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Computed tomography (CT) has long been considered the optimal imaging technique for the detection of cholesteatomas. However, this modality often lacks specificity, particularly in patients with an absence of definite bony erosion or a history of surgical excision. Several investigators have proposed magnetic resonance imaging with diffusion-weighted imaging (DWI) as a means of diagnosing the presence and extent of cholesteatomas, particularly when CT results are equivocal. The rationale for the use of DWI is that cholesteatomas demonstrate restricted diffusion and granulation tissue does not. In this retrospective study, we review our experience with 12 patients who had undergone DWI for evaluation of a mass in the middle ear, mastoid, or petrous apex. Ten of these patients had previously undergone middle ear surgery, 8 for cholesteatoma resection. On DWI, 9 patients demonstrated restricted diffusion. Of these, 8 patients underwent surgical resection, and all were found to have had a cholesteatoma. Of the 3 patients who had not demonstrated restricted diffusion on DWI, 2 did not undergo surgery and the other was found to have only chronic inflammation at surgery. Based on our limited experience, we believe that DWI can be useful in confirming the diagnosis of cholesteatoma. Moreover, it may alter patient management, particularly in patients whose previous tympanoplasty/mastoidectomy does not allow for an adequate clinical inspection of the middle ear cavity. [ABSTRACT FROM AUTHOR]

Objective: Imaging surveillance with serial MRI, or a "wait-and-scan" approach, is a management option for patients with small or medium-sized vestibular schwannomas (VSs). Prior publications have indicated no distinct quality of life advantage to upfront treatment compared with initial wait-and-scan management. However, imaging surveillance is dependent on patient adherence to follow-up. In this study, the authors aimed to identify rates and predictors of patient loss to follow-up during wait-and-scan management of sporadic VS., Methods: A single-center study was conducted including all patients from 2013 to 2018 who had undergone upfront imaging surveillance of sporadic VS. Patient data were retrospectively obtained from the electronic medical record. Outcomes of interest included loss to follow-up unrelated to death and inconsistent adherence to imaging surveillance recommendations. Logistic regression analyses were conducted to evaluate factors associated with loss to follow-up., Results: Over a 6-year study period, 270 patients underwent initial imaging surveillance of a sporadic VS. The median tumor diameter was 8.6 mm (range 1-28.9 mm). At the time of censoring, 106 patients (39.3%) had received treatment, 157 (58.1%) had been advised to continue follow-up, and 7 (2.6%) had died of non-VS-related causes. In total, 73 patients (27.0%) were completely lost to follow-up prior to the first treatment or death. Additionally, 60 patients (22.2%) missed at least 1 MRI follow-up or imaging follow-up was delayed by more than 1 year. Multivariable logistic regression identified an out-of-state residence (OR 3.05, 95% CI 1.58-5.89, p = 0.0009) and a smaller tumor size (unit OR per 1-mm increase in size, OR 0.88, 95% CI 0.83-0.95, p = 0.0006) to be associated with loss to follow-up. Patients living ≥ 350 miles from the hospital or with tumors ≤ 3 mm at the time of initial clinic evaluation were most likely to be lost to follow-up. Only a smaller tumor size was associated with an increased risk of inconsistent imaging follow-up (unit OR per 1-mm increase in size, OR 0.92, 95% CI 0.87-0.98, p = 0.007)., Conclusions: Patients undergoing imaging surveillance of VS are at risk for loss to follow-up and inconsistent imaging surveillance. Patients with smaller tumors or those living farther away from the treating institution are at highest risk for being lost to follow-up.

Objectives: Describe a single institution's cochlear implant outcomes for patients with inner ear schwannomas (IES) in the setting of various tumor management strategies (observation, surgical resection, or stereotactic radiosurgery [SRS])., Study Design: Single-institution retrospective review., Patients: Patients diagnosed with isolated, sporadic IES who underwent cochlear implantation (CI)., Interventions: CI with or without IES treatment., Main Outcome Measures: Speech perception outcomes, tumor status., Results: Twelve patients with IES underwent CI with a median audiologic and radiologic follow-up of 12 months. Six patients underwent complete resection of the tumor at the time of CI, four underwent tumor observation, and two underwent SRS before CI. At 1 year after CI for all patients, the median consonant-nucleus-consonant (CNC) word score was 55% (interquartile range, 44-73%), and the median AzBio sentence in quiet score was 77% (interquartile range, 68-93%). Overall, those with surgical resection performed similarly to those with tumor observation (CNC 58 versus 61%; AzBio in quiet 74 versus 91%, respectively). Patients who underwent tumor resection before implantation had a wider range of speech performance outcomes compared with patients who underwent tumor observation. Two patients had SRS treatment before CI (10 months previous and same-day as CI) with CNC word scores of 6 and 40%, respectively., Conclusions: Patients with IES who underwent CI demonstrated similar speech performance outcomes (CNC 56% and AzBio 82%), when compared with the general cochlear implant population. Patients who underwent either tumor observation or surgical resection performed well after CI., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: To describe the experience and results from coordinated and closely scheduled radiosurgery and cochlear implantation (CI) in a vestibular schwannoma (VS) cohort., Patients: Patients with VS who underwent radiosurgery followed by CI on the same or next day., Interventions: Interventions included sequential radiosurgery and CI., Main Outcome Measures: Tumor control defined by tumor growth on posttreatment surveillance and audiometric outcomes including consonant-nucleus-consonant words and AzBio sentences in quiet., Results: In total, six patients were identified that met the inclusion criteria, with an age range of 38 to 69 years and tumor sizes ranging from 2.0 to 16.3 mm. All patients successfully underwent radiosurgery and CI on the same or immediately successive day. Postoperatively, all patients obtained open-set speech recognition. Consonant-nucleus-consonant word scores ranged from 40 to 88% correct, and AzBio scores ranged from 44 to 94% correct. During posttreatment magnetic resonance imaging surveillance, which ranged from 12 to 68 months, all tumors were noted to be adequately visualized, and no tumor progression was noted., Conclusion: Coordinated radiosurgery and CI can be safely performed in patients with VS on the same or next day, serving to decrease burden on patients and increase access to this vital rehabilitative strategy., (Copyright © 2024, Otology & Neurotology, Inc.)

Objectives: A small number of cochlear implant (CI) users experience facial nerve stimulation (FNS), which can manifest as facial twitching. In some patients, this can be resolved by adjusting the electrical stimulation parameters. However, for others, facial stimulation can significantly impair CI outcomes or even prevent its use. The exact mechanisms underlying FNS are unclear and may vary among patients., Design: Transimpedance measurements were used to assess lateral and longitudinal spread of current within 15 cochlea of nucleus CI recipients with FNS (13 unilateral recipients and 1 bilateral recipient). We compared the transimpedance measurements with programming parameters from clinical visits and pre- and postoperative temporal bone computed tomography (CT) scans to identify factors that may contribute to FNS in each CI ear., Results: In nine ears, transimpedance curves showed inflection, which suggests a localized current sink within the cochlea. This indicates a low-impedance pathway through which current exits the cochlea and stimulates the labyrinthine segment of the facial nerve canal. Electrodes near this current sink were disabled or underfit to minimize facial stimulation. In the other seven ears, current flow peaked toward the basal end of the cochlea, suggesting that current exits through the round window or other structures near the basal end of the cochlea, stimulating the tympanic segment of the facial nerve., Conclusions: Objective transimpedance measurements can be used to elucidate the mechanisms of FNS and to develop strategies for optimizing electrical stimulation parameters and speech coding to minimize or eliminate FNS in a small subset of CI users., Competing Interests: The authors do not have any conflict of interest to report., (Copyright © 2024, Otology & Neurotology, Inc.)

Objective: Comprehensively assess the prevalence of monopolar electrosurgery-related device complications among cochlear implant (CI) recipients., Study Design: Multifaceted retrospective review and survey., Setting: Tertiary medical center., Methods: Multifaceted approach including: (i) review of the current literature; (ii) historical review of institutional data from an academic, tertiary CI center; (iii) review of industry data provided by 3 Food and Drug Administration-approved CI manufacturers; and (iv) survey of high-volume CI centers., Results: Literature review identified 9 human studies, detailing 84 devices with 199 episodes of device-cautery exposure. From studies reporting on patients records, no implant showed evidence of damage after exposure. One cadaveric study using dental cautery reported 1 episode of device damage. Review of institutional records did not identify any CI damage in 84 instances of exposure. Data from the 3 major implant manufacturers showed a single report of damage that could be reasonably linked to monopolar electrosurgery, out of a possible 689,426 CIs. Last, a survey of 8 high-volume CI centers did not identify any adverse events associated with monopolar cautery., Conclusion: These data estimate the risk of adverse device-related events or tissue injury to be extraordinarily low. Short of operating in immediate proximity to the CI (ie, the ipsilateral temporoparietal scalp), these data indicate that monopolar electrosurgery can be used in the body and the head-and-neck of CI recipients with nominal risk. These findings may guide decision-making in cases that are optimally or preferably performed with monopolar electrocautery and can be used to counsel CI patients following inadvertent exposures., (© 2023 American Academy of Otolaryngology-Head and Neck Surgery Foundation.)

Objective: To compare cochlear implant (CI) and auditory brainstem implant (ABI) performance in patients with NF2-related schwannomatosis (NF2)., Study Design: Historical cohort., Setting: Tertiary academic center., Patients: A total of 58 devices among 48 patients were studied, including 27 ABIs implanted from 1997 to 2022 and 31 CIs implanted from 2003 to 2022. Three patients had bilateral ABIs, three had bilateral CIs, three had an ABI on one side and a CI on the other, one had a CI that was later replaced with an ipsilateral ABI, and one had an ABI and CI concurrently on the same side., Interventions: CI or ABI ipsilateral to vestibular schwannoma., Main Outcome Measures: Open-set speech perception, consonant-nucleus-consonant word scores, and AzBio sentence in quiet scores., Results: Among all patients, 27 (47%) achieved open-set speech perception, with 35 (61%) daily users at a median of 24 months (interquartile range [IQR], 12-87 mo) after implantation. Comparing outcomes, CIs significantly outperformed ABIs; 24 (77%) CIs achieved open-set speech perception compared with 3 (12%) ABIs, with median consonant-nucleus-consonant and AzBio scores of 31% (IQR, 0-52%) and 57% (IQR, 5-83%), respectively, for CIs, compared with 0% (IQR, 0-0%) and 0% (IQR, 0-0%), respectively, for ABIs. Patients with ABIs were younger at diagnosis and at implantation, had larger tumors, and were more likely to have postoperative facial paresis., Conclusion: Many patients with NF2-associated vestibular schwannoma achieved auditory benefit with either a CI or an ABI; however, outcomes were significantly better in those patients who were able to receive a CI. When disease and anatomy permit, hearing rehabilitation with a CI should be considered over an ABI in these patients. Tumor management strategies that increase the ability to successfully use CIs should be strongly considered given the high risk of losing bilateral functional acoustic hearing in this population., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: The treatment paradigm of vestibular schwannoma (VS) focuses on preservation of neurologic function, with small tumors increasingly managed with active surveillance. Often, tumor size and hearing outcomes are poorly correlated. The aim of the current work was to describe the natural history of hearing among patients with nongrowing VS during observational management., Study Design: Historical cohort study., Patients: Adults with sporadic VS., Intervention: Wait-and-scan management., Main Outcome Measure: Maintenance of serviceable hearing (SH) after diagnosis., Results: Among 228 patients with nongrowing VS, 157 patients had SH at diagnosis. Rates of maintaining SH (95% CI; number still at risk) at 1, 3, and 5 years after diagnosis were 94% (89-98; 118), 81% (74-89; 65), and 78% (71-87; 42), respectively. Poorer hearing at diagnosis (hazard ratio [HR] per 10 dB hearing level increase in pure-tone average of 2.51, p < 0.001; HR per 10% decrease in word recognition score of 1.70, p = 0.001) was associated with increased likelihood of developing non-SH during observation. When controlling for baseline hearing status, tumors measuring 5 mm or greater in the internal auditory canal or with cerebellopontine angle extension were associated with significantly increased risk of developing non-SH (HR, 4.87; p = 0.03). At 5 years after diagnosis, 95% of patients with nongrowing intracanalicular VS measuring less than 5 mm maintained SH., Conclusions: Hearing worsens during periods of nongrowth in sporadic VS. Patients with small (<5 mm) intracanalicular tumors demonstrate robust maintenance of SH over time, reinforcing the consideration of initial observation in this patient subset., Competing Interests: Conflict of Interest: The authors report no relevant conflict of interest in submitting this article for publication. The views expressed herein are those of the authors and do not reflect the official policy or position of San Antonio Military Medical Center, the US Army Medical Department, the US Army Office of the Surgeon General, the Department of the Army, the Department of the Air Force, the Department of Defense, or the US Government., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications., Study Design: Survey., Setting: A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery., Results: House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting., Conclusions: Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Background: Neurofibromatosis type 2 (NF2)-related schwannomatosis is an autosomal dominant tumor-predisposition syndrome characterized by bilateral vestibular schwannomas (VS). In patients with VS associated with NF2, vascular endothelial growth factor A inhibitor, bevacizumab, is a systemic treatment option. The aim of this study is to retrospectively evaluate NF2 patient responses to bevacizumab on VS growth and symptom progression., Methods: This is a retrospective analysis of patients seen at the Mayo Clinic Rochester Multidisciplinary NF2 Clinic., Results: Out of 76 patients with NF2 evaluated between 2020 and 2022, we identified 19 that received treatment with bevacizumab. Thirteen of these patients discontinued bevacizumab after median treatment duration of 12.2 months. The remaining 6 patients are currently receiving bevacizumab treatment for a median duration of 9.4 months as of March, 2023. Fifteen patients had evaluable brain MRI data, which demonstrated partial responses in 5 patients, stable disease in 8, and progression in 2. Within 6 months of bevacizumab discontinuation, 5 patients had rebound growth of their VS greater than 20% from their previous tumor volume, while 3 did not. Three patients with rebound growth went on to have surgery or irradiation for VS management., Conclusions: Our single-institution experience confirms prior studies that bevacizumab can control progression of VS and symptoms associated with VS growth. However, we note that there is the potential for rapid VS growth following bevacizumab discontinuation, for which we propose heightened surveillance imaging and symptom monitoring for at least 6 months upon stopping anti-VEGF therapy., Competing Interests: None declared., (© The Author(s) 2023. Published by Oxford University Press, the Society for Neuro-Oncology and the European Association of Neuro-Oncology.)

Objective: Compare cochlear implant (CI) performance between patients with ipsilateral sporadic vestibular schwannoma (VS) and NF2-related schwannomatosis (NF2). Compare CI performance according to VS management modality., Study Design: Historical cohort., Setting: Tertiary academic center., Patients: Forty-nine patients (52 ears) undergoing cochlear implantation in the setting of ipsilateral sporadic (n = 21) or NF2-associated VS (n = 28)., Interventions: CI ipsilateral to VS., Main Outcome Measures: Auditory thresholds, consonant-nucleus-consonant (CNC) word scores, and AzBio sentences in quiet scores., Results: Among all patients, median post-CI pure tone average was 28 dB HL (interquartile range [IQR], 21-38), CNC word score was 39% (IQR, 6-62), and AzBio sentences in quiet score was 60% (IQR, 11-83) at a median of 12.5 months postimplantation. Despite the NF2 cohort having larger tumors, when comparing patients with sporadic versus NF2-associated VS, there were no statistically significant differences in CNC word (49% [30-70] vs. 31% [0-52]) or AzBio sentences in quiet (66% [28-80] vs. 57% [5-83]) scores. Regardless of NF2 status, all patients managed with observation, and radiosurgery achieved open-set speech. In patients who underwent microsurgery, 6 (46%) of 13 with NF2 achieved open-set speech recognition compared with 4 (67%) of 6 with sporadic disease., Conclusion: Select patients with VS achieve successful hearing rehabilitation with a CI. In this cohort, tumor management strategy significantly influenced CI performance, whereas differences in NF2 status exhibited less effect. Specifically, all patients managed with observation or radiosurgery achieved open-set speech perception, whereas approximately half of people with NF2-related VS and two-thirds of people with sporadic VS achieved this outcome after tumor microsurgery. When disease permits, observation and radiosurgery should be considered in patients who may later pursue a CI., Competing Interests: Conflict of interest: MLC receives research support from Advanced Bionics Corp., Cochlear Corp., and MED-EL GmbH., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: The objective of this study is to assess the influence of age on facial nerve recovery after microsurgical resection of sporadic vestibular schwannoma., Study Design: A historical cohort study was performed., Setting: The study was performed at a tertiary referral center., Patients: The studied cohort included patients with a House-Brackmann (HB) Grade III or worse in the immediate postoperative period., Interventions: The studied intervention was microsurgical resection., Main Outcome Measures: The main outcome measure was complete recovery of facial nerve function to HB Grade I at least 12 months postoperatively., Results: There were six patients with intracanalicular tumors and 100 with cerebellopontine angle (CPA) tumors eligible for study. Given the few patients with intracanalicular tumors, no further analysis was pursued in this subset. For patients with CPA tumors, a multivariable analysis of several patient and tumor characteristics demonstrated age at surgery (odds ratio for 10-year increase of 0.68; 95% confidence interval [CI], 0.47-0.98; p = 0.04) and immediate postoperative HB grade (odds ratio for one-grade increase of 0.27; 95% CI, 0.15-0.50; p < 0.001) to be jointly significantly associated with complete recovery to HB Grade I, indicating that the likelihood of complete facial nerve recovery was higher for younger patients and for those with better immediate postoperative HB grades. For example, the predicted probability of complete facial nerve recovery for a 30-year-old with immediate postoperative HB Grade III was 0.76 (or 76% when expressed as a percentage), whereas the predicted probability for a 50-year-old with immediate postoperative HB Grade V was only 0.10., Conclusions: After considering immediate postoperative HB grade, younger age at surgery was independently significantly associated with complete facial nerve recovery, which can assist in intraoperative decision-making regarding extent of resection and postoperative counseling., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2023, Otology & Neurotology, Inc.)

Objective: Preoperative differentiation of facial nerve schwannoma (FNS) from vestibular schwannoma (VS) can be challenging, and failure to differentiate between these two pathologies can result in potentially avoidable facial nerve injury. This study presents the combined experience of two high-volume centers in the management of intraoperatively diagnosed FNSs. The authors highlight clinical and imaging features that can distinguish FNS from VS and provide an algorithm to help manage intraoperatively diagnosed FNS., Methods: Operative records of 1484 presumed sporadic VS resections between January 2012 and December 2021 were reviewed, and patients with intraoperatively diagnosed FNSs were identified. Clinical data and preoperative imaging were retrospectively reviewed for features suggestive of FNS, and factors associated with good postoperative facial nerve function (House-Brackmann [HB] grade ≤ 2) were identified. A preoperative imaging protocol for suspected VS and recommendations for surgical decision-making following an intraoperative FNS diagnosis were created., Results: Nineteen patients (1.3%) with FNSs were identified. All patients had normal facial motor function preoperatively. In 12 patients (63%), preoperative imaging demonstrated no features suggestive of FNS, with the remainder showing subtle enhancement of the geniculate/labyrinthine facial segment, widening/erosion of the fallopian canal, or multiple tumor nodules in retrospect. Eleven (57.9%) of the 19 patients underwent a retrosigmoid craniotomy, and in the remaining patients, a translabyrinthine (n = 6) or transotic (n = 2) approach was used. Following FNS diagnosis, 6 (32%) of the tumors underwent gross-total resection (GTR) and cable nerve grafting, 6 (32%) underwent subtotal resection (STR) and bony decompression of the meatal facial nerve segment, and 7 (36%) underwent bony decompression only. All patients undergoing subtotal debulking or bony decompression exhibited normal postoperative facial function (HB grade I). At the last clinical follow-up, patients who underwent GTR with a facial nerve graft had HB grade III (3 of 6 patients) or IV facial function. Tumor recurrence/regrowth occurred in 3 patients (16%), all of whom had been treated with either bony decompression or STR., Conclusions: Intraoperative diagnosis of an FNS during a presumed VS resection is rare, but its incidence can be reduced further by maintaining a high index of suspicion and undertaking further imaging in patients with atypical clinical or imaging features. If an intraoperative diagnosis does occur, conservative surgical management with bony decompression of the facial nerve only is recommended, unless there is significant mass effect on surrounding structures.

Intraoperative electrocochleography (ECOG) is performed using a single low-frequency acoustic stimulus (e.g., 500 Hz) to monitor cochlear microphonics (CM) during cochlear implant (CI) electrode insertion. A decrease in CM amplitude is commonly associated with cochlear trauma and is used to guide electrode placement. However, advancement of the recording electrode beyond the sites of CM generation can also lead to a decrease in CM amplitude and is sometimes interpreted as cochlear trauma, resulting in unnecessary electrode manipulation and increased risk of cochlear trauma during CI electrode placement. In the present study, multi-frequency ECOG was used to monitor CM during CI electrode placement. The intraoperative CM tracings were compared with electrode scan measurements, where CM was measured for each of the intracochlear electrodes. Comparison between the peak CM amplitude measured during electrode placement and electrode scan measurements was used to differentiate between different mechanisms for decrease in CM amplitude during CI electrode insertion. Analysis of the data shows that both multi-frequency electrocochleography and electrode scan could potentially be used to differentiate between different mechanisms for decreasing CM amplitude and providing appropriate feedback to the surgeon during CI electrode placement.

Objective: To characterize the effect of the COVID-19 pandemic on national cochlear implantation utilization by age using inclusive cochlear implantation data from two manufacturers between 2015 and 2020., Study Design: Analysis of prospectively registered consecutive patient data from two major cochlear implant (CI) manufacturers in the United States., Patients: Children or adults who received CIs., Interventions: Cochlear implantation., Main Outcome Measures: Annual implantation utilization by age., Results: A total of 46,804 patients received CIs from the two participating manufacturers between 2015 and 2020. The annual number of implant recipients increased significantly during the first 5 years of the study period for both children and adults, from a total of 6,203 in 2015 to 9,213 in 2019 (p < 0.001). During 2020, there was a 13.1% drop in national cochlear implantation utilization across all ages compared with 2019, including a drop of 2.2% for those ≤3 years old, 3.8% for those 4-17 years old, 10.1% for those 18-64 years old, 16.6% for those 65-79 years old, and 22.5% for those ≥80 years old. In a multivariable linear regression model, the percent drop in CIs differed significantly by age-group (p = 0.005)., Conclusions: Especially in light of the prepandemic projected CI counts for 2020, the COVID-19 pandemic reduced national cochlear implantation utilization by over 15% among Medicare-aged patients and by almost 25% among those ≥80 years old, resulting in more than a 3-year setback in total annual CIs. Children were less affected, with those ≤3 years old experiencing minimal interruption during 2020., Competing Interests: Conflicts of interest: The authors report no relevant conflict of interest in submitting this article for publication. Analysis of the data was performed independently by the research team without input by either cochlear implant manufacturer., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To evaluate the optimal dose and timing of administration of sodium fluorescein (SF) for selective fluorescence of sporadic vestibular schwannoma (VS) during microsurgery with the YELLOW 560-nm microscope filter (YE560) and to characterize the potential benefit of this fluorescence as determined by intraoperative surgeon assessment., Study Design: Prospective cohort study., Setting: Tertiary referral center., Patients: Adult patients undergoing VS microsurgery., Interventions: Intraoperative intravenous administration of SF and visualization with the YE560., Main Outcome Measures: Time to differential fluorescence, duration of fluorescence, correlation of fluorescence of VS with electrostimulation and white light microscopy visual assessment, and likelihood of surgeons to use SF with the YE560 in future cases., Results: Novel use of SF and YE560 during microsurgery achieved selective fluorescence of VS with capabilities to differentiate nerve fascicles and tumor approximately 30 minutes after administration. Nuances of SF administration and timing are discussed. Seventy-five percent of surgeons observed an excellent correlation of selective fluorescence with white light microscopy. Representative images and cases are presented., Conclusions: SF and YE560 may be used in VS microsurgery to visually differentiate VS from surrounding nerves. Potential benefits include enhanced visualization of the tumor-nerve interface for tumor dissection and detection of any residual disease, such as in the fundus after hearing preservation microsurgery., Competing Interests: Sources of support and disclosure of funding: Carl Zeiss Meditec provided the microscope fluorescence module and funding for fluorescein use and database creation. The authors report no relevant, personal conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To determine the relationship between intraoperative electrocochleography (ECochG) measurements and residual hearing preservation after cochlear implant (CI) surgery by comparing differences between preoperative and immediate postoperative bone conduction thresholds., Study Design: Prospective cohort study., Setting: Tertiary academic referral center., Patients: Sixteen patients with preoperative residual hearing and measurable (no-vibrotactile) bone conduction thresholds at 250 and/or 500 Hz who underwent cochlear implantation., Main Outcome Measure: Intraoperative ECochG and air and bone conduction thresholds., Results: Nine patients showed no significant drop (<30%) in ECochG amplitude during CI surgery with an average preoperative and immediate postoperative BC threshold of 46 and 39 dB HL, respectively, at 500 Hz. Seven patients with a decrease in ECochG amplitude of 30% or greater showed an average preoperative 500 Hz BC threshold of 32 dB HL and immediate postoperative threshold of 55 dB HL. Air and bone conduction thresholds measured approximately 1 month after CI surgery show delayed-onset of hearing loss across our study patients., Conclusions: A small decrease (<30%) in difference response or cochlear microphonics amplitude correlates with no significant changes in immediate postoperative residual hearing, whereas patients who show larger changes (≥30%) in difference response or cochlear microphonics amplitude during intraoperative ECochG measurements show significant deterioration in BC thresholds. This study reveals the necessity of prompt postoperative bone conduction measurement to isolate the intraoperative cochlear trauma that may be detected during intraoperative ECochG measurements. Although delayed postoperative audiometrics represent longer-term functional hearing, it includes the sum of all postoperative changes during the recovery period, including subacute changes after implantation that may occur days or weeks later. Measuring air and bone conduction thresholds immediately postoperatively will better isolate factors influencing intraoperative, early postoperative, and delayed postoperative hearing loss. This will ultimately help refine surgical technique, device design, and highlight the use of intraoperative ECochG in monitoring cochlear trauma during CI surgery., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To introduce and discuss implementation strategy for the Complete Cochlear Implant Care (CCIC) model, a highly-coordinated cochlear implant (CI) care delivery model requiring a single on-site visit for preoperative workup, surgery, and postoperative programming., Study Design: Prospective, nonrandomized, two-arm clinical trial., Setting: Tertiary referral CI center., Patients: Adults who meet audiologic criteria for cochlear implantation., Interventions: Cochlear implantation, coordinated care delivery, including remote programming., Main Outcome Measures: Care delivery model feasibility and process implementation., Results: Patients determined to be likely CI candidates based on routine audiometry are eligible for enrollment. The CCIC model uses telemedicine and electronic educational materials to prepare patients for same-day on-site consultation with CI surgery, same or next-day activation, and postoperative remote programming for 12 months. Implementation challenges include overcoming inertia related to the implementation of a new clinical workflow, whereas scalability of the CCIC model is limited by current hardware requirements for remote programming technology. A dedicated CCIC process coordinator is critical for overcoming obstacles in implementation and process improvement through feedback and iterative changes. Team and patient-facing materials are included and should be tailored to fit each unique CI program looking to implement CCIC., Conclusion: The CCIC model has the potential to dramatically streamline hearing healthcare delivery. Implementation requires an adaptive approach, as obstacles may vary according to institutional infrastructure and policies., Competing Interests: A.M.N. received research funding from Cochlear Americas. A.A.S. received research funding from Cochlear Americas and Advanced Bionics Corporation and a consultant for Advanced Bionics Corporation, Oticon Medical and Envoy Medical. C.L.W.D. is a consultant for Advanced Bionics Corporation, Cochlear Americas, Envoy Medical. D.S.H. is a consultant for Cochlear Americas, Med-El GmbH, Advanced Bionics Corporation, Anspach. M.L.C. received research funding from Cochlear Americas. M.D.D., N.M.T., B.A.N. disclose no conflicts of interest., (Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of Otology & Neurotology, Inc.)

Objective: Develop a predictive model for incomplete microsurgical resection of sporadic vestibular schwannoma (VS)., Study Design: Historical cohort., Setting: Tertiary referral center., Patients: Patients with sporadic VS., Interventions: Microsurgery with preoperative intent of gross total resection., Main Outcome Measures: Patient and tumor characteristics that influence extent of resection., Results: Among 603 patients, 101 (17%) had intracanalicular tumors and 502 (83%) had tumors with cerebellopontine angle (CPA) extension. For patients with CPA tumors, 331 (66%) underwent gross total resection and 171 (34%) underwent near-total or subtotal resection (NTR-STR). Multivariable modeling identified older age at surgery, larger linear tumor size, and absence of a fundal fluid cap as predictive of NTR-STR ( p < 0.001). From this model, one can estimate that a 20-year-old with a tumor that has less than 10 mm of CPA extension and a present fundal fluid cap has a predicted probability of NTR-STR of 0.01 (or 1%), whereas a 70-year-old with a tumor that has 30 mm or greater CPA extension and absence of a fundal fluid cap has a predicted probability of NTR-STR of 0.91 (or 91%). Among the 171 patients who underwent NTR-STR, 24 required secondary treatment at the time of last follow-up., Conclusion: The primary predictors of incomplete microsurgical resection of VS include older age at surgery, larger linear tumor size, and absence of a fundal fluid cap. These factors can be used to estimate the likelihood of NTR-STR, aiding in preoperative discussions regarding future surveillance and potential need of secondary treatment, as well as shared clinical decision making., Competing Interests: The authors disclose no conflicts of interest., (Copyright © 2022, Otology & Neurotology, Inc.)

Objectives/hypothesis: To review hearing preservation after microsurgical resection of sporadic vestibular schwannomas according to tumor size., Study Design: Retrospective cohort., Methods: Baseline, intraoperative, and postoperative patient and tumor characteristics were retrospectively collected for a cohort who underwent hearing preservation microsurgery. Serviceable hearing was defined by a pure tone average ≤50 dB and word recognition score ≥50%., Results: A total of 243 patients had serviceable hearing preoperatively. Fifty (21%) tumors were confined to the internal auditory canal, and the median tumor size was 16.2 mm (interquartile range [IQR] 11.3-23.2) for tumors with cerebellopontine angle extension. Serviceable hearing was maintained in 64% of patients with tumors confined to the internal auditory canal, 28% with cerebellopontine angle extension <15 mm, and 9% with cerebellopontine angle extension ≥15 mm. On multivariable analysis, the odds ratios of acquiring nonserviceable hearing postoperatively for tumors extending <15 mm and ≥15 mm into the cerebellopontine angle were 5.75 (95% confidence interval [CI] 2.13-15.53; P < .001) and 22.11 (95% CI 7.04-69.42; P < .001), respectively, compared with intracanalicular tumors., Conclusions: The strongest predictor of hearing preservation with microsurgery after multivariable adjustment is tumor size. Approximately 10% of patients with tumors ≥15 mm of cerebellopontine angle extension will retain serviceable hearing after microsurgery. Furthermore, hearing preservation techniques offer cochlear nerve preservation and cochlear patency allowing for possible future cochlear implantation. An attempt at hearing preservation, including avoiding surgical approaches that necessarily sacrifice hearing, is worthwhile even in larger tumors if serviceable hearing is present preoperatively., Level of Evidence: 4 Laryngoscope, 132:1657-1664, 2022., (© 2021 The American Laryngological, Rhinological and Otological Society, Inc.)

Objective: To determine if temporoparietal scalp thickness assessed via preoperative imaging predicts retention events in patients who have cochlear implants with diametric magnets and various sound processor types., Study Design: Retrospective chart and radiological review., Setting: Tertiary referral center., Patients: One hundred forty-three adult patients who have cochlear implants with diametric magnets., Main Outcome Measures: Skin flap thickness, retention events, body mass index (BMI), and magnet strength., Results: Of 42 patients with the most recent generation off-the-ear sound processor (OTE2), 13 (31.0%) had retention events. Of patients with a temporoparietal scalp thickness less than 8 mm, all patients could ultimately retain the device, though one of 26 was noted to have tenuous retention. Of patients with 8 to 10 mm skin flaps, 3 of 6 (50%) could not retain the device, and with more than 10 mm skin flaps, 7 of 10 (70%) could not retain the device. In the more than 10 mm group, two additional patients could not either retain the device at initial activation or were noted to have tenuous retention. Of 124 patients with behind-the-ear (BTE) sound processors, only 2 (1.6%) could not retain the device at initial activation, and 3 (2.4%) exhibited tenuous retention after 3 months of device use. Results from the first generation off-the-ear sound processor (OTE1) are also reported., Conclusions: Temporoparietal scalp thickness measured by preoperative imaging is associated with processor retention for patients with the OTE2 sound processor and diametric magnets. All patients with less than 8 mm scalp thickness could retain the OTE2, while 50% of patients with 8 to 10 mm scalp thickness and 70% with more than 10 mm scalp thickness could not retain the device. Patients should be counseled regarding their sound processor choice and/or considered candidates for skin flap reduction or other intervention as indicated. Retention events with BTE processors are rare., (Copyright © 2022, Otology & Neurotology, Inc.)

Objective: To evaluate the impact of prolonged auditory deprivation on speech perception outcomes in adult acquired single-sided deafness (SSD) cochlear implant (CI) recipients., Study Design: Retrospective case series., Setting: Tertiary care academic center., Patients: Acquired SSD in adults with and without prolonged duration of deafness (defined as >10 yr) who underwent CI between 2014 and 2019., Interventions: CI., Main Outcome Measures: Consonant-nucleus-consonant (CNC) and AzBio in quiet scores within first year of follow-up., Results: A total of 35 adult patients with SSD were evaluated, with a median overall duration of deafness of 2.4 years (interquartile range [IQR] 1.2-6.0 yr): seven patients with prolonged auditory deprivation (median 18 yr, IQR 15-28) were compared with 28 SSD patients with duration of deafness less than 10 years (median 1.7 yr, IQR 1.1-3.2). At last follow-up, the median CNC scores were 39% (IQR 31-64) and 54% (IQR 46-64) for the prolonged and shorter duration of deafness cohorts, respectively (p = 0.3). The median AzBio scores were 66% (IQR 65-68) and 72% (IQR 60-82) for the prolonged and shorter duration of deafness cohorts, respectively (p = 0.6). In a separate analysis evaluating duration of deafness as a continuous variable across all 35 patients, Spearman correlation coefficients for associations of duration of deafness with most recent CNC and AzBio scores were -0.02 (p = 0.9) and 0.02 (p = 0.9), respectively., Conclusions: Adult CI recipients with acquired SSD, with and without prolonged auditory deprivation, demonstrated comparable speech perception scores. Prolonged duration of deafness alone should not preclude a motivated SSD patient from undergoing cochlear implantation., Competing Interests: Conflicts of interest to declare: A.M.N.: Research funding from Cochlear Americas., (Copyright © 2021, Otology & Neurotology, Inc.)

Objectives: Compare speech perception performance growth and benchmark score achievement among adult cochlear implant (CI) recipients with single-sided deafness (SSD) versus bilateral moderate to profound hearing loss., Study Design: Retrospective matched cohort analysis., Setting: Tertiary referral center., Patients: Adults with SSD or bilateral moderate to profound hearing sensorineural hearing loss who underwent cochlear implantation from 2014 to 2019., Interventions: Cochlear implantation., Main Outcome Measures: Time-to-benchmark speech perception score (CNC, AzBio in quiet) and speech performance within first postoperative year., Results: Thirty-three SSD patients were matched to 66 bilateral hearing loss patients (referent cohort) for duration of deafness and preoperative ipsilateral CNC scores. Although SSD patients were more likely to achieve benchmark CNC scores more quickly compared with matched referents, this difference did not reach statistical significance (HR 1.72; 95% CI 0.78-3.82; p = 0.18). AzBio scores showed similar trends (HR 1.40; 95% CI 0.66-2.98; p = 0.38). At last follow-up, the SSD cohort had lower CNC (median 54% vs. 62%; p = 0.019) and AzBio scores (median 72% vs. 84%; p = 0.029) compared to the referent cohort., Conclusions: No significant difference in speech perception performance growth (i.e., time-to-benchmark speech perception score) was identified between SSD and bilateral hearing loss CI recipients, although patients with bilateral hearing loss achieved higher scores in the implanted ear within the first year of follow-up., Competing Interests: Conflicts of interest to declare: AMN: Research funding from Cochlear Americas. CLWD: Consultant for Advanced Bionics, Cochlear Corporation, Envoy Medical. AAS: Consultant for Advanced Bionics and Envoy Medical. Research funding from Cochlear Americas. MLC: Research funding from Cochlear Americas., (Copyright © 2021, Otology & Neurotology, Inc.)

Background: A variety of neurosensory symptoms including tinnitus have been associated with COVID-19 infection. While most cases of tinnitus are associated with hearing loss, here we report a case of severe tinnitus following COVID-19 infection with normal thresholds through 8000 Hz., Case Report: A 49-year-old male presented with new onset severe tinnitus following COVID-19 infection. Tinnitus was bilateral, constant and nonpulsatile. Audiometric evaluation revealed normal threshold through 8000 Hz, with mild hearing loss at 16,000 Hz. Conservative measures including masking strategies failed to mitigate symptoms. A trial of gabapentin 300 mg twice per day improved tinnitus with no notable side effects., Conclusion: This patient may represent a subpopulation of patients who suffer from severe tinnitus following COVID-19 infection in the setting of largely normal hearing. The pathophysiology may be distinct from the more common hearing loss associated tinnitus and perhaps neuromodulators may play a larger role in mitigating tinnitus in this patient subset., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Objective: To test the hypothesis that severe to profound preoperative hearing loss predicts less acute postoperative vestibulopathy following microsurgical removal of vestibular schwannoma (VS) allowing for earlier postoperative mobilization and hospital discharge., Methods: Patients with VS who underwent microsurgery and were found to have preoperative severe to profound hearing loss (pure tone average [PTA] > 70 dB HL) were matched 1:1 by age and tumor size to a group of randomly selected controls with preoperative serviceable hearing., Results: A total of 57 patients met inclusion criteria and were matched to controls. Median age at the time of microsurgery was 56 years. The median PTA and WRS for cases were 91 dB HL (interquartile range [IQR] 78-120) and 0% (IQR 0-0), respectively. Median tumor size was 14.2 mm (IQR 10.9-20.9). A total of 35 (61%) patients exhibited nystagmus after surgery associated with acute vestibular deafferentation. Median time to ambulation in the hallway was 2 days. Controls exhibited similar tumor size (12.7 mm, p = 0.11) and age (57 years, p = 0.52). Preoperative hearing loss did not predict severity or duration of postoperative nystagmus or days to discharge; however, those with Class D hearing exhibited a shorter time to ambulation (p = 0.04)., Conclusion: Following microsurgical removal of VS, preoperative profound hearing loss was associated with a shorter time to postoperative mobilization; however, there were no observed associations with duration or severity of nystagmus and time to hospital discharge. Although not a predictor of nystagmus, preoperative profound hearing loss may portend quicker recovery from clinically significant postoperative vestibulopathy., (Published by Elsevier Inc.)

Objective: Detection of vestibular schwannoma (VS) growth during observation leads to definitive treatment at most centers globally. Although ≥ 2 mm represents an established benchmark of tumor growth on serial MRI studies, 2 mm of linear tumor growth is unlikely to significantly alter microsurgical outcomes. The objective of the current work was to ascertain where the magnitude of change in clinical outcome is the greatest based on size., Methods: A single-institution retrospective review of a consecutive series of patients with sporadic VS who underwent microsurgical resection between January 2000 and May 2020 was performed. Preoperative tumor size cutpoints were defined in 1-mm increments and used to identify optimal size thresholds for three primary outcomes: 1) the ability to achieve gross-total resection (GTR); 2) maintenance of normal House-Brackmann (HB) grade I facial nerve function; and 3) preservation of serviceable hearing (American Academy of Otolaryngology-Head and Neck Surgery class A/B). Optimal size thresholds were obtained by maximizing c-indices from logistic regression models., Results: Of 603 patients meeting inclusion criteria, 502 (83%) had tumors with cerebellopontine angle (CPA) extension. CPA tumor size was significantly associated with achieving GTR, postoperative HB grade I facial nerve function, and maintenance of serviceable hearing (all p < 0.001). The optimal tumor size threshold to distinguish between GTR and less than GTR was 17 mm of CPA extension (c-index 0.73). In the immediate postoperative period, the size threshold between HB grade I and HB grade > I was 17 mm of CPA extension (c-index 0.65). At the most recent evaluation, the size threshold between HB grade I and HB grade > I was 23 mm (c-index 0.68) and between class A/B and C/D hearing was 18 mm (c-index 0.68). Tumors within 3 mm of the 17-mm CPA threshold displayed similarly strong c-indices. Among purely intracanalicular tumors, linear size was not found to portend worse outcomes for all measures., Conclusions: The probability of incurring less optimal microsurgical outcomes begins to significantly increase at 14-20 mm of CPA extension. Although many factors ultimately influence decision-making, when considering timing of microsurgical resection, using a size threshold range as depicted in this study offers an evidence-based approach that moves beyond reflexively recommending treatment for all tumors after detecting ≥ 2 mm of tumor growth on serial MRI studies.

Objectives: Two pilot studies of AR-42, a pan-histone deacetylase inhibitor, in human neurofibromatosis type 2 (NF2), vestibular schwannomas (VS), and meningiomas are presented. Primary endpoints included safety, and intra-tumoral pharmacokinetics (PK) and pharmacodynamics (PD)., Methods: Pilot 1 is a subset analysis of a phase 1 study of AR-42 in solid tumors, which included NF2 or sporadic meningiomas. Tumor volumes and treatment-related adverse events (TRAEs) are reported (NCT01129193).Pilot 2 is a phase 0 surgical study of AR-42 assessing intra-tumoral PK and PD. AR-42 was administered for 3 weeks pre-operatively. Plasma and tumor drug concentrations and p-AKT expression were measured (NCT02282917)., Results: Pilot 1: Five patients with NF2 and two with sporadic meningiomas experienced a similar incidence of TRAEs to the overall phase I trial. The six evaluable patients had 15 tumors (8 VS, 7 meningiomas). On AR-42, tumor volume increased in six, remained stable in eight, and decreased in one tumor. The annual percent growth rate decreased in eight, remained stable in three, and increased in four tumors. Pilot 2: Four patients with sporadic VS and one patient with meningioma experienced no grade 3/4 toxicities. Expression of p-AKT decreased in three of four VS. All tumors had higher AR-42 concentrations than plasma., Conclusions: AR-42 is safe. Tumor volumes showed a mixed response, but most slowed growth. On a 40-mg regimen, drug concentrated in tumors and growth pathways were suppressed in most tumors, suggesting this may be a well-tolerated and effective dose. A phase 2 study of AR-42 for NF2-associated tumors appears warranted., Level of Evidence: 1b, 4., Competing Interests: D. Bradley Welling is a consultant for CereXis, Science 24/7, NFBio, NF2 Biosolutions, and Mulberry Bio. Craig C. Hofmeister has received research grants from Takeda and Oncolytics Biotech; research and personal grants from Janssen, BMS, Sanofi, Nektar, Karyopharm, Imbrium, and Oncopeptides, all outside the submitted work. Amir Mortazavi is on the advisory board for Seattle Genetics and Pfizer and is on the scientific advisory board for Debiopharm Group. His institution (but not him) has received research funding from Acerta Pharma, Genentech, Roche, Merck, Novartis, Seattle Genetics, Astellas Pharma, Mirati Therapeutics, and Bristol‐Myers Squibb. The other authors declare no potential conflict of interest. The Ohio State University (OSU) holds the patent on the investigational drug AR‐42 (US 10/597022). The Technology Commercialization Office has licensed AR‐42 (now called REC‐2282) to Recursion Pharmaceuticals using the institution's standard terms, conditions, and approval process, in which no author participated. To assure absence of institutional conflict of interest in assessment of response and attribution of toxicity, both were reviewed by the Cancer Therapy Evaluation Program of the National Cancer Institute prior to reporting results for the phase I study. Safety issues related to dose increases and attribution of response were monitored by The OSU Data Safety Monitoring Committee and The OSU Cancer Center Institutional Review Board for the phase 1 pilot. A separate Data Safety and Monitoring Board of Massachusetts Eye and Ear oversaw pilot study 2., (© 2021 The Authors. Laryngoscope Investigative Otolaryngology published by Wiley Periodicals LLC on behalf of The Triological Society.)

Background: Vestibular schwannomas (VS) have a peak incidence in the sixth and seventh decades of life. Stereotactic radiosurgery is often the preferred treatment for VS among patients of advanced age. The fraction of elderly patients potentially requiring consideration for surgical treatment is anticipated to expand, mandating an update to management paradigms in this population., Objective: To describe our experience with surgical management of VS in patients aged 75 yr and older., Methods: Cohort study of all patients aged ≥75 yr with sporadic VS requiring surgical treatment at our institution between 1999 and 2020. Data included preoperative baseline characteristics and outcome data including extent of resection, facial nerve and hearing status, functional outcome, length of stay, and complications., Results: A total of 24 patients were included, spanning an age range of 75 to 90 yr. Average tumor size was 2.76 ± 1.04 cm, and average baseline Modified 5-item Frailty Index (mFI-5) score was 1.08 ± 0.93. Extent of resection was gross total in 5 (20.8%), near total in 3 (12.5%), and sub-total resection in the remaining 16 (66.7%). One patient died in the postoperative period because of an acute sub-dural hematoma. Favorable facial nerve function (HB1-2) was preserved in 12 patients (75%) between 75 and 79 yr and 2 patients (28.6%) aged ≥ 80 yr. No cerebrospinal fluid leak or surgical site infection was observed; 3 patients developed hydrocephalus requiring ventriculo-peritoneal shunt placement. Nine patients required out-of-home disposition; all patients eventually returned to independent living., Conclusion: Microsurgical resection of VS can be safely undertaken in patients greater than 75 y/o but may carry an increased risk of poor facial function., (© Congress of Neurological Surgeons 2021.)

Background: Vestibular schwannomas (VS) present at variable size with heterogeneous symptomatology. Modern treatment paradigms for large VS include gross total resection, subtotal resection (STR) in combination with observation, and/or radiation to achieve optimal function preservation, whereas treatment is felt to be both easier and safer for small VS. The objective is to better characterize the presentation and surgical outcomes of large and small VS., Methods: We collected data of patients who had surgically treated VS with a posterior fossa diameter of 4.0 cm or larger (large tumor group, LTG) and smaller than 1.0 cm in cisternal diameter (small tumor group, STG). Statistical significance was defined as p < 0.05., Results: LTG included 48 patients (average tumor size: 44.9 mm) and STG 38 (7.9 mm). Patients in STG presented more frequently with tinnitus and sudden hearing loss. Patients in LTG underwent more STR than STG (50.0% vs. 2.6%, p < 0.0001). LTG had more complications (31.3% vs. 13.2%, p = 0.049). Postoperative facial nerve function in STG was significantly better than LTG. STG had better hearing preoperatively (p < 0.0001) and postoperatively than LTG (p = 0.0002). Postoperative headache was more common in STG (13.2% vs. 2.1%, p = 0.045). The rate of recurrence/progression needing treatment was not statistically different between the groups (12.5% in LTG vs. 7.9% in STG, p = 0.49). Those patients who required periprocedural cerebrospinal fluid diversion had higher risk of infection (20.8% vs 4.8%, p = 0.022)., Conclusion: Large and small VS present differently. LTG showed more unsatisfactory outcomes in facial nerve function and postoperative hearing despite maximal efforts undertaken toward function-preservation strategy; however, similar tumor control was achieved., (© 2021. The Author(s), under exclusive licence to Springer-Verlag GmbH, AT part of Springer Nature.)

Objective: The object of this study was to ascertain outcomes of cochlear implantation (CI) following stereotactic radiosurgery (SRS) for vestibular schwannoma (VS)., Methods: The authors conducted a retrospective chart review of adult patients with VS treated with SRS who underwent CI between 1990 and 2019 at a single tertiary care referral center. Patient demographics, tumor features, treatment parameters, and pre- and postimplantation audiometric and clinical outcomes are presented., Results: Seventeen patients (18 ears) underwent SRS and ipsilateral CI during the study period. Thirteen patients (76%) had neurofibromatosis type 2 (NF2). Median age at SRS and CI were 44 and 48 years, respectively. Median time from SRS to CI was 60 days, but notably, 4 patients underwent SRS and CI within 1 day and 5 patients underwent CI more than 7 years after SRS. Median marginal dose was 13 Gy. Median treatment volume at the time of SRS was 1400 mm3 (range 84-6080 mm3, n = 15 patients). Median post-CI PTA was 28 dB HL, improved from 101 dB HL preoperatively (p < 0.001). Overall, 11 patients (12 ears) exhibited open-set speech understanding. Sentence testing was performed at a median of 10 months (range 1-143 months) post-CI. The median AzBio sentence score for patients with open-set speech understanding was 76% (range 19%-95%, n = 10 ears). Two ears exhibited Hearing in Noise Test (HINT) sentence scores of 49% and 95%, respectively. Four patients achieved environmental sound awareness without open-set speech recognition. Two had no detectable auditory percepts., Conclusions: Most patients who underwent CI following SRS for VS enjoyed access to sound at near-normal levels, with the majority achieving good open-set speech understanding. Implantation can be performed immediately following SRS or in a delayed fashion, depending on hearing status as well as other factors. This strategy may be applied to cases of sporadic or NF2-associated VS., Abbreviations: AAO-HNS = American Academy of Otolaryngology-Head and Neck Surgery; ABI = auditory brainstem implant; CI = cochlear implantation; CN = cranial nerve; CNC = consonant-nucleus-consonant; CPA = cerebellopontine angle; EPS = electrical promontory stimulation; ESA = environmental sound awareness; HINT = Hearing in Noise Test; IAC = internal auditory canal; NF2 = neurofibromatosis type 2; OSP = open-set speech perception; PTA = pure tone average; SRS = stereotactic radiosurgery; VS = vestibular schwannoma; WRS = word recognition score., Competing Interests: Dr. Carlson is a consultant for Advanced Bionics, Cochlear Corp., and MED-EL GmbH. Dr. Driscoll is a consultant for Advanced Bionics, Cochlear Corp., and Envoy Medical.

Objective: To compare the prevalence of surgical, anesthetic, and device-related complications among infants and older children receiving cochlear implantation (CI)., Study Design: Retrospective chart review., Setting: Tertiary academic referral center., Patients: Pediatric patients who underwent CI from November 1990 to January 2020., Intervention: CI., Main Outcome Measures: Surgical, anesthetic, and device-related complication rates were compared by age group (<12 versus 12-23 versus 24+ months with subset analysis of <9 versus 9-11 months)., Results: A total of 406 primary pediatric CI surgeries encompassing 482 ears were analyzed, including 45 ears in 23 patients implanted less than 9 months and 89 ears in 49 patients less than 12 months. No anesthetic complications occurred. Postoperative surgical and device-related complication rates were not significantly different among the less than 12, 12 to 23, and 24+ month groups (16% versus 16% versus 12%; p = 0.23) or between the less than 9 and 9 to 11 month groups (22% versus 9%; p = 0.09). Thirty-day readmission was significantly higher for patients less than 12 months compared with patients 24+ months (6% versus <1%; p = 0.011), but was not significantly higher compared with patients 12 to 23 months (6% versus 3%; p = 0.65). Reoperation rates did not differ significantly among the less than 12, 12 to 23, and 24+ month groups (10% versus 7% versus 6%; p = 0.31)., Conclusions: The prevalence of surgical, anesthetic, and device related complications was not significantly different among infants implanted less than 9 or less than 12 months of age when compared with older children. These data provide evidence for the continued expansion of pediatric cochlear implant candidacy criteria to include appropriately selected infants less than 9 months of age., Competing Interests: Conflict of Interest: C.M.C., A.J.S., M.M.M., C.M.L., B.A.N., and M.L.C. have no relevant conflicts of interest to declare. C.L.W.D. is a consultant for Advanced Bionics Corp., Cochlear Corp., and MED-EL GmbH., (Copyright © 2021, Otology & Neurotology, Inc.)

Background: Previous cross-sectional studies analyzing quality of life (QOL) outcomes in patients with sporadic vestibular schwannoma (VS) have shown surprisingly little difference among treatment modalities. To date, there is limited prospective QOL outcome data available comparing baseline to posttreatment scores., Study Design: Prospective longitudinal study using the disease-specific Penn Acoustic Neuroma Quality of Life (PANQOL) scale., Setting: Large academic skull base center., Patients: Patients diagnosed with unilateral VS who completed a baseline survey before treatment and at least one posttreatment survey., Main Outcome Measures: Change in PANQOL scores from baseline to most recent survey., Results: A total of 244 patients were studied, including 78 (32%) who elected observation, 118 (48%) microsurgery, and 48 (20%) stereotactic radiosurgery. Patients who underwent microsurgery were younger (p < 0.001) and had larger tumors (p < 0.001) than those who underwent observation or radiosurgery; there was no significant difference in duration of follow-up among management groups (mean 2.1 yrs; p = 0.28). When comparing the total PANQOL score at baseline to the most recent survey, the net change was only -1.1, -0.1, and 0.3 points on a 100-point scale for observation, microsurgery, and radiosurgery, respectively (p = 0.89). After multivariable adjustment for baseline features, there were no statistically significant changes when comparing baseline to most recent scores within each management group for facial function, general health, balance, hearing loss, energy, and pain domains or total score. However, the microsurgical group experienced a 10.8-point improvement (p = 0.002) in anxiety following treatment, compared with 1.5 (p = 0.73) and 5.3 (p = 0.31) for observation and radiosurgery, respectively., Conclusions: In this prospective longitudinal study investigating differences in QOL outcomes among VS treatment groups using the disease-specific PANQOL instrument, treatment did not modify QOL in most domains. Microsurgery may confer an advantage with regard to patient anxiety, presumably relating to the psychological benefit of "cure" from having the tumor removed., Competing Interests: The authors report no relevant conflicts of interest in submitting this article for publication., (Copyright © 2020, Otology & Neurotology, Inc.)

Objective: To evaluate adverse events and feasibility of performing 1.5-T MRI in patients with cochlear implants (CI) and auditory brainstem implants (ABI)., Setting: Single tertiary academic referral center., Patients: CI and ABI recipients undergoing 1.5-T MRI without internal magnet removal., Intervention(s): MRI after tight headwrap application., Main Outcome Measures: Adverse events, patient tolerance., Results: A total of 131 MR studies in 79 patients were performed, with a total of 157 study ears. Sixty-one patients (77%) had unilateral devices. Four patients (5%) underwent MRI with ABI magnets in place. Sixteen patients (20%) had MRI-compatible devices that did not require a head wrap. There were no instances of device stimulation, device malfunction, or excessive heating of the receiver-stimulator package. Magnet tilt requiring manual repositioning occurred during seven studies (4.5%) and magnet displacement requiring operative intervention occurred during seven studies (4.5%). Significant pain where imaging had to be discontinued occurred during three episodes (2%). No adverse events were noted among patients who underwent MRI with an MRI-compatible magnet., Conclusions: MRI with CI or ABI magnets in place is associated with a low prevalence of adverse events when performed in a controlled setting. Many partial magnet displacements can be corrected with firm manual pressure. Devices with magnets that align with the field within their housing were not associated with any adverse events and do not require immobilization of the magnet during the scan. These may be valuable in patients with known or anticipated need for MRI.

Objective: To address variance in clinical care surrounding sporadic vestibular schwannoma, a modified Delphi study was performed to establish a general framework to approach vestibular schwannoma care. A multidisciplinary panel of experts was established with deliberate representation from key stakeholder societies. External validity of the final statements was assessed through an online survey of registered attendees of the 8th Quadrennial International Conference on Vestibular Schwannoma., Study Design: Modified Delphi method., Methods: The panel consisted of 16 vestibular schwannoma experts (8 neurotology and 8 neurosurgery) and included delegates representing the AAOHNSF, AANS/CNS tumor section, ISRS, and NASBS. The modified Delphi method encompassed a four-step process, comprised of one prevoting round to establish a list of focus areas and three subsequent voting rounds to successively refine individual statements and establish levels of consensus. Thresholds for achieving moderate consensus, at ≥67% agreement, and strong consensus, at ≥80% agreement, were determined a priori. All voting was performed anonymously via the Qualtrics online survey tool and full participation from all panel members was required before procession to the next voting round., Results: Through the Delphi process, 103 items were developed encompassing hearing preservation (N = 49), tumor control and imaging surveillance (N = 20), preferred treatment (N = 24), operative considerations (N = 4), and complications (N = 6). As a result of item refinement, moderate (4%) or strong (96%) consensus was achieved in all 103 final statements. Seventy-nine conference registrants participated in the online survey to assess external validity. Among these survey respondents, moderate (N = 21, 20%) or strong (N = 73, 71%) consensus was achieved in 94 of 103 (91%) statements, and no consensus was reached in 9 (9%). Of the four items with moderate consensus by the expert panel, one had moderate consensus by the conference participants and three had no consensus., Conclusion: This modified Delphi study on sporadic vestibular schwannoma codifies 100% consensus within a multidisciplinary expert panel and is further supported by 91% consensus among an external group of clinicians who regularly provide care for patients with vestibular schwannoma. These final 103 statements address clinically pragmatic items that have direct application to everyday patient care. This document is not intended to define standard of care or drive insurance reimbursement, but rather to provide a general framework to approach vestibular schwannoma care for providers and patients.