Temporal changes in endolymphatic hydrops on MRI with or without intervention: A systematic review.

OBJECTIVE: The pathophysiology of Meniere's Disease (MD) involves endolymphatic hydrops (ELH) of the inner ear. Magnetic Resonance Imaging (MRI) has been shown to detect ELH, but changes in ELH have been poorly described using this modality. Our objective was to review MRI-measured changes in ELH over time and after medical and/or surgical intervention in patients with MD. We secondarily aim to associate changes in ELH with changes in MD symptomatology. DATABASES REVIEWED: Medline, Web of Science, and Embase databases. METHODS: A systematic review of articles was performed to identify studies utilizing MRI to measure ELH changes over time, and after medical or surgical treatment. Articles on non-human subjects and without direct measurement of ELH were excluded. RESULTS: Of 532 studies identified, 12 were included, involving 170 patients (mean age 56.3 years). Ten studies were prospective; two were retrospective. Five studies strictly utilized medical means of intervention, four utilized surgical treatments, one utilized both, and two observed temporal changes without treatment. Across all interventions, 72.1 % of patients exhibited the same or worsening ELH on imaging. In studies reporting vertigo outcomes, 95.9 % of patients exhibited improvement after the treatment period. CONCLUSION: Medical and surgical interventions often yield symptomatic relief of vertigo in MD patients despite stable or increasing ELH volume. MRI may have greater clinical utility in diagnosing ELH as opposed to assessing treatment response.

Does Auditory Environment Predict Speech Perception Outcomes in Elderly Cochlear Implant Patients?

INTRODUCTION: Cochlear implantation (CI) is a reliable and safe means by which sensorineural hearing loss can be ameliorated in the elderly population. However, a high degree of variation exists in postimplantation hearing outcomes for which some modifiable factors of the daily natural auditory environment may be contributory. In this study, we analyze the relationship between cochlear implant patient age, natural auditory environment, and postimplantation speech perception among older adults. METHODS: Data log from automatic environment classification enabled sound processors of postlingually deafened CI recipients ≥50 years old (n = 115) were obtained retrospectively and analyzed for time spent (hours per day) in listening environment and loudness (SPL dB). Speech perception testing was assessed in a subset of patients (n = 27) using open-set word recognition in quiet Consonant-Nucleus-Consonant in the short and intermediate postoperative period. RESULTS: The mean subject age was 70 years (range, 53-99 years). Average daily implant use was 10.8 h and was not significantly correlated with age (p = 0.23, Spearman's rho). Age was positively correlated with the percentage of hours spent at <40 and 40-50 dB and negatively correlated to proportional CI use at higher volume (60-70, 70-80, and >80 dB; rs = 0.21, 0.20, -0.20, -0.35, -0.43; p = 0.021, 0.036, 0.033, <0.001, <0.001, respectively). Age was positively correlated with CI use in the quiet scene (rs = 0.26, p = 0.006) and negatively correlated with scenes containing speech and noise (rs = -0.19, -0.25; p = 0.046, 0.007). Total hours of device use and time spent at <40, 40-50 dB, and quiet environments were significantly correlated with improved CNC word scores (rs = 0.48, 0.48, 0.51; p = 0.01, 0.01, <0.01, Spearman's rho). While all speech (speech in noise + speech) was not significantly correlated to improvements in speech perception, a medium effect size was observed (rs = 0.37, p = 0.057). DISCUSSION/CONCLUSION: This study supports a relationship between auditory environment and age, with older CI recipients spending a greater proportion of time in quiet. Older CI users demonstrated greater improvements in speech perception with longer daily device use. Additional examination of the relationship between auditory environment and speech perception is necessary to conclusively guide future auditory rehabilitation efforts.

Burkitt lymphoma of the nasopharynx causing life-threatening airway obstruction: A case report.

OBJECTIVE: To describe a case of Burkitt lymphoma (BL) in a child manifesting with acute airway obstruction. To review available literature on the clinical features and characteristic presentation of this disease. METHODS: Case report with literature review. RESULTS: We present the case of an 8-year-old boy with nasopharyngeal BL manifesting initially as sore throat, nasal congestion, and snoring that progressed to dyspnea and, ultimately, acute airway obstruction requiring emergent tracheostomy. The child was treated with intensive chemotherapy and achieved complete response. CONCLUSION: This case highlights the importance of maintaining high clinical suspicion when evaluating common otolaryngologic symptoms and emphasizes the potential for Burkitt lymphoma to cause rapid patient deterioration.

The utility of augmented reality in lateral skull base surgery: A preliminary report.

OBJECTIVE: To discuss the utility of augmented reality in lateral skull base surgery. PATIENTS: Those undergoing lateral skull base surgery at our institution. INTERVENTION(S): Cerebellopontine angle tumor resection using an augmented reality interface. MAIN OUTCOME MEASURE(S): Ease of use, utility of, and future directions of augmented reality in lateral skull base surgery. RESULTS: Anecdotally we have found an augmented reality interface helpful in simulating cerebellopontine angle tumor resection as well as assisting in planning the incision and craniotomy. CONCLUSIONS: Augmented reality has the potential to be a useful adjunct in lateral skull base surgery, but more study is needed with large series.

Nuances in transcanal endoscopic surgical technique for glomus tympanicum tumors.

OBJECTIVE: To describe the utility and nuances of transcanal endoscopic surgery (TCES) on glomus tympanicum tumors from a single surgeon's experience. PATIENTS/INTERVENTION: Twelve patients, eight female and four males, diagnosed pre-operatively with glomus tympanicum tumors. They all underwent endoscopic resection by a single surgeon. MAIN OUTCOME MEASURES: Feasibility of endoscopic resection of glomus tympanicum tumors without conversion to a microscopic approach. Secondary outcomes include tumor stage, pre and post-operative audiometry, vertigo, sensorineural hearing loss (SNHL) and integrity of the facial nerve, ossicles, chorda tympani and tympanic membrane. RESULTS: Twelve patients underwent TCES, eight patient's pathology results were glomus tympanicum, ranging from Glasscock-Jackson grade I-III. Due to loss in follow up, 6/8 patients had complete audiometric data, which were analyzed. Average pre-operative air-bone-gap (ABG) was 5.41 compared to post-operative ABG of 5.08 (p > 0.89). No patients resulted in any, post-operative vertigo, tinnitus, SNHL, facial nerve injury or chorda tympani nerve injury. Two patients had intentional tympanic membrane perforations secondary to tumor adherence to the membrane. They were repaired with tragal perichondrium graft. No patients have had any recurrences. CONCLUSIONS: Endoscopic resection of glomus tympanicum tumors is a feasible and effective, alternative visualization modality for the neurotologist. Surgical pearls are described herein.

Microdrill in endoscopic stapes surgery: Is it safe?

PURPOSE: To assess the safety of using a microdrill in endoscopic vs microscopic stapes surgery. MATERIALS AND METHODS: A retrospective review of 29 adult ears with otosclerosis who underwent either an endoscopic or microscopic approach to microdrill stapedotomy. PRIMARY OUTCOME: Determine if transcanal endoscopic stapes surgery with the microdrill is as safe as microscopic stapes surgery. Secondary outcome: Bone and air pure-tone averages, air-bone gap, speech discrimination, overall surgical cost, and operative time were measured and analyzed. Complications such as post-operative dysgeusia, vertigo, readmission, revision and hearing loss were noted. RESULTS: 29 patients with otosclerosis were retrospectively reviewed, in total 14 endoscopic and 15 microscopic approaches were included, all performed over one-year period. None of the endoscopic surgeries require conversion to the microscope. No statistically significant audiometric differences between the endoscopic vs microscopic approaches in air pure-tone averages and air-bone gap. There were 82.8% air-bone gap closure to <15 dB with no significant difference in the percent of such closures between the endoscopic (85.7%) and microscopic groups (80%, P = .68). Three prostheses were used: 4.25 mm (17.2%), 4.5 mm (58.6%) and the 4.75 mm (24.1%) smart/eclipse. Endoscopic median operative time was 51 min vs 42 min for microscopic approach (P =.004). CONCLUSIONS: The endoscopic with microdrill approach is criticized to lack depth perception, especially when using a microdrill to perform in stapedotomies. Our study showcases that using the microdrill use produces minimal differences in outcomes, cost, and is a safe modality to stapes surgery in both approaches.

Purely intracranial vagal schwannoma: A case report of a rare lesion.

We present a rare intracranial vagal schwannoma along with its preoperative, intraoperative, and postoperative course.

Angiolymphoid hyperplasia with eosinophilia of the external ear.

Herein we present the rare case of angiolymphoid hyperplasia with eosinophilia of the external ear treated by surgical resection and full-thickness skin graft. Current diagnosis and management options are reviewed.

National 30-day readmission and prolonged length of stay after vestibular schwannoma surgery: Analysis of the Nationwide Readmissions Database.

PURPOSE: To determine the risk factors for unanticipated readmission, prolonged index admission, and discharge to a facility after vestibular schwannoma surgery. MATERIALS AND METHODS: Retrospective cohort study of those undergoing surgery for vestibular schwannoma in the Nationwide Readmissions Database (2013-2014). Main outcome measures included readmission rate, length of stay, discharge destination. RESULTS: There were 4585 cases identified. The overall unanticipated readmission rate was 8.1%, and 9.1% had a prolonged length of stay (PLOS) of ≥7 days. Mean and median LOS were 4.63 and 4.00 days, respectively, and >90% of patients were discharged after 7 days. Disposition to a facility occurred in 6.7% of cases. Teaching hospitals were protective against unintended readmission (odds ratio [OR] 0.44, p < .001). Major functional loss was associated with PLOS (OR 12.55, p < .001). High volume centers were associated with decreased risk of PLOS (OR 0.46, p < .001) and facility discharge (OR 0.68, p < .001). The most common readmission diagnoses included "other nervous system complications" (n = 128), cerebrospinal fluid leak (n = 71), "other postoperative infection" (n = 61), and meningitis (n = 59). CONCLUSIONS: Unanticipated readmission and prolonged LOS following vestibular schwannoma surgery are common, with varied sociodemographic, hospital, and patient factors independently associated with each. Further studies are needed to investigate targeted interventions aimed at minimizing readmission and prolonged LOS using the factors outlined above.

Improving resident familiarity with the translabyrinthine approach to the internal auditory canal.

OBJECTIVE: To increase otolaryngology resident experience with drilling and dissection of the internal auditory canal (IAC) via a translabyrinthine approach. STUDY DESIGN: Pilot study involving temporal bone education and drilling with completion of pre- and post-drilling surveys. METHODS: Participants observed an educational presentation on IAC anatomy and drilling, followed by manipulation of IAC nerves using a prosected cadaveric temporal bone. Participants then drilled the IAC and identified nerves using temporal bones with previously drilled mastoidectomies and labyrinthectomies. Pre- and post-drilling 5-point Likert-based surveys were completed. RESULTS: 7 participants were included in this study ranging in experience from PGY1 through PGY 5. The median number of times the IAC had been drilled previously was 0. Participants reported statistically significantly improved familiarity with the translabyrinthine approach after the session with median scores increasing from 2 to 3 (p=0.02), and a near-significant increase in familiarity with IAC anatomy with median scores increasing from 3 to 4 (p=0.06). Prior to the session, 71% of participants either disagreed or strongly disagreed that they had an idea of what the procedure would be like in a real operating room, whereas after the session 0% reported disagreement. 100% of participants were very satisfied with the overall experience. CONCLUSIONS: An educational session and temporal bone drilling experience using prosected bones significantly increased the reported familiarity with the translabyrinthine approach. Experiences such as this may enhance resident exposure to advanced lateral skull base approaches in a safe environment, and increase comprehension of the complex anatomic relationships of the IAC.

Spontaneous resolution of a petrous apex cholesterol granuloma.

Cholesterol granuloma is the most common primary lesion of the petrous apex. Management of petrous apex cholesterol granuloma has evolved in recent years from primary surgical treatment to conservative observation. In this article, a case of spontaneous resolution of a petrous apex cholesterol granuloma is described. To the authors' knowledge, this is the first known report of spontaneous involution of a petrous apex cholesterol granuloma. Radiographic differential diagnosis of petrous apex lesions and the natural history of cholesterol granulomas are discussed.

Initial radiographic tumor control is similar following single or multi-fractionated stereotactic radiosurgery for jugular paragangliomas.

OBJECTIVE: To evaluate radiographic tumor control and treatment-related toxicity in glomus jugulare tumors treated with stereotactic radiosurgery (SRS). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: Glomus jugulare tumors treated with SRS between 1998 and 2014 were identified. The data analysis only included patients with at least 18months of post-treatment follow up (FU). INTERVENTION: Patients were treated with either single fraction or fractionated SRS. MAIN OUTCOME MEASURE: Patient demographics and tumor characteristics were assessed. Radiographic control was determined by comparing pre and post treatment MRI, and was categorized as no change, regression, or progression. RESULTS: Eighteen patients were treated with SRS, and 14 met inclusion criteria. Median age at treatment was 55years (range 35-79), and 71.4% of patients were female. 5 patients (35.7%) received single fraction SRS (dose range 15-18Gy), and 9 (64.3%) fractionated therapy (dose 3-7Gy×3-15 fractions). Median tumor volume was 3.78cm(3) (range 1.15-30.6). Median FU was 28.8months (range 18.6-56.1), with a mean of 31.7months. At their last recorded MRI, 7 patients (50%) had tumor stability, 6 (42.9%) had improvement, and 1 (7.1%) had progression. Disease improvement and progression rates in the single fraction group were 40% and 0%, and in the multiple-fraction group, 44.4% and 11.1%, respectively. There was no statistically significant difference in disease improvement (p=0.88) or progression (p=0.48) rates between groups (unpaired t-test). CONCLUSIONS: At a median follow up of 28months, both single fraction and fractionated SRS appear to have comparable radiographic tumor control outcomes and toxicity profiles.

Interaural level difference cues determine sound source localization by single-sided deaf patients fit with a cochlear implant.

In this report, we used filtered noise bands to constrain listeners' access to interaural level differences (ILDs) and interaural time differences (ITDs) in a sound source localization task. The samples of interest were listeners with single-sided deafness (SSD) who had been fit with a cochlear implant in the deafened ear (SSD-CI). The comparison samples included listeners with normal hearing and bimodal hearing, i.e., with a cochlear implant in 1 ear and low-frequency acoustic hearing in the other ear. The results indicated that (i) sound source localization was better in the SSD-CI condition than in the SSD condition, (ii) SSD-CI patients rely on ILD cues for sound source localization, (iii) SSD-CI patients show functional localization abilities within 1-3 months after device activation and (iv) SSD-CI patients show better sound source localization than bimodal CI patients but, on average, poorer localization than normal-hearing listeners. One SSD-CI patient showed a level of localization within normal limits. We provide an account for the relative localization abilities of the groups by reference to the differences in access to ILD cues.

A case of sensorineural hearing loss involving a fibroepithelial polyp of the middle ear.

Primary middle ear neoplasms are rare, and commonly cause conductive hearing loss. When aural masses result in sensorineural hearing loss, malignant etiologies are often suspected. Fibroepithelial polyps are benign lesions commonly found in the skin and genitourinary tract and are not commonly identified as primary lesions of the middle ear. Here, we present a case of a benign fibroepithelial polyp of the middle ear causing sensorineural hearing loss and describe its surgical management. Imaging and histologic characteristics are reviewed.

Facial nerve stimulation associated with cochlear implant use following temporal bone fractures.

OBJECTIVE: To describe the incidence and management of patients with facial nerve stimulation (FNS) associated with cochlear implant (CI) use in the setting of a prior temporal bone fracture. PATIENTS: One adult CI recipient is reported who experienced implant associated FNS with a history of a temporal bone fracture. Additionally, a literature search was performed to identify similar patients from previous descriptions of CI related FNS. MAIN OUTCOME MEASURES: Presence of FNS after implantation and ability to modify implant programming to avoid FNS. RESULTS: The patient in the present report experienced FNS for middle and basal electrodes during intraoperative neural response telemetry (NRT) in the absence of any surgical exposure or manipulation of the facial nerve. FNS was absent during device activation, but it recurred during follow-up programming sessions. However, additional programming has prevented further FNS during regular implant use. Four other patients with FNS after temporal bone fracture were identified from the literature, and the present case represents the one of two cases in which reprogramming allowed for implant use without FNS. CONCLUSIONS: CI associated FNS is uncommon in patients with a history of a temporal bone fracture, but it is likely that fracture lines provide a lower impedance pathway to the adjacent facial nerve and thus reduce the threshold for FNS. The present report suggests that, in the setting of a prior temporal bone fracture, NRT is not always a reliable predictor of FNS during implant use, and programming changes can help to mitigate FNS when it occurs.

Retrosigmoid craniotomy for resection of acoustic neuroma with hearing preservation: a video publication.

In this publication, video format is utilized to review the operative technique of retrosigmoid craniotomy for resection of acoustic neuroma with attempted hearing preservation. Steps of the operative procedure are reviewed and salient principles and technical nuances useful in minimizing complications and maximizing efficacy are discussed. The video can be found here: http://youtu.be/PBE5rQ7B0Ls .

Factors associated with recurrence of squamous cell carcinoma involving the temporal bone.

OBJECTIVE: This study aimed to better identify factors associated with recurrence of squamous cell carcinoma (SCC) involving the temporal bone. METHODS: A retrospective study was conducted at a tertiary hospital. Sixty patients who were diagnosed over a 10-year period with SCC involving the temporal bone and underwent surgical resection were analyzed. All patients were staged based on the University of Pittsburgh staging system. Demographic, intraoperative, and pathologic data were analyzed with respect to recurrence. RESULTS: Thirteen (21.7%) patients were T1, 8 (13.3%) T2, 7 (11.7%) T3, and 32 (53.3%) T4. Eighteen patients (30.0%) recurred in the study period. The mean time to recurrence was 5.8 months. Tumors originating in the skin overlying the parotid gland and the external auditory canal had higher recurrence rates than those from the auricle/postauricular skin and temporal bone (P = .05). Direct parotid and perineural spread accounted for 15.0% of all routes of temporal invasion but resulted in 22.2% of all recurrences (P = .04). Increased N stage was statistically associated with increased risk of recurrence (P = .01). Cervical, as compared to perifacial and parotid, lymph node involvement was associated with increased risk of recurrence (odds ratio = 6.91; 95% confidence interval, 1.11-42.87). CONCLUSION: We have identified multiple factors that are associated with increased recurrence of SCC involving the temporal bone.

Acute pediatric facial nerve paralysis as the first indication for familial cerebral cavernoma: case presentation and literature review.

Familial cerebral cavernoma is an autosomal dominant phenotype with incomplete clinical and neuroimaging penetrance. The most common clinical manifestations include seizures and cerebral hemorrhage. We present the case of a 7-year-old boy who developed acute onset facial nerve paralysis secondary to previously unknown familial cerebral cavernoma. Genetic workup revealed a KRIT1 gene deletion which was later confirmed in the patient's asymptomatic father and younger brother.

Concordance and discordance in patient and provider perceptions of dizziness.

PURPOSE: The purpose of the present investigation was to determine whether there are significant differences in patient/healthcare provider perceptions of patient's dizziness severity, dizziness disability/handicap, anxiety, and signs of autonomic system activation. MATERIALS AND METHODS: This was a prospective investigation of 30 patient-provider dyads drawn as a sample of convenience from an otology clinic in a large, tertiary care, medical center. Patients completed both the Dizziness Handicap Inventory (DHI) and the Vestibular Symptom Scale (VSS) prior to vestibular function testing. Providers were instructed to complete the same measures following the patient's clinic visit from what they estimated was the patient's point of view. The two measures were analyzed for concordance and discordance. RESULTS: Patient/provider differences in DHI and VSS vertigo subscale scores were not significantly different. However, difference scores on the VSS anxiety/autonomic subscale indicated that providers significantly under-estimated patient anxiety and symptoms of autonomic system activation. CONCLUSIONS: The results suggest that providers may be missing information pertinent to the role anxiety and autonomic system activation may play in patient visits for complaints of dizziness. We suggest that this problem can be mitigated by administrating to patients prior to their clinic visit a standardized measure that quantifies patient self-report dizziness, vertigo, anxiety and autonomic system arousal. Patterns of response by patients on these measures can enable providers to diagnose correctly dizziness disorders that are rooted in clinically significant anxiety either related to, or unrelated to, a history of vestibular system impairment.