Prevalence, trends, and characteristics of trials investigating local therapy in contemporary phase 3 clinical cancer research

BACKGROUND

Although most patients with cancer are treated with local therapy (LT), the proportion of late-phase clinical trials investigating local therapeutic interventions is unknown. The purpose of this study was to determine the proportion, characteristics, and trends of phase 3 cancer clinical trials assessing the therapeutic value of LT over time.

METHODS

This was a cross-sectional analysis of interventional randomized controlled trials in oncology published from 2002 through 2020 and registered on ClinicalTrials.gov. Trends and characteristics of LT trials were compared to all other trials.

RESULTS

Of 1877 trials screened, 794 trials enrolling 584,347 patients met inclusion criteria. A total of 27 trials (3%) included a primary randomization assessing LT compared with 767 trials (97%) investigating systemic therapy or supportive care. Annual increase in the number of LT trials (slope [m] = 0.28; 95% confidence interval [CI], 0.15-0.39; p < .001) was outpaced by the increase of trials testing systemic therapy or supportive care (m = 7.57; 95% CI, 6.03-9.11; p < .001). LT trials were more often sponsored by cooperative groups (22 of 27 [81%] vs. 211 of 767 [28%]; p < .001) and less often sponsored by industry (5 of 27 [19%] vs. 609 of 767 [79%]; p < .001). LT trials were more likely to use overall survival as primary end point compared to other trials (13 of 27 [48%] vs. 199 of 767 [26%]; p = .01).

CONCLUSIONS

In contemporary late-phase oncology research, LT trials are increasingly under-represented, under-funded, and evaluate more challenging end points compared to other modalities. These findings strongly argue for greater resource allocation and funding mechanisms for LT clinical trials.

PLAIN LANGUAGE SUMMARY

Most people who have cancer receive treatments directed at the site of their cancer, such as surgery or radiation. We do not know, however, how many trials test surgery or radiation compared to drug treatments (that go all over the body). We reviewed trials testing the most researched strategies (phase 3) completed between 2002 and 2020. Only 27 trials tested local treatments like surgery or radiation compared to 767 trials testing other treatments. Our study has important implications for funding research and understanding cancer research priorities.

Immediate CPAP Use after Skull Base Reconstruction with Hydroxyapatite Bone Cement

OBJECTIVE

The timing for resuming continuous positive airway pressure (CPAP) postoperatively after skull base surgery remains controversial because of the risk of pneumocephalus. We determined the safety of immediate CPAP use after middle cranial fossa (MCF) spontaneous cerebrospinal fluid (sCSF) leak repair with bone cement.

STUDY DESIGN

Prospective cohort study.

SETTING

Tertiary academic medical center.

PATIENTS

Thirteen consecutive patients with CPAP-treated obstructive sleep apnea and temporal bone sCSF leaks who underwent skull base repair with hydroxyapatite bone cement between July 2021 and October 2022.

INTERVENTIONS

CPAP use resumed on postoperative day 1 after the confirmation of skull base reconstruction with temporal bone computed tomography (CT).

MAIN OUTCOME MEASURES

Postoperative skull base defects on CT, pneumocephalus, or intracranial complications.

RESULTS

The average age was 55.5 ± 8.8 years (±standard deviation), and 69.2% were female with a BMI of 45.39 ± 15.1 kg/m 2 . Multiple tegmen defects were identified intraoperatively in 53.9% of patients with an average of 1.85 ± 0.99 defects and an average defect size on preoperative imaging of 6.57 ± 3.45 mm. All patients had an encephalocele identified intraoperatively. No residual skull base defects were observed on CT imaging on postoperative day 1. No postoperative complications occurred. One patient developed a contralateral sCSF leak 2 months after repair. There were no recurrent sCSF leaks 1 month postoperatively.

CONCLUSION

Immediate postoperative CPAP use is safe in patients undergoing MCF sCSF leak repair with bone cement because of the robust skull base repair.

Cochlear Implantation in US Military Veterans: A Single Institution Study

Objective

Military veterans have high rates of noise-induced hearing loss (NIHL) which is associated with more significant spiral ganglion neuronal loss. This study explores the relationship between NIHL and cochlear implant (CI) outcomes in veterans.

Study Design

Retrospective case series of veterans who underwent CI between 2019 and 2021.

Setting

Veterans Health Administration hospital.

Methods

AzBio Sentence Test, Consonant-Nucleus-Consonant (CNC) scores, and Speech, Spatial, and Qualities of Hearing Scale (SSQ) were measured pre- and postoperatively. Linear regression assessed relationships between outcomes and noise exposure history, etiology of hearing loss, duration of hearing loss, and Self-Administered Gerocognitive Exam (SAGE) scores.

Results

Fifty-two male veterans were implanted at an average (standard deviation) age of 75.0 (9.2) years without major complications. The average duration of hearing loss was 36.0 (18.4) years. The average time of hearing aid use was 21.2 (15.4) years. Noise exposure was reported in 51.3% of patients. Objectively, AzBio and CNC scores 6 months postoperatively showed significant improvement of 48% and 39%, respectively. Subjectively, average 6-month SSQ scores showed significant improvement by 34 points (p < .0001). Younger age, SAGE score ≥17, and shorter duration of amplification were associated with higher postoperative AzBio scores. Greater improvement in AzBio and CNC scores was associated with lower preoperative scores. Noise exposure was not associated with any difference in CI performance.

Conclusion

Despite high levels of noise exposure and advanced age, veterans derive substantial benefits from cochlear implantation. SAGE score ≥17 may be predictive of overall CI outcomes. Noise exposure does not impact CI outcomes.

Level of Evidence

Level 4.

Characterizing Cochlear Implant Magnet-Related MRI Artifact

OBJECTIVE

To evaluate cochlear implant (CI) magnet-related MRI artifact shape and size, as well as imaging indications and clinical adequacy of scans.

METHODS

A retrospective chart review was performed for patients undergoing CI and subsequent MRI head imaging from 2014 to 2020 at a single institution. Indications and adequacy of each scan was recorded, and interpretability compared by indication. Magnet-related artifact size was determined by performing ellipsoid modeling at axial slice of greatest signal loss. Artifact radius in centimeters was calculated for 5 sequence categories, and size compared between sequences, manufacturers, and by time from implantation.

RESULTS

Twenty patients underwent 58 head MRI scans. Approximately 76% of MRIs (n = 44) for 70% of patients (n = 14) were performed for indications known of prior to implantation; the remainder were performed during workup of new issues. Desired structures were interpretable in 23 (52%) of known-indication MRIs and 8 (57%) of new-indication MRIs, without significant difference (P = .751). Magnet-related artifact magnitude, compared to the reference T1-weighted fast spin echo (FSE) (4.47 cm), was similar in T2 FSE (4.57 cm, P = .068) and T1 gradient echo (GRE) sequences (4.79 cm, P = .28), but significantly greater in T2 GRE (6.86, P < .0001) and DWI (7.56 cm, P < .0001) sequences.

CONCLUSIONS

DWI and T2 GRE sequences are less useful in MRI evaluation of CI patients. With a more favorable artifact profile, T1 FSE, T2 FSE, and T1 GRE sequences more likely yield clinically useful information. The large proportion of scans performed for known pathology represents an opportunity to optimize for magnet location preoperatively.

Attention-Deficit Hyperactivity Disorder and Learning Disabilities Modify Recovery and Sport Behavior Following Sport-Related Concussion

Limited evidence exists concerning how a diagnosis of attention-deficit hyperactivity disorder and/or learning disabilities (ADHD/LD) modifies recovery and behavior following sport-related concussion (SRC). To understand how ADHD/LD modifies the post-SRC experience, we conducted a retrospective cohort study of concussed young athletes through phone interviews with patients and guardians. Outcomes included time until symptom resolution (SR) and return-to-learn (RTL), plus subjective changes in post-SRC activity and sports behavior. Multivariate Cox and logistic regression was performed, adjusting for biopsychosocial characteristics. The ADHD/LD diagnosis was independently associated with worse outcomes, including lower likelihood to achieve SR (hazard ratio [HR] = 0.62, 95% confidence interval [CI] = [0.41-0.94]; P = .02) and RTL (HR = 0.55, 95% CI = [0.36-0.83]; P < .01) at any time following injury, and increased odds of changing sport behavior after concussion (odds ratio [OR] = 3.26, 95% CI = [1.26-8.42], P = .02), often to a safer style of play (62.5% vs 39.6%; P = .02) or retiring from the sport (37.5% vs 18.5%; P = .02). These results provide further evidence of the unique needs for athletes with ADHD/LD following SRC.

Facial Nerve Preservation With Inferior Long-Axis Dissection of Large Vestibular Schwannomas

OBJECTIVE

To describe a tumor resection using the inferior long-axis (ILA) technique for cisternal facial nerve dissection in large vestibular schwannomas (VS).

STUDY DESIGN

Retrospective case series from 2018 to 2021.

SETTING

Tertiary academic medical center.

PATIENTS

Patients who underwent surgical resection with ILA facial nerve dissection of VS (>2.0 cm measured parallel to the petrous ridge) and had at least 3-month follow-up.

INTERVENTIONS

Cisternal facial nerve dissection during retrosigmoid or translabyrinthine approach using standardized ILA technique developed by author R.N.

MAIN OUTCOME MEASURES

Immediate postoperative and last follow-up facial nerve function with House-Brackmann scores of I to II defined as "good" facial nerve function and House-Brackmann scores III to VI defined as "poor" function. Extent of resection was also assessed.

RESULTS

A total of 48 patients underwent large VS resection with ILA dissection of tumor off of the facial nerve from 2018 to 2021. Mean (standard deviation) tumor size was 3.11 (0.76) cm. Mean (standard deviation) follow-up was 9.2 (9.0) months. Gross-total resection or near-total resection were achieved in 75% (radiographic estimate) to 83% (surgeon estimate) of cases. End-of-case facial nerve stimulation at 0.05 mAmp with a response of at least 240 mV was achieved in 80.4% of patients. Good facial nerve function was observed in 72% immediately postoperatively, 70% 1-month postoperatively, and 82% of patients at last follow-up.

CONCLUSIONS

The ILA technique is now the method of choice of the senior surgeon (R.N.) when performing microsurgical dissection of the cisternal facial nerve, with which he has achieved high rates of total or near-total resection with excellent facial nerve preservation.

Trends in Spontaneous Cerebrospinal Fluid Leak Repairs in the United States, 2009-2018

Background

Rates of spontaneous cerebrospinal fluid leak (sCSF) repairs have increased in recent decades in line with increases in obesity rates.

Objectives

To determine if the national rate of sCSF leak has continued to rise in recent years and to identify associated risk factors utilizing a comprehensive national database comprising most academic medical centers.

Methods

A retrospective review from 2009 to 2018 was performed using the Vizient Clinical Database (CDB) of 105 leading academic medical centers in the United States. Patients who underwent CSF leak repair in the CDB database using ICD-9 and ICD-10 diagnostic and procedure codes. Patients with epidural hematomas over the same time frame were used as a control. National rates of craniotomy for sCSF leak repair each quarter were assessed and sCSF leak patient characteristics (age, gender, obesity, hypertension, diabetes) were calculated.

Results

The rate of craniotomy for all sCSF leak repairs increased by 10.2% annually from 2009 to 2015 (P < 0.0001). There was no statistically significant change in the rate of epidural hematomas over the same period. The rate of lateral sCSF leak repair increased on average by 10.4% annually from 2009 (218 cases/year) to 2018 (457 cases/year) (P < 0.0001). A statistically significant increase was observed across all regions of the United States (P ≤ 0.005). sCSF leak patients had an average (standard deviation) age of 55.0 (13.2) years and 67.2% were female. Obesity was the only demographic factors that increased significantly over time. Likely due to comorbid factors, Black patients comprise a disproportionately large percentage of lateral sCSF leak repair patients.

Conclusions

The rate of craniotomy for spontaneous CSF leaks continues to rise by approximately 10% annually.

TMPRSS3 expression is limited in spiral ganglion neurons: implication for successful cochlear implantation

BACKGROUND

It is well established that biallelic mutations in transmembrane protease, serine 3 (TMPRSS3) cause hearing loss. Currently, there is controversy regarding the audiological outcomes after cochlear implantation (CI) for TMPRSS3-associated hearing loss. This controversy creates confusion among healthcare providers regarding the best treatment options for individuals with TMPRSS3-related hearing loss.

METHODS

A literature review was performed to identify all published cases of patients with TMPRSS3-associated hearing loss who received a CI. CI outcomes of this cohort were compared with published adult CI cohorts using postoperative consonant-nucleus-consonant (CNC) word performance. TMPRSS3 expression in mouse cochlea and human auditory nerves (HAN) was determined by using hybridisation chain reaction and single-cell RNA-sequencing analysis.

RESULTS

In aggregate, 27 patients (30 total CI ears) with TMPRSS3-associated hearing loss treated with CI, and 85% of patients reported favourable outcomes. Postoperative CNC word scores in patients with TMPRSS3-associated hearing loss were not significantly different than those seen in adult CI cohorts (8 studies). Robust Tmprss3 expression occurs throughout the mouse organ of Corti, the spindle and root cells of the lateral wall and faint staining within <5% of the HAN, representing type II spiral ganglion neurons. Adult HAN express negligible levels of TMPRSS3.

CONCLUSION

The clinical features after CI and physiological expression of TMPRSS3 suggest against a major role of TMPRSS3 in auditory neurons.

Comparison of Small Intestinal Submucosal Graft and Autologous Tissue in Prevention of CSF leak after Posterior Fossa Craniotomy

Objective  To compare the use of porcine small intestinal submucosal grafts (SISG) and standard autologous material (fascia) in prevention of cerebrospinal fluid (CSF) leak and pseudomeningocele formation after translabyrinthine resection. Setting  Set at the tertiary skull base center. Methods  This is a retrospective chart review. After Institutional Review Board approval, we performed a retrospective cohort study evaluating CSF leak in patients who underwent resection of lateral skull base defects with multilayered reconstruction using either fascia autograft or porcine SISGs. Demographics were summarized with descriptive statistics. Logistic regression was used to compare autograft and xenograft cohorts in terms of CSF complications. Results  Seventy-seven patients underwent lateral skull base resection, followed by reconstruction of the posterior cranial fossa. Of these patients, 21 (27.3%) underwent multilayer repair using SISG xenograft. There were no significant differences in leak-associated complications between autograft and xenograft cohorts. Ventriculoperitoneal shunt was necessary in one (1.8%) autograft and one (4.8) xenograft cases ( p  = 0.49). Operative repair to revise surgical defect was necessary in three (5.4%) autograft cases and none in xenograft cases. Conclusion  The use of SISG as a component of complex skull base reconstruction after translabyrinthine tumor resection may help reduce CSF leak rates and need for further intervention.

The Influence of Extent of Resection and Tumor Morphology on Facial Nerve Outcomes Following Vestibular Schwannoma Surgery

OBJECTIVE

To determine the influence extent of resection and tumor characteristics on facial nerve (FN) outcomes following microsurgical resection of vestibular schwannoma (VS).

STUDY DESIGN

Retrospective chart review.

SETTING

Tertiary referral center.

PATIENTS

Three hundred eighty-five patients who underwent VS microsurgical resection.

INTERVENTIONS

Microsurgical VS resection.

MAIN OUTCOME MEASURES

House-Brackmann (HB) scores postoperatively. Good FN function was defined as HB grade I and II and poor FN function was defined as HB grade III and VI. Gross total resection (GTR) versus subtotal resection (STR). Propensity-score matching was used in subset analysis to balance tumor volume between the surgical cohorts, followed by multivariable analysis.

RESULTS

Seventy-one patients (18%) underwent STR and 314 patients (82%) underwent GTR. Two hundred fourteen patients (63%) had good FN function at 2 to 3 weeks postoperatively, and 80% had good FN function at 1 year. In single predictor analysis, STR did not influence FN function at 2 to 3 weeks (p = 0.65). In propensity-score matched subset analysis (N = 178), patients with STR were less likely to have poor FN function at 2 to 3 weeks (p = 0.02) independent of tumor volume (p = 0.004), but there was no correlation between STR and FN function at 1 year (p = 0.09). Ventral extension of tumor relative to the internal auditory canal plane was associated with poor FN outcomes at 2 to 3 weeks (p = 0.0001) and 1-year postop (p = 0.002).

CONCLUSIONS

When accounting for tumor volume, STR is protective in immediate postoperative FN function compared to GTR. Ventral extension of the tumor is a clinical predictor of long-term FN outcomes.

Outcomes of Initial Observation Versus Upfront Microsurgical Resection for Small to Medium-sized Vestibular Schwannomas

OBJECTIVE

To assess postoperative outcomes and predictive factors of patients observed prior to microsurgery and those undergoing upfront resection for small and medium-sized VS.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary referral center.

PATIENTS

VS patients who had microsurgery from 2003 to 2018 for tumors up to 2.5 cm.

MAIN OUTCOME MEASURES

Postoperative outcomes including facial nerve function and interventions, complications, extent of resection, and salvage therapy.

RESULTS

Of 220 patients, 120 were initially observed, and 100 pursued upfront microsurgery. There was no significant association between initial observation and upfront microsurgery for postoperative facial nerve function at 2 to 3 weeks (p = 0.18) or 12 months (p = 0.5), facial nerve intervention (p = 0.5), major/minor complications (p = 0.48/0.63), recurrence (p = 0.8), subtotal resection (p = 0.6), or salvage therapy (p = 0.9). Time from initial consultation to surgery did not significantly impact outcomes. Intrameatal tumors were more likely to be observed (odds ratios [OR] 2.93; 95% CI 1.53-5.63; p = 0.001). Patients with larger tumor volume (OR 0.52; 95% CI 0.37-0.72; p < 0.0001), brainstem compression (OR 0.28; 95% CI 0.09-0.91; p = 0.03), or higher PTA were less likely to undergo observation (OR 0.99; 95% CI 0.97-0.997; p = 0.02). On multivariable analysis, predictive factors for observation were smaller tumor volume (OR 0.53; 95% CI 0.38-0.75; p < 0.001), lower PTA (OR 0.99; 95% CI 0.98-0.999; p = 0.04), and diabetes (OR 2.54; 95% CI 0.95-6.83; p = 0.06).

CONCLUSIONS

Patients with worse hearing, larger tumor volume, and brainstem compression were more likely to pursue upfront microsurgery. A watchful waiting period does not appear to worsen outcomes and can be considered for patients with better hearing and smaller tumors without brainstem compression.

Diameter-Based Volumetric Models May Inadequately Calculate Jugular Paraganglioma Volume Following Sub-Total Resection

BACKGROUND

As gross total resection of jugular paragangliomas (JPs) may result in cranial nerve deficits, JPs are increasingly managed with subtotal resection (STR) with postoperative radiological monitoring. However, the validity of commonly used diameter-based models that calculate postoperative volume to determine residual tumor growth is dubious. The purpose of this study was to assess the accuracy of these models compared to manual volumetric slice-by-slice segmentation.

METHODS

A senior neuroradiologist measured volumes via slice-by-slice segmentation of JPs pre- and postoperatively from patients who underwent STR from 2007 to 2019. Volumes from three linear-based models were calculated. Models with absolute percent error (APE) > 20% were considered unsatisfactory based on a common volumetric definition for residual growth. Bland-Altman plots were used to evaluate reproducibility, and Wilcoxon matched-pairs signed rank test evaluated model bias.

RESULTS

Twenty-one patients were included. Median postoperative APE exceeded the established 20% threshold for each of the volumetric models as cuboidal, ellipsoidal, and spherical model APE were 63%, 28%, and 27%, respectively. The postoperative cuboidal model had significant systematic bias overestimating volume (p = 0.002) whereas the postoperative ellipsoidal and spherical models lacked systematic bias (p = 0.11 and p = 0.82).

CONCLUSION

Cuboidal, ellipsoidal, and spherical models do not provide accurate assessments of postoperative JP tumor volume and may result in salvage therapies that are unnecessary or inappropriately withheld due to inaccurate assessment of residual tumor growth. While more time-consuming, slice-by-slice segmentation by an experienced neuroradiologist provides a substantially more accurate and precise measurement of tumor volume that may optimize clinical management.

Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes

OBJECTIVE

To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair.

STUDY DESIGN

Retrospective cohort.

SETTING

Tertiary medical center neurotology practice.

METHODS

Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired t-tests. Single-predictor binary logistic regression was used to compare final reported symptoms between cohorts. Linear regression was performed to assess air-bone gap (ABG) changes postoperatively between cohorts.

RESULTS

Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively (P < .001 for each). There was no significant difference in change in ABG between the 2 cohorts. On average, patient-reported symptoms and audiometrically-tested hearing improved postoperatively in both groups.

CONCLUSION

While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.

Exploring the outcomes and experiences of Black and White athletes following a sport-related concussion: a retrospective cohort study

OBJECTIVE

Young American athletes, at risk of sport-related concussion (SRC), represent many races; however, it is unknown how race may influence the experience and outcome of SRC. The authors' objective was to compare White and Black athletes' recovery and subjective experiences after SRC.

METHODS

A retrospective study was performed using the Vanderbilt Sports Concussion registry. Self-reported White and Black young athletes (ages 12-23 years) who had been treated for SRC between 2012 and 2015 were included. Athletes with learning disabilities or psychiatric conditions were excluded. Data were collected by electronic medical record review and phone calls to athletes and parents or guardians. The primary outcomes were as follows: 1) days to symptom resolution (SR), 2) days to return to school, and changes in 3) any daily activity (binary) and 4) sport behavior (binary). Secondary outcomes were changes (more, unchanged, or less) in specific activities such as sleep, schoolwork, and television time, as well as equipment (binary) or playing style (more reckless, unchanged, or less reckless) and whether the athlete retired from sport. Descriptive analyses, multivariable Cox proportional hazards models, and logistic regression were performed.

RESULTS

The final cohort included 247 student-athletes (36 Black, 211 White). Black athletes were male (78% vs 58%) more often than White athletes, but both races were similar in age, sport, and medical/family histories. Black athletes more frequently had public insurance (33.3% vs 5.7%) and lived in areas with a low median income (41.2% vs 26.6%). After adjusting for age, sex, concussion history, insurance status, and zip code median income, Black athletes reached an asymptomatic status (HR 1.497, 95% CI 1.014-2.209, p = 0.042) and returned to school earlier (HR 1.522, 95% CI 1.020-2.270, p = 0.040). Black athletes were less likely to report a change in any daily activity than White athletes (OR 0.368, 95% CI 0.136-0.996, p = 0.049). Changes in sport behavior were comparable between the groups.

CONCLUSIONS

Racial differences appear to exist in the outcomes and experience of SRC for young athletes, as Black athletes reached SR and return to school sooner than White athletes. Race should be considered as an important social determinant in SRC treatment.

Speech Recognition Outcomes in Adults With Slim Straight and Slim Modiolar Cochlear Implant Electrode Arrays

OBJECTIVE

To compare differences in audiologic outcomes between slim modiolar electrode (SME) CI532 and slim lateral wall electrode (SLW) CI522 cochlear implant recipients.

STUDY DESIGN

Retrospective cohort study.

SETTING

Tertiary academic hospital.

METHODS

Comparison of postoperative AzBio sentence scores in quiet (percentage correct) in adult cochlear implant recipients with SME or SLW matched for preoperative AzBio sentence scores in quiet and aided and unaided pure tone average.

RESULTS

Patients with SLW (n = 52) and patients with SME (n = 37) had a similar mean (SD) age (62.0 [18.2] vs 62.6 [14.6] years, respectively), mean preoperative aided pure tone average (55.9 [20.4] vs 58.1 [16.4] dB; P = .59), and mean AzBio score (percentage correct, 11.1% [13.3%] vs 8.0% [11.5%]; P = .25). At last follow-up (SLW vs SME, 9.0 [2.9] vs 9.9 [2.6] months), postoperative mean AzBio scores in quiet were not significantly different (percentage correct, 70.8% [21.3%] vs 65.6% [24.5%]; P = .29), and data log usage was similar (12.9 [4.0] vs 11.3 [4.1] hours; P = .07). In patients with preoperative AzBio <10% correct, the 6-month mean AzBio scores were significantly better with SLW than SME (percentage correct, 70.6% [22.9%] vs 53.9% [30.3%]; P = .02). The intraoperative tip rollover rate was 8% for SME and 0% for SLW.

CONCLUSIONS

Cochlear implantation with SLW and SME provides comparable improvement in audiologic functioning. SME does not exhibit superior speech recognition outcomes when compared with SLW.

Management of vestibular dysfunction and hearing loss in intralabyrinthine schwannomas

PURPOSE

Intralabyrinthine schwannomas (ILS) are rare, benign, slow-growing tumors arising from schwann cells of the cochlear or vestibular nerves within the bony labyrinth. This study provides insight into the management of this rare tumor through a large case series.

MATERIALS AND METHODS

After Institutional Review Board approval, a retrospective chart review was performed of all ILS patients treated at our institution between 2007 and 2019.

RESULTS

20 patients (9 male, 11 female) with ILS were managed at our institution. The right ear was affected in 9 patients (45%) and the left in 11 (55%). Subjective hearing loss was endorsed by all 20 patients. Average pure tone average at presentation was 72 dB nHL. Nine tumors (45%) were intravestibular, 6 (30%) were intracochlear, 4 (20%) were transmodiolar and 1 (5%) was intravestibulocochlear. Hearings aids were used in 3 patients (15%), BiCROS in 2 (10%), CI in 2 (10%), and bone conduction implant in 1 (5%). Vestibular rehabilitation was pursued in 5 patients. Surgical excision was performed for one patient (5%) via translabyrinthine approach due to intractable vertigo. No patients received radiotherapy or intratympanic gentamicin injections.

CONCLUSION

ILS presents a diagnostic and management challenge given the similarity of symptoms with other disorders and limited treatment options. Hearing loss may be managed on a case-by-case basis according to patient symptoms while vestibular loss may be mitigated with vestibular therapy. Surgical excision may be considered in patients with intractable vertigo, severe hearing loss with concurrent CI placement, or in other case-by-case situations.

Socioeconomic Influences on Short-term Postoperative Outcomes in Patients With Oral Cavity Cancer Undergoing Free Flap Reconstruction

OBJECTIVE

To evaluate the associations between median household income (MHI) and area deprivation index (ADI) on postoperative outcomes in oral cavity cancer.

STUDY DESIGN

Retrospective review (2000-2019).

SETTING

Single-institution tertiary medical center.

METHODS

MHI and ADI were matched from home zip codes. Main postoperative outcomes of interest were length of tracheostomy use, length of hospital stay, return to oral intake, discharge disposition, and 60-day readmissions. Linear and logistic regression controlled for age, sex, race, body mass index, tobacco and alcohol use history, primary tumor location, disease staging at presentation, and length of surgery. A secondary outcome was clinical disease staging (I-IV) at time of presentation.

RESULTS

The cohort (N = 681) was 91.3% White and 38.0% female, and 51.7% presented with stage IV disease. The median age at the time of surgery was 62 years (interquartile range [IQR], 53-71). The median MHI was $47,659 (IQR, $39,324-$58,917), and the median ADI was 67 (IQR, 48-79). ADI and MHI were independently associated with time to return of oral intake (β = 0.130, P = .022; β = -0.092, P = .045, respectively). Neither was associated with length of tracheostomy, hospital stay, discharge disposition, or readmissions. MHI quartiles were associated with a lower risk of presenting with more advanced disease (Q3 vs Q1: adjusted odds ratio, 0.56 [95% CI, 0.32-0.97]).

CONCLUSION

MHI is associated with oral cavity cancer staging at the time of presentation. MHI and ADI are independently associated with postoperative return to oral intake following intraoral tumor resection and free flap reconstruction.

Cerebellopontine Angle and Internal Auditory Canal Lipomas: Case Series and Systematic Review

OBJECTIVES/HYPOTHESIS

Cerebellopontine angle (CPA) and internal auditory canal (IAC) lipomas are rare, benign tumors comprising 0.08% of all intracranial tumors and can be mistaken for other, more common lesions of the CPA/IAC such as vestibular schwannoma. The purpose of this study was to review the literature and assess the evolution of CPA/IAC lipoma diagnosis and management. In addition, we present 17 new lipomas, matching the largest known case series of this rare tumor.

STUDY DESIGN

Retrospective case series and systematic review.

METHODS

Systematic review of the literature was performed using PubMed and Google Scholar. References from identified articles were also reviewed to identify potential additional manuscripts. Manuscripts and abstracts were reviewed to identify unique cases. For the case series, the charts of all CPA/IAC lipoma patients seen at a single institution from 2006-2019 were manually reviewed. Logistic regression and chi-squared analysis were performed where appropriate.

RESULTS

A total of 219 unique lipomas have been reported in the literature, including 17 presented in this study. Surgical management has been performed in 46% of cases and has been conducted less often in recent decades, likely due to improved radiographic diagnostic capabilities and understanding of surgical outcomes. Surgical management is associated with worse neurologic outcomes (P = .002) and has become less common in recent decades. Although growth is unlikely, it has been demonstrated in patients into their 30s.

CONCLUSIONS

Accurate radiographic diagnosis is imperative for appropriate patient management, as CPA/IAC lipomas should typically be managed through observation and serial imaging whereas vestibular schwannomas and other CPA/IAC lesions may require microsurgical or radiosurgical intervention depending on growth and symptomatology. Laryngoscope, 131:2081-2087, 2021.

Persistent Conductive Hearing Loss After Tympanostomy Tube Placement Due to High-Riding Jugular Bulb

High-riding jugular bulb (HRJB) is a rare condition not often observed in the clinical setting that occurs in 1% to 3% of cases. The jugular bulb is not present at birth, and the precise size and location likely depends on a myriad of postnatal events. This report describes the case of a male adolescent who experienced persistent conductive hearing loss (CHL) unilaterally following bilateral tympanostomy tube placement. Subsequent workup included computed tomography, which identified a very high jugular bulb eroding the posterior semicircular canal and occluding the round window niche. The patient had no hearing or vestibular symptoms aside from CHL and continues to be observed on a regular basis. HRJB is a rare disorder that has been known to erode the posterior semicircular canal, resulting in possible tinnitus, vertigo, dizziness, and/or sensorineural hearing loss. CHL has been reported in HRJB cases, although it is uncommon. HRJB may result in CHL through a third-window defect shunting hydromechanical energy away from the round window or due to middle ear blockage. Imaging is useful in ascertaining rare causes of CHL, such as HRJB. Because HRJB is not easily fixable, it is important to recognize it as a rare cause of CHL for appropriate patient counseling. Possible interventions should be tailored to the patient after careful consideration of contralateral anatomy and likely benefits. Laryngoscope, 131:E1272-E1274, 2021.

Pregnancy, Estrogen Exposure, and the Development of Otosclerosis: A Case-Control Study of 1196 Women

OBJECTIVE

This study sought to determine whether a history of pregnancy or bilateral oophorectomy is associated with subsequent otosclerosis development or disease severity.

STUDY DESIGN

Population-based case-control study.

SETTING

Olmsted County, Minnesota.

METHODS

Women diagnosed with otosclerosis were matched to 3 women without otosclerosis based on age and historical depth of medical records. Associations of prior delivery and bilateral oophorectomy with subsequent development of otosclerosis and with pure-tone average (PTA) at the time of otosclerosis diagnosis were evaluated.

RESULTS

We studied 1196 women: 299 cases of otosclerosis and 897 matched controls. The odds ratio for the association of ≥1 delivery with otosclerosis was 1.16 (95% confidence interval [CI] 0.85-1.60; P = .35). Odds ratios for the associations of 1, 2, 3, or ≥4 deliveries with otosclerosis were 1.22 (0.83-1.80), 1.09 (0.71-1.68), 1.28 (0.77-2.12), and 1.00 (0.54-1.84), respectively. The odds ratio for the association of prior bilateral oophorectomy with otosclerosis was 1.12 (0.58-2.18; P = .73). In cases with otosclerosis, PTA at diagnosis was not significantly higher for women with ≥1 delivery as compared with those without (median 45 dB hearing loss [HL] [interquartile range {IQR} 36-55] vs 43 [IQR 34-53]; P = 0.18) but was significantly higher for women with bilateral oophorectomy compared with those without (median 54 dB HL [IQR 44-61] vs 44 [IQR 34-53]; P = .03).

CONCLUSION

These data do not support a relationship between endogenous estrogen exposure and development of otosclerosis. Women with otosclerosis who had a history of pregnancy did not have significantly worse hearing at the time of diagnosis, suggesting that pregnancy is not associated with disease severity.

Sinonasal Small Cell Carcinoma-Case Series of a Rare Malignancy

Sinonasal small cell neuroendocrine carcinoma (SNEC) is an extremely rare and aggressive neoplasm that can arise in the sinonasal region. These tumors are associated with high morbidity and mortality, are difficult to diagnose, and are hard to treat. We describe 2 cases of this poorly understood malignancy and review imaging, pathology, and treatment decisions. A 41-year-old male and a 64-year-old female presented to a tertiary center in 2019 after developing nasal obstruction and were found to have sinonasal masses on imaging. Both biopsies showed strong expression of pancytokeratin with dot-like reactivity and expression of neuroendocrine markers chromogranin and synaptophysin. The findings were diagnostic of SNEC. Staging positron emission tomography/computed tomography and brain MRI were performed, and patients were discussed at a multidisciplinary tumor board. Neither had distant metastatic disease at presentation. One patient had no intracranial or orbital disease and underwent a subtotal endoscopic resection with adjuvant chemoradiation. The other patient demonstrated middle cranial fossa, dural, and orbital involvement as well as cranial nerve V palsy. This patient was treated with induction chemotherapy, followed by concurrent chemoradiation. Both patients are presently alive at 4 months follow-up, but one with persistent local disease and the other distant metastasis. Sinonasal small cell neuroendocrine carcinoma is a rare and poorly understood malignancy with an aggressive clinical course. Continued careful review of pathology and study of molecular features are needed for improved understanding of SNEC, and particularly for head and neck SNEC, to establish a staging system and better formulate treatment protocols.

Treatment of Sinonasal Teratocarcinosarcoma: A Systematic Review and Survival Analysis

BACKGROUND

Sinonasal teratocarcinosarcoma (SNTCS) is a rare malignancy of the anterior skull base with only 127 cases described in the English literature. Given the rarity of this tumor, new cases and analysis of published reports may assist in future management of SNTCS.

OBJECTIVES

1) Describe findings from a systematic review of all available literature for malignant SNTCS including the clinical presentation, treatment modalities and outcomes. 2) Present two new cases of this rare anterior skull base tumor. 3) Compare treatment outcomes with respect to recurrence and mortality.

METHODS

A systematic review of all English literature available in 2 comprehensive databases was conducted by two independent reviewers using PRISMA guidelines. 85 publications were identified. Each case was reviewed for demographics, treatment and survival, and aggregate treatment outcomes were compared using Kaplan-Meier analysis.

RESULTS

A total of 64 articles meeting inclusion criteria were reported in the literature between 1977-2018. This represented a total of 127 patients, with a strong male predominance (83%) and mean age of 50 years (range 10-82). Mean follow-up was 21 months. Recurrence rate was 38%, with mean survival at 2 years of 55%. Almost all patients underwent surgery as a primary treatment modality (90%). The majority of cases were treated with multimodal therapy, with 55% receiving surgery and radiation and 20% receiving surgery with adjuvant chemoradiation. Kaplan-Meier analysis demonstrated a significant survival advantage for patients treated with combined therapy compared to surgery alone (p < 0.001) but did not show differences in recurrence (p = 0.085).

CONCLUSION

Two-year survival rates for SNTCS are 55%. Multimodality treatment outcomes appear to be superior to surgery alone based on the published data of this rare skull base tumor, although heterogeneity of treatment methods and reporting bias limits the generalizability of these findings.

With the Incidence of Otosclerosis Declining, Should Stapedectomy Remain a Key-Indicator Case for Otolaryngology Residents?

Stapedectomy remains a joint key-indicator case with ossiculoplasty for otolaryngology residents in the United States. Yet, residents consistently report feeling inadequately prepared to perform stapes surgery following graduation. Applying recently described age- and sex-standardized incidence rates of surgically confirmed cases of otosclerosis to the US populace, upper and lower estimates of residents' case exposure to stapedectomy can be approximated. With this, uppermost projections estimate 6484 new cases of stapes surgery are performed annually nationwide. With approximately 1424 otolaryngology residents nationally, the average case exposure is 7.8 stapedectomies throughout their training, with upper and lower estimates of 17.1 and 4.2 cases, respectively. As such, proficiency in stapedectomy is no longer a realistic expectation for US graduating residents. This reality supports the removal of "stapedectomy" from the list of 14 key-indicator case requirements, leaving ossiculoplasty as its own key-indicator case, thereby reinforcing true competence in this fundamental procedure for the graduating otolaryngologist.

Progressive Vestibular Schwannoma following Subtotal or Near-Total Resection: Dose-Escalated versus Standard-Dose Salvage Stereotactic Radiosurgery

Objective  Local failure of incompletely resected vestibular schwannoma (VS) following salvage stereotactic radiosurgery (SRS) using standard doses of 12 to 13 Gy is common. We hypothesized that dose-escalated SRS, corrected for biologically effective dose, would have superior local control of high-grade VS progressing after subtotal or near-total resection compared with standard-dose SRS. Design  Retrospective cohort study. Setting  Tertiary academic referral center. Participants  Adult patients treated with linear accelerator-based SRS for progressive VS following subtotal or near-total resection. Main Outcome Measures  Dose-escalated SRS was defined by a biologically effective dose exceeding a single-fraction 13-Gy regimen. Study outcomes were local control and neurologic sequelae of SRS. Binary logistic regression was used to evaluate predictors of study outcomes. Results  A total of 18 patients with progressive disease following subtotal (71%) and near-total (39%) resection of Koos grade IV disease (94%) were enrolled. Of the 18 patients, 7 were treated with dose-escalated SRS and 11 with standard-dose SRS. Over a median follow-up of 32 months after SRS, local control was 100% in the dose-escalated cohort and 91% in the standard-dose cohort ( p  = 0.95). Neurologic sequelae occurred in 28% of patients, including 60% of dose-escalated cohort and 40% of the standard-dose cohort ( p  = 0.12), although permanent neurologic sequelae were low at 6%. Conclusions  Dose-escalated SRS has similar local control of recurrent VS following progression after subtotal or near-total resection and does not appear to have higher neurologic sequalae. Larger studies are needed.

Team versus individual sport participation as a modifying factor in the development of post-concussion syndrome after first concussion: A pilot study

Identification of modifying factors that influence the development of post-concussion syndrome (PCS) following sport-related concussion (SRC) has drawn considerable interest. In this pilot study, we investigate the effect of team vs. individual sport participation on the development of PCS in a sample of 136 high school and college student-athletes. Controlling for several confounding variables, we employed a binary logistic regression and chi-squared test. Results of this pilot study indicate that participation in team versus individual sport is not a significant factor in the development of PCS. The identification of other forms of protective mechanisms is discussed.

Socioeconomic status and outcomes after sport-related concussion: a preliminary investigation

OBJECTIVE A significant proportion of patients experience long-term symptoms after sport-related concussion (SRC), and several factors have been associated with this protracted recovery. Limited data exist on the role of socioeconomic status (SES) on SRC outcomes. The objective in this study was to conduct a preliminary investigation to determine the effect of SES on outcomes after SRC in student-athletes treated at a regional sports concussion center. METHODS A retrospective cohort study of 282 middle school, high school, and collegiate student-athletes was conducted. An attempt was made to contact all patients seen at a comprehensive SRC center between January 2012 and May 2015 for in-depth interviews. Subsequent demographic data were collected. The SES was defined as follows: cost of living percentile, median income percentile, percentage of college graduates, percentage of homeowners, county type, and insurance status. Outcomes after SRC were defined as follows: days of symptom duration, days of missed school, and days of missed practice. Statistically controlled covariates included sex, race, age, body mass index, concussion history, neuropsychiatric history, and type of sport. RESULTS A total of 282 student-athletes consented and were studied. The median age was 15.8 years (range 11.6-22.2 years) and 61.4% of student-athletes were male. A previous concussion was incurred by 34.0% of student-athletes. Football was the most common sport (32.3%), followed by soccer (16.3%), and basketball (15.6%). The median symptom duration was 21 days (range 1-365 days); the median missed school days was 2 (range 0-90 days); and median for days of missed practice was 10 (range 0-150 days). After multivariate Cox regression analysis, no relationship between any of the 6 SES variables and symptom duration or missed practice was seen. However, individuals with private insurance had more missed days of school than those with public insurance (hazard ratio 0.46, 95% CI 0.26-0.83, p = 0.009). CONCLUSIONS In a preliminary study of middle school, high school, and collegiate student-athletes, SES had no impact on the outcomes of symptom duration and missed practice. However, for individuals with private insurance, the return to school was slower than for those with public insurance. This pilot study reveals the complex relationship between SES and SRC recovery, which demands further study with more accurate and validated assessments of SES.

Input clustering and the microscale structure of local circuits

The recent development of powerful tools for high-throughput mapping of synaptic networks promises major advances in understanding brain function. One open question is how circuits integrate and store information. Competing models based on random vs. structured connectivity make distinct predictions regarding the dendritic addressing of synaptic inputs. In this article we review recent experimental tests of one of these models, the input clustering hypothesis. Across circuits, brain regions and species, there is growing evidence of a link between synaptic co-activation and dendritic location, although this finding is not universal. The functional implications of input clustering and future challenges are discussed.