Björn Herman

Endoscopic embolization with onyx prior to resection of JNA: a new approach.

OBJECTIVE To report a novel pioneering approach of endoscopic embolization (EE) and resection of juvenile nasopharyngeal angiofibroma (JNA) and describe all outcomes and results. METHODS Four patients presented to the University of Miami with repeated episodes of unilateral epistaxis diagnosed by fiberoptic and radiographic examination as nasal JNA. Subsequently, in conjunction with neurosurgery, endoscopic visualization was provided to perform intratumor needle insertion, through which the liquid embolic agent Onyx was infused to embolize the JNAs under fluoroscopic and endoscopic guidance. The day after EE, endoscopic resection was performed. Operating room time, estimated blood loss (EBL), and other intraoperative and post-operative results are reported and compared to published literature. RESULTS A total of 4 patients (all males), had EE of JNA and subsequent endoscopic resection between September 2008 and January 2009. Average EBL during surgery was 412.5 ml (range 150-800) with an average operating room time of 228 min (range 95-485). We experienced no bleeding from the tumor or its attachments, only from the approach. Two patients experienced mild numbness in the V2 distribution, which began to resolve one week post-operatively. No other complications were encountered. CONCLUSIONS This is the first published report of direct endoscopic embolization of JNA with Onyx. Although further studies are needed, it seems to provide a safe, less invasive alternative to traditional embolization and endoscopic resection, but must be done in cooperation with interventional neurosurgery to maximize its safety profile.

Differences in cochlear nerve cross-sectional area between normal hearing and postlingually deafened patients on MRI

Objectives. To demonstrate that parasagittal constructive interference in steady state (CISS) magnetic resonance imaging (MRI) can be used to accurately measure cochlear nerve cross-sectional area and thereby evaluate for statistically significant differences in the cochlear nerve cross-sectional areas of postlingually deafened and normal-hearing adults. Study Design. Cross-sectional study. Setting. Tertiary care medical center. Subjects and Methods. Parasagittal CISS MRIs of postlingually profoundly deafened cochlear implant candidates and normal-hearing patients at a tertiary care academic medical center between 2006 and 2009 were retrospectively identified. Two independent and blinded investigators measured the cochlear nerve height and width and calculated the cross-sectional area [π(H/2)(W/2)] at the fundus of the internal auditory canals. Measurements of both investigators were analyzed for reliability and agreement with an Altman plot, and deafened patient measurements were compared with results of the normal-hearing patients via Wilcoxon rank sum tests. Results. The cochlear nerve cross-sectional area of postlingually deafened patients (mean ± SD = 0.61 ± 0.16 mm2) was less than normal-hearing patients (0.94 ± 0.28 mm2). The difference was statistically significant (P = .002). There was good agreement between independent observer measurements. Conclusion. Parasagittal CISS MRI can be used to measure the cochlear nerve with good interobserver agreement, and there is a significant difference between the cross-sectional area of postlingually deafened and normal-hearing adults. The cross-sectional area may correlate with residual spiral ganglion cells and provide a prognostic indicator for post–cochlear implant performance, which is the focus of our ongoing research.

Ethnic disparity in skin complications following bone-anchored hearing aid implantation.

Objectives Sound processor loading after implantation of a bone-anchored hearing aid is often delayed by skin-site complications. This study examined the frequency of skin-site complications in various ethnic groups and determined factors that may lead to higher rates of skin-site complications resulting in delayed processor loading. Methods Adult, English-speaking patients who underwent implantation of a bone-anchored hearing aid between 2007 and 2010 were reviewed. Demographic data including ethnicity, tobacco use, diabetes mellitus, immunosuppression, and long-term steroid use were determined. Major and minor skin-site complications and the time to processor loading were recorded. Results The mean time to processor loading was 9.5 weeks, and the mean follow-up time was 23 months. There were no cases of osseointegration failure. African American patients had a significantly higher rate of major skin-site complications (p < 0.005) and a longer time to processor loading (mean, 17.6 weeks; p < 0.05) than the other ethnic groups. There was no significant difference in minor skin complication rates. There was no correlation between diabetes mellitus, long-term immunosuppression, or tobacco use and skin-site complications. Conclusions Skin complications can delay processor loading following implantation of a bone-anchored hearing aid. There is a higher rate of major skin-site complications in African American patients, and these often delay processor loading. The risk of skin-site complications is not correlated with smoking, diabetes mellitus, or immunosuppression. An increased risk of skin-site complications is an important consideration for preoperative counseling.

Early Loading After Single-Stage Bone-Anchored Implantation in Adults

Objective. Classically, processor loading after single-stage bone-anchored implantation (BAI) surgery follows a 3-month osseointegration period. The purpose of this study was to examine audiometric outcomes and postoperative complications in adult patients undergoing single-stage BAI with processor loading at less than 6 weeks postoperatively. Study Design. Retrospective review. Setting. Otology clinic in a tertiary care academic center. Subjects and Methods. A retrospective review was performed of all adult patients (>18 years) undergoing BAI from 2007 to 2010. Sixty-four patients met inclusion criteria. Fifty-five patients had unilateral hearing loss, including single-sided deafness, conductive hearing loss, or mixed hearing loss. Nine patients had bilateral hearing loss. Patients were divided into groups based on time to processor loading (>12 weeks, <12 weeks, <6 weeks). All patients were loaded with the external processor at less than 6 weeks when possible. Preoperative and postoperative audiometric evaluations were performed. Results. There were no cases of osseointegration failure. All groups showed significant improvement in audiometric testing using their BAI (P < .005), and there were no significant differences between patients loaded at less than 12 weeks and those loaded at less than 6 weeks (P > .05). Major skin complications were seen in 9% of subjects and minor complications in 30%. Conclusions. Single-stage BAI implantation with early processor loading is safe and effective in adults. All groups demonstrated significant audiometric benefit that was not affected in patients loaded early. Major and minor skin-site complications frequently delayed processor loading, but there were no cases of osseointegration failure in any group.

Management Outcomes of Facial Nerve Tumors Comparative Outcomes with Observation, CyberKnife, and Surgical Management

Objectives Primary facial nerve tumors (FNTs) present in varying ways. In this study, the authors present their institutional experience with the management of facial nerve tumors, including their recommendations for available therapies such as observation, microsurgical decompression or removal, and stereotactic radiation. They emphasize the auditory and facial nerve function outcomes. Study Design Retrospective case review. Setting Tertiary referral center. Subjects and Methods Retrospective review of all cases of FNT seen at the authors’ tertiary care academic medical center over a 10-year period (2002-2011). The clinical presentation, treatment modality, and outcome parameters of cochlear and facial nerve function were assessed. Results Twelve patients were identified. House-Brackmann grades on presentation were 4 grade I, 2 grade II, 2 grade III, 1 grade IV, and 3 grade V, with 2 grade V patients declining to grade VI shortly after presentation. Seven patients presented with serviceable hearing and 4 with nonserviceable hearing. Treatment options/arms included observation with serial clinicoradiological review (2 cases), stereotactic radiation with the CyberKnife (3 cases), wide fallopian canal decompression (3 cases), microsurgical excision and repair (3 cases), and biopsy followed by observation (1 case). At the end of the review period, facial nerve function was stable in 8 patients, improved in 3, and declined in 1, and none had documented worsening of hearing based on American Academy of Otolaryngology—Head and Neck Surgery Foundation classification. Conclusions Management of FNT is largely based on the clinicoradiological picture. Each treatment arm is different, but overall auditory and facial function can be maintained.

Histopathological Differences between Polyvinyl Alcohol and Ethylene Vinyl Alcohol Copolymer in Preoperative Glomus Jugulare Embolization

Objective: 1) Histopathologically characterize glomus jugulare paragangliomas preoperatively embolized with ethylene vinyl alcohol copolymer (EVAC). 2) Describe histopathological differences between glomus jugulare paragangliomas preoperatively embolized with polyvinyl alcohol (PVA) and EVAC. Method: Case series of glomus jugulare paragangliomas preoperatively embolized with EVAC. The tumors were subsequently resected at a tertiary care center between 2003 and 2010. Patient demographic and clinical data were collected, and histopathological analysis of the preoperatively embolized tumors was performed. Results: Glomus jugulare paragangliomas embolized with EVAC demonstrated 100% or near 100% occlusion of arterial vessels by histopathological analysis, whereas in previous studies PVA demonstrated a significantly lower percentage of embolization. Even when resection was performed several months after embolization, there was no revascularization of EVAC embolized vessels, whereas PVA embolized vessels have demonstrated partial revascularization. In one patient whose tumor was not completely resected after embolization with EVAC, there was no evidence of subsequent growth of the remnant disease. Conclusion: Histopathological analysis of preoperatively embolized glomus jugulare paragangliomas indicates that EVAC provides a more thorough and longer lasting embolic profile than PVA.

Age and Time Interval Differences in Recurrent and Residual Cholesteatoma Rates for Canal Wall Up Tympanomastoidectomy

Objective: 1) Evaluate whether residual or recurrent cholesteatoma found during second-look tympanomastoidectomies correlates with age. 2) To evaluate whether there is a difference in residual or recurrent cholesteatoma found during second-look tympanomastoidectomies done before and after 9 months since the initial procedure. Method: This is a longitudinal study of second-look tympanomastoidectomies performed at a tertiary-care center between 2002 and 2010. Demographic and clinical data was collected prospectively. Statistical analyses were performed to determine whether patient age and time interval between initial and second look procedures correlated with residual or recurrent cholesteatoma. Results: Seventy-two patients qualified for the study. Residual cholesteatoma was more frequent in children (<15 years) than adults (P = .026, Fisher exact test). There was a tendency for recurrent cholesteatoma to occur more frequently in adults than in children. Recurrences tended to occur more frequently in cases with larger canal wall defects. The time interval between the primary and revision surgery did not influence the rate of residual or recurrent cholesteatoma. Conclusion: Younger patients have a higher risk of residual cholesteatoma, possibly secondary to more technically challenging anatomy and surgeon preference to maintain an intact canal wall. Time between primary and revision surgery could be abbreviated or prolonged, since this interval did not influence residual and recurrent cholesteatoma rates.

Single-Stage BAHA Implantation with Early Device Loading

bone. The dissection was videotaped and assessed using a modified version of the Wellings scale by 2 otologists blinded to the participant’s teaching group. RESULTS: The mean performance scores of participants in the simulator-based teaching group were significantly higher than those of the traditional teaching group (78% versus 49%; p-value 0.001). While the inter-rater agreements between the assessors were modest (Kappa 0.40; p-value 0.001), the assessors differed 2 point from a total of 21 point for 90% of the participants. CONCLUSION: This study indicates that self-directed learning on VR simulators can be used to improve performance on cadaver dissection in novice trainees compared traditional teaching methods alone.