Publications by authors named "Matthew L Carlson"

346 Publications

New onset tinnitus in the absence of hearing changes following COVID-19 infection.

Am J Otolaryngol 2021 Sep 10;43(1):103208. Epub 2021 Sep 10.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States of America. Electronic address:

Background: A variety of neurosensory symptoms including tinnitus have been associated with COVID-19 infection. While most cases of tinnitus are associated with hearing loss, here we report a case of severe tinnitus following COVID-19 infection with normal thresholds through 8000 Hz.

Case Report: A 49-year-old male presented with new onset severe tinnitus following COVID-19 infection. Tinnitus was bilateral, constant and nonpulsatile. Audiometric evaluation revealed normal threshold through 8000 Hz, with mild hearing loss at 16,000 Hz. Conservative measures including masking strategies failed to mitigate symptoms. A trial of gabapentin 300 mg twice per day improved tinnitus with no notable side effects.

Conclusion: This patient may represent a subpopulation of patients who suffer from severe tinnitus following COVID-19 infection in the setting of largely normal hearing. The pathophysiology may be distinct from the more common hearing loss associated tinnitus and perhaps neuromodulators may play a larger role in mitigating tinnitus in this patient subset.
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http://dx.doi.org/10.1016/j.amjoto.2021.103208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8429075PMC
September 2021

Global Incidence of Sporadic Vestibular Schwannoma: A Systematic Review.

Otolaryngol Head Neck Surg 2021 Aug 31:1945998211042006. Epub 2021 Aug 31.

Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, Texas, USA.

Objective: Ubiquitous throughout the literature and during patient counseling, vestibular schwannoma is often quoted to affect about 1 per 100,000 people. Yet, reports from distinct international populations suggest that the incidence is likely much higher. The objective of the current work was to systematically characterize the global incidence of sporadic vestibular schwannoma.

Data Sources: Scopus, Embase, and PubMed.

Review Methods: Population-based studies reporting incidence rates of sporadic vestibular schwannoma between January 2010 and August 2020 were searched with language restrictions requiring reports to be published in Chinese, English, German, Italian, or Spanish. The protocol was registered with PROSPERO (CRD42021228208) prior to commencement of data collection. PRISMA guidelines for transparent reporting of systematic reviews were followed.

Results: Among 424 citations, 6 publications covering 4 distinct populations from Denmark, the Netherlands, Taiwan, and the United States met inclusion criteria. Most recent incidence rates of among all ages ranged between 3.0 and 5.2 per 100,000 person-years. Highest incidence rates were reported among patients aged ≥70 years, peaking at 20.6 per 100,000 person-years. One study from the United States reported the incidence of asymptomatic, incidentally diagnosed tumors at a rate of 1.3 per 100,000 person-years from 2012 to 2016.

Conclusions: Recent international incidence rates of sporadic vestibular schwannoma exceed the commonly quoted "1 per 100,000" figure by up to 5-fold among all ages and by up to 20-fold among age groups at highest risk. Based on modern incidence rates, the lifetime prevalence of developing sporadic vestibular schwannoma likely exceeds 1 per 500 persons.
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http://dx.doi.org/10.1177/01945998211042006DOI Listing
August 2021

Development of the National Otolaryngology Interest Group: Conception to Implementation.

Otolaryngol Head Neck Surg 2021 Aug 3:1945998211033237. Epub 2021 Aug 3.

Boston University School of Medicine, Boston, Massachusetts, USA.

Otolaryngology is a small and highly sought-after surgical subspecialty with sparse residency positions, making it competitive to match into. Allopathic (MD) students without home otolaryngology residency programs, osteopathic (DO) medical students, and underrepresented minorities have historically faced additional challenges in matching into otolaryngology. These specific populations generally experience limited opportunities in establishing mentors, engaging in scholarly activity, and gaining early exposure to clinical settings. Even though the American Osteopathic Association and the Accreditation Council for Graduate Medical Education merger was in part established to create equity among applicants, there remains a substantial disparity among the match rates of medical students of various educational and cultural backgrounds. The National Otolaryngology Interest Group is a student-led interest group created to provide all medical students, especially those facing barriers, with the resources needed to best prepare for matching into an otolaryngology residency program and ultimately a career in otolaryngology.
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http://dx.doi.org/10.1177/01945998211033237DOI Listing
August 2021

Vestibular Schwannomas. Reply.

N Engl J Med 2021 07;385(4):381-382

Mayo Clinic, Rochester, MN

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http://dx.doi.org/10.1056/NEJMc2108279DOI Listing
July 2021

Lifetime Cost and Quality-Adjusted Life-Years Across Management Options for Small- and Medium-Sized Sporadic Vestibular Schwannoma.

Otol Neurotol 2021 Oct;42(9):e1369-e1375

Department of Otolaryngology-Head and Neck Surgery.

Objective: Despite the growing emphasis on healthcare costs, limited data address this aspect of care within the vestibular schwannoma (VS) literature. We sought to determine which strategy confers the lowest lifetime cost and greatest quality-adjusted life-years (QALYs) for patients with small- to medium-sized sporadic VS tumors.

Study Design: A Markov model was created to determine the most cost-effective management algorithm. Tumor characteristics, magnetic resonance imaging surveillance schedule, treatment outcomes, and health-related quality of life values were derived from previously published data. Cost estimates were based on CMS Fee Schedule reimbursement rates.

Setting: Economic Evaluation Service within the Kern Center for the Science of Healthcare Delivery.

Patients: Patients diagnosed with small- to medium-sized sporadic VS.

Interventions: Upfront microsurgery following diagnosis, upfront radiosurgery following diagnosis, observation with microsurgery reserved for observed tumor growth, and observation with radiosurgery reserved for observed tumor growth.

Results: Across patient ages at time of diagnosis ranging from 18 to 70 years, observation with subsequent radiosurgery used for tumor growth was the most cost-effective management algorithm while upfront microsurgery was the least. When presented with a hypothetical 50-year-old patient, the strategy with the lowest lifetime cost and highest QALYs was observation with subsequent radiosurgery reserved for tumor growth ($32,161, 14.11 QALY), followed by observation with microsurgery reserved for tumor growth ($34,503, 13.94 QALY), upfront radiosurgery ($43,456, 14.02 QALY), and lastly, upfront microsurgery ($47,252, 13.60 QALY). Sensitivity analyses varying mortality rates, estimated costs, health-related quality of life, and progression to nonserviceable hearing demonstrated consistent ranking among treatments.

Conclusions: When considering initial management of small- and medium-sized sporadic VSs, neither lifetime cost nor QALYs support upfront microsurgery or radiosurgery, even for younger patients. Initial observation with serial imaging, reserving radiosurgery or microsurgery for patients exhibiting tumor growth, confers the greatest potential for optimized lifetime healthcare cost and QALY outcomes.
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http://dx.doi.org/10.1097/MAO.0000000000003266DOI Listing
October 2021

Does early activation within hours after cochlear implant surgery influence electrode impedances?

Int J Audiol 2021 Jul 18:1-6. Epub 2021 Jul 18.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine, Rochester, MN, USA.

Objective: This study aims to determine if early device activation can influence cochlear implant electrode impedances by providing electrical stimulation within hours after cochlear implant surgery.

Design: Electrode impedances were measured intraoperatively, at device activation, and one-month after device activation in three groups: users whose devices were activated (1) on the same day (Same Day), (2) the next day (Next Day), and (3) 10-14 days (Standard), after cochlear implant surgery.

Study Sample: Electrode impedances are reported in fifty-one patients implanted with a Cochlear™ Nucleus Cochlear Implant.

Results: Compared to intraoperative levels, impedances dropped within hours for the Same Day activation group ( < 0.001) and continued dropping on the next day after surgery ( < 0.001). Similarly, electrode impedances were significantly ( < 0.001) lower at device activation for the Next Day group as compared to their intraoperative measurements. For Standard activation, impedances increased significantly from intraoperative levels, prior to device activation ( < 0.001). One-month after initial activation, impedances were not statistically different between the Same Day, Next Day, and Standard activation groups.

Conclusions: Early device activation does not influence long-term impedances in a clinically meaningful manner.
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http://dx.doi.org/10.1080/14992027.2021.1942569DOI Listing
July 2021

Superior Semicircular Canal Dehiscence Syndrome Following Head Trauma: A Multi-institutional Review.

Laryngoscope 2021 Jul 17. Epub 2021 Jul 17.

Division of Otolaryngology-Head and Neck Surgery, University of Utah School of Medicine, Salt Lake City, Utah, U.S.A.

Objective: To evaluate patients who become symptomatic from superior semicircular canal dehiscence (SSCD) following head trauma.

Study Design: Case series assessing patients presenting with SSCD after a trauma.

Methods: A case series was completed assessing patients presenting with SSCD after trauma. Data from three academic medical centers were evaluated, including the following: imaging, videonystagmography (VNG)/vestibular evoked myogenic potential (VEMP) testing, audiometric assessment, and surgical repair. Outcome measures included the following: 1) Description of audio-vestibular symptoms, 2) mean pre- and post-operative pure tone average (PTA), word recognition score (WRS), and air bone gap (ABG).

Results: A total of 14 patients were included; 86% were male. Approximately 43% were found to have bilateral SSCD on imaging, with 57% of patients pursuing surgical management. The most common presenting symptoms included pulsatile tinnitus (93%), autophony (79%), and hearing loss (64%). Approximately 36% of patients underwent VNG/VEMP testing, with 83.3% of those demonstrating abnormal results. The mean audiometric findings on the symptomatic side included an air-conduction PTA of 38.0 dB, bone-conduction PTA of 24.3 dB, WRS of 81%, and ABG of 17.9 dB. Among patients who underwent surgery (57%), there was no significant change in the air-conduction PTA, bone-conduction PTA, or WRS (P > .05). However, there was an improvement in the ABG (preoperative = 22.8 dB versus postoperative = 9.7 dB; P = .005).

Conclusion: Head trauma may be a potentiating event for SSCD syndrome. This study advances the hypothesis that these patients likely have underlying radiographic SSCD prior to their trauma, and a traumatic event increases in intra-vestibular or intracranial pressures, unmasking SSCD syndrome.

Level Of Evidence: IV Laryngoscope, 2021.
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http://dx.doi.org/10.1002/lary.29751DOI Listing
July 2021

Association of Metformin With Volumetric Tumor Growth of Sporadic Vestibular Schwannomas.

Otol Neurotol 2021 08;42(7):1081-1085

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota.

Objective: Recent research demonstrates a potential association between metformin use and reduced sporadic vestibular schwannoma (VS) growth in patients undergoing conservative observation. The current study was designed to elucidate the effect of metformin on tumor growth in sporadic VS using volumetric analyses.

Study Design: Retrospective cohort.

Setting: Tertiary referral center.

Patients: Patients with sporadic VS who elected initial conservative treatment with at least two serial magnetic resonance imaging (MRI) scans were included.

Interventions: Metformin use among patients with observed sporadic VS.

Main Outcome Measures: Tumor growth, defined as an increase in volume of at least 20% from the initial MRI.

Results: A total of 361 patients were evaluated. Thirty-four patients (9%) had a diagnosis of diabetes at baseline. Nineteen patients (5%) were taking metformin at the time of the initial MRI. Metformin use was not significantly associated with a reduced risk of volumetric tumor growth in a univariable analysis in all patients undergoing observation for VS (hazard ratio [HR] 0.75; 95% confidence intervals [CI] 0.40-1.42; p = 0.38) or within the diabetic subset (HR 0.79; 95% CI 0.34-1.83; p = 0.58). Additionally, diabetes status, insulin dependence, hemoglobin A1c value, and metformin dose were not significantly associated with volumetric tumor growth.

Conclusion: Despite promising initial results in several previous studies, our data suggest that metformin use does not significantly reduce the risk of volumetric tumor growth in sporadic VS.
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http://dx.doi.org/10.1097/MAO.0000000000003149DOI Listing
August 2021

Cochlear implantation after radiosurgery for vestibular schwannoma.

J Neurosurg 2021 07 24;135(1):126-135. Epub 2021 Jun 24.

1Department of Otolaryngology-Head and Neck Surgery, and.

Objective: The object of this study was to ascertain outcomes of cochlear implantation (CI) following stereotactic radiosurgery (SRS) for vestibular schwannoma (VS).

Methods: The authors conducted a retrospective chart review of adult patients with VS treated with SRS who underwent CI between 1990 and 2019 at a single tertiary care referral center. Patient demographics, tumor features, treatment parameters, and pre- and postimplantation audiometric and clinical outcomes are presented.

Results: Seventeen patients (18 ears) underwent SRS and ipsilateral CI during the study period. Thirteen patients (76%) had neurofibromatosis type 2 (NF2). Median age at SRS and CI were 44 and 48 years, respectively. Median time from SRS to CI was 60 days, but notably, 4 patients underwent SRS and CI within 1 day and 5 patients underwent CI more than 7 years after SRS. Median marginal dose was 13 Gy. Median treatment volume at the time of SRS was 1400 mm3 (range 84-6080 mm3, n = 15 patients). Median post-CI PTA was 28 dB HL, improved from 101 dB HL preoperatively (p < 0.001). Overall, 11 patients (12 ears) exhibited open-set speech understanding. Sentence testing was performed at a median of 10 months (range 1-143 months) post-CI. The median AzBio sentence score for patients with open-set speech understanding was 76% (range 19%-95%, n = 10 ears). Two ears exhibited Hearing in Noise Test (HINT) sentence scores of 49% and 95%, respectively. Four patients achieved environmental sound awareness without open-set speech recognition. Two had no detectable auditory percepts.

Conclusions: Most patients who underwent CI following SRS for VS enjoyed access to sound at near-normal levels, with the majority achieving good open-set speech understanding. Implantation can be performed immediately following SRS or in a delayed fashion, depending on hearing status as well as other factors. This strategy may be applied to cases of sporadic or NF2-associated VS.

Abbreviations: AAO-HNS = American Academy of Otolaryngology-Head and Neck Surgery; ABI = auditory brainstem implant; CI = cochlear implantation; CN = cranial nerve; CNC = consonant-nucleus-consonant; CPA = cerebellopontine angle; EPS = electrical promontory stimulation; ESA = environmental sound awareness; HINT = Hearing in Noise Test; IAC = internal auditory canal; NF2 = neurofibromatosis type 2; OSP = open-set speech perception; PTA = pure tone average; SRS = stereotactic radiosurgery; VS = vestibular schwannoma; WRS = word recognition score.
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http://dx.doi.org/10.3171/2020.4.JNS201069DOI Listing
July 2021

Absent pyramidal eminence and stapedial tendon associated with congenital stapes footplate fixation: Intraoperative and radiographic findings.

Am J Otolaryngol 2021 Jun 18;42(6):103144. Epub 2021 Jun 18.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States of America. Electronic address:

Objective: Report an association between congenital stapes footplate fixation (CSFF) and radiological absence of the pyramidal eminence and stapedial tendon.

Patients: Children and adults with intraoperatively confirmed CSFF and an absent stapedial tendon.

Interventions: Computed tomography (CT); exploratory tympanotomy with stapedotomy.

Main Outcome Measures: Absence of a pyramidal eminence and stapedial tendon aperture identified on preoperative CT that was confirmed intraoperatively.

Results: Eight patients with intraoperative confirmation of CSFF and absent stapedial tendon were retrospectively identified. The average preoperative bone conduction and air conduction pure tone averages were 19.6 dB (SD 15.6 dB) and 55.9 dB (SD 23.6 dB), respectively. The average air-bone gap was 36.3 dB (SD 17.9 dB) preoperatively. In the seven patients who underwent preoperative CT, all were consistently identified to have an absent or hypoplastic pyramidal eminence and absent stapedial tendon aperture at the pyramidal eminence. In six cases, the stapedial footplate appeared normal, while in one case the footplate appeared abnormal which correlated with severe facial nerve prolapse observed intraoperatively. All eight cases underwent exploratory tympanotomy and demonstrated intraoperative stapes footplate fixation, absent stapedial tendon and either absent or hypoplastic pyramidal eminence, which correlated with preoperative CT findings.

Conclusions: This study identifies a clinically pragmatic association between an absent pyramidal eminence identified on high-resolution CT and the diagnosis of CSFF. In a condition that otherwise generally lacks distinctive radiological features, the absence of a pyramidal eminence on CT in a patient with nonprogressive, congenital conductive hearing loss may strengthen clinical suspicion for CSFF.
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http://dx.doi.org/10.1016/j.amjoto.2021.103144DOI Listing
June 2021

Tympanic Membrane Pneumatocele from Auto-insufflation.

Ann Otol Rhinol Laryngol 2021 Jun 18:34894211024045. Epub 2021 Jun 18.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.

Objective: The differential of an external auditory canal mass is broad. One rare potential cause is a pneumatocele of the tympanic membrane, which has only been described 1 other time in the literature. This report serves to describe the second case of this pathology, including its unique presentation, and benign clinical course.

Methods: Case report.

Results: A case is discussed in which a pneumatocele of the tympanic membrane was incidentally identified during evaluation of contralateral otologic pathology. The etiology was suspected to be habitual auto-insufflation. After cessation of this practice, the pneumatocele was noted to resolve without further intervention.

Conclusion: A tympanic membrane pneumatocele represents a rare cause of an external auditory canal mass. The diagnosis can be made clinically via history, palpation, and otoscopy during auto-insufflation, potentially avoiding further diagnostic testing. Depending on the etiology, resolution can occur after lifestyle modification; however, further interventions may definitively treat the condition if so required.
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http://dx.doi.org/10.1177/00034894211024045DOI Listing
June 2021

Natural History of Growing Sporadic Vestibular Schwannomas During Observation: An International Multi-Institutional Study.

Otol Neurotol 2021 Sep;42(8):e1118-e1124

Department of Oto-rhinolaryngology-Head and Neck Surgery, and Audiology Copenhagen University Hospital Rigshospitalet.

Objective: Active treatment of small- or medium-sized vestibular schwannoma during wait-and-scan management is currently recommended at most centers globally once growth is detected. The primary aim of the current study was to characterize the natural history of growing sporadic vestibular schwannoma during observation.

Study Design: Cohort study.

Setting: Four tertiary referral centers across the United States and Denmark.

Patients: Patients with two prior MRI scans demonstrating ≥2 mm of linear growth who continued observational management.

Intervention: Observation with serial imaging.

Main Outcome Measure: Subsequent linear growth-free survival (i.e., an additional ≥2 mm of growth) following initial growth of ≥2 mm from tumor size at diagnosis.

Results: Among 3,402 patients undergoing observation, 592 met inclusion criteria. Median age at initial growth was 66 years (IQR 59-73) for intracanalicular tumors (N = 65) and 62 years (IQR 54-70) for tumors with cerebellopontine angle extension (N = 527). The median duration of MRI surveillance following initial detection of tumor growth was 5.2 years (IQR 2.4-6.9) for intracanalicular tumors and 1.0 year (IQR 1.0-3.3) for cerebellopontine angle tumors. For intracanalicular tumors, subsequent growth-free survival rates (95% CI; number still at risk) at 1, 2, 3, 4, and 5 years following the initial MRI that demonstrated growth were 77% (67-88; 49), 53% (42-67; 31), 46% (35-60; 23), 34% (24-49; 17), and 32% (22-47; 13), respectively. For cerebellopontine angle tumors, subsequent growth-free survival rates were 72% (68-76; 450), 47% (42-52; 258), 32% (28-38; 139), 26% (21-31; 82), and 22% (18-28; 57), respectively. For every 1 mm increase in magnitude of growth from diagnosis to tumor size at detection of initial growth, the HRs associated with subsequent growth were 1.64 (95% CI 1.25-2.15; p < 0.001) for intracanalicular tumors and 1.08 (95% CI 1.01-1.15; p = 0.02) for cerebellopontine angle tumors.

Conclusions: Growth detected during observation does not necessarily portend future growth, especially for slowly growing tumors. Because early treatment does not confer improved long-term quality of life outcomes, toleration of some growth during observation is justifiable in appropriately selected cases.
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http://dx.doi.org/10.1097/MAO.0000000000003224DOI Listing
September 2021

Underreporting of Vestibular Schwannoma Incidence Within National Brain Tumor and Cancer Registries in the United States.

Otol Neurotol 2021 07;42(6):e758-e763

Department of Otolaryngology-Head and Neck Surgery.

Objective: Reports using large brain tumor and cancer registries suggest that the incidence of vestibular schwannoma is considerably lower in the United States compared with other countries. The current study compares the incidence and disease characteristics of vestibular schwannoma within a large tertiary referral center's brain tumor and cancer registry using nationally mandated reporting protocols to disease incidence in the same population using an externally validated population-based consortium.

Study Design: Population-based study spanning 1,945,007 person-years.

Setting: Large tertiary referral center.

Patients: Adults with sporadic vestibular schwannoma.

Main Outcome Measure: Disease incidence rates from 2004 to 2016.

Results: From 2004 to 2016, the incidence of vestibular schwannoma in the tumor registry was 1.3 per 100,000 person-years whereas the population-based cohort had an incidence of 4.4 per 100,000 person-years. From 2012 to 2016, the incidence in the tumor registry was 1.4 per 100,000 person-years compared with 5.2 in the population-based cohort. Patients within the population-based cohort were significantly more likely to have smaller tumors at diagnosis (78% intracanalicular versus 45%; p = 0.004) and consequently more likely to undergo management consisting of observation with serial imaging as opposed to treatment with either microsurgery or radiosurgery (71% versus 28%; p = 0.001).

Conclusions: The reliance on pathology specimens and cancer-related treatment data for the national registration of new cancer and brain tumor diagnoses may introduce selection bias and underreporting of benign brain tumors that frequently involve observation as a primary treatment modality. This selection bias likely accounts for the discrepant incidence rates of vestibular schwannoma reported between the United States and other countries.
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http://dx.doi.org/10.1097/MAO.0000000000003049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8192892PMC
July 2021

Differential Impact of Advanced Age on Clinical Outcomes After Vestibular Schwannoma Resection in the Very Elderly: Cohort Study.

Oper Neurosurg (Hagerstown) 2021 Aug;21(3):104-110

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota.

Background: Vestibular schwannomas (VS) have a peak incidence in the sixth and seventh decades of life. Stereotactic radiosurgery is often the preferred treatment for VS among patients of advanced age. The fraction of elderly patients potentially requiring consideration for surgical treatment is anticipated to expand, mandating an update to management paradigms in this population.

Objective: To describe our experience with surgical management of VS in patients aged 75 yr and older.

Methods: Cohort study of all patients aged ≥75 yr with sporadic VS requiring surgical treatment at our institution between 1999 and 2020. Data included preoperative baseline characteristics and outcome data including extent of resection, facial nerve and hearing status, functional outcome, length of stay, and complications.

Results: A total of 24 patients were included, spanning an age range of 75 to 90 yr. Average tumor size was 2.76 ± 1.04 cm, and average baseline Modified 5-item Frailty Index (mFI-5) score was 1.08 ± 0.93. Extent of resection was gross total in 5 (20.8%), near total in 3 (12.5%), and sub-total resection in the remaining 16 (66.7%). One patient died in the postoperative period because of an acute sub-dural hematoma. Favorable facial nerve function (HB1-2) was preserved in 12 patients (75%) between 75 and 79 yr and 2 patients (28.6%) aged ≥ 80 yr. No cerebrospinal fluid leak or surgical site infection was observed; 3 patients developed hydrocephalus requiring ventriculo-peritoneal shunt placement. Nine patients required out-of-home disposition; all patients eventually returned to independent living.

Conclusion: Microsurgical resection of VS can be safely undertaken in patients greater than 75 y/o but may carry an increased risk of poor facial function.
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http://dx.doi.org/10.1093/ons/opab170DOI Listing
August 2021

Preoperative embolization of jugular paraganglioma tumors using particles is safe and effective.

Interv Neuroradiol 2021 May 26:15910199211019175. Epub 2021 May 26.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, United States.

Background: Jugular paragangliomas represent a surgical challenge due to their vascularity and proximity to vital neurovascular structures. Preoperative embolization aids in reducing intraoperative blood loss, transfusion requirements, and improves surgical visualization. Several embolization agents have been used.

Objective: The aim of this study is to evaluate the safety and efficacy of PVA in pre-operative embolization of jugular paragangliomas.

Methods: A retrospective review of all patients who underwent jugular paraganglioma resection with pre-operative embolization between 2000 and 2020 was performed. Pre-operative data including baseline patient and tumor characteristics were documented. Outcomes of preoperative embolization including extent of devascularization and post-embolization complications were recorded. Early and long-term postoperative outcomes were reported.

Results: Twenty-nine patients met study criteria with a median age of 38 years. Average tumor size was 3.4±1.8 cm. The most commonly encountered arterial feeder was the ascending pharyngeal artery followed by the posterior auricular artery. More than 50% reduction in tumor blush was achieved in 25 patients (86.2%). None of the patients experienced new or worsening cranial neuropathy following embolization. Gross total or Near total resection was achieved in 13 patients (44.8%). A STR or NTR was chosen in these patients to preserve cranial nerve function or large vessel integrity. Average intraoperative estimated blood loss was 888 ml, 9 patients (31%) required intra-operative transfusion of blood products. Extent of resection and post-operative complications did not correlate with extent of devascularization.

Conclusion: Pre-operative embolization of jugular paraganglioma tumors with PVA particles is an effective strategy with a high safety profile.
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http://dx.doi.org/10.1177/15910199211019175DOI Listing
May 2021

Electrocochleography in cochlear implantation: Development, applications, and future directions.

World J Otorhinolaryngol Head Neck Surg 2021 Apr 4;7(2):94-100. Epub 2020 Jun 4.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, USA.

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http://dx.doi.org/10.1016/j.wjorl.2020.04.006DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8103527PMC
April 2021

Generating a Social Media Ontology for Otology and Neurotology.

Otol Neurotol 2021 06;42(5):635-637

Department of Otolaryngology-Head and Neck Surgery, San Antonio Uniformed Services Health Education Consortium, JBSA-Fort Sam Houston, Texas.

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http://dx.doi.org/10.1097/MAO.0000000000003170DOI Listing
June 2021

Degree of preoperative hearing loss predicts time to early mobilization following vestibular schwannoma microsurgery.

Am J Otolaryngol 2021 Apr 21;42(6):103073. Epub 2021 Apr 21.

Division of Otolaryngology-Head and Neck Surgery, Department of Surgery, University of Utah, Salt Lake City, UT, United States of America. Electronic address:

Objective: To test the hypothesis that severe to profound preoperative hearing loss predicts less acute postoperative vestibulopathy following microsurgical removal of vestibular schwannoma (VS) allowing for earlier postoperative mobilization and hospital discharge.

Methods: Patients with VS who underwent microsurgery and were found to have preoperative severe to profound hearing loss (pure tone average [PTA] > 70 dB HL) were matched 1:1 by age and tumor size to a group of randomly selected controls with preoperative serviceable hearing.

Results: A total of 57 patients met inclusion criteria and were matched to controls. Median age at the time of microsurgery was 56 years. The median PTA and WRS for cases were 91 dB HL (interquartile range [IQR] 78-120) and 0% (IQR 0-0), respectively. Median tumor size was 14.2 mm (IQR 10.9-20.9). A total of 35 (61%) patients exhibited nystagmus after surgery associated with acute vestibular deafferentation. Median time to ambulation in the hallway was 2 days. Controls exhibited similar tumor size (12.7 mm, p = 0.11) and age (57 years, p = 0.52). Preoperative hearing loss did not predict severity or duration of postoperative nystagmus or days to discharge; however, those with Class D hearing exhibited a shorter time to ambulation (p = 0.04).

Conclusion: Following microsurgical removal of VS, preoperative profound hearing loss was associated with a shorter time to postoperative mobilization; however, there were no observed associations with duration or severity of nystagmus and time to hospital discharge. Although not a predictor of nystagmus, preoperative profound hearing loss may portend quicker recovery from clinically significant postoperative vestibulopathy.
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http://dx.doi.org/10.1016/j.amjoto.2021.103073DOI Listing
April 2021

Long-term outcomes of grade I/II skull base chondrosarcoma: an insight into the role of surgery and upfront radiotherapy.

J Neurooncol 2021 Jun 27;153(2):273-281. Epub 2021 Apr 27.

Departments of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA.

Purpose: To clarify the need for post-operative radiation treatment in skull base chondrosarcomas (SBCs).

Methods: A retrospective analysis of patients with grade I or II SBC. Patients were divided according to post-surgical treatment strategies: (A) planned upfront radiotherapy and (B) watchful waiting. Tumor control and survival were compared between the treatment groups. The median follow-up after resection was 105 months (range, 9-376).

Results: Thirty-two patients (Grade 1, n = 16; Grade 2, n = 16) were included. The most frequent location was petroclival (21, 64%). A gross total resection (GTR) was achieved in 11 patients (34%). Fourteen (44%) underwent upfront radiotherapy (group A) whereas 18 (56%) were followed with serial MRI alone (group B). The tumor control rate for the entire group was 77% and 69% at 10- and 15-year, respectively. Upfront radiotherapy (P = 0.25), extent of resection (P = 0.11) or tumor grade (P = 0.83) did not affect tumor control. The majority of Group B patients with recurrent tumors (5/7) obtained tumor control with repeat resection (n = 2), salvage radiotherapy (n = 2), or a combination of both (n = 1). The 10-year disease-specific survival was 95% with no difference between the group A and B (P = 0.50).

Conclusion: For patients with grade I/II SBC, a reasonable strategy is deferral of radiotherapy after maximum safe resection until tumor progression or recurrence. At that time, most patients can be successfully managed with salvage radiotherapy or surgery. Late recurrences may occur, and life-long follow-up is advisable.
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http://dx.doi.org/10.1007/s11060-021-03764-0DOI Listing
June 2021

Potential for selection bias surrounding reporting of benign brain tumors in the United States.

Neuro Oncol 2021 06;23(6):1037-1038

Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA.

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http://dx.doi.org/10.1093/neuonc/noab059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8168805PMC
June 2021

Vestibular Schwannomas.

N Engl J Med 2021 04;384(14):1335-1348

From the Departments of Otolaryngology-Head and Neck Surgery and Neurologic Surgery, Mayo Clinic, Rochester, MN.

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http://dx.doi.org/10.1056/NEJMra2020394DOI Listing
April 2021

Language and Audiological Outcomes Among Infants Implanted Before 9 and 12 Months of Age Versus Older Children: A Continuum of Benefit Associated With Cochlear Implantation at Successively Younger Ages.

Otol Neurotol 2021 06;42(5):686-693

Department of Otolaryngology-Head and Neck Surgery.

Objective: To compare language and audiological outcomes among infants (<9 and <12 mo) and older children receiving cochlear implantation (CI).

Study Design: Retrospective chart review.

Setting: Tertiary academic referral center.

Patients: Pediatric patients receiving CI between October 1995 and October 2019.

Intervention: Cochlear implantation.

Main Outcome Measures: Most recent language and audiological assessment scores were evaluated by age group.

Results: A total of 118 children were studied, including 19 who were implanted <9 months of age, 19 implanted 9 to <12 months of age, and 80 implanted 12 to <36 months of age. The mean duration of follow-up was 7.4 ± 5.0 years. Most recent REEL-3 receptive (88 ± 12 vs. 73 ± 15; p = 0.020) and expressive (95 ± 13 vs. 79 ± 12; p = 0.013) communication scores were significantly higher in the <9 months group compared to the 9 to <12 months group. PLS and OWLS auditory comprehension and oral expression scores were significantly higher in the <12 months group compared to the 12 to <36 months group. The difference in NU-CHIPS scores between <12 and 12 to <36 months was statistically significant (89% ± 6 vs. 83% ± 12; p = 0.009). LNT scores differed significantly between <9 and 9 to <12 months (94% ± 4 vs. 86% ± 10; p = 0.028).

Conclusions: The recent FDA expansion of pediatric CI eligibility criteria to include infants as young as 9 months of age should not serve as a strict clinical cutoff. Rather, CI can be pursued in appropriately selected younger infants to optimize language and audiological outcomes.
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June 2021

Prevalence of Surgical, Anesthetic, and Device-related Complications Among Infants Implanted Before 9 and 12 Months of Age Versus Older Children: Evidence for the Continued Expansion of Pediatric Cochlear Implant Candidacy Criteria.

Otol Neurotol 2021 07;42(6):e666-e674

Department of Otolaryngology-Head and Neck Surgery.

Objective: To compare the prevalence of surgical, anesthetic, and device-related complications among infants and older children receiving cochlear implantation (CI).

Study Design: Retrospective chart review.

Setting: Tertiary academic referral center.

Patients: Pediatric patients who underwent CI from November 1990 to January 2020.

Intervention: CI.

Main Outcome Measures: Surgical, anesthetic, and device-related complication rates were compared by age group (<12 versus 12-23 versus 24+ months with subset analysis of <9 versus 9-11 months).

Results: A total of 406 primary pediatric CI surgeries encompassing 482 ears were analyzed, including 45 ears in 23 patients implanted less than 9 months and 89 ears in 49 patients less than 12 months. No anesthetic complications occurred. Postoperative surgical and device-related complication rates were not significantly different among the less than 12, 12 to 23, and 24+ month groups (16% versus 16% versus 12%; p = 0.23) or between the less than 9 and 9 to 11 month groups (22% versus 9%; p = 0.09). Thirty-day readmission was significantly higher for patients less than 12 months compared with patients 24+ months (6% versus <1%; p = 0.011), but was not significantly higher compared with patients 12 to 23 months (6% versus 3%; p = 0.65). Reoperation rates did not differ significantly among the less than 12, 12 to 23, and 24+ month groups (10% versus 7% versus 6%; p = 0.31).

Conclusions: The prevalence of surgical, anesthetic, and device related complications was not significantly different among infants implanted less than 9 or less than 12 months of age when compared with older children. These data provide evidence for the continued expansion of pediatric cochlear implant candidacy criteria to include appropriately selected infants less than 9 months of age.
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http://dx.doi.org/10.1097/MAO.0000000000003060DOI Listing
July 2021

Acute Sialadenitis After Skull Base Surgery: Systematic Review and Summative Practice Recommendations.

World Neurosurg 2021 06 5;150:205-210.e1. Epub 2021 Mar 5.

Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota, USA; Department of Otolaryngology, Mayo Clinic, Rochester, Minnesota, USA. Electronic address:

Background: Sialadenitis is a rare complication of skull base neurosurgery, in which the submandibular gland undergoes acute inflammation with edema after surgery. Although attributable to transient obstruction or manual compression, presentation may be rapidly life-threatening as a result of airway obstruction. Understanding risk factors is limited at present, and no practical management guidelines have been reported. Our objective was to survey the literature and to characterize the associated risk factors, treatment considerations, and overall trends in outcomes for patients experiencing post skull base neurosurgery sialadenitis.

Methods: A search of the Ovid EMBASE, SCOPUS, and PubMed databases from inception through August 2020 was performed via Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.

Results: Systematic review identified 13 publications describing 18 cases of acute sialadenitis after skull base surgery. We describe the 19th reported case. Commonalities include the need for aggressive respiratory support as intubation or emergent tracheostomy is almost universally required. Risk factors are poorly understood but may include extreme flexion and/or rotation of the head and neck. Outcomes are favorable overall, although secondary complications have been described.

Conclusions: Sialadenitis is a rare but potentially life-threatening complication of skull base neurosurgery, owing to acute loss of airway and the potential for a diverse array of secondary complications.
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http://dx.doi.org/10.1016/j.wneu.2021.02.124DOI Listing
June 2021

Barriers to Access and Health Care Disparities Associated With Cochlear Implantation Among Adults in the United States.

Mayo Clin Proc 2021 03;96(3):547-549

Department of Otolaryngology-Head and Neck Surgery and Department of Neurologic Surgery, Mayo Clinic, Rochester, MN. Electronic address:

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http://dx.doi.org/10.1016/j.mayocp.2020.08.027DOI Listing
March 2021

The importance of imaging in diagnosis of infected otogenic pneumatoceles.

Am J Otolaryngol 2021 Jul-Aug;42(4):102981. Epub 2021 Feb 16.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN, United States of America. Electronic address:

Objective: Spontaneous otogenic pneumatocele is a rare entity resulting from a pressure gradient between a dehiscent temporal bone and the intracranial space. Secondary infection can ensue in patients with concurrent otomastoiditis. The current study discusses the clinical presentation and imaging characteristics of two cases of secondarily infected otogenic pneumatoceles.

Study Design: Case series.

Results: Two patients were diagnosed with a temporal lobe abscess in the setting of otogenic pneumatocele. Diagnosis was aided by both CT and MRI demonstrating a diffusion restricting lesion within brain parenchyma in association with free air in close proximity to an underlying tegmen defect.

Conclusion: Prompt diagnosis of a secondarily infected otogenic pneumatocele with CT and MRI allows for surgical drainage with closure of the tegmen defect to prevent further complications and recurrence.
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http://dx.doi.org/10.1016/j.amjoto.2021.102981DOI Listing
February 2021

Impact of Treatment on Vestibular Schwannoma-Associated Symptoms: A Prospective Study Comparing Treatment Modalities.

Otolaryngol Head Neck Surg 2021 Sep 26;165(3):458-464. Epub 2021 Jan 26.

Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, Minnesota, USA.

Objective: The degree to which various treatment modalities modify vestibular schwannoma (VS)-associated symptoms has received limited attention. The purpose of this study was to determine how different treatment modalities affect subjective symptoms in those presenting with VS.

Study Design: Prospective survey.

Setting: Tertiary neurotology referral center.

Methods: Patients with sporadic VS who received treatment at our institution were prospectively surveyed with a VS symptom questionnaire. Those who completed a baseline survey prior to treatment and at least 1 posttreatment survey were included. The prospective survey evaluated the severity of self-reported symptoms (Likert scale, 1-10), including tinnitus, dizziness or imbalance, headaches, and hearing loss.

Results: A total of 244 patients were included (mean age, 57 years). The mean duration of follow-up was 2.1 years, and the median number of surveys completed was 2 (interquartile range, 1-3). Seventy-eight (32%) cases were managed with observation, 118 (48%) with microsurgery, and 48 (20%) with radiosurgery. Multivariable analyses revealed no statistically significant difference in the change in tinnitus ( = .15), dizziness or imbalance ( = 0.66), or headaches ( = .24) among treatment groups. Evaluation of clinically important differences demonstrated that microsurgery leads to significant bidirectional changes in headaches.

Conclusions: Limited prospective data exist regarding the progression or resolution of subjective symptoms in those presenting with VS. This study suggests that tinnitus, dizziness or imbalance, and headaches are unlikely to be significantly modified by treatment modality and generally should not be used to direct treatment choice.
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http://dx.doi.org/10.1177/0194599820986564DOI Listing
September 2021

A Journey Through 100 Years of Vestibular Schwannoma Surgery at Mayo Clinic: A Historical Illustrative Case Series.

Otol Neurotol 2020 Dec;41(10):e1379-e1392

Department of Otolaryngology-Head and Neck Surgery.

: The present state of vestibular schwannoma (VS) management is the product of over a century of technical progress by revolutionary surgeons who transformed a once perilous operation. At the beginning of the 1900s, patients who did not succumb to their disease were treated exclusively with surgery, which itself was almost assuredly devastating. Through the pioneering work of surgeons such as Harvey Cushing, Walter Dandy, William House, and others, safer surgical approaches were established with concurrent advances in neuromonitoring, neuroanesthesia, radiology, and adoption of the operating microscope. Owing to refinements in radiosurgical treatment and a greater understanding of the natural history of disease, there has been a dramatic shift toward more conservative management in recent years. For more than 100 years, the Mayo Clinic in Rochester, MN, has maintained an active and uninterrupted VS practice with activities that are well documented and preserved through the Mayo Clinic historical archives. We herein report representative early cases to illustrate the fascinating evolution in VS surgery over the past century at a single-tertiary referral center. Original clinical, imaging, pathology, and operative reports are presented from each era of management. To accurately portray the medical context of each era, antiquated terminology is intentionally preserved as originally transcribed.
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December 2020

Working Toward Consensus on Sporadic Vestibular Schwannoma Care: A Modified Delphi Study.

Otol Neurotol 2020 Dec;41(10):e1360-e1371

Hong Kong Neurosurgical Associates, Hong Kong SAR, People's Republic of China.

Objective: To address variance in clinical care surrounding sporadic vestibular schwannoma, a modified Delphi study was performed to establish a general framework to approach vestibular schwannoma care. A multidisciplinary panel of experts was established with deliberate representation from key stakeholder societies. External validity of the final statements was assessed through an online survey of registered attendees of the 8th Quadrennial International Conference on Vestibular Schwannoma.

Study Design: Modified Delphi method.

Methods: The panel consisted of 16 vestibular schwannoma experts (8 neurotology and 8 neurosurgery) and included delegates representing the AAOHNSF, AANS/CNS tumor section, ISRS, and NASBS. The modified Delphi method encompassed a four-step process, comprised of one prevoting round to establish a list of focus areas and three subsequent voting rounds to successively refine individual statements and establish levels of consensus. Thresholds for achieving moderate consensus, at ≥67% agreement, and strong consensus, at ≥80% agreement, were determined a priori. All voting was performed anonymously via the Qualtrics online survey tool and full participation from all panel members was required before procession to the next voting round.

Results: Through the Delphi process, 103 items were developed encompassing hearing preservation (N = 49), tumor control and imaging surveillance (N = 20), preferred treatment (N = 24), operative considerations (N = 4), and complications (N = 6). As a result of item refinement, moderate (4%) or strong (96%) consensus was achieved in all 103 final statements. Seventy-nine conference registrants participated in the online survey to assess external validity. Among these survey respondents, moderate (N = 21, 20%) or strong (N = 73, 71%) consensus was achieved in 94 of 103 (91%) statements, and no consensus was reached in 9 (9%). Of the four items with moderate consensus by the expert panel, one had moderate consensus by the conference participants and three had no consensus.

Conclusion: This modified Delphi study on sporadic vestibular schwannoma codifies 100% consensus within a multidisciplinary expert panel and is further supported by 91% consensus among an external group of clinicians who regularly provide care for patients with vestibular schwannoma. These final 103 statements address clinically pragmatic items that have direct application to everyday patient care. This document is not intended to define standard of care or drive insurance reimbursement, but rather to provide a general framework to approach vestibular schwannoma care for providers and patients.
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http://dx.doi.org/10.1097/MAO.0000000000002917DOI Listing
December 2020
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