Publications by authors named "Cameron C Wick"

40 Publications

Accuracy of an Automated Hearing Aid Fitting Using Real Ear Measures Embedded in a Manufacturer Fitting Software.

J Am Acad Audiol 2021 Jun 1. Epub 2021 Jun 1.

Department of Otolaryngology-Head and Neck Surgery, Washington University in St. Louis School of Medicine, Division of Adult Audiology, St. Louis, Missouri.

Background:  Hearing aid fitting guidelines recommend real ear measures (REM) to verify hearing aid performance. Unfortunately, approximately 70 to 80% of clinicians do not use REM, but instead download manufacturer first-fit. Studies report differences in performance between first-fit and programmed-fit with greatest differences in the higher frequencies. Recently, hearing aid and real ear analyzer (REA) manufacturers allow REA communication with hearing aid software feature to automatically program hearing aids to target. Little research is available reporting the accuracy of this feature.

Purpose:  The aim of the study is to examine whether differences exist at 50, 65, and 80 dB SPL between two ReSound first-fit formulae (Audiogram+ and NAL-NL2) using ReSound AutoREM and Aurical NAL-NL2 RESEARCH DESIGN:  The study design is of repeated measure type.

Study Sample:  The study sample includes 48 ears.

Data Collection And Analysis:  For the two fitting formulae, AutoREM real ear insertion gain (REIG) was measured at 50, 65, and 80 dB SPL and compared with measures from Aurical NAL-NL2.

Results:  Mean AutoREM REIG for ReSound NAL-NL2 was 3 to 8 dB Aurical NAL-NL2 for 50 dB SPL, within 1 to 3 dB for 65 dB SPL and 1 to 5 dB for 80 dB SPL. Mean AutoREM REIG for Audiogram + was 1 to 12 dB Aurical NAL-NL2 for 50 dB SPL, within 2 to 5 dB for 65 dB SPL and 1 to 7 dB NAL-NL2 for 80 dB SPL.

Conclusion:  Relative to the Aurical NAL-NL2, AutoREM REIG for Audiogram + and ReSound NAL-NL2 was lower. Relative to the Aurical NAL-NL2, AutoREM REIG for Audiogram + was higher at 1,000 Hz and lower at 4,000 to 6,000 Hz and for ReSound NAL-NL2 it was lower at 500 Hz and 4,000 Hz and higher at 3,000 Hz. Relative to the Aurical NAL-NL2, AutoREM REIG for Audiogram + was higher at 500 to 3,000 Hz and 6,000 Hz and ReSound NAL-NL2 was higher at 500 to 6,000 Hz. Because of wide intersubject variability clinicians should continue to use REM as a "check and balance" when using AutoREM.
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http://dx.doi.org/10.1055/s-0041-1722947DOI Listing
June 2021

Prevalence, Surgical Management, and Audiologic Impact of Sigmoid Sinus Dehiscence Causing Pulsatile Tinnitus.

Otol Neurotol 2021 01;42(1):82-91

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri.

Objective: To evaluate the prevalence, surgical management, and audiologic impact of pulsatile tinnitus caused by sigmoid sinus dehiscence.

Study Design And Setting: Retrospective chart review at a tertiary care hospital.

Patients: Adults with unilateral pulsatile tinnitus attributable to sigmoid sinus dehiscence who underwent resurfacing between January 2010 and January 2020.

Interventions: Transmastoid sigmoid resurfacing.

Main Outcome Measures: Resolution of pulsatile tinnitus; audiologic outcomes; complications; tinnitus etiologies.

Results: Nineteen patients (89.4% women) had surgery for suspected sigmoid sinus dehiscence. The mean dehiscence size was 6.1 mm (range, 1-10.7 mm). Eight patients had concurrent sigmoid sinus diverticulum and one patient also had jugular bulb dehiscence. Only two patients (10.5%) had the defect identified by radiology. Low-frequency pure-tone average, measured at frequencies of 250 and 500 Hz, showed a significant median improvement of 8.8 dB following resurfacing (18.8 dB versus 10.0 dB, p = 0.02). The majority of patients had complete resolution of pulsatile tinnitus (16/19, 84.2%). Of those without complete resolution, two patients had partial response and one patient had no improvement. There were no significant complications. Of 41 consecutively tracked patients with a pulsatile tinnitus chief complaint, sigmoid pathology represented 32% of cases.

Conclusions: Sigmoid sinus dehiscence represents a common vascular cause of pulsatile tinnitus that, if properly assessed, may be amenable to surgical intervention. Sigmoid sinus resurfacing is safe, does not require decompression, and may improve low-frequency hearing. Radiographic findings of dehiscence are often overlooked without a high index of clinical suspicion. Its relationship with transverse sinus pathology and idiopathic intracranial hypertension remain unclear.
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http://dx.doi.org/10.1097/MAO.0000000000002846DOI Listing
January 2021

Outcomes after mini-craniotomy middle fossa approach combined with mastoidectomy for lateral skull base defects.

Am J Otolaryngol 2021 Jan - Feb;42(1):102794. Epub 2020 Oct 24.

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA. Electronic address:

Purpose: Controversy exists regarding the ideal approach for repair of lateral skull base defects. Our goal is to report the outcomes following middle cranial fossa (MCF) mini-craniotomy combined with mastoidectomy for patients with superior semicircular canal dehiscence (SSCD), spontaneous cerebrospinal fluid (CSF) leak, and cholesteatoma.

Materials And Methods: A retrospective database from chart review was formed consisting of 97 patients who met surgical criteria: SSCD, spontaneous CSF leak, and cholesteatoma. Mini-craniotomy MCF approach (<4 × 2 cm in size) combined with mastoidectomy was performed. All patients were admitted directly to the ICU postoperatively. Multiple factors were assessed, including need for revision surgery, duration of surgery, length of post-operative stay, and hospital readmission.

Results: Average surgery time was 110 min with no intraoperative complications. The average length of hospitalization was 2 days with an average ICU stay of 1 day. There were no neurologic complications; however, there were 3 inpatient complications (3%) which included 1 patient (1%) that had wound breakdown and 2 patients (2%) that had severe post-operative vertigo. A total of 8 patients (8%) required revision surgery and these were primarily for SSCD. The 30-day readmission rate was 3%.

Conclusion: In the current series, all patients that underwent mini-craniotomy MCF surgery combined with mastoidectomy had minimal complications, short surgical time, limited hospital stay, low revision surgery rate and few hospital readmissions. This combined approach offers superior visualization of lateral skull base defects without the morbidity and risk typically associated with traditional, extensive MCF surgery.
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http://dx.doi.org/10.1016/j.amjoto.2020.102794DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8048087PMC
April 2021

A Novel Surgical Technique for the Management of Cerebrospinal Fluid Gusher Encountered During Cochlear Implantation.

Otol Neurotol 2020 10;41(9):e1177

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

: Cerebrospinal fluid (CSF) gusher encountered during cochlear implantation are most commonly encountered in the setting of an inner ear abnormality. Repair of the gusher is essential to prevent CSF egress postoperatively and to decrease the risk of meningitis. Various methods to repair a CSF gusher have been described, including tight packing of the cochleostomy with fascia, lumbar drainage, and Eustachian tube packing with ear canal overclosure. We describe a novel and simple technique using a fascia ring placed around the cochlear implantation electrode (Cochlear Corporation, CI522) as a means to treat CSF gusher. The fascia is slid down the electrode after insertion, allowing circumferential coverage of the defect. The following video will provide an overview of patients at risk for CSF gusher and demonstrate the technique described above.SDC video link: http://links.lww.com/MAO/B52.
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http://dx.doi.org/10.1097/MAO.0000000000002828DOI Listing
October 2020

Cochlear Implant Outcomes Following Vestibular Schwannoma Resection: Systematic Review.

Otol Neurotol 2020 10;41(9):1190-1197

Department of Otolaryngology-Head and Neck Surgery.

Objective: Hearing loss remains a significant morbidity for patients with vestibular schwannomas (VS). A growing number of reports suggest audibility with cochlear implantation following VS resection; however, there is little consensus on preferred timing and cochlear implant (CI) performance.

Data Sources: A systematic literature search of the Ovid Medline, Embase, Scopus, and clinicaltrails.gov databases was performed on 9/7/2018. PRISMA reporting guidelines were followed.

Study Selection: Included studies reported CI outcomes in an ear that underwent a VS resection. Untreated VSs, radiated VSs, and CIs in the contralateral ear were excluded.

Data Extraction: Primary outcomes were daily CI use and attainment of open-set speech. Baseline tumor and patient characteristics were recorded. Subjects were divided into two groups: simultaneous CI placement with VS resection (Group 1) versus delayed CI placement after VS resection (Group 2).

Data Synthesis: Twenty-nine articles with 93 patients met inclusion criteria. Most studies were poor quality due to their small, retrospective design. Group 1 had 46 patients, of whom 80.4% used their CI on a daily basis and 50.0% achieved open-set speech. Group 2 had 47 patients, of whom 87.2% used their CI on a daily basis and 59.6% achieved open-set speech. Group 2 had more NF2 patients and larger tumors. CI timing did not significantly impact outcomes.

Conclusions: Audibility with CI after VS resection is feasible. Timing of CI placement (simultaneous versus delayed) did not significantly affect performance. Overall, 83.9% used their CI on a daily basis and 54.8% achieved open-set speech.
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http://dx.doi.org/10.1097/MAO.0000000000002784DOI Listing
October 2020

Hearing and Quality-of-Life Outcomes After Cochlear Implantation in Adult Hearing Aid Users 65 Years or Older: A Secondary Analysis of a Nonrandomized Clinical Trial.

JAMA Otolaryngol Head Neck Surg 2020 10;146(10):925-932

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri.

Importance: Hearing loss, especially moderate to severe forms, has the potential to negatively affect an individual's physical, social, emotional, and cognitive well-being. Moreover, having ineffective binaural hearing increases difficulty understanding speech in noise and leads to a greater degree of social isolation and loneliness and a reduced quality of life (QoL).

Objective: To explore the audiometric and holistic effects of cochlear implantation in a group of adults 65 years or older compared with an optimized bilateral hearing aid condition.

Design, Setting, And Participants: This ad hoc secondary analysis of a prospective, single-subject, repeated-measures nonrandomized clinical trial included 13 cochlear implantation centers across the United States. Participants 65 years or older with postlingual bilateral moderate-to-profound sensorineural hearing loss with aided Consonant-Vowel Nucleus-Consonant (CNC) word scores in quiet of 40% or less in the ear to undergo implantation and 50% or less in the contralateral ear were included in the analysis. Baseline QoL testing was performed after 1 month of optimized bilateral hearing aid use. Participants were enrolled from February 20, 2017, to May 3, 2018, and follow-up was completed December 21, 2018. Data were analyzed from March 25, 2019, to March 31, 2020.

Interventions: Unilateral implantation with a slim, modiolar cochlear implant device. Hearing aid use in the contralateral ear was required through the 6-month primary end-point interval.

Main Outcomes And Measures: The primary objective was to evaluate speech perception before and 6 months after activation of a new cochlear implant. Secondary objectives were QoL metrics in the everyday listening condition before and 6 months after implantation.

Results: Seventy participants (51 men [73%]) with a median age of 74 (range, 65-91) years were included in the analysis. No major adverse events occurred. Mixed-model analysis with estimated marginal means and 95% CIs compared preimplantation baseline performance with 6-month postimplantation performance. A clinically important improvement in CNC words was shown in the bimodal condition, with a mean difference of 37.2% (95% CI, 32.0%-42.4%), and in the unilateral (cochlear implant only) condition, with a mean difference of 44.1% (95% CI, 39.0%-49.2%). A clinically important improvement in noise (AzBio sentences signal-to-noise ratio of +10 dB) was also shown, with a mean difference of 21.6% (95% CI, 15.7%-27.5%) in the bimodal condition and 24.5% (95% CI, 18.3%-30.7%) in the unilateral condition. The Health Utilities Index Mark 3 multiple-attribute score improved by 0.186 (95% CI, 0.136-0.234); the Speech, Spatial, and Qualities of Hearing Scale total score improved by 2.58 (95% CI, 2.18-2.99); and a novel Device Use Questionnaire reported 94% of participants were satisfied with overall hearing in the everyday listening condition.

Conclusions And Relevance: This subgroup analysis of patients 65 years or older enrolled in a within-subject clinical trial of cochlear implantation demonstrated clinically meaningful audiometric and QoL benefit with an acceptable risk profile. These findings suggest that cochlear implantation in older adults may facilitate the concept of healthy aging.

Trial Registration: ClinicalTrials.gov Identifier: NCT03007472.
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http://dx.doi.org/10.1001/jamaoto.2020.1585DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453343PMC
October 2020

Assessment of Speech Understanding After Cochlear Implantation in Adult Hearing Aid Users: A Nonrandomized Controlled Trial.

JAMA Otolaryngol Head Neck Surg 2020 10;146(10):916-924

Department of Otolaryngology-Head & Neck Surgery, Washington University in St Louis, St Louis, Missouri.

Importance: Cochlear implants were approved for use in adults in the 1980s, but use remains low owing to a lack of awareness regarding cochlear implantation candidacy criteria and expected outcomes. There have been limited, small series examining the safety and effectiveness of cochlear implantation in adult hearing aid (HA) users with and without mild cognitive impairment (MCI).

Objective: To investigate the safety and effectiveness of a single-ear cochlear implant in a group of optimized adult HA users with and without MCI across a variety of domains.

Design, Setting, And Participants: In this nonrandomized controlled trial, a multicenter, prospective, repeated-measures investigation was conducted at 13 US institutions. The setting was academic and community-based cochlear implant programs. Eligible participants were 100 adults (aged >18 years) with postlinguistic onset of bilateral moderate sloping to profound or worse sensorineural hearing loss (≤20 years' duration). Fluent English speakers underwent an optimized bilateral HA trial for at least 30 days. Individuals with aided Consonant-Vowel Nucleus-Consonant (CNC) word score in quiet of 40% or less correct in the ear to be implanted and 50% or less correct in the contralateral ear were offered cochlear implants. The first participant was enrolled on February 20, 2017, and the last participant was enrolled on May 3, 2018. The final follow-up was on December 21, 2018.

Interventions: Participants received the same cochlear implant system and contralateral HA.

Main Outcomes And Measures: The primary outcome measure was speech understanding in quiet (CNC word score) using both the cochlear implant and opposite ear HA. Secondary outcome measures included the following: adverse events; speech understanding in noise (AzBio signal-to-noise ratio of +10 db [+10 SNR]) Health Utilities Index Mark 3 (HUI3); Speech, Spatial, and Qualities of Hearing Questionnaire 49 (SSQ49); and Montreal Cognitive Assessment (MoCA).

Results: The median age at cochlear implantation of the 96 patients included in the trial was 71 years (range, 23-91 years), and 62 patients (65%) were male. Three serious adverse events requiring revision surgery occurred, and all resolved without sequelae. By 6 months after activation, the absolute marginal mean change in CNC word score and AzBio +10 SNR was 40.5% (95% CI, 35.9%-45.0%) and 24.1% (95% CI, 18.9%-29.4%), respectively. Ninety-one percent (87 of 96) of participants had a clinically important improvement (>15%) in the CNC word score in the implant ear. Mild cognitive impairment (MoCA total score ≤25) was observed in 48 of 81 study participants (59%) at baseline. Speech perception marginal mean improvements were similar between individuals with and without baseline MCI, with values of 40.9% (95% CI, 35.2%-46.6%) and 39.6% (95% CI, 31.8%-47.4%), respectively, for CNC word score and 27.5% (95% CI, 21.0%-33.9%) and 17.8% (95% CI, 9.0%-26.6%), respectively, for AzBio +10 SNR. Statistically significant and clinically important improvements in the HUI3 and SSQ49 were evident at 6 months.

Conclusions And Relevance: The findings of this nonrandomized controlled trial seem to indicate that cochlear implants are safe and effective in restoring speech understanding in both quiet and noise and improve quality of life in individuals with and without MCI.

Trial Registration: ClinicalTrials.gov Identifier: NCT03007472.
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http://dx.doi.org/10.1001/jamaoto.2020.1584DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7453346PMC
October 2020

A Position Paper on Systematic and Meta-analysis Reviews.

Otol Neurotol 2020 08;41(7):879-882

Department of Otolaryngology-Head and Neck Surgery, University of Kentucky, Lexington, Kentucky.

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http://dx.doi.org/10.1097/MAO.0000000000002737DOI Listing
August 2020

Immediate and 1-Year Outcomes with a Slim Modiolar Cochlear Implant Electrode Array.

Otolaryngol Head Neck Surg 2020 May 17;162(5):731-736. Epub 2020 Mar 17.

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine in St Louis, St Louis, Missouri, USA.

Objective: To explore the immediate and 1-year outcomes of patients who underwent implantation with the slim modiolar electrode (SME).

Study Design: Consecutive case series with chart review.

Setting: Tertiary referral academic center.

Subject And Methods: Between May 2016 and August 2018, a total of 326 cochlear implantations (CIs) were performed. Intraoperative x-rays were performed in all cases to identify tip rollovers. Scalar location was identified for 76 CIs that had postoperative computed tomography reconstructions. Speech outcomes were measured at 3, 6, and 12 months with consonant-nucleus-consonant word and AzBio sentences in quiet and noise (+10-dB signal-to-noise ratio). Preservation of hearing was defined as maintaining a low-frequency pure tone average ≤80 dB at 250 and 500 Hz.

Results: Among 326 CIs, 23 (7%) had tip rollovers. Postoperative reconstructions revealed 5 of 76 (6.6%) scalar translocations. A subset of 177 cases met criteria for evaluation of speech perception scores. The marginal mean differences between presurgery and 12 months for speech tests were as follows: consonant-nucleus-consonant, 43.7 (95% CI, 39.8-47.6); AzBio in quiet, 49.7 (95% CI, 44.9-54.4); and AzBio in noise, 29.9 (95% CI, 25.2-34.7). Sixty-one patients were identified with preservable hearing (low-frequency pure tone average ≤80 dB), and 12 of 61 (20%) preserved hearing at 1 year.

Conclusion: CI with SME provides reliable scala tympani insertion in a consistent perimodiolar position. An initially increased tip rollover rate improved with case volume and sheath design improvement. For long-term outcomes, speech performance was comparable to that of other cochlear implants. While hearing preservation for the SME may be better than prior perimodiolar electrodes, consistent outcomes are unlikely.
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http://dx.doi.org/10.1177/0194599820907336DOI Listing
May 2020

Comparing Linear and Volumetric Vestibular Schwannoma Measurements Between T1 and T2 Magnetic Resonance Imaging Sequences.

Otol Neurotol 2019 06;40(5S Suppl 1):S67-S71

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: To compare linear and volumetric vestibular schwannoma (VS) measurements between different magnetic resonance imaging (MRI) sequences.

Study Design: Retrospective case series.

Setting: Tertiary care university hospital.

Patients: Those with VS that had at least two separate MRI studies containing both T1-weighted contrast (T1C) and high-resolution T2-weighted (HRT2) images.

Intervention: Two neurotologists measured the greatest linear axial dimension and segmentation volumes of VS.

Main Outcome Measure: 1) Correlation between T1C and HRT2 VS linear and volumetric measurements. 2) Comparing the interpretation of VS growth between T1C and HRT2 sequences and reviewers, defined as an increase in tumor diameter of more than or equal to 2 mm or a volume increase of more than or equal to 20%.

Results: Twenty-three patients met inclusion criteria. Imaging studies encompassed a median of 25.2 months. At the initial imaging study, inter-observer measurements between reviewers, analyzed with intraclass correlation coefficients, for T1C diameters, T1C volumes, HRT2 diameters, and HRT2 volumes were 0.983 (95% confidence interval [CI] 0.972-0.989), 0.989 (95% CI 0.982-0.993), 0.992 (95% CI 0.988-0.995), and 0.998 (95% CI 0.995-0.999), respectively. The Cohen's kappa for growth rates between T1C diameters, T1C volumes, HRT2 diameters, and HRT2 volumes was 0.564 (95% CI 0.284-0.844), 0.704 (95% CI 0.514-0.894), 0.605 (95% CI 0.319-0.891), and 0.475 (95% CI 0.242-0.708), respectively.

Conclusions: There are significant differences in VS volume measurements when utilizing T1C versus HRT2 images. However, there is "excellent" interobserver agreement between T1C and HRT2 diameters and volumes. T1C VS volumes may be more reliable than HRT2 volumes to determine growth.
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http://dx.doi.org/10.1097/MAO.0000000000002208DOI Listing
June 2019

What defines asymmetric sensorineural hearing loss?

Laryngoscope 2019 05 8;129(5):1023-1024. Epub 2018 Nov 8.

Department of Otolaryngology-Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, U.S.A.

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http://dx.doi.org/10.1002/lary.27504DOI Listing
May 2019

Internal carotid artery dissection causing pulsatile tinnitus.

Am J Otolaryngol 2019 Jan - Feb;40(1):121-123. Epub 2018 Sep 13.

Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, MO, USA. Electronic address:

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http://dx.doi.org/10.1016/j.amjoto.2018.09.008DOI Listing
March 2020

Pathophysiology of sensorineural hearing loss in jugular foramen paraganglioma.

Laryngoscope 2019 01 8;129(1):67-75. Epub 2018 Sep 8.

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.

Objectives/hypothesis: Pathologic involvement of the inferior cochlear vein is a mechanism of sensorineural hearing loss in patients with jugular foramen paraganglioma.

Study Design: Retrospective case-control study.

Methods: The presenting audiograms, magnetic resonance imaging, and computed tomography were reviewed in 46 subjects with jugular foramen paragangliomas. Four-frequency bone conduction average was compared between the tumor and nontumor ears in each subject to establish the presence of sensorineural hearing loss. Imaging findings for each subject were recorded. Univariate and multivariate statistical analyses were performed to determine which radiographic features were associated with sensorineural hearing loss. Hearing data were analyzed as a continuous variable and as a categorical variable.

Results: Twenty subjects (43.4%) had a bone-conduction pure-tone asymmetry of greater than 15 dB. Inferior cochlear vein involvement was identified in 19 of the 20 (95%) subjects with sensorineural hearing loss. Inferior cochlear vein involvement was found to be a statistically significant predictor of sensorineural hearing loss using univariate and multivariate analyses. Other imaging findings that were statistically significant predictors of sensorineural hearing loss include Glasscock-Jackson stage, Fisch-Mattox stage, hypoglossal canal involvement, jugulo-carotid spin erosion, and petrous carotid canal erosion.

Conclusions: Involvement of the inferior cochlear vein appears to be a plausible mechanism for sensorineural hearing loss in patients with jugular foramen paraganglioma.

Level Of Evidence: 4 Laryngoscope, 129:67-75, 2019.
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http://dx.doi.org/10.1002/lary.27343DOI Listing
January 2019

Case Series and Systematic Review of Radiation Outcomes for Endolymphatic Sac Tumors.

Otol Neurotol 2018 06;39(5):550-557

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: Surgery is the primary treatment modality for endolymphatic sac tumors (ELST). Two case examples are presented to highlight some rare instances when radiation therapy may be used. The outcomes following radiation therapy for ELST are controversial. This report systematically reviews those outcomes and compares results between external beam radiation and stereotactic radiosurgery.

Data Source: In accordance with PRISMA guidelines a systematic literature search of the Ovid Medline, Embase, Scopus, Cochrane library, and clinicaltrails.gov databases was performed in August 2017.

Study Selection: Twenty-two studies met inclusion criteria and report ELST outcomes following radiation therapy. Additional data on tumor size, previous surgery, radiation modality, and radiation dosing was collected.

Data Extraction: The methodological quality was independently assessed by three reviewers. The included studies were small, heterogeneous case reports with a low level of evidence, and several sources of bias.

Data Synthesis: The primary outcome was tumor control following radiation, defined as no growth. A comparative analysis of external beam versus stereotactic radiation was performed.

Conclusion: Forty-six tumors from 42 patients were independently analyzed. The overall tumor control rate was 67.4%. When analyzing patients in which tumor was present at the time of radiation, external beam radiation controlled 9 of 19 tumors (47.4%) while stereotactic radiosurgery controlled 14 of 18 tumors (77.8%). The effect size of 30.4% favors stereotactic radiosurgery, but the wide confidence interval (-4.4 to 57.4%) limits what conclusions can be drawn. Radiation for ELST remains controversial and more long-term data is needed.
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http://dx.doi.org/10.1097/MAO.0000000000001804DOI Listing
June 2018

Surgical management of spontaneous cerebrospinal fistulas and encephaloceles of the temporal bone.

Laryngoscope 2018 09 18;128(9):2170-2177. Epub 2018 Apr 18.

Department of Otolaryngology, University of Texas Southwestern Medical Center, Dallas, Texas, U.S.A.

Objectives/hypothesis: To describe the presentation, surgical findings, and outcomes in patients with spontaneous temporal bone cerebrospinal fluid (CSF) fistulas and encephaloceles.

Study Design: Retrospective chart review.

Methods: A retrospective chart review of patients treated for a spontaneous temporal bone CSF fistula and/or encephalocele over a 10-year period was performed. Data recorded included demographic information, presenting signs and symptoms, radiographic and laboratory studies, surgical approach, materials used for repair, surgical complications, and successful closure of the CSF fistula.

Results: Fifty patients were identified. Five patients underwent bilateral procedures, for a total of 55 surgical repairs. Thirty-seven of the patients were female, with a mean age of 57.2 years. Seventy percent of patients were obese, with a mean body mass index of 35.0 kg/m . The most common presentation was tympanostomy tube otorrhea (68%). Seven patients (14%) presented with meningitis. The middle fossa craniotomy approach was used in 87.3% of cases. Hydroxyapatite bone cement was used in 82.4% of cases. There were four surgical complications: seizure, mastoid infection, tympanic membrane retraction, and a delayed subdural hematoma. There were five persistent or recurrent CSF fistulas that underwent successful revision surgery.

Conclusions: Spontaneous CSF fistulas are most common in obese females and should be suspected with a chronic middle ear effusion, persistent otorrhea after tympanostomy tube placement, or in patients with a history of meningitis. The middle fossa craniotomy approach with the use of hydroxyapatite bone cement has a high success rate with a low incidence of postoperative complications.

Level Of Evidence: 4 Laryngoscope, 128:2170-2177, 2018.
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http://dx.doi.org/10.1002/lary.27208DOI Listing
September 2018

Unilateral Sensorineural Hearing Loss Presenting With Bilateral Temporal Bone Lesions.

Otol Neurotol 2018 03;39(3):e214-e215

Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1097/MAO.0000000000001697DOI Listing
March 2018

Endoscopic Transcanal Transpromontorial Approach for Vestibular Schwannoma Resection: A Case Series.

Otol Neurotol 2017 12;38(10):e490-e494

*Department of Otolaryngology-Head and Neck Surgery †Department of Neurosurgery, University of Texas, Southwestern Medical Center, Dallas, Texas ‡Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee.

Objective: To demonstrate successful surgical management of vestibular schwannomas via an exclusively endoscopic transcanal transpromontorial approach (EETTA).

Patients: Four patients with vestibular schwannomas.

Interventions: Surgical excision via EETTA.

Main Outcomes: Technique refinements, tumor access, complete tumor removal, and patient morbidity.

Results: Three tumors were Koos grade I and one tumor was Koos grade II. All ears had non-serviceable hearing prior to surgery. The EETTA enabled access to the internal auditory canal and porus acousticus as well as limited access to the cerebellopontine angle. Gross total tumor resection was achieved in all cases. There were no intraoperative or postoperative complications and the mean hospital duration was 2.8 days. After a mean follow-up of 5.0 months, all cases had a good facial nerve outcome.

Conclusions: The EETTA can be successfully used for the management of small vestibular schwannomas in ears without serviceable hearing. Additional studies are needed to fully elucidate the risk-benefit profile of this minimally invasive approach.
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http://dx.doi.org/10.1097/MAO.0000000000001588DOI Listing
December 2017

Audiometric Outcomes Following Endoscopic Ossicular Chain Reconstruction.

Otol Neurotol 2017 10;38(9):1296-1300

*Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University, Nashville, Tennessee †Department of Otolaryngology-Head and Neck Surgery, UT Southwestern, Dallas, Texas.

Objective: To evaluate the audiometric outcomes following endoscopic ossicular chain reconstruction (OCR).

Study Design: Retrospective case series.

Setting: Two tertiary referral centers.

Patients: Sixty two ears with ossicular discontinuity.

Intervention(s): Endoscopic and microscopic OCR in patients with ossicular discontinuity.

Main Outcome Measures: Bone and air pure-tone averages (PTA), air-bone gap (ABG), and word recognition scores (WRS).

Results: Sixty two ears were included for analysis. Patients that underwent ossiculoplasty were subdivided based on prosthesis type (total ossicular replacement prosthesis [TORP] and partial ossicular replacement prosthesis [PORP], primary and staged ossiculoplasties, and surgical approach [microscopic and total endoscopic]). Forty two ears required PORP reconstructions, while 20 ears required TORP reconstructions. The microscope was used to reconstruct the ossicular chain in 31 cases, while an exclusive endoscopic approach was used in the remaining 31 patients. Controlling for the prosthesis, there were no significant postoperative differences in bone PTA, air PTA, and ABG between primary and staged ossiculoplasties, or surgical approach.

Conclusions: Controlling for the type of prosthesis, there were no significant differences in hearing outcomes with respect to staged ossicular chain reconstruction or whether the endoscope or microscope was used for visualization. Thus, in this series, endoscopic OCR yields similar audiometric outcomes when compared with microscopic OCR.
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http://dx.doi.org/10.1097/MAO.0000000000001527DOI Listing
October 2017

The Modified Rambo Transcanal Approach for Cochlear Implantation in CHARGE Syndrome.

Otol Neurotol 2017 10;38(9):1268-1272

*Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center †University of Texas Southwestern Medical School, Texas.

Objective: CHARGE syndrome is associated with a variety of temporal bone anomalies and deafness. The lack of surgical landmarks and facial nerve irregularities make cochlear implantation in this population a challenging endeavor. This study aims to describe a safe and efficacious transcanal approach for cochlear implantation that obviates the need to perform a mastoidectomy and facial recess.

Patients: Three children with profound hearing loss secondary to CHARGE syndrome.

Intervention: Transcanal cochlear implantation with closure of the ear canal via a modified Rambo meatoplasty.

Main Outcome Measure(s): Retrospective chart review of temporal bone anomalies associated with CHARGE syndrome, technical nuances of this transcanal approach, and cochlear implant outcomes.

Results: The mean patient age was 2.5 years (range 1.5-3.8 yr). Two were male and two were left ears. All patients had a hypoplastic mastoid, semicircular canal aplasia, and had some degree of cochlear dysplasia. A full cochlear implant insertion was achieved in all cases, even in the presence of grossly abnormal middle ear and facial nerve anatomy. There were no intraoperative or postoperative complications. The mean follow-up was 12.4 months (range, 3.9-25.2 mo). All three patients use their device daily. Their guardians report improved vocalization and environmental awareness.

Conclusions: The modified Rambo transcanal approach provides a safe corridor for cochlear implantation in patients with CHARGE syndrome. This approach minimizes the anatomical variations associated with the syndrome and may reduce the risk of electrode extrusion. Implant outcomes in this patient population remain highly variable based on the patient's global cognitive capacity.
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http://dx.doi.org/10.1097/MAO.0000000000001528DOI Listing
October 2017

Pediatric Langerhans cell histiocytosis of the lateral skull base.

Int J Pediatr Otorhinolaryngol 2017 Aug 15;99:135-140. Epub 2017 Jun 15.

Department of Otolaryngology - Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA. Electronic address:

Objective: Describe the presentation, imaging characteristics, management, and outcomes of pediatric patients with Langerhans cell histiocytosis (LCH) of the temporal bone.

Methods: A retrospective chart review was performed between 2000 and 2014 at a single tertiary care children's hospital. Fourteen patients were identified with a diagnosis of LCH and involvement of the temporal bone.

Results: Ten patients were female and ten were Caucasian. Mean age at diagnosis was 3 years (range 0.3-9.6 years). The most common presenting symptoms were scalp lesions, postauricular lesions, otalgia, and persistent ear infections. Three patients had documented hearing loss. Four cases had otic capsule invasion. Computed tomography demonstrated a lytic temporal bone lesion within the following subsites: mastoid, squamous temporal bone, external auditory canal, middle ear, and petrous apex. Four patients had intracranial disease. Extent and location of disease prompted all patients to be initially managed with chemotherapy. Surgical excision was limited to one case of localized recurrence. After a mean follow-up of 85.2 months (SD 42.4 months) there were no deaths but eight patients had a recurrence. Two patients developed long-term otologic sequelae requiring surgery. One patient developed labyrinthitis ossificans.

Conclusion: LCH has a varied presentation, age distribution, and treatment algorithm. This series of 14 pediatric patients with temporal bone involvement supports a limited role for surgical resection. Long-term follow-up is critical for detection of local and disseminated disease, and for monitoring of otologic complications.
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http://dx.doi.org/10.1016/j.ijporl.2017.06.011DOI Listing
August 2017

Multiple Unilateral Skull Base Defects in a Child With Conductive Hearing Loss.

Otol Neurotol 2017 08;38(7):e209-e210

*University of Texas Southwestern Medical School †Department of Otolaryngology-Head and Neck Surgery ‡Department of Radiology, University of Texas Southwestern Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1097/MAO.0000000000001473DOI Listing
August 2017

Endoscopic Lateral Cartilage Graft Tympanoplasty.

Otolaryngol Head Neck Surg 2017 10 6;157(4):683-689. Epub 2017 Jun 6.

1 Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas, USA.

Objective To describe a novel technique for lateral graft tympanoplasty. Study Design Case series with chart review. Setting Tertiary care university hospital. Subjects and Methods Pediatric and adult patients with tympanic membrane perforations deemed unfavorable for a medial graft technique due to the perforation characteristics or myringitis. Results Between 2014 and 2016, 34 ears from 31 patients underwent a transcanal endoscopic lateral cartilage graft tympanoplasty. The mean age was 24.4 years (range, 6-71 years), and 22 patients (65%) were younger than 18 years. All patients had tympanic membrane perforations. Eighteen patients (53%) had total or near-total perforations, leaving a minimal anterior remnant, and 16 patients (47%) had extensive myringitis. A bisected tragal cartilage-perichondrium shield graft was used in 33 patients (97%). The mean (SD) follow-up length was 9.8 (5.7) months. Initial perforation closure rate was 88.2% (30/34). Three of the persistent perforations underwent a revision endoscopic medial graft tympanoplasty with successful closure, leaving a final closure rate of 97.1% (33/34). Five patients (15%) required topical therapy for postoperative myringitis. Mean (SD) pure-tone average and air-bone gap significantly improved by 11.5 (10.7) dB ( P < .001) and 11.4 (10.6) dB ( P < .001), respectively. Twenty-seven patients (79%) closed their air-bone gap within 20 dB. Conclusion Transcanal endoscopic lateral cartilage graft tympanoplasty is feasible, and initial data support favorable outcomes. Further data are necessary for evaluation of long-term results and efficacy comparisons.
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http://dx.doi.org/10.1177/0194599817709436DOI Listing
October 2017

Transcanal Endoscopic Ear Surgery for Excision of a Facial Nerve Venous Malformation With Interposition Nerve Grafting: A Case Report.

Otol Neurotol 2017 07;38(6):895-899

*Department of Otolaryngology-Head and Neck Surgery †University of Texas Southwestern Medical School ‡Department of Pathology, University of Texas Southwestern Medical Center, Dallas, Texas.

Objective: To illustrate a novel approach for the surgical management of a venous malformation of the facial nerve, including interposition nerve grafting, via an exclusively transcanal endoscopic ear surgery (TEES) approach.

Patient: Thirty nine-year-old woman with a preoperative House-Brackmann (HB) grade IV facial paresis secondary to a facial nerve tumor.

Intervention(s): Surgical excision and interposition nerve graft via a transcanal endoscopic approach.

Main Outcome Measure(s): Completeness of resection, approach morbidities, and facial nerve outcome.

Results: The TEES approach provided wide exposure of the facial nerve from the geniculate ganglion through the mastoid segment. This visualization facilitated gross total tumor resection, incus interposition ossicular reconstruction, and placement of an interposition nerve graft. The nerve graft was positioned in the fallopian canal and was secured at both ends with surgicel. The patient had no postoperative complications. At 11-month follow-up her facial function had returned to HB grade IV.

Conclusions: This is the first report of resecting a venous malformation of the facial nerve with concomitant interposition nerve graft reconstruction via an exclusively endoscopic approach. This report adds to the growing body of evidence that TEES can manage diverse middle ear and lateral skull base pathology. Additional studies are needed to fully elucidate the risk-benefit profile of this technique.
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http://dx.doi.org/10.1097/MAO.0000000000001424DOI Listing
July 2017

Endoscopic Infracochlear Approach for Drainage of Petrous Apex Cholesterol Granulomas: A Case Series.

Otol Neurotol 2017 07;38(6):876-881

*Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center †University of Texas Southwestern Medical School, Dallas, Texas.

Objective: To describe the feasibility and technical nuances of a transcanal endoscopic infracochlear approach for drainage of petrous apex cholesterol granulomas.

Study Design: Retrospective case review.

Setting: Tertiary care university hospital.

Patients: A 32-year-old man with bilateral petrous apex cholesterol granulomas and a 54-year-old man with a left-sided petrous apex granuloma each with symptoms necessitating surgical intervention.

Interventions: Transcanal endoscopic infracochlear approach for drainage of the cholesterol granulomas.

Main Outcome Measures: Operation efficacy, corridor size, and perioperative morbidity.

Results: All three cholesterol granulomas were successful drained without violating the cochlea, jugular bulb, or carotid artery. The dimensions of the infracochlear surgical corridor measured 5 mm × 6 mm, 3.5 mm × 3.5 mm, and 6 mm × 4 mm, respectively. All corridors facilitated visualization within the cyst and allowed lyses of adhesions for additional cyst content eradication. All patients had resolution of their acute symptoms. Two of the three subjects had serviceable hearing before and after their procedures. One patient required revision surgery 2-months after their initial procedure secondary to recurrent symptoms from acute hemorrhage within the cyst cavity. The infracochlear tract in this patient was noted to be patent.

Conclusions: A transcanal endoscopic infracochlear approach is feasible for the management of cholesterol granuloma. The surgical access was wide enough to introduce the endoscope into the petrous apex cavity in each case. Further studies are needed to compare the efficacy and perioperative morbidity versus the traditional postauricular transtemporal approaches.
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http://dx.doi.org/10.1097/MAO.0000000000001422DOI Listing
July 2017

Conductive Hearing Loss From a Jugular Bulb Anomaly.

Otol Neurotol 2017 04;38(4):e15-e16

*University of Texas Southwestern Medical School†Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center‡Department of Radiology, Dallas Children's Medical Center, Dallas, Texas.

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http://dx.doi.org/10.1097/MAO.0000000000001346DOI Listing
April 2017

Long-term outcomes of endolymphatic sac shunting with local steroids for Meniere's disease.

Am J Otolaryngol 2017 May - Jun;38(3):285-290. Epub 2017 Jan 20.

Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA.

Objectives: To evaluate the long-term efficacy of endolymphatic sac shunt techniques with and without local steroid administration.

Study Design: Retrospective case series and patient survey.

Setting: Tertiary university hospital.

Patients: Meniere's disease (MD) patients that failed medical therapy and subsequently underwent an endolymphatic sac shunt procedure. All patients had definitive or probable MD and at least 18-months of follow-up.

Interventions: Three variations on endolymphatic sac decompression with shunt placement were performed: Group A received no local steroids, Group B received intratympanic dexamethasone prior to incision, and Group C received dexamethasone via both intratympanic injection and direct endolymphatic sac instillation.

Main Outcome Measure(s): Vertigo control, hearing results, and survey responses.

Results: Between 2002 and 2013, 124 patients with MD underwent endolymphatic sac decompression with shunt placement. 53 patients met inclusion criteria. Groups A, B, and C had 6 patients, 20 patients, and 27 patients, respectively. Mean follow-up was 56months. Vertigo control improved in 66%, 83%, and 93% of Groups A, B, and C. Functional level improved for Group B (-2.0) and Group C (-2.2) but was unchanged in Group A. Pure-tone average and speech discrimination scores changed by +22dB and -30%, +6dB and -13%, and +6dB and -5% in Groups A, B, and C. The long-term hearing results were significantly better with steroids (Groups B and C) according to the AAO-HNS 1995 criteria but did not meet significance on non-parametric testing.

Conclusions: Endolymphatic sac shunt procedures may benefit from steroid instillation at the time of shunt placement.
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http://dx.doi.org/10.1016/j.amjoto.2017.01.023DOI Listing
April 2018

Endoscopic Management of Middle Ear Paragangliomas: A Case Series.

Otol Neurotol 2017 03;38(3):408-415

*Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center, Dallas, Texas†Department of Otolaryngology-Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee‡Department of Otolaryngology, Universidade Estadual do Ceará, Ceará, Brazil.

Objective: To investigate the efficacy and safety of endoscopic middle ear paraganglioma (glomus tympanicum) resection.

Study Design: Case series with chart review.

Setting: Multi-institutional tertiary university medical centers.

Patients: Adult patients with middle ear paragangliomas treated via a transcanal endoscopic approach from 1/2012 to 11/2015.

Intervention: All tumors were initially approached via a transcanal endoscopic technique. An operating microscope was used only if the tumor could not be adequately visualized or resected with endoscopic techniques alone.

Main Outcome Measures: The main outcome was completeness of tumor resection via the endoscopic technique. Secondary measures were resolution of pulsatile tinnitus, audiometric outcomes, surgical duration, and surgical complications.

Results: Endoscopic resection was attempted on 14 middle ear paragangliomas. Thirteen patients (93%) were women with a mean age of 61.6 years. The mean tumor size was 6.2 mm (SD, 3.3). Eleven cases (79%) had complete resection via an exclusive endoscopic approach. The mean surgical duration was 108.1 minutes (SD, 55.6). One case required use of an operating microscope via a transcanal route and two cases required postauricular incisions with mastoidectomy. There were no significant postoperative complications. Two patients (14%) had tympanic membrane perforations repaired intraoperatively without residual perforation on follow-up. All patients had normal postoperative facial nerve function. Pulsatile tinnitus resolved after surgery in all 13 patients who presented with this symptom preoperatively. The mean pure-tone average improved by 5.9 dB (SD, 4.6) after surgery.

Conclusions: Endoscopic management of middle ear paraganglioma is safe, feasible, and effective.
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http://dx.doi.org/10.1097/MAO.0000000000001320DOI Listing
March 2017

Contemporary management of carotid blowout syndrome utilizing endovascular techniques.

Laryngoscope 2017 02 30;127(2):383-390. Epub 2016 Nov 30.

Ear Nose and Throat Institute, University Hospitals Case Medical Center, Cleveland, Ohio, U.S.A.

Objectives/hypothesis: To illustrate complex interdisciplinary decision making and the utility of modern endovascular techniques in the management of patients with carotid blowout syndrome (CBS).

Study Designs: Retrospective chart review.

Methods: Patients treated with endovascular strategies and/or surgical modalities were included. Control of hemorrhage, neurological, and survival outcomes were studied.

Results: Between 2004 and 2014, 33 patients had 38 hemorrhagic events related to head and neck cancer that were managed with endovascular means. Of these, 23 were localized to the external carotid artery (ECA) branches and five localized to the ECA main trunk; nine were related to the common carotid artery (CCA) or internal carotid artery (ICA), and one event was related to the innominate artery. Seven events related to the CCA/ICA or innominate artery were managed with endovascular sacrifice, whereas three cases were managed with a flow-preserving approach (covered stent). Only one patient developed permanent hemiparesis. In two of the three cases where the flow-preserving approach was used, the covered stent eventually became exposed via the overlying soft tissue defect, and definitive management using carotid revascularization or resection was employed to prevent further hemorrhage. In cases of soft tissue necrosis, vascularized tissues were used to cover the great vessels as applicable.

Conclusions: The use of modern endovascular approaches for management of acute CBS yields optimal results and should be employed in a coordinated manner by the head and neck surgeon and the neurointerventionalist.

Level Of Evidence: 4. Laryngoscope, 2016 127:383-390, 2017.
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http://dx.doi.org/10.1002/lary.26144DOI Listing
February 2017

Use of concurrent chemoradiation in advanced staged (T4) laryngeal cancer.

Am J Otolaryngol 2017 Jan - Feb;38(1):72-76. Epub 2016 Oct 5.

Ear, Nose, and Throat Institute, University Hospitals Cleveland Medical Center, Cleveland, OH, USA. Electronic address:

Hypothesis: Patients with advanced laryngeal cancer sometimes desire organ preservation protocols even if it portends a worse outcome.

Background: To assess outcomes of patients with T4 laryngeal cancer treated with chemoradiation therapy.

Methods: Case series with chart review at a tertiary university hospital. Twenty-four patients with T4 laryngeal cancer all declined total laryngectomy with adjuvant radiation as the primary treatment modality and alternatively received concurrent chemoradiation therapy. The primary outcome was overall survival. Secondary outcomes were rates of tracheotomy dependence, gastric tube dependence, and need for salvage laryngectomy.

Results: All patients had T4 laryngeal disease, 71% had cartilage invasion and 59% had regional metastasis to the neck. Kaplan-Meier analysis determined 2-year and 5-year overall survival to be 64% and 59% respectively. The locoregional recurrence rate was 25%. The distant metastasis rate was 21%. The rate of salvage laryngectomy was 17%, which occurred at a mean of 56.5months after the original diagnosis. The rate of tracheotomy dependence was 33% while gastric tube dependence was 25%.

Conclusion: Advanced T4 laryngeal cancer, particularly with cartilage invasion, remains a surgical disease best treated with total laryngectomy and adjuvant radiation. This data may help guide patients and practitioners considering concurrent chemoradiation therapy for definitive treatment of advanced laryngeal cancer.
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http://dx.doi.org/10.1016/j.amjoto.2016.10.001DOI Listing
October 2017

Posterior Fossa Spontaneous Cerebrospinal Fluid Leaks.

Otol Neurotol 2017 01;38(1):66-72

*Department of Otolaryngology-Head and Neck Surgery, University of Texas Southwestern Medical Center †University of Texas Southwestern Medical School, Dallas, Texas.

Objective: Describe the diagnosis and management of spontaneous lateral skull base cerebrospinal fluid (CSF) leaks that originate from the posterior fossa.

Study Design: Retrospective case review.

Setting: Tertiary university hospital.

Patients: Adult patients from 2005 to 2015 who underwent surgical repair of a spontaneous lateral skull base CSF leak with intraoperative confirmation of a posterior fossa leak source.

Intervention: Surgical repair.

Main Outcome Measures: CSF leak resolution.

Results: Five patients had CSF leaks from the posterior fossa. The mean age at presentation was 54 years old (range, 19-79), the mean body mass index (BMI) was 32.6 (standard deviation [SD], 8.4), and the mean follow-up length was 34.6 months (SD, 19.4). Presentations did not differ from CSF leaks through middle fossa defects, including three patients with a history of meningitis and all patients with clear otorrhea following tympanostomy tube placement. All patients had resolution of the leak after surgical repair, but two patients required revision surgery for persistent leaks and one patient had a postoperative infection. Surgical approaches included one middle fossa, two transmastoid, one combined middle fossa/transmastoid, and one transcanal. Radiographic studies suggested a posterior fossa source in all cases but findings were often subtle.

Conclusion: Posterior fossa CSF leaks represent a rare subset of spontaneous lateral skull base leaks. Diligent radiographic review and intraoperative assessment of the posterior fossa plate are crucial. The size and location of the defect dictates the optimal surgical approach. Surgeons should consider a posterior fossa source in failed repairs or when the initial surgery did not fully evaluate the posterior fossa plate.
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http://dx.doi.org/10.1097/MAO.0000000000001261DOI Listing
January 2017