Intralabyrinthine schwannoma: Surgical management and cochlear lumen preservation

The present video reports the surgical removal of an intralabyrinthine schwannoma. The video contains patient's medical history, preoperative radiological evaluations and detailed description of surgical steps of the procedure, consisting in labyrinthectomy, cochleostomy and insertion of a dummy electrode in the preserved cochlear lumen within the context of a subtotal petrosectomy.

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.

Current trends on subtotal petrosectomy with cochlear implantation in recalcitrant chronic middle ear disorders

Objective

To establish the safety and effectiveness of subtotal petrosectomy with cochlear implantation in patients affected by chronic middle ear disorders to refractory to previous surgical treatments.

Methods

A multicentre, retrospective study was conducted on patients affected by recalcitrant chronic middle ear disorders who underwent cochlear implantation in combination with subtotal petrosectomy. Patients' details were collected from databases of 11 Italian tertiary referral centres. Additionally, a review of the most updated literature was carried out.

Results

55 patients were included with a mean follow-up time of 44 months. Cholesteatoma was the most common middle ear recurrent pathology and 50.9% of patients had an open cavity. 80% of patients underwent a single stage surgery. One case of explantation for device failure was reported among the 7 patients with post-operative complications.

Conclusions

Subtotal petrosectomy with cochlear implantation is a benchmark for management of patients with recalcitrant chronic middle ear disorders. A single stage procedure is the most recommended strategy. Optimal follow-up is still debated. Further studies are required to investigate the role of this surgery in paediatric patients.

Management of complicated temporal bone fracture

The current video presents the surgical management of a complicated temporal bone fracture. The video contains patient's medical history, preoperative radiological evaluations, and detailed surgical approach to manage the disease. The current video presents the surgical management of a complicated temporal bone fracture. The video contains patient's medical history, preoperative radiological evaluations, and detailed surgical approach to manage the disease.

Revision cochlear implant surgery for clinical reasons

Objective

To report the authors' experience in a series of patients treated with cochlear implant (CI) revision surgery due to medical problems.

Methods

Revision CI surgeries performed in a tertiary referral centre for medical reasons not related to skin conditions were reviewed; patients were included if device removal was required.

Results

17 cochlear implant patients were reviewed. The main reasons requiring revision surgery with device removal were: retraction pocket/iatrogenic cholesteatoma (6/17), chronic otitis (3/17), extrusion in previous canal wall down procedures (2/17) or in previous subtotal petrosectomy (2/17), misplacement/partial array insertion (2/17) and residual petrous bone cholesteatoma (2/17). In all cases surgery was performed through a subtotal petrosectomy. Cochlear fibrosis/ossification of the basal turn was found in 5 cases and uncovered mastoid portion of the facial nerve in 3 patients. The only complication was an abdominal seroma. A positive difference was observed between the number of active electrodes and comfort levels before and after revision surgery.

Conclusions

In CI revision surgeries performed for medical reasons, subtotal petrosectomy offers invaluable advantages and should be considered as first choice during surgical planning.

Management of cochlear fistula and the role of hearing: a five-case report

Objective

Cochlear fistula (CF) is a rare finding, usually associated with extensive middle ear cholesteatoma. There is agreement on the fact that removing the cholesteatoma matrix on a CF exposes the ear to a high risk of sensorineural hearing loss or dead ear. The aim of the study is to describe the presentation, possible treatment strategies and related outcomes for patients with CF in chronic otitis media (COM).

Methods

The study considers a retrospective case series of patients with CF diagnosis supported by CT-scan and intraoperative/otoscopic evidence.

Results

Five cases of CF were identified, 4 associated with cholesteatoma and 1 associated with non-cholesteatomatous COM. Two patients presenting with anacusis underwent a subtotal petrosectomy. Two patients with useful hearing underwent a radical mastoidectomy in order to preserve the cholesteatoma matrix on the promontorium. One patient with good hearing and COM was treated conservatively.

Conclusions

Conservative management should be considered for rare cases of CF in COM with residual hearing. Matrix preservation through radical/modified radical mastoidectomy is strongly advised in the presence of useful preoperative bone conduction. Subtotal petrosectomy should be considered the preferred option in presence of cholesteatoma with preoperative profound hearing loss.

Capillary Venous Malformation With Secondary Aneurysmal Bone Cyst of Temporal Bone

Aneurysmal bone cysts (ABCs) arising from vascular malformation are extremely rare, and none have been reported in the literature in English till now. We report a very rare case of secondary ABC of left temporal bone in a 5-year-old Caucasian boy who presented with a left sudden facial palsy associated with a painless non-tender mass of the left temporo-parietal region. The computed tomography (CT) and magnetic resonance imaging (MRI) features were suggestive of ABC secondary to a capillary venous malformation, with concurrent involvement of the squamous, mastoid, and petrous portions of the temporal bone. Surgical resection was performed. On follow-up, the patient was found to be doing well.

Subtotal petrosectomy and cochlear implantation

Objective

The objective of this study is to analyse surgical outcomes in a series of patients who underwent subtotal petrosectomy in combination with cochlear implantation.

Methods

Retrospective chart review. Thirty patients (32 ears) underwent subtotal petrosectomy and cochlear implantation in one stage. Indications for subtotal petrosectomy included the following: cholesteatoma, chronic otitis media, previous canal wall-down, osteoradionecrosis, revision surgery for clinical reasons, inner ear malformations, middle ear anatomical variations and severe cochlear ossification.

Results

Follow-up ranged from 2 to 54 months. Only 2 complications related to the subtotal petrosectomy (1 subcutaneous abdominal haematoma and 1 subcutaneous abdominal seroma) occurred in this series. Complete electrode insertion was achieved in all but 4 cases.

Conclusions

Subtotal petrosectomy is a safe procedure and can offer technical advantages in some cases of complex cochlear implantation.

Giant Epidermoid Cyst of Posterior Fossa-Our Experience and Literature Review

Introduction. Intracranial epidermoid cysts are the most frequent congenital intracranial lesion. They rare and benign tumors that can present in different clinical situations depending on location and extension of the disease. Diagnosis is obtained with radiological imaging with RM and non-enhanced TC as elective investigating methods. Elective treatment is surgery, based on total/subtotal excision sparring healthy neurovascular structures, considering the benign nature of this lesion. Case Report. In this study we present the case of a 79-year-old woman affected by recidivist epidermal cyst of the posterior fossa. Clinical presentation was characterized by positional subjective vertigo, intense headache localized in the right part of the head increased by Valsalva maneuver and retroarticular subcutaneous swelling. Radiological investigation found a giant epidemoid cyst of the posterior fossa (8,4 x 4,8 x 5,8 cm), treated with surgery. In the postoperative, the patient was fine and no neurological deficit has been encounterd. REVIEW. In this study, we present a review of the literature regarding giant epidermoid cysts of posterior fossa. Only 11 cases were reported before ours, which actually is one of the largest ever described.

Drainage of a petrous apex cholesterol granuloma through an infracochlear approach

The current video presents the surgical management of a cholesterol granuloma of the anterior petrous apex, through the infracochlear approach. The video contains patient's medical history, pre-operative radiological evaluation, surgical approach to the lesion and radiological follow up. Surgery was conducted by an otology and skull base team in a tertiary referral center. The patient is a 49-years-old male, who was referred to our center for a four months history of right tinnitus and fullness. The clinical evaluation was unremarkable and the audiometric testing showed a right sensorineural hearing loss with normal contralateral hearing. A high-resolution CT-scan of the temporal bone was performed showing a lesion occupying the right petrous apex and eroding the cochlea. In a subsequent MRI scan, the lesion appeared hyperintense in both T1- and T2-weighted images. Those radiological features prompted us to the diagnosis of a cholesterol granuloma, and the selected treatment was a drainage via infracochlear approach. The infracochlear approach, firstly described by Giddings et al. [1] in 1991, represents a direct route to the petrous apex, that can be chosen in selected cases with favorable anatomical conditions and that allows respecting of the hearing mechanism. After surgical drainage of the granuloma, no worsening of the pure tone threshold was confirmed by the audiological evaluation. The hospital stay was uneventful and the patient was discharge one day postoperatively. One-year postoperative MRI scan showed signal reduction of the cholesterol granuloma.

An uncommon cause of conductive hearing loss

The current video presents the surgical management of a middle ear osteoma through a retroauricolar endocanalar approach, under local anesthesia. The video contains patient's medical history, pre-operative radiological evaluation, surgical approach to the lesion and clinical follow up.

Mastoid Dermoid Cyst

A case of mastoid dermoid cyst (DC) was presented, and differences with cases of other temporal bone DCs were analyzed. The mastoid DC was also compared with mastoid congenital cholesteatoma. We reported a case of a patient with mastoid DC, evaluating her clinical, radiological, and surgical findings. A review of the literature was performed to compare our findings with those reported. The preoperative radiological evaluation prompted us to plan a surgical approach to the lesion, suspecting the presence of a mastoid congenital cholesteatoma. The surgical findings were in line with the presence of a mastoid DC. Only two cases reported in the literature presented features that fulfilled the criteria of a true mastoid DC. A DC confined to the mastoid region is an extremely rare clinical entity, with asymptomatic and slow growth. Preoperative radiological differentiation between congenital cholesteatoma and DCs with atypical features can be difficult. However, surgical excision is the treatment of choice in both cases. Diagnosis is confirmed by the histological evaluation.

Safety of bedside surgical tracheostomy during COVID-19 pandemic: A retrospective observational study

Data regarding safety of bedside surgical tracheostomy in novel coronavirus 2019 (COVID-19) mechanically ventilated patients admitted to the intensive care unit (ICU) are lacking. We performed this study to assess the safety of bedside surgical tracheostomy in COVID-19 patients admitted to ICU. This retrospective, single-center, cohort observational study (conducted between February, 23 and April, 30, 2020) was performed in our 45-bed dedicated COVID-19 ICU. Inclusion criteria were: a) age over 18 years; b) confirmed diagnosis of COVID-19 infection (with nasopharyngeal/oropharyngeal swab); c) invasive mechanical ventilation and d) clinical indication for tracheostomy. The objectives of this study were to describe: 1) perioperative complications, 2) perioperative alterations in respiratory gas exchange and 3) occurrence of COVID-19 infection among health-care providers involved into the procedure. A total of 125 COVID-19 patients were admitted to the ICU during the study period. Of those, 66 (53%) underwent tracheostomy. Tracheostomy was performed after a mean of 6.1 (± 2.1) days since ICU admission. Most of tracheostomies (47/66, 71%) were performed by intensivists and the mean time of the procedure was 22 (± 4.4) minutes. No intraprocedural complications was reported. Stoma infection and bleeding were reported in 2 patients and 7 patients, respectively, in the post-procedure period, without significant clinical consequences. The mean PaO₂ / FiO₂ was significantly lower at the end of tracheostomy (117.6 ± 35.4) then at the beginning (133.4 ± 39.2) or 24 hours before (135.8 ± 51.3) the procedure. However, PaO₂/FiO₂ progressively increased at 24 hours after tracheostomy (142 ± 50.7). None of the members involved in the tracheotomy procedures developed COVID-19 infection. Bedside surgical tracheostomy appears to be feasible and safe, both for patients and for health care workers, during COVID-19 pandemic in an experienced center.

Bonebridge implantation for mixed hearing loss in a patient with Kabuki syndrome

The high prevalence of middle ear disease with related hearing loss in Kabuki syndrome requires the diagnostic and treatment expertise of otologists. This case report describes outcomes and changes in the quality of life of a patient affected by Kabuki syndrome with a history of recalcitrant chronic otitis media and mixed hearing loss who had undergone several unsuccessful surgical procedures before solving his problems by means of subtotal petrosectomy and active middle ear implant.

Bedside Surgical Tracheostomy in the Intensive Care Unit during Covid-19 Pandemic

OBJECTIVES

To describe Otolaryngologists' perspective in managing COVID-19 patients with acute respiratory distress syndrome (ARDS) requiring tracheostomy in the ICUs during the pandemic peak in a dramatic scenario with limited resources.

SETTING

Tertiary referral university hospital, regional hub in northern Italy during SARS CoV 2 pandemic peak (March 9th to April 10th, 2020).

METHODS

Technical description of open bedside tracheostomies performed in ICUs on COVID-19 patients during pandemic peak with particular focus on resource allocation and healthcare professionals coordination. A dedicated "airway team" was created in order to avoid transportation of critically ill patients and reduce facility contamination.

RESULTS

During the COVID-19 pandemic, bedside minimally invasive tracheostomy in the ICU was selected by the Authors over conventional surgical technique or percutaneous procedures for both technical and operational reasons. Otolaryngologists' experience derived from direct involvement in 24 tracheostomies is reported.

CONCLUSIONS

Tracheostomies on COVID-19 patients should be performed in a safe and standardized setting. The limited resources available in the pandemic peak required meticulous organization and optimal allocation of the resources to grant safety of both patients and healthcare workers.

Seborrheic Keratosis or Squamous Carcinoma? Clinical Examination versus Biopsy: The Importance of Criticism

We compare the results of clinical observation and histopathology analysis for developing a differential diagnosis of seborrheic keratosis (SK) of the external auditory canal (EAC). A 46-year-old man with a history of a recurrent lesion in the EAC underwent clinical observation of the skin lesion's appearance, computed tomography (CT) scan, magnetic resonance imaging (MRI), and several biopsies. Initially, a benign form of SK was diagnosed based on several biopsies performed over a 10-year period. The lesion's appearance was consistent with a malignant disease, which led the clinician to perform a CT scan and an MRI scan. The patient underwent partial petrosectomy to completely remove the lesion as CT and MRI scans showed an infiltrative process. Squamous carcinoma was the final histological diagnosis. The patient was disease free at 1 year of follow-up after petrosectomy. In conclusion, if there are inconsistencies between clinical observation and histological report, additional tests should be performed to exclude the malignity of a lesion.

Jugular Foramen Metastasis from Lung Cancer: A Case of "A Mass without His Syndrome"

Jugular foramen (JF) metastasis is rare and often presents as JF syndrome. A 73-year-old male complained of left-sided mastoid pain that irradiated to the neck since the past 3 months. Onset of facial nerve (FN) palsy and persistence of the symptomatology despite corticosteroid therapy demanded radiologic evaluation. Computed tomography and magnetic resonance imaging showed a wide osteolytic lesion of the left JF with involvement of the third segment of the FN. The patient underwent transmastoid incisional biopsy. Histopathological examination showed an adenocarcinoma that was suggested to be of respiratory origin. A primary pulmonary lesion and metastasis to other sits were detected. The patient died 1 month after the initiation of the chemotherapy. Persistent mastoid pain and progressive FN palsy must be considered indicative of JF malignant lesions. Despite early diagnosis, secondary lesions of the JF are characterized by a poor prognosis; however, accurate diagnosis may avoid unnecessary aggressive surgery.

Multi-electrode sequential versus single electrode stimulation to elicit the stapedial reflex during cochlear implantation: Correlation with maximum comfort level

OBJECTIVES

To assess whether electrical stimulation sequentially delivered through 4 electrodes located in different cochlear areas may elicit the stapedial reflex at lower levels compared to single electrode stimulation and to correlate the sequentially obtained values with the maximum comfort level (C-level).

PATIENTS AND METHODS

A retrospective study was performed on 35 post-verbal adult patients (age 19-80 years) consecutively implanted in 2 cochlear implant centers, evaluating the level of stimulation (pulse width) necessary to electrically evoke the stapedial reflex with two different stimulation modalities: single electrode versus sequential 4 electrode stimulation. Threshold values were compared with C-level obtained at activation.

RESULTS

The average differences of pulse width and C-level were significantly smaller (P<0.0001) when the stapedial reflex was obtained with the sequential stimulation modality and reached statistical significance for every single electrode (P<0.0001).

CONCLUSIONS

Stapedial reflex thresholds obtained with sequential stimulation through 4 different electrodes significantly correlate to the C-level obtained at the first setting and may be helpful in defining the upper limit of the dynamic field during initial CI mapping.

A case of external auditory canal osteoma complicated with cholesteatoma, mastoiditis, labyrinthitis and internal auditory canal pachymeningitis

The association between external auditory canal osteoma and external auditory canal cholesteatoma is rare, with only a few reports in the current literature. Intracranial complications are very rare in the external auditory canal cholesteatoma, especially with direct propagation through the internal auditory canal. A case of 27-year-old male presenting with external auditory canal osteoma with secondary external auditory canal cholesteatoma is described. Progression of the disease created in turn a mastoiditis, labyrinthitis and pachymeningitis confined to the internal auditory canal. The patient was treated by a subtotal petrosectomy, without entering the internal auditory canal. A control MRI after 3 months showed reduction of the internal auditory canal enhancement.

Total Facial Paralysis after Vestibular Schwannoma Surgery: Probability of Regaining Normal Function

The aim of the present study was to ascertain the precise fraction of vestibular schwannoma cases that recover to normal function after postoperative total facial nerve paralysis and to compare our results with those presented in the literature. This was a retrospective case review of 631 cases. Among the 132 cases with immediate postoperative facial nerve palsy (House Brackmann [HB] grade VI), only 2 (1.5%) recovered to normal function (HB grade I). In an attempt to compare our results with those of other series in the literature, we found a large variation in the incidence of recovery of this group of patients to grade I, ranging from 0% to 50%. Our analysis of the reported data revealed widely varying methods of data collection and presentation, making a scientifically valid comparison particularly difficult. According to our data, complete (HB grade I) or near-complete (HB grade II) facial nerve function recovery from an immediate postoperative grade VI palsy is extremely rare.

Long-term clinical outcomes of cochlear implantation in children with symptomatic epilepsy

OBJECTIVES

To describe long-term clinical outcomes of cochlear implantation in deaf children with symptomatic epilepsy.

MATERIALS AND METHODS

A retrospective data analysis review of patients implanted at the Cochlear Implant Center of the University of Parma, Italy, was performed, searching for implanted children with a confirmed diagnosis of symptomatic epilepsy. Clinical data, imaging findings, pre- and post-operative epilepsy pattern and EEG traces were analyzed; communicative skills were assessed using the Profile of Actual Linguistic Skills.

RESULTS

Search retrieved two patients affected by profound bilateral sensorineural hearing loss and symptomatic epilepsy (associated respectively with methylmalonic acidemia and cerebral palsy). After careful parental counselling both patients were offered and underwent cochlear implantation. Activation and use of cochlear implant did not determine substantial changes of pre-existing seizure pattern and EEG traces. Both patients showed substantial development of their communicative abilities.

CONCLUSIONS

Cochlear implantation in children with symptomatic epilepsy did not determine variations in seizure pattern or EEG traces. Both patients experienced substantial benefit from cochlear implantation.

Staged resection for vestibular schwannoma

CONCLUSION

Surgery remains the preferred option for large vestibular schwannoma (VS). The presence of unpredictable intraoperative difficulties may convince the operator to suspend the surgery to avoid risks to patient life. Additional surgeries may be mandatory and are better performed using a transcochlear approach. High rates of complications, poor facial nerve results, and a percentage of incomplete removals should be expected in such unfavorable cases.

OBJECTIVES

To review the results for nine cases of huge VS treated by staged resection.

METHOD

A retrospective case review was performed for all nine patients who underwent staged resection of VS at the Gruppo Otologico between 1984-2012. The decision to perform staged surgery was always made intra-operatively after encountering unpredicted difficulties.

RESULTS

The nine patients represented 0.3% of all patients who underwent VS surgery during the same period. Mean tumor size was 4.7 cm (range = 3.0-6.6 cm). Two cases required three surgeries, resulting in a total of 20 operations. In addition, two cases required pre-operative ventriculoperitoneal shunt and one required temporary tracheotomy. After the final stage of surgery, complete removal had been achieved in six of the nine patients. The facial nerve was never preserved anatomically.

Long term surgical and hearing outcomes in the management of tympanomastoid paragangliomas

OBJECTIVE

To analyze the long term outcomes after surgery in tympanomastoid paragangliomas.

STUDY DESIGN

Retrospective study.

METHODS

The charts of 145 patients with tympanomastoid paragangliomas managed between 1988 and 2013 were reviewed. The clinical features, audiological data, pre- and postoperative notes were noted. The tumors were staged according to the modified Fish and Mattox classification. The surgical approaches for all patients were formulated according to the surgical algorithm developed at our center.

RESULTS

34 (23.5%), 46 (31.7%), 22 (15.2%), 18 (12.4%) and 25 (17.2%) patients were diagnosed to have TMP class A1, A2, B1, B2 and B3 tumors respectively. Gross tumor resection was achieved in 141 (97.2%) patients. The facial nerve was uncovered in four patients and infiltrated in three. The cochlea was found eroded in seven cases. The mean follow-up was 48.4 months. Recurrence was seen in one patient (0.7%). In the cases where the facial nerve was preserved (n=143), the nerve function was graded as HB grade 1 in 138 patients (97%). Postoperatively, the mean AC showed an improvement in all categories except in class B2 and B3, which corresponds to the classes that include patients who underwent subtotal petrosectomy.

CONCLUSION

We report the long term surgical outcomes in tympanomastoid paragangliomas in the largest series published till date. It is possible to completely eradicate all types of tympanomastoid paragangliomas with minimum sequelae by choosing the correct surgical approach to achieve adequate exposure for individual tumor classes as described in our classification and algorithm.

LEVEL OF EVIDENCE

IIb.

Ipsilateral cochlear implantation in patients with sporadic vestibular schwannoma in the only or best hearing ear and in patients with NF2

The aim of this study was to evaluate the cochlear implant (CI) performances in neurofibromatosis type 2 (NF2) patients with bilateral vestibular schwannoma (VS) and in patients with sporadic VS in the only or better hearing ear. All patients with bilateral VS or sporadic VS in the only or better hearing ear who underwent cochlear implantation, either simultaneous to VS surgery or staged after treatment for VS, in the tumor side were chosen for the study. Postimplantation audiometric scores (sound detection, closed-set and open-set discrimination scores) and device use patterns were the main outcome measures. 15 patients were implanted. Eight patients (53 %) were NF2 and seven patients had VS in the only or better hearing ear. One patient was explanted for cerebrospinal fluid leak. In the CI-only condition, the other 14 patients obtained sound detection, 64 % of them achieving open-set discrimination (mean 70 ± 38 %) and 85 % achieving closed-set discrimination (mean 41 ± 33 %). At the last follow-up 10 patients (67 %) were using the CI. Cochlear implantation provides hearing in particular cases of patients with bilateral VS or VS in the only or better hearing ear. As long as anatomic preservation of the cochlear nerve is achieved, cochlear implantation may offer improvement in communication skills for most patients.

Salivary gland choristoma of the middle ear

Choristoma of the middle ear is a rare condition characterized by the presence of normal salivary gland tissue in the middle ear space. Salivary gland choristomas are benign lesions that are frequently associated with ossicular chain and facial nerve anomalies. Total surgical excision is indicated when there is no risk of damaging the facial nerve. We describe a new case of salivary gland choristoma of the middle ear, and we discuss the etiology, histologic features, and management of such lesions. Our patient was a 22-year-old woman in whom we surgically removed a whitish retrotympanic mass. Intraoperatively, we also detected an ossicular chain malformation. Histologic examination of the choristoma revealed the presence of salivary gland tissue. Furthermore, the lesion contained an extensive and previously undescribed component: a well-defined pseudostratified respiratory-type epithelium, similar to that of a normal eustachian tube. Ten months after removal of the choristoma, we surgically repaired the ossicular chain anomalies. No recurrence was noted on follow-up.

Are the current treatment strategies for facial nerve schwannoma appropriate also for complex cases?

OBJECTIVES

To describe the decision-making strategies for complex facial nerve schwannomas (FNSs).

MATERIALS AND METHODS

Charts belonging to 103 consecutive patients with facial nerve tumors managed between 1990 and 2011 were examined retrospectively to identify complex FNSs. To be classified as complex, at least one of the following criteria had to be met: (1) FNS with large intraparotid tumor component and preoperative good facial nerve function (3 cases); (2) multiple-segment FNSs with extension to both the cerebellopontine angle and the middle cranial fossa in patients with preoperative good hearing (5 cases); (3) fast-growing FNS with preoperative good facial nerve function (4 cases), and (4) large FNS compressing the temporal lobe with preoperative normal facial nerve function (1 case).

RESULTS

Thirteen patients were classified as complex; 12 patients had total tumor removal with sural nerve grafting and 1 patient had partial tumor removal. Two patients with intratemporal-intraparotid FNS underwent a transmastoid-transparotid approach. One patient with a tumor extending from the geniculate ganglion to the parotid portion of the facial nerve underwent a combined middle fossa transmastoid-transparotid approach. A transcochlear approach with temporal craniotomy was performed in all the patients with multiple-segment FNS as well as in patients with fast-growing tumors extending both in the cerebellopontine angle and middle cranial fossa. A partial tumor removal through the middle fossa approach was performed in 1 patient with a large tumor compressing the temporal lobe.

CONCLUSIONS

Therapeutic options for patients with FNS include surgical intervention, observation and radiotherapy. Nowadays, surgical resection with facial nerve repair is usually the standard management for patients with poor facial function (House-Brackmann grade III or worse). In patients presenting with normal or near-normal facial nerve function, initial observation with periodic examination and imaging is usually recommended. However, on rare occasions surgeons can be faced with a situation in which the management decision-making process is particularly challenging. In these complex cases treatment should be individualized. We recommend early surgical intervention regardless of the preoperative facial and hearing functions in the following cases: intratemporal FNSs extending with a large tumor component into the parotid, multiple-segment FNSs extending in both the cerebellopontine angle and the middle cranial fossa, fast-growing FNSs, and large FNSs with temporal lobe compression.

Effects of early commercial air travel on graft healing rates after tympanoplasty

OBJECTIVES

We sought to determine whether commercial air travel soon after tympanoplasty significantly affects graft healing rates.

METHODS

We performed a retrospective analysis of 169 patients who underwent tympanoplasty from 1993 to 2009, comparing two groups of patients: 69 patients who flew 1 day after surgery and 100 who did not. The confounding factors analyzed were side of surgery, size of perforation, surgical approach, graft material, and grafting technique. The primary outcome measure analyzed was successful closure of the perforation at the first follow-up visit, at 4 weeks, evidenced by direct otoendoscopic examination.

RESULTS

There was no significant difference in the confounding variables between the two groups. There was no significant difference in the primary outcome measure of graft healing rates between the two groups (p = 0.494). Additionally, the overall graft healing rates compared favorably with previously published data from other authors.

CONCLUSIONS

Early commercial air travel after tympanoplasty does not significantly affect graft healing rates and should be considered a relatively safe option.

Congenital mastoid cholesteatoma: case series, definition, surgical key points, and literature review

OBJECTIVES

We evaluate 3 new cases of congenital cholesteatoma confined to the mastoid process, and compare them with cases presented in the literature in order to better define this rare lesion.

METHODS

We performed a retrospective chart analysis of all congenital cholesteatomas treated surgically in a tertiary referral and skull base center. We performed a complete analysis (history, radiologic, and surgical) of all patients with congenital cholesteatoma confined to the mastoid process; we then performed a literature review and compared our findings with the presented cases.

RESULTS

The results of preoperative imaging were in line with the surgical findings. The most important surgical issue in this type of lesion was the management of the sigmoid sinus and the jugular bulb. Half of the cases previously reported in the literature appeared not to fulfill the definition criteria of a congenital cholesteatoma of the mastoid process.

CONCLUSIONS

Congenital cholesteatoma confined to the mastoid process is a rare lesion, and is even more exceptional upon critical review of the literature. Symptoms are often lacking or nonspecific, and although cases have a congenital origin, the diagnosis often is not made until adulthood. A combined congenital cholesteatoma group with middle ear and mastoid features seems to fill in the gap in the definition. Management of the sigmoid sinus and the jugular bulb is the most demanding surgical key point.

Chondroblastoma of the temporal bone

Chondroblastomas are highly destructive tumors that are derived from immature cartilage cells. The occurrence of this tumor in the temporal bone or skull base is uncommon. Approximately 70 cases have previously been reported, several of which have involved the temporomandibular joint (TMJ). We report here the case of a 67-year-old woman who presented with right-sided mixed hearing loss, a right external auditory canal mass, ear fullness, otalgia, blood-stained otorrhea, and pain around the TMJ, associated with difficulty in opening the mouth. CT and MRI revealed a mass involving the TMJ, infratemporal fossa, and pterygopalatine fossa. The patient underwent tumor resection via an infratemporal fossa approach type B. Gross total tumor removal was achieved, with no facial nerve paralysis or other complications observed after surgery. No recurrence or residual tumors were observed on CT and MRI, even after 7.5 years of follow-up. We conclude that temporal bone chondroblastomas are extremely rare and aggressive, but the outcome after appropriate surgical treatment is favorable. From the review, it may be particularly important to deal with tumors that involve the TMJ, which could affect the long-term outcomes, as well as tumor recurrence.

Nonvascular lesions of the jugular foramen: the gruppo otologico experience

Tumors other than paragangliomas in the jugular foramen are uncommon. Of these, schwannomas and meningiomas predominate. Little clinical data are available in the literature on these tumors at this site. The purpose of this article is to review our experience at the Gruppo Otologico of the management of these tumors. A retrospective series is presented of 32 consecutive patients affected by jugular foramen schwannomas and meningiomas in which their clinical and radiological signs, together with surgical techniques and outcomes, were reviewed. A single-stage resection was possible for the majority of patients when the petro-occipital trans-sigmoid (POTS) approach was used. This allowed resection of both intra- and extradural components of the tumor with hearing preservation and avoidance of facial nerve transposition. No deaths occurred. Lower cranial nerve palsies constituted the major cause of morbidity, but none of the patients required an adjunctive procedure such as vocal cord medialization, tracheostomy, or percutaneous gastrostomy.

Clinical features of paraganglioma syndromes

Head and neck paragangliomas (HNPs) and pheochromocytomas are rare tumors. Sporadic and hereditary forms are recognized. Four different paraganglioma syndromes (PGLs 1-4) have been described: PGL 1 is associated with mutations of the succinate dehydrogenase (SDH) subunit D (SDHD) gene; PGL 3 is caused by SDHC gene mutations; PGL 4 is caused by SDHB gene mutations; the susceptibility gene for PGL 2 is unknown. The objective of this study is to review distinct clinical features of the different PGLs. An international registry for HNPs was founded in Freiburg, Germany, in 2000. The data presented in this article have been acquired from registered HNP patients who have been screened for mutations of the genes SDHB, SDHC, and SDHD. Approximately 30% of apparent sporadic HNPs are caused by a germline mutation in one of these genes. Patients with PGL 1 or 4 have a very high lifetime risk of developing HNPs as well as thoracic and abdominal pheochromocytomas. Compared with sporadic HNPs, tumors developing in SDHB, SDHC, and SDHD mutation carriers arise at a significantly younger age. The SDHB mutations are associated with a high percentage of malignant paraganglionic tumors. We recommend molecular genetic screening of all HNP patients for SDHB, SDHC, and SDHD gene mutations. Mutation carriers must be screened for paraganglial tumors in the head, neck, thorax, and abdomen. Appropriately timed surgical intervention will minimize disease-specific morbidity and mortality. Lifelong follow-up is mandatory.

Combined endovascular-surgical management of the internal carotid artery in complex tympanojugular paragangliomas

The infratemporal fossa approach described by Fisch overcame most of the factors that had previously prevented the total removal of tympanojugular paragangliomas (TJP). The remaining problem has been infiltration of the internal carotid artery (ICA) for which there has been no entirely satisfactory solution. At the least, severe encasement risks the possibility of an arterial rupture at surgery. In order to reduce this risk, preoperative endovascular interventions have been employed-mainly balloon occlusion, with or without arterial bypass. Recently, intra-arterial stents to reinforce the encased segment of the ICA have been introduced. This study evaluates our experience with 20 patients affected by TJP in which the ICA has been subjected to preoperative interventions. Ten patients underwent a preoperative balloon occlusion and the other 10 patients had their ICAs reinforced with stents. Problems that arose during embolization necessitated that one patient with a stent required ligation of their ICA. No other problems were encountered during endovascular treatment or surgical resection. In one patient with a stent, it was impossible to establish a cleavage plane between their recurrent tumour and the ICA. These early results are encouraging and suggest that intra-arterial stents have a part to play in the surgical management of large TJPs.

Meningiomas intrinsic to the geniculate ganglion

Geniculate ganglion meningiomas are extremely rare lesions-only 14 cases have been reported in the literature. Two new cases of these tumors are described. On computed tomography and magnetic resonance imaging, both lesions appeared centered on the area of the geniculate ganglion, extending to the tympanic cleft and eroding the middle cranial fossa floor. The first case was treated through a middle cranial fossa approach. Because the tumor was so large in the second case, a subtotal petrosectomy was used. The authors review the literature to clarify the clinical and radiological characteristics of these tumors and their surgical treatment.

Fast-growing vestibular schwannoma

A case of a Jehovah's witness affected by an intracanalicular vestibular schwannoma with an extremely fast growth rate is presented. Nine months after presentation, the tumor reached 23 mm in the cerebellopontine angle. A partial removal through a retrosigmoid approach was planned. Because of the presence of a dominant high jugular bulb masquering the internal auditory canal, the intracanalicular portion of the tumor was left in place. The residual tumor grew 12 mm in 2 months. Even after a gross total removal through a middle cranial fossa approach, the tumor recurred, reaching the size of 30 mm in 17 months. A modified transcochlear approach was then performed, and the patient was free of disease at the last radiologic follow-up, 8 months after the surgery. We illustrate our strategy in treating this aggressive benign lesion with unusual behavior.

Facial nerve function after vestibular schwannoma surgery

OBJECT

The object of this study was to evaluate long-term postoperative facial nerve (FN) function in patients undergoing vestibular schwannoma (VS) surgery.

METHODS

The authors retrospectively reviewed the clinical course of patients affected by isolated VSs with normal preoperative FN function, with no previous surgical or radiotherapeutic treatment, and who underwent surgery between 1987 and 2007. Facial nerve function was clinically evaluated according to the House-Brackmann (HB) scale. The minimum postoperative follow-up was 12 months.

RESULTS

Among the 1550 patients surgically treated at the authors' center, 1151 matched inclusion criteria for the present study. The FN was anatomically interrupted in 48 cases (4.2%), and 51 patients (4.4%) underwent subtotal tumor removal and were considered separately. Among the 1052 patients with anatomically preserved FNs and total tumor removal, 684 (65%) enjoyed postoperative HB Grade I or II and 309 (29.4%) enjoyed Grade III, with the remaining 59 cases (5.6%) suffering unsatisfactory results (HB Grades IV-VI). As expected, FN function results deteriorated in cases of larger tumors.

CONCLUSIONS

The main factor influencing postoperative FN function was tumor size. Although there was a progressive deterioration in FN function outcome in relation to tumor size, a cutoff point between satisfactory and unsatisfactory results could be identified at around 2 cm in maximum extrameatal tumor diameter, with the "optimal size" for surgery identified at < 1 cm. This finding emphasizes the importance of an early diagnosis and should be kept in mind when selecting the correct timing for VS removal. For small lesions, the results following a middle cranial fossa approach were significantly worse as compared with those following the translabyrinthine and retrosigmoidretrolabyrinthine approaches.

Intracranial facial nerve grafting after removal of vestibular schwannoma

OBJECTIVE

The objectives of this study were to evaluate outcomes from facial nerve (FN) cable grafting in patients who experienced FN transection during vestibular schwannoma removal and to compare the FN outcomes of patients who underwent FN grafting by using fibrin glue with those of patients who underwent FN grafting by using microsuture.

MATERIAL AND METHODS

We retrospectively evaluated a series of 33 patients in whom FN grafting was achieved either by using microsuture (8 cases) or fibrin glue (25 cases). Immediate repair of the FN was performed in all cases at the time of initial resection. The patients FN function was assessed preoperatively, in the immediate postoperative period, and at 3, 6, 9, and 12 months or more postoperatively using the House-Brackmann grading system. All patients had at least 1-year follow-up.

RESULTS

At 12 months, a House-Brackmann grade III was achieved in 75% of those who underwent cable nerve graft interposition by using microsuture and in 76% of those who underwent cable nerve graft interposition by using fibrin glue. Analysis of final FN function outcomes demonstrated no statistically significant difference in FN outcomes between the 2 groups (P = .891, Mann-Whitney U test; P = .1, Fisher exact test).

CONCLUSIONS

The functional results after FN cable grafting by using fibrin glue exclusively were equivalent to those obtained with microsuture. However, the technique of FN repair by means of fibrin glue is technically simple, less time-consuming, and imparts less trauma on the nerve than does the traditional suture method.

Management of intralabyrinthine schwannomas

OBJECTIVES

Our protocol to manage the intralabyrinthine schwannoma (ILS).

METHODS

Retrospective chart review of 7 consecutive patients managed for ILS.

RESULTS

Five patients underwent surgical removal of the lesions and none experienced significant complications or recurrent disease. One patient refused surgical treatment and was closely followed by serial MRI scans with no signs of tumor growth. One patient is presently managed conservatively due to a good hearing.

CONCLUSIONS

Diagnosis of ILS is based on high resolution MRI scans and should be included in the differential diagnosis of patients investigated for cochleovestibular symptoms. Treatment modality of ILS is controversial and depends patients' age, severity of vertigo and hearing loss. In the authors' experience surgery is indicated in all cases with invalidating vertigo and in the young patients with severe hearing loss. Conservative strategy is advised in older patients and in cases with preserved good hearing and no invalidating vertigo. These patients must be followed up using high resolution MRI because of the risk of tumor growth into the internal auditory canal. While tumors with exclusive involvement of the inner ear may be removed by means of a completely extradural approach, tumor growth with involvement of the internal auditory canal dictates the necessity of opening the dura exposing the patients to the potential risks associated with the procedure.

Surgical Management of Jugular Foramen Meningiomas: A Series of 13 Cases and Review of the Literature

OBJECTIVE

Primary meningiomas occurring within the jugular foramen are exceedingly rare lesions presumed to originate from arachnoid-lining cells situated within the jugular foramen. The objective of this study is to analyze the management and outcome in a series of 13 primary jugular foramen meningiomas collected at a single center.

STUDY DESIGN

Retrospective study.

SETTING

Quaternary referral otology and skull base private center.

METHODS

Charts belonging to 13 consecutive patients with pathologically confirmed jugular foramen meningioma surgically treated between September 1991 and May 2005 were examined retrospectively. The follow-up of the series ranged from 12 to 120 (mean, 42.8 +/- 27.5) months.

RESULTS

Four (28.5%) patients underwent single-stage tumor removal through the petro-occipital transigmoid (POTS) approach. In two patients with preoperative unserviceable hearing, a combined POTS-translabyrinthine approach was adopted. Two patients underwent a combined POTS-transotic approach because of massive erosion of the carotid canal. A modified transcochlear approach type D with posterior rerouting of the facial nerve and transection of the sigmoid sinus and jugular bulb was performed in two patients with a huge cerebellopontine angle tumor component with extension to the prepontine cistern together with massive involvement of the petrous bone and middle ear and encasement of the vertical and horizontal segments of the intrapetrous carotid artery. In one patient with evidence of a dominant sinus on the site of the tumor, a subtotal tumor removal via an enlarged translabyrinthine approach (ETLA) was planned to resect the intradural component of the tumor. Two patients in our series underwent a planned staged procedure on account of a huge tumor component in the neck. One of these patients underwent a first-stage infratemporal fossa approach type A to remove the tumor component in the neck; the second-stage intradural removal of the tumor was accomplished via an ETLA. The last patient underwent a first-stage modified transcochlear type D approach to remove the intradural tumor component followed by a second-stage transcervical procedure for removal of the extracranial component. Gross total tumor removal (Simpson grade I-II) was achieved in 11 (84.6%) cases. Subtotal removal of the tumor was accomplished in two patients. Good facial nerve function (grades I and II) was achieved in 46.1% of cases, whereas acceptable function (grade III) was achieved in the remaining cases 1 year after tumor removal. Hearing was preserved at the preoperative level in all four patients who underwent surgery via the POTS approach. After surgery, no patient recovered function of the preoperatively paralyzed lower cranial nerves. A new deficit of one or more of the lower cranial nerves was recorded in 61.5% of cases.

CONCLUSIONS

Surgical resection is the treatment of choice for jugular foramen meningiomas. Among the various surgical techniques proposed for dealing with these lesions, we prefer the POTS approach alone or combined with the translabyrinthine or transotic approaches. Despite the advances in skull base surgery, new postoperative lower cranial nerve deficits still represent a challenge.