Habib G. Rizk

Novel Radiographic Measurement Algorithm Demonstrating a Link between Obesity and Lateral Skull Base Attenuation

Objectives (1) To describe a validated algorithm for measuring tegmen thickness on computed tomography scans. (2) To compare the tegmen thickness in 3 groups: patients with spontaneous cerebrospinal fluid (CSF) leaks, obese controls, and nonobese controls. Study Design Retrospective review. Setting Patients with spontaneous CSF otorrhea often have highly attenuated tegmen plates. This is associated with obesity and/or idiopathic intracranial hypertension (IIH). No evidence exists, however, that objectively links obesity and/or IIH with skull base attenuation. Subjects and Methods This was a retrospective review from 2004 to the present. Patients with spontaneous CSF otorrhea and matched obese (body mass index [BMI] >30 kg/m2) and nonobese (BMI <30 kg/m2) controls were selected. Tegmen thickness was measured radiographically. Interrater validity was assessed. Results Ninety-eight patients were measured: 37 in the CSF group (BMI, 36.6 kg/m2), 30 in the obese group (BMI, 34.6 kg/m2), and 31 in the nonobese group (BMI, 24.2 kg/m2). The CSF group had a significantly thinner tegmen compared to both the obese control (P < .01) and nonobese control (P = .0004) groups. Obese controls had a thinner tegmen than nonobese controls (P < .00001). A significant inverse correlation was detected between skull base thickness and BMI. Signs/symptoms of IIH were most commonly found in the CSF group. Good to very good strength of agreement was detected for measures between raters. Conclusion This is the first study to (1) quantify lateral skull base thickness and (2) significantly correlate obesity with lateral skull base attenuation. Patients who are obese with spontaneous CSF leaks have greater attenuation of their skull base than matched obese controls. This finding supports theories that an additional process, possibly congenital, has a pathoetiological role in skull base dehiscence.

Association between Lateral Skull Base Thickness and Surgical Outcomes in Spontaneous CSF Otorrhea

Objectives (1) Correlate skull base thickness with perioperative outcomes for spontaneous cerebrospinal fluid (CSF) otorrhea. (2) Augment perioperative counseling of patients with abnormally thin skull bases. Study Design Case series with chart review. Setting Tertiary center. Patients with spontaneous CSF otorrhea have thin skull bases. This is associated with obesity and/or idiopathic intracranial hypertension. The influence of skull base thinning on perioperative outcomes is unknown. Subjects and Methods A retrospective review was conducted from 2004 to 2014. Forty-eight cases of spontaneous CSF otorrhea met the inclusion criteria of primary surgery by the senior authors: preoperative dedicated temporal bone computed tomography, absence of other leak etiologies, and follow-up >6 months. Patients were stratified into thin (<0.9 mm) and thick (>0.9 mm) groups based on computed tomography measures of their tegmen. Primary outcomes measures were as follows: postoperative meningitis, recurrent leak, second site leak (contralateral ear/anterior fossa), and permanent shunt placement. Hearing outcomes were not assessed in this study. Results Thirty and 15 patients composed the thin and thick groups, respectively. Both the incidence (P < .0001) and the rate (P = .005) of adverse outcomes were significantly higher in the thin group. Only 2 patients in the thick group experienced an adverse outcome. Eleven patients underwent multiple procedures for spontaneous leaks. The recurrence rate was 14.5%. All but 1 recurrence occurred in the thin group. Conclusions An abnormally thin tegmen was significantly associated with adverse perioperative outcomes in cases of spontaneous CSF otorrhea. A thick skull base and the presence of an encephalocele may be protective against recurrence. The effect of untreated intracranial hypertension on the results is unknown.

The Relation between Obesity and Hospital Length of Stay after Elective Lateral Skull Base Surgery: An Analysis of the American College of Surgeons National Surgical Quality Improvement Program

Purpose: Length of stay is a marker of quality and efficiency of health care delivery. The objective of this study was to identify preoperative, intraoperative, and postoperative variables that impact length of stay after lateral skull base surgery. Methods/Procedures: The American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) databases from 2009-2012 were analyzed, and patients undergoing elective lateral skull base surgery for benign lesions of cranial nerves were identified. The primary outcome measure of interest was length of hospital stay. Protracted length of stay was defined as ≥75th percentile of length of stay for all patients. The impact of demographic factors, intraoperative variables, and postoperative complications on length of stay was assessed. Results: In total, 252 patients were included. Almost half of the patients (41.2%) were classified as obese (body mass index ≥30). Patients who were obese had significantly longer lengths of stay (5.6 ± 3.9 days) when compared to patients who were not obese (4.6 ± 3.4 days, p = 0.006). Multivariate regression analysis demonstrated that operative time, reoperation within 30 days of initial surgery, and obesity were independent predictors for protracted length of stay. Conclusion: National multi-institutional data from the ACS-NSQIP suggest that operative time, reoperation, and obesity are predictors of longer hospital stays after lateral skull base approaches for benign cranial nerve neoplasms.

Lateral Skull Base Attenuation in Superior Semicircular Canal Dehiscence and Spontaneous Cerebrospinal Fluid Otorrhea

Objectives (1) To quantitatively assess the lateral skull base thickness in patients with superior semicircular canal dehiscense (SSCD) using a standardized and validated radiographic measure and to compare it with that of a population with spontaneous cerebrospinal fluid otorrhea (CSFO). (2) To analyze demographic and clinical factors associated with skull base thickness in the SSCD group. Study Design Case series with chart review. Setting Tertiary neurotologic referral center. Subjects and Methods Based on computed tomography imaging of the tegmen, mean skull base thickness was calculated for 16 patients with radiographic and clinical SSCD. Similar measures were performed in 4 comparison groups consisting of adults with spontaneous CSFO (n = 33), as well as 3 control groups recruited from our adult cochlear implant database: 30 obese controls (body mass index [BMI] >30 kg/m2), 11 overweight controls (BMI, 25-30 kg/m2), and 20 normal weight controls (BMI <25 kg/m2). Results The SSCD group had a significantly lower mean BMI (28.6 kg/m2) than the spontaneous CSFO group (37.7 kg/m2; P = .0007). The mean skull base thickness of SSCD patients was 17% thinner than that of the CSFO group, 31% thinner vs obese controls, 49% thinner vs overweight controls, and 45% thinner vs normal weight controls. These differences were all statistically significant (P < .05). Conclusion Patients with SSCD have a marked thinning of the lateral skull base, more so than patients with spontaneous CSF otorrhea and control groups with different BMIs. Skull base attenuation in SSCD patients did not correlate with BMI.

Retrofacial approach to access the round window for cochlear implantation of malformed ears.

Objective To report the use of the retrofacial approach for cochlear implantation in three cases of malformed ears with inaccessible round windows through the standard facial recess. Patients Two children with bilateral profound sensorineural hearing loss who were cochlear implant candidates. One patient had bilateral sequential cochlear implantations and the other a unilateral implant. Intervention(s) Retrofacial approach to access the posterior mesotympanum and visualize the round window. Main Outcome Measure(s) Ability to complete the surgery with full insertion of the implant and no complications such as facial nerve injury. Results We implanted three ears in two patients with multiple external and middle ear malformations with an aberrant facial nerve or a posteriorly displaced round window niche. The standard facial recess approach did not allow visualization of the round window. We resorted to a retrofacial approach to access the posterior mesotympanum and proceeded with the surgery through an anterior and inferior cochleostomy or through the round window. Conclusion In cases with an aberrant facial nerve or inaccessible round window through the facial recess, the retrofacial approach is a good alternative but requires a certain level of expertise and familiarity with temporal bone anatomy. The decision to use an unconventional approach should be considered before surgery, but the ultimate decision may require intraoperative assessment.

Idiopathic intracranial hypertension: Contemporary review and implications for the otolaryngologist

1) Review controversies pertaining to the pathophysiology, diagnosis, and treatment of idiopathic intracranial hypertension. 2) Discuss the evolving role of otolaryngologists in managing this disease and related disorders.

Neuroglial heterotopia of the internal auditory canal.

Heterotopic central nervous tissue has also been observed in 2 locations within the temporal bone: (1) in the middle ear cavity, and (2) in the subarachnoid space of the internal auditory canal (IAC). In addition, heterotopic neuroglial tissue has been identified in other areas of the subarachnoid compartment, more frequently in association with CNS malformations (1). The following is a case report of a young woman who had hearing loss in the context of a rest of neuroglial heterotopia.

Cervical internal carotid artery pseudoaneurysm complicating malignant otitis externa: first case report.

Pseudoaneurysm of the internal carotid artery (ICA) is a rare complication of head and neck infections. To date, three cases of petrous ICA pseudoaneurysm have been described as a complication of otogenic infection, including only one secondary to malignant otitis externa. We present here the first case of cervical ICA pseudoaneurysm as a complication of malignant otitis externa, and stress the importance of timely diagnosis to avoid fatal outcomes. Laryngoscope, 125:733–735, 2015

Quality Improvement in Neurology: Neurotology Quality Measurement Set:

Quality Improvement in Neurology: Neurotology Quality Measurement Set Otolaryngology– Head and Neck Surgery 2018, Vol. 159(4) 603–607 American Academy of Otolaryngology–Head and Neck Surgery Foundation and American Academy of Neurology Institute 2018 Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0194599818790947 http://otojournal.org Habib Rizk, MD, MSc, Yuri Agrawal, MD, MPH, Susan Barthel, Marc L. Bennett, MD, MMHC, Joni K. Doherty, MD, PhD, Patricia Gerend, Daniel R. Gold, DO, David Morrill, John G. Oas, MD, J. Kirk Roberts, MD, Erika Woodson, MD, David A. Zapala, PhD, Amy Bennett, JD, and Anant M. Shenoy, MD

Publishing Trends in Otology and Neurotology

OBJECTIVES 1) Describe publishing trends for otologic/neurotologic disorders over a 35-year span. 2) Compare trends in publishing with disease prevalence. 3) Evaluate changes in topic and journal specific ranking scores over time. METHODS PubMed searches were performed on 35 otologic/neurotologic disorders using medical subject headings (MeSH) terms from 1980 to 2015. Searches were limited in scope to the English language. A Mann-Kendall trend analysis evaluated changes in publication frequency as a discrete variable while correcting for total number of articles published per year. Scopus was used to identify SCImago Country and Journal Rank (SJR) indicator scores and weighted-averages used to calculate changes over time. RESULTS The total number of publications on the 35 topics increased from 853 in 1980 to a peak of 3,068 in 2013. Otitis media (τ = -0.799, p < 0.001) and Menières disease (τ = -0.724, p < 0.001) showed strong decreasing publication trends. Temporal bone encephaloceles (τ = 0.743, p < 0.001) and cochlear implants (τ = 0.740, p < 0.001) showed strong increasing publication trends. Rapid rise in publications on superior canal dehiscence and vestibular migraine illustrate novel diagnoses. The weighted-average SJR score increased from 0.816 in 2000 to 1.160 in 2015 (p < 0.001). CONCLUSION This study displays trends in the literature over the past 35 years that are often inconsistent with common disorders seen by otologists/neurotologists. Certain diagnoses that are currently being researched less commonly continue to impact patients with the same regularity. Quality of otologic/neurotologic literature has become more reputable with regards to SJR scores.