Search

Predict hearing preservation after middle cranial fossa approach for vestibular schwannomas.Application of machine learning algorithms, including classification and regression trees and random forest models to observational data.Single-tertiary referral center.Patients (n = 144) with a previously untreated sporadic vestibular schwannoma who underwent microsurgical resection by middle cranial fossa approach between November 2017 and November 2021.Middle cranial fossa approach.Hearing preservation, defined by postoperative word recognition score of 50% or greater and pure tone average below 50 dB HL or less than 10% reduction in word recognition score. Model performance was evaluated with classification accuracy in an independent validation sample. Variable importance for the random forest model is reported according to entropy, a measure of mean decrease in model accuracy incurred by excluding each variable from the model.Hearing preservation was achieved in 60% of patients (86 of 144) overall. The classification and regression tree model identified preoperative pure tone average with a cut point of 30 dB HL, and more posterior tumor position to be the most important prognostic features for hearing preservation. Model accuracy was 0.68. The random forest model demonstrated perfect accuracy (1). Baseline pure tone average, word recognition score, and anteroposterior tumor position were among the most influential features for hearing preservation prediction.Machine learning algorithms have the potential for accurate prediction of hearing preservation rates after middle fossa approach for vestibular schwannomas at a single institution. These models have the capacity for continued refinement with ongoing addition of data.

OBJECTIVE Analyze delayed facial nerve palsy (DFNP) following resection of vestibular schwannoma (VS) to describe distinct characteristics and facial nerve (FN) functional course. STUDY DESIGN Prospective cohort with retrospective review. SETTING Academic medical center. PATIENTS Consecutive patients undergoing VS resection 11/2017 to 08/2020. Exclusion criteria: preoperative House-Brackmann (HB) ≥ III, postoperative HB ≥ III without delayed palsy

Objective Examine the impact of preoperative cochlear Fast Imaging Employing Steady-state Acquisition (FIESTA) and Constructive Interference in Steady State (CISS) signal intensity on hearing outcomes after middle cranial fossa (MCF) resection of acoustic neuroma (AN). Methods Adult patients (≥18 years) who underwent MCF AN resection for hearing preservation (HP) between November 2017 and September 2019 were retrospectively reviewed. All patients had preoperative word recognition score (WRS) ≥50%. HP was defined as postoperative WRS ≥50%. A neuroradiologist blinded to patients' clinical and audiometric outcomes reviewed patients' preoperative magnetic resonance images. Ipsilateral-to-contralateral cochlear FIESTA/CISS signal intensity ratios were determined using hand-drawn regions of interest focused on the cochlear fluid. Preoperative and postoperative pure tone average (PTA) and WRS were reviewed. Results Fifty-one patients were reviewed (60.8% female). Mean age was 47 years and mean tumor size 9.2 mm (±3.8). Hearing was preserved in 56.9% (n = 29). FIESTA/CISS signal ratios did not significantly differ between patients with and without HP. Lower FIESTA/CISS signal ratios correlated with greater declines in hearing (r = 0.322, p = 0.011 for PTA; and r = 0.384, p = 0.004 for WRS). On multivariate analysis accounting for tumor size and preoperative PTA/WRS, decreases in FIESTA/CISS signal ratios independently predicted greater declines in hearing by PTA (b = -100.9, p = 0.012) and WRS (b = 76.208), although the latter result was not statistically significant (p = 0.078). Conclusions Cochlear FIESTA/CISS signal intensity may be a predictor of postoperative hearing loss after MCF AN resection. In this cohort, degraded preoperative cochlear FIESTA/CISS signal strongly predicted postoperative hearing loss.Level of Evidence: IV.

OBJECTIVES Review experience using a titanium TORP with a footplate shoe; compare early and long-term hearing results and complications with those obtained using a TORP alone. STUDY DESIGN Retrospective chart review. SETTING Tertiary referral neurotologic private practice. PATIENTS Patients undergoing total ossicular replacement with a titanium prosthesis (total ossicular reconstruction prosthesis [TORP]); 74 with a TORP + footplate shoe and 62 with TORP alone. INTERVENTION Ossicular chain reconstruction with a titanium TORP. MAIN OUTCOME MEASURES Short- and long-term air-bone gap (ABG), change in ABG from preoperative to postoperative and from postoperative to last recorded follow-up, sensorineural hearing loss. RESULTS The shoe group had a smaller mean postoperative ABG (17.7 dB versus 21.6 dB, p ≤ 0.048) and a greater average amount of closure in ABG (21.9 dB versus 13.2 dB, p ≤ 0.004), but there was no significant difference in percentage of patients achieving a postoperative ABG of 20 dB or lesser (57.4% versus 61.6%). There were no differences between groups at long-term follow-up or in amount of change in ABG from postoperative to last audiogram or in amount of change in sensorineural hearing from preoperative to postoperative. Although surgical factors (number of previous surgeries, and presence of a cavity) impacted outcomes, there were no interactions with prosthesis group and no differences in complications between groups. CONCLUSION Ossicular reconstruction still presents challenges. A titanium prosthesis with a "shoe" for stabilization may offer advantages. Results in this study consistently favored the TORP + shoe group,although not all differences achieved statistical significance. A larger study might better define possible advantages of the shoe prosthesis for specific subgroups of patients.

Background Meniere's disease (MD) is a debilitating disorder of the inner ear characterized by cochlear and vestibular dysfunction. The cause of this disease is still unknown, and epidemiological data for MD are sparse. From the existing literature, women seem to be more susceptible than men, and Caucasians seem to be more susceptible than Asians. Objective In this article, we characterize a large definite MD cohort for sex and age of onset of disease and use molecular genetic methodologies to characterize ethnicity. Study design Medical record review for sex and age of onset. Ancestry analysis compared results from the principal component analysis of whole-genome genotype data from MD patients to self-identified ancestry in control samples. Setting House Clinic in Los Angeles. Patients Definitive MD patients. Results Our review of medical records for definitive MD patients reveals that women are more susceptible than men. We also find that men and women have nearly identical age of onset for disease. Lastly, interrogation of molecular genetic data with principal component analysis allowed detailed observations about the ethnic ancestry of our patients. Comparison of the ethnicity of MD patients presenting to our tertiary care clinic with the self-recollected ethnicity of all patients visiting the clinic revealed an ethnic bias, with Caucasians presenting at a higher frequency than expected and the remaining major ethnicities populating Los Angeles (Hispanics, Blacks, and Asians) presenting at a lower frequency than expected. Conclusion To the best of our knowledge, this report is the first ethnic characterization of a large MD cohort from a large metropolitan region using molecular genetic data. Our data suggest that there is a bias in sex and ethnic susceptibility to this disease.

Objectives To examine hearing preservation rates, facial nerve outcomes, and tumor recurrence rates in patients with neurofibromatosis Type 2 undergoing a primary middle cranial fossa approach for vestibular schwannoma removal. Study design Retrospective chart review. Setting Private practice tertiary neurotology referral center. Patients All patients with neurofibromatosis Type 2 undergoing attempted hearing preservation via a middle cranial fossa approach for removal of vestibular schwannoma from January 1, 2000, to June 1, 2010. Intervention Primary middle cranial fossa approach for removal of vestibular schwannoma. Main outcome measures Preoperative, postoperative, and change in hearing thresholds, word recognition scores, and American Academy of Otolaryngology-Head and Neck Surgery hearing class, House-Brackmann facial nerve grade, and tumor recurrence. Results Class A or B hearing according to the American Academy of Otolaryngology-Head and Neck Surgery was maintained in 50% of cases, whereas 63.6% had Class A, B, or C hearing, with an average word recognition score of 93.8% at an average follow-up period of 32.5 months. Facial nerve outcomes were excellent; 75% of cases maintained House-Brackmann Grade 1, whereas 94.3% had Grade 1 or 2 at an average of 25 months after surgery. Tumor growth within the surgical field was observed radiographically in 59% of cases. Conclusion In patients with neurofibromatosis Type 2, proactive treatment of smaller tumors provides a chance to maintain serviceable hearing and obtain tumor control for extended periods. When examining hearing outcomes, it is important to use word recognition scores, in addition to American Academy of Otolaryngology-Head and Neck Surgery hearing class, to better assess functionality. Although facial nerve outcomes tend to be favorable, the growth of new tumors, including facial schwannomas, may occur within the surgical field. Continued surveillance with serial magnetic resonance scans after surgery is mandatory.

Determine whether more conservative management for surgical salvage after failed radiation leads to better facial nerve outcomes."Retrospective" review using prospectively planned database.Private practice, tertiary neurotology/neurosurgery referral center.A series of 73 patients with vestibular schwannoma, who underwent primary radiosurgery with no other intervention and then surgical salvage tumor removal using the translabyrinthine approach.Translabyrinthine craniotomy for vestibular schwannoma salvage surgery after failed radiation, with either gross total or partial tumor removal.Long-term (1 yr) House-Brackmann (H-B) facial nerve grade and change in facial nerve grade from before to after surgery.Of the 73 patients, 79.5% had gross total removal, 5.5% had planned partial resection (subtotal or near total), and 15.1% had intraoperatively elected partial removal with most of these being near total removal. At 1 year of follow-up, good facial nerve function (H-B I/II) was found in 50% of patients with gross total removal and 85.7% of those with partial removal (p ≤ 0.03). The H-B grade was maintained postoperatively in 45.8% and 78.6% of the 2 groups, respectively (p ≤ 0.037), with 21.7% of the total removal group having unsatisfactory outcomes (H-B V or VI) compared with 7.1% of patients with partial removal. To date, no patient has required additional treatment.Failed radiosurgery is an increasing indication for salvage surgery in patients with posterior fossa tumors. A conservative approach with a willingness to perform partial and near-total tumor removals leads to better facial nerve outcomes with no current evidence of treatment compromise.

Acoustic Neuroma Association, 2007 2008 PAT SURV; American Academy of Otolaryngology-Head and Neck Surgery Foundation Inc., 1995, OTOLARYNGOL HEAD NEC, V113, P179, DOI DOI 10.1016-S0194-5998(95)70101-X; Balasubramaniam A, 2007, NEURO-ONCOLOGY, V9, P447, DOI 10.1215-15228517-2007-027; Brackmann DE, 2007, OTOLARYNG HEAD NECK, V136, P773, DOI 10.1016-j.otohns.2006.10.009; Chopra R, 2007, INT J RADIAT ONCOL, V68, P845, DOI 10.1016-j.ijrobp.2007.01.001; Coelho DH, 2008, LARYNGOSCOPE, V118, P1909, DOI 10.1097-MLG.0b013e31818226cb; del Valle R, 2005, J NEUROSURG, V102, P140; Friedman RA, 2005, LARYNGOSCOPE, V115, P1827, DOI 10.1097-01.mlg.0000175063.76948.75; Hasegawa T, 2006, NEUROSURGERY, V58, P1119, DOI 10.1227-01.NEU.0000215947.35646.DD; Humphriss RL, 2003, OTOL NEUROTOL, V24, P661, DOI 10.1097-00129492-200307000-00021; Karpinos M, 2002, INT J RADIAT ONCOL, V54, P1410, DOI 10.1016-S0360-3016(02)03651-9; Kondziolka D, 1998, NEW ENGL J MED, V339, P1426, DOI 10.1056-NEJM199811123392003; LINTHICUM FH, 1980, ARCH OTOLARYNGOL, V106, P729; LINTHICU.FH, 1972, ANN OTO RHINOL LARYN, V81, P433; Lunsford LD, 2005, J NEUROSURG, V102, P195; Mathieu D, 2007, NEUROSURGERY, V60, P468; Mathieu D, 2007, NEUROSURGERY, V60, P460, DOI 10.1227-01.NEU.0000255340.26027.53; Okunaga T, 2005, J NEUROSURG, V103, P53, DOI 10.3171-jns.2005.103.1.0053; Pollock BE, 2006, NEUROSURGERY, V59, P77, DOI 10.1227-01.NEU.0000219217.14930.14; Pollock BE, 2006, NEUROSURGERY, V58, P241, DOI 10.1227-01.NEU.0000194833.66593.8B; Rowe JG, 2003, J NEUROL NEUROSUR PS, V74, P1288, DOI 10.1136-jnnp.74.9.1288; Slattery WH, 2003, OTOL NEUROTOL, V24, P666, DOI 10.1097-00129492-200307000-00022; Slattery WH, 1998, AM J OTOL, V19, P638; STROUP DF, 2009, JAMA-J AM MED ASSOC, V283, P15; Surber G, 2004, J NEUROSURG, V101, P334; Wowra B, 2005, J NEUROSURG, V102, P114; Yu CP, 2000, J NEUROSURG, V93, P82; Zohar S, 2008, CLIN TRIALS, V5, P478, DOI 10.1177-1740774508096653

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.