Postoperative surgical site infection in cholesteatoma surgery with and without mastoid obliteration, what can we learn?

INTRODUCTION: This study aims to describe the occurrence of postoperative complications related to cholesteatoma surgery and to determine factors influencing the most common complication, i.e. postoperative surgical site infection (SSI) in cases with and without mastoid obliteration. MATERIALS AND METHODS: Retrospective analyses were performed on surgically treated cholesteatomas in our hospital between 2013 and 2019. Patient characteristics, peri- and postoperative management and complications were reviewed. The cases were divided into two groups based on whether mastoid obliteration was performed or not. RESULTS: A total of 336 cholesteatoma operations were performed, of which 248 cases received mastoid obliteration. In total 21 complications were observed, of which SSI was the most common (15/21). No difference in occurrence of any postoperative complication was seen between the obliteration and no-obliteration group (p = 0.798), especially not in the number of SSI (p = 0.520). Perioperative and/or postoperative prophylactic antibiotics were not associated to the development of an SSI in both groups. In the no-obliteration group a younger age (p = 0.015), as well as primary surgery (p = 0.022) increased the risk for SSI. In the obliteration group the use of bioactive glass (BAG) S53P4 was identified as independent predictor of SSI (p = 0.008, OR 5.940). DISCUSSION: SSI is the most common postoperative complication in cholesteatoma surgery. The causes of SSI are multifactorial, therefore further prospective research is needed to answer which factors can prevent the development of an SSI in cholesteatoma surgery.

Patient-reported factors that influence the vestibular schwannoma treatment decision: a qualitative study.

PURPOSE: In cases of small- to medium-sized vestibular schwannomas, three management strategies can be opted for: active surveillance, surgery or radiotherapy. In these cases, the patient's preference is pivotal in decision-making. The aim of this study was to identify factors that influence a patient's decision for a particular management strategy. METHODS: A qualitative inductive thematic analysis was performed based on semi-structured interviews. Eighteen patients with small- to medium-sized vestibular schwannomas were interviewed. All patients were diagnosed or treated at one of the two participating university medical centers in the Netherlands. RESULTS: Ten themes were identified that influenced the decision, classified as either medical or patient-related. The medical themes that emerged were: tumor characteristics, the physician's recommendation, treatment outcomes and the perceived center's experience. The patient-related themes were: personal characteristics, anxiety, experiences, cognitions, logistics and trust in the physician. CONCLUSION: Knowledge of the factors that influence decision-making helps physicians to tailor their consultations to arrive at a true shared decision on vestibular schwannoma management.

Progression of hearing loss after LINAC-based stereotactic radiotherapy for vestibular schwannoma is associated with cochlear dose, not with pre-treatment hearing level.

BACKGROUND: Although stereotactic radiotherapy (SRT) for vestibular schwannoma has demonstrated excellent local control rates, hearing deterioration is often reported after treatment. We therefore wished to assess the change in hearing loss after SRT and to determine which patient, tumor and treatment-related factors influence deterioration. METHODS: We retrospectively analyzed progression of hearing loss in patients with vestibular schwannoma who had received stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) as a primary treatment between 2000 and 2014. SRS had been delivered as a single fraction of 12 Gy, and patients treated with FSRT had received 30 fractions of 1.8 Gy. To compare the effects of SRS and FSRT, we converted cochlear doses into EQD2. Primary outcomes were loss of functional hearing, Gardner Robertson (GR) classes I and II, and loss of baseline hearing class. These events were used in Kaplan Meier plots and Cox regression. We also calculated the rate of change in Pure Tone Average (PTA) in dB per month elapsed after radiation-a measure we use in linear regression-to assess the associations between the rate of change in PTA and age, pre-treatment hearing level, tumor size, dose scheme, cochlear dose, and time elapsed after treatment (time-to-first-audiogram). RESULTS: The median follow-up was 36 months for 67 SRS patients and 63 months for 27 FSRT patients. Multivariate Cox regression and in linear regression both showed that the cochlear V90 was significantly associated with the progression of hearing loss. But although pre-treatment PTA correlated with rate of change in Cox regression, it did not correlate in linear regression. The time-to-first-audiogram was also significantly associated, indicating time dependency of the rate of change. None of the analysis showed a significant difference between dose schemes. CONCLUSIONS: We found no significant difference between SRS and FSRT. As the deterioration in hearing after radiotherapy for vestibular schwannoma was associated with the cochlea V90, restricting the V90 may reduce progression of hearing loss. The association between loss of functional hearing and baseline PTA seems to be biased by the use of a categorized variable for hearing loss.

Identifying at diagnosis the vestibular schwannomas at low risk of growth in a long-term retrospective cohort.

OBJECTIVES: Identification at time of diagnosis of those vestibular schwannomas that will not grow. DESIGN: Retrospective cohort study of consecutive patients diagnosed with a sporadic vestibular schwannoma that were entered in the wait-and-scan protocol. SETTING: Academic referral centre. PARTICIPANTS: The study group contained 155 patients with a sporadic vestibular schwannoma first seen in the full 8-year period 2000-2007: continual wait-and-scan (n = 89) and initial wait-and-scan until intervention (n = 66). MAIN OUTCOME MEASURES: Tumour growth, defined as more than 2 mm linear difference in any plane between the diagnostic MRI-scan and the last available scan, was related to clinical parameters at diagnosis: localisation of the tumour (solely intracanalicular versus cisternal extension), sudden sensorineural hearing loss, sensorineural hearing loss longer than 2 years and vertigo/instability. RESULTS: Hearing loss longer than 2 years and an entirely intracanalicular localisation were associated with no tumour growth by univariate and multivariate Cox analysis. Combining both factors at time of diagnosis resulted in a group with low risk of growth (n = 36, median follow-up of 6.2 years) with a Hazard Ratio for growth of 0.37 (95% CI, 0.19-0.69). This subgroup is about 25% of the wait-and-scan population. Thirty-one percent showed growth, while in the remaining higher risk group of 119 patients 62% showed growth. For the growing schwannomas, the median time for growth becoming manifest is 1.9 years after diagnostic MRI. CONCLUSIONS: In this study on vestibular schwannoma patients that start in a wait-and-scan protocol, about a quarter may be set apart having a low risk for growth. These patients at diagnosis combine a history of hearing loss longer than 2 years and a fully intracanalicular schwannoma. They seem to be not needed yearly MRI checks.

[Illness due to work or to an overactive thyroid?]. / Ziek door het werk of een te hard werkende schildklier?

An incapacity to work brought about by stress was diagnosed in two women aged 40 and 38. They were both in conflict situations at work and had psychological problems. They stopped working but remained tired and irritable. After being unfit for work for more than a year they were diagnosed with hyperthyroidism which was treated appropriately. They both recovered and resumed work. Hyperthyroidism can impair physical and mental functioning. Presenting symptoms may be confusing, specifically if work-related factors appear to be the obvious implication. In The Netherlands, employees who become ill, consult their general practitioner or a medical specialist, who are concerned with diagnosis and treatment. They also report to their employer's occupational-health department, where the physician focuses on work-related factors that may impair health and on assessment of disability. Communication between all parties should be optimal.

Quantification of visuo-vestibular interaction up to 5.0 Hz in normal subjects.

The gaze stability with respect to an earth-fixed target (compensatory eye movements) and a target moving with the subject (suppression of the vestibulo-ocular reflex) was investigated during high frequency sinusoidal rotation to obtain normative data on visuo-vestibular interaction. Induction coils were used to record eye and head movements. The transition from visually controlled eye movements at low frequencies to vestibular controlled eye movements at 5 Hz was clearly demonstrated during suppression. It was found that the influence of vision was not confined to the lower frequencies. Comparing suppression with the compensatory eye movements at 2.5 Hz, a gain reduction of about 35% and a phase lead of 30 degrees was recorded. In contrast, at 5.0 Hz the visual environment did not influence the gain or phase of the eye movements. A gain value of 0.9 was found in both visual conditions.

The primary vestibulocerebellar projection in the rabbit: absence of primary afferents in the flocculus.

The central projection of vestibular nerve fibers was investigated with anterograde axonal transport of wheatgerm agglutinin-horseradish peroxidase (WGA-HRP) and tritiated leucine following injection in the vestibular ganglion. Labeled fibers and terminal ramifications were observed throughout the vestibular complex, but absent from the lateral vestibular nucleus. Termination in the cortex was restricted to the vermis. Small numbers of mossy fiber terminals were present bilaterally, close to the midline in lobules I and II, and in the depth of the main fissures separating lobules II-VI. In the posterior vermis labeled mossy fiber terminals were found in lobule X and the ventral aspect of lobule IXd. Here, the entire ipsilateral hemivermis contained a large number of terminals, while contralaterally the medial one-third hemivermis contained fewer terminals. Labeled mossy fibers and terminals were absent in the flocculus and adjacent ventral paraflocculus.