Management of Fallopian Canal Spontaneous CSF Leaks, Implications of Elevated Intracranial Pressure: Case Report and Systematic Review of the Literature.

OBJECTIVES: Describe the diagnosis and management of a spontaneous cerebrospinal fluid leak (sCSF-L) through the facial nerve fallopian canal and determine the role of intracranial hypertension (IH). STUDY DESIGN: Retrospective case study and systematic review of the literature. METHODS: Reviewed patient characteristics, radiographic findings, and management of the facial nerve canal CSF leak and postoperative IH. Conducted systematic literature review according to the PRISMA guidelines for surgical management and rates of IH. RESULTS: A 50-year-old female with bilateral tegmen defects and temporal encephaloceles underwent left middle cranial fossa (MCF) repair. Intraoperative CSF egressed from the temporal bone tegmen defects. Facial nerve decompression revealed CSF leak from the labyrinthine segment. A nonocclusive temporalis muscle plug was placed in the fallopian canal, and tegmen repair was completed with bone cement. A ventriculoperitoneal shunt was placed for IH. Postoperative facial nerve function and hearing were normal. A total of 20 studies met inclusion criteria with a total of 25 unique patients. Of 13 total adult cases of fallopian canal CSF leak, there is a 46% recurrence rate, and 86% of patients had documented IH when tested. CONCLUSIONS: Fallopian canal CSF leaks are rare and challenging to manage. Assessment of intracranial hypertension and CSF diversion is recommended along with MCF skull base repair to preserve facial nerve function and conductive hearing.

Management of Post-Infectious Anosmia and Hyposmia: A Systematic Review.

BACKGROUND: Anosmia and hyposmia significantly affect patients' quality of life and have many etiologies, including trauma, inflammatory conditions including chronic rhinosinusitis, neoplasm, and viral infections, such as rhinovirus and SARS-CoV-2. OBJECTIVE: Our purpose was to establish whether a consensus exists regarding optimal management of olfactory dysfunction and to provide insight into the treatment of anosmia in the current climate of increased prevalence secondary to COVID-19. Thus, we aimed to systematically review the literature on the management of non-Chronic-rhinosinusitis- related anosmia/hyposmia. METHODS: PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990 using terms combined with Medical Subject Headings (MeSH). We included articles evaluating management of anosmia and hyposmia written in the English language, with original data, a minimum of 3 months of follow-up except for COVID-related studies, at least 2 patients, and well-defined and measurable outcomes. RESULTS: A total of 3013 unique titles were returned upon the initial search. Of these, 297 abstracts were examined, yielding 19 full texts meeting inclusion criteria (8 with level 1 evidence, 3 with level 2, 1 with level 3, and 7 with level 4). The studies included a total of 1522 subjects, with follow up ranging from 3 to 72 months, with an exception for COVID related studies. Endpoints were based on clinically significant improvements of olfactory functions as measured through validated smell tests. Treatments with the most robust data were intranasal corticosteroids and olfactory training. CONCLUSION: The literature on the treatment of anosmia and hyposmia includes randomized trials showing the efficacy of a few modalities. While further research is needed to expand therapeutic options for this debilitating condition, the current literature supports the use of olfactory training and topical corticosteroids.

Novel Outcome Analysis Tool for Hypoglossal Nerve Stimulator Sensor Lead Function and Comparison by Incision Type (2 Versus 3).

OBJECTIVE: No reported outcome measures have been established to evaluate sensor lead function in the hypoglossal nerve stimulator (HNS). This study describes the development of novel functional outcome measures for intraoperative sensor electrode function and compares 2-incision and 3-incision outcomes for HNS. METHODS: A retrospective cohort study of 100 consecutive patients who underwent HNS between June 2019 and September 2021. Demographic information, intraoperative findings, and immediate postoperative outcomes were recorded. Structured parameters were developed to compare intraoperative waveforms with six outcome measures utilized: waveform syncing, waveform amplitude, sensory current leakage, shark-fin morphology, cardiac artifact, and overall impression. Two sleep surgeons and two sleep medicine specialists compared all waveforms in a blinded fashion and assigned scores on the Likert Scale. RESULTS: The cohort included 50 three-incision and 50 two-incision patients. Age, gender, average body mass index, comorbidity profiles, and sleep endoscopy findings did not significantly differ between the two groups. No major complications occurred. The interclass-correlation-coefficient was greater than 0.7 for all comparisons (good to very good interrater reliability). There was no difference in waveform amplitude, cardiac artifact, sensory current leakage, or shark-fin morphology between the two groups. Waveform syncing and overall impression were statistically better in the 2-incision cohort. CONCLUSIONS: This study is the first to define a structured method of HNS sensor electrode outcome measurement and showed consistent measures by surgeons and sleep medicine specialists. This article supports the transition to the 2-incision technique among surgeons for placement of the sensor lead. Consideration should be given to utilizing this novel tool in the clinical/research setting and validating these measures moving forward. LEVEL OF EVIDENCE: 3 Laryngoscope, 133:423-430, 2023.

Orbital Complications of Acute Sinusitis in Pediatric Patients: Management of Chandler III Patients.

Background: Surgery is often avoided in the setting of pediatric orbital complications from acute sinusitis unless necessitated by alarming ophthalmological signs. Criteria for surgical intervention are not well-defined. Objective: We aim to review our experiences, management practices and patient outcomes over a ten-year period for Chandler III patients. Methods: A retrospective review was performed from January 1, 2007 through December 31, 2016 of patients treated for orbital symptoms secondary to acute sinusitis at a free-standing tertiary-care pediatric hospital. Results: Of the 186 patients reviewed, 42 Chandler III patients were included. Average age was 82.6 months (SD 50.6) with a slight male predominance (M to F, 1.8 to 1). 27 patients (64.3%) underwent intervention including endoscopic sinus surgery (ESS) with or without orbitotomy. Late surgical intervention (>48hrs from admission) demonstrated significant increase in overall length of stay (LOS) when compared with early surgical intervention and/or medical management (median, 6.9 vs 3.6 vs 3.7 days; p < 0.01). Postoperative LOS was also higher in the late surgery group compared with patients who had surgery within 48 hours of admission, but this did not reach statistical significance [median, 3.8 vs 2.8 days, p= 0.12]. There was no significant difference in overall abscess volume between patients who underwent intervention and those who did not (1019 mm3 vs 805 mm3, p = 0.5), but abscess width ≥ 1.2 cm was associated with higher rates of intervention. An alarming extraocular exam was the most common factor associated with surgical intervention. Conclusion: Pediatric subperiosteal orbital abscess may prompt surgical intervention by ESS. An alarming ophthalmologic exam should prompt consideration of early intervention, which may lead to decreased overall and post-operative length of hospital stay. Level of Evidence: 4. Meeting Information: American Rhinologic Society, Fall National Meeting. Chicago, IL, USA. September 8-9, 2017.

Trends in Spontaneous Cerebrospinal Fluid Leak Repairs in the United States, 2009-2018.

Background: Rates of spontaneous cerebrospinal fluid leak (sCSF) repairs have increased in recent decades in line with increases in obesity rates. Objectives: To determine if the national rate of sCSF leak has continued to rise in recent years and to identify associated risk factors utilizing a comprehensive national database comprising most academic medical centers. Methods: A retrospective review from 2009 to 2018 was performed using the Vizient Clinical Database (CDB) of 105 leading academic medical centers in the United States. Patients who underwent CSF leak repair in the CDB database using ICD-9 and ICD-10 diagnostic and procedure codes. Patients with epidural hematomas over the same time frame were used as a control. National rates of craniotomy for sCSF leak repair each quarter were assessed and sCSF leak patient characteristics (age, gender, obesity, hypertension, diabetes) were calculated. Results: The rate of craniotomy for all sCSF leak repairs increased by 10.2% annually from 2009 to 2015 (P < 0.0001). There was no statistically significant change in the rate of epidural hematomas over the same period. The rate of lateral sCSF leak repair increased on average by 10.4% annually from 2009 (218 cases/year) to 2018 (457 cases/year) (P < 0.0001). A statistically significant increase was observed across all regions of the United States (P ≤ 0.005). sCSF leak patients had an average (standard deviation) age of 55.0 (13.2) years and 67.2% were female. Obesity was the only demographic factors that increased significantly over time. Likely due to comorbid factors, Black patients comprise a disproportionately large percentage of lateral sCSF leak repair patients. Conclusions: The rate of craniotomy for spontaneous CSF leaks continues to rise by approximately 10% annually.

Diagnosis of Anosmia and Hyposmia: A Systematic Review.

BACKGROUND: Anosmia and hyposmia have many etiologies, including trauma, chronic sinusitis, neoplasms, and respiratory viral infections such as rhinovirus and SARS-CoV-2. We aimed to systematically review the literature on the diagnostic evaluation of anosmia/hyposmia. METHODS: PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990 using terms combined with Medical Subject Headings (MeSH). We included articles evaluating diagnostic modalities for anosmia, written in the English language, used original data, and had two or more patients. RESULTS: A total of 2065 unique titles were returned upon the initial search. Of these, 226 abstracts were examined, yielding 27 full-text articles meeting inclusion criteria (Level of evidence ranging from 1 to 4; most level 2). The studies included a total of 13,577 patients. The most utilized diagnostic tools were orthonasal smell tests (such as the Sniffin' Sticks and the UPSIT, along with validated abridged smell tests). Though various imaging modalities (including MRI and CT) were frequently mentioned in the workup of olfactory dysfunction, routine imaging was not used to primarily diagnose smell loss. CONCLUSION: The literature includes several studies on validity and reliability for various smell tests in diagnosing anosmia. Along with a thorough history and physical, validated orthonasal smell tests should be part of the workup of the patient with suspected olfactory dysfunction. The most widely studied modality was MRI, but criteria for the timing and sequence of imaging modalities was heterogenous.

Cerebrospinal Fluid Leaks From the Lateral Ventricle: A Case Series.

OBJECTIVES: Describe the diagnosis and management of lateral skull base (LSB) cerebrospinal fluid (CSF) leaks originating from the lateral ventricle. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral academic center. PATIENTS: Patients with CSF leaks with direct communication to the lateral ventricle on preoperative imaging. INTERVENTION: Surgical repair via the middle cranial fossa (MCF) approach. MAIN OUTCOME MEASURES: CSF leak patient characteristics (age, sex, body mass index [BMI]) and postoperative course (complications and CSF leak resolution) were collected. RESULTS: Three patients had CSF leaks from the lateral ventricle and all patients demonstrated encephalomalacia of the temporal lobe on preoperative imaging. Encephalomalacia resulted from trauma in one case (age 5) and neurodegeneration in two cases (age 77 and 84). BMI ranged from 16.3 to 26.6 mg/kg2 and follow-up ranged from 4 to 21 months. Two patients presented with preoperative meningitis and all patients had resolution of CSF leaks after MCF repair. With the exception of the higher rate of meningitis, patient presentations did not differ from other spontaneous CSF leaks through middle fossa defects. There were no minor or major postoperative complications. CONCLUSIONS: CSF leaks from the lateral ventricle represent a rare subset of LSB CSF leaks and can occur in non-obese patients secondary to temporal lobe encephalomalacia. The MCF approach allows for repair of the dura and skull base in this cohort of patients with high-flow CSF leaks and loss of brain parenchyma.

Management of Recurrent Acute Rhinosinusitis: A Systematic Review.

BACKGROUND OBJECTIVE STUDY DESIGN: RARS is a challenging clinical problem that impacts many patients. This article seeks to systematically review the literature on RARS management. METHODS: Cochrane, PubMed, EMBASE, and other databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA guidelines. Inclusion criteria included articles specifically addressing RARS management; studies with 3 or more patients; and articles in English. RESULTS: A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 10 met inclusion criteria (five with level 4 evidence, four with level 3 evidence, one with level 2 evidence). The studies included a total of 890 patients (Age range 5.8 to 53.5 years), with follow up ranging from 1 to 19 months. Endpoints were primarily based on symptomatic improvement, although some articles also reported post-treatment endoscopic and radiographic findings. Management options included medical therapy (intranasal steroids, antibiotics, nasal saline irrigations, N-acetylcysteine, allergy treatment, and decongestants), balloon sinus dilation (BSD), and endoscopic sinus surgery (ESS). Surgical patients (BSD and ESS) had a trend towards greater symptom control than medically-treated patients, but meta-analysis was not possible. CONCLUSION: Despite increasing interest in the treatment of RARS, there remains a lack of consensus regarding optimal management. The literature thus far, largely based on expert opinion, suggests that surgical management, either through balloon sinus dilation or endoscopic sinus surgery, may be helpful in improving symptoms and quality of life in those who do not respond to initial trials of medical management.

Diagnostic Criteria of Recurrent Acute Rhinosinusitis: A Systematic Review.

BACKGROUND: RARS is a challenging clinical phenomenon that affects many patients, and diagnostic criteria for this condition are not fully characterized in the literature. OBJECTIVE: To examine diagnostic criteria for recurrent acute rhinosinusitis (RARS). STUDY DESIGN: Systematic review. METHODS: Cochrane, PubMed (MEDLINE), clinicaltrials.gov, EMBASE, Google Scholar, and Web of Science databases were queried for articles related to RARS dating from 1990 to present, according to PRISMA statement guidelines. Full text articles pertinent to the diagnostic criteria of RARS were included in this review. Inclusion criteria included articles specifically addressing RARS; studies with 3 or more patients; and articles in English. RESULTS: A total of 1022 titles/abstracts potentially related to RARS were identified. Of these, sixty-nine full texts were selected for review, and 22 of these ultimately met inclusion criteria. The level of evidence was generally low. Studies and guidelines have used many different definitions for RARS diagnosis over the years based on symptomatology, physical examination, nasal endoscopy, imaging, and laboratory domains. Clinically important RARS has been defined most commonly as 4 or more discrete episodes of ARS per year, but this frequency is typically based on expert opinion. Additionally, radiologic anatomic associations such as concha bullosa, accessory maxillary os, and narrowed infundibular distance may be associated with RARS. Endoscopic visualization and imaging are sometimes used to confirm the presence of sinus disease during exacerbations of RARS, but there is variability in this practice. CONCLUSION: The diagnostic definition for RARS has developed over time and is currently based on low level 4 and 5 evidence. Because of the migratory definition of RARS, comparing inter-study results of RARS management remains difficult, and future studies should aim to follow current expert guidelines on diagnostic criteria of RARS.

Middle Cranial Fossa Repair of Temporal Bone Spontaneous CSF Leaks With Hydroxyapatite Bone Cement.

OBJECTIVES: To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks. STUDY DESIGN: Retrospective cohort study. METHODS: Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded. RESULTS: The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1-9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short-term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long-term CSF leak recurrences with an average (SD) follow-up of 13.5 (12.9) months (range 0.25-46 months). CONCLUSIONS: MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks. LEVEL OF EVIDENCE: 3 Laryngoscope, 131:624-632, 2021.

The Effects of Age and Race on Calvarium, Tegmen, and Zygoma Thickness.

OBJECTIVE: Temporal bone spontaneous cerebrospinal fluid (sCSF) leaks are characterized by defects in the tegmen along with calvarial thinning without associated thinning of the extracranial zygoma. The authors sought to determine the effect of age and race on calvarial, tegmen, and zygoma thickness. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary Referral Center. PATIENTS: A total of 446 patients with high-resolution head computer tomography (CT) imaging from 2003 to 2018.Intervention(s): Calvarial, tegmen, and zygoma thicknesses were measured using 3D slicer.Main Outcome Measure(s): Effects of age and race on calvarium, tegmen, zygoma thickness. RESULTS: Among all patients, increased age was associated with increased thickness of the calvarium [95% CI, 0.0002 to 0.007 mm/year, P < 0.05] and tegmen [95% CI, 0.00039 to 0.0075 mm/year, P = 0.03], but decreased thickness of the zygoma [95% CI, -0.013 to -0.005 mm/year, P < 0.001]. When compared to white patients, black patients had thicker mean [SD] calvaria (2.63 [0.61] versus 3.30 [0.79] mm; difference, 0.67 mm; [95% CI, 0.57 to 0.77]; Cohen d, 1.02), tegmen (0.73 [0.34] versus 0.92 [0.36] mm; difference 0.19 mm; [95% CI, 0.101 to 0.279]; Cohen d, 0.533) and zygoma (4.89 [0.81] versus 5.55 [0.91] mm; difference, 0.66 mm; [95% CI, 0.53 to 0.79]; Cohen d, 0.78). CONCLUSIONS: Racial differences exist in calvarial and zygoma thickness. Aging generally leads to increased calvarium and tegmen thickness, suggesting that early onset of obesity and comorbid conditions known to thin the skull base may predispose patients to developing sCSF leaks by reversing the effects of age.

CO2 Laser Division of Neo-Vallecula Improves Dysphagia in the Postlaryngectomy Patient: A Case Series and Review of the Literature.

OBJECTIVES: To review the literature on neo-vallecula diagnosis and management and to report our findings regarding 3 patients who developed neo-vallecula in the context of free-flap pharyngeal reconstruction following total laryngectomy. METHODS: This case series reports three patients who developed a neo-vallecula following a laryngectomy and free-flap pharyngeal reconstruction. All three patients were treated with a CO2 laser endoscopic procedure. RESULTS: Neo-vallecula formation is thought to be related to tension on the neopharyngeal closure or closure technique following total laryngectomy. Diagnosis may be obtained with swallow studies, videofluoroscopy, or endoscopy. Treatment has included external excision and endoscopic procedures such as stapling, harmonic scalpel excision, and laser removal. We utilized an endoscopic approach entailing the use of a CO2 laser to divide the neo-vallecula, and all our patients reported improvement in their dysphagia. CONCLUSIONS: Treatment of an anterior neo-vallecula endoscopically using a CO2 laser is an effective way to treat dysphagia in patients following total laryngectomy with free-flap pharyngeal reconstruction.

Nasal bone fractures and the use of radiographic imaging: An otolaryngologist perspective.

OBJECTIVE: To determine radiologic preferences of practicing otolaryngologists regarding isolated nasal bone fractures. STUDY DESIGN: An 8-question survey on isolated nasal bone fractures was designed. SETTING: Surveys were sent to all otolaryngology residency program directors for distribution among residents and faculty. Additional surveys were distributed to private practice otolaryngology groups. RESULTS: 140 physicians responded to the survey. 57% of the respondents were practicing otolaryngologists (75% with 10+ years of experience), while 43% of respondents were residents-in-training. 56% of respondents treated 1-5 nasal bone fractures per month. 80% of all respondents reported imaging being performed prior to consultation. If imaging was obtained before consultation, plain films and computed tomography (CT) maxillofacial/sinus scans were the most frequent modalities. 33% of residents and 70% of practicing otolaryngologists report imaging as 'rarely' or 'never' helpful in guiding management. 42% of residents and 20% of practicing otolaryngologists report asking for imaging when it wasn't already obtained. Decreased use of radiography was associated with greater years in practice and higher frequency of fractures treated. CONCLUSIONS AND RELEVANCE: Otolaryngologists seldom request imaging to evaluate and treat isolated nasal bone fractures. When ordered, imaging is utilized more often among residents-in-training and non-otolaryngology consulting physicians. This study highlights an opportunity to educate primary care and emergency room providers as well as otolaryngology residents on the value of comprehensive physical exam over radiographic imaging in the work-up of isolated nasal fractures. In addition, widespread adoption of a "no x-ray policy" in this setting may result in better resource utilization.

The role of obesity, sleep apnea, and elevated intracranial pressure in spontaneous cerebrospinal fluid leaks.

PURPOSE OF REVIEW: Spontaneous cerebrospinal fluid (sCSF) leaks often occurs in middle age, obese females. Here we investigate the role of obesity, idiopathic intracranial hypertension (IIH), and obstructive sleep apnea (OSA) in the pathophysiology of sCSF leaks. RECENT FINDINGS: The association of obesity and sCSF leaks has been well established in many studies. It has now been revealed that sCSF leak patients have thinner calvariums along with the skull base. An intracranial process likely leads to calvarium and skull base thinning in sCSF leaks patients since this occurs independent of extracranial bone thinning and independent of obesity. OSA, which is known to cause spikes in intracranial pressure (ICP), has been found to be significantly prevalent in the sCSF population and has been shown to lead to both calvarial and skull base thinning. Chronically elevated ICP (IIH) has also been shown to impact calvarial and skull base thicknesses. SUMMARY: The incidence of sCSF leaks has increased in recent decades along with an increasing rate of obesity. OSA and IIH, which are obesity-related factors and cause transient and chronic elevations in ICP, have now been implicated as critical factors leading to calvarial and skull base thinning and resultant sCSF leaks.

Association of Intracranial Hypertension With Calvarial and Skull Base Thinning.

OBJECTIVE: Determine if patients with increased opening pressure (OP) on lumbar puncture (LP) have thinner calvaria and skull bases. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral center. PATIENTS: Patients (≥18 yr of age) who had a recorded OP on LP and high-resolution computed tomography imaging of the head. Patient age, sex, body mass index were calculated. Intracranial hypertension (IH) was defined with an OP≥25 cm-H2O and low intracranial pressure with an OP<15 cm-H2O. INTERVENTION: Measurement of calvarial, zygoma, and skull base thickness when blinded to OP with three-dimensional slicer and radiologic calipers. MAIN OUTCOME MEASURES: Association of calvarial, skull base, and zygoma thickness with OP and age. RESULTS: Fifty-eight patients were included with a mean (SD) age of 53.1 (16.2) years and average (SD) body mass index of 30.1 (9.1) kg/m. Patients with IH had thinner mean (SD) calvaria (3.01 [0.81] versus 2.70 [0.58] mm; p = 0.036) and skull bases (5.17 [1.22] versus 4.60 [1.42] mm; p = 0.043) when compared with patients without IH. The mean (SD) extracranial zygoma thickness was similar between the two groups (5.09 [0.76] versus 5.00 [0.73] mm; p = 0.56). General linear model regression demonstrated advancing age was associated with increasing calvarial thickness in patients without IH and calvarial thinning in patients with IH (p = 0.038). CONCLUSION: IH is independently associated with intracranial bone (calvaria and skull base) thinning and not extracranial (zygoma) thinning. Skull thinning occurs with IH and advancing age. These findings support a possible role of increased ICP in the pathophysiologic development of spontaneous cerebrospinal fluid leaks.

Prevalence of Obstructive Sleep Apnea (OSA) in Spontaneous Cerebrospinal Fluid (CSF) Leaks: A Prospective Cohort Study.

OBJECTIVE: To determine the prevalence of obstructive sleep apnea (OSA) in a prospective cohort of patients with spontaneous CSF (sCSF) leaks of the temporal bone. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: Consecutive sCSF leak patients (21) over a 3-year period. Four patients presented with a history of OSA and 17 patients were prospectively offered polysomnogram (PSG) testing during the initial clinic encounter. INTERVENTION: Level I PSG. MAIN OUTCOME MEASURES: Patient characteristics (age, sex, body mass index), apnea hypopnea index (AHI), presence of snoring, and presence of hypoxia (oxygen saturation <88% for >5 min). OSA was defined as mild (AHI ≥5 and <15/h), moderate (AHI ≥15 and <30/h), and severe (AHI ≥30/h). RESULTS: The prevalence of OSA in sCSF leak patients is 83.3%. PSG studies were performed on 18 of the 21 patients. There were 15 women and 6 men with an average age (standard deviation) of 56.3 (11.2) years and an average body mass index of 35.3 (7.7) kg/m. Objectively, the AHI ranged from mild to severe (range = 5.7-92, median = 19.8). Snoring was present in 61% of patients and hypoxia was present in 39% of patients. sCSF leak patients with OSA were significantly older than sCSF leak patients without OSA (56.7 [8.3] versus 42.7 [14.5] yr, p = 0.03). CONCLUSIONS: OSA is highly prevalent among patients with sCSF leaks. All patients with sCSF leaks should undergo formal PSG testing. Future studies are needed to determine the role of OSA in the development of sCSF leaks.

Association of Obstructive Sleep Apnea With Calvarial and Skull Base Thinning.

Importance: Spontaneous cerebrospinal fluid leaks (sCSF-L) of the temporal bone are associated with obesity, calvarial thinning, and obstructive sleep apnea (OSA), and the incidence has doubled in the past decade. It is currently unknown if OSA is independently associated with skull thinning. Objective: To determine if patients with OSA have thinner skulls than patients without OSA. Design, Setting, and Participants: A retrospective cohort study of patients who underwent a level 1 polysomnogram (PSG) and also had high-resolution computed tomographic (CT) imaging of the head from January 2010 to March 2017 at Indiana University was carried out. Patients with moderate to severe OSA (apnea-hypopnea index [AHI]≥25/h) and without OSA (AHI<5/h) were matched for age and body mass index (BMI, calculated as weight in kilograms divided by height in meters squared). Interventions: Measurement of calvarial thickness, extracranial zygoma thickness, skull base height and tegmen dehiscence (>4 mm) when blinded to OSA status. Main Outcomes and Measures: Primary outcomes were calvarial, skull base, and zygoma thickness differences between patients with OSA vs those without OSA. Results: A total of 22 933 patients had a PSG and 1012 also had head CT imaging. Of the 1012 patients with both PSG and CT, the mean (SD) age was 50.8 (16.2) years and 624 (61.7%) were women. Those patients with moderate to severe OSA (56) and without OSA (58) were matched for mean (SD) age (50.3 [6.5] vs 49.8 [6.1] years]) and BMI (37.4 [8.1] vs 38.6 [6.8]). Patients with OSA had thinner mean (SD) calvaria (2.73 [0.67] vs 2.47 [0.52] mm; difference, -0.26 mm; 95% CI, -0.49 to -0.04; Cohen d, 0.44) and thinner skull bases (5.03 [1.40] vs 4.32 [1.28] mm; difference, -0.71; 95% CI, -1.23 to -0.19; Cohen d, 0.53). The mean (SD) extracranial zygoma thickness was the same (4.92 [0.87] vs 4.84 [0.84] mm; difference, -0.07 mm; 95% CI, -0.39 to 0.24). The tegmen mastoideum was dehiscent in nearly twice as many patients with OSA as those without (37% vs 20%; difference, 17%; 95% CI, 0.4-32). Conclusions and Relevance: Obstructive sleep apnea was independently associated with intracranial bone (calvaria and skull base) thinning and not with extracranial (zygoma) thinning. These findings support a possible role of OSA in the pathophysiologic development of sCSF-L.

Management of long-lasting phantosmia: a systematic review.

BACKGROUND: Interest in the pathophysiology and management of phantom smells has increased rapidly over the last decade. A PubMed search for the term "phantosmia" demonstrated a near-doubling of articles published on phantosmia within the past 7 years. We aimed to systematically review the literature on the management of phantosmia. METHODS: The PubMed, EMBASE, and Cochrane databases were searched for articles published since January 1990, using terms combined with pertinent Boolean search operators. We included articles evaluating management of phantosmia written in the English language, with original data and a minimum of 6 months of follow-up, on at least 2 patients and with well-defined and measurable outcomes. RESULTS: A total of 2151 unique titles were returned upon the initial search. Of these, 146 abstracts were examined, yielding 7 articles meeting the inclusion criteria. All articles were predominantly level 4 evidence. One prospective level 3 study was included. The studies included a total of 96 patients, with follow-up ranging from 6 months to 11 years. Endpoints were primarily based on subjective patient responses. Management options included observation and medical and surgical therapy. Olfactory mucosa excision was the only surgical intervention studied, with short-term symptomatic improvement in 10 of 11 patients. Forty-one patients were treated medically, which included antipsychotic, antimigraine, and antiseizure medications, transcranial stimulation, and topical cocaine application. CONCLUSION: Despite increasing interest in the treatment of phantosmia and reports of successful therapies, there remains a paucity of data and lack of consensus regarding optimal management of this difficult condition.