"Repository of Cochlear Implant Information:" A Multi-Institutional REDCap Database.

PURPOSE: To describe the creation of a multi-center cochlear implant database as a template for future medical database design. The first clinical question examined was the association between BMI on cochlear implant surgical time and postoperative outcome. MATERIALS AND METHODS: A retrospective repository in REDCap, named the "Repository of Cochlear Implant Information" (ROCII), was created and collected de-identified data on patients who underwent cochlear implantation. Data was exported and stratified into three BMI groupings (<25, 25.0-29.9, ≥ 30.0). Differences in surgical time and AZBio Sentence Test postoperative score changes were analyzed using the mixed-effect model. RESULTS: The mean BMI (n = 145) was 28.52, and the mean surgical time was 128.9 min. The BMI < 25 reference group (n = 50) and the BMI 25.0-29.9 group (n = 50) had an identical mean surgical time of 127.5 min. The BMI ≥30.0 group (n = 45) had a mean surgical time of 132 min, however this difference was not statistically significant when compared to the reference group (p = 0.4727). The mean AZBio postoperative score change (n = 74) was 63.32. The BMI < 25 reference group (n = 29) had a mean postoperative change of 56.66. The BMI 25.0-29.9 group (n = 22) and BMI ≥30.0 group (n = 23) had mean postoperative changes of 61.32 and 73.65 respectively, however these differences were not statistically significant compared to the reference group (p = 0.5847, 0.0637). CONCLUSION: BMI did not have a significant association with surgical time or postoperative outcome and therefore should not be a contraindication for implantation. ROCII will facilitate a deeper understanding of the evaluation process, outcomes, and patient experience of cochlear implantation across institutions. LEVEL OF EVIDENCE: Level 1.

Resection of Intracochlear Schwannomas With Immediate Cochlear Implantation.

INTRODUCTION: Intralabyrinthine schwannomas, including the intracochlear variety, are rare benign tumors. They can cause a number of symptoms and have the potential to grow to involve other critical structures of the inner ear and skull base. While surgical resection is feasible, there is typically permanent hearing dysfunction as a result of resection and subsequent fibrosis. Here, we present 2 cases of intracochlear schwannomas (ICS) that were successfully resected with simultaneous cochlear implant placement. METHODS: Patient 1 presented with an intravestibulocochlear schwannoma. This patient underwent a translabyrinthine approach. Endoscopic assistance was used to dissect the tumor from the vestibule and basal turn of the cochlea, through an enlarged round window approach. A cochlear implant was placed via a round window cochleostomy. Patient 2 presented with an intracochlear schwannoma involving the basal and middle turns of the cochlea. The patient underwent a trans-otic approach for resection. A large portion of the cochlear promontory required unroofing for complete exposure of the tumor. A cochlear implant was then placed via a round window cochleostomy. RESULTS: Upon cochlear implant activation, Patient 1's sound field thresholds using the implant were near the normal range of hearing, ranging from 25 to 50 dB HL from 250 to 6000 Hz. Patient 2's 6-month post-operative cochlear implant sound field testing ranged from 20 to 30 dB HL from 250 to 6000 Hz and speech recognition testing revealed 59% on AZ Bio sentences compared to 0% pre-operatively. CONCLUSION: Simultaneous cochlear implantation after resection of intracochlear schwannomas is safe and successful in restoring hearing. Attention to adequate exposure and endoscopic assistance, when required, allow for gross total resection while minimizing trauma to cochlear structures. In such cases, immediate cochlear implantation allows for hearing rehabilitation before likely cochlear fibrosis can occur.

Comparing Outcomes and Billing Costs of Middle Cranial Fossa and Transmastoid Approaches for Otogenic Encephalocele and Cerebrospinal Fluid Leak Repair.

OBJECTIVE: Comparison of outcomes and billing costs of patients treated at our institution using transmastoid (TM), middle cranial fossa (MCF), and combined approaches for repair of otogenic cerebrospinal fluid (CSF) leaks and encephaloceles. STUDY DESIGN: Retrospective cohort review. SETTING: Tertiary-care hospital. PATIENTS: Seventy-seven cases of otogenic CSF leaks or encephaloceles. INTERVENTIONS: Surgical repair of an otogenic encephalocele or CSF leak using either a TM, MCF, or combined approach. MAIN OUTCOME MEASURES: Success of repair, length of operation, cost of operating room materials, postoperative need for intensive care, and postoperative length of stay. RESULTS: Forty cases (52%) were performed by the TM approach, 27 (35%) by MCF, and 10 (13%) by combined TM/MCF. Mean length of stay was not statistically different amongst TM patients (2.1 d), MCF patients (3.3 d), and combined TM/MCF patients (3.70; p = 0.112). Only 3/40 TM cases required intensive care during their admission while all MCF and combined TM/MCF approach cases were admitted to the intensive care unit for at least one night ( p < 0.001). On follow-up, CSF leak recurred in 3/77 (4%) cases: 3/27 (11%) MCF, 0/40 TM, and 0/10 combined TM/MCF patients ( p = 0.056). The mean cost of operating room materials charged to the patient was significantly greater in the MCF group ($9,883) than the TM group ($3,748; p = 0.001). CONCLUSIONS: In carefully selected patients, the TM approach is an effective and less costly alternative to MCF approaches for repair of otogenic CSF leaks and encephaloceles.

Effect of Bending of Carbon Dioxide Laser Fibers on Power Output.

Objective: The power output from carbon dioxide (CO2) laser fibers has the potential to be diminished if there are any bends along its course, which may alter the effect the laser has on the target tissue. In this study, we assess how bending of CO2 laser flexible fiber assemblies affects the energy output measured at the end of the fiber. Study Design: Laboratory study. Setting: Laboratory. Methods: Eight separate flexible fibers were tested-4 were of a type commonly used in endoscopic airway procedures, and the other 4 were a type used in otologic surgery. Fibers were bent in various configurations, and the power output of a CO2 laser fired through the bent fiber was measured. The output through the bent fiber was normalized to the output with a straight fiber. Correlations between bend parameters and power outputs was tested using Spearman's correlation coefficient. Results: For the airway fibers, there was a weak trend toward increasing energy outputs with greater radius of curvature (P = .714) and a negative correlation between the energy output and arc of rotation (P = .043). For the otologic fibers, there was a trend toward increasing energy outputs with greater radius (P = .084) and a strong negative correlation between the energy output and the arc of rotation (P = .006). Conclusion: CO2 laser energy output is reduced by bending of the laser fiber assembly. When using the CO2 laser fiber, surgeons should be aware of any bends in the fiber and are encouraged to take measures to minimize bending.

Transmastoid Repair of Otogenic Encephaloceles in Patients With Canal Wall Down Mastoidectomy.

OBJECTIVE: Description of a series of cases in which otogenic encephaloceles in patients requiring canal wall down (CWD) mastoidectomies were repaired via a transmastoid approach. STUDY DESIGN: Case series. SETTING: Tertiary-care hospital. PATIENTS: Eleven cases of otogenic encephaloceles in patients requiring CWD mastoidectomy for chronic ear disease. INTERVENTIONS: Surgical repair of an otogenic encephalocele using a transmastoid approach. MAIN OUTCOME MEASURES: Success of repair, number and size of defects, materials used for repair, complications encountered in surgery, pure tone average air-bone gap (PTA-ABG). RESULTS: Eleven cases were identified. Two of these patients had a prior CWD cavity while the remainder received CWD mastoidectomy simultaneously with encephalocele repair. None of the patients required revision of encephalocele repair. Mean preoperative PTA-ABG was 30 dB and mean postoperative PTA-ABG was 28 dB (p = 0.66). CONCLUSIONS: A single-stage strictly transmastoid approach to otogenic encephalocele repair may be effective in patients with prior CWD mastoid cavities or requiring concurrent CWD mastoidectomy for chronic ear disease and/or cholesteatoma.

Revision Stapes Surgery: Hearing Symptoms and Associations With Intraoperative Findings and Outcomes.

OBJECTIVE: Stapes surgery for otosclerosis occasionally requires revision due to recurrent or persistent conductive hearing loss (CHL). This study examines outcomes after revision stapes surgery. STUDY DESIGN: Retrospective review. SETTING: Single tertiary neurotology center. METHODS: Patients undergoing revision stapes surgery for otosclerosis from 2008 to 2017 were reviewed. Postoperative air-bone gaps (ABGs) were the primary outcome measure. RESULTS: During the study period, 150 patients underwent revision stapes surgery. One hundred patients (67%) had gradually progressive recurrent CHL; 16 (11%), sudden recurrent CHL; 13 (9%), persistent CHL; and 21 (14%), no CHL. For 129 patients with CHL, the mean ABG improved from 23.7 to 9.3 dB (P < .0005). The most common intraoperative findings for these patients were prosthesis displacement with incus necrosis (38%) or without it (43%), normal anatomy with seemingly good prosthesis placement (6%), and abundant scar tissue (6%). Patients with recurrent hearing loss achieved lower mean ABGs than patients with persistent hearing loss (8.8 vs 13.2 dB, P = .02). There were no associations between onset pattern of CHL or intraoperative findings and hearing outcomes (P > .05). Four patients (2.7%) developed sensorineural hearing loss after revision, defined as an increase in bone conduction pure tone average ≥15 dB, all of whom had previous replacement of a malpositioned prosthesis. CONCLUSIONS: Revision stapes surgery confers significant improvement in hearing for patients with persistent and recurrent CHL, although patients with persistent CHL after initial surgery see less improvement with revision.

Outcomes in primary and revision surgery for pediatric onset stapedial pathology.

OBJECTIVES: To analyze audiometric outcomes of surgery for pediatric onset stapedial pathology (POSP). STUDY DESIGN: Retrospective cohort study. SETTING: Single-institution database. METHODS: Retrospective analysis of 809 stapes procedures performed at a single high-volume tertiary referral otology practice, 75 of which were POSP cases. RESULTS: Oval window drillout for thick footplate and aborting the procedure were more common in POSP cases compared to the rest of the cohort (28.0% versus 9.8% [p < .001] and 5.3% versus 1.2% [p = .007], respectively). Postoperative complications were rare. Postoperative Air-Bone Gap (pABG) closure to ≤20 dB was significantly lower in the POSP group (80.0% versus 89.0%, p = .021). Rates of sensorineural hearing loss (SNHL) were not different between the two groups. Poor audiometric outcomes in the POSP group were largely driven by revision cases; pABG≤10 dB was 60.3% in primary cases but only 11.8% in revisions (p < .001), and postoperative SNHL was significantly higher in revisions (29.4% versus 0.0%, p < .001). In multivariate analysis, POSP was not a predictor of successful closure of the pABG at either level, nor did it predict significant postoperative SNHL. CONCLUSIONS: Surgery for pediatric onset stapedial pathology had significantly worse audiometric outcomes, particularly in revision cases, as compared to the rest of the cohort.

Is Menière's Disease a Contraindication to Stapedectomy?

OBJECTIVE: Review surgical outcomes of stapedectomy for otosclerosis in patients with Menierè's disease. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: Patients with otosclerosis and Menière's disease undergoing stapedectomy between 2010 and 2017. INTERVENTION: Stapedectomy. MAIN OUTCOME MEASURES: Pre- and postoperative hearing and complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone frequency, pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). RESULTS: Among 1,499 patients with otosclerosis, the incidence of concomitant Menière's disease was 1.7%. Fifteen patients with otosclerosis and Menière's disease underwent stapedectomy, 12 primary and three revisions. Mean AC PTA was 43 dB preoperatively, and 25 dB postoperatively (p = 0.0007), while the ABG improved on average from 20 to 5 dB (p = 0.0001). There was no significant difference in BC PTA or WRS postoperatively. Two patients experienced fluctuation of hearing in the postoperative period, one of which resolved with a course of steroids. The mean follow-up time was 41 months. CONCLUSIONS: In patients with otosclerosis and Menière's disease, stapedectomy provides excellent hearing outcomes in a majority of patients. As is characteristic of Menière's disease, some patients will continue to experience fluctuating hearing postoperatively, which may progress to severe sensorineural hearing loss. Menière's disease may not be an absolute contraindication to stapes surgery.

Outcomes in Revision Stapes Surgery.

OBJECTIVES: To compare audiometric outcomes and complication rates between primary and revision stapes surgical cases. STUDY DESIGN: Retrospective cohort study. SETTING: Large single-institution database. METHODS: Data on 809 patients (including 170 revisions) undergoing primary and revision stapes surgery were reviewed, with Pearson chi-square and multivariable logistic regression analysis performed. RESULTS: Rates of postoperative air-bone gap (ABG) closure to ≤10 dB were significantly worse in the revision group (40.2% vs 61.8%, P < .001), as were those to ≤20 dB (78.1% vs 90.9%, P < .001). The bone conduction pure tone average worsened by >10 dB in 7.1% of primary cases and 13.1% of revisions (P = .016). The mean postoperative ABG for revision cases was significantly higher at 15.5 dB as compared with 11.0 dB for primaries (P < .001), despite a slightly higher preoperative ABG for primary cases (30.6 vs 28.24 dB, P = .010). In multivariate analysis, revision surgery had an odds ratio 0.41 (P < .001) in closing the ABG to ≤10 dB. Postoperative reparative granuloma (2.4% vs 0.2%, P = .001) and hydrops (1.8% vs 0.2%, P = .008) were higher in revision cases. CONCLUSIONS: Revision stapes surgery was found to have less predictable and inferior results as compared with primary cases. LEVEL OF EVIDENCE: 4 (retrospective observational research).

Outcomes After Tympanic Membrane Perforation During Primary Stapes Surgery for Otosclerosis.

OBJECTIVE/HYPOTHESIS: Stapes surgery is occasionally complicated by an intraoperative tympanic membrane perforation (ITMP), traditionally indicating abortion of the procedure due to concerns for postoperative infection and sensorineural hearing loss (SNHL). This work examines outcomes and complications in completed primary stapes surgeries with and without ITMP. STUDY DESIGN: Retrospective review. METHODS: All patients diagnosed with otosclerosis between February 2008 and September 2017 at a tertiary otology referral center were reviewed retrospectively. Primary outcome measures were post-operative air-bone gap (ABG), air conduction and bone conduction pure tone averages, and post-operative complications. RESULTS: Review revealed 652 primary stapes operations meeting inclusion criteria, of which ITMP occurred in 10. There were no significant differences in pre-operative hearing metrics or demographic characteristics between ears with and without ITMP. There were also no significant differences in post-operative ABG (6.4 vs. 8.0 dB HL, P = .43) or change in ABG after surgery (-21.6 vs. -18.2 dB, P = .34) between these two groups. Patients with ITMP were more likely to complain of post-operative dysgeusia (30.0% vs. 5.3%, P = .015) but were no more likely to develop reparative granuloma, otitis media, or SNHL (P > .05). CONCLUSIONS: The first review of ITMP and hearing outcomes after stapes surgery is presented. Our findings suggest that it is likely safe and appropriate to proceed with primary stapes surgery and concurrent tympanoplasty in the presence of a small ITMP with minimal risk of infection, SNHL, or worsened hearing outcomes. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2026-E2030, 2021.

Association Between the Duration of Hearing Loss and Hearing Outcomes in Surgery for Otosclerosis.

INTRODUCTION: Hearing loss due to otosclerosis is effectively treated with surgery. The association between duration of hearing loss and surgical outcomes is unknown. STUDY DESIGN: Retrospective review. SETTING: Large otology referral center. METHODS: Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were evaluated according to their self-reported duration of hearing loss. Closure of the air-bone gap (ABG) was the primary outcome measure. RESULTS: A total of 580 stapes operations were included. Sixteen percent of patients reported hearing loss for ≤1 year; 25%, >1 to ≤5 years; 24%, >5 to ≤10 years; 24%, >10 to ≤20 years; and 12%, >20 years, respectively. Average pre- and postoperative ABGs were 26.1 and 9.6 dB (P < .0005). Patients with longer duration of hearing loss had worse preoperative ABGs (P < .0005). After surgery, patients with longer duration of hearing loss had a greater reduction in their ABGs (P < .0005) such that the remaining ABG was not associated with duration of hearing loss (P > .05). There were no significant associations between the duration of hearing loss and complication rates or the need for revision surgery. CONCLUSION: Otosclerosis is effectively treated with surgery even after a long duration of hearing loss, provided that sensorineural hearing and word recognition are favorable. Although far-advanced otosclerosis has known poorer hearing outcomes after stapes surgery, a long duration of hearing loss is an unreliable surrogate for this.

Hearing Outcomes and Complications in Stapes Surgery for Otosclerosis Performed Under General or Local Anesthesia.

OBJECTIVE: Stapes surgery is highly successful in reducing or eliminating the audiometric air-bone gap (ABG) related to otosclerosis, and it can be performed under general anesthesia or local anesthesia with sedation. Literature on the relative outcomes of these 2 modalities is lacking. The purpose of this study was to compare hearing outcomes for these 2 modalities in a large patient population. STUDY DESIGN: Retrospective review. SETTING: Large otology referral center. METHODS: Patients undergoing primary stapes surgery for otosclerosis from 2005 to 2017 were grouped by anesthetic modality and their cases reviewed. Pre- and postoperative ABGs were primary outcomes. RESULTS: A total of 580 patients undergoing stapes surgery were included: 46% received local anesthesia and 54% received general anesthesia. These 2 groups were similar in demographic and disease characteristics. Mean preoperative ABGs were 25.6 and 26.6 dB for patients undergoing local and general anesthesia, respectively (P = .2); mean postoperative ABGs were 9.5 and 9.7 dB (P = .9). There were no significant differences in the rates of complications, the need for revision surgery, or the need to abort surgery intraoperatively between local and general anesthesia. CONCLUSION: Consistent with limited prior data, in this cohort stapes surgery yielded similar hearing outcomes whether performed under general anesthesia or local anesthesia with sedation. While we report the largest sample size to date, this study, like previous work, carries the potential for sampling bias. Prospective study comparing local and general anesthesia for stapes surgery is needed.

Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery.

OBJECTIVES: To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses. METHODS: A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed. RESULTS: Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively (P < .0001), while the ABG improved on average from 27 dB to 9 dB (P < .0001). There was no significant difference in postoperative ABG between primary and revision stapes surgery (6 dB vs 10 dB, P = .07). These results persisted through long-term follow-up in a subgroup of patients with significantly longer follow-up time (mean 44 months). There was no significant change in BC PTA or word recognition scores. Three patients underwent subsequent revisions, one patient developed sensorineural hearing loss. CONCLUSION: Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

Stapes surgery with a persistent stapedial artery.

PURPOSE: To review surgical outcomes of stapes surgery for otosclerosis with persistence of the stapedial artery. MATERIALS AND METHODS: A retrospective case review of a tertiary neurotology referral center of patient with otosclerosis undergoing primary stapes surgery between 2010 and 2017 found to have a persistent stapedial artery. Stapedectomy was performed with or without cauterization of the stapedial artery. The primary outcome measures include pre- and postoperative hearing as well complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Neurologic complications, including facial nerve function, were assessed. RESULTS: Four patients out of 853 with otosclerosis undergoing stapedectomy were found to have a persistence of the stapedial artery. Mean AC PTA was 55 dB preoperatively, and 24 dB postoperatively (p = .0041), while the ABG improved on average from 31 dB to 6 dB (p = .0014). Mean follow-up time was 32 months, and there were no significant complications. Facial nerve function was preserved in all patients (House-Brackmann grade I/VI). CONCLUSIONS: In the case of a persistent stapedial artery, excellent hearing outcomes are achievable for otosclerosis via stapedectomy without an apparent increased risk of neurologic complication.

Management of the Clinical and Academic Mission in an Urban Otolaryngology Department During the COVID-19 Global Crisis.

OBJECTIVE: The objective of this study was to assess the strategic changes implemented in the departmental mission to continue safe delivery of otolaryngology care and to support the broader institutional mission during the COVID-19 pandemic response. STUDY DESIGN: Retrospective assessment was performed to the response and management strategy developed to transform the clinical and academic enterprise. SETTING: Large urban tertiary care referral center. RESULTS: The departmental structure was reorganized along new clinical teams to effectively meet the system directives for provision of otolaryngology care and support for inpatient cases of COVID-19. A surge deployment schedule was developed to assist frontline colleagues with clinical support as needed. Outpatient otolaryngology was consolidated across the system with conversion of the majority of visits to telehealth. Operative procedures were prioritized to ensure throughput for emergent and time-critical urgent procedures. A tracheostomy protocol was developed to guide management of emergent and elective airways. Educational and research efforts were redirected to focus on otolaryngology care in the clinical context of the COVID-19 crisis. CONCLUSION: Emergence of the COVID-19 global health crisis has challenged delivery of otolaryngology care in an unparalleled manner. The concerns for preserving health of the workforce while ethically addressing patient career needs in a timely manner has created significant dilemmas. A proactive, thoughtful approach that reorganizes the overall departmental effort through provider and staff engagement can facilitate the ability to meet the needs of otolaryngology patients and to support the greater institutional mission to combat the pandemic.

Association Between Body Mass Index and Complications in Acoustic Neuroma Surgery.

OBJECTIVES: Elevated body mass index (BMI) is a risk factor for surgical complications, but data in acoustic neuroma surgery are conflicting and limited to small single-institution studies. This work evaluates associations between BMI and complications in surgery for acoustic neuroma (AN). STUDY DESIGN: Retrospective review. SETTING: Two tertiary otology referral institutions. SUBJECTS AND METHODS: Patients undergoing surgery for AN. Univariate and multivariate analysis of association between BMI and complications was performed using two-tailed t tests and binary logistic regression. RESULTS: BMI ranged from 18.0 kg/m2 to 63.9 kg/m2 with mean of 29.2 kg/m2 among 362 included patients. High BMI was associated with increased risk of cerebrospinal fluid (CSF) leak (p = 0.003) and need for revision surgery within 6 months (p = 0.03). CSF leak occurred in 11.6% of obese patients (BMI ≥ 30.0) and 5.1% of patients with BMI < 30.0. There was no association between BMI and post-operative intracranial hemorrhage, wound infection, or incomplete resection (p > 0.05). Multivariate analysis revealed BMI was associated with CSF leak (odds ratio 1.11 per BMI point, p = 0.002) and need for revision surgery (odds ratio 1.07 per BMI point, p = 0.02) independent of age, gender, tumor size, or surgical approach. CONCLUSIONS: The largest series to date investigating BMI in acoustic surgery is presented. Elevated BMI is strongly associated with CSF leak and need for revision surgery but not with other complications. Obese or overweight patients undergoing acoustic neuroma resection should be counseled of their increased risk of CSF leak.

Evolving Role of Non-Total Resection in Management of Acoustic Neuroma in the Gamma Knife Era.

OBJECTIVE: To examine patients with residual tumor after vestibular schwannoma (VS) resection with focus on need for further therapy, including stereotactic radiosurgery (SRS) and revision surgery. STUDY DESIGN AND SETTING: Retrospective review at two tertiary otology referral centers. PATIENTS AND INTERVENTION: Patients undergoing primary surgery for VS from 2007 to 2017. MAIN OUTCOME MEASURE: Degree of resection and need for further treatment. RESULTS: Of 289 patients undergoing surgery, 38 (13.1%) underwent subtotal resections (<95% of tumor resected) and 77 (26.6%) underwent near-total resections (≥95% but <100%). Patients with any residual tumor had larger tumors preoperatively (mean estimated volume 6.3 cm versus 2.1 cm, p < 0.0005) but were otherwise clinically and demographically similar to the population as a whole. Further treatment (surgery or SRS) was needed in 4.6, 14.3, and 50.0% of patients after gross total, near-total, and subtotal resections, respectively (p < 0.0005). Patients undergoing additional therapy had larger residual tumors (median post- to preoperative estimated volume ratio 0.09 versus 0.01, p < 0.0005). Patients undergoing subtotal and near-total resections had poorer facial function at ultimate follow up than those undergoing gross total resections (p = 0.001), likely due to larger tumors and more difficult resections. Literature review revealed higher rates of gross total resection as well as facial palsy in the pre-SRS era. CONCLUSION: Residual tumor following VS resection is more common today than in the pre-SRS era. Availability of SRS may encourage leaving residual tumor intraoperatively to preserve neural structures. Current surgical strategies decrease surgical morbidity but necessitate further treatment in over 10% of cases.

Hydroxyapatite cement cranioplasty for translabyrinthine surgery: A single institution experience.

OBJECTIVE: To assess complication rates in hydroxyapatite cement (HAC) cranioplasty for translabyrinthine acoustic surgery compared with historical controls. METHODS: Retrospective chart review of patients undergoing de novo translabyrinthine surgery with HAC cranioplasty without concurrent adipose tissue graft or additional material between 2010 and 2017 at a tertiary otology center. RESULTS: Fifty-two patients underwent HAC cranioplasty during the study period. The average length of follow-up was 30.5 months. HAC cranioplasty was associated with acceptable rates of cerebrospinal fluid leak (3.8%), wound or intracranial infection (5.8%), need for unplanned revision surgery (9.6%), and all complications (15.3%). All complications occurred within 5 months of surgery. No delayed wound infections or implant extrusions occurred. CONCLUSION: HAC cranioplasty has an acceptable complication profile for translabyrinthine surgery and is a viable alternative to abdominal fat grafting without associated donor site morbidity. LEVEL OF EVIDENCE: 4 Laryngoscope, 130:206-211, 2020.

Natural History of Facial Weakness Following Surgery of the Cerebellopontine Angle: A Tertiary Care Cohort.

OBJECTIVE: Facial function is a key outcome in surgery of the cerebellopontine angle (CPA). This study describes the natural history of facial weakness after CPA surgery. STUDY DESIGN AND SETTING: Retrospective study of two tertiary centers. PATIENTS AND INTERVENTION: Patients undergoing surgery for CPA tumors from 2003 to 2017 with preoperatively normal facial function and without subsequent surgical or adjuvant therapy. MAIN OUTCOME MEASURE: Serial facial nerve examinations using the House-Brackmann (HB) scale. RESULTS: Of 301 patients examined, 149 (49.5%) had facial weakness postoperatively and 74.5% of these occurred within 24 hours. Of patients with HB-1 function within 24 hours after surgery, 95.3% had HB-1 function and 100% had HB-3 or better function at last follow-up. Of patients with HB-4 or worse function within 24 hours after surgery, 22.6% ultimately achieved HB-1 function and 83.9% ultimately achieved HB-3 or better function. By 180 days postoperatively, 83.7% of patients' facial function had stabilized. At last follow-up, 3.0% of patients had facial function poorer than HB-3, which was associated with subtotal resections (12.9% vs. 4.4% for near total and 0.6% for gross total resections, p = 0.002), aspirin use (10.6% vs. 1.6%, p = 0.001), larger tumors (p < 0.0005), longer surgery (p < 0.002), and immediate versus delayed postoperative facial weakness (p = 0.002). CONCLUSIONS: Facial function over time after CPA surgery is presented. While facial function immediately after surgery correlates with future function, delayed weakness or improvement is common. These data inform patient counseling both preceding and following surgery.

HIV, Tuberculosis, and Otogenic Intracranial Sepsis: A Devastating Disease With a Subtle Presentation.

OBJECTIVES: To undertake a large-scale review of otogenic intracranial sepsis in an area of highly prevalent HIV and tuberculosis (TB) to re-examine and inform early diagnosis and treatment efforts. METHODS: Seventy-seven consecutive cases of otogenic intracranial sepsis in KwaZulu-Natal, South Africa were reviewed for demographics, presentation, imaging, HIV status, culture results, and outcomes. RESULTS: The most common intracranial complications were intracranial abscess (46.8%), hydrocephalus (31.2%), subdural empyema (28.6%), and epidural empyema (26.0%). Ear discharge (87.0%), postauricular abscess (29.9%), and hearing loss (29.9%) were notable presenting symptoms. Overall mortality was 15.6%. Of the 45.5% of patients with HIV testing, 54.2% were HIV+, Mortality among HIV+ patients was 15.8% but only 6.3% in HIV- patients (p = 0.61, OR = 2.8). Eight patients (10.4%) had culture or histological evidence of TB infection. CONCLUSIONS: Otogenic intracranial complications continue to present late and are associated with significant mortality and morbidity, despite advances in diagnostic and treatment modalities. This study represents one of the largest case-series in the literature, and the first to specifically evaluate the effects of HIV and TB infection.Patient presentation and severity of illness varied; however, a majority of patients presented with ear discharge and no focal neurological signs. An effect size for higher mortality among HIV+ patients compared with HIV- patients was noted but was not significant. Tuberculosis infection was prevalent compared with previous studies.This study reinforces the need for enhanced screening and early treatment of ear disease to minimize associated mortality and morbidity, particularly in immunocompromised patients.