Sudden Sensorineural Hearing Loss in Patient Incidental to Treatment With Hyaluronic Acid Filler.

Hyaluronic acid fillers comprise a major component of aesthetic practice with few serious adverse effects. Hearing loss has not been previously associated with hyaluronic acid filler. The authors describe a case in which a patient developed sudden sensorineural hearing loss 1 day after filler injection into the nasolabial folds. Audiogram showed moderately severe sensorineural loss, and MRI revealed no abnormalities. Despite transtympanic steroid injections and hyperbaric oxygen therapy, the hearing loss persists at the time of writing. Although no causal relationships can be drawn from this case alone, this case serves to reinforce the importance of continued vigilance for future occurrences to minimize the potential risk of this serious adverse event.

Rationale for the Development of a Novel Clinical Grading Scale for Postoperative Facial Nerve Function: Results of a Multidisciplinary International Working Group.

OBJECTIVE: The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. STUDY DESIGN: Survey. SETTING: A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. RESULTS: House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. CONCLUSIONS: Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Quantification of Fat Graft Retention in the Translabyrinthine Approach Using Magnetic Resonance Imaging Volumetric Analysis.

OBJECTIVE: To characterize the viability and volume of autologous free fat grafts over time, determine clinical/patient factors that may affect free fat graft survival and assess the clinical impact of free fat graft survival on patient outcomes in the translabyrinthine approach for lateral skull base tumor resection. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotologic referral center. PATIENTS: Forty-two adult patients who underwent translabyrinthine craniotomy for resection of a lateral skull base tumor with the mastoid defect filled by autologous abdominal fat graft and subsequently underwent more than one postoperative magnetic resonance imaging (MRI) scans of the brain. INTERVENTIONS: Mastoid obliteration with abdominal fat after craniotomy, postoperative MRI. MAIN OUTCOME MEASURES: Rate of fat graft volume loss, fraction retention of original fat graft volume, initial fat graft volume, time to steady-state fat graft retention, rate of postoperative cerebrospinal fluid (CSF) leak, and/or pseudomeningocele formation. RESULTS: Patients were followed postoperatively with MRI for a mean of 31.6 months with a mean of 3.2 postoperative MRIs per patient. Initial graft size was a mean of 18.7 cm3 with a steady-state fat graft retention of 35.5%. Steady-state graft retention (<5% loss per year) was achieved at a mean of 24.96 months postoperatively. No significant association was found in multivariate regression analysis of clinical factors impact on fat graft retention and CSF leak/pseudomeningocele formation. CONCLUSIONS: In the use of autologous abdominal free fat graft for filling mastoid defects after translabyrinthine craniotomy, there is a logarithmic decline in fat graft volume over time, reaching steady state in 2 years. Rates of CSF leak or pseudomeningocele formation were not significantly affected by initial volume of the fat graft, rate of fat graft resorption, nor the fraction of original fat graft volume at steady state. In addition, no analyzed clinical factors significantly influenced fat graft retention over time.

Predictive Effect of Bone Conduction Pattern on Hearing Outcomes of Stapes Surgery.

OBJECTIVE: Examine the effect of preoperative bone conduction pattern on outcomes of stapedotomy/stapedectomy. STUDY DESIGN: Retrospective case series. SETTING: Tertiary-care academic medical center. PATIENTS: Patients who underwent stapedotomy or stapedectomy from 2013 to 2019. INTERVENTIONS: Primary small-fenestra stapedotomy or partial stapedectomy. MAIN OUTCOME MEASURES: Association between preoperative bone conduction patterns and hearing after stapes surgery. RESULTS: Complete audiometric data were available for 137 patients who had surgery. The mean preoperative air-bone gap (ABG) was 26.8 dBHL. The ABG was closed to less than 20 and 10 dBHL in 88.7 and 65.2% of patients, respectively. A notch at 2000 Hz was present in 32.1% of operated ears and was rarely found at other frequencies. There was no statistically significant association between the presence of a notch and hearing outcomes. The slope of the bone conduction line had no association with hearing outcomes, though an increased bone conduction PTA compared with the contralateral ear was associated with ABG closure less than 10 dBHL and overclosure (odds ratio: 2.14, p = 0.027 and odds ratio: 2.20, p = 0.04). CONCLUSION: In properly selected otosclerosis patients, depressions in bone conduction other than near 2000 Hz are rare and hearing outcomes are generally favorable regardless of the preoperative bone conduction pattern. Despite the association with otosclerosis, the presence of a notch at 2000 Hz is not associated with better hearing outcomes with surgery.

Ultrasound-Guided Placement of Percutaneous Abutments for Bone Conduction Hearing Devices.

OBJECTIVE: To introduce a minimally invasive and image-guided technique for staged placement of a percutaneous abutment after osseointegrated implantation. PATIENTS: Adults undergoing temporal bone resection at two academic medical centers. INTERVENTIONS: Ultrasound-guided percutaneous installation of a bone conduction hearing device abutment. All patients had lateral temporal bone resection with osseointegrated implantation. Abutment placement followed as a planned staged procedure 3 to 6 months later depending on the use of radiotherapy. MAIN OUTCOME MEASURES: Ability to use a bone conduction hearing device and occurrence of skin reactions or wound complications. RESULTS: Twelve patients successfully underwent abutment installation through a 5 mm skin biopsy punch incision, nine of which had minimal to no skin reaction surrounding the abutment. Two patients developed Holgers grade 1 skin reaction (redness with slight swelling). One patient experienced an osseointegration failure 152 days after abutment placement. CONCLUSIONS: Ultrasound is a widely available imaging modality that can be used to precisely localize subcutaneous osseointegrated implants, allowing for minimally invasive percutaneous placement of an abutment under local or general anesthesia.

Determining treatment choices after the cochlear implant evaluation process.

OBJECTIVES: Determine the proportion of patients starting the cochlear implant evaluation (CIE) process proceeding to cochlear implantation.Determine which patient factors are associated with undergoing cochlear implantation. METHODS: Retrospective case series of all patients scheduled for a CIE within a tertiary academic neurotology practice between January 1, 2014 and April 30, 2016. Management pathways of patients undergoing CIE were examined. RESULTS: Two hundred thirty-seven adult patients were scheduled for CIE during the study period. Two hundred twenty-six patients started the evaluation process, and 203 patients completed full evaluation. Of patients that completed CIE, 166/203 (82%) met criteria for implantation and 37/203 (18%) did not meet criteria. Fifty-nine patients out of 166 patients (36%) meeting criteria did not receive implants and 107/166 (64%) underwent implantation, yielding an overall implantation rate of 47% (107/226) among patients scheduled for CIE. Common reasons for deferring CI among candidates included failure to show up for preoperative appointment (24%), choosing hearing aids as an alternative (22%), patient refusal (21%) and insurance issues (17%). Overall, CIE led to a new adjunctive hearing device (CI or hearing aid) in 113 (113/203, 56%) cases. CONCLUSION: Fifty-six (113/203) percent of patients who underwent CIE at an academic medical center underwent CI surgery or received an adjunctive hearing device, but 36% (59/166) of candidates did not receive a CI. Patients who forewent CI despite meeting candidacy criteria did so due to cost/insurance issues, or due to preference for auditory amplification rather than CI. LEVEL OF EVIDENCE: 4.

Middle Cranial Fossa Approach to Vestibular Schwannoma Resection in the Older Patient Population.

OBJECTIVE: Compare outcomes of middle cranial fossa approach (MCF) to vestibular schwannoma (VS) resection in patients 60 years of age and older to patients under 60. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Charts of 216 consecutive VS patients over 18 years of age were reviewed to identify 67 patients who underwent MCF approach to VS resection between 2006 and 2017. INTERVENTION(S): Age at time of surgery. MAIN OUTCOME MEASURE(S): Measured outcomes included postoperative hearing results, facial nerve function, length of hospital stay, wound complications, cerebrospinal fluid leak, myocardial infarction, cerebrovascular accident, seizure, deep vein thrombosis, 30-day readmission, and return to operating room. RESULTS: Sixty-seven patients underwent VS resection via MCF approach including 16 patients > = 60 years (mean 64.4 SD 3.3) and 51 patients < 60 years (mean 45.7 SD 10.2). Between these two groups, there were no differences in sex, tumor laterality, tumor size (10.4 mm versus 9.8 mm, p = 0.6), or other demographic characteristics. Postoperatively, there were no differences between groups in complication rates. Rates of HB 1 or 2 facial nerve function were similar (93.8% versus 88.2%, p = 0.7) as were rates of maintenance of class A or B hearing (58.3% versus 44.4%, p = 0.7). CONCLUSIONS: Patients over 60 undergoing MCF for VS resection experienced similar rates of postoperative complications, facial nerve outcomes, and hearing preservation compared with younger patients. MCF for VS may be considered in the older population. Further research is warranted to evaluate appropriate limitations for this approach based on age.

Early Experience With Telemedicine in Patients Undergoing Otologic/Neurotologic Procedures.

OBJECTIVE: Compare outcomes for patients who were seen via telemedicine visits after otology/neurotology surgical procedures with those who were seen in traditional office visits. STUDY DESIGN: Retrospective case review. SETTING: Tertiary care academic medical center. PATIENTS: Inclusion criteria were patients who underwent otologic/neurotologic surgery and were seen in at least one telemedicine visit for postoperative care. INTERVENTION (S): Telemedicine visit for postoperative care. MAIN OUTCOME MEASURE (S): Comparison of the number of patient calls, unplanned visits, and delayed complications between telemedicine patients and controls matched for age, procedure, and American Society of Anesthesiologists (ASA) status. RESULTS: Eighteen patients were seen in telemedicine visits postoperatively after the following otologic/neurotologic surgical procedures: cochlear implant surgery (10), vestibular schwannoma resection (4), combined middle fossa and transmastoid cerebrospinal fluid (CSF) leak repair (2), middle fossa repair of superior canal dehiscence (1), and stapedectomy (1). All telehealth visits were for the second postoperative visit. The mean number of patient calls after surgery was 2.3 for the telemedicine group and 1.9 for matched controls which was not a statistically significant difference (p = 0.466). Both groups each had two patients who went to the emergency room, with one in each group being admitted. There was one delayed complication in the control group. CONCLUSION: Our preliminary experience suggests telemedicine may be used safely in caring for patients after otologic/neurotologic surgery, though it may be associated with more patient phone calls. Further study and experience, including assessing patient satisfaction, will clarify the future role of telemedicine in otology and neurotology.

The Potential for Preserved Cochleovestibular Function in the Setting of Prolonged Pneumolabyrinth.

OBJECTIVE: To discuss the natural history and management of pneumolabyrinth, with particular attention to illustrative cases where hearing improved after a fluid-filled vestibule was restored. PATIENTS: Adults at two academic medical centers with documented pneumolabyrinth on computed tomography (CT) imaging. INTERVENTION: Middle ear surgery or observation. MAIN OUTCOME MEASURES: Cochlear and vestibular symptoms are reported. Inner ear function was documented with audiometry and vestibular testing. Resolution of pneumolabyrinth was documented on imaging for a subset of patients. RESULTS: All patients presented with severe hearing loss following temporal bone fracture (three cases), penetrating trauma (one case), or stapedectomy (three cases). The radiographic finding was typically seen when imaging was obtained in the first few days after the injury. In two cases, vestibular symptoms resolved and partial recovery of hearing was seen despite a relatively long time interval between the inciting event and repair. CONCLUSION: Management of pneumolabyrinth is individualized based on the mechanism of injury, severity of symptoms, and timing of the imaging study. In most cases, the barrier between the middle ear and inner ear is expected to heal with rapid resolution of pneumolabyrinth. Late repair is demonstrated to result in favorable recovery in selected cases. The presence of air in the vestibule cannot be assumed to be indicative of irreversible inner ear damage.

Visual Speech Recognition: Improving Speech Perception in Noise through Artificial Intelligence.

OBJECTIVES: To compare speech perception (SP) in noise for normal-hearing (NH) individuals and individuals with hearing loss (IWHL) and to demonstrate improvements in SP with use of a visual speech recognition program (VSRP). STUDY DESIGN: Single-institution prospective study. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Eleven NH and 9 IWHL participants in a sound-isolated booth facing a speaker through a window. In non-VSRP conditions, SP was evaluated on 40 Bamford-Kowal-Bench speech-in-noise test (BKB-SIN) sentences presented by the speaker at 50 A-weighted decibels (dBA) with multiperson babble noise presented from 50 to 75 dBA. SP was defined as the percentage of words correctly identified. In VSRP conditions, an infrared camera was used to track 35 points around the speaker's lips during speech in real time. Lip movement data were translated into speech-text via an in-house developed neural network-based VSRP. SP was evaluated similarly in the non-VSRP condition on 42 BKB-SIN sentences, with the addition of the VSRP output presented on a screen to the listener. RESULTS: In high-noise conditions (70-75 dBA) without VSRP, NH listeners achieved significantly higher speech perception than IWHL listeners (38.7% vs 25.0%, P = .02). NH listeners were significantly more accurate with VSRP than without VSRP (75.5% vs 38.7%, P < .0001), as were IWHL listeners (70.4% vs 25.0% P < .0001). With VSRP, no significant difference in SP was observed between NH and IWHL listeners (75.5% vs 70.4%, P = .15). CONCLUSIONS: The VSRP significantly increased speech perception in high-noise conditions for NH and IWHL participants and eliminated the difference in SP accuracy between NH and IWHL listeners.

Is Longer Surgery More Dangerous? Operative Duration Not Associated With Complications After Vestibular Schwannoma Resection.

OBJECTIVE: To examine the association between operative duration and complications after vestibular schwannoma (VS) surgery. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: One hundred forty-eight patients undergoing vestibular schwannoma resection in a single institution. INTERVENTION: Vestibular schwannoma resection. MAIN OUTCOME MEASURES: Operative duration, surgical approach, tumor size, and postoperative complications. RESULTS: Forty-one patients underwent middle cranial fossa (MCF) approach, 46 underwent translabyrinthine (TL) approach, and 61 underwent retrosigmoid (RS) approach. The mean operative duration overall was 407 minutes (MCF-339 min, TL-450 min, RS 420 min). When controlling for tumor size, there was no difference in procedure duration by approach (OR 0.92, CI 0.82-1.02, p=0.11).When controlling for approach, there was a significant increase in procedure duration by tumor size (OR 1.36, CI 1.23-1.50, p < 0.0001). Increased procedure duration was not associated with 30-day readmission (p = 0.82), cerebrospinal fluid leak (CSF) (p = 0.84), return to the operating room (p = 0.75), postoperative deep vein thrombosis (p = 1.0), postoperative stroke (p = 0.23), or postoperative wound complications (p = 0.70). Longer operative time was associated with increased hospital length of stay (p = 0.04). However, when controlling for tumor size and surgical approach, hospital length of stay was no longer associated with increased procedure duration (OR 1.15, CI 0.98-1.33, p = 0.3). CONCLUSION: Increased operative duration was associated with larger tumor size; however contrary to previous reports, increased operative duration was not associated with postoperative complications.

Obesity Is Not Associated With Postoperative Complications After Vestibular Schwannoma Surgery in a Large Single Institution Series.

OBJECTIVE: Determine whether elevated body mass index (BMI) is associated with postoperative complications after vestibular schwannoma (VS) surgery. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Two hundred six patients undergoing surgery for VS between 2010 and 2017, grouped into obese and nonobese patients. INTERVENTION: Surgery for VS resection. MAIN OUTCOME MEASURES: Postoperative facial nerve outcomes, length of hospital stay, presence of postoperative cerebrospinal fluid leak, 30-day readmission, return to the operating room, wound complications, cardiovascular and thromboembolic complications. RESULTS: After excluding 1 patient for missing BMI, our cohort included 205 patients. Seventy-nine patients (38.5%) were obese (mean BMI 36.2 kg/m, range 30-55.1) and the remaining 126 (61.5%) were nonobese (mean BMI 25.0, range 18.8-29.8 kg/m). Compared with nonobese patients, obesity was not associated with postoperative cerebrospinal fluid leak (OR 1.1, 95% CI 0.93-1.1), length of hospital stay (OR 0.98, 95% CI 0.65-1.47), 30-day readmission rates (1.04, 95% CI 0.95-1.14), return to operating room (OR 1.05, 95% CI 0.98-1.11), or other wound-related complications (OR 0.99, 95% CI 0.94-1.04). CONCLUSION: In this cohort, elevated BMI was not associated with an increased risk for postoperative complications after VS surgery. Our findings may mitigate concerns associated with surgical management of VS in obese patients.

Laboratory testing and imaging in the evaluation of cranial cerebrospinal fluid leaks and encephaloceles.

PURPOSE OF REVIEW: To summarize the current evidence on the diagnostic evaluation of cranial cerebrospinal fluid (CSF) leaks and encephaloceles, including laboratory testing and imaging studies. RECENT FINDINGS: The most sensitive and specific laboratory tests for CSF leak diagnosis are beta-2-transferrin and beta trace protein assays, the former more commonly used because of availability. Imaging studies used for localization of the leak site include high resolution computed tomography (HRCT) and magnetic resonance cisternography (MRC), often used in combination. Intrathecal contrast administration is reserved for complex cases with prior equivocal test results or for patients with multiple skull base defects to localize the leak site. SUMMARY: Diagnosis of CSF leaks and encephaloceles is aimed at both confirming the leak and localizing the leak site. Future advancements in testing techniques may shorten the diagnostic process, limit the need for invasive testing, and improve the safety of such testing in indicated cases.

Cerebrospinal Fluid Leak Rate after Vestibular Schwannoma Surgery via Middle Cranial Fossa Approach.

Objective Evaluate the cerebrospinal fluid (CSF) leak rate after the middle cranial fossa (MCF) approach to vestibular schwannoma (VS) resection. Design Retrospective case series. Setting Quaternary referral academic center. Participants Of 161 patients undergoing the MCF approach for a variety of skull base pathologies, 66 patients underwent this approach for VS resection between 2007 and 2017. Main Outcome Measure Postoperative CSF leak rate. Results There were two instances of postoperative CSF leak (3.0%). Age, gender, and BMI were not significantly associated with CSF leak. In the two cases with CSF leakage, tumors were isolated to the internal auditory canal (IAC) and both underwent gross total resection. Both CSF leaks were successfully treated with lumbar drain diversion. For the 64 cases that did not have a CSF leak, 51 were isolated to the IAC, 1 was located only in the cerebellopontine angle (CPA), and 12 were located in both the IAC and CPA. 62 patients underwent gross total resection and 2 underwent near-total resection. Mean maximal tumor diameter in the CSF leak group was 4.5 mm (range: 3-6 mm) versus 10.2 mm (range: 3-19 mm) in patients with no CSF leak ( p = 0.03). Conclusions The MCF approach for VS resection is a valuable technique that allows for hearing preservation and total tumor resection and can be performed with a low CSF leakage rate. This rate of CSF leak is less than the reported rates in the literature in regard to both translabyrinthine and retrosigmoid approaches.

Utility of Magnetic Resonance Imaging in Differentiating Cerebrospinal Fluid Leak from Middle Ear Effusion.

OBJECTIVE: To demonstrate the clinical utility, sensitivity, and specificity of standard magnetic resonance imaging (MRI) sequences in differentiating temporal bone cerebrospinal fluid leaks from all other middle ear effusions. STUDY DESIGN: Retrospective imaging review. SETTING: Academic medical center. SUBJECTS: Patients with cerebrospinal fluid leaks or other middle ear effusions who also underwent MRI. METHODS: Patients were assigned to cerebrospinal fluid leak and other effusion cohorts based on clinical course, findings at surgery/myringotomy, and beta-2 transferrin fluid analysis. Reviewers blinded to the clinical outcome examined T1-weighted, T2-weighted, diffusion-weighted, fluid-attenuated inversion recovery (FLAIR), and 3-dimensional (3D) acquired T2-weighted MRI sequences. For each sequence, fluid imaged in the temporal bone was graded as either similar or dissimilar in signal intensity to cerebrospinal fluid in the adjacent subarachnoid space. Signal similarity was interpreted as being diagnostic of a leak. Test characteristics in predicting the presence of a leak were calculated for each series. RESULTS: Eighty patients met criteria (41 leaks, 39 other effusions). The 3D T2 series was 76% sensitive and 100% specific in diagnosing a leak, and FLAIR was 44% sensitive and 100% specific. The T1-weighted (73% sensitive, 69% specific), T2-weighted (98% sensitive, 5.1% specific), and diffusion-weighted (63% sensitive, 66% specific) series were less useful. CONCLUSIONS: MRI, with attention to 3D T2 and FLAIR series, is a noninvasive and highly specific test for diagnosing cerebrospinal fluid leak in the setting of an indeterminate middle ear effusion.

Impact of Motor-Evoked Potential Monitoring on Facial Nerve Outcomes after Vestibular Schwannoma Resection.

OBJECTIVES:: Assess the utility of intraoperative transcranial facial motor-evoked potential (FMEP) monitoring in predicting and improving facial function after vestibular schwannoma (VS) resection. STUDY DESIGN:: Retrospective chart review. METHODS:: Data were obtained from 82 consecutive VS resections meeting inclusion criteria. Sixty-two cases were performed without FMEP and 20 with FMEP. Degradation of FMEP response was defined as a final-to-baseline amplitude ratio of 0.5 or less. House-Brackmann (HB) grade was assessed preoperatively, postoperatively, at follow-up assessments, and it was compared between pre- and post-FMEP cohorts. Positive predictive value (PPV) and negative predictive value (NPV), sensitivity, and specificity of FMEP degradation in predicting facial weakness were calculated. RESULTS:: In the pre-FMEP group, at length of follow-up (LOF) ⩾9 months, 83.9% (52/62) of patients exhibited HB 1-2 outcome. In the post-FMEP cohort, 75.0% (15/20) exhibited HB 1-2 function at LOF ⩾9 months. There was no difference in rates of HB 1-2 outcomes between groups in the immediate postoperative period ( P = .35) or at long-term follow-up ( P = 1.0). With respect to predicting immediate postoperative facial function, FMEP demonstrated high specificity (88.9%) and moderate sensitivity (54.5%). The PPV and NPV for immediate postoperative facial function were 85.7% and 61.5%, respectively. With respect to long-term (⩾9 months LOF) facial function, intraoperative FMEP was moderately sensitive (71.4%) and highly specific (84.6%); PPV was moderate (71.4%), and NPV was high (84.6%). CONCLUSIONS:: Intraoperative FMEP is highly specific and moderately sensitive in predicting postoperative facial function for patients undergoing VS resection, but its use may not be associated with improved facial nerve outcomes. LEVEL OF EVIDENCE:: 4.

Application of Ultrasonic Bone Aspirator for Decompression of the Internal Auditory Canal via the Middle Cranial Fossa Approach.

OBJECTIVE: Evaluate the safety and efficacy of the ultrasonic bone aspirator (UBA) during middle cranial fossa (MCF) approach to vestibular schwannoma (VS). STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. PATIENTS: Charts of 192 consecutive VS patients over 18 years of age were reviewed to identify 65 patients who underwent MCF approach to VS resection between 2006 and 2017. A combination of UBA and high-speed drill (HSD) was used to decompress the internal auditory canal (IAC) in 25 patients and HSD alone was used in the other 40 patients. INTERVENTION(S): Use of UBA during vestibular schwannoma surgery via MCF approach for decompression of the IAC. MAIN OUTCOME MEASURE(S): Postoperative facial nerve outcomes assessed by the House-Brackmann (HB) facial nerve grading scale. Rates of gross total resection (GTR) and cerebrospinal fluid (CSF) leak. RESULTS: There were no significant differences in postoperative facial nerve function, in rate of GTR of tumor, or in rate of CSF leak. In the UBA group 24/25 (96%) had postoperative HB grade I-II compared with 36/40 (90%) in the HSD group (p-value = 0.66). GTR was achieved in 25/25 (100%) in the UBA group compared with 38/40 (95%) in the HSD group (p-value = 1). In the UBA group, there were 0/25 (0%) cases of CSF leak compared with 1/40 (2.5%) in the HSD group (p-value = 1). CONCLUSIONS: UBA use is a safe and effective alternative or adjunct to HSD during MCF approach to expose the IAC contents. This surgical tool allows for bone removal with low risk of injury to adjacent structures.

Basal cell carcinoma of the temporal bone and external auditory canal.

OBJECTIVES/HYPOTHESIS: To review the presenting features, treatment, and outcomes for patients with basal cell carcinoma (BCC) involving the temporal bone or external auditory canal (EAC). STUDY DESIGN: Retrospective case series. METHODS: Presenting characteristics, treatment strategies, and outcomes for patients with BCC involving the temporal bone or EAC were reviewed. Main outcome measures included rates of overall and disease-free survival at 5 years. RESULTS: Forty-two patients met the inclusion criteria (mean age, 67 years). The most common presenting symptoms were hearing loss (15 patients, 36%) and otorrhea (11 patients, 26%). The 5-year overall survival rate was 78%, and the 5-year disease-free survival rate was 77%. Patients who had undergone surgery elsewhere and presented with facial weakness had significantly worse overall survival (P = .004). Ten patients (24%) underwent sacrifice of at least a portion of the facial nerve at the time of their initial procedure at our institution. Two patients (5%) developed regional nodal disease. There was a trend toward better disease-free survival for patients who received adjuvant radiation therapy after surgery at our institution (P = .06). CONCLUSIONS: BCC originating from or extending to the temporal bone can exhibit a wide range of behavior, ranging from superficial lesions readily managed with surgery to extensive locally invasive tumors with propensity for recurrence, treated with multimodality therapy. BCC may be associated with better prognosis than other temporal bone malignancies. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1425-1430, 2018.

Diagnostic Criteria for Detection of Vestibular Schwannomas in the VA Population.

OBJECTIVE: To investigate the prevalence of vestibular schwannoma (VS) and asymmetric sensorineural hearing loss in the Veterans Administration hospital population and analyze a more efficient method of diagnosing VS in a population with significant noise exposure. STUDY DESIGN: Retrospective review of South Central (VISN 16) Veterans Administration hospitals. METHODS: Record query for ICD-9 codes for asymmetric sensorineural hearing loss or VS between 1999 and 2012. Patient demographics, signs and symptoms at presentation, audiogram and imaging data, and management data were collected and analyzed. Audiograms from tumor patients were compared with controls matched for age, sex, combat experience, and medical comorbidity (2:1 control to case ratio). RESULTS: The prevalence of VS was 1 per 1,145 patients in this population, with average age at diagnosis of 62. Patients with VS presented more commonly with unilateral tinnitus, rollover, and absent acoustic reflexes when compared with matched controls, but positive predictive value was low. Published criteria for defining hearing asymmetry showed variable sensitivity (51-89%) and low specificity (0-42%) for the detection of VS in this population. Criteria meeting the definitions of significant asymmetry with specificity for VS of 80% or greater were as follows: >15 dB threshold difference at 3 kHz and unilateral tinnitus, ≥45 dB threshold difference at 3 kHz regardless of tinnitus, or when the word recognition score difference was ≥80%. With serial audiograms 2.5 years apart or greater, a ≥10 dB threshold increase at any frequency between 0.5 and 4 kHz had a 100% sensitivity for tumor and a ≥10 dB increase at 3 kHz had a specificity of 84%. The majority of patients were observed, whereas only 30% had surgery. Patients who were observed were older than those treated with surgery or radiation (p <0.001). CONCLUSION: Typical audiometric screening criteria should be modified in the veteran population to improve cost efficiency of diagnosis. Observation is the primary management strategy in the veteran population because of age.