Congenital Retrosigmoid Cholesteatoma: Case Series and Literature Review

BACKGROUND

This study aimed to discuss 3 cases of congenital cholesteatoma located posterior to the sigmoid sinus, with no/minimal involvement of mastoid, and compare them with cases presented in the literature to better define this rare entity.

METHODS

Retrospective chart analysis of 3 congenital cholesteatomas located posterior to the sigmoid sinus treated surgically in 2 skull-base centers and literature review. Though congenital cholesteatoma can arise outside the middle ear, only a few cases presenting in the retrosigmoid occipital bone have been described earlier.

RESULTS

In all 3 patients, there was a delay in the presentation, as symptoms were nonspecific or lacking, leading in 1 case to severe complications. Computed tomography and magnetic resonance imaging, especially diffusion-weighted imaging scans, allowed accurate diagnosis and surgical planning. Surgery happened to be challenging due to the tight adherence of the cholesteatoma to the thinned dural surface. Complete excision was achieved in all the cases.

CONCLUSION

Congenital cholesteatoma located posterior to the sigmoid sinus is a rare entity and is even more exceptional after a critical review of the literature. Complete excision is quintessential to prevent intradural extension or infection. The most important surgical issue is the management of the posterior fossa dura and the sigmoid sinus. We recommend meticulous dissection with slow peeling of the epithelial lining from the dura. Bipolar coagulation of the dura may help in avoiding recidivism. Moreover, cerebrospinal fluid (CSF) leak during dissection has to be avoided as long as possible, because the loss of tension of the already thinned dura makes its peeling particularly difficult.

Evaluation of the transmastoid plugging approach for superior semicircular canal dehiscences: a retrospective series of 30 ears

PURPOSE

The classical surgical approach for superior semicircular canal dehiscences (SSCD) is via the extradural middle cranial fossa. This pathway is used to resurface or to plug the SSC. In this paper, we present long-term data on an alternative route: the transmastoid pathway. The predictive factors for a successful surgery are equally presented in this paper.

METHODS

Thirty reports of patients operated between September 2007 to January 2020 were analysed. SSCD was confirmed by the association of concordant complaints, audiometric data, cervical vestibular evoked myogenic potentials (cVEMP) responses and computerized tomography findings. Before and after surgery, the following factors were analysed: auditory and vestibular subjective symptoms, Tullio phenomenon, pure-tone audiometry thresholds for air and bone conduction, air-bone gap, cVEMP threshold, and computerized tomography data, for instance the size of the dehiscence.

RESULTS

The follow-up is 21 months on average. The transmastoid approach significantly improves all symptoms (although there were less probing results for the vestibular symptoms). Objectively, we can observe, a closure of the audiometric air-bone gap on the low frequencies and an improvement in the cVEMP. The only correlation that was identified was between the preoperative cVEMP results and the postoperative air conduction.

CONCLUSIONS

The originality of this study is the long postoperative follow-up. It allowed us to evaluate the symptoms in the long term and to determine a predictive factor of postoperative complication, which has not yet been described until today.The transmastoid plugging technique is safe and effective. Additional long-term data with a larger cohort are needed to confirm our results and correlation studies.

Decompression of the internal auditory canal via the retrosigmoid approach in a patient with Camurati-Engelmann disease: illustrative case

BACKGROUND

Camurati-Engelmann disease (CED) is a rare condition characterized by hyperostosis of the long bones and skull base. Symptoms include contractures and pain in affected extremities but can also include manifestations of cranial hyperostosis such as intracranial hypertension, Chiari malformation, exophthalmia, frontal bossing, and several cranial neuropathies due to cranial foraminal stenosis.

OBSERVATIONS

This report describes a 27-year-old patient with suspected CED who developed progressive intermittent facial nerve paresis, hemifacial spasms, and a decrease in hearing. There were no symptoms of increased intracranial pressure or vertigo. Radiological evaluation showed a significant thickening of the skull base with serious bilateral internal auditory canal stenosis. Because of the progressive nature of the aforementioned cranial neuropathies in combination with the correlating severe radiological compression, a surgical decompression of the facial nerve and vestibulocochlear nerve was performed via a retrosigmoid approach with intraoperative monitoring. Postoperative facial nerve function was intact. Hearing and vestibular function were unchanged. There were no more episodes of facial nerve palsy or spasm.

LESSONS

To the authors' knowledge, this is the first report to describe decompression of the internal auditory canal via a retrosigmoid approach for symptomatic facial and cochlear nerve compression in a patient with CED.

Intratemporal facial nerve schwannomas: multicenter experience of 80 cases

PURPOSE

To provide more data on the clinical presentation and natural evolution of facial nerve schwannomas and to provide guidance for therapeutic decision making.

METHODS

A retrospective case review of eighty patients diagnosed with a facial nerve schwannoma between 1990 and 2018 in ten tertiary referral centers in Europe was performed. Patients' demographics, symptomatology, audiometry, anatomical site (segments involved), size and whenever possible volume measurement were registered.

RESULTS

At presentation, transient or persistent facial palsy was the most common symptom, followed by hearing loss. The schwannoma involved more than one segment in the majority of the patients with the geniculate ganglion being most commonly involved. Initial treatment consisted of a wait and scan approach in 67.5%, surgery in 30% and radiation therapy in 2.5% of the patients. Tympanic segment schwannomas caused mainly conductive hearing loss and were more prone to develop facial palsy at follow-up. Internal auditory canal or cerebellopontine angle schwannomas presented with significantly more sensorineural hearing loss.

CONCLUSIONS

Although modern imaging has improved diagnosis of this tumor, choosing the best treatment modality remains a real challenge. Based on the literature review and current findings, more insights into the clinical course and the management of facial nerve schwannomas are provided.

Cochlear Patency after Translabyrinthine and Retrosigmoid Vestibular Schwannoma Surgery

OBJECTIVES

To assess the incidence and onset of cochlear obliteration after translabyrinthine and retrosigmoid vestibular schwannoma surgery.

MATERIALS AND METHODS

We retrospectively identified a consecutive series of eighty ears in eighty vestibular schwannoma patients who were treated via a translabyrinthine or retrosigmoid approach by a single neuro-otological surgical team in a tertiary referral center from May 2011 to January 2018. Postoperative, high- resolution T2-weighted turbo spin echo three-dimensional magnetic resonance (MR) images of the posterior fossa were evaluated at the level of the membranous labyrinth and internal auditory canal. Perilymphatic patency of the vestibule, basal, and apical cochlear turns were scored and classified as patent, hypointense, partially obliterated, or completely obliterated.

RESULTS

Twenty-five vestibular schwannomas were treated with surgery via a translabyrinthine approach, and fifty-five were treated using a retrosigmoid approach; of these, 8% and 65%, respectively, showed no signs of perilymphatic alterations in the basal or apical turns, while 84% and 20%, respectively, showed partial or complete obliteration in the basal or apical turns with a mean postoperative interval of 127 and 140 days, respectively. All the patients who underwent multiple MR scans and had a completely patent perilymphatic system on the first postoperative scan remained patent during subsequent scans; 16% of the patients showed worsened perilymphatic appearance. The onset of cochlear obliteration occurred within 2-7 months in most translabyrinthine patients.

CONCLUSION

These findings may support the need for simultaneous cochlear electrode or dummy implantation in translabyrinthine surgery. Second-stage implantation could be feasible in cases where a retrosigmoid approach is used; however, the implantation should be considered within the initial months to avoid cochlear obliteration. Findings on the first postoperative MR could indicate the need for intensified MR follow-up and may even predict the occurrence of cochlear obliteration.

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Hearing Results

OBJECTIVE

To present the hearing results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up (CWU) approach with bony obliteration of the mastoid and epitympanic space, with a standard residual rate of 5.8%, a recurrence rate of 2.9%, and all ears waterproof, free of otorrhea and all external ear canals patent and self-cleaning.

STUDY DESIGN

Retrospective consecutive study.

PATIENTS

Thirty-three children (≤18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009.

INTERVENTIONS

Therapeutic.

SETTING

Tertiary referral center.

MAIN OUTCOME MEASURES

Hearing and gain in hearing at 1- and 5-year postsurgery: (1) pure-tone average (PTA), (2) pure-tone average high frequency, (3) pure-tone average including 3 kHz, (4) bone conduction at corresponding frequency averages, (5) gain at corresponding air conduction and bone conduction (gain at corresponding air conduction) frequency averages. (6) The Amsterdam Hearing Evaluation Plots were used to study the individual cases.

RESULTS

The Amsterdam Hearing Evaluation Plots at 5-year showed in 58.8% of patients a positive gain air conduction. In 23.5% a successful functional result was achieved, defined as an air-bone gap closure to 20 dBHL or less. In 6 patients (17.6%) a limited bone conduction deterioration was shown all limited to maximum 20 dBHL.

CONCLUSION

The CWU bony obliteration tympanoplasty in a consecutive series of pediatric extensive cholesteatoma shows a similar to slightly improved hearing outcome as compared with CWU surgery without BOT. Although the series shows a clearly reduced reoperation rate and a significantly improved safety and hygienic outcome as compared with CWU without BOT, better hearing outcomes remain desirable in this group of children.

EAONO position statement on Vestibular Schwannoma: Imaging Assessment Question: How should growth of Vestibular Schwannoma be defined?

The relevance of defining the growth of vestibular schwannoma (VS) is that any significant VS growth may impact treatment strategy. A conservative treatment strategy is often proposed as a primary treatment option in the management of VS. Several authors have demonstrated that a significant proportion of VSs do not grow, and those that do, usually grow slowly. Surgical and/or radiosurgical treatment options may be offered to the patient according to the VS growth. Therefore, defining the VS growth is a determinant in managing treatment strategies. A comprehensive literature search was performed to examine the definition of tumor growth for VS. The literature review was conducted using PubMed and Embase databases dated back to 20 years (1995-2015) and was updated until February 2015. VS growth should be measured on contrast-enhanced T1-weighted images. Although there the overall quality of the present studies is low, all highlight a significant VS growth of > 2 mm, and/or 1.2 cm3, and/or 20% change in volume, and/or the square of the product of the 2 orthogonal diameters. We suggest that VS growth should instead change management strategies when a 3-mm increase in diameter on two consecutive MRI scans are performed 1 year apart.

What is the Required Frequency of MRI Scanning in the Wait and Scan Management?

The wait and scan policy is being increasingly used as the first measure after the diagnosis of a vestibular schwannoma (VS) using magnetic resonance imaging (MRI). As part of the European Academy of Otology and Neuro-Otology (EAONO) position statement on VS, the frequency of imaging has been studied in the literature. Among 163 studies, 29 fulfilled the inclusion criteria and were scored using the Grading of Recommendations, Assessment, Development, and Evaluation system. Because tumor growth rate during the first 5 years of follow-up is predictive of further growth during the upcoming years, a protocol for wait and scan is useful for centers dealing with this condition. The EAONO proposal is that after the initial diagnosis by MRI, a first new MRI would take place after 6 months, annually for 5 years, and then every other year for 4 years, followed by a lifelong MRI follow-up every 5 years. The first early MRI is to screen for fast-growing tumors, and the lifelong follow-up with tapered intervals is to detect late repeated growth.

Cochlear Erosion due to a Facial Nerve Schwannoma

Facial nerve schwannomas are rare benign neoplasms. We report a case of a 60-year-old woman who initially presented with vestibular complaints. Magnetic resonance imaging (MRI) revealed a facial nerve schwannoma centered on the right geniculate ganglion extending in the labyrinthine segment. The patient consulted again after 2 months because she developed a sudden and severe right-sided sensorineural hearing loss. MRI showed no progression or pathological enhancement in the membranous labyrinth. A cone beam computed tomography (CT) of the temporal bone was performed and revealed a large erosion at the region of the geniculate ganglion in open communication with the middle turn of the cochlea. This case report demonstrates the importance of CT in facial nerve schwannomas for evaluating the impact on the surrounding structures.

Surgical Treatment of Acquired Atresia of the External Auditory Ear Canal

Introduction  Acquired atresia of the external auditory canal is characterized by the formation of fibrous tissue in the medial part. The causes include chronic otitis externa, perforated chronic otitis media, postoperative or idiopathic healing problems. Acquired atresia presents with hearing loss and can be associated with otorrhea.

Objective  We analyzed the results of surgery after six months and two years by checking (1) pre- and postoperative hearing thresholds; (2) presence of otorrhea; and (3) whether a dry and patent ear canal is achieved.

Methods  We conducted this retrospective study at a tertiary referral center. In total, 27 ears underwent treatment with resection of the fibrotic plug followed by transplantation of a split-thickness skin graft covering the bare bone and tympanic membrane. When necessary, we combined this with a myringoplasty and a (meato-) canalplasty.

Results  Otorrhea was present in 59.3% of the patients initially and in 14.8% at six months and 11% at two years postoperative. A dry and patent ear canal was obtained in 55.6% after six months and in 89% of the patients after two years ( n  = 27). The pure tone average before surgery was 39.1 dBHL (SD = 20 dBHL), at six months 31.4 dBHL (SD = 16.4 dBHL), and at 24 months postop 30.9 dBHL (SD = 17.1 dBHL). We observed a statistically significant improvement of hearing in 63% of the patients at six months ( p  = 0.005) and in 65% after two years ( p  = 0.022).

Conclusions  Treatment of acquired atresia remains a challenge. Using the appropriate surgical technique, including skin-grafting and regular postoperative check-up, rendered excellent results regarding otorrhea and a moderate improvement of hearing was achieved in 65% of the patients after two years.

Consensus Statements on the BAHA System: Where Do We Stand at Present?

After more than 25 years of clinical experience, the BAHA (bone-anchored hearing aid) system is a well-established treatment for hearing-impaired patients with conductive or mixed hearing loss. Owing to its success, the use of the BAHA system has spread and the indications for application have gradually become broader. New indications, as well as clinical applications, were discussed during scientific roundtable meetings in 2004 by experts in the field, and the outcomes of these discussions are presented in the form of statements. The issues that were discussed concerned BAHA surgery, the fitting range of the BAHA system, the BAHA system compared to conventional devices, bilateral application, the BAHA system in children, the BAHA system in patients with single-sided deafness, and, finally, the BAHA system in patients with unilateral conductive hearing loss.

Iatrogenic facial nerve injuries during chronic otitis media surgery: a multicentre retrospective study

OBJECTIVES

To give an insight into why, when and where iatrogenic facial nerve (FN) injuries may occur and to explain how to deal with them in an emergency setting.

DESIGN AND SETTING

Multicentre retrospective study in eight tertiary referral hospitals over 17 years.

PARTICIPANTS

Twenty patients with partial or total FN injury during surgery for chronic otitis media (COM) were revised.

MAIN OUTCOME MEASURES

Indication and type of surgery, experience of the surgeon, intra- and postoperative findings, value of CT scanning, patient management and final FN outcome were recorded.

RESULTS

In 12 cases, the nerve was completely transected, but the surgeon was unaware in 11 cases. A minority of cases occurred in academic teaching hospitals. Tympanic segment, second genu and proximal mastoid segments were the sites involved during injury. The FN was not deliberately identified in 18 patients at the time of injury, and nerve monitoring was only applied in one patient. Before revision surgery, CT scanning correctly identified the lesion site in 11 of 12 cases and depicted additional lesions such as damage to the lateral semicircular canal. A greater auricular nerve graft was interposed in 10 cases of total transection and in one partially lesioned nerve: seven of them resulted in an HB III functional outcome. In two of the transected nerves, rerouting and direct end-to-end anastomosis was applied. A simple FN decompression was used in four cases of superficially traumatised nerves.

CONCLUSIONS

We suggest checklists for preoperative, intraoperative and postoperative management to prevent and treat iatrogenic FN injury during COM surgery.

Results, Hearing Rehabilitation, and Follow-up with Magnetic Resonance Imaging after Tympanomastoid Exenteration, Obliteration, and External Canal Overclosure for Severe Chronic Otitis Media

Objectives:

We sought to evaluate the results, auditory rehabilitation, and follow-up with magnetic resonance imaging (MRI) after tympanomastoid exenteration with obliteration of the mastoid cavity and overclosure of the external ear canal in patients with severe chronic otitis media that was resistant to medical therapy and conventional surgery and was associated with a profound sensorineural or severe conductive hearing loss.

Methods:

Twenty-nine patients were analyzed and underwent this surgical technique. Twelve patients had, during the same or later stage, either cochlear implantation, fixture implantation for a bone-anchored hearing aid, or middle ear implantation. For follow-up control of the obliterated cavity, delayed gadolinium-enhanced, T1-weighted MRI in combination with non-echo planar imaging diffusion weighted sequences were used.

Results:

No patient had recurrent otorrhea after an average follow-up period of 4.75 years. One patient had a residual cholesteatoma as shown by new MRI techniques, and this was successfully resected. One patient developed complications 6 months after 1-stage tympanomastoid exenteration and cochlear implantation.

Conclusions:

This technique is very useful in selected patients with severe chronic otitis media that is resistant to medical therapy and surgery and is associated with a profound sensorineural or severe conductive hearing loss. New sequences in MRI are used for postoperative follow-up of these obliterated cavities and seem reliable for the detection of residual or recurrent cholesteatoma. Middle ear implantation and cochlear implantation can be relatively safely performed in these patients in a second stage.

Stapedotomy with Microdrill or Carbon Dioxide Laser: Influence on Inner Ear Function

Objectives:

A prospective randomized audiological analysis of 336 otosclerosis operations was conducted to compare the evolution of bone conduction thresholds after primary stapedotomy with Two different techniques to open the footplate: microdrill and carbon dioxide laser stapedotomy.

Methods:

To monitor the inner ear function, we compared the preoperative bone conduction thresholds with the postoperative levels at day 2, week 2, week 6, and month 6. Evolution of the bone conduction was compared for the Two studied groups (laser versus microdrill).

Results:

An average bone conduction loss of 1.8 dB was measured at day 2 for the middle frequencies (0.5, 1, and 2 kHz). At 4 kHz, a bone conduction loss of 7 dB was found. The bone conduction thresholds measured in the first and second months after surgery showed a gradual recovery with overclosure as the end result.

Conclusions:

Our results confirm the transient depression of inner ear function in the immediate postoperative period, with recovery within the first weeks after surgery. In the studied population, no statistically significant difference was found between the Two techniques that were used to make the calibrated hole (laser versus microdrill). These results demonstrate that both techniques possess the same early effect regarding inner ear function. The authors hypothesize that an early inflammatory reaction could be the cause of the transient bone conduction shift.

Validity and Test-Retest Reliability of the Dutch Version of the Chronic Otitis Media Questionnaire 12 (COMQ-12)

OBJECTIVE

To test the validity and test-retest reliability of the Dutch translation of the Chronic Otitis Media Questionnaire 12 (COMQ-12).

MATERIALS AND METHODS

Thirty-five healthy individuals with no history of chronic otitis media (COM) received the questionnaire as well as a group of 35 patients with complaints of COM. The healthy participants had to complete the questionnaire twice (control group 1 and control group 2) to estimate the test-retest reliability, and their scores were compared with those of the patients (group 3) to test the validity.

RESULTS

The overall COMQ-12 score in control group 1 ranged from 0 to 11, in control group 2 from 0 to 6, and in group 3 from 7 to 46. The mean score in control group 1 was 1.43 [standard deviation (SD) 2.30], 1.34 in control group 2 (SD 2.06), and 27.80 in group 3 (SD 10.51). A comparison of the absolute COMQ-12 scores of the two control groups and the patient group showed a significantly higher COMQ-12 score in patients with COM than in controls. The diagnostic accuracy was investigated, and a COMQ-12 cut-off score of 8 was found to have a near-perfect sensitivity and specificity in distinguishing between the presence and absence of COM. The single-measures intraclass correlation coefficient for absolute agreement (ICCAA) was 0.859 (with a 95% confidence interval from 0.738 to 0.926). This clearly exceeded the ICC threshold for acceptable reliability (ICC≥0.75) and therefore confirmed that there was reasonable test-retest reliability when applying the questionnaire to control subjects.

CONCLUSION

The Dutch version of the COMQ-12 has good validity, diagnostic accuracy, and test-retest reliability.

Handling an Isolated Malleus Handle Fracture

Background:

An isolated malleus handle fracture is rare and presents with vague otological symptoms. Diagnosis depends on careful history taking and otoscopic examination. Different treatment options are available. Reconstruction with hydroxyapatite bone cement is a relatively new technique.

Objective:

The aim of this article is to review the current diagnostic work-up and treatment options and to demonstrate our method of treatment with hydroxyapatite bone cement.

Methods:

Three cases, repaired with hydroxyapatite bone cement in a tertiary referral otologic center, were retrospectively analyzed. A review of the literature on diagnosis and treatment procedures was performed.

Results:

One fracture occurred by withdrawing a finger from the external auditory canal and 2 occurred without clear prior trauma. Our 3 cases were successfully repaired with hydroxyapatite bone cement.

Conclusion:

Diagnosis of an isolated malleus handle fracture still depends on careful clinical examination. In addition to pure tone audiometry, both low and higher frequency tympanometry may be useful. High resolution computed tomography with reformatting through the malleus handle is the most accurate imaging modality. Reconstruction with hydroxyapatite bone cement is reliable by restoring the original situation with only minimal manipulation and without additional ossicular interruption.

Amplification options in unilateral aural atresia: an active middle ear implant or a bone conduction device?

BACKGROUND

There is no consensus on treatment of patients with congenital unilateral aural atresia. Currently, 3 intervention options are available, namely, surgical reconstruction, application of a bone-conduction device (BCD), or application of a middle ear implant.

OBJECTIVE

The present study aims to compare the BCD with the application of a middle ear implant. We hypothesized that cross-hearing (stimulating the cochlea by means of bone conduction contralateral to the implanted side) would cause BCD users to have difficulty performing localization tasks.

METHODS

Audiologic data of 4 adult patients with a middle ear implant coupled directly to the cochlea were compared with data of 4 adult patients fitted with an osseointegrated BCD. All patients were fitted during adulthood. The emphasis of this study is on directional hearing.

RESULTS

The middle ear implant and the BCD improved sound localization of patients with congenital unilateral aural atresia. Unaided scores demonstrate a large variation.

CONCLUSION

Our results demonstrate that there was no advantage of the middle ear implant over the BCD for directional hearing in patients who had no amplification in childhood. The BCD users had the best bandwidth.

Psychosocial interventions for managing pain in older adults: outcomes and clinical implications

Interest in the use of psychosocial interventions to help older adults manage pain is growing. In this article, we review this approach. The first section reviews the conceptual background for psychosocial interventions with a special emphasis on the biopsychosocial model of pain. The second section highlights three psychosocial interventions used with older adults: cognitive behavioural therapy, emotional disclosure, and mind-body interventions (specifically mindfulness-based stress reduction and yoga). The final section of the paper highlights important future directions for work in this area.

Transmastoid repair of superior semicircular canal dehiscence

Objective/Hypothesis Superior semicircular canal (Sup SC) dehiscence syndrome is a rare condition, causing a variety of auditory and vestibular symptoms. The traditional surgical management is a middle cranial fossa, extradural approach to resurface the Sup SC. Recently, a transmastoid approach for plugging of the Sup SC has been developed. We present further data supporting the use of the transmastoid approach in preference to the middle fossa approach. Design This is a retrospective multi-institutional case series. Method We included 10 patients in this case series from two tertiary otology institutions. Sup SC dehiscence was confirmed by correlation of clinical symptoms with positive audiometric, vestibular evoked myogenic potential, and computed tomography findings. A transmastoid approach was used for plugging of the Sup SC. Either a single fenestration was created at the site of dehiscence or separate fenestrations sited ampullopetal and ampullofugal to the dehiscence. Results All patients who underwent this procedure had good symptom control and hearing preservation postoperatively. Conclusion In patients with adequate temporal bone pneumatization, the transmastoid approach provides a safe and effective alternative to the middle cranial fossa approach. This series has demonstrated excellent symptom control and preservation of hearing with the transmastoid approach.

Fundus obliteration and facial nerve outcome in vestibular schwannoma surgery

The major objectives in vestibular schwannoma (VS) surgery have evolved from reducing mortality to functional preservation of the facial nerve and hearing. Absence of fluid between the lateral end of the VS and the internal auditory canal fundus on magnetic resonance imaging (MRI) appeared to have a negative influence on hearing outcome. Our goal was to study the prognostic significance of fundus obliteration on facial nerve function after VS surgery in patients with clinically normal facial function. We performed a retrospective review in a tertiary referral neurotology unit or 110 consecutive patients with a surgically removed VS and normal preoperative facial nerve function. Facial nerve function was evaluated at 1 month and 1 year by using the House-Brackmann (HB) scale and correlated to fundus obliteration on MRI. Facial nerve function was intact preoperatively in 114 of 123 patients (92.7%). We noticed a statistically significant difference and worse short-term outcome when the fundus was obliterated: 29.7% had HB 3 or more versus 13.0% if no fundus obliteration was seen. This statistically significant difference disappeared at 1 year. Fundus obliteration has a negative prognostic influence on short-term facial nerve function after VS surgery in patients with clinically normal facial function preoperatively.

Multidisciplinary management of vestibular schwannomas: state of the art

The preferred setting for the treatment for vestibular schwannoma these days is multidisciplinary and multimodal. A balance has to be struck between a wait-and-scan attitude and a more active approach (surgery or radiotherapy). An initial wait-and-scan attitude is a reasonable management option because many tumours do not grow during a prolonged period of observation. The different surgical approaches may or may not involve attempts to preserve hearing. Stereotactic radiotherapy as treatment of choice is often considered in the elderly patient presenting with a vestibular schwannoma smaller than 2.5 cm with documented growth. This paper will review current treatment modalities and the respective pros and cons. A decisional algorithm as currently adopted by our skull base team is presented at the end of the paper.

Ossicular reconstruction: hydroxyapatite bone cement versus incus remodelling: how to manage incudostapedial discontinuity

The objective of this study was to compare the hearing outcome using hydroxyapatite (HA) bone cement to bridge the incudostapedial gap versus incus remodelling for ossiculoplasty in case of incudostapedial discontinuity. A non-randomized retrospective study was conducted at a tertiary referral otologic centre. The intervention in 24 primary cases of conductive hearing loss was subsequent middle ear inspection where incudostapedial discontinuity was observed. HA bone cement was used in 10 consecutive cases, and incus remodelling was performed in 14 consecutive cases. Air-bone gap (ABG), bone-conduction (BC) thresholds, and air-conduction (AC) thresholds were evaluated preoperatively and at 3, 6 and 12 months postoperatively. No patients were lost to follow-up. Pure-tone averages were calculated according to the guidelines of the Committee on Hearing and Equilibrium for the evaluation of conductive hearing loss. The Amsterdam Hearing Evaluation Plots are presented. The postoperative ABG closure to within 20 and 10 dB at 12 months was, respectively, 80 and 40% in the HA bone cement group and 57.1 and 28.6% in the standard ossiculoplasty group (no statistically significant difference). However, we observed a statistically significant difference in ABG gain at 6 and 12 months favoring the HA bone cement cases. No short-term or intermediate-term adverse reactions were observed. Hydroxyapatite bone cement bridging ossiculoplasty offers a better intermediate-term ABG gain than standard ossiculoplasty. This new technique is a valuable alternative to conventional ossiculoplasty and presents the practical advantage of being easier and faster.

Prognostic significance of electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery

OBJECTIVE

To assess the prognostic significance of pre-operative electrophysiological tests for facial nerve outcome in vestibular schwannoma surgery.

METHODOLOGY

Retrospective study design in a tertiary referral neurology unit. We studied a total of 123 patients with unilateral vestibular schwannoma who underwent microsurgical removal of the lesion. Nine patients were excluded because they had clinically abnormal pre-operative facial function. Pre-operative electrophysiological facial nerve function testing (EPhT) was performed. Short-term (1 month) and long-term (1 year) post-operative clinical facial nerve function were assessed.

RESULTS

When pre-operative facial nerve function, evaluated by EPhT, was normal, the outcome from clinical follow-up at 1-month post-operatively was excellent in 78% (i.e. HB I-II) of patients, moderate in 11% (i.e. HB III-IV), and bad in 11% (i.e. HB V-VI). After 1 year, 86% had excellent outcomes, 13% had moderate outcomes, and 1% had bad outcomes. Of all patients with normal clinical facial nerve function, 22% had an abnormal EPhT result and 78% had a normal result. No statistically significant differences could be observed in short-term and long-term post-operative facial function between the groups.

CONCLUSION

In this study, electrophysiological tests were not able to predict facial nerve outcome after vestibular schwannoma surgery. Tumour size remains the best pre-operative prognostic indicator of facial nerve function outcome, i.e. a better outcome in smaller lesions.

Middle ear cholesteatoma: non-echo-planar diffusion-weighted MR imaging versus delayed gadolinium-enhanced T1-weighted MR imaging--value in detection

PURPOSE

To retrospectively compare non-echo-planar (non-EP) diffusion-weighted (DW) imaging, delayed gadolinium-enhanced T1-weighted magnetic resonance (MR) imaging, and the combination of both techniques in the evaluation of patients with cholesteatoma.

MATERIALS AND METHODS

This institutional review board-approved study, for which the need to obtain informed consent was waived, included 57 patients clinically suspected of having a middle ear cholesteatoma without a history of surgery and 63 patients imaged before "second-look" surgery. Four blinded radiologists evaluated three sets of MR images: a set of delayed gadolinium-enhanced T1-weighted images, a set of non-EP DW images, and a set of both kinds of images. Overall sensitivity, specificity, negative predictive value (NPV), and positive predictive value (PPV), as well as intra- and interobserver agreement, were assessed and compared among methods. To correct for the correlation between different readings, a generalized estimating equations logistic regression model was fitted. Results were compared with surgical results, which were regarded as the standard of reference.

RESULTS

Sensitivity, specificity, NPV, and PPV were significantly different between the three methods (P < .005). Sensitivity and specificity, respectively, were 56.7% and 67.6% with the delayed gadolinium-enhanced T1-weighted images and 82.6% and 87.2% with the non-EP DW images. Sensitivity for the combination of both kinds of images was 84.2%, while specificity was 88.2%. The overall PPV was 88.0% for delayed gadolinium-enhanced T1-weighted images, 96.0% for non-EP DW images, and 96.3%for the combination of both kinds of images. The overall NPV was 27.0% for delayed gadolinium-enhanced T1-weighted images, 56.5% for non-EP DW images, and 59.6% for the combination of both kinds of images.

CONCLUSION

MR imaging for detection of middle ear cholesteatoma can be performed by using non-EP DW imaging sequences alone. Use of the non-EP DW imaging sequence combined with a delayed gadolinium-enhanced T1-weighted sequence yielded no significant increases in sensitivity, specificity, NPV, or PPV over the use of the non-EP DW imaging sequence alone.

Diffusion-weighted magnetic resonance imaging of the temporal bone

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

Subarcuate Supralabyrinthine Approach for Supralabyrinthine Petrosal Cholesteatoma

Congenital cholesteatomas of the petrosal apex account for 1% to 3% of all cholesteatomas and often present an important surgical challenge. This report describes an exceptional case of a “nondestructive” translabyrinthine surgical approach to a large congenital petrosal cholesteatoma that threatened the vestibulum, superior semicircular canal, facial nerve, and internal auditory canal. We applied a nonconventional transmastoid subarcuate supralabyrinthine approach in a 20-year-old patient by accessing the lesion through the center of the superior semicircular arch without damaging the integrity of the canal. This led to a complete removal of the petrosal cholesteatoma with preservation of hearing and vestibular function. Follow-up imaging performed 1 and 2 years after operation by means of non—echo-planar diffusion-weighted imaging did not show residual cholesteatoma. This report describes the first successful use of a subarcuate supralabyrinthine approach through the arches of the superior semicircular canal in a case of petrosal cholesteatoma.

Audiological outcomes after cochlear implantation in a patient with Melnick-Needles syndrome

This is the first report on a successful cochlear implantation in a patient suffering from the Melnick-Needles syndrome (MNS). This case study presents an MNS patient with peri-lingual profound hearing loss, implanted at the age of 38. MNS is a rare X-linked genetic bony dysplasia characterized by skeletal and facial abnormalities. Various soft tissue defects and hearing loss have also been described in MNS; however, this is the first report on bilateral inner ear malformation as a phenotypic feature of MNS. At 15 months after cochlear implantation there was 91% speech identification in open-set monosyllabic CVC test. In noise, the results obtained with the CVC lists were the following: 67% for SNR +15 dB, 52% for SNR +10 dB and 36% for SNR +5 dB. The patient is able to discriminate the differences in all 22 phoneme pairs in the APE phoneme discrimination test. This allows the patient to obtain significant communication ability through the telephone. Conclusions are as follows. 1) Bilateral inner ear malformations and bilateral profound perceptive hearing loss possibly belong to the phenotypic features of MNS. 2) Cochlear implant is potentially a good functional solution for patients suffering from MNS and profound hearing loss. 3) Exceptionally good results on auditory performance have been obtained in this MNS patient with peri-lingual profound hearing loss and almost 36 years duration of deafness.

Imaging of intralabyrinthine schwannomas: a retrospective study of 52 cases with emphasis on lesion growth

BACKGROUND AND PURPOSE

Only a few case reports and small series of intralabyrinthine schwannomas (ILSs) have been reported. The purpose of this study was to assess prevalence, MR characteristics, location, clinical management, and growth potential/patterns of ILSs in the largest series reported.

MATERIALS AND METHODS

Lesion localization, MR characteristics, lesion growth, and clinical management were reviewed in 52 patients diagnosed with an ILS between February 1991 and August 2007 in 2 referral centers. The number of ILSs and vestibulocochlear schwannomas in the cerebellopontine angle/internal auditory canal was compared to assess the prevalence.

RESULTS

ILSs most frequently originate intracochlearly, are hyperintense on unenhanced T1-weighted images, enhance strongly after gadolinium administration, and are sharply circumscribed and hypointense on thin heavily T2-weighted 3D images. The scala tympani is more frequently or more extensively involved than the scala vestibuli. Follow-up MR imaging, available in 27 patients, showed growth in 59% of subjects. Growth was seen from the scala tympani into the scala vestibuli and from the scala vestibuli to the saccule and vice versa. Twelve lesions were resected, and the diagnosis of ILS histopathologically confirmed.

CONCLUSION

ILSs can account for up to 10% of all vestibulocochlear schwannomas in centers specializing in temporal bone imaging, grow in more than 50%, and are most frequently found intracochlearly, often anteriorly between the basal and second turn. Cochlear ILSs most often originate in the scala tympani and only later grow into the scala vestibuli. Growth can occur from the cochlea into the vestibule or vice versa through the anatomic open connection between the perilymphatic spaces in the scala vestibuli and around the saccule.

A mutation in HOXA2 is responsible for autosomal-recessive microtia in an Iranian family

Microtia, a congenital deformity manifesting as an abnormally shaped or absent external ear, occurs in one out of 8,000-10,000 births. We ascertained a consanguineous Iranian family segregating with autosomal-recessive bilateral microtia, mixed symmetrical severe to profound hearing impairment, and partial cleft palate. Genome-wide linkage analysis localized the responsible gene to chromosome 7p14.3-p15.3 with a maximum multi-point LOD score of 4.17. In this region, homeobox genes from the HOXA cluster were the most interesting candidates. Subsequent DNA sequence analysis of the HOXA1 and HOXA2 homeobox genes from the candidate region identified an interesting HOXA2 homeodomain variant: a change in a highly conserved amino acid (p.Q186K). The variant was not found in 231 Iranian and 109 Belgian control samples. The critical contribution of HoxA2 for auditory-system development has already been shown in mouse models. We built a homology model to predict the effect of this mutation on the structure and DNA-binding activity of the homeodomain by using the program Modeler 8v2. In the model of the mutant homeodomain, the position of the mutant lysine side chain is consistently farther away from a nearby phosphate group; this altered position results in the loss of a hydrogen bond and affects the DNA-binding activity.

The value of single-shot turbo spin-echo diffusion-weighted MR imaging in the detection of middle ear cholesteatoma

INTRODUCTION

Single-shot (SS) turbo spin-echo (TSE) diffusion-weighted (DW) magnetic resonance imaging (MRI) is a non echo-planar imaging (EPI) technique recently reported for the evaluation of middle ear cholesteatoma. We prospectively evaluated a SS TSE DW sequence in detecting congenital or acquired middle ear cholesteatoma and evaluated the size of middle ear cholesteatoma detectable with this sequence. The aim of this study was not to differentiate between inflammatory tissue and cholesteatoma using SS TSE DW imaging.

METHODS

A group of 21 patients strongly suspected clinically and/or otoscopically of having a middle ear cholesteatoma without any history of prior surgery were evaluated with late post-gadolinium MRI including this SS TSE DW sequence.

RESULTS

A total of 21 middle ear cholesteatomas (5 congenital and 16 acquired) were found at surgery with a size varying between 2 and 19 mm. Hyperintense signal on SS TSE DW imaging compatible with cholesteatoma was found in 19 patients. One patient showed no hyperintensity due to autoevacuation of the cholesteatoma sac into the external auditory canal. Another patient showed no hyperintensity because of motion artifacts.

CONCLUSION

This study shows the high sensitivity of this SS TSE DW sequence in detecting small middle ear cholesteatomas, with a size limit as small as 2 mm.