Daniel E. Killeen

Surgical and Audiologic Outcomes in Endoscopic Stapes Surgery across 4 Institutions

Objectives To investigate intra- and postoperative outcomes of endoscopic stapes surgery. Study Design Case series with chart review. Setting Four tertiary care otologic centers. Subjects and Methods Sixty-five subjects 18 years and older who underwent endoscopic stapes surgeries were analyzed. Variables analyzed included surgical techniques and intraoperative findings. Outcomes measured included postoperative hearing and complications to date. Results Fifty-one patients met inclusion and exclusion criteria. The average patient age was 48.1 years (range, 26-87 years), with 60.0% female patients. Patients had a median follow-up of 5.13 months (range, 0.8-57.4 months). Of the subjects, 71.7% required scutum removal. The chorda tympani nerve was manipulated in 94.0% of subjects and transected in 12.0%. At last follow-up visit, the median air-bone gap decreased from 34.5 dB hearing level (HL) preoperatively to 9.0 dB HL postoperatively (P < .0001). Ninety percent of subjects had closure of their air-bone gap ≤20 dB HL. Intraoperative complications included tympanic membrane tears in 8.0% of subjects, all of which resolved at first follow-up. Postoperatively, 10.0% of subjects complained of altered taste. Conclusions The present multicentered study of endoscopic stapes surgery demonstrates similar audiometric and postoperative outcomes previously published in the literature, with a median postoperative air-bone gap of 9.0 dB HL. Future prospective endoscopic stapes surgery studies, addressing the need for scutum removal, postoperative taste changes, and pain scores, are merited.

Endoscopic Management of Middle Ear Paragangliomas: A Case Series.

OBJECTIVE To investigate the efficacy and safety of endoscopic middle ear paraganglioma (glomus tympanicum) resection. STUDY DESIGN Case series with chart review. SETTING Multi-institutional tertiary university medical centers. PATIENTS Adult patients with middle ear paragangliomas treated via a transcanal endoscopic approach from 1/2012 to 11/2015. INTERVENTION All tumors were initially approached via a transcanal endoscopic technique. An operating microscope was used only if the tumor could not be adequately visualized or resected with endoscopic techniques alone. MAIN OUTCOME MEASURES The main outcome was completeness of tumor resection via the endoscopic technique. Secondary measures were resolution of pulsatile tinnitus, audiometric outcomes, surgical duration, and surgical complications. RESULTS Endoscopic resection was attempted on 14 middle ear paragangliomas. Thirteen patients (93%) were women with a mean age of 61.6 years. The mean tumor size was 6.2 mm (SD, 3.3). Eleven cases (79%) had complete resection via an exclusive endoscopic approach. The mean surgical duration was 108.1 minutes (SD, 55.6). One case required use of an operating microscope via a transcanal route and two cases required postauricular incisions with mastoidectomy. There were no significant postoperative complications. Two patients (14%) had tympanic membrane perforations repaired intraoperatively without residual perforation on follow-up. All patients had normal postoperative facial nerve function. Pulsatile tinnitus resolved after surgery in all 13 patients who presented with this symptom preoperatively. The mean pure-tone average improved by 5.9 dB (SD, 4.6) after surgery. CONCLUSIONS Endoscopic management of middle ear paraganglioma is safe, feasible, and effective.

Intracranial complications of acute sinusitis in children: The role of endoscopic sinus surgery

OBJECTIVE To study the role of endoscopic sinus surgery (ESS) in the management of intracranial complications of children with acute rhinosinusitis METHODS: Retrospective chart review at a tertiary care pediatric hospital MAIN OUTCOMES: Demographics, intracranial complications, length of hospital stay (LOS), neurological sequelae, ESS, neurosurgical procedures RESULTS: Twenty-four children with a mean age (SD) of 12.9 years (+/-3.2) with an intracranial complication(s) of acute rhinosinusitis were identified between 2005-2016. A total of 22 were included and 15 (68%) of these were males. The most common complications were: subdural abscess (n=10), epidural abscess (n=10), meningitis (n=5), intraparenchymal abscess (n=5), and cavernous sinus thrombosis (n= 2). Neurologic symptoms included headache (n=12), hemiparesis (n=5) and aphasia (n=3). Average length of stay was 16 (+/- 9.2) days. Average follow up was 7 (+/-5.6) months. One patient had residual seizures and 1 had recurrent rhinosinusitis. Aphasia and hemiparesis resolved in all patients within 1 year. Nineteen (86%) patients had ESS within 4 days of admission. Fourteen patients (63%) had a neurosurgical procedure, 6 (27%) required more than 1 neurosurgical procedure. Six patients (27%) had concurrent neurosurgical drainage and ESS. Four patients (17%) had neurosurgical procedure followed by ESS and 3 patients (13%) were treated only by a neurosurgical procedure. Patients who underwent ESS prior to a neurosurgical procedure had significantly less risk of needing a neurosurgical intervention (OR = .02, p < .01). There was a significantly higher proportion of neurosurgical patients with positive Strep anginosus cultures compared to the ESS only group (85.7% vs 37.5%, p = .02). Studies with larger patient populations are needed to determine the role of ESS in the management of intracranial complications of children with acute rhinosinusitis. DISCUSSION Early ESS may be associated with less need for neurosurgical procedures.

Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction

OBJECTIVE To evaluate the audiometric outcomes following endoscopic ossicular chain reconstruction (OCR). STUDY DESIGN Retrospective case series. SETTING Two tertiary referral centers. PATIENTS Sixty two ears with ossicular discontinuity. INTERVENTION(S) Endoscopic and microscopic OCR in patients with ossicular discontinuity. MAIN OUTCOME MEASURES Bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS). RESULTS Sixty two ears were included for analysis. Patients that underwent ossiculoplasty were subdivided based on prosthesis type (total ossicular replacement prosthesis [TORP] and partial ossicular replacement prosthesis [PORP], primary and staged ossiculoplasties, and surgical approach [microscopic and total endoscopic]). Forty two ears required PORP reconstructions, while 20 ears required TORP reconstructions. The microscope was used to reconstruct the ossicular chain in 31 cases, while an exclusive endoscopic approach was used in the remaining 31 patients. Controlling for the prosthesis, there were no significant postoperative differences in bone PTA, air PTA, and ABG between primary and staged ossiculoplasties, or surgical approach. CONCLUSIONS Controlling for the type of prosthesis, there were no significant differences in hearing outcomes with respect to staged ossicular chain reconstruction or whether the endoscope or microscope was used for visualization. Thus, in this series, endoscopic OCR yields similar audiometric outcomes when compared with microscopic OCR.

Posterior Fossa Spontaneous Cerebrospinal Fluid Leaks.

OBJECTIVE Describe the diagnosis and management of spontaneous lateral skull base cerebrospinal fluid (CSF) leaks that originate from the posterior fossa. STUDY DESIGN Retrospective case review. SETTING Tertiary university hospital. PATIENTS Adult patients from 2005 to 2015 who underwent surgical repair of a spontaneous lateral skull base CSF leak with intraoperative confirmation of a posterior fossa leak source. INTERVENTION Surgical repair. MAIN OUTCOME MEASURES CSF leak resolution. RESULTS Five patients had CSF leaks from the posterior fossa. The mean age at presentation was 54 years old (range, 19-79), the mean body mass index (BMI) was 32.6 (standard deviation [SD], 8.4), and the mean follow-up length was 34.6 months (SD, 19.4). Presentations did not differ from CSF leaks through middle fossa defects, including three patients with a history of meningitis and all patients with clear otorrhea following tympanostomy tube placement. All patients had resolution of the leak after surgical repair, but two patients required revision surgery for persistent leaks and one patient had a postoperative infection. Surgical approaches included one middle fossa, two transmastoid, one combined middle fossa/transmastoid, and one transcanal. Radiographic studies suggested a posterior fossa source in all cases but findings were often subtle. CONCLUSION Posterior fossa CSF leaks represent a rare subset of spontaneous lateral skull base leaks. Diligent radiographic review and intraoperative assessment of the posterior fossa plate are crucial. The size and location of the defect dictates the optimal surgical approach. Surgeons should consider a posterior fossa source in failed repairs or when the initial surgery did not fully evaluate the posterior fossa plate.

The Modified Rambo Transcanal Approach for Cochlear Implantation in CHARGE Syndrome

OBJECTIVE CHARGE syndrome is associated with a variety of temporal bone anomalies and deafness. The lack of surgical landmarks and facial nerve irregularities make cochlear implantation in this population a challenging endeavor. This study aims to describe a safe and efficacious transcanal approach for cochlear implantation that obviates the need to perform a mastoidectomy and facial recess. PATIENTS Three children with profound hearing loss secondary to CHARGE syndrome. INTERVENTION Transcanal cochlear implantation with closure of the ear canal via a modified Rambo meatoplasty. MAIN OUTCOME MEASURE(S) Retrospective chart review of temporal bone anomalies associated with CHARGE syndrome, technical nuances of this transcanal approach, and cochlear implant outcomes. RESULTS The mean patient age was 2.5 years (range 1.5-3.8 yr). Two were male and two were left ears. All patients had a hypoplastic mastoid, semicircular canal aplasia, and had some degree of cochlear dysplasia. A full cochlear implant insertion was achieved in all cases, even in the presence of grossly abnormal middle ear and facial nerve anatomy. There were no intraoperative or postoperative complications. The mean follow-up was 12.4 months (range, 3.9-25.2 mo). All three patients use their device daily. Their guardians report improved vocalization and environmental awareness. CONCLUSIONS The modified Rambo transcanal approach provides a safe corridor for cochlear implantation in patients with CHARGE syndrome. This approach minimizes the anatomical variations associated with the syndrome and may reduce the risk of electrode extrusion. Implant outcomes in this patient population remain highly variable based on the patients global cognitive capacity.

Effect of Piecemeal vs En Bloc Approaches to the Lateral Temporal Bone on Survival Outcomes

Objectives Lateral temporal bone resection (LTBR) has traditionally been performed en bloc in accordance with oncologic principles. Occasionally, this is not possible due to a low tegmen or lateralized vasculature. We sought to determine if outcomes of piecemeal and en bloc LTBR are comparable. Study Design Retrospective review. Setting Two academic medical centers. Subjects and Methods Multi-institutional retrospective cohort study. Current Procedural Terminology codes were used to identify patients with T1 to T3 squamous cell carcinoma of the external auditory canal (EAC) who underwent LTBR from 2005 to 2015. Kaplan-Meier curves were constructed to compare total survival between the 2 treatment approaches. Pairwise comparisons were performed using χ2 and Fisher exact tests (significance at P = .05), as appropriate. Results Twenty-five patients were identified. Ten patients underwent en bloc LTBR; 15 underwent piecemeal LTBR. Median follow-up time was 11 months (range, 1-60 months). There was not a significant difference in overall survival between en bloc (38.9 months; 95% confidence interval [CI], 22.7-55.2) compared to piecemeal (37.5 months; 95% CI, 21.1-53.9) procedures (P = .519). Estimates of disease-free survival also did not reveal statistically significant differences: estimated mean disease-free survival was 48.1 months (95% CI, 33.7-62.6) in en bloc patients and 32.5 months (95% CI, 17.1-47.8) in piecemeal patients (P = .246). Conclusion These data suggest that piecemeal resection can be considered for cases of squamous cell carcinoma involving the external auditory canal where anatomic constraints preclude a safe en bloc resection. Larger studies or studies with a longer follow-up time may provide improved insight into survival comparisons.

In Reply to: “Effect of Piecemeal vs En Bloc Approaches to the Lateral Temporal Bone on Survival Outcomes”

We read with great interest the article by Muelleman et al concerning piecemeal resection versus lateral temporal bone resection (LTBR) of T1-T3 squamous cell carcinoma (SCC). The authors state that piecemeal resection might be required in cases of low-lying tegmen or laterally placed vascular structures. In the >250 LTBRs performed by our group, these 2 anatomic constraints are exceedingly rare (<5%). Anatomic constraints to standard en bloc LTBR are addressed with careful surgical technique. Low-lying tegmen is handled by following the middle fossa dura medially and anteriorly until the temporomandibular joint capsule is reached. In cases where this bone is <2 mm thick, the superior bony canal is drilled away, but the remaining canal is still intact, allowing en bloc resection. The high-riding jugular bulb and the laterally placed carotid artery present their own challenges. The high-riding jugular bulb is always medial to the facial nerve, and the facial nerve is generally preserved with en bloc LTBR. Thus, staying lateral to the facial nerve and working medial to the annulus allows the surgeon to surpass the highriding jugular. The laterally placed carotid is slightly more difficult to handle and is why osteotomes are not used. Intraoperatively, the lateral carotid canal is identified in the middle ear after the hypotympanic air cells have been removed. The surgeon can then follow the carotid canal and drill between it and the annulus to complete the inferior canal cut. The authors do not adequately describe their patient population. It is unclear if all cases were primary SCC of the ear canal or if they included external ear SCC, periauricular SCC, or metastatic SCC to the parotid gland that secondarily involved the ear canal. The authors omit other confounders between the groups, such as age, bone invasion, perineural invasion, and lymph node metastases. The reason for piecemeal resection is not included. From an oncologic viewpoint, the follow-up time in this series is inadequate (median, 11 months; 40% with <4 months), given that the mean time to recurrence for SCC of the ear canal is 13 months but can be as long as 3 years. In fact, one is unable to determine if there is a simple difference in follow-up time between the groups. This article has too many deficiencies to make any conclusions regarding oncologic safety of such an approach.

Pathophysiology of sensorineural hearing loss in jugular foramen paraganglioma: Sensorineural Hearing Loss Paraganglioma

Pathologic involvement of the inferior cochlear vein is a mechanism of sensorineural hearing loss in patients with jugular foramen paraganglioma.

Traumatic Cochlear Nerve Avulsion Following Otic-Capsule Sparing Temporal Bone Fracture

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