The Cochlear Implant "Seatbelt" Technique for Receiver/Stimulator Fixation.

Receiver/stimulator migration and extrusion are among the most commonly reported complications of cochlear implantation. Current techniques implement either a tight subperiosteal pocket or postauricular bone well. Here we describe a safe and effective technique to secure a cochlear implant receiver/stimulator with a Mersilene cervical cerclage tape "seatbelt." Laryngoscope, 134:3374-3376, 2024.

Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection.

OBJECTIVE: Characterize the incidence, risk factors, and patient outcomes of dural venous sinus thrombosis identified on postoperative imaging after retrosigmoid or translabyrinthine craniotomy for vestibular schwannoma resection. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary academic referral center. PATIENTS: Eighty-one patients 19 to 82 years of age with vestibular schwannomas, 58% female. INTERVENTIONS: Retrosigmoid or translabyrinthine craniotomy with postoperative magnetic resonance imaging/magnetic resonance venography. MAIN OUTCOME MEASURES: Association between operative approach, age, sex, body mass index, tumor size, dominant sinus, operative time, laterality, and perioperative cerebrospinal fluid (CSF) leaks with rate of thrombosis. RESULTS: Translabyrinthine craniotomy was associated with the highest relative risk of thrombosis (odds ratios [OR] = 19.82, 95% confidence interval [CI] = 1.75-224, p = 0.007), followed by male sex (OR = 5.53, 95% CI = 1.63-18.8, p = 0.035). Other patient and demographic risk factors were not associated with increased rates of dural venous thrombosis, nor was there an association with postoperative CSF leak. 81% (25/31) of thrombi had resolved within 3 years of surgery. CONCLUSIONS: Translabyrinthine approach and male sex most strongly predicted postoperative dural venous thrombosis after postauricular craniotomy for vestibular schwannoma resection. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Better understanding of risk factors and management of dural venous thrombosis after vestibular schwannoma surgery. LEARNING OBJECTIVE: Characterize clinically significant risk factors for dural venous thrombosis in vestibular schwannoma surgery. DESIRED RESULT: Identification of patient and operative risk factors for dural venous thrombosis. LEVEL OF EVIDENCE: III. INDICATE IRB OR IACUC: Exempt.

Systematic Review and Meta-analysis for Surgery Versus Stereotactic Radiosurgery for Jugular Paragangliomas.

OBJECTIVE: Comprehensively analyze tumor control and treatment complications for jugular paraganglioma patients undergoing surgery versus stereotactic radiosurgery (SRS). DATABASES REVIEWED: EMBASE, Medline, and Scopus. METHODS: The databases were searched for English and Spanish articles from January 1, 1995, to January, 1, 2019, for studies reporting tumor control and treatment side effects regarding patients with jugular paraganglioma treated with surgery or SRS. Main outcome measures included short-term and long-term tumor recurrence, as well as postintervention complications. RESULTS: We identified 10,952 original abstracts, 705 eligible studies, and 107 studies for final data extraction. There were 3,498 patients-2,215 surgical patients and 1,283 SRS patients. Bayesian meta-analysis was applied to the extracted data, with tau measurements for study heterogeneity. SRS tumors were larger (3.9 cm 3 versus 8.1 cm 3 ). Meta-analysis results demonstrated low rates of long-term recurrence for both modalities (surgery, 15%; SRS, 7%), with SRS demonstrating lower rates of postintervention cerebrospinal fluid leak, dysphagia, and cranial nerve Vll, lX, X, Xl, or Xll palsies. CONCLUSIONS: This study demonstrates excellent control of jugular paragangiomas with both surgery and SRS, with higher rates of lower cranial neuropathies, dysphagia, and cerebrospinal fluid leaks among surgical patients.

Vein Graft Tympanoplasty: How a Transiently Used Graft Material Transformed Middle Ear Surgery.

The inception of medial grafting as a technique for tympanic membrane repair was a critical milestone in the history of otology. John Shea introduced the medial graft technique and the use of vein grafts for tympanoplasty in 1960 after realizing that the vein grafts that he used to repair the oval window after stapedectomy could also be utilized to repair tympanic membrane perforations. At the time, tympanoplasty often utilized skin grafts, which required placement of the graft lateral to the tympanic membrane annulus. Placement of the graft medial to the tympanic membrane annulus allowed for more efficient surgery and avoided the complications associated with lateral grafting, such as blunting and lateralization. The introduction of vein grafts in tympanoplasty prompted a fundamental shift in technique from lateral to medial grafting, paving the way for decades of innovation in tympanoplasty.

Inflammatory Pseudotumor of the Temporal Bone Leading to Atypical Superior Semicircular Canal Dehiscence Syndrome: A Novel Case Report.

OBJECTIVE: Inflammatory pseudotumor of the temporal bone is a benign idiopathic inflammatory process that is rarely encountered in clinical practice. We describe a novel case of a patient who developed superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone. PATIENT: One female patient found to have inflammatory pseudotumor of the temporal bone. After treatment with mastoidectomy and steroids, she subsequently developed superior semicircular canal dehiscence syndrome. INTERVENTIONS: The patient initially underwent myringotomy and pressure equalization tube placement for a unilateral effusion. Imaging with computed tomography and magnetic resonance imaging revealed a lytic mastoid mass. A complete mastoidectomy was diagnostic for inflammatory pseudotumor and the patient was treated with adjuvant long-term corticosteroids. After this procedure, she was discovered to have new development of symptomatic superior semicircular canal dehiscence syndrome. She eventually underwent a trans-mastoid repair of her superior semicircular canal dehiscence. MAIN OUTCOME MEASURES: The patient's clinical course is described with emphasis on the development of superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone. RESULTS: The patient's radiographic and clinical history were found to be consistent with inflammatory pseudotumor of the temporal bone. She underwent a therapeutic mastoidectomy with long-term post-operative corticosteroids. During her post-operative course, she developed symptoms of vertigo, hearing loss, and autophony. She was subsequently diagnosed with superior semicircular canal dehiscence and treated with a trans-mastoid repair of the dehiscence. Her symptoms satisfactorily resolved after this surgery. CONCLUSIONS: Inflammatory pseudotumor of the temporal bone is a rare benign inflammatory process. We present what is to our knowledge the first description of superior semicircular canal dehiscence syndrome developing in the setting of inflammatory pseudotumor.

The Influence of Cerebral Small Vessel Disease on Static and Dynamic Functional Network Connectivity in Subjects Along Alzheimer's Disease Continuum.

Background: Alzheimer's disease (AD) is a chronic neurodegenerative disorder frequently accompanied by cerebral small vessel disease (CSVD). However, the influence of CSVD on the brain functional connectivity in subjects along the AD continuum is still largely unknown. The current study combined the static and dynamic functional network connectivity (FNC) to explore the underlying mechanism. Materials and Methods: In this study, we included 182 healthy controls, 27 individuals with subjective cognitive decline (SCD), 27 with SCD+CSVD, 104 with mild cognitive impairment (MCI), 123 with MCI+CSVD, 16 with AD, and 62 with AD+CSVD. We examined the static and dynamic FNC within the default mode, salience, and cognitive control domains. We also assessed the association between atypical FNC patterns and cognitive impairments, as well as the pathologies. Results: Static FNC results showed progressively increased within-domain connectivity and decreased between-domain connectivity along the AD continuum, especially in CSVD subjects. Dynamic FNC in CSVD subjects showed more occurrences in a highly modularized state and fewer occurrences in the diffusely connected state. Further analysis showed that neuropathology and CSVD burden divergently affect the FNC changes. Conclusions: The overall results demonstrate divergent abnormalities of FNC in CSVD and non-CSVD individuals along the AD continuum, which were divergently affected by neuropathology and CSVD burden. Specifically, those with CSVD show more static and dynamic FNC impairments, associated with cognitive decline. These findings may advance our understanding of the effect of CSVD on AD onset and progression, and provide potential hints for clinical treatment.

Development of a Surgical Video Atlas for Resident Education: 3-Year Experience.

OBJECTIVE: To create a high-quality annotated online surgical video atlas of key indicator otolaryngology cases and assess its use and overall journal trends over time. METHODS: Videos are recorded from multiple viewpoints within the operating room and compiled into a single stream. Postediting includes chaptering videos and overlaying relevant text annotations. Videos are published online and viewership trends analyzed. RESULTS: Over 3 years, 29 otolaryngology videos were published out of 161 journal publications (18%). Eight of the 14 key indicator procedures are included (57%). From the beginning of 2017 to the end of 2019, viewership of otolaryngology pages increased from 548 to 11,139 views per month, totaling >150,000 views. These now represent 10% of the total journal monthly views and 10% of the overall views. Users originate from the United States and from >10 other countries. DISCUSSION: Residents and faculty face challenges of providing the highest standard of clinical care, teaching, and learning in and out of the operating room. Inherent difficulties of surgical training, high-fidelity surgical simulation, and imposed work hour restrictions necessitate additional, more efficient and effective means of teaching and learning. Surgical videos demonstrating key anatomy, procedural steps, and surgical dexterity with hand positioning are increasing in their popularity among learners. IMPLICATIONS FOR PRACTICE: Surgical video atlases provide a unique adjunct for resident education. They are enduring and easily accessible. In a climate of work hour restrictions or elective case reduction, they may supplement how residents learn to operate outside the operating theater.

Patterns of Clinostomum marginatum infection in fishes and amphibians: integration of field, genetic, and experimental approaches.

Digenetic trematodes of the genus Clinostomum are cosmopolitan parasites infecting fishes, amphibians, reptiles, and snails as intermediate hosts. Despite the broad geographical distribution of this genus, debate about the number of species and how they vary in host use has persisted. To better understand patterns of infection among host species and across life stages, we used large-scale field surveys and molecular tools to examine five species of amphibians and seven species of fishes from 125 California ponds. Among the 12,360 examined hosts, infection was rare, with an overall prevalence of 1.7% in amphibians and 9.2% in fishes. Molecular evidence indicated that both groups were infected with Clinostomum marginatum. Using generalized linear mixed effects models, host species identity and host life stage had a strong influence on infection status, such that Lepomis cyanellus (green sunfish) (49.3%) and Taricha granulosa (rough skinned newt) (9.2%) supported the highest overall prevalence values, whereas adult amphibians tended to have a higher prevalence of infection relative to juveniles (13.3% and 2.5%, respectively). Experimentally, we tested the susceptibility of two amphibian hosts (Pseudacris regilla [Pacific chorus frog] and Anaxyrus boreas [western toad]) to varying levels of cercariae exposure and measured metacercariae growth over time. Pseudacris regilla was 1.3× more susceptible to infection, while infection success increased with cercariae exposure dose for both species. On average, metacarcariae size increased by 650% over 20 days. Our study highlights the importance of integrating field surveys, genetic tools, and experimental approaches to better understand the ecology of host-parasite interactions.

Maternal and neonatal demographics of macrosomic infants admitted to the neonatal intensive care unit.

OBJECTIVE: The objective of this study is to determine the incidence, significance, associated demographics and impact of macrosomic infants (⩾4 kg) admitted to the Neonatal Intensive Care Unit (NICU) on NICU census and resources. STUDY DESIGN: A retrospective cohort review was performed from 2010 to 2015. Descriptive statistical analyses were used. RESULTS: Of 19 308 deliveries, 1823 were infants ⩾4000 g and 213 were admitted to the NICU. Cesarean delivery occurred in 70% of the admitted infants, most (74.1%) were Grade 1 macrosomia and male (63%). Preterm birth occurred in 4%. The incidence of maternal diabetes was 25%. Primary admitting diagnoses were respiratory distress, suspected sepsis, hypoglycemia and perinatal depression. The average length of stay was 8±6 days for all macrosomic infants admitted, increased to 22±13 days for infants with Grade 3 macrosomia. CONCLUSION: Macrosomic infants are a growing population, who increase the demand on existing NICU resources. A larger multi-centered study is needed to determine the overall relevance of these findings in other populations.

Treatment of primary aldosteronism is associated with a reduction in the severity of obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is known to commonly co-exist with primary aldosteronism (PA), but it is unknown if treatment of PA improves sleep apnoea parameters in these patients. We therefore aimed to determine whether specific medical or surgical treatment of PA improves OSA, as measured by the apnoea-hypopnoea index (AHI). We recruited patients undergoing diagnostic workup for PA if they had symptoms suggestive of OSA. Patients with confirmed PA underwent polysomnography (PSG) at baseline and again at least 3 months after specific treatment for PA. Of 34 patients with PA, 7 (21%) had no evidence of OSA (AHI <5), 9 (26%) had mild (AHI ⩾5 and <15), 8 (24%) moderate (AHI ⩾15 and <30) and 10 (29%) severe OSA (AHI ⩾30). Body mass index tertile, neck circumference and 24 h urinary sodium correlated with the AHI. Twenty patients had repeat PSG performed after treatment for PA (mineralocorticoid receptor antagonists in 13 with bilateral PA and adrenalectomy in 7 with unilateral PA). In this group the median (s.d.) AHI reduced from 22.5 (14.7) to 12.3 (12.1) (P=0.02). Neck circumference reduced with PA treatment (41.6 vs 41.2 cm, P=0.012). OSA is common in patients with primary aldosteronism and may improve with specific therapy for this disease. Aldosterone and sodium-mediated fluid retention in the upper airways and neck region may be a potential mechanism for this relationship.

Rare Lesions of the Internal Auditory Canal.

BACKGROUND: Approximately 95% of tumors occurring within the internal auditory canal (IAC) are vestibular schwannomas. Many undergo stereotactic radiation without definitive tissue diagnosis. Rare IAC tumors are not all radiosensitive and are poorly described. METHODS: Between 1992 and 2015, 289 consecutive patients with IAC lesions operated on were reviewed retrospectively. RESULTS: Fifteen patients (5.2%) (16 operations) had unusual histologic findings, including nonvestibular schwannomas (2 facial schwannomas, 2 cochlear schwannomas, 2 intermedius schwannomas), 3 meningiomas, 3 cavernous hemangiomas, a mucosa-associated lymphoid tissue lymphoma, an arachnoid cyst, and a lipochoristoma. None of these rare tumors could be identified before surgery. Three operative approaches were used: the retrosigmoid approach, middle fossa subtemporal approach, or translabyrinthine approach. Few complications occurred, including facial nerve palsy, loss of hearing, and vestibular function. Five-year average follow-up revealed one patient with recurrence. CONCLUSIONS: Clinical examination and imaging alone were insufficient to correctly identify these tumors. Definitive pathologicdiagnosis should be strongly considered to help tailor treatment.

Potential interactions among disease, pesticides, water quality and adjacent land cover in amphibian habitats in the United States.

To investigate interactions among disease, pesticides, water quality, and adjacent land cover, we collected samples of water, sediment, and frog tissue from 21 sites in 7 States in the United States (US) representing a variety of amphibian habitats. All samples were analyzed for >90 pesticides and pesticide degradates, and water and frogs were screened for the amphibian chytrid fungus Batrachochytrium dendrobatidis (Bd) using molecular methods. Pesticides and pesticide degradates were detected frequently in frog breeding habitats (water and sediment) as well as in frog tissue. Fungicides occurred more frequently in water, sediment, and tissue than was expected based upon their limited use relative to herbicides or insecticides. Pesticide occurrence in water or sediment was not a strong predictor of occurrence in tissue, but pesticide concentrations in tissue were correlated positively to agricultural and urban land, and negatively to forested land in 2-km buffers around the sites. Bd was detected in water at 45% of sites, and on 34% of swabbed frogs. Bd detections in water were not associated with differences in land use around sites, but sites with detections had colder water. Frogs that tested positive for Bd were associated with sites that had higher total fungicide concentrations in water and sediment, but lower insecticide concentrations in sediments relative to frogs that were Bd negative. Bd concentrations on frog swabs were positively correlated to dissolved organic carbon, and total nitrogen and phosphorus, and negatively correlated to pH and water temperature. Data were collected from a range of locations and amphibian habitats and represent some of the first field-collected information aimed at understanding the interactions between pesticides, land use, and amphibian disease. These interactions are of particular interest to conservation efforts as many amphibians live in altered habitats and may depend on wetlands embedded in these landscapes to survive.

Cost analysis and outcomes of a second-look tympanoplasty-mastoidectomy strategy for cholesteatoma.

OBJECTIVES/HYPOTHESIS: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. STUDY DESIGN: Retrospective review and cost analysis. METHODS: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. RESULTS: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall-up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage (P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P = 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). CONCLUSION: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has historically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2574-2579, 2016.

Surgical management of vestibular schwannomas after failed radiation treatment.

Increasing numbers of patients with vestibular schwannoma (VS) have been treated with focused-beam stereotactic radiation treatment (SRT) including Gamma knife, CyberKnife, X-knife, Novalis, or proton beam therapy. The purpose of this study was to document the incidence of tumor regrowth or symptoms that worsened or first developed following SRT and to discuss surgical strategies for patients who have failed SRT for VS. A consecutive series of 39 patients with SRT failed VS were surgically treated. Clinical symptoms, tumor regrowth at follow-up, intraoperative findings, and surgical outcome were evaluated. There were 15 males and 24 females with a mean age of 51.8 years. Thirty-six patients (92.3%) demonstrated steady tumor growth after SRT. Two (5.1%) patients with slight increase of the mass underwent surgical resection because of development of unbearable facial pain. Symptoms that worsened or newly developed following SRT in this series were deafness (41%), dizziness (35.9%), facial numbness (25.6%), tinnitus (20.5%), facial nerve palsy (7.7%), and facial pain (7.7%). Intraoperative findings demonstrated fibrous changes of the tumor mass, cyst formation, and brownish-yellow or purple discoloration of the tumor capsule. Severe adhesions between the tumor capsule and cranial nerves, vessels, and the brainstem were observed in 69.2%. Additionally, the facial nerve was more fragile and irritable in all cases. Gross total resection (GTR) was achieved in 33.3% of patients, near-total resection (NTR) in 35.9%, and subtotal resection (STR) in 30.8% of patients. New facial nerve palsy was seen in seven patients (19.4%) postoperatively. Our findings suggest that patients with VS who fail SRT with either tumor progression or worsening of clinical symptoms will have an increased rate of adhesions to the neurovascular structures and may have radiation-influenced neuromalacia. Salvage surgery of radiation-failed tumors is more difficult and will have a higher risk of postoperative complications. Radical total resection may not be feasible, and conservative modality of subtotal resection needs to be considered to avoid new neurologic deficits.

Preoperative Lumbar Drain Use During Acoustic Neuroma Surgery and Effect on CSF Leak Incidence.

OBJECTIVE: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. METHODS: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014. RESULTS: Two hundred and eighty-two patients had a mean tumor size of 19.1 mm ± 10.2 mm. Twenty-nine (10.3%) patients developed a postoperative CSF leak. Two hundred and twenty patients (78.0%) received a preoperative LD, and 20 (9.1%) developed a CSF leak. Sixty-two (22.0%) patients did not receive a preoperative LD, and 9 (14.5%) developed a CSF leak. No significant difference in CSF leak frequency was observed with use versus no use of a LD (P = .23). Fifteen (5.3%) patients with an LD placed had a complication related to the LD. No significant difference in CSF leak frequency was observed with patient age, neurofibromatosis type-2 diagnosis, tumor size, or sidedness. CONCLUSIONS: Postoperative CSF leaks are among the most common complications of acoustic neuroma microsurgery. No formal guidelines exist for elective placement of a preoperative LD to lower the incidence of CSF leaks. Our reported CSF leak incidence with preoperative LD placement is not significantly lower than without LD use, and there is a complication rate associated with LD use.

Effects of 6-month supplementation with ß-hydroxy-ß-methylbutyrate, glutamine and arginine on vascular endothelial function of older adults.

BACKGROUND/OBJECTIVES: Vascular endothelial function declines with advancing age, due in part to increased oxidative stress and inflammation, and this age-related vascular dysfunction has been identified as an independent risk factor for cardiovascular diseases. This double-blind, placebo-controlled trial investigated the effects of a dietary supplement containing ß-hydroxy-ß-methylbutyrate (HMB), glutamine and arginine on endothelial-dependent vasodilation of older adults. SUBJECTS/METHODS: A total of 31 community-dwelling men and women aged 65-87 years were randomly assigned to two groups. The treatment group received two doses of the supplement daily (totaling 3 g HMB, 14 g glutamine and 14 g arginine) for 6 months, whereas the control group received an isocaloric placebo. At baseline and week 24, vascular endothelial function was measured by flow-mediated dilation of the brachial artery, and fasting blood samples were obtained to measure high-sensitivity C-reactive protein (hsCRP) and tumor necrosis factor-α (TNF-α). RESULTS: Paired sample t-tests revealed a 27% increase in flow-mediated dilation among the treatment group (P=0.003), whereas no change was observed in the placebo group (P=0.651). Repeated-measures analysis of variance verified a significant time by group interaction (P=0.038). Although no significant changes were observed for hsCRP or TNF-α, a trend was observed for increasing hsCRP among the placebo group only (P=0.059). CONCLUSIONS: These results suggest that dietary supplementation of HMB, glutamine and arginine may favorably affect vascular endothelial function in older adults. Additional studies are needed to elucidate whether reduced inflammation or other mechanisms may underlie the benefits of supplementation.