Jugular Foramen Cerebrospinal Fluid Leak Repaired Via the Infralaybryinthine Approach With Adjunct Use of Intrathecal Fluorescein and Stereotactic Navigation.

OBJECTIVE: This report describes a case of a spontaneous cerebrospinal fluid leak at the jugular foramen that was surgically repaired via the infralabyrinthine approach with adjunct use of intrathecal fluorescein and stereotactic navigation. PATIENTS: A 39-year-old woman presenting with clear otorrhea confirmed to be cerebrospinal fluid (CSF) emanating from a defect in the jugular foramen. INTERVENTION: Surgical repair of the skull base defect using an infralabyrinthine approach to the jugular foramen. During surgery, intrathecal fluorescein and stereotactic navigation were used to localize the defect and confirm a successful repair. MAIN OUTCOME MEASURE: Recurrence of a CSF leak. RESULTS: The defect was successfully repaired using the techniques described, resulting in cessation of the patient's CSF leak. There was no recurrence of the CSF leak up to a 4-month postoperative outpatient follow-up. CONCLUSIONS: Diagnosis and repair of spontaneous otogenic CSF leaks in an uncommon location like the jugular foramen are challenging. This report demonstrates the successful use of the infralabyrinthine approach for control of a CSF from the jugular foramen. In addition, use of techniques, such as intrathecal fluorescein and stereotactic navigation that are not routinely used in otology and neurotology allowed for safe, effective repair of the leak in this case.

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.

Transotic Approach for Resection of Expansile Endolymphatic Sac Tumor.

Objectives and Design Endolymphatic sac tumors (ELSTs) are rare and indolent tumors that arise from the endolymphatic sac in the posterior petrous ridge. We present a video case report illustrating the use of a transotic approach for resection of an expansile ELST. Setting and Participants A 25-year-old male presented with a multiyear history of worsening left-sided hearing loss, vertigo, and headaches. Otoscopy revealed a red mass behind an intact tympanic membrane. Computed tomography revealed a large, locally aggressive mass centered in the posterior petrous temporal bone. Magnetic resonance imaging demonstrated a heterogeneously enhancing 2.4 × 3.1 × 2.4 cm tumor that exerted mass effect on the cerebellar surface with extension into the jugular foramen, tympanic cavity, internal auditory canal, and cistern of the cerebellopontine angle. A transotic approach was planned to obtain the necessary generous exposure. Main Outcome Measures and Results Preoperative angiography revealed arterial supply via the ascending pharyngeal and tumor embolization with Onyx was performed. Surgical resection began with a blind-sac closure created from the external auditory canal. The tympanic membrane and malleus were removed and the incustapedial joint was transected. A subtotal petrosectomy was performed for partial tumor exposure. The facial canal and sigmoid sinus were carefully skeletonized and a labrynthectomy was performed. The tumor was resected using a combination of bipolar cautery and blunt and sharp dissection. For closure, an abdominal fat graft was secured with overlying resorbable mesh followed by sequential closure of all skin layers. Histopathologic analysis revealed an ELST. Conclusion The transotic approach offers wide exposure and facilitates large, complex tumor removal. The link to the video can be found at https://youtu.be/YvhyN8iVi44 .

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.

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.

Facial Nerve Paraganglioma Masquerading as Bell palsy: A Reconstructive Pitfall.

BACKGROUND: Facial paralysis can drastically diminish satisfaction in one's social interactions and overall quality of life. Bell palsy is the most common cause of facial palsy, however, a diagnosis of "atypical" BP may originate from an entirely different pathological process. This case highlights a rare case of facial nerve paraganglioma, initially misdiagnosed as BP, that resulted in facial paralysis from neoplastic invasion of the facial nerve. CASE PRESENTATION: A 66-year old Hispanic woman with systemic lupus erythematosus presented to the plastic surgery clinic with complaints of drooling and being unable to smile. She experienced several episodes of left facial paralysis and was diagnosed with BP at an outside institution. Each episode was only partially responsive to steroid therapy. Imaging at our institution demonstrated lobulated enhancement along the vertical and extratemporal segments of the facial nerve, which prompted surgical intervention. The patient underwent left transmastoid approach for removal of the lesion involving the facial nerve followed by facial nerve reanimation via gracilis free flap without complication. CONCLUSIONS: This report outlines an extraordinarily rare case of a patient with facial nerve paraganglioma. This case represents the importance of reconstructive surgeons in considering a thorough diagnostic work-up with imaging and histopathology in the setting of idiopathic facial paralysis. Successful collaboration between otolaryngology and plastic surgery made streamlined diagnosis and surgical treatment of this unique case possible.

Petrous Apex Cephaloceles: Radiology Features and Surgical Management of a Rare Entity.

OBJECTIVE: To characterize the radiologic findings of petrous apex cephalocele (PAC) in a patient cohort, and report the surgical management for three symptomatic PAC patients and cerebrospinal fluid (CSF) leak via the middle cranial fossa approach. STUDY DESIGN: Retrospective case series. SETTING: Academic center. PATIENTS: Thirty-five patients with PAC were identified by review of the imaging archive between 2008 and 2019 (29 females; mean, 55 yrs; range, 4-86 yrs). All patients underwent magnetic resonance imaging of the skull base and/or computed tomography examination. INTERVENTIONS: Surgical repair of PAC. MAIN OUTCOME MEASURES: Radiologic features of PAC. RESULTS: Radiological features of PAC: 25.7% bilateral; partial or expanded empty sella in 82.9%; arachnoid pits in 14.2%; and enlarged CSF space of optic nerve sheath in 20.0%. Coexisting pathology included temporal, sphenoid, and bilateral jugular foramen meningocele; as well as cribriform, middle crania fossa, and right temporal defect. Three case studies describing the surgical course of spontaneous CSF leak secondary to PAC were managed with the middle cranial fossa approach. CONCLUSIONS: PAC is an exceedingly unusual cause for CSF leak in the adult and pediatric population. A middle fossa approach may be used to treat CSF leak as a result of PAC. Typically, CSF otorrhea originates from an encephalocele that extends via a bony defect in the tegmen tympani or tegmen mastoideum. However, on occasion the source of the CSF otorrhea is not via the tegmen, instead defects in the middle fossa floor, medial to the ridge for the gasserian ganglion (tubercle of Princeteau), need to be considered.

Ipsilateral Cochlear Implantation in the Presence of Observed and Irradiated Vestibular Schwannomas.

OBJECTIVES: Historically, eventual loss of cochlear nerve function has limited patients with neurofibromatosis type 2 (NF2) to auditory brainstem implants (ABI), which in general are less effective than modern cochlear implants (CI). Our objective is to evaluate hearing outcomes following ipsilateral cochlear implantation in patients with NF2 and irradiated vestibular schwannomas (VS), and sporadic VS that have been irradiated or observed. METHODS: Multi-center retrospective analysis of ipsilateral cochlear implantation in the presence of observed and irradiated VS. MESH search in NCBI PubMed database between 1992 and 2019 for reported cases of cochlear implantation with unresected vestibular schwannoma. RESULTS: Seven patients underwent ipsilateral cochlear implantation in the presence of observed or irradiated vestibular schwannomas. Four patients had sporadic tumors with severe-profound contralateral hearing loss caused by presbycusis/hereditary sensorineural hearing loss, and three patients with NF2 lost contralateral hearing after prior surgical resection. Prior to implantation, one VS was observed without growth for a period of 7 years and the others were treated with radiotherapy. Mean post-operative sentence score was 63.9% (range 48-91) at an average of 28 (range 2-84) months follow up. All patients in this cohort obtained open set speech perception. While analysis of the literature is limited by heterogenous data reporting, 85% of implants with observed schwannomas achieved some open set perception, and 67% of patients previously radiated schwannomas. Furthermore, blending literature outcomes for post implantation sentence testing in quiet without lip-reading show 59.0 ± 35% for patients with CI and observed tumors and 55.7 ± 35% for patients with radiated tumors, with both groups ranging 0 to 100%. CONCLUSION: This retrospective series and literature review highlight that hearing outcomes with CI for VS patients are superior to those achieved with ABI. However, important considerations including imaging, delayed hearing loss, and observation time cannot be ignored in this population.

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.

Implementation of Preoperative Screening Protocols in Otolaryngology During the COVID-19 Pandemic.

OBJECTIVE: To highlight emerging preoperative screening protocols and document workflow challenges and successes during the early weeks of the COVID-19 pandemic. METHODS: This retrospective cohort study was conducted at a large urban tertiary care medical center. Thirty-two patients undergoing operative procedures during the COVID-19 pandemic were placed into 2 preoperative screening protocols. Early in the pandemic a "high-risk case protocol" was utilized to maximize available resources. As information and technology evolved, a "universal point-of-care protocol" was implemented. RESULTS: Of 32 patients, 25 were screened prior to surgery. Three (12%) tested positive for COVID-19. In all 3 cases, the procedure was delayed, and patients were admitted for treatment or discharged under home quarantine. During this period, 86% of operative procedures were indicated for treatment of oncologic disease. There was no significant delay in arrival to the operating room for patients undergoing point-of-care screening immediately prior to their procedure (P = .92). DISCUSSION: Currently, few studies address preoperative screening for COVID-19. A substantial proportion of individuals in this cohort tested positive, and both protocols identified positive cases. The major strengths of the point-of-care protocol are ease of administration, avoiding subsequent exposures after testing, and relieving strain on "COVID-19 clinics" or other community testing facilities. IMPLICATIONS FOR PRACTICE: Preoperative screening is a critical aspect of safe surgical practice in the midst of the widespread pandemic. Rapid implementation of universal point-of-care screening is possible without major workflow adjustments or operative delays.

Resection of vestibular schwannomas after stereotactic radiosurgery: a systematic review.

OBJECTIVE: Multiple short series have evaluated the efficacy of salvage microsurgery (MS) after stereotactic radiosurgery (SRS) for treatment of vestibular schwannomas (VSs); however, there is a lack of a large volume of patient data available for interpretation and clinical adaptation. The goal of this study was to provide a comprehensive review of tumor characteristics, management, and surgical outcomes of salvage of MS after SRS for VS. METHODS: The Medline/PubMed, Scopus, CINAHL, Cochrane Library, and Google Scholar databases were queried according to PRISMA guidelines. All English-language and translated publications were included. Studies lacking adequate study characteristics and outcomes were excluded. Cases involving neurofibromatosis type 2, previous MS, or malignant transformation were excluded when possible. RESULTS: Twenty studies containing 297 cases met inclusion criteria. Three additional cases from Rush University Medical Center were added for 300 total cases. Tumor growth with or without symptoms was the primary indication for salvage surgery (92.3% of cases), followed by worsening of symptoms without growth (4.6%) and cystic enlargement (3.1%). The average time to MS after SRS was 39.4 months. The average size and volume of tumor at surgery were 2.44 cm and 5.92 cm3, respectively. The surgical approach was retrosigmoid (42.8%) and translabyrinthine (57.2%); 59.5% of patients had a House-Brackmann (HB) grade of I or II. The facial nerve was preserved in 91.5% of cases. Facial nerve preservation and HB grades were lower for the translabyrinthine versus retrosigmoid approach (p = 0.31 and p = 0.18, respectively); however, fewer complications were noted in the translabyrinthine approach (p = 0.29). Gross-total resection (GTR) was completed in 55.7% of surgeries. Studies that predominantly used subtotal resection (STR) were associated with a lower rate of facial nerve injury (5.3% vs 11.3%, p = 0.07) and higher rate of HB grade I or II (72.9% vs 48.0%, p = 0.00003) versus those using predominantly GTR. However, majority STR was associated with a recurrence rate of 3.6% as compared to 1.4% for majority GTR (p = 0.29). CONCLUSIONS: This study showed that the leading cause of MS after SRS was tumor growth at an average of 39.4 months after radiation. There were no significant differences in outcomes of facial nerve preservation, postoperative HB grade, or complication rate based on surgical approach. Patients who underwent STR showed statistically significant better HB outcomes compared with GTR. MS after SRS was considered by most authors to be more difficult than primary MS. These data support the notion that the surgical goals of salvage surgery are debulking of tumor mass, decreasing compression of the brainstem, and not necessarily pursuing GTR.

Operative Technique and Workflow of Deep Brain Stimulation Surgery With Pre-existing Cochlear Implants.

BACKGROUND: Deep brain stimulation (DBS) surgery in patients with pre-existing cochlear implants (CIs) poses various challenges. We previously reported successful magnetic resonance imaging (MRI)-based, microelectrode recording (MER)-guided subthalamic DBS surgery in a patient with a pre-existing CI. Other case reports have described various DBS procedures in patients with pre-existing CIs using different techniques, leading to varying issues to address. A standardized operative technique and workflow for DBS surgery in the setting of pre-existing CIs is much needed. OBJECTIVE: To provide a standardized operative technique and workflow for DBS lead placement in the setting of pre-existing CIs. METHODS: Our operative technique is MRI-based and MER-guided, following a workflow involving coordination with a neurotology team to remove and re-implant the internal magnets of the CIs in order to safely perform DBS lead placement, altogether within a 24-h time frame. Intraoperative nonverbal communication with the patient is easily possible using a computer monitor. RESULTS: A 65-yr old woman with a 10-yr history of craniocervical dystonia and pre-existing bilateral CIs underwent successful bilateral pallidal DBS surgery at our institution. No merging errors or difficulties in targeting globus pallidus internus were experienced. Also, inactivated CIs do not interfere with MER nor with stimulation, and intraoperative communication with the patient using a computer monitor proved feasible and satisfactory. CONCLUSION: DBS procedures are safe and feasible in patients with pre-existing CIs if precautions are taken following our workflow.

Spontaneous Otogenic Pneumocephalus: Case Series and Update on Management.

Objectives This study is aimed to report the largest independent case series of spontaneous otogenic pneumocephalus (SOP) and review its pathophysiology, clinical presentation, and treatment. Design Four patients underwent a middle cranial fossa approach for repair of the tegmen tympani and tegmen mastoideum. A comprehensive review of the literature regarding this disease entity was performed. Setting U.S. tertiary academic medical center. Participants: Patients presenting to the lead author's clinic or to the emergency department with radiographic evidence of SOP. Symptoms included headache, otalgia, and neurologic deficits. Main Outcome Measures Patients were assessed for length of stay, postoperative length of stay, and neurologic outcome. Three of four patients returned to their neurologic baseline following repair. Results Four patients were successfully managed via a middle cranial fossa approach to repairing the tegmen mastoideum. Conclusion The middle cranial fossa approach is an effective strategy to repair defects of the tegmen mastoideum. SOP remains a clinically rare disease, with little published information on its diagnosis and treatment.

Repair of Temporal Bone Defects via the Middle Cranial Fossa Approach: Treatment of 2 Pathologies With 1 Operation.

BACKGROUND: Temporal bone dehiscence (TBD) often results in leakage of cerebrospinal fluid (CSF) and/or encephalocele. TBD can also occur over the superior semicircular canal, causing debilitating vertigo. Both can be repaired surgically, but traditional treatment is focused only on one pathology, not both. OBJECTIVE: To report our experience in the treatment of TBD via the middle cranial fossa (MCF) approach. METHODS: A retrospective review was conducted for all patients who underwent MCF approach for surgical repair of any temporal fossa dehiscence. RESULTS: A total of 34 patients underwent a total of 37 surgeries. Obesity was prevalent; 21 patients (61.8%) were obese (BMI [body mass index] > 30 kg/m2), and 7 (20.6%) were overweight (BMI 25-30 kg/m2). The most common presenting symptom was hearing disturbance (70.3%), followed by otorrhea (51.4%). Empty sella was noted on computed tomography or magnetic resonance imaging in 15 patients (45.5%). Eight of the 34 patients (23.5%) were found to have superior semicircular canal dehiscence (SCD). Hearing improved with surgical intervention in 25 of 26 patients with hearing loss as a presenting symptom (96%). CSF resolved in 18 of 19 cases (95%). Seventy-three percent of patients reported at least minimal improvement in vertigo. CONCLUSION: TBD may present with symptoms of CSF leak/encephalocele, but may also present with superior SCD. We recommend consistent review of the temporal bone imaging to check for superior SCD, and repair of the SCD first to prevent complications involving the labyrinth and cochlea. MCF approach using a multilayer repair without a lumbar drain is highly effective with minimal risk of complications.

A Cross-sectional Survey of the North American Skull Base Society: Current Practice Patterns of Vestibular Schwannoma Evaluation and Management in North America.

Background Very few studies have examined vestibular schwannoma (VS) management trends across centers and between providers. The objective of this study is to examine current practice trends, variance in treatment philosophies, and nuanced or controversial aspects of VS care across North America. Methods This is a cross-sectional survey of North American Skull Base Society (NASBS) members who report regular involvement in VS care. Results A total of 57 completed surveys were returned. Most respondents claimed to have over 20 years of experience and the majority reported working in an academic practice with an affiliated otolaryngology and/or neurosurgery residency program. Sixty-three percent of respondents claimed to evaluate VS patients in clinic with both an otolaryngologist and neurosurgeon involved. Eighty-six percent of respondents claimed to operate on VS with both an otolaryngologist and neurosurgeon involved, while only 18% of neurosurgeons and 9% of otolaryngologists performed surgery alone. There was a wide range in the number of cases evaluated at each center annually. Similarly, there was wide variation in the number of patients treated with microsurgery and radiation at each center. Additional details regarding management preferences for microsurgery, stereotactic radiosurgery, stereotactic radiotherapy, and conservative observation are presented. Conclusion VS management practices vary between providers and centers. Overall, most centers employ a multidisciplinary approach to management with collaboration between otolaryngology and neurosurgery. Overall, survey responses concur with previous studies suggesting a shift toward conservatism in management.

A Cross-sectional Survey of the North American Skull Base Society on Vestibular Schwannoma, Part 2: Perioperative Practice Patterns of Vestibular Schwannoma in North America.

Introduction Perioperative care of vestibular schwannoma (VS) patients is extremely variable across surgeons and institutions making practice patterns difficult to standardize. No data currently exist detailing this practice variability. Methods The North American Skull Base Society membership was electronically surveyed regarding perioperative care of surgically operated VS patients. Results There were 87 respondents to the survey. Surgical positioning, surgical approach utilized, and perioperative medical adjuncts are quite variable. However, of those performing retrosigmoid approaches, 49% perform this in the supine position, while 33% use a park-bench position with only 2% using the sitting position. In those performing translabyrinthine approaches, 86% perform this in supine position. Although the use of neuromonitoring appears to be standard of care (98%), other than the seventh nerve, there is substantial variability between respondents regarding monitoring of additional cranial nerves. Postoperative antibiotics are used by 65%, postoperative steroids 81%, and postoperative chemical deep vein thrombosis prophylaxis in 68% of survey respondents. Conclusion Although the perioperative adjuncts to VS surgery are variable, there does appear to be a trend in common practice. Therefore, making surgeons aware of these trends may lead to standardized practice or alternatively trials of these variances to instruct which truly improve patient outcomes.

Deep brain stimulation with a pre-existing cochlear implant: Surgical technique and outcome.

BACKGROUND: Patients with previously implanted cranial devices pose a special challenge in deep brain stimulation (DBS) surgery. We report the implantation of bilateral DBS leads in a patient with a cochlear implant. Technical nuances and long-term interdevice functionality are presented. CASE DESCRIPTION: A 70-year-old patient with advancing Parkinson's disease and a previously placed cochlear implant for sensorineural hearing loss was referred for placement of bilateral DBS in the subthalamic nucleus (STN). Prior to DBS, the patient underwent surgical removal of the subgaleal cochlear magnet, followed by stereotactic MRI, frame placement, stereotactic computed tomography (CT), and merging of imaging studies. This technique allowed for successful computational merging, MRI-guided targeting, and lead implantation with acceptable accuracy. Formal testing and programming of both the devices were successful without electrical interference. CONCLUSION: Successful DBS implantation with high resolution MRI-guided targeting is technically feasible in patients with previously implanted cochlear implants by following proper precautions.

Sound localization in unilateral deafness with the Baha or TransEar device.

OBJECTIVE: To evaluate the sound localization capabilities of patients with unilateral, profound sensorineural hearing loss who had been treated with either a bone-anchored hearing device (Baha BP100) or a TransEar 380-HF bone-conduction hearing device. STUDY DESIGN: Nonrandomized, prospective study. SETTING Tertiary referral private practice. PATIENTS: Patients with unilateral, profound sensorineural hearing loss treated with a BP100 (n = 10) or a TransEar (n = 10) device. Patients wore the hearing device for at least 1 month and had normal hearing in the contralateral ear. Ten patients with normal, bilateral hearing were used for control. INTERVENTIONS: Sound localization of a 3-second recorded sound with and without a TransEar or Baha device was assessed using an array of 7 speakers at head level separated by approximately 45 degrees. The recorded sounds were that of a barking dog or a police siren. Randomized trials of 4 presentations per speaker were given for each hearing condition. MAIN OUTCOME MEASURES: Sound localization was assessed by the accuracy in response and the generalized laterality of response. RESULTS: The mean accuracy of speaker localization was 24% and 26% for the aided condition using the BP100 and TransEar devices, respectively. The mean accuracy of laterality judgment was 59% and 69% for the aided condition using the BP100 and TransEar devices, respectively. These results were only slightly better than chance. There was no statistical difference in localization accuracy or laterality judgment between the BP100 and TransEar groups. CONCLUSION: Neither the BP100 nor the TransEar device improved sound localization accuracy or laterality judgment ability in patients with unilateral, profound sensorineural hearing loss compared with performance in the unaided condition.

Hearing outcomes in stapes surgery: a comparison of fat, fascia, and vein tissue seals.

OBJECTIVE: To compare short- and long-term hearing results following stapedectomy using 3 different oval window grafting materials with the same stapes prosthesis. STUDY DESIGN: Database review. SETTING: Tertiary referral private practice. SUBJECTS AND METHODS: Subjects were ears that underwent stapedectomy for otosclerosis, with placement of fat, fascia, or vein as an oval window seal and reconstruction with a titanium bucket handle prosthesis. A total of 365 procedures met these inclusion criteria: 98 fat grafts, 135 fascia grafts, and 132 vein grafts. Outcome measures included short-term (<1 year) and long-term follow-up air-bone gap. We compared the preoperative and postoperative amount of change in air-bone gap and preoperative and postoperative amount of change in the high-frequency bone conduction average. RESULTS: Overall median times to short-term and long-term follow-ups were 2.2 months and 36.1 months, respectively. There were no statistically significant differences between the 3 tissue seal groups in the amount of change in air-bone gap. There was no significant difference in amount of change in high-frequency bone conduction (representing sensorineural hearing level) between the 3 tissue seal groups. Most patients in all 3 groups had an air-bone gap at long-term follow-up of ≤ 10 dB (fat, 79.5%; fascia, 78.8%; and vein, 75.6%), with 90.3% of all patients at ≤ 20 dB. CONCLUSIONS: In both the short-term postoperative period and long-term follow-up, there were no significant differences in hearing results among 3 types of tissue seals of the oval window in stapes surgery. Fat, fascia, and vein grafts all provide satisfactory hearing outcomes in stapedectomy.