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OBJECTIVES: Describe a single institution's cochlear implant outcomes for patients with inner ear schwannomas (IES) in the setting of various tumor management strategies (observation, surgical resection, or stereotactic radiosurgery [SRS]). STUDY DESIGN: Single-institution retrospective review. PATIENTS: Patients diagnosed with isolated, sporadic IES who underwent cochlear implantation (CI). INTERVENTIONS: CI with or without IES treatment. MAIN OUTCOME MEASURES: Speech perception outcomes, tumor status. RESULTS: Twelve patients with IES underwent CI with a median audiologic and radiologic follow-up of 12 months. Six patients underwent complete resection of the tumor at the time of CI, four underwent tumor observation, and two underwent SRS before CI. At 1 year after CI for all patients, the median consonant-nucleus-consonant (CNC) word score was 55% (interquartile range, 44-73%), and the median AzBio sentence in quiet score was 77% (interquartile range, 68-93%). Overall, those with surgical resection performed similarly to those with tumor observation (CNC 58 versus 61%; AzBio in quiet 74 versus 91%, respectively). Patients who underwent tumor resection before implantation had a wider range of speech performance outcomes compared with patients who underwent tumor observation. Two patients had SRS treatment before CI (10 months previous and same-day as CI) with CNC word scores of 6 and 40%, respectively. CONCLUSIONS: Patients with IES who underwent CI demonstrated similar speech performance outcomes (CNC 56% and AzBio 82%), when compared with the general cochlear implant population. Patients who underwent either tumor observation or surgical resection performed well after CI.
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OBJECTIVES: Radiation treatment, particularly at a young age, creates theoretical risk for long-term adverse radiation effects, including the development of malignancy. The literature is sparse on radiation-induced vestibular schwannomas (VSs). METHODS: A retrospective review was performed for cases of suspected radiation-induced VS at 2 high-volume centers. Only cases where radiation included coverage of the posterior fossa were included with those diagnosed within 3 years of radiation treatment being excluded. Patient and tumor characteristics were collected. A systematic literature review was also performed for any previously published series on radiation-induced VS. RESULTS: Eight cases of radiation-induced VS were identified with a median follow-up 125 months (range 7-131). The median age at incident radiation was 15 years (range 2-46). The median age at VS diagnosis was 57 years (range 26-83) with median interval from radiation to diagnosis of 51-years (range 15-66). The median tumor size was 6 mm (range 3-21). Two patients underwent surgical resection. Lesions were described as soft and highly vascular, with medium to high adherence to the facial nerve. Five articles with a total of 52 patients were identified, median age at VS diagnosis was 42-years (range 23-73) with a median interval from radiation to diagnosis of 19 years (range 15-23). CONCLUSIONS: The development of VS following radiation exposure appears rare and our understanding of the condition remains incomplete. Further studies are required to determine the best management of these patients and determine whether there is a causative relationship between radiation exposure and the development of VS.
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Neoplasias Inducidas por Radiación , Neuroma Acústico , Humanos , Neuroma Acústico/radioterapia , Persona de Mediana Edad , Adulto , Femenino , Anciano , Masculino , Neoplasias Inducidas por Radiación/etiología , Estudios Retrospectivos , Anciano de 80 o más Años , Adulto Joven , Adolescente , Radioterapia/efectos adversosRESUMEN
OBJECTIVE: To describe the experience and results from coordinated and closely scheduled radiosurgery and cochlear implantation (CI) in a vestibular schwannoma (VS) cohort. PATIENTS: Patients with VS who underwent radiosurgery followed by CI on the same or next day. INTERVENTIONS: Interventions included sequential radiosurgery and CI. MAIN OUTCOME MEASURES: Tumor control defined by tumor growth on posttreatment surveillance and audiometric outcomes including consonant-nucleus-consonant words and AzBio sentences in quiet. RESULTS: In total, six patients were identified that met the inclusion criteria, with an age range of 38 to 69 years and tumor sizes ranging from 2.0 to 16.3 mm. All patients successfully underwent radiosurgery and CI on the same or immediately successive day. Postoperatively, all patients obtained open-set speech recognition. Consonant-nucleus-consonant word scores ranged from 40 to 88% correct, and AzBio scores ranged from 44 to 94% correct. During posttreatment magnetic resonance imaging surveillance, which ranged from 12 to 68 months, all tumors were noted to be adequately visualized, and no tumor progression was noted. CONCLUSION: Coordinated radiosurgery and CI can be safely performed in patients with VS on the same or next day, serving to decrease burden on patients and increase access to this vital rehabilitative strategy.
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Implantación Coclear , Implantes Cocleares , Neuroma Acústico , Radiocirugia , Percepción del Habla , Humanos , Adulto , Persona de Mediana Edad , Anciano , Implantación Coclear/métodos , Neuroma Acústico/cirugía , Radiocirugia/métodos , Estudios Retrospectivos , Audiometría , Resultado del TratamientoRESUMEN
OBJECTIVES: A small number of cochlear implant (CI) users experience facial nerve stimulation (FNS), which can manifest as facial twitching. In some patients, this can be resolved by adjusting the electrical stimulation parameters. However, for others, facial stimulation can significantly impair CI outcomes or even prevent its use. The exact mechanisms underlying FNS are unclear and may vary among patients. DESIGN: Transimpedance measurements were used to assess lateral and longitudinal spread of current within 15 cochlea of nucleus CI recipients with FNS (13 unilateral recipients and 1 bilateral recipient). We compared the transimpedance measurements with programming parameters from clinical visits and pre- and postoperative temporal bone computed tomography (CT) scans to identify factors that may contribute to FNS in each CI ear. RESULTS: In nine ears, transimpedance curves showed inflection, which suggests a localized current sink within the cochlea. This indicates a low-impedance pathway through which current exits the cochlea and stimulates the labyrinthine segment of the facial nerve canal. Electrodes near this current sink were disabled or underfit to minimize facial stimulation. In the other seven ears, current flow peaked toward the basal end of the cochlea, suggesting that current exits through the round window or other structures near the basal end of the cochlea, stimulating the tympanic segment of the facial nerve. CONCLUSIONS: Objective transimpedance measurements can be used to elucidate the mechanisms of FNS and to develop strategies for optimizing electrical stimulation parameters and speech coding to minimize or eliminate FNS in a small subset of CI users.
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Implantación Coclear , Implantes Cocleares , Humanos , Nervio Facial , Cóclea , Estimulación EléctricaRESUMEN
OBJECTIVE: Comprehensively assess the prevalence of monopolar electrosurgery-related device complications among cochlear implant (CI) recipients. STUDY DESIGN: Multifaceted retrospective review and survey. SETTING: Tertiary medical center. METHODS: Multifaceted approach including: (i) review of the current literature; (ii) historical review of institutional data from an academic, tertiary CI center; (iii) review of industry data provided by 3 Food and Drug Administration-approved CI manufacturers; and (iv) survey of high-volume CI centers. RESULTS: Literature review identified 9 human studies, detailing 84 devices with 199 episodes of device-cautery exposure. From studies reporting on patients records, no implant showed evidence of damage after exposure. One cadaveric study using dental cautery reported 1 episode of device damage. Review of institutional records did not identify any CI damage in 84 instances of exposure. Data from the 3 major implant manufacturers showed a single report of damage that could be reasonably linked to monopolar electrosurgery, out of a possible 689,426 CIs. Last, a survey of 8 high-volume CI centers did not identify any adverse events associated with monopolar cautery. CONCLUSION: These data estimate the risk of adverse device-related events or tissue injury to be extraordinarily low. Short of operating in immediate proximity to the CI (ie, the ipsilateral temporoparietal scalp), these data indicate that monopolar electrosurgery can be used in the body and the head-and-neck of CI recipients with nominal risk. These findings may guide decision-making in cases that are optimally or preferably performed with monopolar electrocautery and can be used to counsel CI patients following inadvertent exposures.
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Implantación Coclear , Implantes Cocleares , Humanos , Electrocirugia/efectos adversos , Implantes Cocleares/efectos adversos , Electrocoagulación , Implantación Coclear/efectos adversos , CauterizaciónRESUMEN
OBJECTIVE: The treatment paradigm of vestibular schwannoma (VS) focuses on preservation of neurologic function, with small tumors increasingly managed with active surveillance. Often, tumor size and hearing outcomes are poorly correlated. The aim of the current work was to describe the natural history of hearing among patients with nongrowing VS during observational management. STUDY DESIGN: Historical cohort study. PATIENTS: Adults with sporadic VS. INTERVENTION: Wait-and-scan management. MAIN OUTCOME MEASURE: Maintenance of serviceable hearing (SH) after diagnosis. RESULTS: Among 228 patients with nongrowing VS, 157 patients had SH at diagnosis. Rates of maintaining SH (95% CI; number still at risk) at 1, 3, and 5 years after diagnosis were 94% (89-98; 118), 81% (74-89; 65), and 78% (71-87; 42), respectively. Poorer hearing at diagnosis (hazard ratio [HR] per 10 dB hearing level increase in pure-tone average of 2.51, p < 0.001; HR per 10% decrease in word recognition score of 1.70, p = 0.001) was associated with increased likelihood of developing non-SH during observation. When controlling for baseline hearing status, tumors measuring 5 mm or greater in the internal auditory canal or with cerebellopontine angle extension were associated with significantly increased risk of developing non-SH (HR, 4.87; p = 0.03). At 5 years after diagnosis, 95% of patients with nongrowing intracanalicular VS measuring less than 5 mm maintained SH. CONCLUSIONS: Hearing worsens during periods of nongrowth in sporadic VS. Patients with small (<5 mm) intracanalicular tumors demonstrate robust maintenance of SH over time, reinforcing the consideration of initial observation in this patient subset.
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Neuroma Acústico , Adulto , Humanos , Neuroma Acústico/patología , Estudios de Cohortes , Espera Vigilante , Audición , Pruebas Auditivas , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: To compare cochlear implant (CI) and auditory brainstem implant (ABI) performance in patients with NF2-related schwannomatosis (NF2). STUDY DESIGN: Historical cohort. SETTING: Tertiary academic center. PATIENTS: A total of 58 devices among 48 patients were studied, including 27 ABIs implanted from 1997 to 2022 and 31 CIs implanted from 2003 to 2022. Three patients had bilateral ABIs, three had bilateral CIs, three had an ABI on one side and a CI on the other, one had a CI that was later replaced with an ipsilateral ABI, and one had an ABI and CI concurrently on the same side. INTERVENTIONS: CI or ABI ipsilateral to vestibular schwannoma. MAIN OUTCOME MEASURES: Open-set speech perception, consonant-nucleus-consonant word scores, and AzBio sentence in quiet scores. RESULTS: Among all patients, 27 (47%) achieved open-set speech perception, with 35 (61%) daily users at a median of 24 months (interquartile range [IQR], 12-87 mo) after implantation. Comparing outcomes, CIs significantly outperformed ABIs; 24 (77%) CIs achieved open-set speech perception compared with 3 (12%) ABIs, with median consonant-nucleus-consonant and AzBio scores of 31% (IQR, 0-52%) and 57% (IQR, 5-83%), respectively, for CIs, compared with 0% (IQR, 0-0%) and 0% (IQR, 0-0%), respectively, for ABIs. Patients with ABIs were younger at diagnosis and at implantation, had larger tumors, and were more likely to have postoperative facial paresis. CONCLUSION: Many patients with NF2-associated vestibular schwannoma achieved auditory benefit with either a CI or an ABI; however, outcomes were significantly better in those patients who were able to receive a CI. When disease and anatomy permit, hearing rehabilitation with a CI should be considered over an ABI in these patients. Tumor management strategies that increase the ability to successfully use CIs should be strongly considered given the high risk of losing bilateral functional acoustic hearing in this population.
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Implantación Auditiva en el Tronco Encefálico , Implantes Auditivos de Tronco Encefálico , Implantación Coclear , Implantes Cocleares , Neurofibromatosis 2 , Neuroma Acústico , Percepción del Habla , Humanos , Neuroma Acústico/complicaciones , Neuroma Acústico/cirugía , Neuroma Acústico/patología , Implantes Cocleares/efectos adversos , Neurofibromatosis 2/complicaciones , Neurofibromatosis 2/cirugía , Neurofibromatosis 2/patología , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Background: Neurofibromatosis type 2 (NF2)-related schwannomatosis is an autosomal dominant tumor-predisposition syndrome characterized by bilateral vestibular schwannomas (VS). In patients with VS associated with NF2, vascular endothelial growth factor A inhibitor, bevacizumab, is a systemic treatment option. The aim of this study is to retrospectively evaluate NF2 patient responses to bevacizumab on VS growth and symptom progression. Methods: This is a retrospective analysis of patients seen at the Mayo Clinic Rochester Multidisciplinary NF2 Clinic. Results: Out of 76 patients with NF2 evaluated between 2020 and 2022, we identified 19 that received treatment with bevacizumab. Thirteen of these patients discontinued bevacizumab after median treatment duration of 12.2 months. The remaining 6 patients are currently receiving bevacizumab treatment for a median duration of 9.4 months as of March, 2023. Fifteen patients had evaluable brain MRI data, which demonstrated partial responses in 5 patients, stable disease in 8, and progression in 2. Within 6 months of bevacizumab discontinuation, 5 patients had rebound growth of their VS greater than 20% from their previous tumor volume, while 3 did not. Three patients with rebound growth went on to have surgery or irradiation for VS management. Conclusions: Our single-institution experience confirms prior studies that bevacizumab can control progression of VS and symptoms associated with VS growth. However, we note that there is the potential for rapid VS growth following bevacizumab discontinuation, for which we propose heightened surveillance imaging and symptom monitoring for at least 6 months upon stopping anti-VEGF therapy.
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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.
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Nervio Facial , Parálisis Facial , Humanos , Nervio Facial/cirugía , Reproducibilidad de los Resultados , Parálisis Facial/diagnóstico , Parálisis Facial/etiología , Cara , Cabeza , Complicaciones Posoperatorias/diagnósticoRESUMEN
OBJECTIVE: Compare cochlear implant (CI) performance between patients with ipsilateral sporadic vestibular schwannoma (VS) and NF2-related schwannomatosis (NF2). Compare CI performance according to VS management modality. STUDY DESIGN: Historical cohort. SETTING: Tertiary academic center. PATIENTS: Forty-nine patients (52 ears) undergoing cochlear implantation in the setting of ipsilateral sporadic (n = 21) or NF2-associated VS (n = 28). INTERVENTIONS: CI ipsilateral to VS. MAIN OUTCOME MEASURES: Auditory thresholds, consonant-nucleus-consonant (CNC) word scores, and AzBio sentences in quiet scores. RESULTS: Among all patients, median post-CI pure tone average was 28 dB HL (interquartile range [IQR], 21-38), CNC word score was 39% (IQR, 6-62), and AzBio sentences in quiet score was 60% (IQR, 11-83) at a median of 12.5 months postimplantation. Despite the NF2 cohort having larger tumors, when comparing patients with sporadic versus NF2-associated VS, there were no statistically significant differences in CNC word (49% [30-70] vs. 31% [0-52]) or AzBio sentences in quiet (66% [28-80] vs. 57% [5-83]) scores. Regardless of NF2 status, all patients managed with observation, and radiosurgery achieved open-set speech. In patients who underwent microsurgery, 6 (46%) of 13 with NF2 achieved open-set speech recognition compared with 4 (67%) of 6 with sporadic disease. CONCLUSION: Select patients with VS achieve successful hearing rehabilitation with a CI. In this cohort, tumor management strategy significantly influenced CI performance, whereas differences in NF2 status exhibited less effect. Specifically, all patients managed with observation or radiosurgery achieved open-set speech perception, whereas approximately half of people with NF2-related VS and two-thirds of people with sporadic VS achieved this outcome after tumor microsurgery. When disease permits, observation and radiosurgery should be considered in patients who may later pursue a CI.
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Implantación Coclear , Implantes Cocleares , Neurofibromatosis 2 , Neuroma Acústico , Percepción del Habla , Humanos , Neurofibromatosis 2/complicaciones , Neurofibromatosis 2/cirugía , Neuroma Acústico/complicaciones , Neuroma Acústico/cirugía , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
OBJECTIVE: The objective of this study is to assess the influence of age on facial nerve recovery after microsurgical resection of sporadic vestibular schwannoma. STUDY DESIGN: A historical cohort study was performed. SETTING: The study was performed at a tertiary referral center. PATIENTS: The studied cohort included patients with a House-Brackmann (HB) Grade III or worse in the immediate postoperative period. INTERVENTIONS: The studied intervention was microsurgical resection. MAIN OUTCOME MEASURES: The main outcome measure was complete recovery of facial nerve function to HB Grade I at least 12 months postoperatively. RESULTS: There were six patients with intracanalicular tumors and 100 with cerebellopontine angle (CPA) tumors eligible for study. Given the few patients with intracanalicular tumors, no further analysis was pursued in this subset. For patients with CPA tumors, a multivariable analysis of several patient and tumor characteristics demonstrated age at surgery (odds ratio for 10-year increase of 0.68; 95% confidence interval [CI], 0.47-0.98; p = 0.04) and immediate postoperative HB grade (odds ratio for one-grade increase of 0.27; 95% CI, 0.15-0.50; p < 0.001) to be jointly significantly associated with complete recovery to HB Grade I, indicating that the likelihood of complete facial nerve recovery was higher for younger patients and for those with better immediate postoperative HB grades. For example, the predicted probability of complete facial nerve recovery for a 30-year-old with immediate postoperative HB Grade III was 0.76 (or 76% when expressed as a percentage), whereas the predicted probability for a 50-year-old with immediate postoperative HB Grade V was only 0.10. CONCLUSIONS: After considering immediate postoperative HB grade, younger age at surgery was independently significantly associated with complete facial nerve recovery, which can assist in intraoperative decision-making regarding extent of resection and postoperative counseling.
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Traumatismos del Nervio Facial , Neuroma Acústico , Humanos , Adulto , Persona de Mediana Edad , Nervio Facial , Neuroma Acústico/cirugía , Estudios de Cohortes , Resultado del Tratamiento , Complicaciones Posoperatorias/epidemiología , Estudios RetrospectivosRESUMEN
OBJECTIVE: Preoperative differentiation of facial nerve schwannoma (FNS) from vestibular schwannoma (VS) can be challenging, and failure to differentiate between these two pathologies can result in potentially avoidable facial nerve injury. This study presents the combined experience of two high-volume centers in the management of intraoperatively diagnosed FNSs. The authors highlight clinical and imaging features that can distinguish FNS from VS and provide an algorithm to help manage intraoperatively diagnosed FNS. METHODS: Operative records of 1484 presumed sporadic VS resections between January 2012 and December 2021 were reviewed, and patients with intraoperatively diagnosed FNSs were identified. Clinical data and preoperative imaging were retrospectively reviewed for features suggestive of FNS, and factors associated with good postoperative facial nerve function (House-Brackmann [HB] grade ≤ 2) were identified. A preoperative imaging protocol for suspected VS and recommendations for surgical decision-making following an intraoperative FNS diagnosis were created. RESULTS: Nineteen patients (1.3%) with FNSs were identified. All patients had normal facial motor function preoperatively. In 12 patients (63%), preoperative imaging demonstrated no features suggestive of FNS, with the remainder showing subtle enhancement of the geniculate/labyrinthine facial segment, widening/erosion of the fallopian canal, or multiple tumor nodules in retrospect. Eleven (57.9%) of the 19 patients underwent a retrosigmoid craniotomy, and in the remaining patients, a translabyrinthine (n = 6) or transotic (n = 2) approach was used. Following FNS diagnosis, 6 (32%) of the tumors underwent gross-total resection (GTR) and cable nerve grafting, 6 (32%) underwent subtotal resection (STR) and bony decompression of the meatal facial nerve segment, and 7 (36%) underwent bony decompression only. All patients undergoing subtotal debulking or bony decompression exhibited normal postoperative facial function (HB grade I). At the last clinical follow-up, patients who underwent GTR with a facial nerve graft had HB grade III (3 of 6 patients) or IV facial function. Tumor recurrence/regrowth occurred in 3 patients (16%), all of whom had been treated with either bony decompression or STR. CONCLUSIONS: Intraoperative diagnosis of an FNS during a presumed VS resection is rare, but its incidence can be reduced further by maintaining a high index of suspicion and undertaking further imaging in patients with atypical clinical or imaging features. If an intraoperative diagnosis does occur, conservative surgical management with bony decompression of the facial nerve only is recommended, unless there is significant mass effect on surrounding structures.
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Neoplasias de los Nervios Craneales , Neurilemoma , Neuroma Acústico , Humanos , Estudios Retrospectivos , Recurrencia Local de Neoplasia/patología , Neurilemoma/diagnóstico por imagen , Neurilemoma/cirugía , Neuroma Acústico/diagnóstico por imagen , Neuroma Acústico/cirugía , Neoplasias de los Nervios Craneales/diagnóstico por imagen , Neoplasias de los Nervios Craneales/cirugía , Nervio Facial/diagnóstico por imagen , Nervio Facial/cirugía , Nervio Facial/patología , Resultado del Tratamiento , Estudios Multicéntricos como AsuntoRESUMEN
Intraoperative electrocochleography (ECOG) is performed using a single low-frequency acoustic stimulus (e.g., 500 Hz) to monitor cochlear microphonics (CM) during cochlear implant (CI) electrode insertion. A decrease in CM amplitude is commonly associated with cochlear trauma and is used to guide electrode placement. However, advancement of the recording electrode beyond the sites of CM generation can also lead to a decrease in CM amplitude and is sometimes interpreted as cochlear trauma, resulting in unnecessary electrode manipulation and increased risk of cochlear trauma during CI electrode placement. In the present study, multi-frequency ECOG was used to monitor CM during CI electrode placement. The intraoperative CM tracings were compared with electrode scan measurements, where CM was measured for each of the intracochlear electrodes. Comparison between the peak CM amplitude measured during electrode placement and electrode scan measurements was used to differentiate between different mechanisms for decrease in CM amplitude during CI electrode insertion. Analysis of the data shows that both multi-frequency electrocochleography and electrode scan could potentially be used to differentiate between different mechanisms for decreasing CM amplitude and providing appropriate feedback to the surgeon during CI electrode placement.
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OBJECTIVE: To characterize the effect of the COVID-19 pandemic on national cochlear implantation utilization by age using inclusive cochlear implantation data from two manufacturers between 2015 and 2020. STUDY DESIGN: Analysis of prospectively registered consecutive patient data from two major cochlear implant (CI) manufacturers in the United States. PATIENTS: Children or adults who received CIs. INTERVENTIONS: Cochlear implantation. MAIN OUTCOME MEASURES: Annual implantation utilization by age. RESULTS: A total of 46,804 patients received CIs from the two participating manufacturers between 2015 and 2020. The annual number of implant recipients increased significantly during the first 5 years of the study period for both children and adults, from a total of 6,203 in 2015 to 9,213 in 2019 (p < 0.001). During 2020, there was a 13.1% drop in national cochlear implantation utilization across all ages compared with 2019, including a drop of 2.2% for those ≤3 years old, 3.8% for those 4-17 years old, 10.1% for those 18-64 years old, 16.6% for those 65-79 years old, and 22.5% for those ≥80 years old. In a multivariable linear regression model, the percent drop in CIs differed significantly by age-group (p = 0.005). CONCLUSIONS: Especially in light of the prepandemic projected CI counts for 2020, the COVID-19 pandemic reduced national cochlear implantation utilization by over 15% among Medicare-aged patients and by almost 25% among those ≥80 years old, resulting in more than a 3-year setback in total annual CIs. Children were less affected, with those ≤3 years old experiencing minimal interruption during 2020.
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COVID-19 , Implantación Coclear , Implantes Cocleares , Anciano , Humanos , Estados Unidos/epidemiología , Adulto , Niño , Preescolar , Adolescente , Adulto Joven , Persona de Mediana Edad , Anciano de 80 o más Años , Pandemias , MedicareRESUMEN
OBJECTIVE: To evaluate the optimal dose and timing of administration of sodium fluorescein (SF) for selective fluorescence of sporadic vestibular schwannoma (VS) during microsurgery with the YELLOW 560-nm microscope filter (YE560) and to characterize the potential benefit of this fluorescence as determined by intraoperative surgeon assessment. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Adult patients undergoing VS microsurgery. INTERVENTIONS: Intraoperative intravenous administration of SF and visualization with the YE560. MAIN OUTCOME MEASURES: Time to differential fluorescence, duration of fluorescence, correlation of fluorescence of VS with electrostimulation and white light microscopy visual assessment, and likelihood of surgeons to use SF with the YE560 in future cases. RESULTS: Novel use of SF and YE560 during microsurgery achieved selective fluorescence of VS with capabilities to differentiate nerve fascicles and tumor approximately 30 minutes after administration. Nuances of SF administration and timing are discussed. Seventy-five percent of surgeons observed an excellent correlation of selective fluorescence with white light microscopy. Representative images and cases are presented. CONCLUSIONS: SF and YE560 may be used in VS microsurgery to visually differentiate VS from surrounding nerves. Potential benefits include enhanced visualization of the tumor-nerve interface for tumor dissection and detection of any residual disease, such as in the fundus after hearing preservation microsurgery.
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Neuroma Acústico , Adulto , Humanos , Neuroma Acústico/patología , Fluoresceína , Estudios Prospectivos , Estudios de Factibilidad , Microcirugia/métodos , Resultado del TratamientoAsunto(s)
Neoplasias de los Nervios Craneales , Neoplasias Meníngeas , Meningioma , Neoplasias de los Nervios Craneales/cirugía , Nervio Facial/cirugía , Humanos , Neoplasias Meníngeas/diagnóstico por imagen , Neoplasias Meníngeas/cirugía , Meningioma/diagnóstico por imagen , Meningioma/cirugía , Hueso Petroso/cirugíaRESUMEN
OBJECTIVE: To determine the relationship between intraoperative electrocochleography (ECochG) measurements and residual hearing preservation after cochlear implant (CI) surgery by comparing differences between preoperative and immediate postoperative bone conduction thresholds. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary academic referral center. PATIENTS: Sixteen patients with preoperative residual hearing and measurable (no-vibrotactile) bone conduction thresholds at 250 and/or 500 Hz who underwent cochlear implantation. MAIN OUTCOME MEASURE: Intraoperative ECochG and air and bone conduction thresholds. RESULTS: Nine patients showed no significant drop (<30%) in ECochG amplitude during CI surgery with an average preoperative and immediate postoperative BC threshold of 46 and 39 dB HL, respectively, at 500 Hz. Seven patients with a decrease in ECochG amplitude of 30% or greater showed an average preoperative 500 Hz BC threshold of 32 dB HL and immediate postoperative threshold of 55 dB HL. Air and bone conduction thresholds measured approximately 1 month after CI surgery show delayed-onset of hearing loss across our study patients. CONCLUSIONS: A small decrease (<30%) in difference response or cochlear microphonics amplitude correlates with no significant changes in immediate postoperative residual hearing, whereas patients who show larger changes (≥30%) in difference response or cochlear microphonics amplitude during intraoperative ECochG measurements show significant deterioration in BC thresholds. This study reveals the necessity of prompt postoperative bone conduction measurement to isolate the intraoperative cochlear trauma that may be detected during intraoperative ECochG measurements. Although delayed postoperative audiometrics represent longer-term functional hearing, it includes the sum of all postoperative changes during the recovery period, including subacute changes after implantation that may occur days or weeks later. Measuring air and bone conduction thresholds immediately postoperatively will better isolate factors influencing intraoperative, early postoperative, and delayed postoperative hearing loss. This will ultimately help refine surgical technique, device design, and highlight the use of intraoperative ECochG in monitoring cochlear trauma during CI surgery.
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Implantación Coclear , Implantes Cocleares , Sordera , Pérdida Auditiva , Audiometría de Respuesta Evocada/métodos , Umbral Auditivo , Conducción Ósea , Implantación Coclear/métodos , Sordera/cirugía , Progresión de la Enfermedad , Pérdida Auditiva/etiología , Pérdida Auditiva/cirugía , Humanos , Estudios ProspectivosRESUMEN
OBJECTIVE: To introduce and discuss implementation strategy for the Complete Cochlear Implant Care (CCIC) model, a highly-coordinated cochlear implant (CI) care delivery model requiring a single on-site visit for preoperative workup, surgery, and postoperative programming. STUDY DESIGN: Prospective, nonrandomized, two-arm clinical trial. SETTING: Tertiary referral CI center. PATIENTS: Adults who meet audiologic criteria for cochlear implantation. INTERVENTIONS: Cochlear implantation, coordinated care delivery, including remote programming. MAIN OUTCOME MEASURES: Care delivery model feasibility and process implementation. RESULTS: Patients determined to be likely CI candidates based on routine audiometry are eligible for enrollment. The CCIC model uses telemedicine and electronic educational materials to prepare patients for same-day on-site consultation with CI surgery, same or next-day activation, and postoperative remote programming for 12 months. Implementation challenges include overcoming inertia related to the implementation of a new clinical workflow, whereas scalability of the CCIC model is limited by current hardware requirements for remote programming technology. A dedicated CCIC process coordinator is critical for overcoming obstacles in implementation and process improvement through feedback and iterative changes. Team and patient-facing materials are included and should be tailored to fit each unique CI program looking to implement CCIC. CONCLUSION: The CCIC model has the potential to dramatically streamline hearing healthcare delivery. Implementation requires an adaptive approach, as obstacles may vary according to institutional infrastructure and policies.
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Implantación Coclear , Implantes Cocleares , Telemedicina , Adulto , Audición , Humanos , Estudios ProspectivosRESUMEN
OBJECTIVE: Develop a predictive model for incomplete microsurgical resection of sporadic vestibular schwannoma (VS). STUDY DESIGN: Historical cohort. SETTING: Tertiary referral center. PATIENTS: Patients with sporadic VS. INTERVENTIONS: Microsurgery with preoperative intent of gross total resection. MAIN OUTCOME MEASURES: Patient and tumor characteristics that influence extent of resection. RESULTS: Among 603 patients, 101 (17%) had intracanalicular tumors and 502 (83%) had tumors with cerebellopontine angle (CPA) extension. For patients with CPA tumors, 331 (66%) underwent gross total resection and 171 (34%) underwent near-total or subtotal resection (NTR-STR). Multivariable modeling identified older age at surgery, larger linear tumor size, and absence of a fundal fluid cap as predictive of NTR-STR ( p < 0.001). From this model, one can estimate that a 20-year-old with a tumor that has less than 10 mm of CPA extension and a present fundal fluid cap has a predicted probability of NTR-STR of 0.01 (or 1%), whereas a 70-year-old with a tumor that has 30 mm or greater CPA extension and absence of a fundal fluid cap has a predicted probability of NTR-STR of 0.91 (or 91%). Among the 171 patients who underwent NTR-STR, 24 required secondary treatment at the time of last follow-up. CONCLUSION: The primary predictors of incomplete microsurgical resection of VS include older age at surgery, larger linear tumor size, and absence of a fundal fluid cap. These factors can be used to estimate the likelihood of NTR-STR, aiding in preoperative discussions regarding future surveillance and potential need of secondary treatment, as well as shared clinical decision making.