The Cochlear Implant "Seatbelt" Technique for Receiver/Stimulator Fixation.

Receiver/stimulator migration and extrusion are among the most commonly reported complications of cochlear implantation. Current techniques implement either a tight subperiosteal pocket or postauricular bone well. Here we describe a safe and effective technique to secure a cochlear implant receiver/stimulator with a Mersilene cervical cerclage tape "seatbelt." Laryngoscope, 134:3374-3376, 2024.

Translabyrinthine Craniotomy Is Associated with Higher Risk of Asymptomatic Dural Venous Sinus Thrombosis in Vestibular Schwannoma Resection.

OBJECTIVE: Characterize the incidence, risk factors, and patient outcomes of dural venous sinus thrombosis identified on postoperative imaging after retrosigmoid or translabyrinthine craniotomy for vestibular schwannoma resection. STUDY DESIGN: Retrospective cohort study. SETTING: Single tertiary academic referral center. PATIENTS: Eighty-one patients 19 to 82 years of age with vestibular schwannomas, 58% female. INTERVENTIONS: Retrosigmoid or translabyrinthine craniotomy with postoperative magnetic resonance imaging/magnetic resonance venography. MAIN OUTCOME MEASURES: Association between operative approach, age, sex, body mass index, tumor size, dominant sinus, operative time, laterality, and perioperative cerebrospinal fluid (CSF) leaks with rate of thrombosis. RESULTS: Translabyrinthine craniotomy was associated with the highest relative risk of thrombosis (odds ratios [OR] = 19.82, 95% confidence interval [CI] = 1.75-224, p = 0.007), followed by male sex (OR = 5.53, 95% CI = 1.63-18.8, p = 0.035). Other patient and demographic risk factors were not associated with increased rates of dural venous thrombosis, nor was there an association with postoperative CSF leak. 81% (25/31) of thrombi had resolved within 3 years of surgery. CONCLUSIONS: Translabyrinthine approach and male sex most strongly predicted postoperative dural venous thrombosis after postauricular craniotomy for vestibular schwannoma resection. PROFESSIONAL PRACTICE GAP AND EDUCATIONAL NEED: Better understanding of risk factors and management of dural venous thrombosis after vestibular schwannoma surgery. LEARNING OBJECTIVE: Characterize clinically significant risk factors for dural venous thrombosis in vestibular schwannoma surgery. DESIRED RESULT: Identification of patient and operative risk factors for dural venous thrombosis. LEVEL OF EVIDENCE: III. INDICATE IRB OR IACUC: Exempt.

Systematic Review and Meta-analysis for Surgery Versus Stereotactic Radiosurgery for Jugular Paragangliomas.

OBJECTIVE: Comprehensively analyze tumor control and treatment complications for jugular paraganglioma patients undergoing surgery versus stereotactic radiosurgery (SRS). DATABASES REVIEWED: EMBASE, Medline, and Scopus. METHODS: The databases were searched for English and Spanish articles from January 1, 1995, to January, 1, 2019, for studies reporting tumor control and treatment side effects regarding patients with jugular paraganglioma treated with surgery or SRS. Main outcome measures included short-term and long-term tumor recurrence, as well as postintervention complications. RESULTS: We identified 10,952 original abstracts, 705 eligible studies, and 107 studies for final data extraction. There were 3,498 patients-2,215 surgical patients and 1,283 SRS patients. Bayesian meta-analysis was applied to the extracted data, with tau measurements for study heterogeneity. SRS tumors were larger (3.9 cm 3 versus 8.1 cm 3 ). Meta-analysis results demonstrated low rates of long-term recurrence for both modalities (surgery, 15%; SRS, 7%), with SRS demonstrating lower rates of postintervention cerebrospinal fluid leak, dysphagia, and cranial nerve Vll, lX, X, Xl, or Xll palsies. CONCLUSIONS: This study demonstrates excellent control of jugular paragangiomas with both surgery and SRS, with higher rates of lower cranial neuropathies, dysphagia, and cerebrospinal fluid leaks among surgical patients.

Vein Graft Tympanoplasty: How a Transiently Used Graft Material Transformed Middle Ear Surgery.

The inception of medial grafting as a technique for tympanic membrane repair was a critical milestone in the history of otology. John Shea introduced the medial graft technique and the use of vein grafts for tympanoplasty in 1960 after realizing that the vein grafts that he used to repair the oval window after stapedectomy could also be utilized to repair tympanic membrane perforations. At the time, tympanoplasty often utilized skin grafts, which required placement of the graft lateral to the tympanic membrane annulus. Placement of the graft medial to the tympanic membrane annulus allowed for more efficient surgery and avoided the complications associated with lateral grafting, such as blunting and lateralization. The introduction of vein grafts in tympanoplasty prompted a fundamental shift in technique from lateral to medial grafting, paving the way for decades of innovation in tympanoplasty.

Inflammatory Pseudotumor of the Temporal Bone Leading to Atypical Superior Semicircular Canal Dehiscence Syndrome: A Novel Case Report.

OBJECTIVE: Inflammatory pseudotumor of the temporal bone is a benign idiopathic inflammatory process that is rarely encountered in clinical practice. We describe a novel case of a patient who developed superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone. PATIENT: One female patient found to have inflammatory pseudotumor of the temporal bone. After treatment with mastoidectomy and steroids, she subsequently developed superior semicircular canal dehiscence syndrome. INTERVENTIONS: The patient initially underwent myringotomy and pressure equalization tube placement for a unilateral effusion. Imaging with computed tomography and magnetic resonance imaging revealed a lytic mastoid mass. A complete mastoidectomy was diagnostic for inflammatory pseudotumor and the patient was treated with adjuvant long-term corticosteroids. After this procedure, she was discovered to have new development of symptomatic superior semicircular canal dehiscence syndrome. She eventually underwent a trans-mastoid repair of her superior semicircular canal dehiscence. MAIN OUTCOME MEASURES: The patient's clinical course is described with emphasis on the development of superior semicircular canal dehiscence syndrome in the setting of active inflammatory pseudotumor of the temporal bone. RESULTS: The patient's radiographic and clinical history were found to be consistent with inflammatory pseudotumor of the temporal bone. She underwent a therapeutic mastoidectomy with long-term post-operative corticosteroids. During her post-operative course, she developed symptoms of vertigo, hearing loss, and autophony. She was subsequently diagnosed with superior semicircular canal dehiscence and treated with a trans-mastoid repair of the dehiscence. Her symptoms satisfactorily resolved after this surgery. CONCLUSIONS: Inflammatory pseudotumor of the temporal bone is a rare benign inflammatory process. We present what is to our knowledge the first description of superior semicircular canal dehiscence syndrome developing in the setting of inflammatory pseudotumor.

Development of a Surgical Video Atlas for Resident Education: 3-Year Experience.

OBJECTIVE: To create a high-quality annotated online surgical video atlas of key indicator otolaryngology cases and assess its use and overall journal trends over time. METHODS: Videos are recorded from multiple viewpoints within the operating room and compiled into a single stream. Postediting includes chaptering videos and overlaying relevant text annotations. Videos are published online and viewership trends analyzed. RESULTS: Over 3 years, 29 otolaryngology videos were published out of 161 journal publications (18%). Eight of the 14 key indicator procedures are included (57%). From the beginning of 2017 to the end of 2019, viewership of otolaryngology pages increased from 548 to 11,139 views per month, totaling >150,000 views. These now represent 10% of the total journal monthly views and 10% of the overall views. Users originate from the United States and from >10 other countries. DISCUSSION: Residents and faculty face challenges of providing the highest standard of clinical care, teaching, and learning in and out of the operating room. Inherent difficulties of surgical training, high-fidelity surgical simulation, and imposed work hour restrictions necessitate additional, more efficient and effective means of teaching and learning. Surgical videos demonstrating key anatomy, procedural steps, and surgical dexterity with hand positioning are increasing in their popularity among learners. IMPLICATIONS FOR PRACTICE: Surgical video atlases provide a unique adjunct for resident education. They are enduring and easily accessible. In a climate of work hour restrictions or elective case reduction, they may supplement how residents learn to operate outside the operating theater.

Rare Lesions of the Internal Auditory Canal.

BACKGROUND: Approximately 95% of tumors occurring within the internal auditory canal (IAC) are vestibular schwannomas. Many undergo stereotactic radiation without definitive tissue diagnosis. Rare IAC tumors are not all radiosensitive and are poorly described. METHODS: Between 1992 and 2015, 289 consecutive patients with IAC lesions operated on were reviewed retrospectively. RESULTS: Fifteen patients (5.2%) (16 operations) had unusual histologic findings, including nonvestibular schwannomas (2 facial schwannomas, 2 cochlear schwannomas, 2 intermedius schwannomas), 3 meningiomas, 3 cavernous hemangiomas, a mucosa-associated lymphoid tissue lymphoma, an arachnoid cyst, and a lipochoristoma. None of these rare tumors could be identified before surgery. Three operative approaches were used: the retrosigmoid approach, middle fossa subtemporal approach, or translabyrinthine approach. Few complications occurred, including facial nerve palsy, loss of hearing, and vestibular function. Five-year average follow-up revealed one patient with recurrence. CONCLUSIONS: Clinical examination and imaging alone were insufficient to correctly identify these tumors. Definitive pathologicdiagnosis should be strongly considered to help tailor treatment.

Cost analysis and outcomes of a second-look tympanoplasty-mastoidectomy strategy for cholesteatoma.

OBJECTIVES/HYPOTHESIS: To analyze cost and compare cholesteatoma recidivism and hearing outcomes with single-stage and second-look operative strategies. STUDY DESIGN: Retrospective review and cost analysis. METHODS: Adult and pediatric patients who underwent a tympanoplasty with mastoidectomy for cholesteatoma with a single-stage or second-look operative strategy were identified. Variables included procedure approach, residual or recurrent cholesteatoma, ossicular chain reconstruction frequency, and operative complications. Audiologic outcomes included pre-/postoperative air bone gap (ABG) and word recognition score (WRS). Cost analysis included charges for consultation and follow-up visits, surgical procedures, computed tomography temporal bone scans, and audiology visits. RESULTS: One hundred and six patients had a tympanoplasty with mastoidectomy for cholesteatoma, with 80 canal wall-up procedures (CWU) as initial approach. Of these, 46 (57.5%) CWU patients had a planned second look. Two (4.3%) CWU patients had recurrent cholesteatoma and 20 (43.4%) had residual identified at second look. Four (11.7%) single-stage CWU strategy patients developed recurrent cholesteatoma. There was no significant difference in pre-/postoperative ABG and WRS between second look and single stage (P > 0.05). Compared to second-look patients, single-stage patients had significantly fewer postoperative visits (6.32 vs. 10.4; P = 0.007), and significantly lower overall charges for care ($23,529. vs. $41.411; P < 0.0001). CONCLUSION: The goal of cholesteatoma surgery is to produce a safe ear, and a second-look strategy after CWU has historically been used to evaluate for recurrent or residual disease. The cholesteatoma recurrence rate at a second look after a CWU tympanoplasty-mastoidectomy is low. Costs of operative procedures are a significant proportion of healthcare resource expenditures. Considering the low rate of cholesteatoma recurrence and relatively high cost of care, implementation of a second-look strategy should be individually tailored and not universally performed. LEVEL OF EVIDENCE: 4. Laryngoscope, 126:2574-2579, 2016.

Surgical management of vestibular schwannomas after failed radiation treatment.

Increasing numbers of patients with vestibular schwannoma (VS) have been treated with focused-beam stereotactic radiation treatment (SRT) including Gamma knife, CyberKnife, X-knife, Novalis, or proton beam therapy. The purpose of this study was to document the incidence of tumor regrowth or symptoms that worsened or first developed following SRT and to discuss surgical strategies for patients who have failed SRT for VS. A consecutive series of 39 patients with SRT failed VS were surgically treated. Clinical symptoms, tumor regrowth at follow-up, intraoperative findings, and surgical outcome were evaluated. There were 15 males and 24 females with a mean age of 51.8 years. Thirty-six patients (92.3%) demonstrated steady tumor growth after SRT. Two (5.1%) patients with slight increase of the mass underwent surgical resection because of development of unbearable facial pain. Symptoms that worsened or newly developed following SRT in this series were deafness (41%), dizziness (35.9%), facial numbness (25.6%), tinnitus (20.5%), facial nerve palsy (7.7%), and facial pain (7.7%). Intraoperative findings demonstrated fibrous changes of the tumor mass, cyst formation, and brownish-yellow or purple discoloration of the tumor capsule. Severe adhesions between the tumor capsule and cranial nerves, vessels, and the brainstem were observed in 69.2%. Additionally, the facial nerve was more fragile and irritable in all cases. Gross total resection (GTR) was achieved in 33.3% of patients, near-total resection (NTR) in 35.9%, and subtotal resection (STR) in 30.8% of patients. New facial nerve palsy was seen in seven patients (19.4%) postoperatively. Our findings suggest that patients with VS who fail SRT with either tumor progression or worsening of clinical symptoms will have an increased rate of adhesions to the neurovascular structures and may have radiation-influenced neuromalacia. Salvage surgery of radiation-failed tumors is more difficult and will have a higher risk of postoperative complications. Radical total resection may not be feasible, and conservative modality of subtotal resection needs to be considered to avoid new neurologic deficits.

Preoperative Lumbar Drain Use During Acoustic Neuroma Surgery and Effect on CSF Leak Incidence.

OBJECTIVE: To determine if preoperative lumbar drain (LD) use reduces the incidence of postoperative cerebrospinal fluid (CSF) leak in patients undergoing acoustic neuroma resection. METHODS: Retrospective review of 282 patients presenting for acoustic neuroma resection between 2005 and 2014. RESULTS: Two hundred and eighty-two patients had a mean tumor size of 19.1 mm ± 10.2 mm. Twenty-nine (10.3%) patients developed a postoperative CSF leak. Two hundred and twenty patients (78.0%) received a preoperative LD, and 20 (9.1%) developed a CSF leak. Sixty-two (22.0%) patients did not receive a preoperative LD, and 9 (14.5%) developed a CSF leak. No significant difference in CSF leak frequency was observed with use versus no use of a LD (P = .23). Fifteen (5.3%) patients with an LD placed had a complication related to the LD. No significant difference in CSF leak frequency was observed with patient age, neurofibromatosis type-2 diagnosis, tumor size, or sidedness. CONCLUSIONS: Postoperative CSF leaks are among the most common complications of acoustic neuroma microsurgery. No formal guidelines exist for elective placement of a preoperative LD to lower the incidence of CSF leaks. Our reported CSF leak incidence with preoperative LD placement is not significantly lower than without LD use, and there is a complication rate associated with LD use.

Less invasive transjugular approach with Fallopian bridge technique for facial nerve protection and hearing preservation in surgery of glomus jugulare tumors.

For the past three decades, surgery of glomus jugulare tumors (GJTs) has been characterized by extensive combined head and neck, neuro-otologic, and neurosurgical approaches. In recent years, the authors have modified the operative technique to a less invasive approach for preservation of cranial nerves while achieving satisfactory tumor resection. We evaluated and compared the clinical outcomes of our current less invasive approach with our previous more extensive procedures. The clinical records of 39 cases of GJT surgically treated between 1992 and 2011 were retrospectively reviewed. The less invasive transjugular approach with Fallopian bridge technique (LI-TJ) was used for the most recent five cases. The combined transmastoid-transjugular and high cervical (TM-HC) approach was performed in 30 cases, while four cases were treated with a transmastoid-transsigmoid approach with facial nerve translocation. Operative technique, extent of tumor resection, operating time, hospital stay, and morbidity were examined through the operative records, and a comparison was made between the LI-TJ cases and the more invasive cases. No facial nerve palsy was seen in the LI-TJ group while the TM-HC group demonstrated six cases (17.6%) of facial palsy (House-Brackmann facial nerve function grading scale grade II and III). The complication rate was 0 % in the LI-TJ group and 16.7% in the more invasive group. The mean operative time and hospital stay were shorter in the LI-TJ group (6.4 h and 4.3 days, respectively) compared with the more invasive group (10.7 h and 8.0 days, respectively). The LI-TJ approach with Fallopian bridge technique provided adequate tumor resection with cranial preservation and definitive advantage over the more extensive approach.

Middle fossa approach for total resection of petrous apex cholesterol granulomas: use of vascularized galeofascial flap preventing recurrence.

BACKGROUND: Cholesterol granulomas (CGs) of the petrous apex (PA) are rare, benign, expanding lesions. Surgical treatment is recommended for patients with symptomatic disease; however, the optimal surgical procedure is still controversial due to high recurrence rates. The main treatment strategy is divided into drainage and complete resection. OBJECTIVE: We advocate radical resection of the lesion by the middle fossa approach and reconstruction with a vascularized galeofascial flap. METHODS: A 10-year retrospective case review of 17 patients undergoing surgical treatment of PA CGs between 2000 and 2010 was undertaken. Operative outcomes and surgical complications were analyzed. In addition, our operative method and the related anatomy are described from cadaveric dissections. RESULTS: All but 1 patient was operated on via a middle fossa approach. Using the middle fossa approach, radical resection of all PA CGs was achieved with obliteration of the cyst cavity using a vascularized flap. Important surrounding structures included the internal auditory canal, cochlea, petrous carotid artery, and abducens nerve. There was 1 death caused by internal carotid artery occlusion. No other major complications or cranial nerve deficits occurred postoperatively. Clinical recurrence occurred in 1 patient (5.9%). CONCLUSION: Our technique of radical resection and reconstruction with a vascularized flap has the advantage of being less invasive with less cosmetic deformity and allows preservation of cranial nerve function with a low recurrence rate. Knowledge of the surgical anatomy and the characteristics of CG is prudent because important neurovascular structures may be exposed behind the CG wall due to bony erosion.

Contemporary surgical management of vestibular schwannomas: analysis of complications and lessons learned over the past decade.

BACKGROUND: Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months). RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed.

External auditory canal closure: an alternative management for the refractory chronically draining ear.

OBJECTIVE: To discuss the surgical technique and evaluate the effectiveness of external auditory canal (EAC) closure in patients with refractory chronically draining ears. STUDY DESIGN AND SETTING: A retrospective case review of seven patients who underwent EAC closure for chronically draining ears at a private tertiary otologic referral center between 2001 and 2004. Three patients underwent concomitant placement of a BAHA implant, and one patient underwent cochlear implantation during a second-stage procedure. RESULTS: All seven patients had successful closure of the external auditory canal with elimination of chronic drainage. The follow-up interval ranged from 10 to 35 months. There were no cases of iatrogenic cholesteatoma formation or breakdown of the ear canal closure. CONCLUSION AND SIGNIFICANCE: In patients with refractory chronically draining ears, EAC closure, alone or in conjunction with a bone-anchored implant, may be a treatment option. A BAHA implant can be placed during the initial procedure or staged.

Neurotologic skull base surgery in pediatric patients.

OBJECTIVE: Innovations in diagnosis, surgical techniques, and perioperative care have dramatically improved outcomes in lateral skull base procedures in recent years. There is a belief, however, that children with skull base tumors have yet to benefit from these technological and procedural advances. The purpose of this study is to provide a clinical review of neurotologic skull base surgery in the pediatric population. STUDY DESIGN: Retrospective case review. SETTING: Private practice tertiary referral center. PATIENTS: Eighty-nine pediatric patients undergoing 115 neurotologic procedures for lateral skull base tumors from July 1992 to September 2003. MAIN OUTCOME MEASURES: Initial clinical presentation, tumor type, pre- and postoperative hearing and facial nerve status, treatment course, complications, and functional outcomes. RESULTS: The majority of tumors in this series were vestibular schwannomas, and 65 patients were diagnosed with neurofibromatosis Type 2. Surgical approaches included 70 middle fossa, 40 translabyrinthine, 2 transcochlear, 2 infratemporal fossa, and 1 retrosigmoid craniotomy. Complete tumor removal was accomplished in the majority of cases (97%), with good preservation of facial nerve function (House-Brackmann Grade I or II) in 80% of patients. In patients undergoing middle fossa surgery for hearing preservation, measurable hearing was preserved in 61.4% of cases. The incidence of complications was low. CONCLUSION: With advances in diagnostic procedures and use of current neurotologic techniques, pediatric patients may undergo successful treatment of lateral skull base tumors, with good functional outcomes and minimal morbidity.

Postoperative infection in cochlear implant patients.

OBJECTIVE: Recently, the association of meningitis with cochlear implants has raised concern over the safety of these devices. We examined the incidence of all postoperative infections in patients undergoing cochlear implant surgery. Study design and settings A retrospective chart review of all patients undergoing cochlear implants at a private tertiary referral center from 1993 to 2002 was performed. Cochlear implant surgeries in 462 adults and 271 children were reviewed. Patients with evidence of a postoperative infection or infectious complication related to cochlear implantation were identified, and data on patient characteristics, surgery, and treatment outcome were obtained. RESULTS: The overall incidence of postoperative infection in our cochlear implant series was 4.1%. Major infectious complications occurred in 3.0% of cases, and the majority of infections required surgical intervention. A history of chronic ear disease may increase the risk of infectious complications. There were no cases of meningitis. CONCLUSIONS: Cochlear implants remain a safe procedure with a low complication rate. The majority of infections can be managed without removing the implant device. Advances in surgical technique and flap design have decreased the occurrence of wound-related complications. However, identification of risk factors for infection and optimization of treatment regimens will further reduce the complications associated with postoperative infection.

Use of Alloderm in the neurotologic setting.

PURPOSE: To determine whether Alloderm (Life Cell Corporation, The Woodlands, TX) can be used to cover canal wall down mastoid defects, as well as repair dural defects from translabyrinthine and transpetrosal approaches to the skull base. METHODS: A retrospective analysis was performed at an academic tertiary care medical center. Eighteen patients were operated on with canal wall down mastoidectomies, and Alloderm was used to reconstruct the tympanic membrane and line the mastoid cavity. Eleven patients had dural defects reconstructed after skull base approach surgery. We wanted to determine whether the Alloderm graft healed in canal wall down mastoidectomy procedures with good epithelialization. For the skull base approaches, we determined whether a cerebrospinal fluid leak had occurred. RESULTS: The 18 patients who were reconstructed with an Alloderm graft after a canal wall down mastoidectomy all had good epithelialization. As with fascia reconstruction, some granulation tissue occurred, but this was easily controlled in the office setting. Of the 11 patients who underwent reconstruction for skull base surgery approaches, none developed a cerebrospinal fluid leak. CONCLUSION: Alloderm may provide a suitable grafting material when fascia is either not readily available, or the size of the defect precludes the use of fascia.