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Objective: To explore the relationship between tumor size and facial nerve outcomes following vestibular schwannoma (VS) resection., Study Design: Single institutional retrospective chart review of all adult patients with untreated sporadic VS who underwent surgical resection from 2008 to 2018 with preoperative magnetic resonance imaging (MRI) and 1 year of follow-up. The primary outcome measure was facial nerve outcome as assessed by the House-Brackmann facial nerve grading system., Results: One hundred sixty-seven patients, 54.5% female, with a median age of 49 years (20-76 years), were identified who underwent VS resection. Surgical resection was performed by translabyrinthine (76.7%), middle cranial fossa (14.4%), retrosigmoid (7.2%), and transpromontorial (1.8%) approaches. The median tumor diameter and volume were 25.3 mm (range: 4.1-47.1 mm) and 3.17 cm 3 (range: 0.01-30.6 cm 3 ), respectively. The median follow-up was 24.2 months (range: 12-114.2 months). Gross total resection was performed in 79% of cases, with residual tumor identified on MRI in 17% of cases. For patients with tumors <3 cm 3 , 92.7% had grade 1 or 2 facial function after at least 1 year follow-up, compared to 81.2% for those with tumors >3 cm 3 (univariate logistic regression OR = 2.9, P = .03). Tumor volume >3 cm 3 was predictive of facial weakness on multivariate regression analysis (OR = 7.4, P = .02) when controlling for surgical approach, internal auditory canal extension, anterior extension, age, gender, and extent of resection., Conclusions: Tumor volume >3 cm 3 is associated with worse facial nerve outcomes 12 months following surgical resection., Level of Evidence: IV Laryngoscope, 131:E1328-E1334, 2021., (© 2020 American Laryngological, Rhinological and Otological Society Inc, "The Triological Society" and American Laryngological Association (ALA).)

Objectives: To determine the safety and effectiveness of the middle cranial fossa (MCF) approach in repairing spontaneous cerebrospinal fluid (sCSF) leaks., Study Design: Retrospective cohort study., Methods: Patient with sCSF leaks repaired by MCF approach between January 1, 2014 and August 31, 2019 were included. Demographic information, clinical and surgical findings, and postoperative outcomes were recorded., Results: The cohort (n = 45) included 24 tegmen repairs by multilayer reconstruction using hydroxyapatite cement and 21 cases of multilayer repair without hydroxyapatite cement. Ten MCF repairs were performed on patients ≥65 years old. Twenty (53%) ears had multiple tegmen defects (range, 1-9 tegmen defects) and 78% of patients had ≥1 encephaloceles. All sCSF leaks were resolved with one surgical intervention. There were no major intracranial complications. Transient expressive aphasia occurred in 2 patients. Medical complications occurred in four patients. There were no short-term postoperative CSF leaks with bone cement reconstruction and two postoperative leaks without bone cement. One resolved with lumbar drain (LD) and the other resolved without treatment. The average (SD) length of stay (LOS) with bone cement was shorter than in patients without bone cement (2.54 [0.83] days vs. 3.52 [1.99] days, P < .05). There have been no long-term CSF leak recurrences with an average (SD) follow-up of 13.5 (12.9) months (range 0.25-46 months)., Conclusions: MCF approach for sCSF repairs demonstrate efficacious outcomes, particularly with tegmen reconstruction using hydroxyapatite cement. The approach exhibited no serious adverse events and few complications requiring intervention. Therefore, MCF is a safe and effective approach to resolve sCSF leaks., Level of Evidence: 3 Laryngoscope, 131:624-632, 2021., (© 2020 The American Laryngological, Rhinological and Otological Society, Inc.)

Background: The management of small- to medium-size (< 20 mm) sporadic vestibular schwannomas (VSs) continues to inspire debate. Preoperative pure tone thresholds and tumor size are recognized prognostic features of hearing preservation after surgery., Objective: To investigate what preoperative characteristics were associated with nonserviceable hearing after surgery for VSs., Methods: We retrospectively reviewed the audiological results of 92 patients treated with the middle cranial fossa (MCF) approach for resection of VSs (< 20 mm). Sex, age, symptoms, tumor site, tumor size, growth rate, and hearing class according to American Academy of Otolaryngology-Head and Neck Surgery guidelines were evaluated. Negative outcome was progression after surgery to nonserviceable hearing according to Gardner-Robertson classification. We included only patients with preoperative serviceable hearing., Results: After surgery, 48 patients (52.2%) had nonserviceable hearing. At univariate analysis, sex age, symptoms, tumor site, and size were not associated to hearing outcome. Tumor growth rate ≥ 2.16 mm/year (P = 0.02, odds ratio 8.5) and preoperative hearing class B (P = 0.03, OR 5.89) were statistically associated to nonserviceable hearing after VSs resection. Tumor growth rate ≥ 2.16 mm/year was also significantly associated to preoperative hearing class B (P = 0.01). At multivariate analysis, the only independent prognostic factor of progression to nonserviceable hearing in operated VSs was tumor growth rate ≥ 2.16 mm/year (P = 0.01, OR = 4.15)., Conclusion: We found a new prognostic indicator of hearing preservation after VS surgery with the MCF approach: the tumor growth rate. This feature should be further investigated before being considered in the decision-making process of VS treatment., Level of Evidence: 4 Laryngoscope, 129:2378-2383, 2019., (© 2019 The American Laryngological, Rhinological and Otological Society, Inc.)

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 2 . 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., (© 2018 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: To explore the perioperative utility of three-dimensionally (3D)-printed temporal bone models of patients undergoing repair of lateral skull base defects and spontaneous cerebrospinal fluid leaks with the middle cranial fossa approach., Study Design: Case series., Methods: 3D-printed temporal bone models-based on patient-specific, high-resolution computed tomographic imaging-were constructed using inexpensive polymer materials. Preoperatively, the models demonstrated the extent of temporal lobe retraction necessary to visualize the proposed defects in the lateral skull base. Also preoperatively, Silastic sheeting was arranged across the modeled tegmen, marked, and cut to cover all of the proposed defect sites. The Silastic sheeting was then sterilized and subsequently served as a precise intraoperative template for a synthetic dural replacement graft. Of note, these grafts were customized without needing to retract the temporal lobe., Results: Five patients underwent the middle cranial fossa approach assisted by 3D-printed temporal bone models to repair tegmen defects and spontaneous cerebrospinal fluid leaks. No complications were encountered. The prefabricated dural repair grafts were easily placed and fit precisely onto the middle fossa floor without any additional modifications. All defects were covered as predicted by the 3D temporal bone models. At their postoperative visits, all five patients maintained resolution of their spontaneous cerebrospinal fluid leaks., Conclusions: Inexpensive 3D-printed temporal bone models of tegmen defects can serve as beneficial adjuncts during lateral skull base repair. The models provide a panoramic preoperative view of all tegmen defects and allow for custom templating of dural grafts without temporal lobe retraction., Level of Evidence: 4 Laryngoscope, 127:2347-2351, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Image-guided optical tracking systems are being used with increased frequency in lateral skull base surgery. Recently, electromagnetic tracking systems have become available for use in this region. However, the clinical accuracy of the electromagnetic tracking system has not been examined in lateral skull base surgery. This study evaluates the accuracy of electromagnetic navigation in lateral skull base surgery., Study Design: Cadaveric and radiographic study., Methods: Twenty cadaveric temporal bones were dissected in a surgical setting under a commercially available, electromagnetic surgical navigation system. The target registration error (TRE) was measured at 28 surgical landmarks during and after performing the standard translabyrinthine and middle cranial fossa surgical approaches to the internal acoustic canal. In addition, three demonstrative procedures that necessitate navigation with high accuracy were performed; that is, canalostomy of the superior semicircular canal from the middle cranial fossa, 1 cochleostomy from the middle cranial fossa, 2 and infralabyrinthine approach to the petrous apex. 3 RESULTS: Eleven of 17 (65%) of the targets in the translabyrinthine approach and five of 11 (45%) of the targets in the middle fossa approach could be identified in the navigation system with TRE of less than 0.5 mm. Three accuracy-dependent procedures were completed without anatomical injury of important anatomical structures., Conclusion: The electromagnetic navigation system had sufficient accuracy to be used in the surgical setting. It was possible to perform complex procedures in the lateral skull base under the guidance of the electromagnetically tracked navigation system., Levels of Evidence: N/A. Laryngoscope, 2016 127:450-459, 2017., (© 2016 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: The goals of this study are to: 1) investigate the urgency for repair of middle cranial fossa spontaneous cerebrospinal fluid (CSF) leaks in adults, and 2) review the literature and treatment recommendations for adult spontaneous CSF otorrhea., Data Sources: 1) All patients who were referred to a tertiary center with spontaneous CSF otorrhea, exposed middle cranial fossa dura, or encephalocele from 2004 to 2015; and 2) landmark references on spontaneous CSF leaks, Review Methods: Electronic medical records of patients with a documented spontaneous CSF leak, exposed dura, or encephalocele were reviewed. Subjects were excluded if they had a congenital, traumatic, or iatrogenic CSF leak. Main outcome measure was duration of CSF leak and development of meningitis after clinical presentation., Results: Twenty-two patients (27 ears) who were at risk for meningitis from spontaneous CSF otorrhea, encephalocele, or a dural breach with or without mastoiditis were evaluated. Duration of CSF leaks in patients who refused repair or who continued to have CSF leak after repair or prior to successful repair ranged from 4 months to 11 years. Duration of encephaloceles and dural exposure in an uninfected mastoid ranged from 24 months to 6 years. Only one patient presented with meningitis. None of these 22 patients developed meningitis during the time periods they were under our care., Conclusion: Should patients with CSF otorrhea, exposed dura, or encephalocele refuse operation, it may be reasonable to follow them with close observation and education about warning signs for meningitis., (© 2015 The American Laryngological, Rhinological and Otological Society, Inc.)

Wound complications after middle cranial fossa craniotomy are rare. We describe a patient who underwent a left middle fossa craniotomy for resection of a small internal auditory canal tumor with subsequent development of wound breakdown and infection 1 week postoperatively. Prompting of the patient elicited a history of bilateral rhytidectomies. Wound debridement, hyperbaric oxygen therapy, dermal regeneration template placement, and prolonged antibiotic treatment were performed. Complete secondary intention healing occurred with an acceptable cosmetic outcome. Prior rhytidectomy scars must be identified and incorporated into the surgical planning prior to performing middle fossa craniotomy incisions., (Copyright © 2013 The American Laryngological, Rhinological and Otological Society, Inc.)

Objectives/hypothesis: Anterior and central skull base lesions and their surgical treatment (endoscopic or open approaches) can affect quality of life. A disease-specific instrument is needed to compare quality of life for different surgical approaches., Study Design: Items were generated using a composite strategy consisting of chart review, systematic review of skull base instruments, expert interviews, and qualitative analysis of patient focus groups. A cross-sectional survey study was performed to reduce items based on an item impact score., Methods: Charts of 138 patients who underwent skull base surgery were reviewed to identify physical items and domains. Five experts were interviewed for item and domain identification. Thirty-four patients were recruited into eight focus groups based on their surgical approach (open or endoscopic) and tumor location (anterior or central). Items were generated using a composite approach and then reduced into a final questionnaire using item impact scores., Results: Chart review identified 47 physical items. Systematic review revealed nine relevant instruments with 217 relevant items. Experts identified 11 domains with 69 additional items. Qualitative analysis of focus groups generated 49 items. A total of 382 items were identified and reduced to 77 items after eliminating overlapping and irrelevant items. Further item reduction using item impact scores yielded 41 items., Conclusions: The Skull Base Inventory is a disease-specific quality-of-life instrument. Psychometric properties have yet to be tested. It may serve to compare quality of life for endoscopic or open procedures., (Copyright © 2012 The American Laryngological, Rhinological, and Otological Society, Inc.)

Objectives: Endoscopic endonasal approaches to the pterygopalatine and infratemporal fossae are technically challenging due to the complex anatomy of these areas. This project attempts to develop an anatomic and surgical model to enhance the understanding of these spaces from the endonasal endoscopic perspective., Methods: Eight pterygopalatine and infratemporal fossae were dissected in four adult human specimens in accordance with institutional protocols. All specimens were prepared with vascular injections using colored latex. Both the pterygopalatine and infratemporal fossae were accessed using a transpterygoid approach, which included a medial maxillectomy. Rod lens endoscopes (with 0°, 30°, and 45° lenses), surgical microscope, microsurgical and endoscopic instruments were used to complete the dissections., Results: Endoscopic endonasal approaches provided adequate access to the pterygopalatine and infratemporal fossae. Dissection of the internal maxillary artery and its terminal branches, and detachment of the medial and lateral pterygoid muscles were critical steps to access deeper structures of the infratemporal fossa. The lateral pterygoid plate was the most useful landmark to locate foramen ovale, and the mandibular branch of the trigeminal nerve. The Eustachian tube, medial pterygoid plate, and styloid process were the most useful landmarks to locate parapharyngeal poststyloid structures (parapharyngeal segment of the internal carotid artery, internal jugular vein, cranial nerves IX and X)., Conclusions: A medial maxillectomy coupled with a transpterygoid endoscopic approach, provides adequate access to the pterygopalatine and infratemporal fossae. The complex anatomy of the infratemporal fossa requires precise identification of surgical landmarks to assure preservation of neurovascular structures.

Objectives/hypothesis: Temporal bone meningoencephalic herniation is a rare condition with potentially dangerous complications. The aim of this study is to analyze the pathogenesis, clinical presentation, surgical treatment, and postoperative outcome of 133 cases of surgically confirmed temporal bone meningoencephalic herniations. A review of the literature is also presented., Study Design: Retrospective case series (quaternary referral otology and skull base center)., Methods: This study is based on the analysis of the collected data of 133 cases of temporal bone meningoencephalic herniations surgically treated from 1984 to 2006. The follow-up ranged from 12 to 204 months with a mean of 38.4 months., Results: Meningoencephalic herniations were divided into four etiologic groups: spontaneous (24.8%), secondary to chronic otitis media (21.8%), iatrogenic (45.9%), and posttraumatic (7.5%). Different surgical techniques were used for treatment: transmastoid approach (27.8%), middle cranial fossa approach (27.8%), combined technique (transmastoid plus minicraniotomy, 3%), and middle ear obliteration with blind sac closure of the external auditory canal (41.4%)., Conclusions: Temporal bone meningoencephalic herniations are potentially life threatening, and surgery must take place expeditiously. The choice of the most appropriate surgical approach must be based on the localization and size of the herniated tissue, preoperative auditory function, the presence of active infection, intraoperative cerebrospinal fluid leak, and concomitant pathology.

A 44-year-old woman presented with typical vestibular symptoms of superior semicircular canal dehiscence syndrome (SSCDS). In addition, the patient experienced a rapidly progressive mixed hearing loss in the affected ear prior to surgical intervention that was unresponsive to oral steroid administration. Following middle fossa craniotomy with repair of the dehiscence, the patient's mixed hearing loss resolved to normal levels with no air-bone gap. In this report, we discuss the possible etiology of this rapidly progressive hearing loss and its implications on the differential diagnosis of patients with new onset mixed hearing losses. We also contrast the index case of progressive mixed loss with the more frequent conductive hearing loss seen in SSCDS.

Objectives: We present a transoral approach using image guidance to approach inferiorly based lesions of the pterygopalatine fossa., Study Design: Case report., Methods: A 49-year-old male presenting with a benign cyst of the inferior pterygopalatine fossa. The presentation, workup, and management are discussed., Results: The patient underwent a computed tomography scan that confirmed the location of the lesion in the left pterygopalatine fossa. An image guidance system was used to effect a complete transoral resection of the benign cyst., Conclusions: Benign lesions of the pterygopalatine fossa may be successfully accessed using a transoral approach with image guidance, which minimizes postoperative morbidity.

Objective: Successful hearing preservation after acoustic neuroma resection is sometimes complicated by delayed hearing deterioration. The middle fossa approach appears to offer superior long-term hearing results when compared to the retrosigmoid surgical approach. The goal of this study is to investigate the hypothesis that internal auditory canal (IAC) drilling during middle fossa acoustic neuroma removal is associated with a lower incidence of endolymphatic duct (ELD) injury, a potential cause of delayed hearing loss (HL) known to accompany retrosigmoid hearing preservation dissection techniques., Study Design: A human temporal bone anatomic and radiographic study complemented with a literature review., Methods: Twenty human temporal bones were analyzed with high-resolution multislice computed tomography (HRMCT) and subjected to standard extended middle fossa IAC dissection with labyrinthine preservation and follow-up HRMCT for analyses of the ELD., Results: Zero of 20 (0%) temporal bones were found to have violation of the ELD with preservation of the labyrinthine structures and the endolymphatic sac. Reviews of human and animal studies indicate that injury to the ELD may create endolymphatic hydrops, a known cause of hearing deterioration., Conclusion: The ELD is not vulnerable to injury during IAC dissection using the middle fossa approach. A previous radiographic study has shown that the ELD is violated in 24% of temporal bones during retrosigmoid dissection of the IAC. These findings support and may help explain other outcome studies that show that long-term hearing results are superior with the use of the middle fossa approach when compared to results following retrosigmoid dissection.

Objectives: On the basis of survey results of the Acoustic Neuroma Association (ANA), we report patient ratings of postoperative headache (POH) symptoms, determine its effect on quality of life (QOL), and review the literature regarding POH after acoustic neuroma (AN) treatment., Study Design: In this cohort study, 1,657 patients who underwent surgical treatment of AN reported their experiences of POH., Methods: A detailed questionnaire was mailed to members of the ANA to identify preoperative and postoperative headache symptoms, complications, and long-term effects on physical and psychosocial function. Questions were answered by 1657 (85.4%) respondents that were intended to qualify and quantify the effects of POH, including QOL issues. Responses were analyzed by tumor size, surgical approach, and patient age and sex. Statistical analysis was performed with the SPSS software., Results: Preoperative headache was reported in approximately one third of respondents. Typical POHs occurred more than once daily (46%), lasted 1 to 4 hours in duration (43.1%), and were of moderate intensity (62.6%). The worst headaches were rated as "severe" by 77% of respondents. Treatment most often reported for typical headaches were nonprescription medications including nonsteroidal anti-inflammatory drugs in 61.3% (P < .01) and regular use of narcotics in 15%. Patients who underwent the retrosigmoid approach were significantly more likely to report their worst POH as "severe" (82.3%) compared with the translabyrinthine (75.2%) and middle fossa approaches (63.3%). Women and younger patients tended to have poorer outcomes with regard to POHs., Conclusions: In this large cohort study of AN patients, POH was a significant morbidity among AN patients with persistent headaches. Treating physicians should be aware of the risk factors identified and the effect POH has on the QOL when counseling patients regarding optimal treatment management.

Unlabelled: OBJECTIVES/HYPOTHESIS; Anatomical landmarks including the arcuate eminence and the superficial petrosal nerve serve as orienting landmarks for middle fossa dissection. However, because of considerable variation among patients, these landmarks are not always readily identifiable. We expand on a previously described method for identifying the head of the malleus as a constant anatomical landmark to optimize exposure when employing a middle fossa approach. METHODS; We completed an anatomical study using 10 preserved human cadaveric temporal bones to define the anatomical relationship among the root of the zygoma, the posterior-lateral lip of the foramen spinosum, and the bony tegmen over the head of the malleus. Subsequently, 5 fresh whole human cadaveric heads (10 temporal bones) were dissected using a surgically oriented anterior petrosectomy-middle fossa approach to evaluate the consistency of localizing the head of the malleus. RESULTS; We defined the superior petrosal triangle as a stable anatomical relationship. Our cadaveric data demonstrated that the distance from the root of the zygoma to the head of the malleus was 18.7 mm (SD = 1.7 mm) and the distance from the foramen spinosum to the head of the malleus was 19.2 mm (SD = 1.0 mm). The intersection of an arc transcribed 19 mm from the root of the zygoma and an arc transcribed 19 mm from the foramen spinosum localized the head of the malleus within 2.5 mm (SD = 2.4 mm)., Conclusions: The landmarks defined by the superior petrosal triangle represent a means to localize the bony tegmen over the head of the malleus. Identification of the head of the malleus as a landmark in middle fossa surgery when other landmarks are not recognizable optimizes patient safety and surgeon confidence during complex surgical procedures.

Objective: To report our experience in reconstructing defects of the anterior and middle cranial fossa skull base using endoscopic placement of acellular dermal allograft (AlloDerm, LifeCell Corp., The Woodlands, TX)., Study Design: Retrospective chart review., Methods: In all cases, the skull base repair was completed with a similar technique. After identification of the defect boundaries, endoscopic transnasal repair was performed through placement of a layered reconstruction of acellular dermal allograft, septal bone/cartilage, and acellular dermal allograft, which were all placed on the intracranial side of the defect. A mucosal free graft was draped over the reconstruction. Fibrin glue was used to hold the mucosal graft in place, and the reconstruction was supported by both absorbable and nonabsorbable nasal packing., Results: Eight patients with nine skull base defects underwent the procedure for repair of cerebrospinal fluid rhinorrhea. All defects were successfully repaired. One patient underwent successful reconstruction of bilateral ethmoid roof defects that resulted from endoscopic resection of ethmoid adenocarcinoma. Twenty-four patients underwent primary resection of hypophyseal adenomas. Twenty-three patients had macroadenomas, and intraoperative cerebrospinal fluid leaks were noted in 11 patients. Sellar repairs after trans-sphenoidal hypophysectomy were successful in 22 of 24 patients. One patient with hypophysectomy required reoperation (1 of 24 [4%]) for secondary closure of a cerebrospinal fluid leak. Serious complications were avoided in all patients. Patients were followed for a period ranging from 5 to 57 months (mean period, 34 mo)., Conclusions: Acellular dermal allograft can be successfully used for the reconstruction of anterior and middle cranial fossa skull base defects. This allograft, which is easy to manipulate endoscopically, provides an effective seal and barrier in skull base reconstruction and avoids the need for a donor site.

Objective: The objective was to describe the relationship of anatomical landmarks required for the middle fossa approach to lesions of the petrous apex and internal auditory canal (IAC). Landmarks for safe identification of the IAC are defined, as are two zones (safe zones I and II) anterior and posterior to the IAC., Study Design: Temporal bone anatomical study., Methods: Ten temporal bones underwent high-resolution computed tomography followed by wet bench dissection. A set of 39 different distances between vital structures was measured, where possible, from both radiology films and under the microscope. Mean, median, minimum, and maximum measurements of all distances were determined. Angular measurements were made using a specially designed instrument., Results: Measurements were made in an anatomical position to mimic the middle fossa surgical technique. Measurements are presented for the superior surface of the temporal bone from the sigmoid sinus and inner table to vital structures, from the anterior and posterior petrous apex, and from the IAC., Conclusions: Petrous apex anatomical knowledge is required for the safe middle fossa approach to the IAC and petrous apex. Two safe zones are defined that should prevent damage to the cochlea and the superior semicircular canal.