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Background: Salvage surgery for progressive symptoms or recurrent growth of vestibular schwannoma (VS) after stereotactic radiosurgery (SRS) is uncommon. It has been reported to be more difficult, the same or easier than expected compared with microsurgical resection (MS) of treatment-naive VS, with variable facial nerve outcomes. We conducted a matched cohort analysis to evaluate facial nerve outcomes for patients undergoing MS for progressive symptoms or recurrent growth of VS after SRS compared with MS for treatment-naive VS. Methods: We evaluated the records of 365 non-NF2 VS patients treated with MS from 2001 to 2014. All patients who had postoperative notes were considered to have "adequate follow-up" and included in the study. Nine patients underwent resection for VS after prior SRS (MS-POST SRS) with no prior intervention, 7 of which had adequate follow-up, and 331 patients that underwent MS for treatment naive VS (MS-NO SRS), 317 of which had adequate follow-up. From this dataset, we created propensity score matched cohorts to retrospectively compare facial nerve preservation and clinical outcomes. The propensity score model incorporated age at surgery, tumor size, and pre-operative HB grade, and cases were matched at a ratio of 4:1 MS-NO SRS to MS-POST SRS cases. Results: The MS-POST SRS (n = 7) and MS-NO SRS (n = 28) groups differed only in preoperative hearing status (p < 0.01). Preoperative HB grades were similar between MS-POST SRS and MS-NO SRS groups (p>0.3). The average time-to-intervention after SRS in the MS-POST SRS group was 44.4 months. The indication for MS after SRS was symptom progression with tumor growth in 4 cases, and only tumor growth in the remaining 3. Postoperatively, 3 cases in the MS-POST SRS group demonstrated improvement in HB grade and none became worse whereas 3 of 28 cases in the MS-NO SRS group demonstrated improvement and 12 cases had decrement in HB grade relative to baseline (p < 0.05). There was no significant difference in the extent of resection with both cohorts (MS-POST SRS and MS-NO SRS) attaining gross total resection in 85.7% of cases. Subsequent intervention was not required for any case in the MS-POST SRS group and 2 cases in the MS-NO SRS group, although this difference was not significant. Both cases requiring subsequent intervention in the MS-POST SRS group were gross total resections via the translabyrinthine approach, with subsequent intervention required at 62 and 48 months. There were no significant differences in the complication rate for individual complications or the overall complication rate between cohorts. Conclusions: At a center with high clinical volume, microsurgical resection of VS after prior SRS was associated with good postoperative facial nerve preservation and low morbidity, comparable to those observed in resection of treatment-naive VS. In addition there were similar outcomes in terms of extent of resection between the two groups. The good outcomes reported here may reflect a confluence of factors which include patient selection, the experience of the attending surgeons, the use of more contemporary SRS dosing protocols during initial treatment for these patients, and divergent goals of therapy between cohorts

OBJECTIVE: Intracranial aneurysms are a public health issue with a potential for rupturing, causing significant morbidity/mortality. The prevalence of unruptured intracranial aneurysms, including those that are asymptomatic, varies largely, since it has been determined through autopsy studies as well as conventional angiography. However, computed tomography (CT) angiography, a less invasive procedure, has replaced the use of conventional angiography in the recent decades. The objective of the present study is to determine the prevalence of incidental aneurysms. METHODS: The present study reviews all CT angiography cases within the last decade at a single institution. RESULTS: Out of 2195 cases included in the study, 39 (1.8%) were found to have asymptomatic unruptured aneurysms. CONCLUSION: An increased number of asymptomatic incidental aneurysms was detected.

BACKGROUND: Hemangiopericytomas are typically found in soft-tissue, but only rarely found in the sinonasal tract. Sinonasal hemangiopericytomas have been reported mostly through case studies, and optimal treatment is considered surgical excision. Classically, open surgical methods of tumor extirpation have been considered standard of care. With the wider use of endoscopic methods, an updated systematic review in terms of treatment is warranted. METHODS: Cases were identified using a MEDLINE and PubMed search. Relevant studies were identified, and data was extracted regarding patient demographics, presenting symptoms, tumor characteristics, treatment, and outcomes. RESULTS: A total of 128 cases were collected from 56 articles, consisting of case reports and series. The most common presenting symptoms were epistaxis, nasal obstruction, and facial pain/swelling/pressure. Computed tomography (CT) and X-ray were the most common modes of imaging during diagnosis and operative planning. The tumor often occupied multiple locations in the sinonasal tract at initial presentation. Surgical resection was the mainstay of treatment in 126 of the 128 cases (98.4%), either through open resection or endoscopic techniques. Surgical removal resulted in no recurrence in 79.7% of the cases. The use of endoscopic techniques increased significantly in the past decade. This review found no significant difference in terms of recurrence between endoscopic and open treatment groups, age, gender, and unilocality vs multilocality of tumor. CONCLUSION: Surgical management remains the mainstay of treatment for hemangiopericytomas. Endoscopic resection of these lesions has increased over the last few decades and has become a safe, viable, and reasonable alternative to open resection.

Conjunctivodacryocystorhinostomy (CDCR) with Jones tube placement is usually performed as a primary procedure for severe stenosis or obstruction of both upper and lower canaliculi of the lacrimal drainage pathway, or occasionally, after unsuccessful dacryocystorhinostomy (DCR). Jones tube obstruction is quite common, and often requires removal of the obstructed tube and replacement or exchange of the tube in the operating room. This procedure is typically performed under general anesthesia, and is associated with the risks of general anesthesia, a significant investment of time, and the cost of the operating suite. Recently, there has been a movement toward in-office procedures in otolaryngology and ophthalmology due to greater patient satisfaction and savings in time and money for patients and physicians. In this report, we describe a novel in-office method to exchange an obstructed Jones tube that provides the aforementioned benefits while preserving patient comfort. No similar case has been previously reported in the literature.

BACKGROUND: Advances in endoscopic sinus surgery have led to a greater number of in-office procedures away from the traditional operating room setting. Rhinologists acting independently of anesthesiologists must be prepared for potential complications, such as vasovagal response (VVR), that may arise during in-office rhinologic manipulations. In this study, we review our experience with this condition and discuss risk factors and a management algorithm for in-office VVR. METHODS: A retrospective analysis at a large tertiary referral center was performed on all patients undergoing in-office endoscopic procedures with rhinologic manipulation between July 2008 and June 2012. A total of 4973 patients underwent in-office endoscopic procedures and 8 patients with VVR were identified. Demographic data, diagnosis, procedure performed, and outcomes were reviewed. RESULTS: Eight patients out of 4973 (0.16%) experienced VVR during in-office endoscopic procedures. Seven (87.5%) of these 8 patients recovered from the VVR within 30 minutes and subsequently completed their scheduled procedure. One (12.5%) of the 8 patients did not fully recover after 30 minutes and was sent to the Emergency Department, where he was stabilized and subsequently discharged. The most common comorbidities in these 8 patients with VVR were hypercholesterolemia in 3 patients (37.5%), and hypertension and benign prostatic hyperplasia, each found in 2 patients (25.0%). CONCLUSION: Although the incidence of VVR during rhinologic procedures is low, rhinologists should be familiar with this condition and be prepared for its management.