Otolith Dysfunction Is Prevalent in Refractory Benign Paroxysmal Positional Vertigo

Objectives: Determine the prevalence of otolith dysfunction in patients who have failed treatment for benign paroxysmal positional vertigo (BPPV). Methods: Case-control study of patients with BPPV who failed standard treatment and subsequently underwent vestibular testing and supervised vestibular rehabilitation. Interventions included videonystagmography, rotary chair, subjective visual vertical test (SVV), and cervical vestibular evoked myogenic potentials (VEMP). We compared the prevalence of abnormalities in tests of otolith dysfunction (SVV and VEMP) in patients who responded or failed vestibular rehabilitation. Results: In 2012, 46 of 251 patients with BPPV failed initial treatment with canalith repositioning maneuvers performed in the office; of these 46 patients, 28 patients had posterior semicircular canal BPPV and 18 cases had atypical presentations (multicanal BPPV, anterior canal BPPV, or signs of uncompensated unilateral peripheral vestibulopathy). Vestibular testing followed by customized vestibular rehabilitation was completed in 40 patients: 21 patients had resolution of their positional vertigo and nystagmus, and 19 patients did not respond to therapy. Abnormal otolith tests (SVV and/or VEMP) were more common in patients who failed therapy (Pearson Chi square, P = 0.002). Conversely, abnormalities of caloric testing did not predict response to therapy. Conclusions: Abnormalities of utricle and saccular function are prevalent in patients with refractory BPPV. This fact is important to take into account when designing rehabilitation strategies for BPPV patients who fail canalith repositioning maneuvers

Body Mass Index and Imaging Abnormalities in Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone

Objectives: Determine if (1) increased body mass index (BMI) is associated with spontaneous cerebrospinal fluid leak (SCSFL) of the temporal bone when compared with NSCSFL; (2) if body mass index (BMI) is a prognostic factor in the management of SCSFL; (3) if aberrant arachnoid granulations and empty sella are associated with SCSFL when compared to NSCSFL. Methods: Retrospective chart review of patients from 2002 to 2013 of all patients treated for CSFL. Results: Eighteen patients were treated for SCSFL and 17 for NSCSFL between 2002 and 2013. The mean BMI of the SCSFL group was 32.86 (median 33.53). The mean BMI of the NSCSFL group was 28.54 (median 29) ( P = .0683). The average BMI of patients requiring revision surgery was 37.88 compared to patients who only required a single intervention 30.35 ( P = .012). 100% of patients with SCSFL had ectopic arachnoid granulations identified on CT temporal bone while none of the patients with NSCSFL had these ( P < .001). 66% (8/12) of patients with SCSFL had empty sella on MRI compared to 16 % (2/12) of those with NSCSFL ( P = .04). Conclusions: Patients with SCSFL of the temporal bone have an elevated BMI when compared with NSCSFL. The presence of arachnoid granulations and empty sella on diagnostic imaging is associated with SCSFL when compared to NSCSFL. Patients with SCSFL requiring multiple interventions demonstrated a higher BMI than those treated successfully with a single intervention, indicating that this may be a poor prognostic factor

Utricular Dysfunction in Refractory Benign Paroxysmal Positional Vertigo

To determine the prevalence of otolith dysfunction in patients with refractory benign paroxysmal positional vertigo (BPPV). Unmatched case control. Tertiary care institution. Patients included were diagnosed with BPPV, failed initial in-office canalith repositioning maneuvers (CRMs), and completed vestibular testing and vestibular rehabilitation (n = 40). Refractory BPPV (n = 19) was defined in patients whose symptoms did not resolve despite vestibular rehabilitation. These patients were compared with a control group of those with nonrefractory BPPV (n = 21) for results of a caloric test, cervical vestibular evoked myogenic potential (cVEMP), and subjective visual vertical (SVV). Forty-six of 251 patients failed initial treatment with in-office CRM. Forty patients met inclusion criteria. There was no significant difference between the cases (refractory BPPV) (n = 19) and controls (nonrefractory BPPV) (n = 21) in terms of age, duration of symptoms, laterality of BPPV, and BPPV symptoms. There was no difference in the prevalence of caloric weakness and cVEMP abnormalities (P > .05), with odds ratios (ORs [95% confidence interval (CI)]) of having abnormal results among cases vs controls of 1.1818 (0.3329-4.1954) and 4.3846 (0.7627-25.2048), for caloric and cVEMP, respectively. Abnormal eccentric SVV was more prevalent in refractory BPPV cases (58%) than in controls (14%) (P < .0072). The OR (95% CI) of having abnormal SVV was 8.25 (1.7967-37.8822) higher among patients with refractory BPPV than those with nonrefractory BPPV. Patients with refractory BPPV are more likely to have abnormal eccentric SVV and thus underlying utricular dysfunction. This finding is important to take into account when designing rehabilitation strategies for patients with BPPV who fail CRM

Transcanal Approach for Removal of Displaced Petrous Carotid Aneurysm Embolization Coil in the Middle Ear

Introduction: Aneurysms arising from the petrous segment of the internal carotid artery (ICA) are rare. Surgical treatment of petrous ICA aneurysms can be challenging due to their close proximity to inner ear structures. In this case, a rare complication of endovascular coiling is described of a patient who presented with ear bleeding, pulsatile tinnitus, and hearing loss shortly after undergoing the embolization procedure. This case report describes our unique management of the patient through intraoperative removal of the displaced coil through a transcanal approach and correction of the tympanic membrane perforation. Case Description: Patient is a 55-year-old woman who was found to have a left petrous ICA aneurysm coursing through the middle ear cavity over the cochlear promontory. She underwent endovascular stenting and coiling of the left petrous ICA. However, immediately after the surgery, the patient had ear bleeding, acute loss of hearing in the left ear, as well as complaints of pulsatile popping and crackling sounds in the ear. Physical examination revealed a tympanic membrane perforation and extrusion of the embolization coil through the perforation. She was scheduled to undergo a transcanal approach to access, clip, and remove the coil from the middle ear. Procedure: Exploration of the middle ear revealed that the ossicular chain was eroded at the level of the incus, and that the coil was filling the majority of the middle ear space. Excess coil was clipped and removed from the middle ear. A conchal bowl cartilage graft was removed and fashioned to be placed medial to the tympanic membrane remnant and lateral to the remaining middle ear, coiling to prevent future extrusion of the coil. Follow-Up: On follow-up 1 month after the procedure, the patient was satisfied to have resolution of her pulsatile crackling and popping sounds. On examination, the cartilage graft was well in place, with complete epithelialization of the tympanic membrane perforation. On 4-month follow-up, she remained free of any ear infections, continued to demonstrate full closure of the perforation with cartilage graft in place, and had no symptoms of tinnitus. Conclusions: This case is a rare example of a complication arising from endovascular treatment of petrous ICA aneurysms using coil embolization. As evidenced in this case, close attention should be given to otologic symptoms postoperatively after endovascular embolization of petrous ICA aneurysms. Our surgical technique to remove the excess coil, and repair the tympanic membrane provided the patient with improvement of her symptoms. In particular, the use of a cartilage graft to protect the remaining coil from protruding through the tympanic membrane proved especially useful

Spontaneous CSF Rhinorrhea: Prevalence of Multiple Simultaneous Skull Base Defects

Background Spontaneous cerebrospinal fluid (CSF) leaks are caused by intracranial hypertension. Given this underlying etiology, patients may be at risk for developing multiple skull base defects. Objective The purpose of our study is to present the prevalence of multiple simultaneous skull base defects in patients with spontaneous CSF rhinorrhea. Methods We performed a retrospective chart review in a tertiary care practice of 44 consecutive patients with spontaneous CSF rhinorrhea who underwent endoscopic repair by the senior author (R.R.C.) to determine the prevalence of having multiple simultaneous skull base defects identified at the time of surgery. We defined this as two or more bony defects identified endoscopically with intact intervening bone with or without soft tissue prolapse into the nasal cavity or paranasal sinus cavity. Results Eight of 44 patients (18.2%) were found to have multiple simultaneous skull base defects. The average body mass index (BMI) of the study population was 34.5 (range, 22.7-59). Conclusion A significant number of patients with spontaneous CSF rhinorrhea may have more than one skull base defect present at the time of presentation. The clinical significance of this finding in surgical and medical decision making is not clear at this time. </jats:sec

Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors using Onyx

The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.). The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded. Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction). Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization

Conservative management of vestibular schwannoma: Predictors of growth and hearing

To describe the clinical outcomes of patients undergoing serial observation for vestibular schwannoma (VS) and identify factors that may predict tumor growth or hearing loss. Retrospective review. A retrospective review was conducted of patients seen at a tertiary care medical center between 2002 and 2013 with an International Classification of Diseases-9 diagnosis code of 225.1. Patients electing observation as initial management, with at least two documented imaging results, were included. Exclusion criteria comprised bilateral VS, diagnosis of neurofibromatosis type 2, and neoplasms other than VS. Decline in serviceable hearing, tumor growth, and changes in management strategy were recorded. Survival analysis to assess median time to outcomes and multiple logistic regression analyses were performed. A total of 94 patients met inclusion criteria. While undergoing observation, 22.3% of patients underwent a change in management strategy to microsurgical excision or stereotactic radiotherapy. For patients with initial serviceable hearing, 24.3% observed a decline to a nonserviceable level. No significant clinical factors were identified to predict changes in hearing. Survival analysis revealed that an estimated 69.1% of patients electing observation as initial management continued to do so at 5 years. Imbalance or disequilibrium at presentation was found to be associated with an increased adjusted odds ratio (OR) (OR 2.96; 95% confidence interval, 1.03-8.50; P = 0.04) for tumor growth. Serial observation of VS is a viable treatment strategy for selected patients, with two-thirds of patients electing to continue this management option after 5 years. Disequilibrium as a presenting symptom may be associated with subsequent tumor growth. 4

Delayed Wound Infection Associated with Bone Wax in Lateral Skull Base Surgery

Background: Bone wax (Ethicon, Somerville, NJ) is a commonly used agent in neurotologic and skull base procedures. Its pliable nature makes it well suited for both hemostasis, especially for marrow-related bleeding, and obliteration of bony air cell tracts. The objective of this study was to review the first series to our knowledge of delayed wound infections associated with bone wax in lateral skull base surgery. We review the clinical presentations, imaging findings, microbiology, and outcomes. Design: Retrospective case series. Setting: Two tertiary academic referral hospitals. Participants: Five patients underwent lateral skull base surgery for vestibular schwannoma or meningioma and presented with delayed wound infections. All patients underwent operative wound exploration as a part of their treatment. Results: All patients presented with significantly delayed wound complications, from 4 months to 8 years after their original procedure. Purulence and inflammatory tissue surrounding bone wax was noted in each case, and fistula formation in some. Bacterial species cultured included pseudomonas aeruginosa, Proteus mirabilis, staphylococcus epidermidis, and Acremonium species (a fungus). Three of the four cases underwent some form of wound debridement or removal of hardware that was insufficient to clear the infection until a deeper nidus of bone wax was removed. Conclusion: Although a valuable tool in lateral skull base surgery, bone wax should be used sparingly, and perhaps not to obstruct air cells. Residual accumulation of this material can be associated with foreign body reaction, fistula formation, and significantly delayed wound infections