Approach to Cochlear Implantation in Patients With Ventriculoperitoneal Shunts.

OBJECTIVE: To evaluate the safety and outcomes of cochlear implantation (CI) in patients with ventriculoperitoneal (VP) shunts to inform clinical practice. STUDY DESIGN: Historical cohort study. SETTING: Tertiary referral centers. METHODS: A multi-institutional historical cohort of patients with VP shunts and CI was identified and analyzed. RESULTS: A total of 46 patients (median age 8 years [interquratile range, IQR: 2-46]) with VP shunts and CI were identified. Of these, 41 (89%) patients had a VP shunt prior to CI. Based on institutional preference and individual patient factors, CI was performed contralateral to a pre-existing VP shunt in 24 of these 41 cases (59%) and ipsilateral in 17 (41%). Furthermore, pre-CI relocation of the VP shunt was performed in 3 cases (7%), and 2 patients (5%) underwent planned revision of their VP shunt concurrent with CI. In total, 2 of 27 pediatric patients (7%) required unanticipated revision shunt surgery, both contralateral to CI device placement, given VP shunt malfunction. One of 19 adult patients (5%) required shunt revision during CI due to shunt damage noted intraoperatively. Among 43 patients with available follow-up, 38 (88%) are regular CI users, with a median consonant-nucleus vowel-consonant word: score of 58% (IQR: 28-72). CONCLUSION: CI can be performed at low risk, either contralateral or ipsilateral, to a VP shunt, and does not mandate shunt revision in most cases. Additional considerations regarding CI receiver-stimulator placement are necessary with programmable shunts to mitigate device interaction. Preoperative planning, including coordination of care with neurosurgery, is important to achieving optimal outcomes.

Tinnitus cases after COVID-19 vaccine administration, one institution's observations.

OBJECTIVE: After the role out of the COVID-19 vaccine in the United States, there has been increase in case reports of tinnitus attributed to the vaccine reported. We present our institution's experience over the initial 13 month period the vaccines were available. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic otology and general otolaryngology practice. PATIENTS: Patients who received a COVID-19 vaccine and a tinnitus diagnosis code. INTERVENTIONS: Observation, steroids (oral and intratympanic), diagnostic imaging and audiometry. MAIN OUTCOME MEASURES: Patients who received a COVID-19 vaccine in the time frame of 12/1/2020-12/31/21 with a diagnosis of tinnitus, an audiogram, and at least one visit with one of our Otolaryngologists were included in the study. Twenty-seven of the 1254 patients identified met these criteria. The patients ranged in age from 41 to 84 years old including seven male and twenty female patients. Sixteen received the Pfizer vaccine, seven received the Moderna vaccine and four patients received the Janssen vaccine. CONCLUSIONS: No definite correlation could be established between COVID-19 vaccine and tinnitus. Any concurrent sudden hearing loss should be treated as usual with oral or intratympanic steroids. Health care providers should be aware of the tinnitus onset and if new or recent onset, to refer for prompt audiogram and Otolaryngology evaluation.

A Case-Case Analysis of Intralabyrinthine Schwannoma Versus Intracanalicular Vestibular Schwannoma.

OBJECTIVES: Determine the differences in presentation of intracanalicular and intralabyrinthine schwannomas. STUDY DESIGN: Retrospective chart review at a single center. SETTING: Tertiary academic referral center. PATIENTS: Eighteen subjects with an intralabyrinthine schwannoma (ILS) and 216 patients with an intracanalicular vestibular schwannoma (VS). MAIN OUTCOME MEASURES: Variables collected included age at diagnosis, gender, presenting signs and symptoms, imaging findings, treatment modality, pure-tone average (PTA), and word recognition scores (WRS) at presentation and at follow-up visits. RESULTS: Incidence of subjective hearing loss was 100% in the ILS group and 80.6% in the intracanalicular VS group. The degree of hearing loss was significantly worse in the ILS group (average PTA of 83.9 dB; average WRS of 46.9%) compared with the VS group (average PTA of 38.7 dB; average WRS of 71.8%) (PTA p = 0.000006; WRS p = 0.007). Other subjective signs and symptoms, including vestibular symptoms, did not differ significantly between the two groups. Approximately one-third of both groups underwent microsurgical resection. 22.2% of ILSs were missed on initial imaging by radiologists. CONCLUSION: Intralabyrinthine schwannomas differ from intracanalicular schwannomas in the severity of hearing loss at presentation. Otherwise, these two tumors present in a very similar fashion-age at presentation, presenting signs and symptoms-and are treated comparably. Otolaryngologists should maintain a high degree of suspicion for ILS in patients presenting with an asymmetric hearing loss, vertigo, and tinnitus.

Cochlear Implantation for Unilateral Hearing Loss.

Pediatric cochlear implantation for unilateral hearing loss is a new application of cochlear implants with Federal Drug Administration approval for this indication in 2019. The criteria for cochlear implant candidacy include evaluation of the etiology of hearing loss, the duration of deafness, child and family motivation, and the child's comorbidities. Studies have demonstrated significant improvements in speech perception in quiet and noise, sound localization, and speech and language development after implantation. Additional research is required to determine the best candidate and device for cochlear implantation.

Cochlear Implantation in the Setting of Menière's Disease After Labyrinthectomy: A Meta-Analysis.

OBJECTIVE: Characterize the speech recognition and sound source localization of patients with unilateral Menière's disease who undergo labyrinthectomy for vertigo control with simultaneous or sequential cochlear implantation. DATABASES REVIEWED: PubMed, Embase, and Cochrane databases. METHODS: The search was performed on May 6, 2020. The keywords utilized included: "Menière's disease AND cochlear implant;" "cochlear implant AND single sided deafness;" "cochlear implant AND vestibular;" and "labyrinthectomy AND cochlear implant." Manuscripts published in English with a publication date after 1995 that assessed adult subjects (≥18 years of age) were included for review. Subjects must have been diagnosed with Menière's disease unilaterally and underwent labyrinthectomy with simultaneous or sequential cochlear implantation. Reported outcomes with cochlear implant (CI) use included speech recognition as measured with the consonant-nucleus-consonant (CNC) word test and/or sound source localization reported in root-mean squared (RMS) error. The method of data collection and study type were recorded to assess level of evidence. Statistical analysis was performed with Wilcoxon signed ranks test. RESULTS: Data from 14 CI recipients met the criteria for inclusion. Word recognition comparisons between the preoperative interval and a postactivation interval demonstrated a significant improvement with the CI (p = 0.014), with an average improvement of 23% (range -16 to 50%). Sound source localization postoperatively with the CI demonstrated an average RMS error of 26° (SD 6.8, range 18.7-43.1°) compared to the 42° (SD 19.1, range 18-85°) in the preoperative or CI off condition, these two conditions were not statistically different (p = 0.148). CONCLUSION: Cochlear implantation and labyrinthectomy in adult patients with Menière's disease can support improvements in speech recognition and sound source localization for some CI users, though observed performance may be poorer than traditional CI candidates.

Vestibular Schwannoma Measurements-Is Volumetric Analysis Clinically Necessary?

OBJECTIVE: 1) To compare vestibular schwannoma maximum linear dimensions and calculated volume with measured volume in accurately determining tumor volume and growth. 2) To determine natural growth history of vestibular schwannomas utilizing volumetric measurements in an observed patient population. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral. PATIENTS: One hundred fifty two adults with a vestibular schwannoma who underwent observational management with sequential magnetic resonance imaging (MRI) scans (496 scans). INTERVENTION: MRI scans. MAIN OUTCOME MEASURES: Tumor volume calculated from linear dimensions compared with measured volume. The percentage change in tumor size (linear or volume) between consecutive MRI scans. RESULTS: The percentage change in tumor size between consecutive MRIs is significantly different between maximum linear dimension (MLD) and measured tumor volume (p = 0.03), but no difference exists in the percentage change between measured and calculated tumor volume (p = 0.882 for three linear measurements, p = 0.637 for two linear measurements). The overall number of growing tumors is 57.2% (n = 87) with an average growth rate of 62.6%. If a criterion for growth of 20% change is used, 32.2% of tumors monitored by linear volume would have demonstrated growth while 57.2% of tumors with measured volume demonstrated growth. CONCLUSION: Maximum linear dimensions are a significantly less sensitive measure of tumor growth compared with measured volumes. Calculated tumor volume utilizing three linear measurements is an accurate predictor of both measured tumor volume and tumor growth.

Cerebrospinal Fluid Leak Following Translabyrinthine Vestibular Schwannoma Surgery-Is Mesh Cranioplasty Necessary for Prevention?

OBJECTIVE: Evaluate the incidence of cerebrospinal fluid leak following vestibular schwannoma surgery for mesh cranioplasty closure versus periosteal closure in the translabyrinthine approach. Determine nonsurgical variables associated with higher rates of cerebrospinal fluid leak following vestibular schwannoma surgery. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: One hundred thirty-two patients with adequate documentation who underwent sporadic vestibular schwannoma resection via a translabyrinthine approach between 2000 and 2019. INTERVENTION: Translabyrinthine excision of vestibular schwannoma with mesh cranioplasty closure or watertight periosteal closure. MAIN OUTCOME MEASURES: Primary outcome measures included the incidence of postoperative cerebrospinal fluid leak, total length of hospital stay (including the initial hospital stay as well as hospital days during any readmission within 30 days), and total operative time. RESULTS: Our overall cerebrospinal fluid leak rate was 9.1% with a leak rate of 12.8% in our translabyrinthine titanium mesh closure group and 0% in our translabyrinthine periosteal closure. There was no statistically significant effect of age, body mass index, or size of tumor on the incidence of cerebrospinal fluid leak. There was also no statistically significantly difference between the two groups on length of operative time or number of days spent in the intensive care unit. CONCLUSION: Mesh cranioplasty is not a prerequisite for achieving a low cerebrospinal fluid leak rate following translabyrinthine approach for vestibular schwannoma resection. In our series, a significantly lower cerebrospinal fluid leak rate was demonstrated with the periosteal closure.

Predicting Hearing Outcomes in Conservatively Managed Vestibular Schwannoma Patients Utilizing Magnetic Resonance Imaging.

OBJECTIVE: Management of small vestibular schwannomas has evolved to where observation with interval imaging is an accepted treatment strategy. Loss of residual hearing is a known complication of observation. Magnetic resonance imaging (MRI) may provide critical information to assist in determining which tumors are at highest risk of hearing loss. We wished to determine what effect fundal cap size and cochlear fluid-attenuated inversion recovery (FLAIR) signal had on the progression of hearing loss in a large cohort of observed subjects. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: Three hundred ninety-three adults with a vestibular schwannoma who underwent expectant management with serial audiograms and MRI. INTERVENTIONS: Audiogram and MRI. MAIN OUTCOME MEASURES: Hearing outcomes included pure-tone average and word discrimination score (WRS). Cochlear FLAIR signal was measured as a ratio between the affected and nonaffected cochlea. Cerebrospinal fluid fundal cap was measured from the most lateral aspect of the tumor to the fundus of the internal auditory canal. RESULTS: An increased cochlear FLAIR ratio was associated with a worse initial WRS (p = 0.0001, ß=-0.25). A multivariate regression analysis demonstrated the variables fundal cap and initial WRS to significantly predict change in WRS over time. The larger the fundal cap size, the smaller the change in the WRS (p = 0.047, ß=-0.35). CONCLUSIONS: Cerebrospinal fluid fundal cap size predicts the natural history of hearing in vestibular schwannoma patients. The presence of a smaller fundal cap is correlated with a greater risk of progression of hearing loss and should be a variable considered in the management of small vestibular schwannomas.

When Opposites Attract: Pediatric Cochlear Implantation in the Setting of Cerebrospinal Fluid Shunts.

OBJECTIVE: The Food and Drug Administration (FDA) has recently raised concern regarding the safety of cochlear implantation in the setting of programmable cerebrospinal fluid shunts. The purpose of this study was to evaluate the outcomes and complications of cochlear implantation in children who have a cerebrospinal fluid shunt. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. PATIENTS: Twenty pediatric subjects with a cerebrospinal fluid shunt and cochlear implant (CI). INTERVENTION: Cochlear implantation in the setting of a cerebrospinal fluid shunt. MAIN OUTCOME MEASURES: Primary outcome measures included descriptive data regarding age at implantation, etiology of hearing loss, medical management, complications, and speech perception outcomes. RESULTS: The average age of CI candidacy was 30 months with an average 21.5 months delay to implantation. In 45% of cases the laterality of the shunt determined the ear to be implanted. Three of the subjects required a surgical intervention on the shunt before cochlear implantation. Three subjects had a concurrently programmable shunt and activated CI. Two of the three subjects had no complications as a result of the two devices; however, the third subject had significant interactions requiring multiple revision surgeries. For those with the cognitive ability to perform open set, recoded speech perception, the average postoperative Consonant Nucleus Consonant word score in the best aided condition was 65.2% (n = 5). CONCLUSIONS: Children with a cerebrospinal fluid shunt are viable candidates for cochlear implantation, although they often require additional procedures and considerations before and after implantation.

Intraparotid Superficial Temporal Artery Arteriovenous Malformation Causing Persistent Pulsatile Tinnitus.

OBJECTIVES: This article discusses the diagnosis, imaging workup, and management of a rare cause of pulsatile tinnitus: intraparotid arteriovenous malformation. PATIENT: A single patient with a superficial temporal arteriovenous malformation diagnosed by carotid duplex causing pulsatile tinnitus that failed initial surgical management. Repeat imaging failed to identify a cause for the persistent tinnitus. INTERVENTION: Reoperation with a parotid approach based on physical exam findings. RESULTS: Removal of a more proximal arteriovenous malformation in the parotid gland resulted in long-term resolution of the patient's pulsatile tinnitus. CONCLUSIONS: Physical examination is essential in the workup and management of pulsatile tinnitus. Imaging is a useful adjunct in the diagnosis of pulsatile tinnitus but should not be solely relied upon.

Factors Influencing Pediatric Cochlear Implant Outcomes: Carolina Sibling Study.

OBJECTIVE: To determine the correlation between speech perception performance between pediatric sibling pairs with severe to profound sensory hearing loss receiving cochlear implants, and in cases of discordance in performance, determine which variables negatively impacted performance. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary academic referral center. SUBJECTS: Eighty-nine pediatric subjects, 43 sibling groups, under the age of 18 with severe to profound sensory hearing loss who received a cochlear implant with a sibling who also received a cochlear implant. INTERVENTION: Cochlear implantation. MAIN OUTCOME MEASURES: Speech perception scores, consonant-nucleus- consonant score. RESULTS: A statistically significant correlation was found between speech perception performance of pediatric siblings. Depth of insertion is positively correlated with better speech perception in siblings with discordant results. There was no significant relationship with either electrode type, unilateral/bilateral status, or age of implantation. CONCLUSION: Pediatric siblings have a high correlation in speech perception outcomes following cochlear implantation, suggesting family environment plays a strong role. In circumstances in which outcomes between siblings are substantially different, greater depth of implant insertion is correlated with better consonant-nucleus- consonant word scores.

Management of Frontal Sinus Tumors.

The most common primary tumors of the frontal sinus are osteomas and inverted papillomas, although a variety of other tumors involving this space have been reported. With the advent of new surgical techniques and instrumentation, an endoscopic approach to this region has become feasible. The preoperative assessment and decision making must take into account the complexity of frontal sinus anatomy, tumor type, tumor location, and associated attachments. These procedures allow adequate visualization, tumor removal, and postoperative monitoring, and preserve fairly normal sinus function. Open techniques may also be required and should be in the surgeon's armamentarium.