Ted A. Meyer

Small acoustic neuromas: surgical outcomes versus observation or radiation.

Objective: Evaluate factors affecting outcomes of small acoustic neuroma (AN) removal via a middle cranial fossa (MCF) approach, and compare results to published data on observation and radiation therapy. Study Design: Retrospective chart review. Setting: Academic tertiary referral center. Methods: 162 consecutive patients (ages 19-70) with unilateral AN (0.2-2.5 cm in largest dimension) removed through a MCF approach were reviewed focusing on preservation of hearing, facial nerve function and complications. One hundred thirteen patients had pre-operative word recognition scores (WRS) >70%. Results: Both tumor size and pre-operative WRS were related to post-operative WRS (p < 0.01). Overall, at least some hearing was preserved in 94 (60%) of the 156 patients who had hearing before surgery. If the WRS was also >70% (N = 113), 56 (50%) maintained WRS >70%. Importantly, WRS for 12 others improved to >70% after surgery. When the patients were stratified by tumor size, the patients with small tumors (2-10 mm) faired better than the overall group. At least some hearing was preserved in 65 (72%) of the 90 patients. If the WRS was also >70% (N = 66), 39 (59%) maintained WRS >70%. WRS for eight others improved to >70% after surgery. When the tumor was 1.1-1.4 cm (N = 34), the chance of preserving some hearing decreased to 42% (14/33). If the WRS was also >70% (N = 23), 9 (39%) maintained WRS >70%. WRS for three others improved to >70% after surgery. When the tumor reached 1.5-2.5 cm (N = 35), the hearing preservation rate was 43%. If the WRS was also >70% (N = 24), only eight (33%) maintained WRS of 70%, and one other improved to >70%. The addition of intra-operative whole eighth nerve near field monitoring improved results during small tumor (≤ 1.0 cm) removal preserving some hearing in 80% (32/40) and preserving >70% WRS in 76% (22/29) of those with >70% pre-operative WRS. Good facial nerve function (HB I-II) was achieved in 97% (86% HB I). When tumor size was ≤ 1.0 cm (N = 93), however, good facial nerve function was obtained in 100% (94% HB I). Complications included CSF leak: 9 (5.5%); seizure: 2 (1.2%); and recurrence: 1 (0.6%). Conclusion: Our results suggest that removal of unilateral AN through an MCF approach when the tumor is small and hearing is good provides the best opportunity for hearing preservation and normal facial nerve function. Observation historically results in tumor growth in young and middle-age patients with subsequent hearing loss. Radiation may prevent most tumors from growing, and more data are needed to determine long-term tumor control and hearing preservation rates.

Steroids for treatment of sudden sensorineural hearing loss: a meta-analysis of randomized controlled trials.

To systematically review the available evidence regarding steroid treatment for sudden sensorineural hearing loss (SSHL) and to update prior analyses when possible.

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.

Case report: Cochlear implant magnet migration.

A 13‐month‐old cochlear implant recipient underwent routine device activation. Three months postoperatively, the patient sustained a fall with contact to the area of the implant without immediate complication. Ten months postoperatively, the position of the external coil appeared to have moved and the patient did not seem to be responding as well to sound. Audiological testing could not elicit normal device impedances. AP and lateral plain radiographs of the skull revealed migration of the internal magnet from its position within the internal coil to a position over the receiver/stimulator. This is the first known published case of cochlear implant magnet migration.

Temporal bone pneumatization and its relationship to paranasal sinus development in cystic fibrosis

BACKGROUNDnThere is significant debate on the influence of inflammatory mucosal disease on paranasal sinus pneumatization (PSP) and temporal bone pneumatization (TBP) in cystic fibrosis patients (CF). It is often assumed that mucosal disease of the paranasal sinuses will negatively influence development and pneumotization of the paranasal sinuses and temporal bone system.nnnMETHODSnA case-control study of TBP and PSP in CF, chronic rhinosinusitis (CRS) and healthy control patients from a tertiary rhinology clinic. TBP and PSP were assessed by computed tomography (CT) using a previously validated scale. Genotype data for patients with CF was determined.nnnRESULTSnIn total, 186 temporal bones and paranasal sinuses from 93 adult patients were assessed through evaluation of CT scans. Tha patients had a mean age of 43.4 +/- 14.9 yrs. The interobserver correlation for TB scoring was 0.86. TBP did not differ between CF, CRS and controls (chi(2) = 6.93, p = 0.38). PSP was less in the CF group (chi(2) = 34.2, p < 0.001) than the CRS and control groups. CRS and controls did not differ in PSP. 51.6% of CF patients were homozygous for DeltaF508 and 16.1% were heterozygous. The DeltaF508 status correlated with poorer SP (chi(2) = 34.2, p < 0.001), but greater TBP (chi(2) = 14.9, p = 0.002)nnnCONCLUSIONSnPSP is impaired in CF and DeltaF508 homozygosity is related to poor PSP. TBP is well preserved in the CF population and DeltaF508 homozygosity correlates with greater TBP, with the underlying mechanisms being unclear. Genotype might play a role in skull base pneumatization.

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.

Lateral Skull Base Attenuation in Patients with Anterior Cranial Fossa Spontaneous Cerebrospinal Fluid Leaks

Objective (1) Determine if patients with anterior fossa spontaneous cerebrospinal fluid (SCSF) leaks demonstrate lateral skull base bone attenuation. (2) Examine the relation between body mass index (BMI; kg/m2) and skull base thickness. Study Design Retrospective cohort study. Setting Tertiary care hospital. Subjects and Methods Retrospective review from 2004 to 2013 identified 96 patients with anterior cranial fossa SCSF leaks. A control group was identified from a consecutive series of clinic patients. Controls had no history of chronic sinonasal or temporal bone pathology and were divided according to BMI into nonobese (<30 kg/m2) and obese (≥30 kg/m2) groups. Composite skull base thickness was calculated for lateral and anterior subsites through predefined points according to previously published protocols. Results Thirty-two patients were included in each group. Composite lateral skull base thickness was less in patients with SCSF leaks(0.7 ± 0.1 mm) when compared with nonobese controls (0.8 ± 0.1 mm, P = .004); no differences were apparent when SCSF leaks were compared with obese controls (0.7 ± 0.1 mm, P = .99). A direct relation was observed between anterior skull base and lateral skull base thickness (r = 0.48, P < .0001). An inverse correlation was noted between BMI and lateral skull base (r =−0.40, P < .0001). Conclusions Patients with anterior fossa SCSF leaks demonstrate attenuation of the lateral skull base. A significant correlation between anterior skull base thickness and lateral skull base thickness was observed. BMI was inversely related to lateral skull base thickness. Taken together, SCSF leaks are associated with obesity, which appears to be partly responsible for diffuse skull base erosion observed in patients with this condition.

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.

Safety of cochlear implantation before 12 months of age: Medical University of South Carolina and Pediatric American College of Surgeons–National Surgical Quality improvement program outcomes

The primary objective of this study was to determine the safety profile of cochlear implantation (CI) in infants <12 months old.

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.