Intraoperative Electrocochleography in Subjects Affected by Vestibular Schwannoma and Ménière's Disease: Comparison of Results.

OBJECTIVES: Histologic reports of temporal bones of ears with vestibular schwannomas (VSs) have indicated findings of endolymphatic hydrops (ELH) in some cases. The main goal of this investigation was to test ears with VSs to determine if they exhibit electrophysiological characteristics similar to those of ears expected to experience ELH. DESIGN: Fifty-three subjects with surgically confirmed VS aged ≥18 and with normal middle ear status were included in this study. In addition, a second group of adult subjects (n = 24) undergoing labyrinthectomy (n = 6) or endolymphatic sac decompression and shunt (ELS) placement (n = 18) for poorly controlled vestibular symptoms associated with Meniere's disease (MD) participated in this research. Intraoperative electrocochleography (ECochG) from the round window was performed using tone burst stimuli. Audiometric testing and word recognition scores (WRS) were performed preoperatively. ECochG amplitudes, cochlear microphonic/auditory nerve neurophonic (ANN) in the form of the "ongoing" response and summation potential, were analyzed and compared between the two groups of subjects. In addition, to evaluate any effect of auditory nerve function, the auditory nerve score was calculated for each subject. Pure-tone averages were obtained using the average air conduction thresholds at 0.5, 1, and 2 kHz while WRS was assessed using Northwestern University Auditory Test No. 6 word lists. RESULTS: In the VS group the average pure-tone averages and WRS were 59.6 dB HL and 44.8%, respectively, while in the MD group they were 52.3 dB HL and 73.8%. ECochG findings in both groups revealed a reduced trend in amplitude of the ongoing response with increased stimulus frequency. The summation potential amplitudes of subjects with VS were found to be less negative than the MD subjects for nearly all test frequencies. Finally, the VS group exhibited poorer amounts of auditory nerve function compared to the MD group. CONCLUSIONS: The current findings suggest cochlear pathology (e.g., hair cell loss) in both groups but do not support the hypothesis that VSs cause ELH.

Identifying Tumor Microenvironment Biomarkers in Adherent and Cystic Vestibular Schwannomas.

OBJECTIVE: A subset of vestibular schwannomas (VSs), including cystic tumors, have higher postoperative morbidity because of the presence of adhesions between the tumor, facial nerve (FN), and brainstem. We identify tumor microenvironment (TME) biomarkers to better classify these tumors and predict the degree of tumor adherence. STUDY DESIGN: Retrospective case series. SETTING: Tertiary skull base referral center. METHODS: Adult patients with cystic and solid VS matched in tumor size who underwent surgical resection were included. Expressions of seven biomarkers of extracellular matrix remodeling and tumor immune response were quantified via immunohistochemistry. The distribution of CD45+ immune cells was evaluated in intratumoral and perivascular compartments. The degree of tumor adherence was categorized as none, adherent to FN, or adherent to both FN and brainstem. RESULTS: Twenty-eight patients were included. Cystic VSs were significantly more adherent than solid VSs ( p = 0.02). Patients with adherent VS had shorter duration of symptoms and were more likely to undergo subtotal resection. In solid tumors, matrix metalloproteinase (MMP)-2 expression ( p = 0.02) and CD163+ macrophage infiltration ( p = 0.007) were correlated with tumor size. Linear discriminant analyses (LDAs) demonstrated MMP-2, MMP-14, CD80, CD163, and perivascular CD45 to be individually predictive of the degree of tumor adherence (all p < 0.05), with perivascular CD45 being the best independent predictor ( p = 0.005). An LDA model including these biomarkers demonstrated 100% accurate discrimination of all three levels of tumor adherence ( p = 0.04). CONCLUSIONS: Adherent VS have a distinct proinflammatory TME characterized by elevated MMP expression, enrichment of tumor-associated macrophages, and perivascular immune cell infiltration.

Comparison of Postoperative Outcomes in Cystic Versus Solid Vestibular Schwannoma in a Multi-institutional Cohort.

OBJECTIVE: Cystic vestibular schwannomas (cVSs) have more variable and less favorable clinical outcomes after microsurgical resection compared with solid VS (sVS). This study compares the preoperative presentation and postoperative outcomes between cVS and sVS. STUDY DESIGN: Retrospective cohort study. SETTING: Two tertiary skull base referral centers. METHODS: Consecutive adult patients who underwent VS resection from 2016 to 2021 were included. Univariate and multivariate analyses compared differences in baseline symptoms and postoperative outcomes between cVS and sVS. RESULTS: There were a total of 315 patients (64% female; mean age, 54 yrs) and 46 (15%) were cystic. cVS were significantly larger than sVS (maximum diameter, 28 vs. 18 mm, p < 0.001) and had higher rates of dysphagia and dysphonia preoperatively (p < 0.02). cVSs were more likely to undergo translabyrinthine resection (76 vs. 50%, p = 0.001) and have a higher rate of subtotal resection (STR) compared with sVS (30 vs. 13%, p = 0.003). At latest follow-up, fewer cVS achieved good facial nerve (FN) outcome (House-Brackmann [HB] I/II) (80 vs. 90%, p = 0.048). Subanalysis of cVS and sVS matched in tumor size, and surgical approach did not show differences in the rate of STR or FN outcomes (HB I/II, 82 vs. 78%, p = 0.79). CONCLUSION: In this large multi-institutional series, cVSs represent a distinct entity and are characterized by larger tumor size and higher incidence of atypical symptoms. Although cVSs were more likely to undergo STR and portend worse FN outcomes than sVSs, this may be due to their larger tumor size rather than the presence of the cystic component.

Outcomes After Transcutaneous Bone-Conduction Implantation in Adults and Children.

OBJECTIVE: To evaluate clinical and audiometric outcomes of adult and pediatric patients implanted with a semi-implantable transcutaneous active bone-conduction implant. STUDY DESIGN: Retrospective chart review. SETTING: Two tertiary referral centers. PATIENTS: Subjects implanted with the semi-implantable transcutaneous active bone-conduction implant called BoneBridge. INTERVENTION: Implantation of the BoneBridge and audiometric evaluations. MAIN OUTCOME MEASURES: Audiometric, clinical, and surgical outcomes as well as complications. RESULTS: Forty-two adults and 20 children were implanted for conductive or mixed hearing loss as well as single-sided deafness. Implantation significantly improved mean air-conduction pure-tone average from 72.8 ± 22.3 to 35 ± 9 dB in adults and from 65.7 ± 24.3 to 19.6 ± 8.2 dB in children (both p < 0.001). Word recognition score improved from 63.7 ± 38.8% to 85.6 ± 10.6% in adults and 57.8 ± 38% to 89.3 ± 10.1% in children (both p < 0.05). The rate of revision surgery was 11.3%, with four patients (6.5%) undergoing removal for device-related complications, two (3.2%) for complications associated with implantation, and one (1.6%) for device failure secondary to external trauma. CONCLUSIONS: In a large retrospective series consisting of both pediatric and adult patients, implantation with a transcutaneous active bone-conduction implant was found to be a reliable aural rehabilitation option for a variety of hearing loss etiologies.

Melatonin: can it stop the ringing?

OBJECTIVES: We sought to report the efficacy of oral melatonin as treatment for chronic tinnitus and to determine whether particular subsets of tinnitus patients have greater benefit from melatonin therapy than others. METHODS: This was a prospective, randomized, double-blind, crossover clinical trial in an ambulatory tertiary referral otology and neurotology practice. Adults with chronic tinnitus were randomized to 3 mg melatonin or placebo nightly for 30 days followed by a 1-month washout period. Each group then crossed into the opposite treatment arm for 30 days. The tests audiometric tinnitus matching (TM), Tinnitus Severity Index (TSI), Self Rated Tinnitus (SRT), Pittsburgh Sleep Quality Index (PSQI), and Beck Depression Inventory (BDI) were administered at the outset and every 30 days thereafter to assess the effects of each intervention. RESULTS: A total of 61 subjects completed the study. A significantly greater decrease in TM and SRT scores (p < 0.05) from baseline was observed after treatment with melatonin relative to the effect observed with placebo. Male gender, bilateral tinnitus, noise exposure, no prior tinnitus treatment, absence of depression and/or anxiety at baseline, and greater pretreatment TSI scores were associated with a positive response to melatonin. Absence of depression and/or anxiety at baseline, greater pretreatment TSI scores, and greater pretreatment SRT scores were found to be positively associated with greater likelihood of improvement in both tinnitus and sleep with use of melatonin (p<0.05). CONCLUSIONS: Melatonin is associated with a statistically significant decrease in tinnitus intensity and improved sleep quality in patients with chronic tinnitus. Melatonin is most effective in men, those without a history of depression, those who have not undergone prior tinnitus treatments, those with more severe and bilateral tinnitus, and those with a history of noise exposure.

Optimizing Management of Otophyma: A Case Series Highlighting the Role of Surgical and Retinoid Therapy.

Otophyma is a rare condition that can result in conductive hearing loss. Current otophyma literature does not examine validated treatment outcomes for patients. Utilizing a medical and surgical approach to maintain a patent canal can lead to significant objective improvements. The aim of this case series is to describe a combined successful approach in 3 cases from an academic, multidisciplinary center. The main outcomes analyzed were pre and post air-bone gap audiogram analysis and disimpaction frequency. The results showed that post-management, patient 1 had substantial improvement in hearing, recovering 49 dB in his right ear and 25 dB in his left ear, demonstrating near complete air-bone gap closure. Patient 2 showed a similar dermatologic and functional improvement, although objective audiometric assessment related to otophyma could not be performed due to coexisting chronic otitis media and cholesteatoma. Patient 3, in the 12 months prior to comanagement, had 8 bilateral disimpactions, and following comanagement had 2 disimpactions in 23 months. All 3 patients were pleased with the resultant functional and physical appearance following comanagement. By presenting this approach and objective measures of treatment, we hope to improve future clinical decision-making in a rare condition.

Intraoperative Electrocochleography of Posterior Fossa Tumors Producing Menière's Syndrome.

OBJECTIVES: Intraoperative electrocochleography (ECochG) has provided insight regarding inner ear pathophysiology during neurotologic procedures. In this study, intraoperative ECochG findings are reported in patients who presented with episodic aural and vestibular symptoms during resection of posterior fossa neoplasms. PATIENTS: Three patients with episodic vertigo who underwent resection of posterior fossa tumors. INTERVENTION: Intraoperative ECochG was performed before and after tumor resection with the active electrode at the round window. Acoustic stimuli consisted of click and tone bursts presented in alternating polarity. MAIN OUTCOME MEASURE: ECochG responses including summation potential (SP), action potential (AP), and SP:AP ratio values to evaluate for endolymphatic hydrops. RESULTS: All subjects presented with asymmetric sensorineural hearing loss (SNHL), episodic vertigo, and tinnitus. Subject 1 was a 63-year-old woman who underwent left translabyrinthine excision of an endolymphatic sac (ELS) tumor and demonstrated no measurable responses until fenestration of the lateral semicircular canal, suggesting severe hydrops relieved by labyrinthotomy. Subject 2 was a 44-year-old woman who underwent right ELS tumor resection and exhibited an elevated SP:AP ratio. Subject 3 was a 55-year-old woman who underwent right retrolabyrinthine resection of a meningioma and exhibited robust responses without hydrops. CONCLUSIONS: Endolymphatic hydrops secondary to mechanical obstruction by a posterior fossa neoplasm may be demonstrated using intraoperative ECochG. Immediate improvement of hydrops may not be demonstrated after tumor resection.

Comparison of Opioid Prescription Patterns and Consumption Following Otologic Surgery.

OBJECTIVE: To examine opioid prescribing patterns and consumption among patients undergoing common otologic surgeries. STUDY DESIGN: Retrospective cohort study with chart review and telephone survey. SETTING: Tertiary academic medical center. METHODS: Retrospective chart review and telephone survey of those undergoing tympanoplasty, tympanomastoidectomy, stapedectomy, and cochlear implantation in 2018. The survey consisted of questions regarding the details of the number of pills taken, duration of opioid use, subjective pain control, the use of over-the-counter pain medications, opioid disposal, and their history of substance abuse. RESULTS: Sixty-one patients were able to be contacted and agreed to participate in the study. Fifty-nine (96.7%) stated that their pain was controlled, and 10 (16.4%) did not take any opioids postoperatively despite their prescription. The mean morphine milligram equivalent (MME) prescribed was 99.9 (44.3) and MME taken was 45.2 (SD 46.3) (p < 0.001). Similarly, the mean number of pills prescribed was 17.8 (SD 8.6) and mean taken was 7.9 (SD 8.3) (p < 0.001). Comparison between males and females regarding MME and pills prescribed and taken were not statistically significantly different (p > 0.05). Analysis of the MME and pills prescribed and taken among the different surgeries (tympanoplasty, stapes surgery, tympanomastoidectomy, and cochlear implantation) revealed no statistically significant interactions (p > 0.05). Pain control was achieved for 50% of patients with 5 pills (MME = 25 mg), for 75% with 12 pills (MME = 60 mg), and for 90% with 24 pills (MME = 135 mg). CONCLUSION: The opioid epidemic continues to be an ongoing issue in the United States, and prescription opioid abuse is a large contributor. There is increasing literature to suggest a practice of overprescribing in multiple surgical specialties. This same finding appears to be present in common otologic surgeries, where on average patients took less than half of the prescribed MME/pills, and 75% of patients had their pain controlled with 12 pills or fewer. Otolaryngologists performing otologic surgery should strongly consider adjusting their postoperative regimens to reflect these findings. LEVEL OF EVIDENCE: 2b.

Electrocochleography During Translabyrinthine Approach for Vestibular Schwannoma Removal.

HYPOTHESIS: Intraoperative electrocochleography (ECochG) can differentiate hair cell and neural dysfunction caused by a vestibular schwannoma (VS) and help define the site of lesion as peripheral or central to the spiral ganglion. BACKGROUND: Hearing loss in patients with a VS can be caused by both sensory (cochlear) and neural dysfunction. METHODS: Round-window ECochG using low and high-frequency tone bursts was performed in 49 subjects with a VS. Responses were analyzed for magnitude, spectrum, and shape of the time waveform. Components examined included the cochlear microphonic, auditory nerve neurophonic, compound action potential (CAP), and summating potential (SP). RESULTS: Variability in the summed response magnitudes across frequency, or "total response" (ECochG-TR), varied from 0.1 to 100 µV. Responses were larger for lower frequencies. Subjective estimates revealed a wide range of neural contributions from the auditory nerve neurophonic to low frequencies and the CAP to high frequencies. Cases with larger CAPs had smaller SPs. The correlation of ECochG-TR, with word recognition score (WRS), was moderate (r = 0.67), as well as the correlation between pure-tone averages and ECochG (r = 0.63). The cochlea remained functional in two cases of sudden sensorineural hearing loss with 0% WRS. CONCLUSION: Reduced ECochG-TR and neural activity in many cases indicates both sensory and neural deficits. Smaller SPs when CAPs are present indicate a neural contribution to the SP. Good cochlear function with 0% WRS, and cases of sudden sensorineural hearing loss with retained cochlear function, indicate retrocochlear effects, typically proximal to the spiral ganglion cells.

Intraoperative Electrocochleography in Patients With Menière's Disease Undergoing Endolymphatic Sac Decompression and Shunt Surgery.

HYPOTHESIS: Objective physiologic changes measured using electrocochleography at the round window (ECOG) are observable during endolymphatic sac decompression and shunt surgery (ELS). BACKGROUND: Limited effective treatment options are available to patients with Menière's disease (MD) who have failed conservative management, experience persistent vertigo symptoms, and have substantial residual hearing. ELS is a feasible therapeutic option for these patients. However, the efficacy of this procedure has been questioned, and objective measures assessing inner ear physiologic alterations are lacking. METHODS: ECOG was measured in patients with MD undergoing ELS. Stimuli consisted of tone bursts (250, 500, 1000, 2000, 4000 Hz) and 100 µs broadband clicks at various intensities (60-90 dB nHL). Cochlear microphonic (CM), summation potential (SP), compound action potential (AP), SP:AP ratio, and CM harmonic distortions were measured. RESULTS: ECOG was completed in 18 patients. The mean SP magnitude at 500 Hz changed significantly from -7.1 µV before to -5.1 µV after ELS (p < 0.05). However, the mean SP:AP ratio in those tested (n = 13) did not significantly change after ELS. CM harmonic magnitudes remained unchanged from pre- to post-ELS (n = 12) across all frequencies. CONCLUSION: ECOG allows detection of acute electrophysiological changes in the cochlea. However, our results indicate only small objective changes in the low-frequency SP magnitude (500 Hz) immediately after ELS, but not in other frequencies or measures tested (CM, SP:AP, CM harmonic distortions). These results suggest minimal electrophysiological changes occur in the cochlea as a result of ELS.

Conductive hearing loss in chronic inflammatory demyelinating polyneuropathy (CIDP): A case report.

Chronic inflammatory demyelinating polyneuropathy (CIDP) is a progressive autoimmune disorder that targets peripheral nerves. It commonly presents with motor-predominant dysfunction and enlargement of cranial nerves. With regards to hearing loss, a few cases of sensorineural loss have been described. We present a novel case of conductive hearing loss caused by a mass on the tympanic segment of the facial nerve in the setting of CIDP.

Hearing Preservation After Translabyrinthine Vestibular Schwannoma Excision: Audiometry and Electrocochleography Results.

OBJECTIVES: To describe a case of inadvertent hearing preservation following a classical translabyrinthine resection of a vestibular schwannoma of the internal auditory canal in an otherwise healthy patient. METHODS: Herein, we describe the case of an otherwise healthy patient who underwent resection of an intracanalicular vestibular schwannoma via a translabyrinthine approach. Furthermore, as part of an ongoing study aimed at characterizing hearing changes due to intraoperative events, cochlear hair cell and nerve activity were monitored using electrocochleography throughout surgery. Unexpectedly, the patient maintained serviceable hearing following surgery. As a result, we are able to provide electrophysiologic evidence of cochlear hair cell activity at various stages of this surgery. RESULTS: Hair cell responses across tested frequencies were detectable prior to and following completion of the translabyrinthine procedure. Neural integrity of the auditory division of cranial nerve VIII was maintained throughout. Lastly, postoperative audiometric testing supported the patient's subjective assertion of serviceable hearing in the surgical ear. CONCLUSION: Our results suggest that some degree of hair cell and neural integrity can be maintained throughout the course of the translabyrinthine approach, and if preservation of the auditory division of cranial nerve VIII is feasible, a functional amount of hearing preservation is attainable.

Nerve of origin, tumor size, hearing preservation, and facial nerve outcomes in 359 vestibular schwannoma resections at a tertiary care academic center.

OBJECTIVE: To determine nerve of origin, tumor size, hearing preservation rates, and facial nerve outcomes in a retrospective cohort study of patients undergoing translabyrinthine (TL), middle cranial fossa (MCF), and retrosigmoid/suboccipital (SO) approaches to vestibular schwannomas (VS). STUDY DESIGN: Retrospective. METHODS: Chart review. RESULTS: Patient charts from 231 TL, 70 MCF, 53 SO, and 5 combined TL/SO procedures for VS were evaluated in 356 patients. The inferior vestibular nerve (IVN) was the nerve of origin in 84 of 359 cases (23.3%), while the superior vestibular nerve (SVN) was the nerve of origin in 36 patients (10%). In 239 of 359 cases (66.6%), the nerve of origin was not identified. Forty patients undergoing hearing preservation surgery had hearing results and nerve of origin data available for review. Functional hearing (<50dB PTA and >50% speech discrimination) was preserved in 10 of 15 patients (75%) with SVN tumors, while only 7 of 25 patients (28%) with IVN tumors retained functional hearing. Facial nerve outcomes and nerve of origin were recorded simultaneously in 109 patients. Seventy-one of 74 patients (95%) patients with IVN tumors achieved a House-Brackmann (HB) grade I-III, while 35 of 35 patients (100%) with SVN tumors retained HB I-III facial function. Looking at tumor size versus hearing preservation, functional hearing was preserved in 22 of 49 patients (45%) with <1-cm tumors, and 4 of 20 patients (20%) with 1- to 1.5-cm tumors. For all cases with documented facial nerve function, HB I-III were achieved in 96% of SO, 94% of MCF, and 88% of TL procedures. CONCLUSIONS: Our retrospective data indicated that IVN tumors were twice as common as SVN tumors. The nerve of origin did not affect facial nerve outcomes but did impact hearing preservation rates. Patients with tumors <1 cm in size had the best chance for hearing preservation. Overall facial nerve preservation was excellent with >90% achieving HB 1 to 3 function at final follow-up.

Does packing the eustachian tube impact cerebrospinal fluid rhinorrhea rates in translabyrinthine vestibular schwannoma resections?

OBJECTIVE: To calculate cerebrospinal fluid (CSF) leak rates for translabyrinthine (TL), middle cranial fossa (MCF), and retrosigmoid/suboccipital (SO) craniotomies performed for removal of vestibular schwannoma (VS) and analyze whether packing the eustachian tube (ET) in TL VS resections impacts CSF rhinorrhea rates. STUDY DESIGN: Retrospective. SETTING: Tertiary care center. METHODS: Chart review. RESULTS: Three hundred fifty-nine VS resections were reviewed in 356 patients ranging from 10 to 86 years of age. Two hundred thirty-one TL, 70 MCF, 53 SO, and 5 combined TL/SO procedures were analyzed. Total CSF leak rates (incisional, otorrhea, and rhinorrhea) were 14.2% for TL, 11.4% for MCF, and 13.2% for SO approaches. Differences in overall CSF leak rates were not statistically significant. For those who underwent TL craniotomies, 2 groups of patients were identified based on whether their ETs were packed during surgery. In 1 group, the incus was removed, the aditus enlarged, the ET packed, and the middle ear filled with muscle. In the second group, the aditus, epitympanum and middle ear were packed without removing the incus, and the ET was not packed. Of 148 patients who had their ET packed, 12 developed CSF rhinorrhea (8.1%). The CSF rhinorrhea rate for patients who did not have ET packing was 5.9% (3 of 51 patients). This difference was not statistically significant (p = 0.80). When Proplast was used to pack the ET (121 patients), the CSF rhinorrhea rate was 5.8%. Unfortunately, this material extruded in 4 of 121 patients (3.3%) and presented clinically as delayed purulent otorrhea. CONCLUSION: Cerebrospinal fluid leak rates were similar in patients undergoing TL, SO, and MCF approaches, and CSF rhinorrhea was not decreased by ET packing. Patients whose ETs are packed with Proplast are at risk for extrusion and otorrhea years after their initial VS resection.

Hearing health access in developing countries.

PURPOSE OF REVIEW: The developing world carries a disproportionate burden of hearing loss. Individuals with hearing loss in austere settings worldwide are also potentially impacted by their impairment to a greater extent owing to underdeveloped or nonexistent hearing health infrastructure. The purpose of this review is to examine the state of the literature on hearing health access in developing countries and identify areas for improvement. RECENT FINDINGS: Over the last 10 years progress has been made in some areas, whereas other aspects of hearing health in developing countries have changed very little. There has been expansion of efforts to train primary care and local hearing healthcare providers to recognize and appropriately treat preventable causes of hearing loss in the developing world. Applications of telehealth to connect providers and patients in rural locales have grown. Adaptions of newborn hearing screening programs that better fit local resources and customs have been reported. There has been a considerable increase in interest, including cost-benefit analyses, with regard to the use of cochlear implants in the developing world. SUMMARY: In spite of progress, the developing world still shoulders a disproportionate amount of the world's hearing loss, in particular chronic ear disease, and there is a paucity of well trained local hearing healthcare professionals to deal with the challenge. The role of international humanitarian efforts, telemedicine, and education is highlighted.

Predictive factors in pediatric stapedectomy.

OBJECTIVE/HYPOTHESIS: The objective of the study was to investigate predictive factors in the postoperative hearing outcomes in pediatric stapedectomy. STUDY DESIGN: Retrospective case series. The study was performed in a tertiary academic otological practice. METHODS: The outcome of 66 stapedectomies in children 17 years of age and younger were analyzed according to the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium guidelines. Factors evaluated included patient age, underlying diagnosis (tympanosclerosis, otosclerosis, congenital fixation), type of footplate graft and type of prosthesis used, associated ossicular abnormalities, and revision surgery. RESULTS: The mean postoperative air-bone gap following stapedectomy in children with tympanosclerotic footplate fixation (24.9 dB [+/-11 dB]) was significantly worse than in patients with an underlying diagnosis of congenital stapes fixation (15.7 dB [+/-9 dB]) or otosclerosis (13.1 dB [+/-3 dB]) (P =.024). Revision stapedectomy was also associated with a poorer outcome, but patient age and prosthesis and graft type did not contribute to the outcome in a statistically significant manner. CONCLUSIONS: Pediatric patients with stapes fixation resulting from tympanosclerosis showed poorer outcomes from stapedectomy than patients with congenital or otosclerotic fixation. Outcomes for congenital or otosclerosis fixation more nearly matched the outcomes in the literature for adult series.

Transmastoid approach to spontaneous temporal bone cerebrospinal fluid leaks: hearing improvement and success of repair.

OBJECTIVE: To determine whether the transmastoid approach to repair of spontaneous temporal bone cerebrospinal fluid (CSF) leak is safe and effective and if improvement in conductive hearing loss is an achievable goal with this approach. STUDY DESIGN: Case series with chart review. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: Fifteen consecutive patients (16 ears) presented with spontaneous temporal bone CSF leaks over a 6-year period. Clinical data, imaging, audiometry, operative reports, and postoperative course were reviewed. RESULTS: Median age was 59.5 years. Mean body mass index was 40.7 kg/m2. All presented with chronic otorrhea after tympanostomy tube placement and conductive/mixed hearing loss. The mean preoperative air-bone gap was 19 dB. A transmastoid approach alone was used in 15 cases; 1 underwent middle fossa craniotomy. Most defects were located in the tegmen mastoideum and tympani. All repairs were multilayered, typically using autologous mastoid bone, temporalis fascia, and tissue sealant. Primary repair was successful in 15 cases; 1 patient with persistent postoperative otorrhea subsequently underwent middle fossa craniotomy, but no frank leakage was found. No serious complications were encountered. Following transmastoid repair, postoperative audiograms were available for 14 patients. The mean improvement in air-bone gap was 12 dB. Closure of the air-bone gap to ≤12 dB occurred in 100% of cases. CONCLUSION: The transmastoid approach to repair of spontaneous temporal bone CSF leak is highly successful. Furthermore, patients in this series had excellent hearing results with closure of their air-bone gap to ≤12 dB, which has not been previously described.

Dizziness in the elderly.

Vertigo, unsteadiness, and other balance-related symptoms are common among older adults. These complaints should be taken seriously because they can lead to falls, injuries, loss of independence, and even death. This article provides a review of the underlying causes for the increased prevalence of dizziness with age, and discusses how specific test procedures may need to be modified for older individuals. Issues related to the management of these symptoms in the aging population are also considered.