants may be warranted in a specific subset of patients, but clinicians should consider the potential benefits and harms of this intervention.

Return to the Emergency Room with or without Readmission After Endoscopic Transsphenoidal Surgery in Socioeconomically Disadvantaged Patients at an Urban Medical Center.

BACKGROUND: Although reducing 30-day hospital readmissions is now a priority in neurosurgical quality improvement, postoperative emergency room (ER) visits have remained poorly understood, in particular, in populations with limited access to outpatient care. After endoscopic transsphenoidal surgery, the unique pathologic entities treated can engender a variety of surgical and metabolic complications-often dangerous, delayed, and nonspecific in presentation. We sought to characterize the causes and timing of ER visits-with or without readmission-in a socioeconomically disadvantaged population. METHODS: We reviewed all the patients undergoing ETS by our skull base team from 2009 to 2017 to determine their socioeconomic profile and causes of ER visits. For external validation, we compared our results with national data from the American College of Surgeons National Surgical Quality Improvement Program. RESULTS: Of the 229 patients, 35 (15.3%) had visited the ER within 30 days of discharge. Of these 229 patients, 21 (9.2%) were readmitted, and 109 (47.6%) were insured by Medicaid. The most common reasons for the ER visits were headache (8 of 35 [22.9%]), hyponatremia (7 of 35 [20.0%]), and epistaxis (5 of 35 [14.3%]). The most common cause for readmission was symptomatic hyponatremia (6 of 21 [28.6%]). The other reasons for readmission included meningitis (2 of 21 [9.5%]), adrenal crisis (2 of 21 [9.5%]), and cerebrospinal fluid leakage (1 of 21 [4.8%]). The average time to readmission was 10.9 days. According to the National Surgical Quality Improvement Program database, the 30-day readmission rate was 5.5%, of which 22.2% were for hyponatremia. CONCLUSION: Delayed hyponatremia accounts for a large proportion of ER visits and unplanned readmissions. Close follow-up with diligent, multidisciplinary care might reduce the number of ER visits and readmission in this population.

Limitations of the endoscopic endonasal transcribriform approach.

The endoscopic endonasal transcribriform approach (EETA) has become a useful strategy in the treatment of various anterior skull base pathologies, including meningoencephaloceles, olfactory groove meningiomas, schwannomas, esthesioneuroblastomas, and other sinonasal malignancies. However, not all pathologies are optimally treated through this approach due to tumor size, extent of the lesion, vascular involvement, and the presence of intact olfaction. One must be prepared to use a transcranial approach if the EETA is not favorable. In some patients, a combined approach (transcranial-EETA) may be needed in appropriate cases. Therefore, patient selection is paramount for achieving a successful result with avoidance of complications. For certain tumors, the limitations of the EETA may result in lower rates of gross-total resection, higher rates of cerebrospinal fluid leakage, postoperative impairment of olfaction, and higher complication rates. In this paper, we discuss the limitations of the EETA when considering approach selection to treat anterior skull base lesions.

Superior semicircular canal dehiscence: Diagnosis and management.

The authors provide an update on the clinical manifestations, diagnosis and various approaches to the treatment of superior semicircular canal dehiscence (SSCD). SSCD is a rare condition where the bone overlying the superior semicircular canal thins or dehisces causing characteristic clinical findings. Since this was first reported in 1998 by Minor and colleagues, there has been much advancement made in terms of diagnosis and treatment. Signs and symptoms include a wide variation of both vestibular and auditory manifestations. Diagnosis made solely on clinical signs is difficult due to how varied the presentations can be and the overlap with other otologic pathologies. High-resolution CT temporal scans have been the standard in confirming superior semicircular canal dehiscence, however, MRI FIESTA scans have recently been used to image SSCD. Additionally, audiometry and vestibular evoked myogenic potential (VEMP) testing are useful screening tools. Currently, the middle fossa approach is the most common and standard surgical approach to repair SSCD. The transmastoid, endoscopic and transcanal or endaural approaches have also been recently utilized. Presently, there is no consensus as to the best approach, material or technique for repair of SSCD. As we learn more, newer and less invasive approaches and techniques are being used to treat SSCD. We present a comprehensive review of SSCD, including clinical symptoms and presentation, histopathology, diagnosis, treatment strategies and outcomes of intervention.

The Impact of Duty-Hour Restrictions on Complication Rates Following Major Head and Neck Procedures.

OBJECTIVES/HYPOTHESIS: To assess the impact of resident duty-hour restrictions (DHR) in otolaryngology via comparison of postoperative outcomes between otolaryngology teaching hospitals (Oto-TH) and nonteaching hospitals (NTH) before and after complete implementation. STUDY DESIGN: Retrospective database review. METHODS: The Nationwide Inpatient Sample was queried for all major head and neck cases between 2000 and 2002 (n = 34,064) and 2008 and 2010 (n = 33,094). Cases were stratified into Oto-TH (n = 28,771) and NTH (n = 38,387) and assessed for procedure type, patient comorbidities, and complications. A subpopulation matched by procedure type was generated for direct comparison of complication rates using χ2 and binary logistic regression analyses. RESULTS: In the years following DHR, total case volume and average case complexity increased at Oto-TH only. Using a case-matched subpopulation, regression analysis found Oto-TH status to be protective for medical complications both before (odds ratio [OR]: 0.60, P < .001) and after (OR: 0.76, P = .001) DHR. In contrast, Oto-TH cases had lower risk for surgical complications in 2000 to 2002 (OR: 0.77, P < .001) but not 2008 to 2010 (OR: 1.07, P = .275). When comparing time periods, the years following DHR were associated with a significant decrease in medical complications and mortality across hospital cohorts. For surgical complications, rates significantly improved at NTH only (OR: 0.82, P = .002), with no difference at Oto-TH (OR: 0.95, P = .450). CONCLUSIONS: In the years following DHR, rates of medical complications, surgical complications, and mortality have significantly improved at NTH. At Oto-TH, there has been a lack of similar improvement in surgical complications, even after accounting for increasing case volume and complexity in more recent years. While the cause is likely multifactorial, DHR in otolaryngology residency may play a role. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2804-2810, 2018.

Episodic memory after trauma exposure: Medial temporal lobe function is positively related to re-experiencing and inversely related to negative affect symptoms.

Hippocampal structure is particularly sensitive to trauma and other stressors. However, previous findings linking hippocampal function with trauma-related psychopathology have been mixed. Heterogeneity in psychological responses to trauma has not been considered with respect to hippocampal function and may contribute to mixed findings. To address these issues, we examined associations between data-driven symptom dimensions and episodic memory formation, a key function of the hippocampus, in a trauma-exposed sample. Symptom dimensions were defined using principal components analysis (PCA) in 3881 trauma-exposed African-American women recruited from primary care waiting rooms of a large urban hospital. Hippocampal and amygdala function were subsequently investigated in an fMRI study of episodic memory formation in a subset of 54 women. Participants viewed scenes with neutral, negative, and positive content during fMRI, and completed a delayed cued recall task. PCA analysis produced five symptom dimensions interpreted as reflecting negative affect, somatic symptoms, re-experiencing, hyper-arousal, and numbing. Re-experiencing was the only symptom type associated with hippocampal function, predicting increased memory encoding-related activation in the hippocampus as well as the amygdala. In contrast, the negative affect component predicted lower amygdala activation for subsequently recalled scenes, and lower functional coupling with other important memory-related regions including the precuneus, inferior frontal gyrus, and occipital cortex. Symptom dimensions were not related to hippocampal volume. The fMRI findings for re-experiencing versus negative affect parallel differences in behavioral memory phenomena in PTSD versus MDD, and highlight a need for more complex models of trauma-related pathology.

The Role of Fast Imaging Employing Steady-State Acquisition (FIESTA) Magnetic Resonance Imaging for Assessment of Delayed Enhancement of Fat Graft Packing on Postoperative Imaging After Vestibular Schwannoma Surgery.

OBJECTIVE: To investigate the role and efficacy of fast imaging employing steady-state acquisition (FIESTA) imaging in distinguishing fat graft enhancement from residual or recurrent tumor after vestibular schwannoma (VS) surgery. METHODS: A retrospective study of 33 patients who underwent VS resection via the retrosigmoid or translabyrinthine approach with fat graft reconstruction was performed. Magnetic resonance imaging (MRI) was collected at different time points: preoperative, immediate postoperative (24-48 hours), delayed postoperative (3-6 months after surgery), and yearly postoperative. The image sets contained T1, T2, fat-suppressed T1-weighted with gadolinium, and FIESTA. The radiographs were analyzed for tumor recurrence by the primary neurosurgeon and an independent blinded neuroradiologist. If fat-suppressed T1-weighted images demonstrated postoperative enhancement in the resection bed, a comparison was made with FIESTA imaging. RESULTS: At 3-6 months postoperatively and at 1 year and beyond, 28 (84.8%) and 33 (100%) of patients, respectively, displayed delayed enhancement of the fat graft on postgadolinium fat-suppressed T1-weighted MRI. The enhancement seen on postgadolinium, fat-suppressed, T1-weighted MRI consistently correlated with the characteristic fat graft signal on FIESTA imaging and not tumor recurrence. FIESTA imaging was able to distinguish residual tumor from enhancing fat graft compared with postgadolinium, fat-suppressed, T1-weighted MRI (P < 0.0001) due to distinctive signaling patterns. CONCLUSIONS: FIESTA is an effective tool in discerning fat graft enhancement from residual or recurrent tumor on delayed postoperative imaging after VS resection. Fat graft used in reconstruction consistently enhances on delayed postoperative postgadolinium, fat-suppressed, T1-weighted imaging, which correlates with the fat graft signal seen on FIESTA images.

Psychological and psychobiological responses to immediate early intervention in the emergency department: Case report of one-session exposure therapy for the prevention of PTSD.

Research suggests that exposure therapy provided in the hours immediately following trauma exposure may prevent PTSD development. This case report presents data on an at-risk for PTSD participant involved in a motor-vehicle crash that caused her severe distress. She received one session of exposure therapy in the emergency department (ED) as part of an ongoing randomized controlled study examining the optimal dose of exposure therapy in the immediate aftermath of trauma. PTSD and depression measures were collected at pre-treatment assessment and one- and three-month follow-up. Potential PTSD biomarkers were also examined. Psychophysiological reactions were measured using skin conductance data measured on an iPad during the exposure therapy session and the follow-up assessments. A fear-potentiated startle paradigm and an functional magnetic resonance imaging (fMRI) behavioral inhibition task were used at follow-up. The participant demonstrated subjective and psychophysiological extinction from pre- to post-imaginal exposure. At follow-up, she did not meet DSM-IV criteria for PTSD or demonstrate hyperarousal to trauma reminders and showed robust fear extinction and the ability to inhibit responses in an fMRI behavioral inhibition task. In line with previous early intervention for the prevention of PTSD studies, this case report supports the need for ongoing empirical research investigating the possibility that one session of exposure therapy in the ED may attenuate risk for PTSD. Furthermore, the current findings demonstrate psychophysiological extinction serving as a prognostic indicator of treatment response for PTSD early intervention to be an exciting avenue to explore in future systematic research.

Amygdala Reactivity and Anterior Cingulate Habituation Predict Posttraumatic Stress Disorder Symptom Maintenance After Acute Civilian Trauma.

BACKGROUND: Studies suggest that exaggerated amygdala reactivity is a vulnerability factor for posttraumatic stress disorder (PTSD); however, our understanding is limited by a paucity of prospective, longitudinal studies. Recent studies in healthy samples indicate that, relative to reactivity, habituation is a more reliable biomarker of individual differences in amygdala function. We investigated reactivity of the amygdala and cortical areas to repeated threat presentations in a prospective study of PTSD. METHODS: Participants were recruited from the emergency department of a large level I trauma center within 24 hours of trauma. PTSD symptoms were assessed at baseline and approximately 1, 3, 6, and 12 months after trauma. Growth curve modeling was used to estimate symptom recovery trajectories. Thirty-one individuals participated in functional magnetic resonance imaging around the 1-month assessment, passively viewing fearful and neutral face stimuli. Reactivity (fearful > neutral) and habituation to fearful faces was examined. RESULTS: Amygdala reactivity, but not habituation, 5 to 12 weeks after trauma was positively associated with the PTSD symptom intercept and predicted symptoms at 12 months after trauma. Habituation in the ventral anterior cingulate cortex was positively associated with the slope of PTSD symptoms, such that decreases in ventral anterior cingulate cortex activation over repeated presentations of fearful stimuli predicted increasing symptoms. CONCLUSIONS: Findings point to neural signatures of risk for maintaining PTSD symptoms after trauma exposure. Specifically, chronic symptoms were predicted by amygdala hyperreactivity, and poor recovery was predicted by a failure to maintain ventral anterior cingulate cortex activation in response to fearful stimuli. The importance of identifying patients at risk after trauma exposure is discussed.

Gruber, Gradenigo, Dorello, and Vail: key personalities in the historical evolution and modern-day understanding of Dorello's canal.

A century ago an ambitious young anatomist in Rome, Primo Dorello, who sought to understand the cause of abducent nerve palsy that often occurred in patients with severe middle ear infections, conducted intricate studies on the intracranial course of the nerve. In his findings, he identified that the abducent nerve passes through a narrow sinus near the apex of the petrous bone, which formed an osteofibrous canal. Dorello suggested that in this enclosed region the abducent nerve may be particularly vulnerable to compression due to the vascular edema accompanying the infection. Although his work was widely appreciated, it was not well received by all. Interestingly, Giuseppe Gradenigo, one of the most prominent Italian otologists of the early 20th century, who was known for his work on a triad of symptoms (Gradenigo's syndrome) that accompanies petrous apicitis, a result of severe middle ear infections, was obstinate in his criticism of Dorello's findings. Thus a scientific duel began, with a series of correspondence between these two academics-one who was relatively new to the otological community (Dorello) and one who was well reputed in that community (Gradenigo). The disagreement ultimately ebbed in 1909, when Dorello published a report in response to Gradenigo's criticisms and convinced Gradenigo to change his views. Today Dorello's canal is widely recognized as a key landmark in skull base surgery of the petroclival region and holds clinical significance due to its relation to the abducent nerve and surrounding vascular structures. Yet, although academics such as Dorello and Gradenigo are recognized for their work on the canal, it is important not to forget the others throughout history who have contributed to the modern-day understanding of this anatomical structure. In fact, although the level of anatomical detail found in Dorello's work was previously unmatched, the first description of the canal was made by the experienced Austrian anatomist Wenzel Leopold Gruber in 1859, almost 50 years prior to Dorello's landmark publication. Another critical figure in building the understanding of Dorello's canal was Harris Holmes Vail, a young otolaryngologist from Harvard Medical School, who in 1922 became the first person to describe Dorello's canal in the English language. Vail conducted his own detailed anatomical studies on cadavers, and his publication not only reaffirmed Dorello's findings but also immortalized the eponym used today-"Dorello's canal." In this article the authors review the life and contributions of Gruber, Dorello, Gradenigo, and Vail, four men who played a critical role in the discovery of Dorello's canal and paved the way toward the current understanding of the canal as a key clinical and surgical entity.