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Objectives: Elevated body mass index (BMI) is a risk factor for surgical complications, but data in acoustic neuroma surgery are conflicting and limited to small single-institution studies. This work evaluates associations between BMI and complications in surgery for acoustic neuroma (AN).Study Design: Retrospective review.Setting: Two tertiary otology referral institutions.Subjects and Methods: Patients undergoing surgery for AN. Univariate and multivariate analysis of association between BMI and complications was performed using two-tailed t tests and binary logistic regression.Results: BMI ranged from 18.0 kg/m2 to 63.9 kg/m2 with mean of 29.2 kg/m2 among 362 included patients. High BMI was associated with increased risk of cerebrospinal fluid (CSF) leak (p = 0.003) and need for revision surgery within 6 months (p = 0.03). CSF leak occurred in 11.6% of obese patients (BMI ≥ 30.0) and 5.1% of patients with BMI < 30.0. There was no association between BMI and post-operative intracranial hemorrhage, wound infection, or incomplete resection (p > 0.05). Multivariate analysis revealed BMI was associated with CSF leak (odds ratio 1.11 per BMI point, p = 0.002) and need for revision surgery (odds ratio 1.07 per BMI point, p = 0.02) independent of age, gender, tumor size, or surgical approach.Conclusions: The largest series to date investigating BMI in acoustic surgery is presented. Elevated BMI is strongly associated with CSF leak and need for revision surgery but not with other complications. Obese or overweight patients undergoing acoustic neuroma resection should be counseled of their increased risk of CSF leak. [ABSTRACT FROM AUTHOR]

Objective: To assess complication rates in hydroxyapatite cement (HAC) cranioplasty for translabyrinthine acoustic surgery compared with historical controls.Methods: Retrospective chart review of patients undergoing de novo translabyrinthine surgery with HAC cranioplasty without concurrent adipose tissue graft or additional material between 2010 and 2017 at a tertiary otology center.Results: Fifty-two patients underwent HAC cranioplasty during the study period. The average length of follow-up was 30.5 months. HAC cranioplasty was associated with acceptable rates of cerebrospinal fluid leak (3.8%), wound or intracranial infection (5.8%), need for unplanned revision surgery (9.6%), and all complications (15.3%). All complications occurred within 5 months of surgery. No delayed wound infections or implant extrusions occurred.Conclusion: HAC cranioplasty has an acceptable complication profile for translabyrinthine surgery and is a viable alternative to abdominal fat grafting without associated donor site morbidity.Level Of Evidence: 4 Laryngoscope, 130:206-211, 2020. [ABSTRACT FROM AUTHOR]

Objectives/hypothesis: The cause of superior semicircular canal dehiscence (SSCD) is unknown. Because of a demonstrated association with tegmental defects and obesity, some have suggested idiopathic intracranial hypertension (IIH) could contribute by eroding the bone over the canal and resulting in SSCD. However, an association between IIH and SSCD has not previously been evaluated. Our objective was to evaluate an association between IIH and SSCD.Study Design: Retrospective cohort.Methods: A retrospective study was performed of opening pressures for consecutive patients presenting at a lumbar puncture clinic between August 2012 and October 2015. Imaging for patients who also had thin-sectioned computed tomography (CT) imaging was reviewed for the presence of radiographic SSCD. Association between IIH and SSCD was evaluated using the Student t test and multivariate logistic regression.Results: One hundred twenty-one patients had both a lumbar puncture performed and thin-sectioned CT imaging available, of which 24 patients (19.8%) met the criteria for IIH with an opening pressure >25 cm H2 O. The remaining 97 patients (80.2%) did not have elevated opening pressures and served as the control cohort. None of the 24 patients with IIH had radiographic SSCD, whereas eight of the 97 patients (8.2%) without IIH had radiographic SSCD. The average opening pressure in patients without radiographic SSCD was 20.2 cm H2 O compared to 19.3 cm H2 O in patients with radiographic SSCD (P = .521). In multivariate logistic regression controlling for age, body mass index, gender, and comorbidities (hypertension, diabetes, hyperlipidemia), opening pressure was not a significant predictor of radiographic SSCD.Conclusions: The results of this retrospective pilot study do not suggest an association between IIH and SSCD.Level Of Evidence: 3b. Laryngoscope, 128:1196-1199, 2018. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis: To investigate the relationship between obesity, obstructive sleep apnea (OSA), and spontaneous cerebrospinal fluid (CSF) otorrhea. Study Design: Retrospective review of patients presenting with the diagnosis of CSF otorrhea during a 15-year period to a tertiary care medical center. Methods: Patient records were reviewed and the following data were extracted: age, sex, height, weight, past medical/surgical history, laterality of otorrhea, findings at operation, and method of repair. Otorrhea was considered spontaneous in the absence of trauma, otologic surgery, infection, and neoplasm. Results: Of the 29 adult patients identified, 14 patients presented with CSF otorrhea that was spontaneous in nature. The average body mass index among these patients was 35.2 ± 8, which was higher than the average in the nonspontaneous group, 28.5 ± 5 ( P = .01). Diagnoses of OSA were also more common in the spontaneous group (n = 4) compared with the nonspontaneous group (n = 0). One case of bilateral spontaneous CSF leaks was recorded. The majority of patients were repaired with hydroxyapatite cement through a transmastoid approach. There were no recurrences. Conclusions: In this series, patients with spontaneous CSF otorrhea were more likely to be severely and morbidly obese than were patients with nonspontaneous otorrhea. OSA was also more common in these patients. The findings from this study support an association between obesity and spontaneous CSF leaks. Patients presenting with spontaneous CSF otorrhea should therefore be screened for OSA and signs of increased intracranial pressure. [ABSTRACT FROM AUTHOR]

Objective This report introduces a new method to control cerebrospinal fluid (CSF) otorrhea using hydroxyapatite cement (HAC) via a transmastoid approach. This technique eliminates the need for a transmastoid or middle cranial fossa approach with soft tissue repair and prolonged hospitalization caused by lumbar drainage. Study Design Retrospective review. Methods Thirteen cases of transmastoid repairs of CSF otorrhea using HAC from August 1996 to February 1999 were reviewed. Results The CSF leak was controlled in every patient using HAC through a transmastoid approach. The reconstruction involved eight tegmen defects, three posterior fossa dural plate defects, and two congenital inner ear fistula secondary to Mondini malformation. Postoperative wound infection in one patient was the only complication that occurred. The average hospital stay was 48 hours. Follow-up ranged from 12 to 44 months with no recurrence of CSF otorrhea. Conclusion The successful use of HAC to control CSF otorrhea through a transmastoid approach reduces patient morbidity by obviating the need for middle cranial fossa approaches, donor soft tissue sites, and spinal drainage. [ABSTRACT FROM AUTHOR]

Hydroxyapatite cement, a new biomaterial presently under clinical investigation, has been demonstrated to have potentially wide application in cranial reconstruction. We describe our experience with this biologic bone cement in the reconstruction of suboccipital craniectomy defects in seven patients after vestibular schwannoma removal. With up to 2-year follow-up, cranial bone integrity has been reestablished in five patients. Dissolution of cement has occurred in dependent areas and appears to be technique related. Cranial bone contour appears dependent on the amount of cement used. The frequency of debilitating postoperative headache was reduced in these patients when compared to patients who had no reconstruction of the craniectomy defect. Reconstruction of the bony defect after suboccipital craniectomy with hydroxypatite cement is not only useful to restore cranial contour, but also appears to reduce some of the functional deficits attributed to this surgical approach. [ABSTRACT FROM AUTHOR]

Patients with localized damage to the taste system often experience no subjective change in real-world taste experience. In an effort to understand this, eight patients who recently underwent acoustic neuroma removal were evaluated for taste loss. Localized taste testing showed that taste intensities decreased in the distribution of cranial nerve VII ipsilateral to tumor removal as expected, but asymmetries occurred for IX. Intensities were greater on the side contralateral to the tumor removal. In addition, palatal taste, also thought to be mediated by VII, was not totally abolished. It is concluded that cranial nerve IX is normally inhibited by cranial nerve VII in the taste network. When VII is damaged, this inhibition is abolished. This release of inhibition serves as a compensation mechanism that preserves normal taste experience. [ABSTRACT FROM AUTHOR]

Unlike the eventual resolution of facial paralysis in most patients with intact facial nerves, delayed hearing return after acoustic tumor resection is rare. This discrepancy in recovery has been ascribed to the inherent resilience of the facial nerve (a special visceral efferent nerve) to injury versus the cochlear nerve (a special somatic afferent nerve). In the presence of an intact cochlear nerve, hearing loss has been attributed to transection or spasm of the internal auditory artery or to direct mechanical trauma to the cochlear nerve during manipulation of the tumor. The possibility of a reversible conduction block in the cochlear nerve has not been considered. A review of three instances of delayed spontaneous hearing recovery several months after acoustic tumor resection suggests that a conduction block phenomenon can exist. This report describes the patho-physiology and the possible intraoperative predisposing features of this condition. [ABSTRACT FROM AUTHOR]

Hearing rehabilitation with an intracochlear prosthesis is well documented in patients who have an intact otic capsule prior to implantation. However, the suitability for implantation of patients who have undergone extensive procedures involving the otic capsule such as labyrinthectomy has not been directly addressed. This report documents a case of a patient deafened by a transmastoid labyrinthectomy who subsequently received a cochlear implant. Postimplantation performance of this patient was compared with the performance of three other postlingual implant recipients. The results suggest that labyrinthectomy is not a contraindication to auditory rehabilitation by a cochlear implant. The implications of implantation in a surgically manipulated otic capsule are discussed. [ABSTRACT FROM AUTHOR]

Contemporary otomicrosurgical techniques have made total removal of acoustic tumor with preservation of the seventh and sometimes the eighth cranial nerves possible. The four approaches currently used in acoustic tumor surgery are the middle cranial fossa, the translabyrinthine, the suboccipital, and the combined translabyrinthine-suboccipital. This review examines the surgical results in the removal of more than 600 acoustic tumors and outlines a rationale for the choice of approach. Tumor size on computed tomographic scan and auditory reserve establish the parameters used in planning the surgical procedure. The translabyrinthine exposure is used most frequently followed by the combined translabyrinthine-suboccipital. The middle fossa and suboccipital approaches are used when preservation of hearing is attempted. Total removal of tumor was accomplished in more than 99% of patients with a mortality rate of less than 1%. Anatomic preservation of the facial nerve, which is directly related to tumor size, was achieved in more than 80% of patients. Preservation of hearing is unlikely when the tumor is larger than 2 cm; anatomic preservation of the cochlear nerve was successful in 73% of hearing preservation procedures. [ABSTRACT FROM AUTHOR]

We describe a rare complication of stereotactic radiotherapy for large acoustic neuromas in a patient with type 2 neurofibromatosis. We retrospectively reviewed the case of a 14-year-old girl who had been referred to our tertiary care center. Prior to referral, the patient had been evaluated for hoarseness. During the work-up, magnetic resonance imaging (MRI) detected two large bilateral acoustic neuromas and two bilateral jugular foramen tumors. The patient was diagnosed with type 2 neurofibromatosis, and she underwent stereotactic radiotherapy for treatment of the two acoustic neuromas; the jugular foramen tumors were not irradiated. The patient's post-treatment course was complicated by hydrocephalus and symptoms of brainstem compression, which required urgent surgical intervention. Follow-up MRI 7 months following radiotherapy demonstrated a rapid growth of the acoustic neuromas, but no appreciable change in the size of the jugular foramen neuromas. These findings suggest that the radiotherapy might have been the cause of the rapid growth of the acoustic neuromas. To our knowledge, no such report has been published in the literature, and this phenomenon might be unique. Our findings suggest that radiotherapy might not be the optimal first-line treatment for acoustic neuromas in patients with type 2 neurofibromatosis. [ABSTRACT FROM AUTHOR]

Permanent obliteration of the eustachian tube via the middle ear traditionally has met with limited success. Combinations of muscle, fascia, adipose tissue, bone fragments, and inert material such as Proplast have been used to seal the middle ear from the nasopharynx by inciting a fibrous reaction within the lumen of the eustachian tube. Long-term follow-up has demonstrated repneumatization of the middle ear cleft in the majority of cases, indicating failure of the obliteration technique. This report describes a technique for successful long-term obliteration using hydroxyapatite cement. This new biomaterial possesses osseointegrative and osseoconductive properties that result in permanent obliteration by producing new bone formation within the lumen of the eustachian tube. This technique eliminates the complication of cerebrospinal fluid rhinorrhea in lateral skull base procedures that expose the eustachian tube to cerebrospinal fluid. [ABSTRACT FROM AUTHOR]

As the identification of patients with small acoustic neuromas and salvageable hearing increases, intraoperative auditory nerve monitoring has been used increasingly in an attempt to improve the hearing preservation rate. Far-field recordings obtained by brainstem auditory evoked potentials (BAEP), at times enhanced by electrocochleography, have become a standard method of intraoperative auditory nerve assessment. To evaluate the usefulness of this monitoring technique, the hearing preservation results of a series of unmonitored acoustic tumor removals were compared to a series of patients monitored via the standard brainstem auditory evoked potentials. With comparable average tumor sizes, 4 of 7 unmonitored patients had hearing preserved at preoperative levels compared to 4 of 9 monitored patients. Neither preoperative BAEP assessments nor absolute tumor size were predictive of hearing preservation. This report brings into question the effectiveness of far-field intraoperative BAEP monitoring during acoustic tumor resection and suggests that direct auditory nerve monitoring may be more appropriate. [ABSTRACT FROM AUTHOR]

A review of four cases of severe trauma to the temporal bone involving fracture of the external auditory canal indicates that adipose obliteration of the mastoid and middle-ear cleft with closure of the external auditory canal is the optimal method of repair. In two of four patients, one-stage repair was successful using this technique, and in the other two patients, obliteration was required as a revision operation after cholesteatoma developed from previous procedures. [ABSTRACT FROM AUTHOR]

Objectives: To describe the indications for successful use of hydroxyapatite cement (HAC) in temporal bone surgery., Study Design: Retrospective case review., Methods: One hundred nine temporal bone defects related to surgical approaches to the skull base, infection, neoplasms, or congenital defect in 102 adults and children were corrected using HAC over a 10-year period. The results and complications were obtained through retrospective chart review., Results: Ninety-seven percent of temporal bone defects were successfully repaired using HAC, and the reconstruction remained stable over the course of this study. There was one case of postoperative cerebrospinal fluid leak. Wound infection occurred in three patients, which required reoperation and removal of the biomaterial., Conclusions: HAC is a biomaterial that should be used as the primary method to reconstruct temporal bone defects. Proper use of this biomaterial results in restoration of the integrity of the temporal bone and elimination of cerebrospinal fluid leak as a postoperative complication.

Objective: To demonstrate the efficacy of intact canal wall procedure coupled with a second-stage exploration for the treatment of cholesteatoma., Design: Retrospective case study of patients with cholesteatomas treated with staged surgical extirpation. A minimum of 6 months' postoperative follow-up time was required for inclusion into the study., Setting: Tertiary academic referral center. Patients A total of 35 adult and pediatric patients, ranging from 9 to 65 years of age, who underwent 2-stage procedures for removal of cholesteatomas., Interventions: Two-stage procedures, separated by 6 months, performed with posterior tympanotomy approaches., Main Outcome Measures: The presence or absence of cholesteatoma on second-stage look and the subsequent surgical treatment for recurrent cholesteatoma. The overall hearing results after the completion of the 2-staged procedure were calculated., Results: Disease was controlled in 26 (74%) of the patients. Residual and/or recurrent cholesteatomas were found in 9 (26%) of the patients during the second-stage operation. Of these patients, 5 (14% of the total group) ultimately required conversion to canal-wall-down procedure. Average hearing gain at the completion of the second-stage procedure was 9 dB., Conclusions: A planned 2-stage procedure that uses the posterior tympanotomy approach for the control of cholesteatoma is an effective technique. This approach offers significant potential for hearing preservation and restoration.

We describe a rare complication of stereotactic radiotherapy for large acoustic neuromas in a patient with type 2 neurofibromatosis. We retrospectively reviewed the case of a 14-year-old girl who had been referred to our tertiary care center. Prior to referral, the patient had been evaluated for hoarseness. During the work-up, magnetic resonance imaging (MRI) detected two large bilateral acoustic neuromas and two bilateral jugular foramen tumors. The patient was diagnosed with type 2 neurofibromatosis, and she underwent stereotactic radiotherapy for treatment of the two acoustic neuromas; the jugular foramen tumors were not irradiated. The patient's post-treatment course was complicated by hydrocephalus and symptoms of brainstem compression, which required urgent surgical intervention. Follow-up MRI 7 months following radiotherapy demonstrated a rapid growth of the acoustic neuromas, but no appreciable change in the size of the jugular foramen neuromas. These findings suggest that the radiotherapy might have been the cause of the rapid growth of the acoustic neuromas. To our knowledge, no such report has been published in the literature, and this phenomenon might be unique. Our findings suggest that radiotherapy might not be the optimal first-line treatment for acoustic neuromas in patients with type 2 neurofibromatosis.