Theodore R. McRackan

Effect of body mass index on chemoradiation outcomes in head and neck cancer.

Objective: To investigate the association between initial body mass index (BMI) and chemoradiation therapy (CRT) outcomes in head and neck cancer patients.

Assessment of electrode placement and audiological outcomes in bilateral cochlear implantation.

Objective: The goal of this study was to use highly accurate nonrigid algorithms to locate the position of cochlear implant (CI) electrodes and correlate this with audiological performance. Patients: After obtaining institutional review board approval, adult patients who had bilateral CIs were identified, and those with preoperative temporal bone computed tomographic scans were asked to return for a postintervention computed tomography. Sixteen adult patients agreed. Demographics, cause of deafness, length of auditory deprivation, and audiological performance were recorded. Intervention: Using a nonrigid model of the shape variations of intracochlear anatomy, the location of the basilar membrane was specified in relationship to the electrode array. The number of electrodes within each compartment of the cochlea was correlated with hearing in noise and consonant-noun-consonant scores for the known confounding variable: length of deafness. Main Outcomes: Mann-Whitney U tests of differences were used to compare the hearing performance resulting from implants completely in the scala tympani (ST) versus those not completely in the ST. Results: Of all implants, 62.5% were fully inserted in the ST; 34.4% were partially inserted into the ST and 3.1% was fully inserted in the scala vestibuli. Controlling for the known contributing variable of length of auditory deprivation, our results show that the location of electrodes in relationship to the scala is not predictive of audiological performance. Conclusion: We have assessed electrode placement and correlated it with audiological outcome. The presence of the electrodes solely in the ST was not predictive of outcome. We estimate that it would take analyzing data of thousands of CI patients before any valid correlations can be made.

Facial nerve outcomes in facial nerve schwannomas.

Objective To better understand the characteristics and outcomes of facial nerve schwannomas (FNSs) over a 30-year period. Study Design Retrospective study. Setting Subspecialty practice at a tertiary hospital. Patients Fifty-six patients diagnosed with FNS over a 30-year period. Methods Preoperative data (audiologic data, facial nerve [FN] function, and patient symptoms), intraoperative data (tumor location, total versus subtotal resection, and FN status), and postoperative data (audiologic data, FN function, and recurrence) were collected. Mann-Whitney and &khgr;2 analyses were done to determine which factors correlated with poor FN outcomes (defined as House-Brackmann ≥4). Results Of the 56 patients in this study, 53 (94.6%) underwent surgical resection of their FNS. Of those patients, 45 (84.9%) underwent total resection, and 8 (15.1%) underwent subtotal resection. Subtotal resection was associated with a statistically significant decreased risk of having postoperative HB grade ≥4 (odds ratio, 0.09; 95% confidence interval, 0.01–0.77; p = 0.028). Of those undergoing a subtotal resection, no patient had further tumor growth seen on postoperative magnetic resonance imaging (average time of last magnetic resonance imaging since operation, 44.9 mo). Tumor location was not statistically associated with poor FN outcome (all p > 0.05). Preoperative FN paralysis was the only preoperative clinical finding statistically associated with poor FN outcomes (p = 0.004). Conclusion We have identified multiple characteristics of FNS as well as multiple factors associated with increased statistical risk of poor FN outcomes.

Evaluation of Second Look Procedures for Pediatric Cholesteatomas

Objective. This study aims to identify factors that may help predict recurrence, the need for second-look operations, and other outcomes in the pediatric population. Study Design. Case series with chart review. Setting. Tertiary medical center. Subjects and Methods. Five hundred and seventeen ears in 493 patients underwent primary acquired cholesteatoma resection over a 37-year period. Demographic (age, sex, and other medical conditions), cholesteatoma laterality, presence of perforation or otorrhea on otoscopic exam, preoperative and most recent audiologic data, and detailed intraoperative data were collected. Results. Overall, 47.2% of patients underwent second-look operations, with 48.0% having recurrent cholesteatoma visualized with attic recurrence being the most common location. In total, 22.7% of all patients in this study had recurrent disease. Factors at initial operation associated with a statistically significant increased risk of recurrence included cholesteatoma in the sinus tympani (odds ratio = 2.09; 95% confidence interval, 1.36-3.22) and incus destruction (1.65; 1.01-2.71). Conclusion. The authors have successfully identified multiple factors at the time of initial operation that can have significant postoperative implications.

Comparison of Cochlear Implant Relevant Anatomy in Children Versus Adults

Hypothesis To test whether there are significant differences in pediatric and adult temporal bone anatomy as related to cochlear implant (CI) surgery. Background Surgeons rely upon anatomic landmarks including the round window (RW) and facial recess (FR) to place CI electrodes within the scala tympani. Anecdotally, clinicians report differences in orientation of such structures in children versus adults. Methods Institutional review board approval was obtained. High-resolution computed tomographic scans of 24 pediatric patients (46 ears) and 20 adult patients (40 ears) were evaluated using software consisting of a model-based segmentation algorithm that automatically localizes and segments temporal bone anatomy (e.g., facial nerve, chorda tympani, external auditory canal [EAC], and cochlea). On these scans, angles pertinent anatomy were manually delineated and measured blinded as to the age of the patient. Results The EAC and FR were more parallel to the basal turn (BT) of the cochlea in children versus adults (∠ EAC:BT 20.55 degrees versus 24.28 degrees, p = 0.003; ∠FR:BT 5.15degrees versus 6.88 degrees, p = 0.009). The RW was more closely aligned with the FR in children versus adults (∠FR:RW 30.43 degrees versus 36.67 degrees, p = 0.009). Comparing the lateral portion of the EAC (using LatEAC as a marker) to the most medial portion (using ⊥TM as a marker), the measured angle was 136.57 degrees in children and 172.20 degrees in adults (p < 0.001). Conclusion There are significant differences in the temporal bone anatomy of children versus adults pertinent to CI electrode insertion.

Cochlear Implantation in Meniere's Disease Patients

Objective A significant portion of the Ménière’s disease (MD) population will ultimately have severe-to-profound hearing loss in their affected ear. When this occurs bilaterally or when a patient has poor hearing in the contralateral ear, these patients may meet criteria for cochlear implantation (CI). Here, we describe our institution’s CI outcomes in MD patients. Study Design Retrospective chart and literature review. Setting Tertiary referral center. Patients Twenty-one patients with either bilateral MD or unilateral MD who underwent CI in their ear affected with MD. Intervention(s) Cochlear implantation. Main Outcome Measure(s) Postoperative speech perception. Results Results for the MD patients were also compared with a standard sample of 178 adult recipients implanted with newest generation technology. Collapsing across status of MD activity, there was a significant difference between the MD CNC word recognition scores and that of the standard sample (43.2 versus 59.1%, p = 0.02). When separating the MD patients into groups according to the status of disease activity, those with active MD achieved scores that were not significantly different from the standard sample (55.7 versus 59.1%, p = 0.94), although those without active MD were significantly different from the standard group (38.2 versus, p = 0.002). Patients undergoing surgical or ablative procedures for their MD symptoms had statistically significant improvement in their CI hearing outcomes compared with those who did not (CNC words: p = 0.014; CNC phonemes: p = 0.035). Six patients had persistent vertiginous symptoms of MD before CI. After CI, 2 had complete resolution of vertigo, 3 had subjective improvement in their symptoms, and 1 noticed no change. Conclusion Ménière’s disease patients’ hearing outcomes seem to be worse than the general CI population. However, those with active MD perform similarly to the general CI population

Intratympanic dexamethasone as a symptomatic treatment for Ménière's disease.

Objective Determine whether intratympanic (IT) dexamethasone, when given on an as needed basis, can successfully control Ménière’s disease (MD) symptoms in a large percentage of patients and allow them to avoid ablative therapies. Study Design Retrospective chart review. Setting Tertiary medical center. Patients One hundred fifty-nine patients met the American Academy of Otolaryngology–Head and Neck Surgery criteria for unilateral definitive MD. All patients failed dietary and medical therapy and received at least one IT dexamethasone treatment by one of 4 otologists in an academic center. Intervention(S) IT dexamethasone. Main Outcome Measure(s) Patients were determined to be treatment failures if they did not achieve satisfactory control of their symptoms with IT dexamethasone and chose another treatment modality. Treatment success was defined as IT dexamethasone providing control of MD symptoms to the degree that they did not require any other further treatment modalities. Results Successful avoidance of ablative surgery was achieved in 81.1% of patients with greater than 24 months of follow-up. No statistically significant associations were found related to age, sex, laterality, or duration of symptoms. For each IT dexamethasone perfusion sequence, there was a 20.0% increase in likelihood of successful treatment (OR, 1.20; 95% CI, 1.01–1.40; p = 0.01). Conclusion IT dexamethasone is a successful adjuvant treatment for Ménière’s disease in patients on medial therapy and dietary restrictions.

Validation of minimally invasive, image-guided cochlear implantation using Advanced Bionics, Cochlear, and Medel electrodes in a cadaver model

PurposeValidation of a novel minimally invasive, image-guided approach to implant electrodes from three FDA-approved manufacturers—Medel, Cochlear, and Advanced Bionics—in the cochlea via a linear tunnel from the lateral cranium through the facial recess to the cochlea.MethodsCustom microstereotactic frames that mount on bone-implanted fiducial markers and constrain the drill along the desired path were utilized on seven cadaver specimens. A linear tunnel was drilled from the lateral skull to the cochlea followed by a marginal, round window cochleostomy and insertion of the electrode array into the cochlea through the drilled tunnel. Post-insertion CT scan and histological analysis were used to analyze the results.ResultsAll specimens (

Stereotactic radiosurgery for facial nerve schwannomas: meta-analysis and clinical review.

N=7