Objective: Determine whether Superior semicircular canal dehiscence (SSCD) patients have thinner skull bases compared with controls and spontaneous cerebrospinal fluid leak (sCSFL) patients. Study design: Case control. Setting: Tertiary referral center. Patients: Radiographically confirmed SSCD, temporal bone sCSFL, matched (BMI and age), and unmatched control cohorts. Intervention: Measurement of calvarium, zygomatic arch, and lateral skull base thickness. Main outcome measures: Compare BMI, average skull base, calvarial, and zygomatic arch thicknesses of controls and sCSFL patients. Results: SSCD patients have an average [SD] BMI similar to unmatched controls (29.2 [7.7] vs. 31.4 [7.9] kg/m 2 , P =0.18), but significantly lower BMI than sCSFL patients (29.2 [7.7] vs. 38.5 [10.6] kg/m 2 , P <0.001). The average skull base thickness of SSCD patients was 50% thinner than matched control patients (2.12 [0.92] vs. 4.23 [1.13] mm, P <0.001, Cohen d =2.05) and 33% thinner than sCSFL patients (2.12 [0.92] vs. 3.13 [1.46] mm, P <0.001, Cohen d =0.83). No significant difference in skull base thickness was observed between symptomatic and asymptomatic SSCD patients ( P =0.45). SSCD patients had a small yet significantly reduced calvarium to zygomatic arch thickness ratio compared with controls (0.44 [0.09] vs. 0.51 [0.11], P <0.001, Cohen d =0.70), but not sCSFL patients (0.44 [0.09] vs. 0.47 [0.12], P =0.09). Conclusions: SSCD patients possess dramatically thinner skull bases than control and sCSFL patients, despite a lack of predisposing factors like obesity. These data implicate a developmental deficiency in the pathophysiology of SSCD.

Department of Otorhinolaryngology Head and Neck Surgery University Medicine Halle Halle (Saale), Germany Address correspondence and reprint requests to Torsten Rahne, Prof. Dr., Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Halle, Halle (Saale), Germany; E-mail: [email protected]

Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112 [email protected] The author discloses no conflicts of interest.

Louisiana State University Health Sciences Center New Orleans, New Orleans, LA Address correspondence and reprint requests to Moises Arriaga, MD, Bullington Louisiana State University Health Sciences Center New Orleans, Suite 501, 533 Bolivar Street, New Orleans, LA 70112; E-mail: [email protected] The authors disclose no conflicts of interest.

Louisiana State University Health Sciences Center New Orleans, New Orleans, LA 70112 [email protected] The author discloses no conflicts of interest.

To characterize the viability and volume of autologous free fat grafts over time, determine clinical/patient factors that may affect free fat graft survival and assess the clinical impact of free fat graft survival on patient outcomes in the translabyrinthine approach for lateral skull base tumor resection. Retrospective chart review. Tertiary neurotologic referral center. Forty-two adult patients who underwent translabyrinthine craniotomy for resection of a lateral skull base tumor with the mastoid defect filled by autologous abdominal fat graft and subsequently underwent more than one postoperative magnetic resonance imaging (MRI) scans of the brain. Mastoid obliteration with abdominal fat after craniotomy, postoperative MRI. Rate of fat graft volume loss, fraction retention of original fat graft volume, initial fat graft volume, time to steady-state fat graft retention, rate of postoperative cerebrospinal fluid (CSF) leak, and/or pseudomeningocele formation. Patients were followed postoperatively with MRI for a mean of 31.6 months with a mean of 3.2 postoperative MRIs per patient. Initial graft size was a mean of 18.7 cm3 with a steady-state fat graft retention of 35.5%. Steady-state graft retention (<5% loss per year) was achieved at a mean of 24.96 months postoperatively. No significant association was found in multivariate regression analysis of clinical factors impact on fat graft retention and CSF leak/pseudomeningocele formation. In the use of autologous abdominal free fat graft for filling mastoid defects after translabyrinthine craniotomy, there is a logarithmic decline in fat graft volume over time, reaching steady state in 2 years. Rates of CSF leak or pseudomeningocele formation were not significantly affected by initial volume of the fat graft, rate of fat graft resorption, nor the fraction of original fat graft volume at steady state. In addition, no analyzed clinical factors significantly influenced fat graft retention over time.

To evaluate social determinants of health and their effect on the management of vestibular schwannoma (VS). Retrospective chart review. Tertiary referral center. Patients >18 years old with sporadic VS newly diagnosed between January 1, 2010, and December 31, 2020. Magnetic resonance imaging; audiogram; treatment recommendations. Differences in treatment recommendations for patients based on their social determinants of health, including race, ethnicity, and socioeconomic status. A total of 811 patients were included in analysis. Patients with a higher area deprivation index (ADI) presented with larger tumors. A higher ADI was associated with a higher likelihood of recommending radiation (or the option of surgery or radiation) compared with a recommendation of surgery alone. Tumor grade and patient age were significantly associated with treatment recommendation. Older age was associated with a recommendation of observation alone or a recommendation of radiation. Higher tumor grade was associated with a recommendation of surgery. There was a trend for higher hearing class to be associated with a recommendation of surgery, but this did not reach statistical significance. Race, ethnicity, and gender were not significantly associated with treatment recommendation. Patients with higher levels of disadvantage presented with higher tumor grade, suggesting that access to care influences diagnosis. Factors including age, ADI, and tumor grade were associated with treatment recommendation.

To the Editor: I read with great interest the article entitled “Intratemporal intraosseous hemangioma: imaging case of the month” by Shah et al. (1). The authors reported a case of a 75-year-old woman with a temporal bone lesion referred to as an intraosseous hemangioma, which was initially treated with propranolol (without improvement of symptoms) and then surgically resected. However, I would like to comment on the term “hemangioma,” as this lesion probably represents an intraosseous venous malformation (IOVM), especially considering the typical “honeycomb” appearance observed on computed tomography imaging (2). According to the widely accepted classification of the International Society for the Study of Vascular Abnormalities (ISSVA) (3), vascular anomalies are primarily divided into vascular malformations and vascular tumors. Whereas vascular malformations arise through dysmorphogenesis and have stable endothelial turnover, vascular tumors are characterized by endothelial proliferation (4). The ISSVA classification was based on the landmark article by Mulliken and Glowacki (5), who first proposed the differentiation between hemangiomas and vascular malformations based on endothelial characteristics. Venous malformations represent congenitally malformed and dilated venous channels with a slow internal flow. IOVM is a subtype of venous malformation that occurs primarily in bone, commonly found in the craniofacial region. In the temporal bone, it is often seen at the geniculate ganglion of the facial nerve. Like all vascular malformations, IOVMs grow as a result of gradual vascular ectasia, potentially exacerbated by hormonal, inflammatory, or traumatic factors and intralesional hemorrhage. Most IOVMs are asymptomatic and found incidentally on cross-sectional imaging examinations; on computed tomography, the presence of internal bony spicules is near-pathognomonic. IOVMs that cause cosmetic or functional issues are treated by surgical excision, as they neither respond to antiangiogenic drugs nor involute over time (2). Conversely, hemangiomas are considered benign neoplasms that grow by endothelial hyperplasia and express cellular proliferation markers. Hemangiomas usually refer to infantile hemangiomas, the most common benign neoplasms in infants that typically appear within the first month of life and have a distinct triphasic growth pattern (rapid enlargement, followed by a stationary period and progressive involution). Despite the benign evolution, complications may occur such as ulceration, disfigurement, visual impairment, and airway narrowing; in these cases, propranolol is the mainstay of treatment (2,4,6). In fact, the terms “hemangioma” and “angioma” have been widely misused to refer to vascular malformations in clinical and surgical practice. In a literature review, Hassanein et al. (4) demonstrated that the term “hemangioma” was misused in 71.3% of articles published in 2009; notably, patients whose lesions were mislabeled were more likely to receive improper treatment compared with patients whose lesions were accurately labeled. Likewise, a recent literature review showed that the majority of intraosseous hemangiomas, angiomas, or hemangioendotheliomas reported in the head and neck were, in fact, IOVMs (7). Because venous malformations have distinct clinical, histopathological, and radiological features, using the correct terminology may avoid unnecessary workup (such as angiographic examinations, which are not suitable for low-flow lesions), pharmacological treatment, and patient distress (2,4). Widespread adoption of the ISSVA classification is essential to prevent diagnostic confusion and inappropriate patient management. Rafael Maffei Loureiro, M.D. Department of Radiology Hospital Israelita Albert Einstein Av. Albert Einstein Sao Paulo SP, Brazil [email protected]