Marlon Maducdoc

Migraine features in patients with Meniere's disease

To better understand the features of migraine in Menieres disease (MD).

Evaluation of Reported Malignant Transformation of Vestibular Schwannoma: De Novo and After Stereotactic Radiosurgery or Surgery

Objective To critically analyze each reported case of malignant transformation of vestibular schwannoma (VS) after either stereotactic radiosurgery (SRS) or microsurgery (MS). Data Sources We searched the Pubmed/Medline database using the relevant key words vestibular schwannoma, acoustic neuroma, malignant, transformation, radiation, induced, stereotactic, radiosurgery, malignancy, GammaKnife, and CyberKnife and combinations thereof. Study Selection Inclusion criteria for malignant transformation of VS after SRS included histopathology of initially benign VS, subsequent histopathology confirming malignant VS, reasonable latency period between malignancy and benign diagnoses. Data Extraction A neurotologist and a skull base neurosurgeon independently assessed each case report for quality, entry, exclusion criteria, and comparability of extracted data. Data Synthesis We calculated median age, latency times, and survival times for each case report. Results Malignant transformation has been documented to occur after either SRS or MS. Eight cases were included that showed histopathologic evidence of malignant transformation after SRS and MS. Four cases of malignant transformation were included that demonstrated malignant transformation after MS only. Malignant transformation of VS can also occur de novo, and de novo malignant VSs are also encountered, which can confound a causal inference from either SRS or MS. Eighteen cases of primary malignant VS were included. Studies that were identified but not included in the review are summarized and tabulated. We found 12 studies of malignant transformation associated with NF2. Conclusion The potential mechanism leading to malignant transformation of VS seems more obvious for SRS and is less understood for MS. Given a low incidence of de novo malignant schwannoma, the possibility that these are spontaneous events in either setting cannot be ruled out. Risk of malignant transformation of VS after either SRS or MS is not zero; however, the magnitude of this risk is probably minimal based on the evidence from eight histopathologically confirmed cases.

Vestibular Schwannoma Excision in Sporadic versus Neurofibromatosis Type 2 Populations

Objective To understand the differences in characteristics of neurofibromatosis type 2 (NF2) and sporadic patients with surgically excised vestibular schwannomas in the state of California. Study Design Cross-sectional. Setting, Subjects, and Methods The records of all patients who underwent vestibular schwannoma excision between 1997 and 2011 were extracted from the California Hospital Inpatient Discharge Databases (CHIDD). NF2 cases were identified using ICD-9-CM diagnosis code 237.72, neurofibromatosis, type 2. All other cases were recoded as sporadic. Trends in total number and population-adjusted rates (per 1 million California residents) of surgery, demographics, hospital case volume, state of residency, complications, length of stay, total charges, expected source of payment, and disposition were examined. Results Vestibular schwannoma (VS) excision was performed on 7017 patients, of which 464 patients (6.6%) had NF2. The population-adjusted surgery rate declined from 11.8 to 6.2 (P < .001) for sporadic cases and from 0.3 to 0.2 (P = .01) for NF2 cases over the study period. NF2 was associated with younger age (mean, 32.9 vs 51.3), higher rate of other complications (8.8% vs 4.4%) and facial nerve complications (32.3% vs 16.8%), higher total charges (median

Postoperative Complications and Readmission Rates Following Surgery for Cerebellopontine Angle Schwannomas

70,106 vs

Estimation of Nasal Tip Support Using Computer-Aided Design and 3-Dimensional Printed Models

46,395), longer stay (median 5 vs 4), and high volume hospitals (80.4% vs 48.8%) (all P < .001). Conclusion The surgery rates for vestibular schwannoma excision for both sporadic and NF2 patients have declined, but the decline is more prominent for sporadic cases. NF2 patients tend to be younger and have a longer hospitalization and possibly higher corresponding hospital charges compared to patients with sporadic VS.

Curved adjustable fiberoptic laser for endoscopic cholesteatoma surgery

Objective: To investigate the 30-day postoperative complication, readmission, and reoperation rates following surgery for cerebellopontine angle (CPA) schwannomas. Study Design: Cross-sectional analysis. Setting: National surgical quality improvement program dataset (NSQIP) 2009 through 2013. Patients: All surgical cases with an International Classification of Diseases, 9th edition, Clinical Modification (ICD-9-CM) diagnosis code of 225.1, benign neoplasms of cranial nerves, and one of the following current procedural terminology (CPT) codes, were included: 61616, 61526, 61530, and 61520. Intervention(s): Surgical resection as indicated by the CPT codes above. Main Outcome Measure(s): Demographics, comorbidities, 30-day postoperative complications, readmission rate, and reoperation rate. Results: Overall, 404 cases were identified, of which 42.6% were men. The average age was 51 years. Comorbidities were present in 45.3%. NSQIP-tracked complications occurred in 9.7% of patients. Most common complications were wound infections including surgical-site infection and wound dehiscence (11 patients, 2.7%), sepsis (10 patients, 2.5%), blood loss (nine patients, 2.2%), and deep vein thrombosis (DVT; seven patients, 1.7%). Mortality occurred in four patients (1.0%). The complication rate was statistically higher in patients with comorbidities versus those without (10.2% versus 4.1%, p = 0.04). Patients with complications were more likely to undergo reoperation (2.5% with versus 4.1% without, p = 0.001). Unplanned readmissions occurred in 41 cases (10.1%) and reoperations occurred in 23 patients (5.7%). Conclusions: Most common NSQIP-tracked complications in excision of CPA neoplasms are infections, sepsis, blood loss, and deep vein thrombosis (DVT). Further, investigation of patients with unplanned readmission and reoperation are warranted. Neurotologists need to take an active role in the data to be gathered in the NSQIP database as it relates to vestibular schwannomas.

Transcanal Micro-Osteotome Only Technique for Excision of Exostoses.

IMPORTANCE Palpation of the nasal tip is an essential component of the preoperative rhinoplasty examination. Measuring tip support is challenging, and the forces that correspond to ideal tip support are unknown. OBJECTIVE To identify the integrated reaction force and the minimum and ideal mechanical properties associated with nasal tip support. DESIGN, SETTING, AND PARTICIPANTS Three-dimensional (3-D) printed anatomic silicone nasal models were created using a computed tomographic scan and computer-aided design software. From this model, 3-D printing and casting methods were used to create 5 anatomically correct nasal models of varying constitutive Young moduli (0.042, 0.086, 0.098, 0.252, and 0.302 MPa) from silicone. Thirty rhinoplasty surgeons who attended a regional rhinoplasty course evaluated the reaction force (nasal tip recoil) of each model by palpation and selected the model that satisfied their requirements for minimum and ideal tip support. Data were collected from May 3 to 4, 2014. RESULTS Of the 30 respondents, 4 surgeons had been in practice for 1 to 5 years; 9 surgeons, 6 to 15 years; 7 surgeons, 16 to 25 years; and 10 surgeons, 26 or more years. Seventeen surgeons considered themselves in the advanced to expert skill competency levels. Logistic regression estimated the minimum threshold for the Young moduli for adequate and ideal tip support to be 0.096 and 0.154 MPa, respectively. Logistic regression estimated the thresholds for the reaction force associated with the absolute minimum and ideal requirements for good tip recoil to be 0.26 to 4.74 N and 0.37 to 7.19 N during 1- to 8-mm displacement, respectively. CONCLUSIONS AND RELEVANCE This study presents a method to estimate clinically relevant nasal tip reaction forces, which serve as a proxy for nasal tip support. This information will become increasingly important in computational modeling of nasal tip mechanics and ultimately will enhance surgical planning for rhinoplasty. LEVEL OF EVIDENCE NA.

Congenital anomalies of the incudostapedial joint

Objective To determine whether endoscopic cholesteatoma removal can be performed efficiently and safely using a curved fiberoptic-based laser. Background Angled instruments are required in endoscopic ear surgery to access recesses of the middle ear without extra drilling. Lasers are effective at ablating visible and microscopic cholesteatoma matrix and removing granulation tissue. Study Design Retrospective case review from 2006 to 2013. Setting Single tertiary care center. Patients Patients who underwent cholesteatoma surgery with otoendoscopy. Intervention Residual cholesteatoma that could not be reached by conventional microinstruments was identified using an endoscope. This residual cholesteatoma was ablated in a contactless manner using a fiberoptic-based curved laser carrier with an argon laser. The laser tip through the carrier probe has a 45-degree curve, and the length of the tip is adjustable, allowing it to be used in recesses or around corners, such as in the sinus tympani, around the stapes suprastructure, in the oval window, or in the Eustachian tube orifice. Main Outcome Measures Presence or absence of residual cholesteatoma after laser ablation and complications. Results In 7 cases, the fiberoptic curved laser was used to ablate cholesteatoma completely with no injury to surrounding structures and with no evidence of recidivism with a mean follow-up period of 19 months. There were no cases of sensorineural hearing loss or perilymphatic fistula. Conclusion The curved laser probe allows for precise removal of cholesteatoma endoscopically.

Tympanic Membrane and Ossicular-Sparing Modified Lateral Temporal Bone Resection

Objectives: To evaluate the outcomes and complications of transcanal excision of exostoses using micro-osteotomes, without a postauricular incision or the use of the drill. Study Design: A retrospective chart review of patients undergoing exostoses excision. Setting: Tertiary Care Medical Center. Subjects and Methods: All of the patients underwent surgical removal of the exostoses using only a 1 or 2 mm micro-osteotomes. Patients were followed postoperatively and associated complications were evaluated. Results: One-hundred thirty-eight ears in 106 patients were treated for obstructive exostosis. The average age of patients was 43 ± 16 years. Of these, 99 were man (93%) and 7 were woman (7%). A majority of the patients (84%, n = 89) had 90 to 100% obstruction of the ear canal. Complete ear canal healing was observed in 80% of patients by 3 weeks. All but one patient had healed by 6 weeks postoperatively. There were 9 (6.5%) slit tympanic membrane perforations that healed with intraoperative gelfoam or fascia myringoplasty. One patient had an anterior canal mobilization which required Xeroform packing for 3 weeks for stabilization. There were no postoperative vertigo, facial paresis, conductive/sensorineural hearing loss, soft tissue stenoses, and no skin grafting required. Conclusions: This is the first study to report a series of patients performing solely a transcanal approach using micro-osteotomes for removing exostoses. Results indicate that it is a safe procedure with low complication rate and expeditious healing. Patients with 100% obstruction can have this procedure performed with no significant increase in morbidity.

Radiosurgical Trends for Treatment of Vestibular Schwannomas in the United States

OBJECTIVE To describe congenital anomalies of the incudostapedial joint (ISJ) and to discuss the possible unique embryogenesis of the ISJ based on the two anomalies that were encountered. SETTING Tertiary care medical center. SUBJECTS AND METHODS Retrospective review of the medical records of all patients with ISJ anomalies. RESULTS Four patients presented with congenital hearing loss. Upon further workup, we observed a preserved incudostapedial joint (ISJ) with deficiencies of the incus and stapes in three cases. Our fourth case demonstrated the inverse pattern of the congenital anomalies in which the ISJ was missing with an intact proximal incus and stapes crura. Three patients opted for surgical intervention with improvement in hearing. One case preferred hearing amplification over surgery. CONCLUSION Isolated ISJ malformations are uncommon potential causes of congenital conductive hearing loss. Although numerous patterns of ossicular anomalies have been reported in the literature, our case series is the first to demonstrate both the absence of the ISJ in one patient and the presence of the ISJ in the presence of missing stapes crura and incus body in other patients. Though limited by the small number of cases, the inverse relationship of the single case compared to the three other cases, suggests a possible independent embryological development pathway for the ISJ. Therefore, an embryological explanation of the defects should be considered. Additionally, surgical intervention can improve hearing outcomes for patients with isolated ISJ anomalies.