David M. Kaylie

A Meta-analysis Comparing Outcomes of Microsurgery and Gamma Knife Radiosurgery†

Objectives/Hypothesis Surgery has been the most common treatment for acoustic neuromas, but gamma knife radiosurgery has emerged as a safe and efficacious alternative to microsurgery. This meta‐analysis compares the outcomes of the two modalities.

Acoustic neuroma surgery outcomes.

Objective The outcomes of surgery for acoustic neuromas have improved dramatically since the development of modern surgical techniques, the operating microscope, magnetic resonance imaging (MRI), and cranial nerve monitoring. The goals of acoustic neuroma surgery are now preservation of facial nerve function and, when feasible, hearing preservation. Many large series do not report standardized hearing and facial function grading, and they include patients who did not benefit from the most modern techniques. The purpose of this study was to present the results of acoustic neuroma surgery using the most modern techniques and equipment, using standardized grading systems. Study Design Retrospective review. Setting Tertiary referral center. Patients 97 patients who underwent surgical removal of acoustic neuromas from 1992 to 1998. Intervention All patients underwent acoustic neuroma surgery and had preoperative audiograms and MRI with contrast. In addition, all patients had preoperative and postoperative facial function graded by the House-Brackmann scale and intraoperative facial nerve monitoring. Hearing preservation was attempted in patients with tumors of any size who had preoperative function of grade A or B according to the Committee on Hearing and Equilibrium guidelines for reporting results of acoustic neuroma surgery. Main Outcome Measures Hearing preservation was considered successful if the patient retained serviceable hearing grade A or B. House-Brackmann grade 1 or 2 was considered excellent facial function. Complications were recorded. Results Facial nerve integrity was preserved in 96 of 97 patients (99%). Eight of 8 (100%) patients with intracanalicular tumors had excellent facial nerve function (HB 1–2). Fifty-two of 55 (95%) of patients with small tumors had excellent facial nerve function, and 15 of 24 (63%) with medium tumors had HB grade 1–2. Hearing was preserved in 29% of patients with tumors under 2 cm. The overall complication rate was 20%; cerebrospinal fluid leak was the most common. Conclusion These results show that with modern imaging and surgical techniques, acoustic neuroma surgery is extremely safe and outcomes are very good. Surgery remains the treatment of choice for most tumors until alternative therapies, such as gamma knife, use uniform grading scales and show long-term facial and hearing results.

Revision Chronic Ear Surgery

OBJECTIVE: To report results of revision chronic ear surgery following guidelines of the American Academy of Otolaryngology–Head and Neck Surgery and to establish expectations for infection and cholesteatoma control and hearing outcomes. STUDY DESIGN: Retrospective case review of all patients who underwent revision chronic ear surgery from January 1, 1990 to December 31, 2000. Revision chronic ear surgery included canal wall up and canal wall down procedures with ossicular chain reconstruction performed as needed. Cholesteatoma control, hearing improvement, and closure of middle ear space are main outcome measures. SETTING: Tertiary referral center. RESULTS: Cholesteatoma recurrence rate was 57% at 1 year after surgery and 14% in patients with a minimum of a 5-year follow-up. Disease control was achieved in 96% of patients. Hearing was significantly improved in all surgical groups. Closure of the air-bone gap for revision partial ossicular replacement prosthesis cases (PORP) to less than 20 dB occurred in 50% of patients. Closure of the air-bone gap to within 30 dB for revision total ossicular replacement prosthesis (TORP) occurred in 60% of patients. Canal wall down status had a significant impact on hearing results after PORPs and TORPs; patients with intact canal walls had significantly better hearing results. Diagnosis of cholesteatoma significantly impacted hearing results for TORPs but not PORPS. CONCLUSIONS: Cholesteatoma control rates after revision surgery are similar to primary cases. Significant improvement in hearing can be expected after revision chronic ear surgery. Hearing results after a revision surgery that requires a PORP is worse than primary cases and is canal wall status dependant. Closure of the middle ear space and creation of a safe dry ear can be expected after revision chronic ear surgery. SIGNIFICANCE: This is a review of a large series of exclusively revision chronic ear surgery. EBM rating: C-4

Management of brain herniation and cerebrospinal fluid leak in revision chronic ear surgery.

Objectives/Hypothesis: Brain herniation and cerebrospinal fluid (CSF) leakage into the middle ear and mastoid are rare but described complications of chronic ear disease. This paper will discuss the presentation and management of brain herniation and/or CSF leak encountered in revision chronic ear surgery.

Hearing preservation with the transcrusal approach to the petroclival region.

Objective: We studied the hearing results and outcomes after transcrusal craniotomy. Study Design: We conducted a retrospective review. Setting: This study was conducted at a tertiary care hospital. Patients: We studied 10 consecutive patients, including two men and eight women, who underwent transcrusal craniotomy for petroclival masses or tumors. Intervention: The intervention consisted of therapeutic removal of petroclival meningioma. Main Outcome Measure: The main outcome measure of this study was hearing preservation as measured by standard audiogram. Results: There were six meningiomas, one eighth nerve schwannoma, one fifth nerve schwannoma, one chordoma, and one midbasilar artery aneurysm. Postoperative hearing was measured according to the AAOHNS criteria. Complications and further therapies were recorded. Postoperative hearing was measured in eight. The cochlear nerve was severed in one patient. One was unavailable for follow up. Eight patients retained hearing at or near preoperative levels, seven with SRT within 10 dB and speech discrimination within 10% of preoperative levels. Four patients presented with trigeminal symptoms, one with third nerve palsy and two with facial weakness. Postoperative deficits included fourth, sixth, seventh, and eighth nerve palsies in three patients. Complications included one wound infection, two cerebrospinal fluid leak, and two cases of meningitis, both of which were sterile. There were secondary procedures in five patients—three radiosurgery, two shunts, one tracheotomy, and one g-tube. Conclusions: Transcrusal craniotomy is a safe and effective approach to the petroclival region. Excellent hearing results can be expected with this technique.

Bone-anchored hearing aid abutment skin overgrowth reduction with clobetasol

Objectives The bone-anchored hearing aid (BAHA) osseointegrated cochlear stimulator can treat hearing loss in a variety of clinical situations. Occasionally skin/scar overgrowth may cover the abutment. This overgrowth interferes with affixing the BAHA to the abutment. Surgical scar revision/excision has been used to treat this problem. Clobetasol (0.05%), a steroid gel, can reduce skin overgrowth. Experience with skin overgrowth and the efficacy of clobetasol to treat this problem was reviewed. Subjects and Methods The authors conducted a retrospective analysis of patients who underwent BAHA abutment implantation from January 2003 through December 2006. Results Eighty-eight patients (2 patients received bilateral BAHAs) were reviewed. Twenty (22%) of 90 sites developed overgrowth. Thirteen of 20 sites were treated with clobetasol. The overgrowth resolved in 11 (85%) of 13 sites after treatment. Patients with incomplete skin graft survival were significantly more likely to develop skin overgrowth (P = 0.0017). Conclusion Clobetasol is an effective treatment for abutment skin/scar overgrowth. Clobetasol allows patients to resume BAHA use and obviates the need for scar revision.

CURRENT TREATMENT PRACTICES FOR EARLY LARYNGEAL CARCINOMA

OBJECTIVE : Controversy regarding the management of early laryngeal carcinoma persists in the absence of a definitive comparison of treatment modalities. This study examines the basic management practices for early laryngeal cancer among the American Academy of Otolaryngology–Head and Neck Surgery membership with an emphasis on the role of conservation surgery. METHODS : Questionnaires were randomly distributed to 3000 members with 1000 responses. The results were collated and statistically evaluated with multivariable frequency analysis. RESULTS : For operable supraglottic tumors, supraglottic laryngectomy was advocated by 41.6% of those responding. Definitive radiation therapy was suggested by 5.3% of participants and total laryngectomy by 1.4%. Explanation of treatment options with the patient deciding the therapy was selected by 48.3% of responders. For suitable glottic tumors, hemilaryngectomy was recommended by 37.1%, definitive radiation therapy by 8.1%, total laryngectomy by 1.9%, and patient choice by 50.4% of members completing the survey. When patients were left to weigh the treatment options, surgery was much less likely to be chosen than if it was advocated by the physician. Trends were evident according to practice region and setting, but these variables did not correlate strongly with physician recommendations. However, date of residency completion and rating of available radiation oncology services were significant factors. The evaluation of postoperative considerations in laryngeal conservation surgery demonstrated large variability in the definition of a close margin and the perceived need for additional therapy. CONCLUSIONS : The varied practice patterns among the American Academy of Otolaryngology–Head and Neck Surgery membership reflect the lack of a comparative outcome analysis for the treatment of early laryngeal carcinoma. Consequently, the full reliance on patient choice, which is more pronounced among young physicians, and cost considerations may have the greatest impact on the future treatment of this disease.

Neurotologic Management of Intracranial Epidermoid Tumors

Objectives: Epidermoid cysts are the most common intracranial embryonal tumor, although they account for only 1% of all intracranial tumors. Epidermoids often spread into several intracranial compartments. Thorough preoperative surgical planning is imperative for safe epidermoid removal. This paper discusses the neurotologic management of intracranial epidermoid cysts

Chemical meningitis following cerebellopontine angle tumor surgery

OBJECTIVE: Postoperative chemical meningitis mimics bacterial meningitis, complicating the diagnosis until results of cerebrospinal fluid (CSF) cultures can be obtained. We analyzed clinical and laboratory data from a series of 1146 patients to identify findings that could exclude bacterial meningitis. SUBJECTS AND METHODS: We reviewed the charts of patients who developed meningitis after cerebellopontine angle surgery. Lumbar puncture data from asymptomatic postoperative patients were our control. STUDY DESIGN: Clinical symptoms, CSF profiles, and serum white blood cell (WBC) counts were compared between patients with chemical meningitis, bacterial meningitis, and asymptomatic patients. RESULTS: The incidence of meningitis in our series of 1146 patients was 4.54 percent; 0.87 percent was culture-proven bacterial meningitis. The patients with bacterial meningitis had significantly higher CSF and serum WBC counts, and lower CSF glucose. The major difference between asymptomatic patients and those with chemical meningitis was the significantly lower ratio of CSF WBCs to red blood cells (RBCs) in asymptomatic patients. CONCLUSION: Patients with mild CSF leukocytosis and normal CSF glucose without high serum WBC counts or focal neurological deficits may be treated for chemical meningitis.

Otologic surgery following ear trauma

Objectives To investigate common presentations and expected outcomes in patients with traumatically induced otologic dysfunction. Study Design Retrospective case review of patients who underwent otologic surgery for sequelae of otologic trauma over a 28-year period. Patients were stratified into major and minor trauma cohorts. Major trauma was designated as closed head injury with or without temporal bone fracture; lower-energy insults comprised the minor trauma group. Preoperative and postoperative audiograms were obtained and correlated with extent of injury. Setting Tertiary referral center. Results Major trauma accounted for 44.9 percent of all patients. The remaining 55.1 percent suffered minor trauma, of which simple traumatic tympanic membrane perforation was the most common insult (33.6%). Two hundred twenty-seven cases were performed on 214 patients. Pure tone averages improved a significant 20.8 dB to essentially normal levels postoperatively. Conclusion Regardless of injury extent, surgical rehabilitation of conductive losses attains excellent hearing results that surpass those historically reported for the chronic ear population.