Percutaneous versus surgical tracheotomy: an updated meta-analysis.

OBJECTIVE: Perform an updated meta-analysis investigating differences in complication rates, procedure times, and costs between percutaneous dilational tracheotomy (PDT), operating room surgical tracheotomy (ST), and bedside surgical tracheotomy (BST). METHODS: Meta-analysis using the Mantel-Haenszel fixed effects model. Prospective and randomized trials comparing ST with PDT from 1999 to present were identified through two independent searches. Outcome measures analyzed included mortality, early complications, late complications, procedure times, and cost. RESULTS: Fourteen studies were identified (1,273 patients) that satisfied the search criteria. Analysis of randomized studies demonstrated significantly more minor early complications with PDT compared with ST (odds ratio [OR], 1.6; 95% confidence interval [CI], 1.01-2.66). Randomized studies comparing PDT with BST demonstrated significantly more early complications with PDT (OR, 4.66; 95% CI, 1.46-14.91). There was no significant difference in late serious complications in studies that randomized patients to ST or PDT (OR, 1.39; 95% CI, 0-16,000). PDT is significantly faster to perform than ST (OR, 0.51; 95% CI, 95% 0.49-0.53). BST and PDT have similar costs, and both are less expensive than ST. CONCLUSIONS: Although significantly faster than ST, PDT has more early complications compared with open tracheotomy in the operating room or at the bedside. The long-term complications of the two techniques appear comparable but have not been thoroughly investigated. These findings suggest that a team approach between surgeons and critical care specialists is essential to select the appropriate tracheotomy technique for a given patient.

Stereotactic Radiosurgical Treatment of Glomus Jugulare Tumors.

OBJECTIVE: Determine treatment outcomes of stereotactic radiosurgery (SRS) for glomus jugulare tumors (GJT), focusing on three-dimensional volume change and symptoms before and after SRS, as well as complications related to SRS. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Thirty-eight patients treated with SRS between 2000 and 2015. INTERVENTION: SRS treatment of GJT. MAIN OUTCOME MEASURES: The tumor volumes on pre- and posttreatment imaging were compared utilizing the Leskell GammaPlan treatment plan software to assess tumor progression. Pre- and posttreatment symptoms, Fisch classification, and complications were recorded. RESULTS: The mean radiographic follow-up was 39.1 months. The mean dose-to-tumor margin was 13.2 Gy. The mean tumor size at treatment was 5.8 and 5.2 cm at last follow-up. Thirty-three patients had follow-up imaging suitable for analysis. When defining both 10 and 15% tumor size increases as significant, 27 (82%) and 29 (88%) tumors decreased in size or remained stable, respectively. For the seven tumors with documented pre-SRS growth, treatment success was 86%. The mean marginal dose for treatment success and failure were 13.2 and 13.7 Gy, respectively. Patients receiving a higher margin dose had a greater risk of tumor progression (p = 0.0277). Fisch classification did not impact tumor progression rate. Initial tumor volume had no significance on tumor response to SRS. CONCLUSIONS: SRS is an effective treatment option for GJT. Both initial tumor volume and Fisch classification did not impact tumor progression. There were no significant patient or lesion characteristics that distinguished treatment success and/or failure.

Cochlear Implantation in Ménière's Disease.

IMPORTANCE: Though the effects of cochlear implantation (CI) on patients with hearing loss has been well described, its effect on the auditory and vestibular symptoms in patients with Ménière's disease (MD) has not been firmly established. OBJECTIVES: To determine whether CI in patients with MD improves hearing performance as measured by standard post-CI audiometric testing and to describe the impact of CI on subjective auditory and vestibular quality-of-life measures. DESIGN, SETTING, AND PARTICIPANTS: Retrospective review of all patients with MD 18 years or older who met diagnostic criteria for definite MD and underwent CI at Wake Forest University Baptist Medical Center, a tertiary care academic medical center, from 2000 through 2012. INTERVENTIONS: Patients were invited to answer questions regarding their current hearing ability, subjective perception of symptoms, and functional status related to their MD before and after CI. Patient records were reviewed for pertinent information. Results were then analyzed for statistical significance. MAIN OUTCOMES AND MEASURES: Pre-CI and post-CI sentence testing scores, frequency and severity of MD vestibular and auditory symptoms via the MD Functional Level Scale (FLS), and hearing quality of life via the Hearing Handicap Index were reviewed. RESULTS: Eleven CIs were performed in 10 patients. Mean long-term follow-up was 41 months. The mean age at first implantation was 64 years. The mean sentence testing scores in quiet improved from 22.8% before CI to 77.0% after CI (P < .001) at the most recent follow-up. Mean (SD) pre-CI and post-CI MD-FLS vestibular scores were similar: 3.9 (1.9) and 3.4 (1.9) (P = .52). CONCLUSIONS AND RELEVANCE: Patients with MD who undergo CI are capable of achieving substantial receptive communication improvement comparable to the gains experienced by patients without MD. Implantation seems to neither adversely alter the natural history of vestibular function nor notable exacerbate auditory symptoms.

Cavernous sinus metastases treated with gamma knifeTM stereotactic radiosurgery.

BACKGROUND: Cavernous sinus metastases represent difficult clinical scenarios because of the lack of surgical options. We investigate the use of Gamma Knife stereotactic radiosurgery (GKRS) as a treatment option of these metastases. OBJECTIVES: To determine the patterns of failure for cavernous sinus metastases and to identify factors that predict for improved outcomes. METHODS: This is a retrospective review of 19 patients treated with GKRS for cavernous sinus metastases over a 9-year period between May 2002 and October 2011. The median marginal tumor dose was 18 Gy. Patients were followed with serial imaging. Kaplan Meier analysis was used to estimate local control and overall survival. Fischer exact test was used to determine any predictive factors for local control or survival. RESULTS: Median follow-up time was 22.4 months. Kaplan Meier estimate of overall survival at 1, 2, and 4 years was 76%, 44%, and 44% survival, respectively. 11 patients experienced intracranial failure. Of these, 7 (64%) were local and 4 (36%) were distant intracranial failures. Local control was 76%, 44%, and 44% at 1, 2 and 4 years, respectively. Six of seven local failures in the series were considered to be marginal failures because they were abutting the 50% isodose volume. Head and neck primary tumors were associated with 86% of local failures (P = 0.017) and was the only factor that predicted for local failure. CONCLUSIONS: GKRS appears to be a feasible and safe modality for treatment of cavernous sinus metastases. Local failures appear to be due to a marginal miss of microscopically occult disease.

Specializations of intercellular junctions are associated with the presence and absence of hair cell regeneration in ears from six vertebrate classes.

Sensory hair cell losses lead to hearing and balance deficits that are permanent for mammals, but temporary for nonmammals because supporting cells in their ears give rise to replacement hair cells. In mice and humans, vestibular supporting cells grow exceptionally large circumferential F-actin belts and their junctions express E-cadherin in patterns that strongly correlate with postnatal declines in regeneration capacity. In contrast, chicken supporting cells retain thin F-actin belts throughout life and express little E-cadherin. To determine whether the junctions in chicken ears might be representative of other ears that also regenerate hair cells, we investigated inner ears from dogfish sharks, zebrafish, bullfrogs, Xenopus, turtles, and the lizard, Anolis. As in chickens, the supporting cells in adult zebrafish, Xenopus, and turtle ears retained thin circumferential F-actin belts and expressed little E-cadherin. Supporting cells in adult sharks and bullfrogs also retained thin belts, but were not tested for E-cadherin. Supporting cells in adult Anolis exhibited wide, but porous webs of F-actin and strong E-cadherin expression. Anolis supporting cells also showed some cell cycle reentry when cultured. The results reveal that the association between thin F-actin belts and low E-cadherin is shared by supporting cells in anamniotes, turtles, and birds, which all can regenerate hair cells. Divergent junctional specializations in supporting cells appear to have arisen independently in Anolis and mammals. The presence of webs of F-actin at the junctions in Anolis appears compatible with supporting cell proliferation, but the solid reinforcement of the F-actin belts in mammals is associated with its absence.

Bilateral posterior semicircular canal dehiscence in the setting of Hallermann-Streiff syndrome.

Hallermann-Streiff syndrome, also known as oculomandibulofacial syndrome, is a rare congenital disorder affecting growth and cranial, dental, ocular, pilocutaneous, and mental development. In addition to routine audiologic testing in patients with this syndrome, high-resolution computed tomography of the temporal bones should be performed in those with documented or suspected sensorineural hearing loss. Cochlear implantation may be considered, as in other children with syndromic hearing loss and certain inner ear abnormalities, if the appropriate audiologic, psychosocial, and medical criteria are met. The current case report radiographically and clinically characterizes inner ear dysplasia in an 8-year-old patient with Hallermann-Streiff syndrome. High-resolution computed tomography of the temporal bones revealed a hypoplastic bony island between the vestibule and horizontal semicircular canals, as well as incomplete bony coverage of the posterior semicircular canal crura bilaterally. To our knowledge, this is the first report of a pediatric patient demonstrating bilateral posterior semicircular canal dehiscence.

Revision aural atresia surgery: indications and outcomes.

OBJECTIVE: To determine the most common indications for revision congenital aural atresia (CAA) surgery and the postoperative healing and hearing outcomes of revision surgery. STUDY DESIGN: Retrospective case review. SETTING: Tertiary care academic otologic practice. PATIENTS: Patients undergoing revision surgery for CAA. INTERVENTION: Revision surgery for CAA. MAIN OUTCOME MEASURES: Indications for revision atresiaplasty, time to revision surgery, postoperative external auditory canal (EAC) patency, incidence of chronic drainage and/or infection, and postoperative speech reception thresholds (SRTs), and air-bone gaps. RESULTS: Indications for 75 ears (69 patients) undergoing 107 revision operations for CAA included 58% for EAC stenosis, 19% for chronic drainage and/or infection, and 20% for conductive hearing loss (CHL) alone. Fifty ears (67%) required a single revision. Twenty-five ears (33%) required more than 1 revision. With follow-up longer than 3 months (mean, 41 mo), 69% of ears revised for EAC stenosis achieved a patent canal (29% required >1 revision); 75% of ears revised for chronic drainage and/or infection (mean follow-up, 53 mo) realized a dry canal (22% required >1 revision). For all revision surgeries with adequate follow-up (n = 80), the mean postoperative short-term SRT of 24 dB HL was a significant improvement from the mean preoperative SRT of 39 dB HL (p < 0.01, paired t test). CONCLUSION: EAC stenosis is the most common indication for revision atresiaplasty. Despite the challenges of revision surgery, improvement in canal patency, epithelialization, and hearing utcomes can be achieved.

Prevention of cerebrospinal fluid leak after translabyrinthine resection of vestibular schwannoma.

OBJECTIVE: Evaluate the rate of cerebrospinal fluid (CSF) leak after translabyrinthine craniotomy for the removal of vestibular schwannoma and describe details of closure technique. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: All individuals undergoing translabyrinthine craniotomy for removal of vestibular schwannoma from January 2000 to October 2008. INTERVENTION: Translabyrinthine craniotomy for removal of vestibular schwannoma with abdominal fat graft harvest and layered closure. MAIN OUTCOME MEASURES: Presence of cerebrospinal fluid leak and need for additional surgeries or medical interventions. RESULTS: Sixty-one patients underwent translabyrinthine craniotomy for the removal of vestibular schwannoma during a 9-year period. None of the patients had a CSF leak in the immediate postoperative period or during the mean follow-up period of 31.3 months. CONCLUSION: Successful wound closure and CSF leak prevention after translabyrinthine craniotomy for the removal of vestibular schwannomas do not require the creation of a facial recess, manipulation of the ossicles, direct Eustachian tube plugging, or the use of alloplastic space-occupying materials. The closure technique used in the current study has proven effective over time with no evidence of CSF leak among patients seen in follow-up.

Middle ear dimensions in congenital aural atresia and hearing outcomes after atresiaplasty.

OBJECTIVE: To determine if middle ear dimensions in congenital aural atresia (CAA) patients can predict early postoperative audiometric outcomes in order to establish specific parameters that facilitate stratification of surgical candidates. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Twenty-five patients with CAA (28 atretic ears and 22 nonatretic ears) and 12 controls (24 ears). INTERVENTION: Primary repair of congenital aural atresia. MAIN OUTCOME MEASURES: Measure and compare middle ear dimensions in controls, atretic ears, and nonatretic ears in unilateral CAA. Determine correlations between the dimensions and best speech reception threshold during the first postoperative year (SRT-1). RESULTS: The epitympanic depth, medial canal diameter, and the mesotympanic height, area, and estimated volume measurements in atretic ears differ significantly with those in control ears. The mesotympanic length, area, and estimated volume measurements each correlate significantly with SRT-1. Atretic ears with a mesotympanic volume estimate measurement greater than or equal to 42 mm3 are 24 times more likely to have an SRT-1 of 25 dB or better than those measuring less than 42 mm3 (odds ratio = 24.5; 95% confidence interval, 2.826-212.4; Fisher's exact test, p = 0.0022). CONCLUSION: Middle ear measurements in appropriately selected patients may help predict successful early hearing outcomes after atresiaplasty, thus offering a valuable tool for the surgical decision-making process.