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1.
Int J Audiol ; : 1-8, 2020 Aug 04.
Artigo em Inglês | MEDLINE | ID: mdl-32749178

RESUMO

OBJECTIVE: Electrode impedances play a critical role in cochlear implant programming. It has been previously shown that impedances rise during periods of non-use, such as the post-operative recovery period. Then when the device is activated and use is initiated, impedances fall and are typically stable. In this study, we report a new pattern where electrode impedances increase with device use and decrease with device rest. DESIGN: Electrode impedances were measured three to four times every day over a span of 1-3 months for two cochlear implant patients. STUDY SAMPLE: Two patients with a Nucleus cochlear implant participated in this study. RESULTS: Both subjects in this study show wide fluctuations in electrode impedances. By taking serial electrode impedance measurements throughout a day of use, we observe that electrode impedances consistently increase with device use and decrease with device rest. CONCLUSION: In this study, we report two cases of electrode impedances increasing as a function of device use. Numerous management strategies were employed to reduce this effect but none prevailed; a clear pathophysiologic mechanism remains elusive. Further study into the cause of this electrode impedance pattern is warranted to establish a management strategy for these cochlear implant users.

2.
Otolaryngol Head Neck Surg ; 162(4): 530-537, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31986971

RESUMO

OBJECTIVE: To ascertain the relationship among vestibular schwannoma (VS) tumor volume, growth, and hearing loss. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary center. SUBJECTS AND METHODS: Adults with observed VS and serviceable hearing at diagnosis were included. The primary outcome was the development of nonserviceable hearing as estimated using the Kaplan-Meier method. Associations of tumor volume with baseline hearing were assessed using Spearman rank correlation coefficients. Associations of volume and growth with the development of nonserviceable hearing over time were assessed using Cox proportional hazards models and summarized with hazard ratios (HRs). RESULTS: Of 230 patients with VS and serviceable hearing at diagnosis, 213 had serial volumetric tumor data for analysis. Larger tumor volume at diagnosis was associated with increased pure-tone average (PTA) (P < .001) and decreased word recognition score (WRS) (P = .014). Estimated rates of maintaining serviceable hearing at 6 and 10 years following diagnosis were 67% and 49%, respectively. Larger initial tumor volume was associated with development of nonserviceable hearing in a univariable setting (HR for 1-cm3 increase: 1.36, P = .040) but not after adjusting for PTA and WRS. Tumor growth was not significantly associated with time to nonserviceable hearing (HR, 1.57; P = .14), although estimated rates of maintaining serviceable hearing during observation were poorer in the group that experienced growth. CONCLUSION: Larger initial VS tumor volume was associated with poorer hearing at baseline. Larger initial tumor volume was also associated with the development of nonserviceable hearing during observation in a univariable setting; however, this association was not statistically significant after adjusting for baseline hearing status.


Assuntos
Perda Auditiva/etiologia , Neuroma Acústico/complicações , Neuroma Acústico/patologia , Carga Tumoral , Idoso , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
3.
Otol Neurotol ; 40(10): 1363-1372, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31725593

RESUMO

OBJECTIVE: To ascertain long-term hearing outcomes in patients with serviceable hearing following microsurgical resection of sporadic vestibular schwannoma (VS). STUDY DESIGN: Retrospective cohort. SETTING: Tertiary academic referral center. PATIENTS: Forty-three adult subjects with unilateral sporadic VS who had serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] class A or B) on initial postoperative audiogram following microsurgical resection between 2003 and 2016 with a minimum of two postoperative audiograms available for review. INTERVENTION: Surgical treatment with a retrosigmoid or middle cranial fossa approach. MAIN OUTCOME MEASURE: Rate of maintaining serviceable hearing, as estimated using the Kaplan-Meier method, in accordance with the 1995 and 2012 AAO-HNS guidelines on reporting hearing outcomes. RESULTS: The median immediate postoperative pure-tone average (PTA) and word recognition score (WRS) were 31 dB and 95%, respectively. At last follow-up, the median PTA was 38 dB with a median change of 5 dB from initial postoperative audiogram, and the median WRS was 90% with a median change of 0% from initial postoperative audiogram. Eight patients developed non-serviceable hearing at a median of 4.1 years following microsurgical resection (interquartile range, 2.9-7.0). The median duration of hearing follow-up for the 35 patients who maintained serviceable hearing was 3.1 years (interquartile range, 2.2-7.5). Tumor control was achieved in 41 (95%) patients. The rate of maintaining serviceable hearing at 5 years was 81%. CONCLUSION: Microsurgical resection provides excellent tumor control and durable long-term hearing in those with AAO-HNS class A or B hearing postoperatively. The paradigm of proactive microsurgical resection-when the tumor is small and hearing is good-hinges on the surgeon's ability to preserve residual hearing in a very high percentage of cases at or near preoperative hearing levels to maintain an advantage over conservative observation with regard to long-term hearing preservation.

4.
Otol Neurotol ; 40(10): e1012-e1017, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31634279

RESUMO

OBJECTIVE: To date, prediction models for estimating risk of acquiring non-serviceable hearing in subjects with observed vestibular schwannoma (VS) have evaluated outcomes primarily based on features at initial diagnosis. Herein, we evaluate the association of rate of hearing decline during the initial period of observation with time to non-serviceable hearing. If significant, rate of hearing decline may inform decision making after an introductory period of observation. SETTING: Two tertiary care centers. PATIENTS: VS patients with serviceable hearing who underwent at least three audiograms and two magnetic resonance imaging (MRI) studies before intervention or being lost to follow-up. The rate of change in pure-tone average (PTA) and word recognition score (WRS) was calculated as the score from the second audiogram minus the score from the first audiogram, divided by the duration in months between the two. MAIN OUTCOME MEASURE(S): Serviceable hearing, defined as PTA ≤50 dB HL and WRS ≥50%. RESULTS: Among 266 patients meeting inclusion criteria, 52 developed non-serviceable hearing at last follow-up. Kaplan-Meier estimated rates of maintaining serviceable hearing (95% CI; number still at risk) at 1, 3, 5, 7, and 10 years were 97% (95-100; 206), 78% (72-85; 98), 68% (60-77; 39), 60% (50-73; 17), and 44% (29-67; 2), respectively. In a univariable setting, each 1 dB increase per month in the rate of initial PTA change was associated with a 96% increased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 1.96; 95% CI 1.44-2.68; p < 0.001). Each 1% increase per month in the rate of initial WRS change was associated with a decreased likelihood of acquiring non-serviceable hearing (hazard ratio [HR] 0.79; 95% confidence interval [CI] 0.66-0.94; p = 0.009). After multivariable adjustment, both rate of PTA change (HR 2.42; 95% CI 1.72-3.41; p < 0.001) and rate of WRS change (HR 0.81; 95% CI 0.67-0.99; p = 0.043) remained statistically significantly associated with time to non-serviceable hearing. CONCLUSION: Rate of early PTA and WRS decline during the initial period of observation are significantly associated with time to development of non-serviceable hearing. This information may facilitate accurate patient counseling and inform decision-making regarding prospective disease management.

5.
J Neurosurg ; : 1-9, 2019 Oct 04.
Artigo em Inglês | MEDLINE | ID: mdl-31585433

RESUMO

OBJECTIVE: Tumor-associated macrophages (TAMs) have been implicated as pathologic actors in phenotypically aggressive vestibular schwannoma (VS), potentially mediated via programmed death-ligand 1 (PD-L1). The authors hypothesized that PD-L1 is a key regulator of the VS immune microenvironment. METHODS: Forty-six consecutive, radiation-naïve, sporadic VSs that were subtotally resected at primary surgery were assessed via immunohistochemical analysis, including analysis of CD163 and PD-L1 expression. Pathologic data were correlated with clinical endpoints, including tumor control, facial nerve function, and complications. RESULTS: Baseline parameters were equivalent between stable and progressive post-subtotal resection (STR) VS. CD163 percent positivity and M2 index were significantly increased among tumors that remained stable (34% vs 21%, p = 0.02; 1.13 vs 0.99, p = 0.0008), as well as patients with favorable House-Brackmann grade I or II facial nerve function (31% vs 13%, p = 0.04; 1.11 vs 0.97, p = 0.05). PD-L1 percent positivity was significantly associated with tumor progression (1% vs 11%, p = 0.01) and unfavorable House-Brackmann grade III-VI facial nerve function (1% vs 38%, p = 0.02). On multivariate analysis, PD-L1 was independently significant in all models (likelihood ratio 4.4, p = 0.04), while CD163 was dependent in all iterations. CONCLUSIONS: In contrast to prior reports, in this study, the authors observed significantly increased levels of M1, CD163+ TAMs in association with VS that progressed after STR. Progressive tumors are characterized by increased PD-L1, potentially highlighting a mechanism of immune evasion that results in TAM deactivation, tumor growth, and further infiltration of anti-tumor immune cells. Targeting PD-1/PD-L1 may offer therapeutic promise, particularly in the setting of disease control after STR.

6.
Otol Neurotol ; 40(10): 1287-1291, 2019 12.
Artigo em Inglês | MEDLINE | ID: mdl-31644474

RESUMO

OBJECTIVE: To report the use of multi-frequency intra-cochlear electrocochleography (ECOG) in monitoring and optimizing electrode placement during cochlear implant surgery. An acoustic pure tone complex comprising of 250, 500, 1000, and 2000 Hz was used to elicit ECOG, or more specifically cochlear microphonics (CMs), responses from various locations in the cochlea. The most apical cochlear implant electrode was used as the recording electrode. STUDY DESIGN: Clinical capsule report. SETTING: Tertiary academic referral center. RESULTS: ECOG measurements were performed during cochlear implant surgery in an adult patient with significant residual acoustic hearing. The 500, 1000, and 2000 Hz CM tracings from the most apical electrode showed an amplitude peak at three different instances during the early phase of cochlear implant electrode insertion. These results are consistent with the tonotopic organization of the cochlea. During final electrode placement a slight advancement of the electrode array resulted in a correlated decrease in 250, 500, and/or 1000 Hz CM amplitude. The electrode array was retracted and repositioned which resulted in a recovery of CM amplitude. Intraoperative CM thresholds revealed a correlation of r = 0.87 with preoperative audiometric thresholds. CONCLUSION: We present a report on simultaneous multi-frequency ECOG monitoring during cochlear implant surgery. Multi-frequency ECOG can be used to differentiate between electrode trauma and the advancement of the apical electrode beyond the CM source in the cochlea.

7.
Otol Neurotol ; 40(9): 1230-1236, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31469795

RESUMO

OBJECTIVE: The etiology of sensorineural hearing loss (SNHL) in patients with jugular paraganglioma (JP) whose tumors lack inner ear fistulae or vestibulocochlear nerve involvement is unknown. Recent literature has proposed that occlusion of the inferior cochlear vein may be causative. Herein, we assess the association between radiologic involvement of the cochlear aqueduct (CA) and the development of SNHL. STUDY DESIGN: Blinded, retrospective review of imaging and audiometry. SETTING: Tertiary center. PATIENTS: Adults with JP. INTERVENTION(S): None. MAIN OUTCOME MEASURES: Asymmetric SNHL was assessed continuously as the difference in bone conduction pure-tone average (BCPTA) between ears and as a categorical variable (≥15 dB difference at two consecutive frequencies, or a difference in speech discrimination score of ≥15%). Involvement of the CA was considered present if there was evidence of medial T2 fluid signal loss, contrast enhancement, or bony erosion/expansion. RESULTS: Of 30 patients meeting inclusion criteria, 15 (50%) had asymmetric SNHL. CA involvement was observed in 87% of patients with asymmetric SNHL compared with 13% in those with symmetric hearing (p = 0.0001). Univariate analysis demonstrated that age, sex, and tumor volume were not associated with asymmetric SNHL. The median difference in BCPTA between ears in patients with CA involvement was 21.3 dB HL compared to 1.2 dB HL in those without CA involvement (p < 0.0001). Regression analysis demonstrates that enhancement within the CA is associated with a BCPTA difference of 19.4 dB HL (p = 0.0006). CONCLUSIONS: Cochlear aqueduct involvement by JP is associated with SNHL in the absence of inner ear fistula, vestibulocochlear nerve involvement, or brainstem compression. Correlation with operative findings or histopathologic evidence of tumor involvement may validate this intriguing imaging finding.

8.
J Neurol Surg B Skull Base ; 80(4): 338-351, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31316880

RESUMO

Introduction Although numerous anatomical and operative atlases have been published, those that have focused on the skull base either have provided views that are quite difficult to achieve in the operating room to better depict surgical anatomy or are written at the level of an audience with considerable knowledge and experience. Methods Five sides of three formalin-fixed latex-injected specimens were dissected under microscopic magnification. A posterior petrosectomy approach was performed by three neurosurgical residents at different training levels with limited previous experience in anatomical dissection mentored by the senior authors (C. L. W. D. and M. J. L.) and a clinical skull base fellow with additional anatomical dissection experience (M. P. C.). Anatomical dissections were performed until the expected level of dissection quality was achieved to demonstrate each important step of the surgical approach that would be understandable to all trainees of all levels. Following dissection education, representative case applications were reviewed. Results The posterior petrosectomy (also known as presigmoid retrolabyrinthine approach) affords excellent access to cranial nerves III to XI and a diverse array of pathologies. Key steps include positioning and skin incision, scalp and muscle flaps, burr holes, craniotomy flap elevation, superficial mastoidectomy, otic capsule exposure and presigmoid dura decompression, primary presigmoid durotomy, inferior temporal durotomy, superior petrosal sinus ligation, tentorium sectioning, and final exposure. Conclusion The posterior petrosectomy is a challenging approach; thorough operative-style laboratory dissection is essential to provide trainees with a suitable guide. We describe a comprehensive approach to learning this technique, intended to be understandable and usable by a resident audience.

9.
World Neurosurg ; 131: e128-e135, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31319187

RESUMO

BACKGROUND: As the endoscopic endonasal approach (EEA) has gained popularity as an alternative to microsurgery (MS) for transsphenoidal resection (TSR), numerous studies have attempted to assess the differential risk of internal carotid artery (ICA) injury between the techniques, yet results have been equivocal and contradictory. The aim of this study was to evaluate ICA injury in MS versus EEA among highly experienced neurosurgeons. METHODS: We performed a systematic literature review of publications from 2002-2017 reporting ICA injury outcomes in ≥250 cases using MS or EEA. RESULTS: Seventeen series reporting 11,149 patients were included: 3 MS series, 13 EEA series, and 1 series with adequate samples for each. ICA injury incidences were 0.0%-1.6% in cohorts of 275-3000. MS series documented 5 ICA injuries in 2672 operations, for an overall incidence of 0.2% (range, 0.0%-0.4%), and EEA series reported 30 ICA injuries in 8477 operations, for a 0.4% injury rate (range, 0.0%-1.6%); the difference was nonsignificant (P = 0.25). Increased operative experience was associated with decreased incidence of ICA injury, a finding preserved in the overall study cohort and within discretely examined MS and EEA subgroups (overall r2 = 0.08, MS r2 = 0.23, EEA r2 = 0.07). CONCLUSIONS: ICA injury is the most serious complication of TSR of pituitary neoplasms. Operator inexperience may be a more important risk factor than choice of surgical technique, given the comparably low rates of injury obtained by highly experienced surgeons independent of technique. This emphasizes the need for consolidated care in pituitary centers of excellence, improvement of high-fidelity simulators, and skull base mentorship between senior and junior staff.


Assuntos
Adenoma/cirurgia , Lesões das Artérias Carótidas/epidemiologia , Artéria Carótida Interna , Microcirurgia/efeitos adversos , Neuroendoscopia/efeitos adversos , Neoplasias Hipofisárias/cirurgia , Lesões das Artérias Carótidas/etiologia , Humanos , Incidência , Curva de Aprendizado , Cavidade Nasal , Cirurgia Endoscópica por Orifício Natural/efeitos adversos , Procedimentos Neurocirúrgicos/efeitos adversos
10.
J Neurol Surg B Skull Base ; 80(Suppl 3): S284, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31143591

RESUMO

Objectives This video was aimed to describe the relevant anatomy and key surgical steps of retrosigmoid approach for gross total resection of a medium-sized vestibular schwannoma (VS). Design The procedure is described in a surgical instructional video. Setting The surgery took place at a tertiary skull base referral center. Participant Patient is a 63-year-old woman who reported with nonserviceable hearing (Pure Tone Average 60 dB Hearing level, Word Recognition Score 45%), occasional tinnitus, and a VS in the left cerebellopontine angle (CPA), extending into internal auditory canal (IAC), measuring 1.7 cm parallel to the petrous temporal bone. Main Outcome Measures The VS was resected by retrosigmoid approach. Results The surgery results gross total resection of the VS with postoperative House-Brackmann grade 1 facial nerve function and no postoperative complications. Conclusion The retrosigmoid approach is a good strategy to remove VS involving the CPA and the IAC. The link to the video can be found at: https://youtu.be/B6K_UkrKitg .

11.
J Neurol Surg B Skull Base ; 80(Suppl 3): S285, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-31143592

RESUMO

Objectives This video was aimed to describe the surgical indications, relevant anatomy, and surgical steps of retrosigmoid approach for resection of a large cystic vestibular schwannoma (VS). Design The operative steps are described in a surgical instructional video. Setting The surgery took place at a tertiary skull base referral center. Participant Patient is a 62-year-old man who reported with right sided profound hearing loss with no word recognition, progressive dizziness and tinnitus, excruciating burning pain in the V2 distribution of right trigeminal nerve, wide-based gait, and a right cerebellopontine angle (CPA) cystic VS measuring 3.3 cm. Main Outcome Measures The large cystic VS was resected through retrosigmoid approach. Results The surgery resulted in removal of the large cystic VS with initial delayed facial weakness that completely resolved (House Brackmann grade 1) by 3 month follow-up. The patient had no other postoperative complications and is convalescing well from the procedure. Conclusion Cystic VS presents some unique challenges compared with their solid counterparts. The cystic tumor capsule may be very adherent to the adjacent structures, and distinguishing thin cyst walls from the arachnoid of the CPA, can be quite challenging. The retrosigmoid approach provides adequate surgical exposure for VS tumor resection. The link to the video can be found at: https://youtu.be/sFNvRWG465Q .

12.
Otol Neurotol ; 40(4): 517-528, 2019 04.
Artigo em Inglês | MEDLINE | ID: mdl-30870370

RESUMO

PURPOSE: To examine the etiology, clinical course, and management of recurrent peripheral facial nerve paralysis. METHODS: Retrospective review at a single tertiary academic center and systematic review of the literature. Clinical presentation, laboratory and imaging findings, treatment and outcome for all cases of recurrent ipsilateral, recurrent contralateral, and bilateral simultaneous cases of facial paralysis are reviewed. RESULTS: Between 2000 and 2017, 53 patients [41.5% men, 29 median age of onset (range 2.5 wk-75 yr)] were evaluated for recurrent facial nerve paralysis at the authors' institution. Twenty-two (41.5%) cases presented with ipsilateral recurrences only, while the remaining 31 patients (58.5%) had at least 1 episode of contralateral recurrent paralysis. No cases of bilateral simultaneous facial nerve paralysis were observed. The median number of paretic events for all patients was 3 (range 2-20). The median nadir House-Brackmann score was 4, with a median recovery to House-Brackmann grade 1.5 over a mean recovery time of 61.8 days (range 1-420 d). Diagnostic evaluation confirmed Melkersson-Rosenthal syndrome in four (7.5%) cases, neurosarcoidosis in two (3.7%), traumatic neuroma in one (1.9%), Ramsay Hunt syndrome in one (1.9%), granulomatosis with polyangiitis in one (1.9%), and neoplastic causes in three (5.7%) cases [facial nerve schwannoma (n = 2; 3.7%), metastatic squamous cell carcinoma to the deep lobe of the parotid gland (n = 1; 1.9%)]; ultimately, 77.4% (41) of cases were deemed idiopathic. Facial nerve decompression via a middle cranial fossa approach was performed in three (5.7%) cases without subsequent episodes of paralysis. CONCLUSION: Recurrent facial nerve paralysis is uncommon and few studies have evaluated this unique population. Recurrent ipsilateral and contralateral episodes are most commonly attributed to idiopathic facial nerve paralysis (i.e., Bell's palsy); however, a subset harbor neoplastic causes or local manifestations of underlying systemic disease. A comprehensive diagnostic evaluation is warranted in patients presenting with recurrent facial nerve paralysis and therapeutic considerations including facial nerve decompression can be considered in select cases.


Assuntos
Doenças do Nervo Facial/complicações , Nervo Facial/cirurgia , Paralisia Facial , Fossa Craniana Média/cirurgia , Descompressão Cirúrgica/métodos , Paralisia Facial/etiologia , Paralisia Facial/terapia , Herpes Zoster da Orelha Externa/complicações , Humanos , Síndrome de Melkersson-Rosenthal/complicações , Dissinergia Cerebelar Mioclônica/complicações , Recidiva Local de Neoplasia/cirurgia , Estudos Retrospectivos
13.
J Neurosurg ; : 1-10, 2018 Nov 01.
Artigo em Inglês | MEDLINE | ID: mdl-30497156

RESUMO

OBJECTIVEMiddle fossa surgery is challenging, and reliable surgical landmarks are essential to perform accurate and safe surgery. Although many descriptions of the middle fossa components have been published, a clinically practical description of this very complex anatomical region is lacking. Small structure arrangements in this area are often not well visualized or accurately demarcated with neuronavigation systems. The objective is to describe a "roadmap" of key surgical reference points and landmarks during middle fossa surgery to help the surgeon predict where critical structures will be located.METHODSThe authors studied 40 dry skulls (80 sides) obtained from the anatomical board at their institution. Measurements of anatomical structures in the middle fossa were made with a digital caliper and a protractor, taking as reference the middle point of the external auditory canal (MEAC). The results were statistically analyzed.RESULTSThe petrous part of the temporal bone was found at a mean of 16 mm anterior and 24 mm posterior to the MEAC. In 87% and 99% of the sides, the foramen ovale and foramen spinosum, respectively, were encountered deep to the zygomatic root. The posterior aspect of the greater superficial petrosal nerve (GSPN) groove was a mean of 6 mm anterior and 25 mm medial to the MEAC, nearly parallel to the petrous ridge. The main axis of the IAC projected to the root of the zygoma in all cases. The internal auditory canal (IAC) porus was found 5.5 mm lateral and 4.5 mm deep to the lateral aspect of the trigeminal impression along the petrous ridge (mean measurement values). A projection from this point to the middle aspect of the root of the zygoma, being posterior to the GSPN groove, could estimate the orientation of the IAC.CONCLUSIONSIn middle fossa approaches, the external acoustic canal is a reliable reference before skin incision, whereas the zygomatic root becomes important after the skin incision. Deep structures can be related to these 2 anatomical structures. An easy method to predict the location of the IAC in surgery is described. Careful study of the preoperative imaging is essential to adapt this knowledge to the individual anatomy of the patient.

14.
J Neurosurg ; : 1-9, 2018 Apr 01.
Artigo em Inglês | MEDLINE | ID: mdl-29652232

RESUMO

OBJECTIVEThe morbidity of gross-total resection of jugular paraganglioma (JP) is often unacceptable due to the potential for irreversible lower cranial neuropathy. Stereotactic radiosurgery (SRS) has been used at the authors' institution since 1990 for the treatment of JP and other benign intracranial tumors. Conventional means of assessing tumor progression using linear measurements or elliptical approximations are imprecise due to the irregular shape and insinuating growth pattern of JP. The objective of this study was to assess long-term tumor control in these patients by using slice-by-slice 3D volumetric segmentation of serial MRI data.METHODSRadiographic data and clinical records were reviewed retrospectively at a single, tertiary-care academic referral center for patients treated from 1990 to 2017. Volumetric analyses by integration of consecutive tumor cross-sectional areas (tumor segmentation) of serial MRI data were performed. Tumor progression was defined as volumetric growth of 15% or greater over the imaging interval. Primary outcomes analyzed included survival free of radiographic and clinical progression. Secondary outcomes included new or worsened cranial neuropathy.RESULTSA total of 85 patients were treated with Gamma Knife radiosurgery (GKRS) for JP at the authors' institution over the last 27 years. Sixty patients had pretreatment and serial posttreatment contrast-enhanced MRI follow-up suitable for volumetric analysis. A total of 214 MR images were analyzed to segment tumor images in a slice-by-slice fashion to calculate integral tumor volume. The median follow-up duration was 66 months (range 7-202 months). At 5 years the tumor progression-free survival rate was 98%. Three tumors exhibited progression more than 10 years after GKRS. Estimated survival free of radiographic progression rates (95% confidence interval [CI]; n = number still at risk) at 5, 10, and 15 years following radiosurgery were 98% (95% CI 94%-100%; n = 34), 94% (95% CI 85%-100%; n = 16), and 74% (95% CI 56%-98%; n = 6), respectively. One patient with tumor progression required treatment intervention using external beam radiation therapy, constituting the only case of clinical progression. Two patients (3%) without preexisting lower cranial nerve dysfunction developed new ipsilateral vocal fold paralysis following radiosurgery.CONCLUSIONSSRS achieves excellent long-term tumor control for JP without a high risk for new or worsened cranial neuropathy when used in primary, combined modality, or recurrent settings. Long-term follow-up is critical due to the potential for late radiographic progression (i.e., more than 10 years after SRS). As none of the patients with late progression have required salvage therapy, the clinical implications of this degree of tumor growth have yet to be determined.

15.
Neurosurgery ; 82(4): 541-547, 2018 04 01.
Artigo em Inglês | MEDLINE | ID: mdl-29554375

RESUMO

BACKGROUND: The goal of microsurgical removal of a vestibular schwannoma is to completely remove the tumor, to provide long-term durable cure. In many cases, less than gross total resection (GTR) is performed to preserve neurological, and especially facial nerve function. OBJECTIVE: To analyze long-term quality of life (QoL) in a cohort of patients who received either GTR or less than GTR. METHODS: Patients operated for vestibular schwannoma less than 3.0 cm in posterior fossa diameter at 1 of 2 international tertiary care centers were surveyed using generic and disease-specific QoL instruments. RESULTS: A total of 143 patients were analyzed. GTR was performed in 122, and 21 underwent less than GTR. QoL was assessed at a mean of 7.7 yr after surgery (interquartile range: 5.7-9.6). Patients who underwent GTR had smaller tumors; otherwise, there were no baseline differences between groups. Patients who underwent GTR, after multivariable adjustment for baseline features and facial nerve and hearing outcomes, reported statistically significantly better Short Form Health Survey-36 (SF-36) physical and mental scores, Patient-Reported Outcomes Measurement Information System (PROMIS-10) physical and mental scores, and Penn Acoustic Neuroma Quality of Life (PANQOL) facial, energy, general health, and total scores compared to patients receiving less than GTR. CONCLUSION: GTR is associated with better QoL using the general QoL measures SF-36 and PROMIS-10 and the disease-specific PANQOL, even after controlling for baseline and outcome differences. This is especially significant in the assessment of mental health, indicating there may indeed be a psychological advantage to the patient that translates to overall well-being to have the entire tumor removed if microsurgical resection is undertaken.


Assuntos
Neuroma Acústico/cirurgia , Procedimentos Neurocirúrgicos/métodos , Procedimentos Neurocirúrgicos/psicologia , Qualidade de Vida , Adulto , Idoso , Estudos de Coortes , Traumatismos do Nervo Facial/prevenção & controle , Feminino , Humanos , Microcirurgia/efeitos adversos , Microcirurgia/métodos , Pessoa de Meia-Idade , Procedimentos Neurocirúrgicos/efeitos adversos , Estudos Retrospectivos , Inquéritos e Questionários
16.
Otol Neurotol ; 39(3): 340-343, 2018 03.
Artigo em Inglês | MEDLINE | ID: mdl-29337715

RESUMO

OBJECTIVE: To report the presentation, diagnosis, management, and convalescence of labyrinthine sequestrum (LS) and summarize all previously published cases. PATIENT(S): Eleven-year-old female with LS. INTERVENTION(S): Multidisciplinary diagnostic evaluation and treatment. MAIN OUTCOME MEASURES: Imaging and laboratory findings, medical and surgical treatment. RESULTS: We describe a case of LS secondary to medically recalcitrant suppurative otitis media in an 11-year-old female and review all eight previously reported cases. The index patient presented after 6 months of otitis media, profound unilateral hearing loss, with symptoms suggesting meningitis. Temporal bone CT demonstrated marked bony destruction of the left otic capsule. Gadolinium-enhanced MRI showed an enhancing process with evidence of meningitis and subdural empyema. The patient was treated with surgical debridement and culture directed antibiotic therapy. Posttreatment imaging showed resolution of intracranial infection with fibrous bony healing of the otic capsule resembling fibrous dysplasia. CONCLUSION: LS is a rare form of labyrinthitis characterized by centrifugal destruction of the otic capsule. The current index case highlights the importance of combined medical and surgical treatment and describes for the first time in the literature the fibrous ossification of the otic capsule following disease resolution.


Assuntos
Labirintite/etiologia , Otite Média Supurativa/complicações , Infecções Estreptocócicas/complicações , Criança , Orelha Interna , Empiema Subdural/etiologia , Feminino , Perda Auditiva Unilateral/etiologia , Humanos , Meningite/etiologia , Streptococcus anginosus
17.
Otol Neurotol ; 39(1): 99-105, 2018 01.
Artigo em Inglês | MEDLINE | ID: mdl-29194225

RESUMO

OBJECTIVE: To describe audiometric outcomes following stereotactic radiosurgery (SRS) for jugular paraganglioma (JP). STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Patients with pretreatment serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery [AAO-HNS] Class A or B) and serial post-SRS audiometric follow-up who underwent Gamma Knife SRS for JP between 1990 and 2017. INTERVENTION(S): Gamma Knife SRS. MAIN OUTCOME MEASURES: Progression to nonserviceable hearing; correlation between baseline hearing and treatment parameters with audiometric outcomes. RESULTS: Of 85 patients with JP who underwent SRS during the study period, 35 (66% female, median age 53) had pretreatment serviceable hearing and serial post-treatment audiometry available for review. Median tumor volume at the time of treatment was 7,080 mm, median cochlear point dose was 5.8 Gy (interquartile range [IQR] 4.1 to 7.3 Gy), and median marginal and maximum tumor doses were 16 and 32 Gy, respectively. After a median follow-up of 37 months (IQR 16 to 77 mo), the median change in pure-tone average and speech discrimination score in the treated ear was -1.2 dB HL/yr (IQR -4.5 to 0.3) and 0%/yr (IQR 0-3.5%), compared with 0.07 dB HL/yr (IQR -0.03 to 0.12) and 0 %/yr (IQR 0 to 0%) in the contralateral untreated ear. Seven patients developed nonserviceable hearing (AAO-HNS Class C or D) at a median of 13.2 months following SRS (IQR 4.8 to 24 mo). Among those who maintained serviceable hearing, median audiometric follow-up was 42 months (IQR 18 to 77 mo). The Kaplan-Meier estimated rates of serviceable hearing at 1, 3, and 5 years following SRS were 91%, 80%, and 80%, respectively. Sixty percent of patients with pulsatile tinnitus who underwent SRS experienced varying levels of symptomatic improvement following treatment. CONCLUSION: The short- and intermediate-term risk of progression to nonserviceable hearing following SRS for JP is low. Data regarding the impact of cochlear dose from the vestibular schwannoma literature should not be freely applied to JP, since the impact of SRS parameters on hearing preservation seems to be less significant.


Assuntos
Tumor do Glomo Jugular/cirurgia , Radiocirurgia/métodos , Adulto , Idoso , Progressão da Doença , Feminino , Tumor do Glomo Jugular/patologia , Humanos , Masculino , Pessoa de Meia-Idade , Radiocirurgia/efeitos adversos , Estudos Retrospectivos , Resultado do Tratamento
19.
Otol Neurotol ; 38(7): 948-955, 2017 08.
Artigo em Inglês | MEDLINE | ID: mdl-28604576

RESUMO

OBJECTIVES: To compare the diagnostic yield of high-resolution volumetric T2-weighted MRI (HRT2-MRI) with high-resolution computed tomography (HRCT) for diagnosis of large vestibular aqueduct (LVA). STUDY DESIGN: Three board-certified neuroradiologists performed an independent, blinded radiological review for diagnosing LVA with 2:1 age-matched controls on patients with both HRCT and HRT2-MRI imaging. SETTING: Tertiary referral center. PATIENTS: All patients between 2002 and 2016 with hearing loss who underwent both HRCT and HRT2-MRI and were diagnosed with LVA on either modality. MAIN OUTCOME MEASURES: Concordance rate for LVA between HRCT and HRT2-MRI. RESULTS: Concordance rate for HRCT and HRT2-MRI for diagnosing LVA was 88% (124/141) when assessing both the midpoint and external aperture diameters. Fifteen ears had LVA on computed tomography (CT), but not on magnetic resonance imaging (MRI); in comparison, two ears had LVA on MRI, but not on CT (p = 0.002). Excellent inter-rater reliability among the three radiologists was demonstrated. CONCLUSION: Historically, HRCT has been the imaging modality of choice for diagnosing LVA. Although a higher concordance rate of HRT2-MRI was found compared with previous studies utilizing earlier MRI technology, HRCT still detected a larger number of patients with clinically significant hearing loss compared with MRI. Given the high concordance rate and efficacy of both modalities in diagnosing LVA, the ultimate decision of which modality to choose may depend on other patient-specific and clinical factors.


Assuntos
Imagem por Ressonância Magnética/métodos , Tomografia Computadorizada por Raios X/métodos , Aqueduto Vestibular/diagnóstico por imagem , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Perda Auditiva/diagnóstico por imagem , Humanos , Processamento de Imagem Assistida por Computador , Lactente , Masculino , Pessoa de Meia-Idade , Variações Dependentes do Observador , Reprodutibilidade dos Testes , Estudos Retrospectivos , Aqueduto Vestibular/anormalidades , Adulto Jovem
20.
World Neurosurg ; 105: 737-744, 2017 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-28647663

RESUMO

BACKGROUND: In an era where subtotal resection (STR) is increasingly used, we have encountered a growing number of patients referred to our institution with limited resection of large vestibular schwannomas (VSs), sometimes associated with grave complications. Our aim was to highlight lessons learned in the management of large VSs and provide a rationale for specialized care. METHODS: A prospectively maintained database of >2000 patients with VSs evaluated at our institution between 2000 and 2016 was reviewed. Details of 10 patients with residual tumor after limited subtotal resection were reviewed, with 3 presented in detail to illustrate key aspects of management. RESULTS: All but 1 patient underwent initial surgery at private hospitals without a designated skull base team. The median posterior fossa tumor diameter at the time of initial operation was 4.0 cm, whereas median diameter of residual tumor at the time of our evaluation was 3.5 cm. Before referral, 3 patients had undergone fractionated radiation therapy after their initial operation; 1 had undergone stereotactic radiosurgery. Four patients had moderate to severe facial weakness; 2 had permanent sequelae from stroke, including hemiparesis and blindness; and 7 had ongoing symptomatic brainstem compression and/or hydrocephalus. CONCLUSIONS: Management of large VSs remains challenging, including treating presenting hydrocephalus, maximizing extent of resection while optimizing facial nerve outcome, and avoiding complications. Most cases should be approached with the intent of complete resection, realizing that subtotal resection may become necessary based on intraoperative findings.


Assuntos
Gerenciamento Clínico , Margens de Excisão , Neuroma Acústico/diagnóstico por imagem , Neuroma Acústico/cirurgia , Assistência ao Paciente/métodos , Adolescente , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasia Residual , Estudos Prospectivos
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