Outcomes in primary and revision surgery for pediatric onset stapedial pathology.

OBJECTIVES: To analyze audiometric outcomes of surgery for pediatric onset stapedial pathology (POSP). STUDY DESIGN: Retrospective cohort study. SETTING: Single-institution database. METHODS: Retrospective analysis of 809 stapes procedures performed at a single high-volume tertiary referral otology practice, 75 of which were POSP cases. RESULTS: Oval window drillout for thick footplate and aborting the procedure were more common in POSP cases compared to the rest of the cohort (28.0% versus 9.8% [p < .001] and 5.3% versus 1.2% [p = .007], respectively). Postoperative complications were rare. Postoperative Air-Bone Gap (pABG) closure to ≤20 dB was significantly lower in the POSP group (80.0% versus 89.0%, p = .021). Rates of sensorineural hearing loss (SNHL) were not different between the two groups. Poor audiometric outcomes in the POSP group were largely driven by revision cases; pABG≤10 dB was 60.3% in primary cases but only 11.8% in revisions (p < .001), and postoperative SNHL was significantly higher in revisions (29.4% versus 0.0%, p < .001). In multivariate analysis, POSP was not a predictor of successful closure of the pABG at either level, nor did it predict significant postoperative SNHL. CONCLUSIONS: Surgery for pediatric onset stapedial pathology had significantly worse audiometric outcomes, particularly in revision cases, as compared to the rest of the cohort.

Stapes surgery with a persistent stapedial artery.

PURPOSE: To review surgical outcomes of stapes surgery for otosclerosis with persistence of the stapedial artery. MATERIALS AND METHODS: A retrospective case review of a tertiary neurotology referral center of patient with otosclerosis undergoing primary stapes surgery between 2010 and 2017 found to have a persistent stapedial artery. Stapedectomy was performed with or without cauterization of the stapedial artery. The primary outcome measures include pre- and postoperative hearing as well complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Neurologic complications, including facial nerve function, were assessed. RESULTS: Four patients out of 853 with otosclerosis undergoing stapedectomy were found to have a persistence of the stapedial artery. Mean AC PTA was 55 dB preoperatively, and 24 dB postoperatively (p = .0041), while the ABG improved on average from 31 dB to 6 dB (p = .0014). Mean follow-up time was 32 months, and there were no significant complications. Facial nerve function was preserved in all patients (House-Brackmann grade I/VI). CONCLUSIONS: In the case of a persistent stapedial artery, excellent hearing outcomes are achievable for otosclerosis via stapedectomy without an apparent increased risk of neurologic complication.

Reliability of clinical diagnosis of masses of the cerebellopontine angle: A retrospective multi-institutional study.

OBJECTIVES: To assess the accuracy of pre-operative diagnosis of masses of the cerebellopontine angle (CPA) when compared to surgical pathology. DESIGN: Retrospective chart review. PARTICIPANTS: Patients who underwent surgery for CPA masses at two tertiary care institutions from 2007 to 2017. MAIN OUTCOME MEASURES: Percent concordance between pre-operative and surgical pathologic diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value for predicted diagnoses. RESULTS: Concordance between pre-operative diagnosis and surgical pathology was 93.2% in 411 sampled patients. Concordance was 57.9% for masses other than vestibular schwannoma. Prediction of vestibular schwannoma and meningioma had high positive (0.95 and 0.97, respectively) and negative (0.76 and 0.99, respectively) predictive values. Prediction of facial neuroma had sensitivity of 0.13 and positive predictive value of 0.25. Headache (p = 0.001) and facial weakness (p = 0.003) were significantly associated with different pathologic profiles. Hearing loss was associated with differences in diagnostic prediction (p = 0.02) but not with differences in surgical pathology (p > 0.05). CONCLUSIONS: Comparison between pre-operative predicted diagnosis and surgical pathology for cerebellopontine angle masses is presented. Vestibular schwannoma and meningioma were effectively identified while rarer CPA masses including facial neuroma were rarely identified correctly. Clinicians caring for patients with CPA masses should be mindful of diagnostic uncertainty which may lead to changes in treatment plan or prognosis.

Hydroxyapatite bone cement for suboccipital retrosigmoid cranioplasty: A single institution case series.

OBJECTIVE: To report rates of cerebrospinal fluid leak, wound infection, and other complications after repair of retrosigmoid craniotomy with hydroxyapatite bone cement. METHODS: Retrospective case review at tertiary referral center of patients who underwent retrosigmoid craniotomy from 2013 to 2016 with hydroxyapatite cement cranioplasty. OUTCOME MEASURES: Presence of absence of cerebrospinal fluid leak, wound infection, and other complications. RESULTS: Twenty cases of retrosigmoid craniotomy repaired with hydroxyapatite cement were identified. Median length of follow up was 9.8months. No cases of cerebrospinal fluid leak were identified. One patient developed a wound infection which was thought to be related to a chronic inflammatory response to the implanted dural substitute. No other major complications were noted. CONCLUSIONS: A method and case series of suboccipital retrosigmoid cranioplasty using hydroxyapatite cement and a are reported. Hydroxyapatite cement cranioplasty is a safe and effective technique for repair of retrosigmoid craniotomy defects.

High rate of bilaterality in internal auditory canal metastases.

PURPOSE: Presentation of three cases of metastatic carcinoma to the internal auditory canal bilaterally, as well as a systematic review of the literature regarding the characteristics of these lesions. MATERIALS AND METHODS: Using a MEDLINE Ovid search (1946-2015), we identified and reviewed 102 cases of metastatic carcinoma to the internal auditory canal. Metrics recorded include: patient age, sex, tumor type, laterality, past oncologic history, co-occurring metastatic sites, clinical findings, radiographic findings, therapy received, and outcome. Cases of unilateral versus bilateral IAC were compared. RESULTS: Remarkably, 52.9% reported cases of internal auditory canal metastases have bilateral occurrence. The most common primary tumor sites for internal auditory canal metastases were lung (21.2%), skin (18.6%), and breast (16.7%), with lung and skin cancers having the highest rates of bilateral metastasis. Meningeal metastasis occurred at a much higher rate in bilateral cases (47.2%) versus unilateral cases (8.5%). Brain parenchymal metastasis also occurred at a higher rate in bilateral cases (38.2%) versus unilateral cases (19.2%). Outcomes for cases of internal auditory canal metastases are generally poor, with 56.3% of unilateral cases and 86.1% of bilateral cases reporting patient death within 5 years from diagnosis. CONCLUSIONS: In cases of internal auditory canal metastasis, clinicians should carefully assess for not only contralateral disease but also additional metastatic disease of the central nervous system. Rapid-onset hearing loss, tinnitus, vertigo, or facial palsy should raise suspicion for internal auditory canal metastasis, particularly in patients with a known oncologic history.

Hemifacial spasm and neurovascular compression.

Hemifacial spasm (HFS) is characterized by involuntary unilateral contractions of the muscles innervated by the ipsilateral facial nerve, usually starting around the eyes before progressing inferiorly to the cheek, mouth, and neck. Its prevalence is 9.8 per 100,000 persons with an average age of onset of 44 years. The accepted pathophysiology of HFS suggests that it is a disease process of the nerve root entry zone of the facial nerve. HFS can be divided into two types: primary and secondary. Primary HFS is triggered by vascular compression whereas secondary HFS comprises all other causes of facial nerve damage. Clinical examination and imaging modalities such as electromyography (EMG) and magnetic resonance imaging (MRI) are useful to differentiate HFS from other facial movement disorders and for intraoperative planning. The standard medical management for HFS is botulinum neurotoxin (BoNT) injections, which provides low-risk but limited symptomatic relief. The only curative treatment for HFS is microvascular decompression (MVD), a surgical intervention that provides lasting symptomatic relief by reducing compression of the facial nerve root. With a low rate of complications such as hearing loss, MVD remains the treatment of choice for HFS patients as intraoperative technique and monitoring continue to improve.

Contemporary management of pediatric lateral sinus thrombosis: a twenty year review.

OBJECTIVES: A case of pediatric otogenic lateral sinus thrombosis is reported, followed by a substantive literature review. DESIGN: 104 patients were reviewed, culled from published case reports from 1993 to 2011 on the PubMed database. METHODS: All full text case reports on the PubMed database from 1993 to 2011 with patients less than or equal to 16 years of age that outlined specific treatments were included. RESULTS: 73% of patients were male and average age of presentation was 7.7 years. The most common symptoms were fever, headache, and otalgia, while the most common signs included otorrhea and neck stiffness. CT scans had a sensitivity of 87% and MR studies had a sensitivity of 100%. Single bacterial organisms were isolated in 46% of cases, with beta hemolytic streptococcus, streptococcus pneumoniae, and staphylococcus aureus being most common. Management included broad spectrum antibiotics (100%), mastoidectomy (94%), manipulation of the thrombosed sinus (50%), and anticoagulation (57%). The mortality rate was one in 104 patients. Morbidities occurred in 10% of patients and included cranial nerve palsy, sensorineural hearing loss, stroke, and septic hip joint. CONCLUSION: Lateral sinus thrombosis is a rare but treatable complication of otologic disease in the pediatric population, warranting a high index of suspicion. Management should include broad spectrum antibiotics and surgical removal of all perisinus infection. Anticoagulation is not definitively associated with improved outcomes and warrants further investigation.

Resection of Intracochlear Schwannomas With Immediate Cochlear Implantation.

INTRODUCTION: Intralabyrinthine schwannomas, including the intracochlear variety, are rare benign tumors. They can cause a number of symptoms and have the potential to grow to involve other critical structures of the inner ear and skull base. While surgical resection is feasible, there is typically permanent hearing dysfunction as a result of resection and subsequent fibrosis. Here, we present 2 cases of intracochlear schwannomas (ICS) that were successfully resected with simultaneous cochlear implant placement. METHODS: Patient 1 presented with an intravestibulocochlear schwannoma. This patient underwent a translabyrinthine approach. Endoscopic assistance was used to dissect the tumor from the vestibule and basal turn of the cochlea, through an enlarged round window approach. A cochlear implant was placed via a round window cochleostomy. Patient 2 presented with an intracochlear schwannoma involving the basal and middle turns of the cochlea. The patient underwent a trans-otic approach for resection. A large portion of the cochlear promontory required unroofing for complete exposure of the tumor. A cochlear implant was then placed via a round window cochleostomy. RESULTS: Upon cochlear implant activation, Patient 1's sound field thresholds using the implant were near the normal range of hearing, ranging from 25 to 50 dB HL from 250 to 6000 Hz. Patient 2's 6-month post-operative cochlear implant sound field testing ranged from 20 to 30 dB HL from 250 to 6000 Hz and speech recognition testing revealed 59% on AZ Bio sentences compared to 0% pre-operatively. CONCLUSION: Simultaneous cochlear implantation after resection of intracochlear schwannomas is safe and successful in restoring hearing. Attention to adequate exposure and endoscopic assistance, when required, allow for gross total resection while minimizing trauma to cochlear structures. In such cases, immediate cochlear implantation allows for hearing rehabilitation before likely cochlear fibrosis can occur.

Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes.

OBJECTIVE: Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. STUDY DESIGN: Retrospective review. SETTING: Single tertiary neurotology center. METHODS: Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. RESULTS: During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB (P < .0005). The most common intraoperative findings for these patients were prosthesis displacement with incus necrosis (38%) or without it (43%), normal anatomy with seemingly good prosthesis placement (6%), and abundant scar tissue (6%). Patients with recurrent hearing loss achieved lower mean ABGs than patients with persistent hearing loss (8.8 vs 13.2 dB, P = .02). There were no associations between onset pattern of CHL or intraoperative findings and hearing outcomes (P > .05). Four patients (2.7%) developed sensorineural hearing loss after revision, defined as an increase in bone conduction pure tone average ≥15 dB, all of whom had previous replacement of a malpositioned prosthesis. CONCLUSIONS: Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

Use of middle ear immittance testing in the evaluation of patulous eustachian tube.

BACKGROUND: Patulous Eustachian tube is the uncommon condition of a persistently open Eustachian tube, which causes the disturbing symptoms of autophony and respiratory-synchronous tinnitus. We review this condition and propose a specific evaluation protocol that can be performed quickly and easily using standard audiologic test equipment. We have used this protocol in the evaluation of a number of patients and will discuss our findings. PURPOSE: To establish a standardized protocol for the audiologic evaluation of patulous Eustachian tube using a standard clinical tympanometer and to establish norms with respect to tympanic membrane movement during breathing tasks. RESEARCH DESIGN: Quantitative analysis of test results obtained during clinical evaluation of patients referred for suspected patulous Eustachian tube during 2008 and 2009. STUDY SAMPLE: The cohort was 35 individuals including 25 patients referred for suspected patulous Eustachian tube and 10 control (normal) patients. Of the total group, 25 individuals were female, 10 were male, and the overall age range was 8 yr to 82 yr. DATA COLLECTION AND ANALYSIS: Patients underwent audiologic and otologic testing including quantitative measurement of middle ear compliance during breathing and nasal endoscopy. Two tympanometers were used to assess middle ear compliance: the Grason-Stadler Instruments Model 33 and Tympstar. Endoscopy was performed using either a Storz Endoskope Xenon Nova 175 or a Pentax EPM 1000. Results of middle ear immittance tests performed during breathing tasks were compared with results of endoscopy as well as the impressions of the examining physician. Magnitude of middle ear compliance was examined for mean and standard deviation, and the control/normal group results were compared with those of individuals complaining of symptoms suggestive of patulous Eustachian tube. RESULTS: We found that slightly greater than 75% of individual ears with patulous Eustachian tube exhibited middle ear compliance greater than 0.07 ml during breathing tasks. All ears with patulous Eustachian tube exhibited a respiratory-synchronous compliance pattern during breathing tasks. Of individual ears without patulous Eustachian tube, 97% exhibited middle ear compliance during breathing of less than 0.07 ml with no respiratory-synchronous pattern. CONCLUSIONS: Measurement of middle ear compliance during breathing appears to be a sensitive and specific tool in the examination of patulous Eustachian tube, particularly when both the magnitude of compliance and the pattern of compliance are considered.

Outcomes in Revision Stapes Surgery.

OBJECTIVES: To compare audiometric outcomes and complication rates between primary and revision stapes surgical cases. STUDY DESIGN: Retrospective cohort study. SETTING: Large single-institution database. METHODS: Data on 809 patients (including 170 revisions) undergoing primary and revision stapes surgery were reviewed, with Pearson chi-square and multivariable logistic regression analysis performed. RESULTS: Rates of postoperative air-bone gap (ABG) closure to ≤10 dB were significantly worse in the revision group (40.2% vs 61.8%, P < .001), as were those to ≤20 dB (78.1% vs 90.9%, P < .001). The bone conduction pure tone average worsened by >10 dB in 7.1% of primary cases and 13.1% of revisions (P = .016). The mean postoperative ABG for revision cases was significantly higher at 15.5 dB as compared with 11.0 dB for primaries (P < .001), despite a slightly higher preoperative ABG for primary cases (30.6 vs 28.24 dB, P = .010). In multivariate analysis, revision surgery had an odds ratio 0.41 (P < .001) in closing the ABG to ≤10 dB. Postoperative reparative granuloma (2.4% vs 0.2%, P = .001) and hydrops (1.8% vs 0.2%, P = .008) were higher in revision cases. CONCLUSIONS: Revision stapes surgery was found to have less predictable and inferior results as compared with primary cases. LEVEL OF EVIDENCE: 4 (retrospective observational research).

Outcomes After Tympanic Membrane Perforation During Primary Stapes Surgery for Otosclerosis.

OBJECTIVE/HYPOTHESIS: Stapes surgery is occasionally complicated by an intraoperative tympanic membrane perforation (ITMP), traditionally indicating abortion of the procedure due to concerns for postoperative infection and sensorineural hearing loss (SNHL). This work examines outcomes and complications in completed primary stapes surgeries with and without ITMP. STUDY DESIGN: Retrospective review. METHODS: All patients diagnosed with otosclerosis between February 2008 and September 2017 at a tertiary otology referral center were reviewed retrospectively. Primary outcome measures were post-operative air-bone gap (ABG), air conduction and bone conduction pure tone averages, and post-operative complications. RESULTS: Review revealed 652 primary stapes operations meeting inclusion criteria, of which ITMP occurred in 10. There were no significant differences in pre-operative hearing metrics or demographic characteristics between ears with and without ITMP. There were also no significant differences in post-operative ABG (6.4 vs. 8.0 dB HL, P = .43) or change in ABG after surgery (-21.6 vs. -18.2 dB, P = .34) between these two groups. Patients with ITMP were more likely to complain of post-operative dysgeusia (30.0% vs. 5.3%, P = .015) but were no more likely to develop reparative granuloma, otitis media, or SNHL (P > .05). CONCLUSIONS: The first review of ITMP and hearing outcomes after stapes surgery is presented. Our findings suggest that it is likely safe and appropriate to proceed with primary stapes surgery and concurrent tympanoplasty in the presence of a small ITMP with minimal risk of infection, SNHL, or worsened hearing outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2026-E2030, 2021.

Is Menière's Disease a Contraindication to Stapedectomy?

OBJECTIVE: Review surgical outcomes of stapedectomy for otosclerosis in patients with Menierè's disease. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Patients with otosclerosis and Menière's disease undergoing stapedectomy between 2010 and 2017. INTERVENTION: Stapedectomy. MAIN OUTCOME MEASURES: Pre- and postoperative hearing and complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone frequency, pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). RESULTS: Among 1,499 patients with otosclerosis, the incidence of concomitant Menière's disease was 1.7%. Fifteen patients with otosclerosis and Menière's disease underwent stapedectomy, 12 primary and three revisions. Mean AC PTA was 43 dB preoperatively, and 25 dB postoperatively (p = 0.0007), while the ABG improved on average from 20 to 5 dB (p = 0.0001). There was no significant difference in BC PTA or WRS postoperatively. Two patients experienced fluctuation of hearing in the postoperative period, one of which resolved with a course of steroids. The mean follow-up time was 41 months. CONCLUSIONS: In patients with otosclerosis and Menière's disease, stapedectomy provides excellent hearing outcomes in a majority of patients. As is characteristic of Menière's disease, some patients will continue to experience fluctuating hearing postoperatively, which may progress to severe sensorineural hearing loss. Menière's disease may not be an absolute contraindication to stapes surgery.

Hearing Outcomes and Complications in Stapes Surgery for Otosclerosis Performed Under General or Local Anesthesia.

OBJECTIVE: Stapes surgery is highly successful in reducing or eliminating the audiometric air-bone gap (ABG) related to otosclerosis, and it can be performed under general anesthesia or local anesthesia with sedation. Literature on the relative outcomes of these 2 modalities is lacking. The purpose of this study was to compare hearing outcomes for these 2 modalities in a large patient population. STUDY DESIGN: Retrospective review. SETTING: Large otology referral center. METHODS: Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were grouped by anesthetic modality and their cases reviewed. Pre- and postoperative ABGs were primary outcomes. RESULTS: A total of 580 patients undergoing stapes surgery were included: 46% received local anesthesia and 54% received general anesthesia. These 2 groups were similar in demographic and disease characteristics. Mean preoperative ABGs were 25.6 and 26.6 dB for patients undergoing local and general anesthesia, respectively (P = .2); mean postoperative ABGs were 9.5 and 9.7 dB (P = .9). There were no significant differences in the rates of complications, the need for revision surgery, or the need to abort surgery intraoperatively between local and general anesthesia. CONCLUSION: Consistent with limited prior data, in this cohort stapes surgery yielded similar hearing outcomes whether performed under general anesthesia or local anesthesia with sedation. While we report the largest sample size to date, this study, like previous work, carries the potential for sampling bias. Prospective study comparing local and general anesthesia for stapes surgery is needed.

Association Between the Duration of Hearing Loss and Hearing Outcomes in Surgery for Otosclerosis.

INTRODUCTION: Hearing loss due to otosclerosis is effectively treated with surgery. The association between duration of hearing loss and surgical outcomes is unknown. STUDY DESIGN: Retrospective review. SETTING: Large otology referral center. METHODS: Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were evaluated according to their self-reported duration of hearing loss. Closure of the air-bone gap (ABG) was the primary outcome measure. RESULTS: A total of 580 stapes operations were included. Sixteen percent of patients reported hearing loss for ≤1 year; 25%, >1 to ≤5 years; 24%, >5 to ≤10 years; 24%, >10 to ≤20 years; and 12%, >20 years, respectively. Average pre- and postoperative ABGs were 26.1 and 9.6 dB (P < .0005). Patients with longer duration of hearing loss had worse preoperative ABGs (P < .0005). After surgery, patients with longer duration of hearing loss had a greater reduction in their ABGs (P < .0005) such that the remaining ABG was not associated with duration of hearing loss (P > .05). There were no significant associations between the duration of hearing loss and complication rates or the need for revision surgery. CONCLUSION: Otosclerosis is effectively treated with surgery even after a long duration of hearing loss, provided that sensorineural hearing and word recognition are favorable. Although far-advanced otosclerosis has known poorer hearing outcomes after stapes surgery, a long duration of hearing loss is an unreliable surrogate for this.

Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery.

OBJECTIVES: To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses. METHODS: A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed. RESULTS: Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively (P < .0001), while the ABG improved on average from 27 dB to 9 dB (P < .0001). There was no significant difference in postoperative ABG between primary and revision stapes surgery (6 dB vs 10 dB, P = .07). These results persisted through long-term follow-up in a subgroup of patients with significantly longer follow-up time (mean 44 months). There was no significant change in BC PTA or word recognition scores. Three patients underwent subsequent revisions, one patient developed sensorineural hearing loss. CONCLUSION: Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

Evolving Role of Non-Total Resection in Management of Acoustic Neuroma in the Gamma Knife Era.

OBJECTIVE: To examine patients with residual tumor after vestibular schwannoma (VS) resection with focus on need for further therapy, including stereotactic radiosurgery (SRS) and revision surgery. STUDY DESIGN AND SETTING: Retrospective review at two tertiary otology referral centers. PATIENTS AND INTERVENTION: Patients undergoing primary surgery for VS from 2007 to 2017. MAIN OUTCOME MEASURE: Degree of resection and need for further treatment. RESULTS: Of 289 patients undergoing surgery, 38 (13.1%) underwent subtotal resections (<95% of tumor resected) and 77 (26.6%) underwent near-total resections (≥95% but <100%). Patients with any residual tumor had larger tumors preoperatively (mean estimated volume 6.3 cm versus 2.1 cm, p < 0.0005) but were otherwise clinically and demographically similar to the population as a whole. Further treatment (surgery or SRS) was needed in 4.6, 14.3, and 50.0% of patients after gross total, near-total, and subtotal resections, respectively (p < 0.0005). Patients undergoing additional therapy had larger residual tumors (median post- to preoperative estimated volume ratio 0.09 versus 0.01, p < 0.0005). Patients undergoing subtotal and near-total resections had poorer facial function at ultimate follow up than those undergoing gross total resections (p = 0.001), likely due to larger tumors and more difficult resections. Literature review revealed higher rates of gross total resection as well as facial palsy in the pre-SRS era. CONCLUSION: Residual tumor following VS resection is more common today than in the pre-SRS era. Availability of SRS may encourage leaving residual tumor intraoperatively to preserve neural structures. Current surgical strategies decrease surgical morbidity but necessitate further treatment in over 10% of cases.

Association Between Body Mass Index and Complications in Acoustic Neuroma Surgery.

OBJECTIVES: Elevated body mass index (BMI) is a risk factor for surgical complications, but data in acoustic neuroma surgery are conflicting and limited to small single-institution studies. This work evaluates associations between BMI and complications in surgery for acoustic neuroma (AN). STUDY DESIGN: Retrospective review. SETTING: Two tertiary otology referral institutions. SUBJECTS AND METHODS: Patients undergoing surgery for AN. Univariate and multivariate analysis of association between BMI and complications was performed using two-tailed t tests and binary logistic regression. RESULTS: BMI ranged from 18.0 kg/m2 to 63.9 kg/m2 with mean of 29.2 kg/m2 among 362 included patients. High BMI was associated with increased risk of cerebrospinal fluid (CSF) leak (p = 0.003) and need for revision surgery within 6 months (p = 0.03). CSF leak occurred in 11.6% of obese patients (BMI ≥ 30.0) and 5.1% of patients with BMI < 30.0. There was no association between BMI and post-operative intracranial hemorrhage, wound infection, or incomplete resection (p > 0.05). Multivariate analysis revealed BMI was associated with CSF leak (odds ratio 1.11 per BMI point, p = 0.002) and need for revision surgery (odds ratio 1.07 per BMI point, p = 0.02) independent of age, gender, tumor size, or surgical approach. CONCLUSIONS: The largest series to date investigating BMI in acoustic surgery is presented. Elevated BMI is strongly associated with CSF leak and need for revision surgery but not with other complications. Obese or overweight patients undergoing acoustic neuroma resection should be counseled of their increased risk of CSF leak.

Natural History of Facial Weakness Following Surgery of the Cerebellopontine Angle: A Tertiary Care Cohort.

OBJECTIVE: Facial function is a key outcome in surgery of the cerebellopontine angle (CPA). This study describes the natural history of facial weakness after CPA surgery. STUDY DESIGN AND SETTING: Retrospective study of two tertiary centers. PATIENTS AND INTERVENTION: Patients undergoing surgery for CPA tumors from 2003 to 2017 with preoperatively normal facial function and without subsequent surgical or adjuvant therapy. MAIN OUTCOME MEASURE: Serial facial nerve examinations using the House-Brackmann (HB) scale. RESULTS: Of 301 patients examined, 149 (49.5%) had facial weakness postoperatively and 74.5% of these occurred within 24 hours. Of patients with HB-1 function within 24 hours after surgery, 95.3% had HB-1 function and 100% had HB-3 or better function at last follow-up. Of patients with HB-4 or worse function within 24 hours after surgery, 22.6% ultimately achieved HB-1 function and 83.9% ultimately achieved HB-3 or better function. By 180 days postoperatively, 83.7% of patients' facial function had stabilized. At last follow-up, 3.0% of patients had facial function poorer than HB-3, which was associated with subtotal resections (12.9% vs. 4.4% for near total and 0.6% for gross total resections, p = 0.002), aspirin use (10.6% vs. 1.6%, p = 0.001), larger tumors (p < 0.0005), longer surgery (p < 0.002), and immediate versus delayed postoperative facial weakness (p = 0.002). CONCLUSIONS: Facial function over time after CPA surgery is presented. While facial function immediately after surgery correlates with future function, delayed weakness or improvement is common. These data inform patient counseling both preceding and following surgery.

Dickkopf-related Protein 3 as a Sensitive and Specific Marker for Cerebrospinal Fluid Leaks.

HYPOTHESIS: Cerebrospinal fluid (CSF) can be identified by using an enzyme-linked immunosorbent assay (ELISA) for Dickkopf-related protein 3 (DKK3). BACKGROUND: Cerebrospinal fluid leakage from the subarachnoid space is a potentially alarming condition that, left unrepaired, may result in increased risk of meningitis and encephalitis. Current biochemical methods of CSF leak detection involve using beta-2-transferrin-based or beta trace protein-based assays, both of which, at present, have limitations that hinder practical clinical application. This study presents the immunological detection of the CSF-enriched protein DKK3 as a method for detection of a CSF leak. METHODS: Antibodies against DKK3 were generated in rabbits and goats immunized with recombinant human DKK3. Varying dilutions and combinations of human CSF and serum were tested on immunoblots and sandwich ELISA using antibodies to DKK3. RESULTS: ELISA data show that there is a negligible amount of detectable DKK3 in serum samples compared with CSF samples. Inclusion of sera (up to 30%) in a sample containing CSF failed to produce a positive signal, whereas concentrations of CSF as low as 1% produced a positive signal. The minimum concentration required for reliable CSF detection in a sandwich ELISA was determined to be 0.5  µl. CONCLUSION: ELISA sandwich assays for DKK3 can reliably detect the presence of as little as 0.5 µl of human CSF, even in the presence of excessive serum. This study provides quantitative evidence of the utility of DKK3 immunoreactivity as an assay for the presence of CSF in samples that contain contaminating sera. The robustness of this assay has allowed for the development of a rapid, point of care test for the detection of CSF in clinical and surgical setting.