J. Walter Kutz

Cochlear implantation in children with enlarged vestibular aqueduct

To determine audiometric outcomes and complications of cochlear implantation in patients with enlarged vestibular aqueduct (EVA).

Pediatric otogenic intracranial abscesses

Objective: To describe the presentation and management of otogenic intracranial abscesses in a tertiary care pediatric hospital. Study Design: Case series and chart review. Setting: Tertiary care pediatric hospital. Subjects and Methods: An inpatient database was queried for the following diagnostic codes from 2000 to 2008: [383.2] petrositis, [383] acute mastoiditis, [386.3] labyrinthitis, [351.0] facial paralysis (Bells palsy), [351.9] facial nerve disorder unspecified, [351.8] other facial nerve disorders, [383.01] subperiosteal abscess, [383.02] Gradenigos syndrome, [320] meningitis, [324.9] extradural or subdural abscess, [324.0] intracranial abscess, [325] thrombosis of intracranial venous sinus, and [348.2] otic hydrocephalus. Presenting signs and symptoms, microbiology, length of stay, surgical findings, and outcomes were recorded for each patient. Results: Forty patients were identified with an otogenic intracranial complication. Thirty patients had evidence of an intraparenchymal, epidural, subdural, or petrous apex suppurative complication of otitis media. Twenty-four of 30 (80%) patients had a canal wall up mastoidectomy, three (10%) patients had a craniotomy without a mastoidectomy, and three (10%) patients were managed with intravenous antibiotics with or without pressure equalization tubes. There were no mortalities in this series of patients. Conclusion: Patients with intracranial abscesses, in selected cases, can be managed with intravenous antibiotics without mastoidectomy. The use of canal wall up mastoidectomy is an acceptable alternative to radical mastoidectomy when surgical intervention is necessary.

Pediatric otogenic lateral sinus thrombosis recanalization

OBJECTIVE To describe the recovery outcomes in pediatric patients with otogenic lateral sinus and internal jugular vein thrombosis. METHODS An inpatient database from a tertiary care pediatric hospital was queried from 1999 to 2010 for the diagnosis code [325] thrombosis of intracranial venous sinus. Demographics, extent of thrombosis, surgical intervention, use of anticoagulation, and the presence of recanalization on follow-up imaging was collected. RESULTS Fifteen patients (10 male, 5 female) were identified with otogenic lateral sinus thrombosis. Eleven patients (73.3%) had evidence of thrombus in the transverse sinus, while 10 patients (66.7%) had thrombus in the internal jugular vein, and one patient (6.7%) had thrombus in the cavernous sinus. Five patients (33%) had otitic hydrocephalus. Twelve patients (80%) underwent operative manipulation of the lateral sinus including: three decompressions 20%, three needle aspirations 20%, and six venotomies with evacuation of clot or pus 40%. Twelve patients were anticoagulated with low molecular weight heparin, and three patients were not anticoagulated. Ten of fourteen patients (71.4%) who underwent follow-up magnetic resonance venography had evidence of partial (57.1%) or complete (14.3%) recanalization of the lateral sinus. All five patients with otitic hydrocephalus recovered as determined by a normal fundoscopic exam and recovery of abducens paresis. CONCLUSION Recanalization of the lateral intracranial venous sinus occurred in the majority of the patients in this series. The role of operative intervention and/or anticoagulation remains unclear.

Superior Semicircular Canal Dehiscence in Patients with Spontaneous Cerebrospinal Fluid Otorrhea

Objective To determine the prevalence of superior semicircular canal dehiscence (SCD) in patients with spontaneous cerebrospinal fluid (CSF) otorrhea. Study Design Case series with chart review. Setting Tertiary care referral center. Subjects and Methods Patients included have undergone a middle fossa craniotomy for repair of spontaneous CSF otorrhea between January 2007 and December 2011. The main outcome measure is the presence or absence of SCD observed during spontaneous CSF leak repair. Computed tomography (CT) imaging was also reviewed to determine the diagnostic accuracy of this modality. Results Thirty-three ears in 31 patients underwent surgical repair for spontaneous CSF otorrhea via a middle fossa craniotomy. The average age at the time of repair was 60.5 years, and 80.6% of patients were female. A dehiscence of the superior canal was observed in 15.2% of ears (16.1% of individuals). No significant difference in age, body mass index, or sex was noted between those patients with or without a superior canal dehiscence. For the diagnosis of SCD, coronal CT was 100% sensitive and 91.7% specific. The positive predictive value and negative predictive value of CT were 66.7% and 100%, respectively. Conclusion The prevalence of superior semicircular canal dehiscence in ears with spontaneous otorrhea is 15.2%. This prevalence is greater than the 0.5% reported in a temporal bone study of ears not selected for CSF otorrhea.

Elevated intracranial pressure in patients with spontaneous cerebrospinal fluid otorrhea

To determine the prevalence of elevated intracranial hypertension in patients with spontaneous cerebrospinal fluid otorrhea (SCSFO).

The Association of Meningitis with Postoperative Cerebrospinal Fluid Fistula

Objective To determine the risk factors for and the clinical course of postoperative meningitis following lateral skull base surgery and to determine its relationship to cerebrospinal fluid (CSF) fistula. Patients Patients undergoing lateral skull base surgery between July 1999 and February 2010 at an academic tertiary referral center. All subjects had culture-proven meningitis or suspected bacterial meningitis in the postoperative period. Medical records were compared with the lateral skull base patients who did not develop meningitis. Results Of 508 procedures, 16 patients developed meningitis (3.1%). The most common diagnosis was acoustic neuroma in 81.3%; 68.8% of patients had a CSF leak prior to onset of meningitis, and 50% received a lumbar drain. The median time from surgery to the onset of meningitis was 12 days with a range of 2 to 880 days. The relative risk of developing meningitis in the setting of postoperative CSF fistula is 10.2 (p < 0.0001). No meningitis-associated mortality was observed. Conclusions Postoperative meningitis occurred in a small number of patients undergoing lateral skull base surgery. A postoperative CSF fistula leads to an increased risk of meningitis by a factor of 10.2.

Patterns of regional metastasis in advanced stage cutaneous squamous cell carcinoma of the auricle

Objective. To determine patterns of regional metastasis in patients with advanced stage cutaneous squamous cell carcinoma of the auricle. Study Design. Case series with chart review. Setting. University-based tertiary care hospitals. Subjects and Methods. We analyzed 41 patients with stage III and IV squamous cell carcinoma of the auricle. Results. The mean age was 74.2 years (range, 20.6-91.7 years). Thirty-five patients (85.4%) were stage IV. Twenty-nine patients (70.7%) had a prior history of nonauricular, nonmelanotic skin carcinoma. Twenty-four patients (58.5%) had regional metastasis to either the cervical or parotid nodal basin. In patients with cervical metastasis, the involvement by level was 6.7% (n = 1), 80.0% (n = 12), 46.6% (n = 7), 13.3% (n = 2), and 40.0% (n = 6), respectively. Of the 6 patients with a level 5 metastasis, 3 had primaries in the preauricular region, 2 had primaries of the auricle, and 1 had a primary of the postauricular region. Occult disease was present in 2 patients (9.1%) with cervical metastasis and in 4 patients (18.2%) with periparotid lymph node metastasis. Perineural invasion was seen in 84.4% of the study population. The recurrence rate was 46.3% (n = 19). The median time to recurrence was 28.3 months. Conclusion. Patients with advanced stage auricular cutaneous squamous cell carcinoma have a high rate of regional metastasis and recurrence. When planning neck dissections for these patients, level 5 should be included in the resection. Patients demonstrating locally advanced disease without clinical or radiographic evidence of metastasis to the parotid or cervical drainage basin should undergo a parotidectomy and comprehensive neck dissection.

Radiographic diagnosis of trans-stapedial cerebrospinal fluid fistula

Objective: To report the high-resolution computed tomography and magnetic resonance imaging (MRI) findings of a bulging oval window in children with recurrent meningitis and congenital cerebrospinal fluid fistula. Study Design: Case series. Setting: Academic medical center childrens hospital. Subjects and Methods: A series of eight ears in four children with profound, bilateral sensorineural hearing loss and perilymphatic hydrops were evaluated. Two patients presented with recurrent meningitis. All children were assessed with high-resolution computed tomography, and two children also underwent MRI. Results: Seven of eight ears had a common cavity malformation. The vestibular compartment showed severe dysplasia (n = 5), moderate dysplasia (n = 1), or a single semicircular canal (n = 2). The lamina cribrosa was clearly absent in four of eight ears. Its presence was difficult to assess in ears with small internal auditory canals. A bulging oval window, present in six of eight ears, was defined as a fluid density on high-resolution computed tomography or a hyperintense mass demonstrated by T2-weighted MRI protruding from the vestibule into the middle ear cavity. When present, this herniation of a fluid-filled sac could be seen on both MRI and computed tomography. This imaging finding was surgically confirmed in two patients. Conclusion: The bulging oval window, which represents a fluid-filled sac, can be identified by both high-resolution computed tomography and MRI. Communication between the middle ear and the subarachnoid space through the inner ear is an important etiology for recurrent meningitis in children with sensorineural hearing loss.

Clinical Impact of Early CT Scans after Lateral Skull-Base Surgery

Objective To determine the frequency and clinical significance of abnormalities on postoperative computerized tomography (CT) scans performed within 24 hours after lateral skull base surgery. Study Design Case series with chart review. Setting Inpatient tertiary care hospital. Methods Adult patients undergoing lateral skull base surgery were identified using CPT code search from January 2010 to January 2013. Patient demographics, type of skull base lesion, surgical approach, length of operation, time between end of the surgery and CT scan, CT scan findings, and patients’ postsurgical neurologic status were collected. Results One hundred and seventy-two patients were identified who had a postoperative CT scan after lateral skull base surgery. Diagnoses included schwannoma (95), cerebrospinal fluid fistula (29), middle fossa encephaloceles (9), meningioma (13), superior semicircular canal dehiscence (12), and other disease processes (14). The approaches were middle fossa (64), translabyrinthine (70), suboccipital (17), infratemporal (8), and combined/other (13). Mild pneumocephalus was almost always found, along with mild extra-axial blood. Twenty-four patients had significant mass effect found on CT scan, but this was present preoperatively. Three patients had a mild subdural without neurological decline. No patient suffered any clinically significant neurological decline, although 5 patients reported finger numbness that resolved spontaneously and 2 patients had confusion in the immediate postoperative period. Conclusion Clinically significant abnormalities on immediate postoperative CT scans were rare, as were cases of neurological decline. Further prospective studies could determine a more cost-effective algorithm for routine use of postoperative imaging.

Utility of MRIs in adult cochlear implant evaluations

Objectives To determine the prevalence of MRI abnormalities in adults undergoing cochlear implantation and to correlate abnormalities to audiology data. Study Design Case series. Setting Academic medical center. Methods Adult patients (>18 yr old) undergoing cochlear implant evaluation from January 2008 to December 2012 were identified based on CPT code search. Demographics, preoperative MRI findings, operative findings, and audiometric data were collected. Results The study included 188 patients. Seventeen (9%) patients had significant otic capsule or vestibulocochlear nerve pathologies: 5 vestibular schwannomas, 4 enlarged vestibular aqueducts, 2 hypoplastic cochlear nerves, 2 labyrinthitis ossificans, 1 cochlear aplasia, 1 posterior semicircular canal malformation, 1 calcified meningioma, and 1 cholesterol granuloma. MRI results were normal (65%) or with findings not directly related to hearing loss (incidental findings, 25%) in the remaining patients. Mean pure tone average (PTA) differences (between the implanted and contralateral ear) did not significantly vary between normal-incidental and abnormal MRI scans (-6.6 dB versus -6.7 dB, p = 0.99) nor did speech discrimination scores (SDS) scores (8.5% versus 8.4%, p = 0.99). No significant difference was found in HINT scores for patients with a normal versus an abnormal MRI (19% versus 16,%, p = 0.62). Conclusion Although the majority of precochlear implantation MRIs were normal or demonstrated incidental findings, such as white matter changes, significant MRI findings affecting implantation site and patient counseling were found in almost 10% of patients. Audiogram findings did not correlate with abnormal findings on MRIs. Routine use of MRI in adult cochlear implant candidates may be warranted.