To report our results on hearing preservation after linear accelerator (LINAC)-based stereotactic radiotherapy for vestibular schwannomas (VS) in a tertiary referral center.All patients who presented with VS in our center between 2010 and 2018 and who were treated with LINAC-based radiotherapy were retrospectively analyzed. Pure tone average and speech discrimination score represented hearing outcome, pre- and postradiotherapy. A Gardner-Robertson grade I or II hearing represented functional hearing.In total, 35 patients were treated with LINAC-based radiotherapy. Median age was 55 years (range 18-86 years), 22 (63%) were female. Sixteen patients had a Koos grade III or IV tumor. Twenty-four patients were treated with radiosurgery (1 or 5 fractions; stereotactic radiosurgery), and eleven patients were treated with fractionated stereotactic radiotherapy. Mean follow-up was 4.8 years (range 1.8-8.4 years). In 34 patients, hearing was assessed pre- and post-radiotherapy. In seventeen patients, hearing remained stable. In eleven patients, a decrease in GR scale was observed, of which seven patients showed a decrease from a functional to a non-functional level (4 GR III, 2 GR IV, and 1 GR V). Tumor control was 95% (34/35), and except for hearing loss, all post-radiation complications and morbidity were transient.These data emphasize that although the rate of tumor control (the primary goal of radiotherapeutic treatment) is high, it is important to adequately manage patients' expectations regarding the outcomes of the secondary possibly positive outcome; hearing preservation.
Objectives: Necrotizing otitis externa (NOE) is a rare infection of the ear that causes osteomyelitis. We aimed to evaluate treatment outcomes and the role of imaging in diagnosing and monitoring disease resolution in a single-center study of patients with NOE. Methods: In this retrospective cohort study, patients with NOE who were diagnosed and treated in a tertiary otology center in Utrecht, The Netherlands, between January 1, 2013 and August 1, 2022, were included. Data were retrieved from the medical records on demographics, symptoms, physical and diagnostic findings, type and duration of treatment, and course of disease. Results: A total of 24 cases were included. Patients were often elderly (mean age = 75 years) and diabetic (88%). Pseudomonas aeruginosa was the most commonly found microorganism (63%). Twenty-two cases (92%) received intravenous antibiotic treatment, and 7 cases (29%) received additional systemic antifungal treatment. The mean duration of systemic treatment was 29 weeks. In 20 out of 22 cases (91%), imaging was used to determine the end point of treatment. None of the cases with a total resolution of disease activity (n = 5) on 18 F-fluorodeoxyglucose-positron emission tomography-computed tomography imaging at the time of cessation of therapy showed clinical relapse, compared with 1 out of 4 cases on gallium single-photon emission computerized tomography. Conclusion: Based on the experience from our center, we demonstrated that patients with NOE can successfully be treated with prolonged systemic treatment. Molecular imaging is reasonably successful for disease evaluation and decision-making on the eradication of disease.
The aim of this study was to preoperatively asses the feasibility of drilling a bony recess for the fixation of a cochlear implant in the temporal bone. Even though complications are rare with cochlear implantations, drilling at the site of implantation have resulted in hematoma or cerebrospinal fluid leakage. Mainly in cases with a reduced temporal bone thickness, the risk for complications has increased, such as in paediatric patients. Methods An in-house designed semi-automatic algorithm was developed to analyse a 3D model of the skull. The feasibility of drilling the recess was determined by a gradient descent method to search for the thickest part of the temporal bone. Feasibility was determined by the residual bone thickness which was calculated after a simulated drilling of the recess at the thickest position. An initial validation of the algorithm was performed by measuring the accuracy of the algorithm on five 3D models with known thickest locations for the recess. The accuracy was determined by a part comparison between the known position and algorithm provided position. Results In four of the five validation models a standard deviation for accuracy below the predetermined cut-off value of 4.2 mm was achieved between the actual thickest position and the position determined by the algorithm. Furthermore, the residual thickness calculated by the algorithm showed a high agreement (max. 0.02 mm difference) with the actual thickness. Conclusion With the developed algorithm, a semi-automatic method was created to analyse the temporal bone thickness within a specified region of interest on the skull. Thereby, providing indications for surgical feasibility, potential risks for anatomical structures and impact on procedure time of cochlear implantation. This method could be a valuable research tool to objectively assess feasibility of drilling a recess in patients with thin temporal bones preoperatively.
Abstract Objectives Sigmoid sinus (SS) compression and injury is associated with postoperative SS occlusion and corresponding morbidity. Leaving the SS skeletonized with a thin boney protection during surgery might be favorable. This study quantifies the effect of the SS position on the operative exposure in the translabyrinthine approach and assesses the feasibility of retracting a skeletonized SS. Methods Twelve translabyrinthine approaches were performed on cadaveric heads with varying SS retraction: skeletonized stationary (TL-S), skeletonized posterior retraction (TL-R), and deskeletonized collapsing of the sinus (TL-C). High-definition three-dimensional reconstruction of the resection cavity was obtained. The primary outcome, “surgical freedom” (mm2), was the area at the level of the craniotomy from which the internal acoustic porus could be reached in an unobstructed straight line. Secondary outcomes include the “exposure angle,” “angle of attack,” and presigmoid depth. Results During TL-R, surgical freedom increased by a mean of 41% (range: 9–92%, standard deviation [SD]: 28) when compared to no retraction (TL-S). Collapsing the SS in TL-C provided a mean increase of 52% (range: 19–95%, SD: 22) compared to TL-S. In most cases, the exposure is the greatest when the SS is collapsed. In 40% of the specimens, the provided exposure while retracting (TL-R) instead of collapsing (TL-S) the sinus is equal or greater than 50% of other specimens in which the sinus is collapsed. Conclusion In cases with favorable anatomy, a translabyrinthine resection in which the skeletonized SS is retracted provides comparably sufficient exposure for adequate and safe tumor resection.
Painful neuromas are a devastating condition that is notoriously difficult to treat. The large number of techniques that have been attempted suggest that no one technique is superior. Neuromas often occur in the extremities, but iatrogenically caused pain in the head and neck area has also been described. This article describes 3 consecutive patients diagnosed with traumatic neuroma who underwent transection of the causative nerve, followed by capping of the nerve stump with a Neurocap. With a follow-up of 7 to 24 months, our results show a marked reduction in the pain scores of all 3 patients. The preliminary results indicate that this technique might be a viable treatment option for patients with a suspected neuroma in the head and neck area.
Objectives/Hypothesis To investigate hearing capabilities and self‐reported benefits of simultaneous bilateral cochlear implantation (BiCI) compared with unilateral cochlear implantation (UCI) after a 2‐year follow‐up and to evaluate the learning effect of cochlear implantees over time. Study Design Multicenter randomized controlled trial. Methods Thirty‐eight postlingually deafened adults were included in this study and randomly allocated to either UCI or simultaneous BiCI. Our primary outcome was speech intelligibility in noise, with speech and noise coming from straight ahead (Utrecht–Sentence Test with Adaptive Randomized Roving levels). Secondary outcomes were speech intelligibility in noise with spatially separated sources, speech intelligibility in silence (Dutch phoneme test), localization capabilities and self‐reported benefits assessed with different quality of hearing and quality of life (QoL) questionnaires. This article describes the results after 2 years of follow‐up. Results We found comparable results for the UCI and simultaneous BiCI group, when speech and noise were both presented from straight ahead. Patients in the BiCI group performed significantly better than patients in the UCI group, when speech and noise came from different directions ( P = .01). Furthermore, their localization capabilities were significantly better. These results were consistent with patients' self‐reported hearing capabilities, but not with the questionnaires regarding QoL. We found no significant differences on any of the subjective and objective reported outcomes between the 1‐year and 2‐year follow‐up. Conclusions This study demonstrates important benefits of simultaneous BiCI compared with UCI that remain stable over time. Bilaterally implanted patients benefit significantly in difficult everyday listening situations such as when speech and noise come from different directions. Furthermore, bilaterally implanted patients are able to localize sounds, which is impossible for unilaterally implanted patients. Level of Evidence 1b Laryngoscope , 127:1161–1168, 2017
Abstract Purpose To evaluate the effect of piston diameter in patients undergoing primary stapes surgery on audiometric results and postoperative complications. Methods A retrospective single-center cohort study was performed. Adult patients who underwent primary stapes surgery between January 2013 and April 2022 and received a 0.4-mm-diameter piston or a 0.6-mm-diameter piston were included. The primary and secondary outcomes were pre- and postoperative pure-tone audiometry, pre- and postoperative speech audiometry, postoperative complications, intraoperative anatomical difficulties, and the need for revision stapes surgery. The pure-tone audiometry included air conduction, bone conduction, and air–bone gap averaged over 0.5, 1, 2 and 3 kHz. Results In total, 280 otosclerosis patients who underwent 321 primary stapes surgeries were included. The audiometric outcomes were significantly better in the 0.6 mm group compared to the 0.4 mm group in terms of gain in air conduction (median = 24 and 20 dB, respectively), postoperative air–bone gap (median = 7.5 and 9.4 dB, respectively), gain in air–bone gap (median = 20.0 and 18.1 dB, respectively), air–bone gap closure to 10 dB or less (75% and 59%, respectively) and 100% speech reception (median = 75 and 80 dB, respectively). We found no statistically significant difference in postoperative dizziness, postoperative complications and the need for revision stapes surgery between the 0.4 and 0.6 mm group. The incidence of anatomical difficulties was higher in the 0.4 mm group. Conclusion The use of a 0.6-mm-diameter piston during stapes surgery seems to provide better audiometric results compared to a 0.4-mm-diameter piston, and should be the preferred piston size in otosclerosis surgery. We found no statistically significant difference in postoperative complications between the 0.4- and 0.6-mm-diameter piston. Based on the results, we recommend always using a 0.6-mm-diameter piston during primary stapes surgery unless anatomical difficulties do not allow it.
Aim: To report on symptoms and diagnostic workup in SSCD. Vestibular, audiological, and functional results after superior semicircular canal plugging through a middle fossa approach (MFA) are considered as well. Material: Patients showing a decreased threshold and increased amplitude in the VEMPs were included as SSCD cases. Overall 13 patients underwent surgery. One had been operated previously through a transmastoid approach. Only patients suffering from disabling vestibular symptoms were considered for surgery. The lumen of the superior canal was obscured with bone wax and bone dust through a MFA. Clinical symptoms, audiological, and vestibular data were analyzed and compared, pre- and postoperatively. Results: No neurosurgical complications were observed. Eight patients suffered from mixed hearing loss and Tullio phenomenon. A total of 12 patients had to stop their daily work, due to disability. Postoperatively, two patients had immediate severe vertigo and nystagmus associated with a sensorineural hearing loss. After 5 days, the audiological thresholds normalized. All patients improved from a clinical point of view and started working again. Two patients underwent vestibular rehabilitation during 4 months to assist and improve compensation. No patient had postoperative hearing deterioration. In seven of the eight preoperative hearing-impaired patients, we observed an air-bone gap closure and postoperative (sub)normal hearing. In 11 cases cVEMPs returned to normal.
Abstract Objective The primary aim of this study was to investigate the accuracy of a semi‐automatic algorithm in assessing the feasibility and complexity of endoscopic stapes surgery preoperatively. Methods A semi‐automatic algorithm was developed to simulate endoscopic stapes surgery in 3D. To test the accuracy of the algorithm, five fresh‐frozen cadaveric heads (ten ears) were used. Each head was CT‐scanned, followed by segmentation and 3D reconstruction of the bones including the ear canal, middle ear, and ossicular chain. Two interventions were tested on each ear. Initially, the algorithm was digitally employed to simulate the endoscopic ear surgery. Subsequently, the actual endoscopic ear surgery was performed. Primary outcomes for each intervention included the amount of scutum removal (postoperative 3D model subtracted from preoperative 3D model), visibility of important landmarks, feasibility score, and a complexity questionnaire. Finally, the outcomes of the pre‐operative planning and the actual procedure were directly compared to evaluate the algorithm's accuracy and usability. Results The preoperative planning method achieved an accuracy rate of 70% in predicting the need for scutum removal. The mean volume of the removed scutum was 0.5 mm 3 . Endoscopic surgery was feasible in all ten ears, with all relevant anatomical landmarks adequately visualized as estimated by the preoperative planning algorithm. Conclusion Preoperative planning models can assist ENT surgeons in evaluating the feasibility and complexity of endoscopic stapes surgery. With adequate training and testing on clinical cases, these models can significantly improve their predictive accuracy and thereby improve patient outcomes.
