Breen, Joseph T.

Objective: To compare the prevalence and patterns of transverse sinus stenosis (TSS) in patients with lateral skull base spontaneous cerebrospinal fluid (sCSF) leaks and idiopathic intracranial hypertension (IIH), to clarify its role in leak pathogenesis and implications for venous-directed therapies. Study design: Retrospective case-control study. Setting: Single tertiary care institution. Patients: Adults with lateral skull base sCSF leaks confirmed by clinical, laboratory, or surgical findings, and adults with IIH without cranial CSF leaks meeting Modified Dandy criteria. Intervention: Independent magnetic resonance venography evaluation by 2 fellowship-trained neuroradiologists. Main outcome measures: Presence, laterality, and severity of TSS. Results: Eighteen patients with sCSF leaks and 78 patients with IIH were included. The rate of individual TSS, including both unilateral and bilateral cases, was higher in the IIH cohort than in the sCSF leak cohort (bilateral TSS: n=66, 84.6% vs. n=6, 33.3%; P <0.001). Severe bilateral TSS was observed more in the IIH cohort (n=40, 51.3%) compared with the sCSF leak cohort (n=1, 5.6%; P <0.001). Conclusions: Though patients with lateral skull base sCSF leaks have TSS, the significantly lower rate compared with patients with IIH suggests that TSS may play a lesser role in the pathogenesis of lateral skull base defects. These findings indicate that the role of transverse sinus stenting in lateral skull base sCSF leaks remains uncertain and highlight the need to further investigate local remodeling processes when considering the role of venous sinus stenting in this population.

Objective To identify the incidence of positive autoimmune laboratory markers in idiopathic sudden sensorineural hearing loss (iSSNHL) and its impact on hearing prognosis. Study Design Retrospective cohort database study Setting A collaborative national database (TriNetX) sourced from 79 large healthcare organizations in the United States. Patients Adults (≥18 years old) diagnosed with iSSNHL (ICD-10 H91.2) treated with systemic steroids. Interventions Autoimmune laboratory markers and salvage intratympanic (IT) steroids for SSNHL (CPT 69801). Main Outcome Measures 1) Positivity of autoimmune laboratory markers—rheumatoid factor (RF), ANCA, DNA double strand antibody (Ab), Sjogren syndrome A and B Abs, SCL-70 Ab, cardiolipin IgG Ab, Jo-1 Ab, ANA, mitochondria Ab. 2) Percent of patients that underwent salvage IT steroids, cochlear implantation, or hearing aid evaluation—all utilized as a proxy for hearing outcomes. Results Subjects with iSSNHL who had autoimmune testing (n = 17,413) were marginally more likely to be positive for at least one autoimmune laboratory marker compared to subjects without iSSNHL (n = 17,413; 23.0% vs. 21.4%, p = 0.0006). Statistical significance was lost after removing nonspecific autoimmune markers, however. Of those with iSSNHL who received systemic steroid treatment, subjects with positive autoimmune markers (n = 5,153) versus negative autoimmune markers (n = 5,153) underwent similar rates of salvage IT steroids (7.1% vs. 7.8%, p = 0.154), hearing aid evaluation (2.76% vs 2.47%, p = 0.354), and cochlear implantation (1.65% vs. 1.69%, p = 0.878). Conclusions Patients with iSSNHL have a marginally higher incidence of nonspecific positive autoimmune laboratory markers compared to those without iSSNHL; however, the presence of these markers does not predict treatment response or prognosis. Specifically, autoimmune markers did not predict the need for salvage IT steroids, nor CI and hearing aid use in iSSNHL. Autoimmune laboratory testing may be useful in iSSNHL patients with additional symptoms suspicious for an autoimmune disorder; however, a generalized screening is not recommended as it is unlikely to alter management or prognosis.

Objective: To evaluate for equivalence in postoperative changes of speech recognition scores in a veteran patient population undergoing cochlear implantation (CI) compared to matched nonveteran patients. Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: A total of 83 veteran patients who underwent CI at a single Veterans Affairs Medical Center (VA cohort) were matched to 83 nonveteran patients from the Health Insurance Portability and Accountability Act-secure, Encrypted, Research, Management and Evaluation Solution database (HERMES cohort) based on age, sex, and baseline Consonant–Nucleus–Consonant (CNC) scores. Intervention: Patients underwent CI. Main Outcome Measures: Comparison of postoperative CNC and Arizona Biomedical Institute recognition scores. Results: The mean difference and lower confidence interval of CNC scores between matched Veterans Affairs and HERMES cohorts were within a −ΔNI boundary of −15% at the 3-month (mean = 6.15, lower confidence interval = −2.38), 6-month (mean = 7.36, lower confidence interval = −2.21), and 12-month (mean = 4.03, lower confidence interval = −4.88) postoperative time points. The mean difference and lower confidence interval of Arizona Biomedical Institute scores between cohorts were within the −ΔNI boundary of −30% at 3 months (mean = 1, lower confidence interval = −8.71), 6 months (mean = 0.31, lower confidence interval = −12.30), and 12 months (mean = 0.72, lower confidence interval = −10.48). Conclusion: Our veteran population demonstrated improvements in speech recognition scores after CI comparable to a matched nonveteran population. Although veterans face unique factors that affect their hearing, access to medical care, and baseline general health, these findings affirm appropriate veteran candidates should be offered CI.

Objective The objective of the current study was to present the results of an international working group survey identifying perceived limitations of existing facial nerve grading scales to inform the development of a novel grading scale for assessing early postoperative facial paralysis that incorporates regional scoring and is anchored in recovery prognosis and risk of associated complications. Study Design Survey. Setting A working group of 48 multidisciplinary clinicians with expertise in skull base, cerebellopontine angle, temporal bone, or parotid gland surgery. Results House-Brackmann grade is the most widely used system to assess facial nerve function among working group members (81%), although more than half (54%) agreed that the system they currently use does not adequately estimate the risk of associated complications, such as corneal injury, and confidence in interrater and intrarater reliability is generally low. Simplicity was ranked as the most important attribute of a novel postoperative facial nerve grading system to increase the likelihood of adoption, followed by reliability and accuracy. There was widespread consensus (91%) that the eye is the most critical facial region to focus on in the early postoperative setting. Conclusions Members were invited to submit proposed grading systems in alignment with the objectives of the working group for subsequent validation. From these data, we plan to develop a simple, clinically anchored, and reproducible staging system with regional scoring for assessing early postoperative facial nerve function after surgery of the skull base, cerebellopontine angle, temporal bone, or parotid gland.

Objective To characterize the viability and volume of autologous free fat grafts over time, determine clinical/patient factors that may affect free fat graft survival and assess the clinical impact of free fat graft survival on patient outcomes in the translabyrinthine approach for lateral skull base tumor resection. Study Design Retrospective chart review. Setting Tertiary neurotologic referral center. Patients Forty-two adult patients who underwent translabyrinthine craniotomy for resection of a lateral skull base tumor with the mastoid defect filled by autologous abdominal fat graft and subsequently underwent more than one postoperative magnetic resonance imaging (MRI) scans of the brain. Intervention(s) Mastoid obliteration with abdominal fat after craniotomy, postoperative MRI Main Outcome Measure(s) Rate of fat graft volume loss, fraction retention of original fat graft volume, initial fat graft volume, time to steady-state fat graft retention, rate of postoperative cerebrospinal fluid (CSF) leak, and/or pseudomeningocele formation. Results Patients were followed postoperatively with MRI for a mean of 31.6 months with a mean of 3.2 postoperative MRIs per patient. Initial graft size was a mean of 18.7 cm3 with a steady-state fat graft retention of 35.5%. Steady-state graft retention (<5% loss per year) was achieved at a mean of 24.96 months postoperatively. No significant association was found in multivariate regression analysis of clinical factors impact on fat graft retention and CSF leak/pseudomeningocele formation. Conclusions In the use of autologous abdominal free fat graft for filling mastoid defects after translabyrinthine craniotomy, there is a logarithmic decline in fat graft volume over time, reaching steady state in 2 years. Rates of CSF leak or pseudomeningocele formation were not significantly affected by initial volume of the fat graft, rate of fat graft resorption, nor the fraction of original fat graft volume at steady state. In addition, no analyzed clinical factors significantly influenced fat graft retention over time.

Objective: To introduce a minimally invasive and image-guided technique for staged placement of a percutaneous abutment after osseointegrated implantation. Patients: Adults undergoing temporal bone resection at two academic medical centers. Interventions: Ultrasound-guided percutaneous installation of a bone conduction hearing device abutment. All patients had lateral temporal bone resection with osseointegrated implantation. Abutment placement followed as a planned staged procedure 3 to 6 months later depending on the use of radiotherapy. Main Outcome Measures: Ability to use a bone conduction hearing device and occurrence of skin reactions or wound complications. Results: Twelve patients successfully underwent abutment installation through a 5 mm skin biopsy punch incision, nine of which had minimal to no skin reaction surrounding the abutment. Two patients developed Holgers grade 1 skin reaction (redness with slight swelling). One patient experienced an osseointegration failure 152 days after abutment placement. Conclusions: Ultrasound is a widely available imaging modality that can be used to precisely localize subcutaneous osseointegrated implants, allowing for minimally invasive percutaneous placement of an abutment under local or general anesthesia.