MAUDE database and Eustachian tube balloon dilation: Evaluation of adverse events and sales data.

STUDY DESIGN: Review of database. SETTING: Tertiary care neurotology center. PATIENTS: Patients undergoing adverse events. INTERVENTION: MAUDE database evaluation of Eustachian tube balloon dilation (ETBD) for the treatment of Eustachian tube dysfunction. MAIN OUTCOME MEASURES: Medical device reports (MDRs) from the MAUDE database were analyzed for adverse patient events (AE) and device malfunctions (DM) among different devices for ETBD. The objective of this analysis is to assess AE rates and compare them across different devices. Sales data was also used to calculate AE rates. RESULTS: There were 18 MDRs noted in the MAUDE database for patients undergoing ETBD out of an initial 23 results. When separated into devices, the Aera had 9 total MDRs (50 %), Xpress had 8 (44.4 %) and Audion had 1 (5.6 %). There were 10 AE and 8 DM. When separated by device, Aera had 4 AEs and 5 DMs, Xpress had 5 AEs and 3 DMs, and Audion had 1 AE. The most common AE was subcutaneous emphysema (n = 4), in the head and neck region with one report of mediastinal involvement. Using this sales data, the Aera balloon has an MDR rate of 0.0128 % is established, with a rate of AE at 0.0058 %. The Audion balloon had an MDR and AE rate of 0.0164 %. CONCLUSIONS: ETBD is a safe procedure with minimal complications, with subcutaneous emphysema being the most commonly reported adverse event, consistent with literature findings. A comprehensive analysis of AE, coupled with sales data, indicates a commendably low MDR rate of 0.0128 % for the Aera balloon while the Audion balloon had an MDR rate of 0.0164 %. These findings offer valuable insights on post-procedure expectations and engaging in informed consent discussions with patients, highlighting the overall safety of ETBD as an intervention.

Effect of pre-incident antiplatelet therapy on sudden sensorineural hearing loss.

OBJECTIVE: Identify if pre-incident aspirin influences severity and outcome of idiopathic sudden sensorineural hearing loss (SSNHL). STUDY DESIGN: Retrospective review. SETTING: Tertiary care center. METHODS: Patients with idiopathic SSNHL were identified and separated into aspirin and non-aspirin groups. Variables, including demographics, comorbid conditions, audiologic outcomes were identified and compared between groups. RESULTS: One hundred forty-eight patients were included that met inclusion criteria. There were 38 patients who were on pre-incident aspirin therapy and 110 patients not on aspirin prior to the onset of SSNHL. Pre- and post-treatment audiologic status was worsened in the aspirin group. Other comorbid conditions, including hyperlipidemia, coronary artery disease (CAD), cerebrovascular accident (CVA), and vertigo symptoms had an effect as well. With multivariate analysis, CAD, CVA, and vertigo symptoms appeared to have an effect more than aspirin. CONCLUSIONS: Patients on aspirin have a worsened pre- and post-treatment audiologic status. This appears to be more due to the underlying CAD or history of CVA rather than aspirin use itself.

Impact of superior semicircular canal dehiscence on cochlear implant audiologic outcomes.

PURPOSE: Determine whether adult cochlear implant users with radiographic superior semicircular canal dehiscence experience clinically significant differences in audiological outcomes when compared to cochlear implant users with normal temporal bone anatomy. MATERIALS AND METHODS: Retrospective, single institution review. Adult, post-lingual deaf patients implanted between 2010 and 2020. Inclusion criteria included age 18 years or older, available preoperative computed tomography imaging, and preoperative and postoperative AzBio audiological data for at least 6 months of cochlear implant use. Preoperative and postoperative AzBio Sentence Test scores were compared between patients with normal temporal bone anatomy and those with radiographic superior semicircular canal dehiscence or near dehiscence. RESULTS: 110 patients met inclusion criteria. Mean AzBio score for normal temporal bone anatomy group improved from 35.2 % (SD 28.2) preoperatively to 70.3 % (SD 25.7) postoperatively, an improvement of 35.1 % (SD 28.6). Mean AzBio score for near dehiscent temporal bone anatomy group improved from 26.6 % (SD 28.9) preoperatively to 64.5 % (SD 30.6) postoperatively, an improvement of 37.9 % (SD 27.9). Mean AzBio score for dehiscent temporal bone anatomy group improved from 26.3 % (SD 20.4) preoperatively to 65.1 % (SD 27.6) postoperatively, an improvement of 38.7 % (SD 26.9). Utilizing the one-way analysis of variance test, there was no significant difference in audiologic outcomes between the three groups. CONCLUSIONS: Patients with complete or near complete radiographic superior canal dehiscence at the time of cochlear implantation achieve similar improvements in speech perception scores compared to normal anatomy adult cochlear implant users.

Endolymphatic sac decompression effect on secondary symptoms of Meniere's disease.

OBJECTIVE: To evaluate if endolymphatic sac decompression (ESD) significantly improves secondary symptoms of Meniere's disease including tinnitus and aural fullness. STUDY DESIGN: Survey study with retrospective chart review. SETTING: Tertiary care center. METHODS: Survey of adult patients with Meniere's disease that underwent primary ESD surgery from 2015 to 2020. Subjective reporting of pre- and postoperative aural fullness and tinnitus based on postoperative survey. Survey results and audiologic data of the patients that reported were compared pre- and postoperatively. RESULTS: Statistical analysis was performed using weighted kappa statistics to examine the level of agreement. There was a value of 0.12 for pre- and postoperative aural fullness, indicating a difference in the two groups with 77 % having improvement and only 4 % having worsening. There was a value of 0.21 for pre- and postoperative tinnitus, demonstrating a lack of agreement with 58 % having improvement and 4 % having worsening. Overall, there was significant improvement in both tinnitus and aural fullness postoperatively. There was no significant difference in word recognition score, speech reception threshold, or pure tone average between the pre- and postoperative group based on paired t-test. CONCLUSIONS: There is a significant improvement in both aural fullness and tinnitus for patients undergoing ESD with no negative effect on audiologic status. ESD is a viable option for treatment of Meniere's disease with vertigo, aural fullness, and tinnitus relief. Future prospective studies are needed to further improve the evidence of ESD's effect on secondary symptoms of Meniere's disease.

Does labyrinthectomy have an impact on hearing in the contralateral ear during long-term follow-up?

OBJECTIVE: To quantify contralateral hearing outcomes after labyrinthectomy for unilateral Ménière's disease (MD). STUDY DESIGN: Retrospective case series. SETTING: Tertiary neurotology referral center. PATIENTS: Labyrinth removal for the management of MD or translabyrinthine (TLAB) acoustic neuroma resection between 2008 and 2012. MAIN OUTCOME MEASURE: Long-term hearing changes via pure tone averages (PTA). RESULTS: Upon comparison of low-frequency PTA (250, 500, 1000 Hz), MD patients experienced a greater degree of hearing loss during the follow-up period when compared to the TLAB lab group (7.54 ± 2.11 dB vs 2.39 ± 1.10 dB, p = 0.035). This difference as attributable to 12 (28.6 %) MD patients experiencing a ≥30 dB increase in low-frequency PTA, whereas none (0.0 %) of the TLAB surpassed this threshold. CONCLUSIONS: At 10 years post-labyrinthectomy there is a heightened risk for MD patients to develop low-frequency sensorineural hearing loss. Clinicians should monitor for audiometric changes through regular testing in the decade following labyrinth removal.

Outcomes in primary and revision surgery for pediatric onset stapedial pathology.

OBJECTIVES: To analyze audiometric outcomes of surgery for pediatric onset stapedial pathology (POSP). STUDY DESIGN: Retrospective cohort study. SETTING: Single-institution database. METHODS: Retrospective analysis of 809 stapes procedures performed at a single high-volume tertiary referral otology practice, 75 of which were POSP cases. RESULTS: Oval window drillout for thick footplate and aborting the procedure were more common in POSP cases compared to the rest of the cohort (28.0% versus 9.8% [p < .001] and 5.3% versus 1.2% [p = .007], respectively). Postoperative complications were rare. Postoperative Air-Bone Gap (pABG) closure to ≤20 dB was significantly lower in the POSP group (80.0% versus 89.0%, p = .021). Rates of sensorineural hearing loss (SNHL) were not different between the two groups. Poor audiometric outcomes in the POSP group were largely driven by revision cases; pABG≤10 dB was 60.3% in primary cases but only 11.8% in revisions (p < .001), and postoperative SNHL was significantly higher in revisions (29.4% versus 0.0%, p < .001). In multivariate analysis, POSP was not a predictor of successful closure of the pABG at either level, nor did it predict significant postoperative SNHL. CONCLUSIONS: Surgery for pediatric onset stapedial pathology had significantly worse audiometric outcomes, particularly in revision cases, as compared to the rest of the cohort.

Audiologic comparison of classification systems of advanced otosclerosis.

OBJECTIVE: To identify which patients with advanced otosclerosis may have the greatest audiologic improvement with stapedotomy based on different classifications of advanced otosclerosis. STUDY DESIGN: Retrospective chart review. SETTING: Single tertiary neurotology center. METHODS: Patients were divided into different classifications of advanced otosclerosis based on either a bone conduction threshold of greater than 60 dB HL (Bone Conduction (BC) Group), a word recognition score of less than 70% (Word Recognition (WRS) Group), or pure tone average of greater than 85 dB HL (Pure Tone Average (PTA) Group). Audiologic outcomes and complication profiles were compared between these groups. RESULTS: Nineteen patients met criteria for one or more group. There were 18 patients in the PTA group, 11 in the BC group, and 12 in the WRS group. There was no significant difference in the pre- or postoperative audiologic status between the different groups. CONCLUSIONS: Patients with advanced otosclerosis have significant improvements in pure tone averages and air-bone gaps following stapedotomy regardless of the classification criteria used. Stapedotomy remains a reasonable primary intervention for the majority of patients with advanced otosclerosis.

Absent pyramidal eminence and stapedial tendon associated with congenital stapes footplate fixation: Intraoperative and radiographic findings.

OBJECTIVE: Report an association between congenital stapes footplate fixation (CSFF) and radiological absence of the pyramidal eminence and stapedial tendon. PATIENTS: Children and adults with intraoperatively confirmed CSFF and an absent stapedial tendon. INTERVENTIONS: Computed tomography (CT); exploratory tympanotomy with stapedotomy. MAIN OUTCOME MEASURES: Absence of a pyramidal eminence and stapedial tendon aperture identified on preoperative CT that was confirmed intraoperatively. RESULTS: Eight patients with intraoperative confirmation of CSFF and absent stapedial tendon were retrospectively identified. The average preoperative bone conduction and air conduction pure tone averages were 19.6 dB (SD 15.6 dB) and 55.9 dB (SD 23.6 dB), respectively. The average air-bone gap was 36.3 dB (SD 17.9 dB) preoperatively. In the seven patients who underwent preoperative CT, all were consistently identified to have an absent or hypoplastic pyramidal eminence and absent stapedial tendon aperture at the pyramidal eminence. In six cases, the stapedial footplate appeared normal, while in one case the footplate appeared abnormal which correlated with severe facial nerve prolapse observed intraoperatively. All eight cases underwent exploratory tympanotomy and demonstrated intraoperative stapes footplate fixation, absent stapedial tendon and either absent or hypoplastic pyramidal eminence, which correlated with preoperative CT findings. CONCLUSIONS: This study identifies a clinically pragmatic association between an absent pyramidal eminence identified on high-resolution CT and the diagnosis of CSFF. In a condition that otherwise generally lacks distinctive radiological features, the absence of a pyramidal eminence on CT in a patient with nonprogressive, congenital conductive hearing loss may strengthen clinical suspicion for CSFF.

Perioperative cost evaluation of canal wall down mastoidectomy.

INTRODUCTION: To evaluate perioperative costs of canal wall-down (CWD) mastoidectomy as an initial surgery compared to revision surgery following initial canal wall-up (CWU) mastoidectomy. METHODS: This study is a retrospective chart review of adult patients who underwent CWD mastoidectomy for chronic otitis media with or without cholesteatoma at a tertiary referral center. Patients were divided into groups that had previous CWU surgery and were undergoing revision CWD and those that were having an initial CWD mastoidectomy. Cost variables including previous surgeries, imaging costs, audiometric testing, and post-operative visits were compared between the two groups using t-test analysis. RESULTS: There was no significant difference with regards to the cost of post-operative visits, peri-operative imaging, or revision surgeries between the two groups. Hearing outcomes based on mean speech reception threshold (SRT) were not statistically different between the two groups (p = 0.087). There was a significant difference in total cost with the revision group having a higher mean cost by $6967.84, most of which was accounted for by the difference in the cost of the previous surgeries of $6488.53. CONCLUSIONS: The revision CWD surgery group had increased total cost that could be attributed to the cost of previous surgery. Increased peri-operative cost was not noted with the initial CWD surgery group for any individual variables examined. Initial CWD mastoidectomy should be considered in the proper patient population to help decrease healthcare costs.

Stapes surgery with a persistent stapedial artery.

PURPOSE: To review surgical outcomes of stapes surgery for otosclerosis with persistence of the stapedial artery. MATERIALS AND METHODS: A retrospective case review of a tertiary neurotology referral center of patient with otosclerosis undergoing primary stapes surgery between 2010 and 2017 found to have a persistent stapedial artery. Stapedectomy was performed with or without cauterization of the stapedial artery. The primary outcome measures include pre- and postoperative hearing as well complications. Hearing was measured by air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Neurologic complications, including facial nerve function, were assessed. RESULTS: Four patients out of 853 with otosclerosis undergoing stapedectomy were found to have a persistence of the stapedial artery. Mean AC PTA was 55 dB preoperatively, and 24 dB postoperatively (p = .0041), while the ABG improved on average from 31 dB to 6 dB (p = .0014). Mean follow-up time was 32 months, and there were no significant complications. Facial nerve function was preserved in all patients (House-Brackmann grade I/VI). CONCLUSIONS: In the case of a persistent stapedial artery, excellent hearing outcomes are achievable for otosclerosis via stapedectomy without an apparent increased risk of neurologic complication.

Comparison of associated comorbid conditions in patients with benign paroxysmal positional vertigo with or without migraine history: A large single institution study.

PURPOSE: In the largest reported United States (U.S.) cohort of benign paroxysmal positional vertigo (BPPV), does the presence or absence of migraine correlate with increased associations of other factors? MATERIALS & METHODS: A retrospective chart review from a single U.S. neurotology center. Adult patients with BPPV from 2003 to 2017 classified into two groups: 1) with migraine; 2) without migraine. RESULTS: The prevalence of self-reported migraine history in a BPPV-positive population (n = 1481) was 25.8% (n = 382). Among those with BPPV and migraine, 88.5% were female, 8.1% had diabetes, 22.5% had prior history of BPPV, 8.9% had Meniere's disease and recurrence rate was 38.3%. No statistically significant differences between recurrence or resolution rates between the two groups were demonstrated (p > 0.05). Adjusted logistic regression model found that women and those with a prior history of BPPV had significantly higher odds of having both BPPV and migraine conditions compared to their counterparts. In contrast, older age and diabetes were associated with significantly lower odds of concomitant BPPV and migraine. CONCLUSIONS: The prevalence of migraine among the study sample was 25.8%. Female gender, prior history of BPPV, younger age, and lack of diabetes were independently associated with the concurrent comorbidity of BPPV and migraine. These data further substantiate previously reported rates (from smaller studies); and, demonstrate that recurrence and resolution rates are not worse in those with BPPV and migraine compared to the general BPPV population. Findings support an association between migraine and BPPV and enhances one's ability to accurately counsel patients regarding these diseases.

The effect of intratympanic steroid injection frequency in idiopathic sudden sensorineural hearing loss.

PURPOSE: To evaluate the effect of intratympanic steroid injection frequency on hearing outcomes for patients with idiopathic sudden sensorineural hearing loss. MATERIALS AND METHODS: A retrospective chart review was performed from 2007 to 2015 at a neurotology tertiary referral center. Adults who met academy criteria for idiopathic sudden sensorineural hearing loss within two months of onset and negative imaging were grouped based on injection frequency. Injection schedules were every 1-4 (group 1), 5-10 (group 2), or 11-30 (group 3) days. All patients had at least two injections with Dexamethasone 10 mg/ml. All patients had pre- and post-injection audiograms. RESULTS: Seventy patients met inclusion criteria (group 1, n = 21; group 2, n = 29; group 3, n = 20). There was no significant difference between group demographics or baseline audiometric data. Mean gains were significant and similar between groups for pure tone average (group 1 = -23.6 ±â€¯22.0 dB; group 2 = -19.7 ±â€¯18.4 dB; group 3 = -24.9 ±â€¯24.7 dB; p = 0.67) and word recognition score (group 1 = +26.3 ±â€¯34.8%; group 2 = +23.3 ±â€¯29.9%; group 3 = +33.4 ±â€¯28.9%; p = 0.53). CONCLUSIONS: Frequency of intratympanic steroid injections does not significantly affect hearing outcomes. Following injection therapy, hearing outcomes improved regardless of prior or concomitant oral steroid regimen. Earlier time to initiating injections yielded a higher rate of hearing improvement. Long term hearing outcomes >6 months did not show significant additional improvement.

Round window reinforcement for superior semicircular canal dehiscence: a retrospective multi-center case series.

PURPOSE: To evaluate the outcome of round window (RW) tissue reinforcement in the management of superior semicircular canal dehiscence (SSCD). MATERIALS AND METHODS: Twenty-two patients with confirmed diagnosis of SSCD by clinical presentation, imaging, and/or testing were included in the study. Six surgeons at four institutions conducted a multicenter chart review of patients treated for symptomatic superior canal dehiscence using RW tissue reinforcement or complete RW occlusion. A transcanal approach was used to reinforce the RW with various types of tissue. Patients completed a novel postoperative survey, grading preoperative and postoperative symptom severity. RESULTS: Analysis revealed statistically significant improvement in all symptoms with the exception of hearing loss in 19 patients who underwent RW reinforcement. In contrast, 2 of 3 participants who underwent the alternate treatment of RW niche occlusion experienced worsened symptoms requiring revision surgery. CONCLUSION: RW tissue reinforcement may reduce the symptoms associated with SSCD. The reinforcement technique may benefit SSCD patients by reducing the "third window" effect created by a dehiscent semicircular canal. Given its low risks compared to middle cranial fossa or transmastoid canal occlusion, RW reinforcement may prove to be a suitable initial procedure for intractable SSCD. In contrast, complete RW occlusion is not advised.

Rurality Effect on Michigan Newborn Hearing Screening.

OBJECTIVES: Evaluate the effect of rurality on newborn hearing screen outcomes in Michigan. METHODS: Patients in the Michigan Department of Health and Human Services (MDHHS) Newborn Hearing Screening database that failed or did not receive their initial screen from 2015 to 2020 were evaluated. Using the U.S. Department of Agriculture Rural-Urban Continuum Codes (RUCC), patients were assigned a 1-9 code based on the population of their zip code, with 1 being the most urban and 9 being the most rural and outcomes between these patients were compared. RESULTS: There were 34,928 patients initially identified. Patients that had follow-up testing after a failed NBHS had a slightly higher RUCC than those that did not follow-up, 2.3 versus 2.2, respectively (p < 0.001). There was a significant difference between those that refused screening, with a mean RUCC of 4.2, and those that had a failed initial screen having a mean RUCC of 2.1 (p < 0.001). Similarly, those with equipment failure had a higher mean RUCC, 2.8, compared to those that had screening completed (p < 0.001). CONCLUSIONS: More rural areas are more likely to refuse a newborn hearing screen as well as have equipment failure options. There was no difference in rurality scores of those that had a follow-up screen after a failure and those that did not. LEVEL OF EVIDENCE: IV Laryngoscope, 134:2937-2940, 2024.

Quantifying the effect of shoulder size on operation duration: an analysis of stapes surgery outcomes.

OBJECTIVE: To investigate the effect of body mass index on hearing outcomes, operative time and complication rates following stapes surgery. METHOD: This is a five-year retrospective review of 402 charts from a single tertiary otology referral centre from 2015 to 2020. RESULTS: When the patient's shoulder was adjacent to the surgeon's dominant hand, the average operative time of 40 minutes increased to 70 minutes because of a significant positive association between higher body mass index and longer operative times (normal body mass index group (<25 kg/m2) r = 0.273, p = 0.032; overweight body mass index group (25-30 kg/m2) r = 0.265, p = 0.019). Operative times were not significantly longer upon comparison of low and high body mass index groups without stratification by laterality (54.9 ± 19.6 minutes vs 57.8 ± 19.2 minutes, p = 0.127). CONCLUSION: There is a clinically significant relationship between body mass index and operating times. This may be due to access limitations imposed by shoulder size.

Gender Differences in Letters of Recommendations and Personal Statements for Neurotology Fellowship over 10 Years: A Deep Learning Linguistic Analysis.

OBJECTIVE: Personal statements (PSs) and letters of recommendation (LORs) are critical components of the neurotology fellowship application process but can be subject to implicit biases. This study evaluated general and deep learning linguistic differences between the applicant genders over a 10-year span. STUDY DESIGN: Retrospective cohort. SETTING: Two institutions. MAIN OUTCOME MEASURES: PSs and LORs were collected from 2014 to 2023 from two institutions. The Valence Aware Dictionary and Sentiment Reasoner (VADER) natural language processing (NLP) package was used to compare the positive or negative sentiment in LORs and PSs. Next, the deep learning tool, Empath, categorized the text into scores, and Wilcoxon rank sum tests were performed for comparisons between applicant gender. RESULTS: Among 177 applicants over 10 years, 120 were males and 57 were females. There were no differences in word count or VADER sentiment scores between genders for both LORs and PSs. However, among Empath sentiment categories, male applicants had more words of trust (p = 0.03) and leadership (p = 0.002) in LORs. Temporally, the trends show a consistently higher VADER sentiment and Empath "trust" and "leader" in male LORs from 2014 to 2019, after which there was no statistical significance in sentiment scores between genders, and females even have higher scores of trust and leadership in 2023. CONCLUSIONS: Linguistic content overall favored male applicants because they were more frequently described as trustworthy and leaders. However, the temporal analysis of linguistic differences between male and female applicants found an encouraging trend suggesting a reduction of gender bias in recent years, mirroring an increased composition of women in neurotology over time.

Outcomes After Exoscopic Versus Microscopic Type 1 Tympanoplasty.

OBJECTIVE: To analyze the outcomes of exoscopic versus microscopic type 1 tympanoplasty. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary care otology-neurotology practice. PATIENTS: Adult subjects with a diagnosis of tympanic membrane perforation from 2018 to 2022. INTERVENTION: Exoscopic or microscopic tympanoplasty with cartilage + perichondrium or perichondrium/fascia graft. MAIN OUTCOME MEASURES: Primary outcomes were graft success rate (1 wk, 3 wk, 3 mo, and 6 mo postoperatively) and operative time. Secondary outcomes included audiometric outcomes of postoperative air-bone gap (ABG), change in ABG, pure tone average (PTA), speech reception threshold (SRT), and word recognition score (WRS) at 6-month follow-up and complication rates of cerebrospinal fluid leak, facial nerve injury, persistent tinnitus, and persistent vertigo. RESULTS: Seventy-one patients underwent type 1 tympanoplasty by a single surgeon. Thirty-six patients underwent exoscopic tympanoplasty, and 35 patients underwent microscopic tympanoplasty. Cartilage and perichondrium were utilized in 27 subjects (75.0%) in the exoscopic group and in 25 subjects (71.4%) in the microscopic group (p = 0.7, Cramer's V = 0.04). Graft success rate was as follows (exoscope versus microscope): 100% (36/36) versus 100% (35/35) at 1 week (p = 1.0, Cramer's V = 0.0), 97.2% (35/36) versus 100% (35/35) at 3 weeks (p = 1.0, Cramer's V = 0.1), 97.2% (35/36) versus 94.3% (33/35) at 3 months (p = 1.0, Cramer's V = 0.07), and 91.7% (33/36) versus 91.4% (32/35) at 6 months (p = 0.7, Cramer's V = 0.0). Operative time was 57.7 minutes for the exoscopic group and 65.4 minutes for the microscopic group (p = 0.08, 95% CI [-16.4, 0.9], Cohen's d = 0.4). There were no serious complications. All preoperative and postoperative audiometric outcomes were comparable. CONCLUSIONS: The outcomes after exoscopic versus microscopic type 1 tympanoplasty are comparable.

Salvage Microsurgery Following Failed Primary Radiosurgery in Sporadic Vestibular Schwannoma.

Importance: Management of sporadic vestibular schwannoma with radiosurgery is becoming increasingly common globally; however, limited data currently characterize patient outcomes in the setting of microsurgical salvage for radiosurgical failure. Objective: To describe the clinical outcomes of salvage microsurgery following failed primary stereotactic radiosurgery (SRS) or fractionated stereotactic radiotherapy (FSRT) among patients with sporadic vestibular schwannoma. Design, Setting, and Participants: This was a cohort study of adults (≥18 years old) with sporadic vestibular schwannoma who underwent salvage microsurgery following failed primary SRS/FSRT in 7 vestibular schwannoma treatment centers across the US and Norway. Data collection was performed between July 2022 and January 2023, with data analysis performed between January and July 2023. Exposure: Salvage microsurgical tumor resection. Main Outcomes and Measures: Composite outcome of undergoing less than gross total resection (GTR) or experiencing long-term facial paresis. Results: Among 126 patients, the median (IQR) age at time of salvage microsurgery was 62 (53-70) years, 69 (55%) were female, and 113 of 117 (97%) had tumors that extended into the cerebellopontine angle at time of salvage. Of 125 patients, 96 (76%) underwent primary gamma knife SRS, while 24 (19%) underwent linear accelerator-based SRS; the remaining patients underwent FSRT using other modalities. Postoperative cerebrospinal fluid leak was seen in 15 of 126 patients (12%), hydrocephalus in 8 (6%), symptomatic stroke in 7 (6%), and meningitis in 2 (2%). Each 1-mm increase in cerebellopontine angle tumor size was associated with a 13% increased likelihood of foregoing GTR (64 of 102 patients [63%]) or long-term postoperative House-Brackmann grade higher than I (48 of 102 patients [47%]) (odds ratio, 1.13; 95% CI, 1.04-1.23). Following salvage microsurgery, tumor growth-free survival rates at 1, 3, and 5 years were 97% (95% CI, 94%-100%), 93% (95% CI, 87%-99%), and 91% (95% CI, 84%-98%), respectively. Conclusions: In this cohort study, more than half of patients who received salvage microsurgery following primary SRS/FSRT underwent less than GTR or experienced some degree of facial paresis long term. These data suggest that the cumulative risk of developing facial paresis following primary SRS/FSRT by the end of the patient's journey with treatment approximates 2.5% to 7.5% when using published primary SRS/FSRT long-term tumor control rates.

Retrosigmoid Approach for Sporadic Vestibular Schwannoma: Patient Selection, Technical Pearls, and Hearing Results.

The retrosigmoid corridor provides the most broadly applied approach for resection of sporadic vestibular schwannoma. It may be utilized for any size tumor and for patients with intact hearing with the intention of hearing preservation. For larger tumors, the skull base surgeon must weigh the benefits the retrosigmoid approach against those of the translabyrinthine route. For smaller tumors where hearing preservation is a goal, the retrosigmoid approach is contrasted to the middle fossa route. Hearing preservation is most likely for patients with small and medially located intracanalicular tumors with minimal extension into the cerebellopontine angle, and excellent preoperative hearing.