Improved Postoperative Speech Recognition and Processor Use With Early Cochlear Implant Activation.

OBJECTIVE: To report speech recognition outcomes and processor use based on timing of cochlear implant (CI) activation. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: A total of 604 adult CI recipients from October 2011 to March 2022, stratified by timing of CI activation (group 1: ≤10 d, n = 47; group 2: >10 d, n = 557). MAIN OUTCOME MEASURES: Average daily processor use; Consonant-Nucleus-Consonant (CNC) and Arizona Biomedical (AzBio) in quiet at 1-, 3-, 6-, and 12-month visits; time to peak performance. RESULTS: The groups did not differ in sex ( p = 0.887), age at CI ( p = 0.109), preoperative CNC ( p = 0.070), or preoperative AzBio in quiet ( p = 0.113). Group 1 had higher median daily processor use than group 2 at the 1-month visit (12.3 versus 10.7 h/d, p = 0.017), with no significant differences at 3, 6, and 12 months. The early activation group had superior median CNC performance at 3 months (56% versus 46%, p = 0.007) and 12 months (60% versus 52%, p = 0.044). Similarly, the early activation group had superior median AzBio in quiet performance at 3 months (72% versus 59%, p = 0.008) and 12 months (75% versus 68%, p = 0.049). Both groups were equivalent in time to peak performance for CNC and AzBio. Earlier CI activation was significantly correlated with higher average daily processor use at all follow-up intervals. CONCLUSION: CI activation within 10 days of surgery is associated with increased early device usage and superior speech recognition at both early and late follow-up visits. Timing of activation and device usage are modifiable factors that can help optimize postoperative outcomes in the CI population.

Presbycusis and Hearing Preservation in Observed Vestibular Schwannomas.

OBJECTIVE: We reviewed a cohort of patients with untreated sporadic vestibular schwannoma (VS) and examined the relationship between high-frequency hearing loss (HFHL) in the non-VS ear and long-term hearing outcomes in the VS-affected ear. We hypothesized that the progression of HFHL is associated with accelerated hearing decline in sporadic VS. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary center. PATIENTS: We studied 102 patients with sporadic VS diagnosed from 1999 to 2015 with ≥5 years of observation (median, 6.92; interquartile range, 5.85-9.29). Sixty-six patients had AAO-HNS class A/B hearing at presentation and were included in analysis. INTERVENTIONS: Audiometry, serial magnetic resonance imaging for observation of VS. MAIN OUTCOME MEASURES: Four-frequency pure tone average (PTA) and word recognition scores (WRS) in the VS-affected ear. Decline in high-frequency PTA (average of thresholds at 4000, 6000, and 8,000 Hz) was defined as ≥10 dB during the study period. Decline in WRS was defined as ≥10%. RESULTS: Compared with those without, patients with progressive HFHL in the non-VS ear were more likely to experience a decline in WRS in the VS ear (80% vs. 54%, p = 0.031). However, the same group showed no difference (52% vs. 41%, p = 0.40) in decline in PTA of the VS ear. CONCLUSIONS: Patients with observed VS who experience progressive HFHL in the non-VS ear are more likely to experience significant declines in speech understanding in the VS-affected ear over time. Patients with a history of presbycusis may have an increased risk of losing serviceable hearing because of sporadic VS.

Electrode array positioning after cochlear reimplantation from single manufacturer.

OBJECTIVE: To investigate whether revision surgery with the same device results in a change in three key indicators of electrode positioning: scalar location, mean modiolar distance (M¯), and angular insertion depth (AID). METHODS: Retrospective analysis of a cochlear implant database at a university-based tertiary medical center. Intra-operative CT scans were obtained after initial and revision implantation. Electrode array (EA) position was calculated using auto-segmentation techniques. Initial and revision scalar location, M¯, and AID were compared. RESULTS: Mean change in M¯ for all ears was -0.07 mm (SD 0.24 mm; P = 0.16). The mean change in AID for all ears was -5° (SD 67°; P = 0.72). Three initial implantations with pre-curved EAs resulted in a translocation from Scala Tympani (ST) to Scala Vestibuli (SV). Two remained translocated after revision, while one was corrected when revised with a straight EA. An additional five translocations occurred after revision. CONCLUSIONS: In this study examining revision cochlear implantation from a single manufacturer, we demonstrated no significant change in key indicators of EA positioning, even when revising with a different style of electrode. However, the revision EA is not necessarily confined by the initial trajectory and there may be an increased risk of translocation.

Radiographic Sigmoid Sinus Wall Abnormalities and Pulsatile Tinnitus: A Case-Control Study.

OBJECTIVE: Compare incidence of sigmoid sinus wall abnormalities (SSWAs) and other radiographic abnormalities in patients with pulsatile tinnitus (PT) versus controls. STUDY DESIGN: Retrospective case-control. SETTING: Tertiary referral center. PATIENTS: Adults with PT and high-resolution computed tomography imaging were compared with adults undergoing cochlear implant workup including high-resolution computed tomography imaging. MAIN OUTCOME MEASURES: Incidence of SSWA in PT cohort (n = 141) compared with control (n = 149, n = 298 ears). Secondary outcome measures included differences in demographics and in other radiographic abnormalities between cohorts. RESULTS: Patients with PT had a higher incidence of SSWA (34% versus 9%, p < 0.001) and superior canal dehiscence (23% versus 12%, p = 0.017) than controls. Spearman product component correlations demonstrated that ipsilateral PT was weakly associated with SSWA ( r = 0.354, p < 0.001). When SSWA was present in the PT cohort (n = 48 patients, n = 59 ears), in 31 cases (64.6%), the SSWA correlated with PT laterality (e.g., left SSWA, left PT); in 12 (25.0%), SSWA partially correlated with PT laterality (e.g., bilateral SSWA, right PT); and in 5 (10.4%), the SSWA did not correlate with PT laterality (e.g., right SSWA, left PT). CONCLUSIONS: For our patients with both PT and SSWA, the SSWA is likely a contributing factor in approximately 65% of cases. For a third of patients with PT and concomitant SSWA, the association between the two is either not causative or not solely causative. Surgeons counseling patients with PT and SSWA may be optimistic overall regarding sigmoid resurfacing procedures but must appreciate the possibility of treatment failure, likely because of untreated comorbid conditions.

Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management.

TITLE: Facial Paralysis in Skull Base Osteomyelitis - Comparison of Surgical and Nonsurgical Management. OBJECTIVE: To compare outcomes of surgical and nonsurgical management in cases of facial paresis secondary to skull base osteomyelitis. METHODS: A 14 patients presenting with skull base osteomyelitis complicated by facial nerve paresis at a single tertiary referral center from 2009 to 2019 were retrospectively reviewed. Patients were treated with medical therapy with or without surgical intervention, consisting of mastoidectomy and debridement with or without facial nerve decompression. House-Brackmann (HB) Grade was the main outcome measure. RESULTS: A 14 patients (average age 68 years, range 58-82 years, 71% male) were analyzed, with 5 undergoing facial nerve decompression (36%), 5 undergoing mastoidectomy without facial nerve decompression (36%), and 4 undergoing medical management alone (28%). Of the 4 patients who underwent medical therapy alone, none experienced significant improvement in facial function. Of the 5 patients who underwent facial nerve decompression, 3 patients experienced improved facial function. Of the 5 patients who underwent mastoidectomy without decompression, 4 experienced improved facial function. There was no clear link between the severity of infection and the severity of facial paresis. When comparing HB score changes before and after treatment across groups, there was no statistically significant difference seen (p = 0.47). CONCLUSIONS: Mastoidectomy and debridement with or without facial nerve decompression may improve facial nerve outcomes when compared to isolated medical management, although differences were not of statistical significance. The best facial nerve recoveries occurred in patients undergoing surgery within 14 days of the onset of paralysis. LEVEL OF EVIDENCE: 4 - Case Series Laryngoscope, 133:179-183, 2023.

Association of Postoperative Sigmoid Sinus Occlusion and Cerebrospinal Fluid Leak in Translabyrinthine Surgery.

OBJECTIVE: To characterize the incidence of sigmoid sinus occlusion (SSO) following translabyrinthine (TL) surgery for posterior fossa tumor resection and determine the association with cerebrospinal fluid (CSF) leak. STUDY DESIGN: Retrospective case series. SETTING: Tertiary referral center. METHODS: Patients undergoing TL surgery for vestibular schwannoma from 2012 to 2020 were included. Demographic data, medical history, preoperative tumor length and volume, and postoperative complications including CSF leak were recorded. Neuroradiology review of postoperative magnetic resonance imaging was used to determine the presence or absence of flow through the sigmoid sinus. RESULTS: Of 205 patients undergoing TL, 21 (10.2%) experienced CSF leak postoperatively. Overall 56 (27%) demonstrated SSO on immediate postoperative magnetic resonance imaging. CSF leaks were more likely in those with SSO (19.6%) than those without SSO (6.7%; odds ratio, 3.54 [95% CI, 1.25-10.17]). Tumor volume and body mass index were not significantly associated with CSF leak. In total, 105 (51%) patients had some degree of sigmoid sinus thrombosis, but nonocclusive thrombosis was not associated with CSF leak. CONCLUSION: SSO after TL approaches is common and appears to be significantly associated with postoperative CSF leak development. Minimizing manipulation of the sigmoid sinus during TL surgery and compression after surgery may have a role in preventing CSF leak.

Characterizing Cochlear Implant Magnet-Related MRI Artifact.

OBJECTIVE: To evaluate cochlear implant (CI) magnet-related MRI artifact shape and size, as well as imaging indications and clinical adequacy of scans. METHODS: A retrospective chart review was performed for patients undergoing CI and subsequent MRI head imaging from 2014 to 2020 at a single institution. Indications and adequacy of each scan was recorded, and interpretability compared by indication. Magnet-related artifact size was determined by performing ellipsoid modeling at axial slice of greatest signal loss. Artifact radius in centimeters was calculated for 5 sequence categories, and size compared between sequences, manufacturers, and by time from implantation. RESULTS: Twenty patients underwent 58 head MRI scans. Approximately 76% of MRIs (n = 44) for 70% of patients (n = 14) were performed for indications known of prior to implantation; the remainder were performed during workup of new issues. Desired structures were interpretable in 23 (52%) of known-indication MRIs and 8 (57%) of new-indication MRIs, without significant difference (P = .751). Magnet-related artifact magnitude, compared to the reference T1-weighted fast spin echo (FSE) (4.47 cm), was similar in T2 FSE (4.57 cm, P = .068) and T1 gradient echo (GRE) sequences (4.79 cm, P = .28), but significantly greater in T2 GRE (6.86, P < .0001) and DWI (7.56 cm, P < .0001) sequences. CONCLUSIONS: DWI and T2 GRE sequences are less useful in MRI evaluation of CI patients. With a more favorable artifact profile, T1 FSE, T2 FSE, and T1 GRE sequences more likely yield clinically useful information. The large proportion of scans performed for known pathology represents an opportunity to optimize for magnet location preoperatively.

Cochlear Implants for Single-Sided Deafness: Quality of Life, Daily Usage, and Duration of Deafness.

OBJECTIVE: To report our experience for adults undergoing cochlear implantation (CI) for single-sided deafness (SSD). METHODS: This is a retrospective case series for adults with SSD who underwent CI between January 2013 and May 2021 at our institution. CNC and AzBio speech recognition scores, Tinnitus Handicap Inventory (THI), Speech, Spatial, and Qualities of Hearing Scale (SSQ12), datalogging, and the Cochlear Implant Quality of Life (CIQOL)-10 Global measure were utilized. RESULTS: Sixty-six adults underwent CI for SSD (median 51.3 years, range 20.0-74.3 years), and 57 (86.4%) remained device users at last follow-up. Compared to pre-operative performance, device users demonstrated significant improvement in speech recognition scores and achieved peak performance at six months post-activation for CNC (8.0% increased to 45.6%, p < 0.0001) and AzBio in quiet (12.2% increased to 59.5%, p < 0.0001). THI was decreased at 6 months post-implantation (58.1-14.6, p < 0.0001), with 77% of patients reporting improved or resolved tinnitus. Patients demonstrated improved SSQ12 scores as well as the disease-specific CIQOL-10 Global questionnaire. Duration of deafness was not associated with significant differences in speech recognition performance. Average daily wear time was positively associated with CNC and AzBio scores as well as post-operative CIQOL-10 scores. CONCLUSIONS: Herein we present the largest cohort of adult CI recipients with SSD with data on speech recognition scores, tinnitus measures, and SSQ12. Novel insights regarding the correlation of datalogging, duration of deafness, and CI-specific quality of life (CIQOL-10) metrics are discussed. Data continue to support CI as an efficacious treatment option for SSD. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2362-2370, 2023.

A Five-Year Update on the Profile of Adults Undergoing Cochlear Implant Evaluation and Surgery-Are We Doing Better?

OBJECTIVE: To characterize the influence of expanding indications on the profile of adults undergoing cochlear implantation (CI) at a high-volume CI center. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: 774 adults undergoing CI evaluation from August 2015 to August 2020. MAIN OUTCOME MEASURES: Demographics; audiometry; speech recognition; speech, spatial, and qualities of hearing scale (SSQ-12). RESULTS: Of 745 (96.3%) patients qualifying for implantation, 642 (86.6%) pursued surgery. Median age at evaluation was 69 years; 56.3% were men; 88.2% were Caucasian. Median distance to our center was 95 miles. The majority (51.8%) had public insurance (Medicare, Medicaid), followed by private (47.8%) and military (0.4%). Mean PTA, CNC, and AzBio in quiet and noise for the ear to be implanted were 85.2 dB HL, 15.0%, and 19.2% and 3.5%, respectively. Hybrid/EAS criteria were met by 138 (18.5%) CI candidates, and 436 (77.0%) unilateral CI recipients had aidable contralateral hearing for bimodal hearing configurations. Younger age (odds ratio [OR], 0.96; 95% confidence interval, 0.93-0.99) and non-Caucasian race (OR, 6.95; 95% confidence interval, 3.22-14.98) predicted candidacy. Likelihood of surgery increased for Caucasian (OR, 8.08; 95% confidence interval, 4.85-13.47) and married (OR, 2.28; 95% confidence interval, 1.50-3.47) patients and decreased for those with public insurance (OR, 0.45; 95% confidence interval, 0.29-0.69). A lower SSQ-12 score predicted both candidacy and surgery. CONCLUSION: Despite expansions in criteria, speech understanding remained extremely low at CI evaluation. Younger age and non-Caucasian race predicted candidacy, and Caucasian, married patients with private insurance and lower SSQ scores were more likely to pursue surgery.

Further Evidence for Individual Ear Consideration in Cochlear Implant Candidacy Evaluation.

OBJECTIVE: To report speech outcomes after cochlear implantation (CI) for asymmetric hearing loss (AHL) and assess the influence of contralateral hearing. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: One hundred eighty-eight adults (mean age, 70 yr) undergoing CI for AHL from 2015 to 2020. Candidacy included pure-tone average (PTA) at least 70 dB hearing level and AzBio in quiet 60% or less in the implanted ear and AzBio in quiet greater than 40% in the contralateral ear. MAIN OUTCOME MEASURES: PTA; Consonant-Nucleus-Consonant (CNC) word, AzBio sentences scores; Speech, Spatial, and Qualities of Hearing Scale (SSQ). RESULTS: Mean preoperative PTA and AzBio in the implanted and contralateral ears were 85.2 and 68.1 dB hearing level and 24.7% and 69.2%, respectively. Mean CNC in the implanted ear increased from 18.3% preoperatively to 44.4% ( p < 0.0001) at 6 months and 49.3% ( p < 0.0001) at 12 months. Mean AzBio in the implanted ear improved from 24.7% preoperatively to 60.3% ( p < 0.0001) at 6 months and 64.3% ( p < 0.0001) at 12 months. Patients demonstrated significant improvement in all SSQ domains at 6 and 12 months. When comparing patients with preoperative contralateral AzBio greater than 60% versus 41% to 60%, no significant differences existed in postoperative CNC scores (6-mo: 47% versus 41%, p = 0.276; 12-mo: 51% versus 47%, p = 0.543). There were no significant differences in 6-month ( p = 0.936) or 12-month ( p = 0.792) CNC scores between patients with AHL (contralateral ear AzBio >40%) and 169 unilateral CI patients meeting the traditional Medicare criteria (contralateral ear AzBio ≤40%). CONCLUSION: CI recipients with AHL derive significant speech improvements, supporting individual ear consideration for CI candidacy and patient benefit outside of current Medicare criteria.

Vestibular Migraine Confounds Management of Superior Canal Dehiscence Syndrome.

OBJECTIVE: To investigate the prevalence of vestibular migraine (VM) in a cohort of patients with radiologic confirmation of superior canal dehiscence (SCD) and to compare management of superior canal dehiscence syndrome (SCDS) in patients with and without comorbid VM. STUDY DESIGN: Retrospective review of a SCD database. SETTING: University-based tertiary medical center. PATIENTS: Ninety-one patients identified with SCD from 2009 to 2017. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Coincidence of VM and SCD, and resolution of symptoms. RESULTS: Ninety-one patients with SCD met the inclusion and exclusion criteria. VM was diagnosed in 36 (39.6%) patients. Of those receiving medical therapy for VM alone, five (45.5%) reported symptom resolution, five (45.5%) reported partial improvement, one (9.1%) had no change, and none worsened. Fifteen patients (41.7%) were treated with both surgery (for SCD) and medical therapy (for VM). Seven (46.7%) reported symptom resolution, seven (46.7%) reported partial improvement, and one (6.7%) worsened. There was no statistically significant difference in symptom resolution between SCD + VM patients who were treated medically compared with those treated with medical therapy and surgery (p = 0.951). There was no significant difference in symptom resolution after surgery between SCD + VM and SCD-only cohorts (p = 0.286). CONCLUSIONS: This is the first study describing the incidence of VM in a cohort of patients with SCDS. The symptoms of VM confound those of SCDS and unrecognized or undertreated VM may contribute to surgical failure in SCDS. Therefore, we recommend a high index of suspicion for VM in patients with SCDS and a trial of medical therapy in the setting of suspected VM.

Predictors of Recurrence After Sub-total or Near-total Resection of Vestibular Schwannoma: Importance of Tumor Volume and Ventral Extension.

OBJECTIVE: To evaluate the predictors of remnant tumor regrowth and need for salvage therapy after less than gross total resection (GTR) of vestibular schwannoma (VS). STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotologic referral center. PATIENTS: Patients who underwent VS resection between 2008 and 2019 either with GTR, near total resection (NTR), and subtotal resection (STR). INTERVENTIONS: Microsurgical resection, salvage radiosurgery. MAIN OUTCOME MEASURES: Regrowth free interval, salvage free interval, tumor doubling rate. RESULTS: Three hundred eighty five cases (GTR = 236, NTR = 77, and STR = 71) from 2008 to 2019 were included. STR cohort had much larger and complex tumors with significant differences in tumor volume, ventral extension and brainstem compression (p  < 0.001). On single predictor analysis, tumor volume, ventral extension, brainstem compression as well as STR strategy was associated with significant increased risk of regrowth and need for salvage therapy. Multivariate analysis revealed STR strategy as significant predictor of regrowth (hazard ratio 3.79, p  < 0.0005). Absolute remnant volume and extent of resection (EOR) did not predict regrowth. A small proportion of cases (NTR = 4%, STR = 15%) eventually needed salvage radiosurgery with excellent ultimate local tumor control with no known recurrence to date. CONCLUSIONS: Conservative surgical strategy employing NTR or STR can be employed safely in large and complex VS. While there is increased risk of regrowth in the STR cohort, excellent local control can be achieved with appropriate use of salvage radiosurgery. No disceret radiologic or operative predictors of regrowth were identified.

Cochlear Implantation Outcomes in Observed Vestibular Schwannoma: A Preliminary Report.

OBJECTIVE: Over the last decade there has been a trend toward observation for small nongrowing vestibular schwannoma (VS). Even without tumor growth, patients commonly experience ipsilateral hearing decline, and hearing rehabilitation remains challenging. This study analyzes hearing and speech performance outcomes after cochlear implantation (CI) in observed VS. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. METHODS: Chart review was used to include patients with observed VS who had undergone ipsilateral CI, pre- and postimplantation audiometry, and speech performance. Tumor size pre- and postimplantation was measured with volumetric analysis. RESULTS: Seven patients with ipsilateral VS and CI were identified. Preimplantation tumor volume was 0.11 to 1.02 cm3. Five subjects were implanted with a straight electrode and two with a perimodiolar electrode. The average preimplant pure tone average was 91.3 dB (range, 80-117 dB) and 61.2 dB (range, 12-118 dB) for the implanted and nonimplanted ears, respectively. In all subjects with at least 1 year of listening experience (n = 6), consonant-nucleus-consonant word scores improved at 6 months and 1 year in the CI-alone and bimodal listening conditions. AzBio scores in quiet also improved at 6 months and 1 year. Of subjects with serial pre- and postoperative magnetic resonance imaging, volumetric analysis demonstrated no tumor growth. CONCLUSION: Our results demonstrate that CI is a successful option for subjects with small nongrowing VS. All subjects had improved performance postimplantation. VS may continue to be observed with serial magnetic resonance imaging given increasing conditionality among CI manufacturers and ability to assess cerebellopontine angle extension despite implant artifact.

Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes.

OBJECTIVE: To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary medical center neurotology practice. METHODS: Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired t-tests. Single-predictor binary logistic regression was used to compare final reported symptoms between cohorts. Linear regression was performed to assess air-bone gap (ABG) changes postoperatively between cohorts. RESULTS: Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively (P < .001 for each). There was no significant difference in change in ABG between the 2 cohorts. On average, patient-reported symptoms and audiometrically-tested hearing improved postoperatively in both groups. CONCLUSION: While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.

Outcomes of Initial Observation Versus Upfront Microsurgical Resection for Small to Medium-sized Vestibular Schwannomas.

OBJECTIVE: To assess postoperative outcomes and predictive factors of patients observed prior to microsurgery and those undergoing upfront resection for small and medium-sized VS. STUDY DESIGN: Retrospective cohort. SETTING: Tertiary referral center. PATIENTS: VS patients who had microsurgery from 2003 to 2018 for tumors up to 2.5 cm. MAIN OUTCOME MEASURES: Postoperative outcomes including facial nerve function and interventions, complications, extent of resection, and salvage therapy. RESULTS: Of 220 patients, 120 were initially observed, and 100 pursued upfront microsurgery. There was no significant association between initial observation and upfront microsurgery for postoperative facial nerve function at 2 to 3 weeks (p = 0.18) or 12 months (p = 0.5), facial nerve intervention (p = 0.5), major/minor complications (p = 0.48/0.63), recurrence (p = 0.8), subtotal resection (p = 0.6), or salvage therapy (p = 0.9). Time from initial consultation to surgery did not significantly impact outcomes. Intrameatal tumors were more likely to be observed (odds ratios [OR] 2.93; 95% CI 1.53-5.63; p = 0.001). Patients with larger tumor volume (OR 0.52; 95% CI 0.37-0.72; p < 0.0001), brainstem compression (OR 0.28; 95% CI 0.09-0.91; p = 0.03), or higher PTA were less likely to undergo observation (OR 0.99; 95% CI 0.97-0.997; p = 0.02). On multivariable analysis, predictive factors for observation were smaller tumor volume (OR 0.53; 95% CI 0.38-0.75; p < 0.001), lower PTA (OR 0.99; 95% CI 0.98-0.999; p = 0.04), and diabetes (OR 2.54; 95% CI 0.95-6.83; p = 0.06). CONCLUSIONS: Patients with worse hearing, larger tumor volume, and brainstem compression were more likely to pursue upfront microsurgery. A watchful waiting period does not appear to worsen outcomes and can be considered for patients with better hearing and smaller tumors without brainstem compression.

Investigating Predictors of Increased Length of Stay After Resection of Vestibular Schwannoma Using Machine Learning.

OBJECTIVE: To evaluate the predictors of prolonged length of stay (LOS) after vestibular schwannoma resection. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. PATIENTS: Patients who underwent vestibular schwannoma resection between 2008 and 2019. INTERVENTIONS: Variables of interest included age, body mass index, comorbidities, symptoms, previous intervention, microsurgical approach, extent of resection, operative time, preoperative tumor volume, and postoperative complications. Predictive modeling was done through multivariable linear regression and random forest models with 80% of patients used for model training and the remaining 20% used for performance testing. MAIN OUTCOME MEASURES: LOS was evaluated as the number of days from surgery to discharge. RESULTS: Four hundred one cases from 2008 to 2019 were included with a mean LOS of 3.0 (IQR = 3.0-4.0). Postoperatively, 14 (3.5%) of patients had LOS greater than two standard deviations from the mean (11 days). In a multivariate linear regression model (adjusted R2 = 0.22; p < 0.001), preoperative tumor volume (p < 0.001), coronary artery disease (p = 0.002), hypertension (p = 0.029), and any major complication (p < 0.001) were associated with increased LOS (by 0.12, 3.79, 0.87, and 3.20 days respectively). A machine learning analysis using a random forest identified several potential nonlinear relationships between LOS and preoperative tumor dimensions (length, volume) and operative time that were not captured on regression. The random forest model had lower prediction error compared to the regression model (RMSE 5.67 vs. 44.59). CONCLUSIONS: Tumor volume, coronary artery disease, hypertension, and major complications impact LOS. Machine learning methods may identify nonlinear relationships worthy of targeted clinical investigation and allow for more accurate patient counseling.

Contemporary Management of Jugular Paragangliomas With Neural Preservation.

OBJECTIVES: Management of jugular paragangliomas (PGL) has evolved toward subtotal resection (STR). The purpose of this study is to analyze neural preservation and adjuvant treatment for long-term local control. STUDY DESIGN: Retrospective chart review. SETTINGS: Tertiary neurotology practice. SUBJECTS AND METHODS: Adults undergoing surgical treatment of jugular PGL between 2006 and 2019. Patients, disease, and treatment variables were collected retrospectively. Single predictor logistic regression was used to ascertain predictors of regrowth or need for salvage radiation. RESULTS: A total of 41 patients (median age, 47 years; 76% female) were identified. Most patients presented with advanced-stage disease (Glasscock-Jackson stage III-IV = 76%). Subtotal resection (STR) was performed in 32 (78%) patients. Extended STR (type 1) was the most commonly performed conservative procedure (n = 19, 59%). Postoperative new low cranial neuropathy (LCN) involving CN X and XII was rare (n = 3 and n = 1, respectively). Seventeen patients (41%) underwent postsurgical therapy for tumor regrowth or recurrence, including 15 patients who underwent adjuvant (n = 4) or salvage (n = 11) radiation. Overall tumor control of 94.7% was achieved at a mean follow-up of 35 months. All patients treated with combined modality treatment had local control at last follow-up. Logistic regression identified no single predictor for postsurgical radiation treatment or salvage-free survival. CONCLUSION: Management of jugular PGL with a conservative approach is safe and effective with a low rate of new LCN deficit. Active surveillance of residual tumor with salvage radiation for growth results in excellent long-term tumor control.

Hearing Preservation Outcomes Using a Precurved Electrode Array Inserted With an External Sheath.

OBJECTIVES: Describe audiologic outcomes in hearing preservation cochlear implantation (CI) using a precurved electrode array inserted using an external sheath and evaluate association of electrode positioning and preservation of residual hearing. STUDY DESIGN: Retrospective review. SETTING: Tertiary otologic center. PATIENTS: Twenty-four adult patients who underwent hearing preservation CI with precurved electrode array. INTERVENTIONS: CI, intraoperative computed tomography (CT) OUTCOME MEASURES:: Audiologic measures (consonant-nucleus-consonant [CNC] words, AzBio sentences, low-frequency pure tone averages [LFPTA]) and electrode location (scalar location, electrode-to-modiolus distance ((Equation is included in full-text article.)), angular insertion depth). RESULTS: Twenty-four adults with less than 80 dB LFPTA with a precurved electrode array inserted using an external sheath; 16 underwent intraoperative CT. LFPTA was 58.5 dB HL preoperatively, with a 17.3 dB threshold shift at CI activation (p = 0.005). CNC word scores improved from 6% preoperatively to 64% at 6 months postoperatively (p < 0.0001). There was one scalar translocation and no tip fold-overs. The average angular insertion depth was 388.2 degrees, and the average (Equation is included in full-text article.)across all electrodes was 0.36 mm. Multivariate regression revealed a significant correlation between CNC scores at 6 months and angular insertion depth (p = 0.0122; r = 0.45, adjusted r = 0.35). Change in LFPTA was not significantly associated with angular insertion depth or (Equation is included in full-text article.). CONCLUSIONS: A low rate of translocation allows a precurved electrode array inserted using an external sheath to maintain hearing preservation rates comparable to straight electrode arrays. With scala tympani insertion, angular insertion depth is a positive marker of improved speech performance postoperatively but may be a confounder variable based on individual cochlear size.

Use of intraoperative CT scanning for quality control assessment of cochlear implant electrode array placement.

Background: Imaging of cochlear implant (CI) electrode arrays (EAs) consists of intraoperative fluoroscopy to rule out tip fold-over and/or post-operative computerized tomography (CT) if concern exists regarding extrusion or misplacement of the EA. Intraoperative CT (iCT) can satisfy these current needs and enables specification of final intracochlear position.Aims/objectives: To describe iCT scanning of CI recipients at an academic medical center.Materials and methods: iCT was used to scan CI recipients within the operating room before recovering from general anesthesia.Results: In fiscal year 2019, 301 CI were placed (83 children, 218 adult). One hundred, seventy-five iCTs were performed (58% of total CIs) of which 52 were children (63% of pediatric CIs) and 123 were adult (57% of adult CIs). Of 7 CI surgeons, use of iCT ranged from 14% to 100% (mean 60%). Four tip fold-overs were identified and corrected intraoperatively. Surgeons reported using the images to improve technique (i.e. pulling back precurved EAs to improve perimodiolar positioning).Conclusion and significance: The current standard of care for CI is to insert EAs without feedback as to final location. iCT provides surgeons with rapid post-insertion feedback which allows detection and correction of suboptimally placed EAs as well as refinement of surgical technique.

Delayed Facial Nerve Paralysis after Vestibular Schwannoma Resection.

Objective To describe the incidence and clinical course of patients who develop delayed facial nerve paralysis (DFNP) after surgical resection of vestibular schwannoma. Setting Tertiary skull base center. Methods Retrospective chart review. Results Two hundred and forty six consecutive patients, who underwent surgical resection for vestibular schwannoma at a single center between 2010 and 2015, were analyzed. Of these patients, 22 (8.9%) developed DFNP, defined here as deterioration of function by at least 2 House-Brackmann (HB) grades within 30 days in patients with immediate postoperative HB ≤ 3. The mean age of DFNP patients was 47.2 years (range: 17-67) and 16 (73%) were female. The mean tumor size in greatest dimension was 2.1 cm (range: 0.7-3.5 cm). At the conclusion of each case, the facial nerve stimulated at the brainstem. Mean immediate postoperative facial nerve function was HB 1.8 (range: 1-3). Average facial nerve function at the 3-week-postoperative visit was 4.4 (range: 2-6). In 1-year, 8 patients (36%) recovered HB 1 function, 10 patients (46%) recovered to HB 2, and 2 patients (9%) were HB 3. The remaining 2 patients did not recover function and were HB 6 at last follow-up. Initial postoperative facial nerve function (HB 1 or HB 2) was associated with improved recovery to normal (HB 1) function ( p = 0.018). Conclusion A majority of patients that develop delayed paralysis will recover excellent facial nerve function. Patients should be counseled; however, a small percentage of patients will not recover function long-term, despite having a previously functioning and anatomically intact nerve.