Outcomes of Endolymphatic Sac Surgery for Meniere's Disease with and without Comorbid Migraine.

PURPOSE: To explore outcomes of endolymphatic sac surgery for patients with Meniere's disease with and without the comorbid condition of migraine. MATERIALS AND METHODS: A retrospective chart review of adult patients undergoing endolymphatic sac surgery at a single tertiary care center from 1987 to 2019 was performed. All adult patients who failed medical therapy and underwent primary endolymphatic sac surgery were included. The main outcome measures were vertigo control and functional level scale (FLS) score. Patient characteristics, comorbidities, and audiometric outcomes were tracked as well. RESULTS: Patients with Meniere's disease and migraine had a stronger association with psychiatric comorbidities (64.29% vs. 25.80%, p=0.01), shorter duration of vertigo episodes (143 vs. 393 min, p=0.02), and younger age (36.6 vs. 50.8 yr, p=0.005) at the time of endolymphatic sac surgery. Postoperative pure tone averages and word recognition scores were nearly identical to preoperative baselines. Class A vertigo control (47.92%) was most common, followed by class B vertigo control (31.25%). The FLS score improved from 4.2 to 2.8 (p < 0.001). Both patients with and without migraine had classes A-B vertigo control (66.67% vs. 80.95%) without any statistically significant difference (p=0.59). Of the patients who required secondary treatment (10.42%), none had migraine. CONCLUSIONS: Endolymphatic sac surgery is an effective surgical intervention for Meniere's disease with and without migraine. Patients with comorbid migraine tend to be younger and present with psychiatric comorbidities.

Changes in Wide-band Tympanometry Absorbance Following Cochlear Implantation.

OBJECTIVE: Determine if changes in middle ear absorbance measured with wide-band tympanometry (WBT) occur following hearing-preservation cochlear implantation (CI). Such measures may provide insight into the mechanisms of acoustic hearing loss postimplantation. STUDY DESIGN: Clinical capsule report. SETTING: Tertiary academic referral center. DESIGN: WBT absorbance was measured bilaterally during pre- and postoperative clinical office visits in five unilaterally-implanted cochlear implant recipients. Pre- and postoperative WBT measures were compared within each subject in the implanted and contralateral, unimplanted ears. RESULTS: In general, WBT absorbance measurements show a broad spectral pattern including two or three distinct peaks measured over a frequency range of 226 to 8000 Hz. Grand average and linear mixed model comparisons between the pre- and postoperative WBT patterns show significantly reduced (p < 0.05) low-frequency absorbance in the implanted ears in the frequency region over 0.6 to 1.1 kHz, but not in the unimplanted ears. The maximum effect occurred at 1 kHz with absorbance decreasing from ∼0.8 to ∼0.5 after implantation. The limited data are consistent with expected relationships between WBT absorbance and air- and bone-conduction thresholds, assuming an increased air-bone gap reflects conductive hearing loss. CONCLUSION: Cochlear implantation can result in reduction of low-frequency acoustic absorbance as measured by WBT. WBT may be a useful and sensitive tool for monitoring the mechanical status of the middle and inner ears following cochlear implantation.

Middle ear choristoma presenting as cholesteatoma with conductive hearing loss.

A 6-year-old male was seen for evaluation of middle ear polyp with associated hearing loss and otorrhea. CT scan revealed canal polyp with a stalk extending to the middle ear with malformation of the malleus and incus. The patient underwent exploratory tympanotomy which revealed a fistula from the bony-cartilaginous junction connecting to a middle ear mass which had eroded the incus. Intraoperative pathology suggested columnar epithelium without cholesteatoma or muscle. Final pathologic diagnosis reported dense fibrous tissue as well as ectopic salivary gland tissue, consistent with salivary gland choristoma. After removal of the mass, a partial prosthesis was successfully placed. Middle ear salivary gland choristoma is a rare entity. It can be confused clinically with cholesteatoma and is usually diagnosed on pathology. This diagnosis is often associated with other external, middle, and inner ear abnormalities.

Eustachian Tube Foreign Body with Endoscopic-Assisted Surgical Removal.

OBJECTIVES: Foreign bodies of the external and middle ear are not uncommon; however, foreign bodies in the eustachian tube are rare. Here we describe the presentation, imaging, and endoscopic-assisted surgical management of a case of eustachian tube foreign body. METHODS: A 34-year-old male was seen for evaluation of foreign body of the left eustachian tube while working with metal at a machine shop. Imaging and surgical management are highlighted and review of available literature regarding foreign bodies of the eustachian tube is presented. RESULTS: A CT scan revealed a foreign body present approximately 1 cm into the bony eustachian tube. The patient underwent middle ear exploration which required endoscopic assistance to adequately visualize the foreign body. The foreign body was unable to be removed and required the creation of a bony tunnel lateral to the eustachian tube for visualization and access to the foreign body. CONCLUSIONS: This report presents a rare case of eustachian tube foreign body. Use of the endoscope during the surgical removal greatly enhanced the ease and safety of removal. This report also highlights the importance of ear protection with any machining and welding work.

Cochlear Ossification in a Patient with Cogan's Syndrome Undergoing Bilateral Cochlear Implantation.

We present the case of a young female patient diagnosed with Cogan's syndrome after the rapid onset of profond hearing and vestibular loss with concomitant eye symptoms. After appropriate medical treatment, her hearing did not respond and she underwent bilateral simultaneous cochlear implantation with findings of extensive cochlear ossification in both ears. The case and outcome are described in the body of the paper.

Bilateral spontaneous temporomandibular joint herniation: A case report and literature review.

In this article we report the case of a 41-year-old man with bilateral aural fullness and hearing loss. On examination he was found to have bilateral, dehiscent anterior canal walls with herniation of the mandibular condyle. This herniation partially obstructed the canals and contributed to his symptoms. To the best of our knowledge, this is only the third reported case of bilateral spontaneous temporomandibular joint herniation, and only 28 cases of unilateral spontaneous herniation can be found in the English language literature. While it is a rare phenomenon, it should be considered when evaluating a patient with fluctuating ear symptoms.

Outcomes of Primary Radiosurgery Treatment of Glomus Jugulare Tumors: Systematic Review With Meta-analysis.

OBJECTIVE: 1) Determine tumor control, symptomatic control, and complication rates of primary radiosurgery (PRS) for treatment of glomus jugulare tumors (GJTs) via systematic review and meta-analysis. 2) Identify risk factors for these outcomes. DATA SOURCES: 1) Search of English articles in PubMed, Web of Science, Cochrane, and EBSCOhost databases from January 1950 to August 2017. STUDY SELECTION: Inclusion criteria: 1) treated GJT patients who had no previous treatment with radiosurgery, 2) follow-up with magnetic resonance imaging for at least 12 months, 3) reported pre and posttreatment symptoms, tumor control, or complications for individual PRS patients or for PRS patients as a cohort. DATA EXTRACTION: The following were extracted: number of patients, level of evidence, mean age, mean pretreatment tumor volume, tumor control rate, criteria for change in tumor size, symptom control rate, and complications. At the individual patient level the following were extracted: age, number of treatment fractions, total radiation dose to tumor margin, pretreatment tumor volume, Fisch or Glasscock-Jackson stage, pre- and posttreatment symptoms, tumor control, symptom control/improvement, length of follow-up, and complications. DATA SYNTHESIS: Fifteen studies encompassing 91 patients met criteria. Tumor control was achieved in 92% of patients, symptom control in 93%, and complications occurred in 8%. There was one major complication. Smaller tumor volume predicted improvement in symptoms with PRS. CONCLUSIONS: In the short term, PRS is safe and effective at controlling growth and clinical symptoms for patients with GJTs, though there exists significant selection bias, inconsistent reporting, and clinical heterogeneity among existing studies.

BAHA Skin Complications in the Pediatric Population: Systematic Review With Meta-analysis.

OBJECTIVE: Compare the incidence of skin and surgical site complications for children undergoing percutaneous and transcutaneous bone conduction implant (pBCI and tBCI) surgery via systematic review and meta-analysis of the available data. DATA SOURCES: 1) Search of PubMed, Web of Science, and EBSCOhost databases from January 2012 to April 2017. 2) References of studies meeting initial criteria. STUDY SELECTION: Inclusion criteria were studies that involved patients less than 18 years old undergoing tBCI or pBCI surgery with a BI300 implant and reported skin complications, implant loss, and need for revision surgery. Exclusion criterion was use of a previous generation implant. DATA EXTRACTION: Implants used, number of patients, age, surgical technique, Holgers score, incidence of skin complication, implant loss, and reoperation. Bias assessment performed with the Newcastle-Ottawa Scale. DATA SYNTHESIS: Twenty-two studies (14 tBCI, 8 pBCI) met criteria. Meta-analysis was performed using a random effects model. Cochran's Q score and I inconsistency were used to assess for heterogeneity. Overall estimated skin complication rate for tBCIs was 6.3% versus 30% for pBCIs (p = 4 × 10). Implant loss was 0% for tBCIs and 5.3% for pBCIs (p = 0.004). Reoperation rate was 3.0% and 6.2% for tBCIs and pBCIs respectively (p = 0.00002). CONCLUSION: There is strong evidence to suggest that in pediatric patients, the incidence of skin complications, implant loss, and rate of reoperation are higher for pBCIs compared with tBCIs. This information should be part of any discussion about BCI surgery on a pediatric patient.

Complete Malleus Removal for Cholesteatoma: A Multivariate Analysis of Ossiculoplasty Success and Residual Disease.

OBJECTIVE: Determine the effect of complete malleus removal during canal wall up tympanomastoidectomy for cholesteatoma on ossiculoplasty success and rate of residual cholesteatoma. METHODS: We reviewed the operative, audiogram, and clinical reports of patients who underwent canal wall up tympanomastoidectomy for cholesteatoma between 2009 and 2016 at a tertiary academic medical center with at least 8 months of follow-up after surgery. To control for extent of disease, we independently catalogued the subsites of the middle ear and mastoid that cholesteatoma involved from each operation. We performed multivariate logistic regression to determine the independent effect of complete removal of the malleus on the rate of residual disease and success of ossiculoplasty. RESULTS: One hundred eighty surgeries were included in the analysis. For ossiculoplasty success, the adjusted odds ratio of complete malleus removal was 1.7 (95% CI, 0.43-7.0, P = .43), which was not statistically significant. For residual disease, the adjusted odds ratio of complete malleus removal versus not was 0.29 (95% CI, 0.074-1.1, P = .076), which approached but did not meet statistical significance. CONCLUSION: Though complete malleus removal does not independently decrease the rate of residual cholesteatoma, it may be a safe technique as it did not compromise ossiculoplasty success.

Hearing Outcomes after Middle Fossa or Retrosigmoid Craniotomy for Vestibular Schwannoma Tumors.

OBJECTIVE: The objective of this study was to evaluate hearing outcomes following middle fossa (MF) or retrosigmoid (RS) craniotomy for vestibular schwannoma (VS) removal with the goal of hearing preservation. DESIGN: This is a retrospective series. SETTING: This study was set at a skull base referral center. PARTICIPANTS: In this study, 377 sporadic VS patients underwent primary microsurgery for VS from 2002 to 2012 using the MF (n = 305) or RS (n = 72) approaches. MAIN OUTCOME MEASURES: The main outcome measures were change in pure-tone average (PTA) and word recognition score from pre- to postoperative and surgical complications. RESULTS: Preoperative hearing did not differ between approaches. Tumors were larger in the RS group (mean = 1.78 cm) than the MF group (mean = 0.97 cm) (p ≤ 0.001). Mean times to last audiometric follow-up were MF 1.0 year and RS 0.7 years. Mean decline in hearing from preoperative to last follow-up was greater in the RS group (55.5 dB in PTA and 45.6% in discrimination) than the MF group (38.9 dB and 31.7%) (p ≤ 0.011 and 0.033, respectively). The effect of surgical approach on hearing outcome remained after controlling for tumor size. Facial nerve outcomes and cerebrospinal fluid leak rates were not significantly different. CONCLUSION: Loss of hearing was greater with the RS approach than the MF approach, even when accounting for differences in tumor size. Postoperative facial nerve function and other complications did not differ between approaches.

Side-to-end hypoglossal to facial anastomosis with transposition of the intratemporal facial nerve.

OBJECTIVE: To describe results in a large series of patients using a recent variation of hypoglossal-facial nerve anastomosis (HFA) in which the intratemporal facial nerve segment is used, obviating the need for a sensory nerve "jump graft." STUDY DESIGN: Retrospective chart review. SETTING: Tertiary neurotologic referral center. PATIENTS: Nineteen patients (12 female/7 male subjects) with facial paralysis because of posterior fossa surgery for tumor (n = 15), Bell's palsy (n = 1), facial neuroma (n = 1), hemangioma (n = 1), and trauma (n = 1) who underwent HFA from 1997 to 2011, with at least 1-year follow-up. Mean age at surgery is 47.4 years (range, 11.2-83 yr). Mean follow-up is 4.0 years. INTERVENTION: Side-to-end hypoglossal to facial anastomosis with transposition of the intratemporal facial nerve (swingdown HFA). MAIN OUTCOME MEASURE: House-Brackmann (H-B) facial nerve grade. RESULTS: Seven patients (36.8%) achieved an H-B Grade III, 9 patients (47.4%) a grade IV, and 3 patients (15.8%) a grade V at last follow-up. No patients complained of dysphagia, dysarthria, or had evidence of oral incompetence. One patient complained of mild tongue weakness. Age at time of HFA (p ≤ 0.049, III younger than V) and time from facial nerve injury to HFA (p ≤ 0.02, III