Surgical Navigation in the Anterior Skull Base Using 3-Dimensional Endoscopy and Surface Reconstruction.

Importance: Image guidance is an important adjunct for endoscopic sinus and skull base surgery. However, current systems require bulky external tracking equipment, and their use can interrupt efficient surgical workflow. Objective: To evaluate a trackerless surgical navigation system using 3-dimensional (3D) endoscopy and simultaneous localization and mapping (SLAM) algorithms in the anterior skull base. Design, Setting, and Participants: This interventional deceased donor cohort study and retrospective clinical case study was conducted at a tertiary academic medical center with human deceased donor specimens and a patient with anterior skull base pathology. Exposures: Participants underwent endoscopic endonasal transsphenoidal dissection and surface model reconstruction from stereoscopic video with registration to volumetric models segmented from computed tomography (CT) and magnetic resonance imaging. Main Outcomes and Measures: To assess the fidelity of surface model reconstruction and accuracy of surgical navigation and surface-CT model coregistration, 3 metrics were calculated: reconstruction error, registration error, and localization error. Results: In deceased donor models (n = 9), high-fidelity surface models of the posterior wall of the sphenoid sinus were reconstructed from stereoscopic video and coregistered to corresponding volumetric CT models. The mean (SD; range) reconstruction, registration, and localization errors were 0.60 (0.24; 0.36-0.93), 1.11 (0.49; 0.71-1.56) and 1.01 (0.17; 0.78-1.25) mm, respectively. In a clinical case study of a patient who underwent a 3D endoscopic endonasal transsphenoidal resection of a tubercular meningioma, a high-fidelity surface model of the posterior wall of the sphenoid was reconstructed from intraoperative stereoscopic video and coregistered to a volumetric preoperative fused CT magnetic resonance imaging model with a root-mean-square error of 1.38 mm. Conclusions and Relevance: The results of this study suggest that SLAM algorithm-based endoscopic endonasal surgery navigation is a novel, accurate, and trackerless approach to surgical navigation that uses 3D endoscopy and SLAM-based algorithms in lieu of conventional optical or electromagnetic tracking. While multiple challenges remain before clinical readiness, a SLAM algorithm-based endoscopic endonasal surgery navigation system has the potential to improve surgical efficiency, economy of motion, and safety.

Intrasellar Arachnoid Diverticulae as a Risk Factor for Intraoperative Cerebrospinal Fluid Leakage in Patients Undergoing Endoscopic Transsphenoidal Surgery.

BACKGROUND AND OBJECTIVES: Intrasellar arachnoid diverticulae can often be identified on preoperative imaging in patients undergoing endoscopic transsphenoidal surgery. The objective of this study was to characterize arachnoid diverticulae both qualitatively and quantitatively in a large institutional cohort of patients with pituitary tumors and to evaluate its association with intraoperative cerebrospinal fluid (CSF) leak. METHODS: Preoperative imaging studies of 530 patients who underwent primary endoscopic transsphenoidal resection of pituitary tumors were examined both quantitatively and qualitatively for the presence of an intrasellar arachnoid diverticulum. A matched cohort analysis was performed to compare patients with a "significant" (>50% sellar depth) diverticulum with those with nonsignificant/no diverticulum. Morphologically, diverticulae were separately classified as Type 1 (ventral CSF cleft with no tumor/gland tissue between sellar face and infundibulum) or Type 2 (central CSF cleft with tumor/gland tissue between sellar face and infundibulum). RESULTS: Arachnoid diverticulae were noted in 40.2% of cases, and diverticulum depth was linearly correlated with tumor size and body mass index. A significant diverticulum was identified in 66 cases (12.5%) and was significantly associated with the functional tumor subtype (P = .005) and intraoperative CSF leak (P < .001). Type 1 clefts were associated with nonfunctional pathology (P = .034) and the presence of suprasellar extension (P = .035) and tended to be deeper than Type 2 clefts (P < .001), with a higher incidence of intraoperative CSF leak (P = .093). On logistic regression analysis, only the presence of a significant diverticulum was independently associated with intraoperative CSF leak (odds ratio 4.545; 95% CI 2.418-8.544; P < .001). CONCLUSION: The presence of an intrasellar arachnoid diverticulum should alert the surgeon to an elevated risk of intraoperative CSF leak during transsphenoidal surgery for pituitary tumors. A relatively limited surgical exposure tailored to the craniocaudal extent of the sellar pathology should be considered in these patients.

Inner Ear Breaches from Vestibular Schwannoma Surgery: Revisiting the Incidence of Otologic Injury from Retrosigmoid and Middle Cranial Fossa Approaches.

OBJECTIVE: To assess the rate of iatrogenic injury to the inner ear in vestibular schwannoma resections. STUDY DESIGN: Retrospective case review. SETTING: Multiple academic tertiary care hospitals. PATIENTS: Patients who underwent retrosigmoid or middle cranial fossa approaches for vestibular schwannoma resection between 1993 and 2015. INTERVENTION: Diagnostic with therapeutic implications. MAIN OUTCOME MEASURE: Drilling breach of the inner ear as confirmed by operative note or postoperative computed tomography (CT). RESULTS: 21.5% of patients undergoing either retrosigmoid or middle fossa approaches to the internal auditory canal were identified with a breach of the vestibulocochlear system. Because of the lack of postoperative CT imaging in this cohort, this is likely an underestimation of the true incidence of inner ear breaches. Of all postoperative CT scans reviewed, 51.8% had an inner ear breach. As there may be bias in patients undergoing postoperative CT, a middle figure based on sensitivity analyses estimates the incidence of inner ear breaches from lateral skull base surgery to be 34.7%. CONCLUSIONS: A high percentage of vestibular schwannoma surgeries via retrosigmoid and middle cranial fossa approaches result in drilling breaches of the inner ear. This study reinforces the value of preoperative image analysis for determining risk of inner ear breaches during vestibular schwannoma surgery and the importance of acquiring CT studies postoperatively to evaluate the integrity of the inner ear.

Morphological Classification of Pituitary Tumors With Suprasellar Extension.

BACKGROUND AND OBJECTIVES: The objective of this study was to study the association among various morphological parameters and surgical outcomes in pituitary macroadenomas with suprasellar extension. METHODS: MRI studies of 160 patients undergoing endoscopic transsphenoidal resection of pituitary macroadenomas with suprasellar extension were reviewed. In the coronal plane, tumors were classified into Type 1 (dome-shaped, no constriction at the level of diaphragma sellae) and Type 2 (dumbbell-shaped, with constriction at the level of diaphragma sellae). Based on the dome-to-neck ratio (D/Nr), Type 2 tumors were further classified as Type 2A (wide neck; D/Nr >1 and <1.3) and Type 2B (narrow neck; D/Nr ≥1.3). Surgical outcomes and complications were analyzed using a logistic regression model. Overall extent of resection (EOR) and presence of residual sellar-suprasellar tumor was separately assessed in all patients with available postoperative MRI (n = 149). RESULTS: There were 108 Type 1 tumors and 26 patients each in the Type 2A and Type 2B subgroups. Tumor subtype was significantly associated with tumor size (P < .001), intraoperative cerebrospinal fluid leak (P < .001), EOR (P < .001), postoperative suprasellar residual tumor (P < .001), and postoperative complications, including diabetes insipidus (P = .005) and visual worsening (P = .003). On multivariate analysis, after adjusting for confounders, Type 2B tumors were negatively associated with EOR (odds ratio [OR] 0.22; 95% CI 0.07-0.68; P = .008) and associated with the presence of postoperative suprasellar residual tumor (OR 18.08; 95% CI 5.20-62.89; P < .001), intraoperative cerebrospinal fluid leak (OR 5.33; 95% CI 1.89-14.99; P = .002), and postoperative diabetes insipidus (OR 4.89; 95% CI 1.67-14.35; P < .001). CONCLUSION: Preoperative tumor classification based on D/Nr is clinically and surgically relevant, and Type 2B macroadenomas are significantly associated with lower rates of gross total resection and higher rates of postoperative complications after endoscopic transsphenoidal resection.

Development of a Predictive Model for Persistent Dizziness Following Vestibular Schwannoma Surgery.

OBJECTIVE: In an era of vestibular schwannoma (VS) surgery where functional preservation is increasingly emphasized, persistent postoperative dizziness is a relatively understudied functional outcome. The primary objective was to develop a predictive model to identify patients at risk for developing persistent postoperative dizziness after VS resection. METHODS: Retrospective review of patients who underwent VS surgery at our institution with a minimum of 12 months of postoperative follow-up. Demographic, tumor-specific, preoperative, and immediate postoperative features were collected as predictors. The primary outcome was self-reported dizziness at 3-, 6-, and 12-month follow-up. Binary and multiclass machine learning classification models were developed using these features. RESULTS: A total of 1,137 cases were used for modeling. The median age was 67 years, and 54% were female. Median tumor size was 2 cm, and the most common approach was suboccipital (85%). Overall, 63% of patients did not report postoperative dizziness at any timepoint; 11% at 3-month follow-up; 9% at 6-months; and 17% at 12-months. Both binary and multiclass models achieved high performance with AUCs of 0.89 and 0.86 respectively. Features important to model predictions were preoperative headache, need for physical therapy on discharge, vitamin D deficiency, and systemic comorbidities. CONCLUSION: We demonstrate the feasibility of a machine learning approach to predict persistent dizziness following vestibular schwannoma surgery with high accuracy. These models could be used to provide quantitative estimates of risk, helping counsel patients on what to expect after surgery and manage patients proactively in the postoperative setting. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:3534-3539, 2023.

Hajek and Hirsch: Otolaryngology Pioneers of Endonasal Transsphenoidal Pituitary Surgery.

OBJECTIVE: To evaluate the historical descriptive origins of the extracranial transnasal transsphenoidal route to the sphenoid sinus and sella turcica focusing on the works of two otolaryngologists: Markus Hajek (1861-1941) and Oskar Hirsch (1877-1965). DATA SOURCES: A collection of primary references of author publications, and contemporary references and textbooks. REVIEW METHODS: Primary references were reviewed with specific focus on surgical routes to the sphenoid sinus and sella turcica. Chronology was cross-referenced with contemporary publications by contemporaries. Translations from German were conducted by author AM when necessary. RESULTS: Markus Hajek elegantly described the surgical approach to the posterior ethmoids and sphenoid sinus in 1904 using a transnasal route. Building on this foundation, Oskar Hirsch described the fully extracranial endonasal transethmoid transsphenoidal approach in 1909. He was first to describe surgical entrance to the sella using this exclusively unilateral endonasal route, which he demonstrated on a cadaver. He reports performing this procedure on a live patient in April, 1910, under local anesthesia in stages over 5 weeks. For better exposure, Hirsch consolidated his method with Killian's submucosal window resection of the posterior nasal septum allowing for bilateral access to the sphenoid sinus and sella, and completed a single stage procedure on a patient in June 1910. CONCLUSION: Oskar Hirsch was the first to describe and perform a stepwise surgical approach to the sella using an exclusively extracranial, endonasal, transethmoid, and transsphenoidal approach. He built upon his mentor Markus Hajek's approaches to the posterior ethmoid cells and sphenoid sinus. LEVEL OF EVIDENCE: NA: Background information, synthesis from multiple sources emphasizing factual information Laryngoscope, 133:807-813, 2023.

Audiovestibular symptoms and facial nerve function comparing microsurgery versus SRS for vestibular schwannomas: a systematic review and meta-analysis.

OBJECTIVE: Surgery and radiosurgery represent the most common treatment options for vestibular schwannoma. A systematic review and meta-analysis were conducted to compare the outcomes of surgery versus stereotactic radiosurgery (SRS). METHODS: The Cochrane library, PubMed, Embase, and clinicaltrials.gov were searched through 01/2021 to find all studies on surgical and stereotactic procedures performed to treat vestibular schwannoma. Using a random-effects model, pooled odds ratios (OR) and their 95% confidence intervals (CI) comparing post- to pre-intervention were derived for pre-post studies, and pooled incidence of adverse events post-intervention were calculated for case series and stratified by intervention type. RESULTS: Twenty-one studies (18 pre-post design; three case series) with 987 patients were included in the final analysis. Comparing post- to pre-intervention, both surgery (OR: 3.52, 95%CI 2.13, 5.81) and SRS (OR: 3.30, 95%CI 1.39, 7.80) resulted in greater odds of hearing loss, lower odds of dizziness (surgery OR: 0.10; 95%CI 0.02, 0.47 vs. SRS OR: 0.22; 95%CI 0.05, 0.99), and tinnitus (surgery OR: 0.23; 95%CI 0.00, 37.9; two studies vs. SRS OR: 0.11; 95%CI 0.01, 1.07; one study). Pooled incidence of facial symmetry loss was larger post-surgery (14.3%, 95%CI 6.8%, 22.7%) than post-SRS (7%, 95%CI 1%, 36%). Tumor control was larger in the surgery (94%, 95%CI 83%, 98%) than the SRS group (80%, 95%CI 31%, 97%) for small-to-medium size tumors. CONCLUSION: Both surgery and SRS resulted in similar odds of hearing loss and similar improvements in dizziness and tinnitus among patients with vestibular schwannoma; however, facial symmetry loss appeared higher post-surgery.

Decreased Incidence of CSF Leaks after Skull Base Fractures in the 21st Century: An Institutional Report.

Objectives Cerebrospinal fluid (CSF) leaks are a possible complication in patients with skull base fractures (SBFs). The widely cited incidence of CSF leaks is 10 to 30% in SBF patients; however, this estimate is based only on a few outdated studies. A recent report found CSF leaks in <2% SBF patients, suggesting the incidence may be lower now. To investigate this, we report here our institutional series. Design This study is a retrospective chart review. Setting The study was conducted at two major academic medical centers (2000-2018). Participants Adult patients with SBF were included in this study. Main Outcome Measures Variables included age, gender, CSF leak within 90 days, management regimen, meningitis within 90 days, and 1-year mortality. Results Among 4,944 patients with SBF, 199 (4%) developed a CSF leak. SBF incidence was positively correlated with year of clinical presentation ( r -squared 0.78, p < 0.001). Among CSF leaks, 42% were conservatively managed, 52% were treated with lumbar drain, and 7% required surgical repair. Meningitis developed in 28% CSF leak patients. The 1-year mortality for all SBF patients was 11%, for patients with CSF leaks was 12%, and for patients with meningitis was 16%. Conclusion In the largest institutional review of SBF patients in the 21st century, we found CSF leak incidence to be 4%. This is lower than the widely cited range of 10 to 30%. Nevertheless, morbidity and mortality associated with this complication remains clinically significant, and SBF patients should continue to be monitored for CSF leaks. We provide here our institutional treatment algorithm for these patients that may help to inform the treatment strategy at other institutions.

Impact of Powered Air-Purifying Respirator Devices on Word Recognition in Health Care Providers.

The coronavirus 2019 pandemic has increased the use of powered air-purifying respirator (PAPR) devices, which produce appreciable noise levels during filtration. Our objective was to determine if active PAPR usage significantly impairs auditory communication in health care providers. We additionally sought to assess what volume of speech presentation was required for adequate communication with providers wearing a PAPR. In subjects with normal hearing at baseline, audiometric data demonstrated a 93% (95% CI, 86%-99%) decrease in word recognition scores during active PAPR usage. Presentation at 85 to 90 dB was needed to obtain word recognition scores similar to baseline in subjects with normal hearing without a PAPR. Pure tone averages also significantly decreased with PAPR usage, by 54 dB (95% CI, 46-62). Active PAPR usage has a substantial impact on auditory perception when utilized by health care providers. The potential longer-term effect of these devices on providers with regular active usage is of interest for future study.

Tumor Control Following Stereotactic Radiosurgery in Patients with Vestibular Schwannomas - A Retrospective Cohort Study.

BACKGROUND: To better counsel vestibular schwannoma patients, it is necessary to understand the tumor control rates of stereotactic radiosurgery (SRS). OBJECTIVES: To determine tumor control rates, factors determining control and complication rates following SRS. METHODS: Tertiary hospital retrospective cohort. RESULTS: 579 tumors (576 patients) were treated with SRS. 477 tumors (474 patients, 82%) had ≥1 year follow up and 60% (344) ≥3 years follow up. 88% of tumors had primary SRS and 6.7% salvage SRS. Median follow up time was 4.6 years. At 3 years, the tumor control rate of primary SRS was 89% (258 of 290) in sporadic tumors compared to 43% in Neurofibromatosis type II (3 of 17) (p < 0.01). Our bivariable survival data analysis showed that Neurofibromatosis type II, documented pre-SRS growth, tumor measured by maximum dimension, SRS given as nonprimary treatment increased hazard of failure to control. There was one case of malignancy and another of rapid change following intra-tumoral hemorrhage. For tumors undergoing surgical salvage (25 of 59), 56% had a total or near-total resection, 16% had postoperative CSF leak, with 12% new facial paralysis (House-Brackmann grade VI) and worsening of facial nerve outcomes (House-Brackmann grade worse in 59% at 12 mo). CONCLUSIONS: Control of vestibular schwannoma after primary SRS occurs in the large majority. Salvage surgical treatment was notable for higher rates of postoperative complications compared to primary surgery reported in the literature.

A novel dual-network architecture for mixed-supervised medical image segmentation.

In medical image segmentation tasks, deep learning-based models usually require densely and precisely annotated datasets to train, which are time-consuming and expensive to prepare. One possible solution is to train with the mixed-supervised dataset, where only a part of data is densely annotated with segmentation map and the rest is annotated with some weak form, such as bounding box. In this paper, we propose a novel network architecture called Mixed-Supervised Dual-Network (MSDN), which consists of two separate networks for the segmentation and detection tasks respectively, and a series of connection modules between the layers of the two networks. These connection modules are used to extract and transfer useful information from the detection task to help the segmentation task. We exploit a variant of a recently designed technique called 'Squeeze and Excitation' in the connection module to boost the information transfer between the two tasks. Compared with existing model with shared backbone and multiple branches, our model has flexible and trainable feature sharing fashion and thus is more effective and stable. We conduct experiments on 4 medical image segmentation datasets, and experiment results show that the proposed MSDN model outperforms multiple baselines.

Skull Base Osteomyelitis Complicated by Petrous Internal Carotid Artery Blowout.

Skull base osteomyelitis (SBO) is an invasive infection of the external auditory canal, with involvement of the skull base, typically in the elderly diabetic population. Diagnosis may be challenging, as it requires a combination of clinical, laboratory, and radiographical findings. The mainstay of treatment is long-term antibiotic therapy, but surgical debridement of the temporal bone may be necessary in refractory cases. Commonly reported complications include cranial neuropathies, meningitis, temporal lobe abscess, and dural venous sinus thrombosis. A rare and life-threatening complication of SBO is petrous internal carotid artery (ICA) blowout, which has been described as presenting with bleeding from the ear. Here, we describe the case of a 77-year-old woman with SBO complicated by a petrous ICA blowout, which presented with fulminant epistaxis. To our knowledge, this is the second reported case of a massive hemorrhage from a petrous ICA blowout secondary to SBO and the first presentation with massive epistaxis. We present this case to raise awareness of this potential impending complication in patients with SBO and recommend consideration of this etiology when assessing patients with massive epistaxis in the appropriate clinical setting. Level of evidence: III.

The Sinonasal Outcome Test-22 or European Position Paper: Which Is More Indicative of Imaging Results?

OBJECTIVE: The 22-item Sinonasal Outcome Test (SNOT-22) is a trusted measure of symptom severity in chronic rhinosinusitis. The European Position Paper on Rhinosinusitis (EPOS) provides widely accepted diagnostic criteria, which include sinonasal symptoms, their duration, and imaging results. Our objective was to compare these approaches to assessing symptoms to determine if either was more indicative of radiologic findings, to support decisions in telehealth. STUDY DESIGN: Observational outcomes study. SETTING: Tertiary care center. METHODS: In total, 162 consecutive patients provided a structured sinonasal history, completed the SNOT-22, and underwent sinus computed tomography (CT) within 1 month. SNOT-22 scores, EPOS-defined symptom sets, and Lund-Mackay results were assessed. To facilitate direct comparisons, we performed stepwise evaluations of sinonasal symptoms alone and combined with duration. The discriminatory capacity for imaging results was determined through areas under the receiver operating characteristic curves (ROC-AUC) for dichotomous outcomes and ordinal regression for multilevel outcomes. RESULTS: In ROC-AUC analyses, SNOT-22 and EPOS-defined symptoms had similar discriminatory capacity for Lund-Mackay scores, regardless of duration. Within ordinal regression analyses, SNOT-22 nasal scores were significantly associated with Lund-Mackay scores, while EPOS-defined nasal symptoms were not statistically significantly related. CONCLUSIONS: SNOT-22 nasal scores and EPOS-defined nasal symptoms may have similar associations with imaging results when assessed via ROC-AUC, while SNOT-22 may have more association within ordinal data. Understanding the implications of discrete patterns of symptoms may confer benefit, particularly when in-person and fiberoptic exams are limited.

Sinonasal Outcome Scores and Imaging: A Concurrent Assessment of Factors Influencing Their Association.

OBJECTIVE: The overall discriminatory ability of validated instrument scores for computed tomography (CT) findings of chronic rhinosinusitis has limitations and may be modified by multiple factors. To support optimal methods for assessment, we studied which factors could influence this relationship, including the concurrent impact of multiple discrete CT scoring mechanisms, colocalized imaging findings, and nasal comorbid conditions. STUDY DESIGN: Observational outcomes study. SETTING: Academic medical center. METHODS: Patients with sinonasal complaints who completed the 22-item Sinonasal Outcome Test (SNOT-22) and underwent CT were included. Multivariate ordinal regression was utilized to assess associations. CT data were quantified with the Lund-Mackay system, Zinreich system, and a direct measure of maximal mucosal thickness. The impact of incidental findings (mucous retention cysts, periapical dental disease) and nasal comorbid conditions was also assessed. RESULTS: A total of 233 patients were included. SNOT-22 nasal scores were significantly associated with CT results when those with incidental findings were excluded, regardless of the radiologic scoring mechanism utilized: Lund-Mackay regression coefficient, 0.321 (P = .046); Zinreich, 0.340 (P = .033); and maximum mucosal thickness, 0.316 (P = .040). This relationship subsided when incidental findings were present. SNOT-22 overall scores, sleep scores, and psychological domain scores had no significant association with imaging results, regardless of radiologic scoring system utilized. Nasal comorbid conditions had inconsistent associations. CONCLUSIONS: SNOT-22 nasal domain scores were associated with all 3 radiologic scoring systems when incidental findings were absent but not when they were present. Delineating the presence or absence of these colocalized findings affected the relationship between SNOT-22 scores and radiological results, beyond other concurrent factors.

Benign purely intraosseous meningioma of the skull: Diagnosis and surgical outcomes.

Primary intraosseous meningioma (PIM) is a rare subtype of extradural meningiomas that originates within bone. We aimed to characterize the clinical, radiographic, and pathologic features of PIM and the resulting outcomes following resection. Herein we examined a retrospective case series of all patients with a pathologically confirmed WHO grade I PIM that were managed at one of three tertiary care centers. Patients with tumors that demonstrated extraosseous extension or involvement of the dura mater were excluded. The main outcomes included surgical safety and duration of local tumor control. Nine patients were identified with benign PIMs, presenting with headaches or painless enlarging subcutaneous masses if involving the calvarium or with neurologic deficits if involving the skull base, or otherwise incidentally identified. Surgery was pursued for symptomatic relief and/or tissue diagnosis. Lesions were evaluated by radiographic imaging - including sensitive detection by plain X-ray films - and definitive diagnosis ascertained by histopathological examination. Maximal resection of both calvarial and skull base lesions was safely tolerated. PIM represents a rare benign skull lesion, whose identification depends on the integration of radiographic findings with intraoperative findings and histopathological confirmation; it should be considered in the differential for slow-growing expansile intraosseous lesions of the skull.

Diagnosis of Stapedial Myoclonus Using Endoscopic Visualization.

BACKGROUND: Stapedial myoclonus is an uncommon condition involving the rhythmic contraction of the stapedial tendon that may result in a host of symptoms, including tinnitus . There is a dearth of robust diagnostic modalities to diagnose stapedial myoclonus, and most patients are treated without definitive diagnosis. Herein, we hypothesize that stapedial myoclonus can be readily diagnosed by awake otoendoscopy (see Video, Supplemental Digital Content 1, http://links.lww.com/MAO/A997). CASE REPORT: A 21-year-old healthy male professional singer presented with a rhythmic "thumping sound" heard in both ears for 5 years. Symptoms were triggered by singing and were worse on the right side. Work-up, including otologic exam, audiologic testing, and high resolution imaging, was unrevealing. Given symptomatology, stapedial tendon myoclonus was suspected.While awake in the operating room, an inferior myringotomy was made, and both 1.9 mm 0 and 30 degree 3-CCD Hopkins rod endoscopes were used to visualize the middle ear space using a transcanal approach. There was robust movement of the tendon with patient vocalization that corresponded precisely with the timing of tinnitus. The patient subsequently underwent transection of the right stapedial tendon under general anesthesia using otoendoscopic visualization. The pyramidal eminence was also removed to avoid future regeneration. The patient underwent an identical procedure on the contralateral ear 3 months later with complete resolution of symptoms bilaterally. CONCLUSION: Stapedial myoclonus was diagnosed by transtympanic otoendoscopy in an awake patient. This approach may be readily applied in awake patients suspected of having stapedial myoclonus. Transection of the stapedial tendon in these patients resolves tinnitus.

Prevalence and significance of cranial nerve imaging abnormalities in patients with hereditary neuropathies: Clinical implications at the skull base.

OBJECTIVE: To estimate the prevalence and significance of cranial nerve (CN) imaging abnormalities in patients with hereditary neuropathy and discuss clinical implications. METHODS: We retrospectively analyzed data from patients at four tertiary academic medical centers with hereditary neuropathy diagnoses who had undergone gadolinium-enhanced magnetic resonance imaging (MRI) of the brain or skull base between 2004 and 2018. MRI scans, as well as computed tomography imaging when available, were reviewed and bivariable analysis was performed to identify predictors of CN abnormalities on imaging. RESULTS: Among 39 patients meeting study criteria, 11 had clinical CN deficits (28%) and 8 had CN abnormalities on imaging (21%). Of the patients with CN abnormalities on imaging, half had CN deficits (4/8) and only a quarter had imaging abnormalities of the CNs with the deficits (2/8). Imaging abnormalities were found in varied CNs, including CNs III, V, VII, and the VII/VIII complex in the internal auditory canal. MRI obtained for the purpose of evaluating CN deficits had a statistically significant increased likelihood of containing CN imaging abnormalities. However, CN deficits themselves were not predictive of imaging abnormalities. CONCLUSION: Thickening and enhancement of CNs on MRI may be found in approximately 1/5 of patients with hereditary neuropathies and are inconsistently associated with clinical deficits. These imaging findings should not be mistaken for neoplastic and infectious processes as they may be manifestations of the patients' underlying genetic neuropathy. LEVEL OF EVIDENCE: 4.

Invasive Fungal Carotiditis: A Rare Manifestation of Cranial Invasive Fungal Disease: Case Series and Systematic Review of the Literature.

BACKGROUND: Rhinosinusitis, malignant otitis externa, and skull base osteomyelitis represent a spectrum of cranial invasive fungal disease (IFD). These syndromes have distinct characteristics, yet they may progress to involve similar structures, resulting in inflammation and invasion of the adjacent internal carotid artery (ICA). Invasive fungal carotiditis can have devastating consequences, including cerebral infarction, subarachnoid hemorrhage, and death. METHODS: We retrospectively studied all patients diagnosed with cranial IFD and carotid involvement at our institution from 2003 to 2018. We also searched Medline/PubMed for reports of Aspergillus or Mucorales cranial infections with ICA involvement. All cases with mycologic evidence of cranial IFD and radiographic or pathologic evidence of ICA involvement were included. RESULTS: We identified 78 cases of invasive fungal carotiditis between 1958 and 2018, including 4 cases at our own institution. Forty-one were caused by Aspergillus and 37 by Mucorales species. Presenting symptoms included vision changes (73%), cranial nerve palsy (69%), and headache (42%). Carotid events included occlusion, aneurysm formation, and vessel rupture. Cerebral infarcts occurred in 50% of cases. Mortality at 6 weeks, 12 weeks, and 2 years was 27%, 41%, and 71% respectively. The median time from symptom onset to death was 150 days for cases due to Aspergillus and 51 days for cases due to Mucorales species. CONCLUSIONS: Invasive fungal carotiditis is a rare but morbid manifestation of cranial IFD. Early suspicion of IFD and administration of antifungal treatment, vascular imaging, and endovascular interventions should be considered to reduce the high mortality of this disease.

Variation in Coding Practices for Vestibular Schwannoma Surgery.

Introduction Nationwide databases are frequently used resources for assessing practice patterns and clinical outcomes. However, analyses based on billing codes may be limited by the inconsistent application of current procedural terminology (CPT) codes to specific operations. We investigated the variability among commonly used CPT codes for vestibular schwannomas resection and sought to identify factors that underlie this variation. Methods The surgical procedure for 274 cases of vestibular schwannoma resections from two institutions was reviewed and classified as retrosigmoid, translabyrinthine, or middle fossa approaches. We then assessed the CPT codes assigned to each case and analyzed their association with surgical approach, surgeons involved, the coding specialty, and year of surgery. We further compared the incidence of CPT codes assigned for vestibular schwannoma surgeries in the American College Surgeons National Surgical Quality Improvement Program (NSQIP) database from 2010 to 2014. Results The majority (65%) of vestibular schwannoma resections within the institutional cohort were billed with skull base approach and/or excision codes, whereas 76% of cases in NSQIP were associated with a single craniotomy for tumor code. The use of skull base codes over the past decade increased within our institutional cohort but remained relatively stable within NSQIP. CPT codes did not consistently reflect the operative approaches for vestibular schwannomas. Conclusion We observed significant variability in coding patterns for vestibular schwannoma surgeries within institutions, surgical practices, and national databases. These results call for discretion in interpretation of data from aggregated billing code-based nationwide databases and suggests a role for institutional standardization of CPT assignments for the same approaches.

Mixed-Supervised Dual-Network for Medical Image Segmentation.

Deep learning based medical image segmentation models usually require large datasets with high-quality dense segmentations to train, which are very time-consuming and expensive to prepare. One way to tackle this difficulty is using the mixed-supervised learning framework, where only a part of data is densely annotated with segmentation label and the rest is weakly labeled with bounding boxes. The model is trained jointly in a multi-task learning setting. In this paper, we propose Mixed-Supervised Dual-Network (MSDN), a novel architecture which consists of two separate networks for the detection and segmentation tasks respectively, and a series of connection modules between the layers of the two networks. These connection modules are used to transfer useful information from the auxiliary detection task to help the segmentation task. We propose to use a recent technique called 'Squeeze and Excitation' in the connection module to boost the transfer. We conduct experiments on two medical image segmentation datasets. The proposed MSDN model outperforms multiple baselines.