Rate of Development of Venous Thromboembolism in Lateral Skull Base Surgery.

OBJECTIVES: Venous thromboembolism (VTE) is a major cause of morbidity and mortality for surgical patients. This article aims to determine factors that may have contributed to the development of VTE in patients undergoing lateral skull base surgery, to assess the validity of the Caprini Risk Assessment Model (RAM) score in this subset of patients, and to determine the efficacy of mechanical DVT prophylaxis alone in preventing VTE. STUDY DESIGN: Retrospective chart review. METHODS: A retrospective chart review was conducted of patients who underwent skull base surgery for vestibular schwannoma, and the rate of VTE was assessed. Patient demographics, comorbidities, and treatment factors were examined to determine risk factors associated with the development of a postoperative thrombotic event. Caprini RAM scores were compared for patients who developed a VTE. RESULTS: Among 197 patients, the rate of VTE formation was 3.5%. No individual risk factor independently contributed to the development of a thrombotic event. The mean Caprini RAM score was 4.06 in patients who did not develop a VTE and 5.14 in the patients that did develop a VTE (P = .005). The Caprini score was significant for the risk of VTE formation, with an odds ratio of 2.8 (P = .009, 95% CI = 1.3-6.2). CONCLUSION: Venous thromboembolism rates are relatively low following lateral skull base surgery. While there is no individual risk factor associated with increased VTE risk, the Caprini RAM score appears to be a useful predictor of risk. The Caprini score may be useful in identifying high-risk patients who may benefit from chemoprophylaxis for VTE prevention. LEVEL OF EVIDENCE: 3 Laryngoscope, 132:662-667, 2022.

Risk Factors for Complications Following Lateral Skull Base Surgery and the Utility of ICU Monitoring.

OBJECTIVE: To examine the role of intensive care unit (ICU) management following lateral skull base surgery for vestibular schwannoma and identify risk factors for complications warranting admission to the ICU. STUDY DESIGN: Retrospective review. SETTING: Tertiary referral center. PATIENTS: Two hundred consecutive patients undergoing lateral skull base surgery for vestibular schwannomas. INTERVENTION: Lateral skull base approach for resection of vestibular schwannoma and postoperative monitoring. MAIN OUTCOME MEASURES: Patients were grouped if they sustained an ICU complication, a non-ICU complication, or no complication. Analysis was performed to determine patient or treatment factors that may be associated with ICU complications. Multivariate and three-way analysis of variance compared groups, and multivariate logistic regression determined adjusted odds ratios (aOR) for analyzed factors. RESULTS: Seventeen of 200 patients sustained ICU complications (8.5%), most commonly hypertensive urgency (n = 15). Forty-six (23%) sustained non-ICU complications, and 137 (68.5%) had no complications. When controlling for age, sex, obesity, and other comorbidities, only hypertension (aOR 5.43, 95% confidence interval (CI) 1.35-21.73, p = 0.017) and tumor volume (aOR 3.29, 95% CI 1.09-9.96, p = 0.035) were independently associated with increased risk of ICU complications. CONCLUSIONS: The necessity of intensive care following lateral skull base surgery is rare, with the primary ICU complication being hypertensive urgency. Preoperative hypertension and large tumor volume (>4500 mm3) were independently associated with increased risk for ICU complications. These findings may allow for risk stratification of patients appropriate for admission to stepdown units following resection of vestibular schwannomas. Further prospective, multi-center, randomized studies are necessary to validate these findings before systematic changes to current postoperative care practices.

Bone Cement Fixation of Stapedotomy Prostheses: Long-term Outcomes in Primary and Revision Stapes Surgery.

OBJECTIVES: To describe audiologic outcomes following hydroxyapatite bone cement fixation of stapedotomy prostheses. METHODS: A retrospective case review at a tertiary neurotology referral center was performed of patients undergoing primary or revision stapedotomy between 2010 and 2017. Patients with hydroxyapatite bone cement fixation of stapes prostheses were assessed. Pre- and postoperative hearing was compared, consisting of air conduction (AC) and bone conduction (BC) pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). Short and long-term outcomes were assessed. RESULTS: Forty-six patients with otosclerosis underwent stapedotomy with bone cement fixation: 21 primary cases and 25 revision cases, with an average follow-up time of 17 months. Mean AC PTA was 56 dB preoperatively, and 34 dB postoperatively (P < .0001), while the ABG improved on average from 27 dB to 9 dB (P < .0001). There was no significant difference in postoperative ABG between primary and revision stapes surgery (6 dB vs 10 dB, P = .07). These results persisted through long-term follow-up in a subgroup of patients with significantly longer follow-up time (mean 44 months). There was no significant change in BC PTA or word recognition scores. Three patients underwent subsequent revisions, one patient developed sensorineural hearing loss. CONCLUSION: Stapedotomy with bone cement fixation of the prosthesis provides excellent hearing outcomes in both primary and revision treatment of otosclerosis. Results are consistent and stable through long-term follow-up. The use of bone cement should be incorporated into the surgical armamentarium of the otologist for the prevention and treatment of loose-wire syndrome and incus necrosis.

Reliability of clinical diagnosis of masses of the cerebellopontine angle: A retrospective multi-institutional study.

OBJECTIVES: To assess the accuracy of pre-operative diagnosis of masses of the cerebellopontine angle (CPA) when compared to surgical pathology. DESIGN: Retrospective chart review. PARTICIPANTS: Patients who underwent surgery for CPA masses at two tertiary care institutions from 2007 to 2017. MAIN OUTCOME MEASURES: Percent concordance between pre-operative and surgical pathologic diagnosis; sensitivity, specificity, positive predictive value, and negative predictive value for predicted diagnoses. RESULTS: Concordance between pre-operative diagnosis and surgical pathology was 93.2% in 411 sampled patients. Concordance was 57.9% for masses other than vestibular schwannoma. Prediction of vestibular schwannoma and meningioma had high positive (0.95 and 0.97, respectively) and negative (0.76 and 0.99, respectively) predictive values. Prediction of facial neuroma had sensitivity of 0.13 and positive predictive value of 0.25. Headache (p = 0.001) and facial weakness (p = 0.003) were significantly associated with different pathologic profiles. Hearing loss was associated with differences in diagnostic prediction (p = 0.02) but not with differences in surgical pathology (p > 0.05). CONCLUSIONS: Comparison between pre-operative predicted diagnosis and surgical pathology for cerebellopontine angle masses is presented. Vestibular schwannoma and meningioma were effectively identified while rarer CPA masses including facial neuroma were rarely identified correctly. Clinicians caring for patients with CPA masses should be mindful of diagnostic uncertainty which may lead to changes in treatment plan or prognosis.

Traumatic versus Idiopathic Benign Positional Vertigo: Analysis of Disease, Treatment, and Outcome Characteristics.

OBJECTIVE: To compare characteristics between traumatic and idiopathic benign paroxysmal positional vertigo (BPPV) focusing on outcomes. STUDY DESIGN: Retrospective chart review. SETTING: High-volume tertiary otology center. SUBJECTS AND METHODS: Records of patients with BPPV treated at a single institution from 2007 to 2017 were analyzed. Traumatic BPPV was defined as BPPV symptoms beginning within 30 days following head trauma. Patient, disease, treatment, and outcome characteristics were compared between traumatic and idiopathic BPPV groups. RESULTS: A total of 1378 patients with BPPV were identified, 110 (8%) of which had traumatic BPPV. The overall resolution rate was 76%, and the recurrence rate was 38%. Patients with traumatic BPPV were younger (mean age: 61 vs 65 years, P = .007) and more likely to be male (40% vs 27%, P = .004) than patients with idiopathic BPPV. Traumatic BPPV was more likely to affect both ears (32% vs 19%, P = .009). No significant association was detected between trauma history and resolution rate, recurrence rate, number of treatment visits, or affected semicircular canals. CONCLUSION: Patients with traumatic BPPV are more likely to be young and male than those with idiopathic disease. Although traumatic BPPV is often bilateral, outcomes for traumatic BPPV may be similar to those for idiopathic BPPV, contrary to prior reports.

Causes of Persistent Positional Vertigo Following Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo.

OBJECTIVE: To report causes of persistent recalcitrant positional vertigo (PRPV) after posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Retrospective chart review. SETTING: Single high-volume otology practice. PATIENTS: Patients diagnosed with BPPV from 2007 to 2017. INTERVENTION: PSCO and follow-up care including diagnostic and particle repositioning maneuvers for recurrent BPPV. MAIN OUTCOME MEASURES: PRPV, defined as recalcitrant positional vertigo for any reason following PSCO. RESULTS: Twenty seven PSCO operations were performed in 26 patients. Twenty five patients (96.2%) had resolution of the Dix-Hallpike test in the operated ear. Eleven patients (42.3%) developed BPPV postoperatively, three (11.5%) in the operated ear and eight (30.8%) in the contralateral ear. Five of eight patients (62.5%) who developed contralateral BPPV had unilateral BPPV preoperatively. Eight patients (30.8%) developed BPPV at least twice after surgery or did not resolve, qualifying as PRPV, and all but one of these events occurred in the nonsurgical ear. No instances of cerebrospinal fluid leak, postoperative infection, facial palsy, clinically significant hearing loss, or death occurred. CONCLUSIONS: PSCO is a safe and effective option for recalcitrant BPPV. However, 30.8% of patients, including patients with initially unilateral BPPV, had recalcitrant positional vertigo postoperatively, usually due to contralateral BPPV. Patients considering PSCO should be counseled regarding this risk to ensure realistic expectations.

Endolymphatic Sac Decompression With Intra-Sac Dexamethasone Injection in Menière's Disease.

OBJECTIVE: Endolymphatic sac decompression surgery (ELSD) may be used to treat patients who have Menière's 's disease refractory to medical therapy. In this study, we investigated whether or not the injection of steroid into the endolymphatic sac at the time of ELSD provides additional benefit to patient outcomes. STUDY DESIGN: Randomized prospective single-blinded placebo-controlled study. SETTING: Tertiary center. PATIENTS: Patients with Menière's disease with poorly controlled vertigo despite medical therapy and serviceable hearing that were offered ELSD. INTERVENTION(S): Patients randomized into two groups, with control group (n = 17) undergone ELSD without steroid injection and experimental group undergone ELSD with steroid injection (n = 18) MAIN OUTCOME MEASURE(S):: Audiogram, dizziness handicap inventory, tinnitus handicap inventory, frequency of vertigo spells, functional level scale, and quality of life were obtained at multiple intervals from preoperatively to 24 months postoperatively. RESULTS: ELSD resulted in a statistically significant improvement in vertigo control whether or not steroid was injected into the endolymphatic sac at the time of surgery. However, no additional benefit was observed with the addition of intra-sac steroid injection. No statistical difference in pure-tone average, tinnitus handicap inventory, dizziness handicap inventory, or quality of life was observed between the steroid and nonsteroid surgical groups up to 24 months postoperatively. CONCLUSION: ELSD is an effective treatment for Menière's disease refractory to medical therapy; however, the addition of intra-sac steroid injection at the time of surgery does not seem to result in a further improvement in patient outcomes.

Treatment of Patients With Benign Paroxysmal Positional Vertigo and Severe Immobility Using the Particle Repositioning Chair: A Retrospective Cohort Study.

OBJECTIVE: To report treatment of benign paroxysmal positional vertigo (BPPV) in patients unable to undergo traditional canalith repositioning maneuvers (CRMs) using a particle repositioning chair (PRC). METHODS: A retrospective chart review was conducted at a single high-volume otology practice of patients diagnosed with BPPV from 2007 to 2017 with immobility prohibiting use of traditional CRMs. Patients were diagnosed and treated using a PRC, and outcome measures including resolution, recurrence, and number of treatment visits were recorded. RESULTS: A total of 34 patients meeting criteria were identified, 24 of whom had cervical spine disease and 10 of whom had other prohibitive immobility. Symptoms were present for between 5 days and 11 years at presentation, with mean and median of 552 and 90 days, respectively. Symptoms resolved in 68% of patients and recurred in 13% of those patients. Most patients required 1 treatment visit. CONCLUSIONS: Successful treatment of patients with BPPV and concomitant immobility prohibiting traditional CRMs is reported using the PRC. Benign paroxysmal positional vertigo in the setting of immobility is an indication for treatment with a PRC if available.

Recurrence in Benign Paroxysmal Positional Vertigo: A Large, Single-Institution Study.

OBJECTIVE: To report rates of recurrence in benign paroxysmal positional vertigo (BPPV) and associated patient and disease factors. STUDY DESIGN: Retrospective chart review. SETTING: Single high-volume otology practice. PATIENTS: Patients diagnosed with BPPV from 2007 to 2016 with documented resolution of symptoms. INTERVENTION: Diagnostic and particle repositioning maneuvers for BPPV. MAIN OUTCOME MEASURES: BPPV recurrence, time to recurrence, and ear(s) affected at recurrence. RESULTS: A total of 1,105 patients meeting criteria were identified. Of this population, 37% had recurrence of BPPV in either ear or both ears. Overall same-ear recurrence rate was 28%; 76% of recurrences involved the same ear(s) as initial presentation. Recurrences that occurred after longer disease-free intervals were more likely to involve the opposite ear than early recurrences (p = 0.02). Female sex (40.4% versus 32.7%, p = 0.01) and history of previous BPPV (57.5% versus 32.4%, p < 0.0005) were associated with increased risk of recurrence, while history of Menière's disease, diabetes mellitus, and traumatic etiology were not. Approximately, half (56%) of recurrences occurred within 1 year of resolution. CONCLUSIONS: A large single-institution study of recurrence in BPPV is presented along with Kaplan-Meier disease-free survival curves. Female sex and history of previous BPPV were associated with increased recurrence, while previously suspected risk factors for recurrence including history of Menière's disease, diabetes, and trauma were not. Remote recurrence is more likely to involve the contralateral ear than early recurrence. These data solidify the expected course of treated BPPV allowing for improved clinical care and patient counseling.

Analysis of non-posterior canal benign paroxysmal positional vertigo in patients treated using the particle repositioning chair: A large, single-institution series.

PURPOSE: Benign paroxysmal positional vertigo (BPPV) involving the horizontal and superior semicircular canals is difficult to study due to variability in diagnosis. We aim to compare disease, treatment, and outcome characteristics between patients with BPPV of non-posterior semicircular canals (NP-BPPV) and BPPV involving the posterior canal only (P-BPPV) using the particle repositioning chair as a diagnostic and therapeutic tool. METHODS: Retrospective review of patients diagnosed with and treated for BPPV at a high volume otology institution using the particle repositioning chair. RESULTS: A total of 610 patients with BPPV were identified, 19.0% of whom had NP-BPPV. Patients with NP-BPPV were more likely to have bilateral BPPV (52.6% vs. 27.6%, p < 0.0005) and Meniere's disease (12.1% vs. 5.9%, p = 0.02) and were more likely to have caloric weakness (40.3% vs. 24.3%, p = 0.01). Patients with NP-BPPV required more treatments for BPPV (average 3.4 vs. 2.4, p = 0.01) but did not have a significantly different rate of resolution, rate of recurrence, or time to resolution or recurrence than patients with posterior canal BPPV. CONCLUSIONS: Comparison of NP-BPPV and P-BPPV is presented with reliable diagnosis by the particle repositioning chair. NP-BPPV affects 19% of patients with BPPV, and these patients are more likely to have bilateral BPPV and to require more treatment visits but have similar outcomes to those with P-BPPV. NP-BPPV is common and should be part of the differential diagnosis for patients presenting with positional vertigo.

Cochlear Patency After Transmastoid Labyrinthectomy for Ménière's Syndrome.

OBJECTIVE: Labyrinthectomy is considered the "gold standard" in the treatment of intractable vertigo attacks because of Ménière's Disease (MD) but sacrifices all residual hearing. Interest in auditory rehabilitation has lead to cochlear implantation in some patients. Concern remains that the cochlear lumen may fill with tissue or bone after surgery. This study sought to determine the incidence of obliteration of the cochlea after transmastoid labyrinthectomy. STUDY DESIGN: Retrospective observational study. SETTING: Tertiary referral center. PATIENTS: Eighteen patients with intractable vertigo from MD who underwent surgery. INTERVENTIONS: Transmastoid labyrinthectomy between 2008 and 2013. Cochleas were imaged with unenhanced, heavily T2-weighted magnetic resonance imaging (MRI). MAIN OUTCOME MEASURE: Presence of symmetrical cochlear fluid signals on MRI. RESULTS: There was no loss of fluid signal in the cochleas of operated ear compared with the contralateral, unoperated ear in any subject an average of 3 years (standard deviation [SD]: 1.2) after surgery. Five of 18 patients had the vestibule blocked with bone wax at the time of surgery. Blocking the vestibule with bone wax did not change the cochlear fluid signal. CONCLUSION: The risk of cochlear obstruction after labyrinthectomy for MD is very low. The significance of this finding is that patients with MD who undergo labyrinthectomy will likely remain candidates for cochlear implantation in the labyrinthectomized ear long after surgery if this becomes needed. Immediate cochlear implantation or placement of a cochlear lumen keeper during labyrinthectomy for MD is probably not necessary.

Acoustic Reflex Screening of Conductive Hearing Loss for Third Window Disorders.

OBJECTIVE: This study examines the effectiveness of acoustic reflexes in screening for third window disorders (eg, superior semicircular canal dehiscence) prior to middle ear exploration for conductive hearing loss. STUDY DESIGN: Case series with chart review. SETTING: Outpatient tertiary otology center. SUBJECTS AND METHODS: A review was performed of 212 ears with acoustic reflexes, performed as part of the evaluation of conductive hearing loss in patients without evidence of chronic otitis media. The etiology of hearing loss was determined from intraoperative findings and computed tomography imaging. The relationship between acoustic reflexes and conductive hearing loss etiology was assessed. RESULTS: Eighty-eight percent of ears (166 of 189) demonstrating absence of all acoustic reflexes had an ossicular etiology of conductive hearing loss. Fifty-two percent of ears (12 of 23) with at least 1 detectable acoustic reflex had a nonossicular etiology. The positive and negative predictive values for an ossicular etiology were 89% and 57% when acoustic reflexes were used alone for screening, 89% and 39% when third window symptoms were used alone, and 94% and 71% when reflexes and symptoms were used together, respectively. CONCLUSION: Acoustic reflex testing is an effective means of screening for third window disorders in patients with a conductive hearing loss. Questioning for third window symptoms should complement screening. The detection of even 1 acoustic reflex or third window symptom (regardless of reflex status) should prompt further workup prior to middle ear exploration.

The challenge of vestibular migraine.

PURPOSE OF REVIEW: Migraine is a common illness and migraine-related dizziness occurs in up to 3% of the population. Because the diagnosis is controversial and may be difficult, many patients go undiagnosed and untreated. This review summarizes current understanding of the taxonomy and diagnosis of vestibular migraine, the relation of vestibular migraine to labyrinthine disease, and the treatment of the condition in adults and children. RECENT FINDINGS: The categories of migraine accepted by the International Headache Society do not reflect the complex presentations of patients suspected of having vestibular migraine. In clinical practice and research, criteria are increasingly accepted that divide patients suspected of vestibular migraine into 'definite vestibular migraine' and 'probable vestibular migraine.' Because vertigo itself may trigger migraine, patients with vestibular migraine should be suspected of having vestibular end-organ disease until proven otherwise. Treatment remains controversial because of a notable lack of randomized controlled studies of vestibular migraine treatment. SUMMARY: For now, the best strategy for the treatment of suspected vestibular migraine patients is dietary/lifestyle modification, antinausea/antiemetics for acute vertigo, and preventive medication for patients who have continued disruptive symptoms. Patients with vestibular migraine should be monitored regularly for the development of latent audiovestibular end-organ disease.

Quality-of-life assessment of Ménière's disease patients after surgical labyrinthectomy.

OBJECTIVE: To examine the impact of surgical labyrinthectomy on quality of life of Ménière's disease patients. STUDY DESIGN: Cross-sectional survey. SETTING: Otology subspecialty referral center. PATIENTS: All patients with Ménière's disease who underwent surgical labyrinthectomy between 1998 and 2004 were selected. Fifty-three patients satisfied inclusion criteria. Completed questionnaires were obtained from 44 patients. INTERVENTION(S): The Ménière's Disease Outcomes Questionnaire is a disease-specific quality-of-life questionnaire. It was used to assess the quality of life of patients before and after surgical labyrinthectomy. The questionnaire encompasses physical, mental, and social well-being domains of quality of life. MAIN OUTCOME MEASURE(S): Change in total quality-of-life score was used to assess the overall impact of surgical labyrinthectomy on subjective patient outcome. Individual quality-of-life domains were also assessed. RESULTS: Forty-three of 44 respondents (98%) had improvement in total score after surgery. The one patient who demonstrated deterioration developed latent contralateral disease. Average preoperative and postoperative scores were 34 +/- 14 and 67 +/- 15, respectively (p < 0.001). All questions showed significant improvement with surgery (p < 0.001) except questions pertaining to memory (no change) and hearing loss (nonsignificant decrease in score). CONCLUSION: This study comprises the first patient-directed assessment of quality-of-life outcomes in Ménière's disease patients after labyrinthectomy. Despite the disadvantage of hearing loss, patients consistently reported significant improvement in all quality-of-life domains and do not report a significant loss of quality of life in terms of their hearing loss. Surgical labyrinthectomy remains a highly effective treatment for Ménière's disease patients.

Tumors and pseudotumors of the endolymphatic sac.

This article reports on the presentation, diagnosis, management, and treatment outcomes of lesions of the endolymphatic sac in patients treated at a tertiary neurotology referral center. It summarizes survival results in the largest series groups and presents a new diagnostic entity of pseudotumor of the endolymphatic sac. The study includes retrospective review of all patients diagnosed with lesions of the endolymphatic sac within our practice between 1994 and 2005 as well as review of the literature. The primary outcome measure was survival, and the secondary outcome measure was disease-free survival following definitive resection. Postoperative complications were assessed. Survival characteristics of the largest reported case series groups were reviewed. Five cases of endolymphatic sac lesions were identified. Of these, three were true endolymphatic sac tumors and two were inflammatory pseudotumors of the endolymphatic sac. All three of the endolymphatic sac tumors patients survived (100%), and two of the three had disease-free survival (67%). Two of three patients maintained persistent facial paresis postoperatively. Both patients with benign pseudotumors survived (100%). Our study concluded that endolymphatic sac tumors are rare neoplasms of the temporal bone that, although locally aggressive and invasive, have excellent prognosis for survival with complete resection. We report a new entity of pseudotumor of the endolymphatic sac that mimics true sac tumors in every respect on presentation but which is non-neoplastic in origin.

Success of posterior semicircular canal occlusion and application of the dizziness handicap inventory.

OBJECTIVES: To determine the long-term efficacy and patient satisfaction of posterior semicircular canal occlusion (PSCO) as a treatment for intractable benign paroxysmal positional vertigo (BPPV). STUDY DESIGN AND SETTING: Retrospective analysis of patients with BPPV who underwent PSCO was conducted in a tertiary referral center. Demographic data, clinical records, and audiometric data were reviewed. Dix-Hallpike maneuver, dizziness handicap inventory (DHI), and a specific PSCO questionnaire (PCOQ) were used to measure outcome. RESULTS: Twenty-eight patients underwent PSCO. The mean follow-up time was 40 months. All patients had normalization of the Hallpike test. DHI scores of 20 patients were recorded. The mean preoperative score was 70 compared with postoperative mean of 13 (P < 0.001). Mild hearing loss was found in 1 patient. CONCLUSIONS AND SIGNIFICANCE: PSCO is highly successful. The DHI scores postoperatively show significant improvement. The PCOQ revealed an overall 85% patient satisfaction rate. PSCO is a safe and effective intervention for intractable BPPV with a high patient satisfaction rate. EBM RATING: C-4.

Intracranial blood flow velocities and CO2 reactivity in diagnosing migraine-related dizziness.

OBJECTIVE: Migraine-related dizziness can present with or without headache, often making diagnosis difficult. Flow velocity and CO 2 reactivity testing using transcranial Doppler (TCD) measurement of intracranial blood flow has been described as abnormal in patients with classic or common migraine. This study sought to determine the utility, if any, of this noninvasive technique in the diagnosis of migraine-related dizziness. STUDY DESIGN AND SETTING: A prospective, controlled study in academic neurotology and neurology practices was conducted. Nine patients with migraine-related dizziness and 10 patients with no history of migraine or dizziness were tested with transcranial Doppler ultrasound in a blinded fashion. RESULTS: No statistically significant differences in intracranial blood flow velocities or in cerebrovascular reactivity to hypocapnia were found between patients and controls. CONCLUSIONS: Assessment of intracranial blood flow velocity and CO 2 reactivity using TCD does not help in the diagnosis of migraine-related dizziness. SIGNIFICANCE: A reliable objective test for the diagnosis of migraine-related dizziness remains elusive, and the diagnosis of this patient group continues to be suboptimal.

The learning curve revisited: stapedotomy.

OBJECTIVE: To determine whether the outcome of stapedotomy changes with experience. STUDY DESIGN AND SETTING: Retrospective case review of an academic otologic practice of a fellowship-trained otologist that consisted of 50 consecutive patients who underwent primary stapedotomy. The main outcome measures were preoperative and postoperative audiograms for both the operated ear and the opposite ear (control). RESULTS: There were no major complications or loss of hearing among the 50 patients. Minor complications included 1 middle ear infection, 2 torn flaps, and 1 tympanic membrane perforation. One patient had worse conductive hearing loss after surgery. The hearing of 2 patients was unchanged. Hearing for the entire group improved (P > 0.001) from a speech reception threshold of 55 dB (SD, 17 dB) to 30 dB (SD, 19 dB). Complete closure of the air-bone gap was achieved in 20% of the first 10 patients and 30% of the last 10 patients. CONCLUSIONS: The results of stapedotomy improve with experience, although the learning curve seems less steep than has been reported for total or near-total footplate removal. SIGNIFICANCE: Stapedotomy can be successfully performed early in surgical experience, but the learning curve should be acknowledged and discussed with the patient.