Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery.

OBJECTIVES: Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE. RESULTS: Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2). CONCLUSION: Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:662-667, 2022.

Audiologic Outcomes After Oval and Round Window Reinforcement Surgery.

INTRODUCTION: Oval window (OW) and round window (RW) reinforcement surgery has been used for symptomatic treatment of multiple clinical entities, most commonly perilymphatic fistula and superior semicircular canal dehiscence. Owing to the theoretical acoustically negative effect of stiffening the windows, there has been concern of an unfavorable effect on audiologic outcomes due to the procedure. The purpose of this study is to specifically evaluate audiologic outcomes after OW and RW reinforcement. METHODS: A retrospective review of patients undergoing transcanal OW or RW reinforcement was completed. Patients were evaluated both as a total group and as two groups separated into "third window" and "two-window" groups based on their specific diagnosis. Primary outcomes included changes in individual pure-tone thresholds, pure-tone average (PTA), air-bone gap, speech reception threshold (SRT), and word recognition scores (WRS) between the preoperative and postoperative groups. RESULTS: Seventy-one patients were included in the study. The combined cohort demonstrated a significant postoperative 2.75 dB increase in the air conduction hearing level at 4000 Hz (p < 0.05). This was almost entirely accounted for by a 2.18 dB increase in the air-bone gap at this frequency (p < 0.05). There were no significant changes in PTA, SRT, or WRS between in the combined group or in the subgroup analysis. CONCLUSION: OW and RW tissue reinforcement resulted in a statistically significant but likely clinically insignificant decrease in hearing at the 4000 Hz frequency. There was no worsening of PTA, WRS, or SRT.

Risk Factors for Complications Following Lateral Skull Base Surgery and the Utility of ICU Monitoring.

OBJECTIVE: To examine the role of intensive care unit (ICU) management following lateral skull base surgery for vestibular schwannoma and identify risk factors for complications warranting admission to the ICU. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Two hundred consecutive patients undergoing lateral skull base surgery for vestibular schwannomas. INTERVENTION: Lateral skull base approach for resection of vestibular schwannoma and postoperative monitoring. MAIN OUTCOME MEASURES: Patients were grouped if they sustained an ICU complication, a non-ICU complication, or no complication. Analysis was performed to determine patient or treatment factors that may be associated with ICU complications. Multivariate and three-way analysis of variance compared groups, and multivariate logistic regression determined adjusted odds ratios (aOR) for analyzed factors. RESULTS: Seventeen of 200 patients sustained ICU complications (8.5%), most commonly hypertensive urgency (n = 15). Forty-six (23%) sustained non-ICU complications, and 137 (68.5%) had no complications. When controlling for age, sex, obesity, and other comorbidities, only hypertension (aOR 5.43, 95% confidence interval (CI) 1.35-21.73, p = 0.017) and tumor volume (aOR 3.29, 95% CI 1.09-9.96, p = 0.035) were independently associated with increased risk of ICU complications. CONCLUSIONS: The necessity of intensive care following lateral skull base surgery is rare, with the primary ICU complication being hypertensive urgency. Preoperative hypertension and large tumor volume (>4500 mm3) were independently associated with increased risk for ICU complications. These findings may allow for risk stratification of patients appropriate for admission to stepdown units following resection of vestibular schwannomas. Further prospective, multi-center, randomized studies are necessary to validate these findings before systematic changes to current postoperative care practices.

Quality-of-life assessment of Ménière's disease patients after surgical labyrinthectomy.

OBJECTIVE: To examine the impact of surgical labyrinthectomy on quality of life of Ménière's disease patients. STUDY DESIGN: Cross-sectional survey. SETTING: Otology subspecialty referral center. PATIENTS: All patients with Ménière's disease who underwent surgical labyrinthectomy between 1998 and 2004 were selected. Fifty-three patients satisfied inclusion criteria. Completed questionnaires were obtained from 44 patients. INTERVENTION(S): The Ménière's Disease Outcomes Questionnaire is a disease-specific quality-of-life questionnaire. It was used to assess the quality of life of patients before and after surgical labyrinthectomy. The questionnaire encompasses physical, mental, and social well-being domains of quality of life. MAIN OUTCOME MEASURE(S): Change in total quality-of-life score was used to assess the overall impact of surgical labyrinthectomy on subjective patient outcome. Individual quality-of-life domains were also assessed. RESULTS: Forty-three of 44 respondents (98%) had improvement in total score after surgery. The one patient who demonstrated deterioration developed latent contralateral disease. Average preoperative and postoperative scores were 34 +/- 14 and 67 +/- 15, respectively (p < 0.001). All questions showed significant improvement with surgery (p < 0.001) except questions pertaining to memory (no change) and hearing loss (nonsignificant decrease in score). CONCLUSION: This study comprises the first patient-directed assessment of quality-of-life outcomes in Ménière's disease patients after labyrinthectomy. Despite the disadvantage of hearing loss, patients consistently reported significant improvement in all quality-of-life domains and do not report a significant loss of quality of life in terms of their hearing loss. Surgical labyrinthectomy remains a highly effective treatment for Ménière's disease patients.

Success of posterior semicircular canal occlusion and application of the dizziness handicap inventory.

OBJECTIVES: To determine the long-term efficacy and patient satisfaction of posterior semicircular canal occlusion (PSCO) as a treatment for intractable benign paroxysmal positional vertigo (BPPV). STUDY DESIGN AND SETTING: Retrospective analysis of patients with BPPV who underwent PSCO was conducted in a tertiary referral center. Demographic data, clinical records, and audiometric data were reviewed. Dix-Hallpike maneuver, dizziness handicap inventory (DHI), and a specific PSCO questionnaire (PCOQ) were used to measure outcome. RESULTS: Twenty-eight patients underwent PSCO. The mean follow-up time was 40 months. All patients had normalization of the Hallpike test. DHI scores of 20 patients were recorded. The mean preoperative score was 70 compared with postoperative mean of 13 (P < 0.001). Mild hearing loss was found in 1 patient. CONCLUSIONS AND SIGNIFICANCE: PSCO is highly successful. The DHI scores postoperatively show significant improvement. The PCOQ revealed an overall 85% patient satisfaction rate. PSCO is a safe and effective intervention for intractable BPPV with a high patient satisfaction rate. EBM RATING: C-4.

Intralabyrinthine schwannomas mimic cochleovestibular disease: symptoms from tumor mass effect in the labyrinth.

OBJECTIVE: To describe symptoms from intralabyrinthine schwannomas specific from more common vestibular schwannomas of the internal auditory canal or cerebellopontine angle resulting from mass effect from the tumor within the labyrinth. PATIENTS: Eight patients diagnosed as having intralabyrinthine schwannomas from 2000 to 2014 were examined retrospectively from two tertiary neurotologic centers. INTERVENTIONS: Diagnosis of intralabyrinthine schwannoma was made with gadolinium-enhanced magnetic resonance imaging scans. Heavily T2-weighted sequences were used to verify mass within the fluid-filled labyrinth. Patients then underwent audiometric and vestibular testing when appropriate. Treatment consisted of observation or surgical resection. MAIN OUTCOME MEASURES: Clinical symptoms, magnetic resonance imaging scans, audiometric and videonystagmography data, and operative findings were reviewed. RESULTS: Five of the eight patients had positional vertigo or nystagmus on testing. One patient's only complaint was positional vertigo without auditory symptoms. Three of the patients demonstrated mixed hearing loss. Two patients underwent resection of their tumors, one because of tumor growth and the other because of intractable vertigo. CONCLUSION: These data show that a high proportion within our series displayed symptoms of positional vertigo and mixed hearing loss, which are symptoms not typical of nonintralabyrinthine schwannomas. One patient's only reported symptom was positional vertigo. These symptoms may arise from the effect of the tumor's mass exerted on the cochlear and vestibular end organs.

Round window gentamicin absorption: an in vivo human model.

OBJECTIVE/HYPOTHESIS: Using a novel human labyrinthine sampling model, in vivo gentamicin absorption through the round window can be measured. STUDY DESIGN: A prospective study. METHODS: Gentamicin was delivered either transtympanically (preoperative) or through a facial recess approach (intraoperative). The lateral semicircular canal and vestibule were opened, and by means of a microsyringe, labyrinthine fluid was aspirated. A sample of serum was also drawn. In all patients cerebrospinal fluid was also drawn. The samples were analyzed using a standard chemistry analyzer. RESULTS: Intratympanic gentamicin diffused through the round window membrane and achieved concentrations in the labyrinthine fluid ranging from 0 to 16 mg/L. Intratympanic gentamicin was absorbed into the systemic circulation in 4 of 11 patients with serum levels ranging from 0.3 to 0.4 mg/L. No gentamicin was detected in the cerebrospinal fluid. CONCLUSIONS: Intratympanic gentamicin diffuses rapidly through the round window membrane and achieves significant levels in the inner ear. Thus, this new model can be used to assess round window permeability to clinically relevant medications such as steroids and ototopical antibiotics.

Benign paroxysmal positional vertigo.

PURPOSE OF REVIEW: To review benign paroxysmal positional vertigo (BPPV) and some of the recent literature. As BPPV is such a common diagnosis, it is important to understand the disorder and treatment considerations. RECENT FINDINGS: Although BPPV is typically an easy diagnosis to make, one must be aware of the differential diagnosis. An unusual entity, convergence spasm, is recently presented and discussed as an addition to the differential diagnosis. The recent literature confirms the efficacy of treatment of BPPV. Large studies of horizontal canal BPPV support the success of the barbeque roll and present the simple head shake as a possible treatment in the apogeotropic form. There is reported success with the less often discussed Gufoni (and its variations) maneuver. The presence of orthoptic nystagmus during treatment has positive predictive value for the success of the maneuver. Although uncommon, canal conversion is important to recognize during treatment as it can be readily treated. SUMMARY: BPPV is a very common cause of dizziness and generally straightforward to identify and treat. Awareness of possible horizontal canal variants and nonvestibular differential diagnosis possibilities is important. Repositioning maneuvers of various types are typically successful and understanding the nuances is important in assuring successful outcomes.