Bone-anchored hearing implant surgery: our experience with linear incision and punch techniques

SUMMARY

In recent years, bone-anchored hearing implants (BAHIs) have found wider application in the treatment of conductive and mixed hearing loss. Several surgical techniques have been developed to reduce complications, enhance healing and improve audiological and aesthetic results. We report our experience on the use of three BAHI surgery techniques: Group 1, linear incision with thinning of the subcutaneous tissue; Group 2, linear incision without thinning of the subcutaneous tissue; Group 3, punch technique (Minimally Invasive Ponto Surgery, MIPS). We retrospectively analysed patients undergoing BAHI surgery; results were evaluated on the basis of any intra-operative complication, duration of surgery and occurrence of adverse effects at the implantation site over 1 year of follow-up. We collected a total of 30 implantations (12 for Group 1, 8 for Group 2, 10 for Group 3) with an intra-operative complication rate of 25%, 0% and 10%, respectively. The average surgical time was 62.08 minutes, 34.37 minutes and 18.7 minutes respectively. During follow-up, we reported the occurrence of adverse effects in 10.63% of observations in Group 1, 3.12% in Group 2 and 2.5% in Group 3. This study confirms the low rate of intra and postoperative complications during BAHI surgery and documents the simplicity of execution of the novel MIPS technique, with a significant reduction in surgical time compared to the other two techniques, and positive effects in terms of health care costs.

Pilot study on microvascular anastomosis: performance and future educational prospects

The introduction of microvascular free flaps has revolutionised modern reconstructive surgery. Unfortunately, access to training opportunities at standardised training courses is limited and expensive. We designed a pilot study on microvascular anastomoses with the aim of verifying if a short course, easily reproducible, could transmit microvascular skills to participants; if the chosen pre-test was predictive of final performance; and if age could influence the outcome. A total of 30 participants (10 students, 10 residents and 10 surgeons) without any previous microvascular experience were instructed and tested during a single 3 to 5 hour course. The two microanastomoses evaluated were the first ever performed by each participant. More than the half of the cohort was able to produce both patent microanastomoses in less than 2 hours; two-thirds of the attempted microanastomoses were patent. The pretest predicted decent scores from poor performances with a sensitivity of 61.5%, specificity of 100%, positive predictive value of 100% and negative predictive value of 40%. Students and residents obtained significantly higher scores than surgeons. Since our course model is short, cost-effective and highly reproducible, it could be introduced and implemented anywhere as an educational prospect for preselecting young residents showing talent and natural predisposition and having ambitions towards microvascular reconstructive surgery.

Utilità del Gadolinio-DTPA nello studio RM dei neurinomi dell'acustico

Sono stati esaminati con RM a media intensità di campo, prima e dopo somministrazione endovenosa di Gadolinio-DTPA, 18 pazienti con neurinoma del nervo acustico verificato chirurgicamente.

In 14 pazienti con neurinoma a sviluppo intra ed extra-canalare l'esame RM diretto ha permesso di identificare la lesione e le sequenze Spin-Echo dipendenti dal tempo di rilassamento Tl si sono dimostrate le più utili a tal fine.

In questi pazienti il Gadolinio-DTPA ha permesso una migliore delineazione dei rapporti topografici della lesione con le strutture troncoencefaliche e della fossa cranica posteriore.

Nei rimanenti quattro pazienti, con neurinoma strettamente intracanalare, solo l'esame dopo somministrazione del mezzo di contrasto paramagnetico ha permesso di dimostrare inequivocabilmente il neurinoma sotto forma di una lesione ad elevata intensità di segnale all'interno del condotto uditivo interno.

Questi risultati suggeriscono un ruolo fondamentale del Gadolinio-DTPA nella valutazione con RM di pazienti con sospetto neurinoma dell'acustico. Solo dopo la somministrazione del contrasto è infatti possibile ottenere un preciso bilancio spaziale della lesione e soprattutto concludere circa la presenza o meno di neurinomi esclusivamente intracanalari.

Middle ear adenoma is an amphicrine tumor: why call it adenoma?

Middle ear adenoma (MEA) is a rare tumor postulated to take origin from the lining epithelium of the middle ear cavity. The authors report on a case of MEA arising in a 53-year old woman suffering from a sensation of fullness in her left ear, otalgia, and light left-sided hearing loss. Histopathologically, the lesion was composed of cuboidal and polygonal cells displaying a trabecular, tubulo-glandular, and solid pattern of growth. Immunohistochemically, neoplastic cells diffusely stained with anti-vimentin antibodies and were focally positive for chromogranin A, neuron-specific enolase, lysozyme, and cytokeratins AE1/AE3. The majority of tumor cells showed weak and diffuse staining with both anti-PP and anti-ACTH antibodies and intense positivity with anti-glucagon and anti Leu-7 antibodies. Ultrastructural investigation revealed both mucinous-glandular and neuroendocrine differentiation. The authors suggest that the appropriate terminology would be adeno-carcinoid or amphicrine tumor of the middle ear rather than "adenoma," a term that does not reflect its dual nature.

[Delayed endolymphatic hydrops]

Delayed Endolymphatic Hydrops (DEH) is a disease entity that must be distinguished from idiopathic endolymphatic hydrops (Ménière's disease). Idiopathic hydrops is characterized by the following symptoms: 1) vertigo often accompanied by nausea and vomiting; 2) tinnitus; 3) hearing loss, usually fluctuating; and 4) sensation of pressure or fullness in the affected ear. Idiopathic hydrops most commonly occurs in middle-aged patients, usually between 30 and 50 years. It may involve one or both ears and usually exibits fluctuating hearing loss and episodic vertigo, although one symptom may precede the other by months or years. It is rare for Ménière's disease to present with a severe sensorineural hearing loss. Delayed Endolymphatic Hydrops was first described, under the name of "unilateral deafness with subsequent vertigo", by Wolfson and Lieberman and Nadol et al.; this was later confirmed by other authors. The disease is characterized by a profound sensorineural hearing loss in one ear, found to have been present in most cases from early childhood, due to an unknown cause, trauma or viral infections. After a prolonged period (usually many years) patients with DEH experience the onset of episodic vertigo from the deaf ear (Ipsilateral Delayed Endolymphatic Hydrops) or develop a fluctuating hearing loss and/or episodic vertigo in the opposite ear, previously with normal hearing (Controlateral Delayed Endolymphatic Hydrops). Vestibular symptoms are identical to those of Ménière's disease: in fact there is evidence that endolymphatic hydrops in the previously damaged ear or in the previously normal ear represents at least part of the labyrinthine pathology. Histopathology studies recently conducted on temporal bones of subjects affected with controlateral DEH show pathologic changes in the deaf ears similar to those found in viral labyrinthitis, whereas pathologic changes in the hearing ears resemble those known to occur in Ménière's disease. Medical treatment has not been found to be effective in patients with DEH, but it must be the first choice of treatment especially in controlateral forms of the disease. So far, surgical intervention has been demonstrated to give the best results; either conservative or more radical, depending on the type of DEH. Pharmacological labyrinthectomy with ototoxic drugs could be the therapy of choice in the future. In this paper we review the literature in order to summarize the clinical features and criteria for diagnosing DEH, we also report histopathologic findings and pathogenetic hypotheses formulated for this syndrome. Moreover, we discuss the best therapeutic approach for the ipsilateral and controlateral variants of DEH.

Treatment of Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

We evaluated a new therapeutic maneuver-Prolonged Position on the healthy side, for Benign Paroxysmal Positional Vertigo (BPPV) of the horizontal semicircular canal. We devised this type of physical treatment in accordance with the “canalolithiasis” theory of BPPV, in order to try to free the horizontal semicircular canal of otoconial debris. We compared the results obtained by Prolonged Position with two other physical therapies by dividing our horizontal canal BPPV patients into three therapeutic groups: 1) 35 patients treated with Prolonged Position; 2) 24 patients treated with head shaking in a supine position; 3) 15 patients for whom therapy was omitted. More than 90% of the patients treated with Prolonged Position recovered within 3 days, although 6 patients out of 35 subsequently developed BPPV of the posterior semicircular canal, which then responded well to a particular repositioning maneuver. The results of Prolonged Position were significantly better than those obtained by performing head shaking or by omitting treatment. Prolonged Position can be applied to patients of all ages and general conditions and does not require hospitalization.

Treatment of horizontal semicircular canal benign paroxysmal positional vertigo

We evaluated a new therapeutic maneuver-Prolonged Position on the healthy side, for Benign Paroxysmal Positional Vertigo (BPPV) of the horizontal semicircular canal. We devised this type of physical treatment in accordance with the "canalolithiasis" theory of BPPV, in order to try to free the horizontal semicircular canal of otoconial debris. We compared the results obtained by Prolonged Position with two other physical therapies by dividing our horizontal canal BPPV patients into three therapeutic groups: 1) 35 patients treated with Prolonged Position; 2) 24 patients treated with head shaking in a supine position; 3) 15 patients for whom therapy was omitted. More than 90% of the patients treated with Prolonged Position recovered within 3 days, although 6 patients out of 35 subsequently developed BPPV of the posterior semicircular canal, which then responded well to a particular repositioning maneuver. The results of Prolonged Position were significantly better than those obtained by performing head shaking or by omitting treatment. Prolonged Position can be applied to patients of all ages and general conditions and does not require hospitalization.

Benign paroxysmal positional vertigo of the horizontal canal: a form of canalolithiasis with variable clinical features

Benign paroxysmal positional vertigo of the horizontal semicircular canal (HC-BPPV) is a well-defined syndrome characterized by direction-changing horizontal positional nystagmus. We report the clinical features of 5 patients who illustrate the possible variables of the syndrome. In most cases, nystagmus is geotropic and more intense when the pathological ear is lowermost; less often the syndrome presents with apogeotropic nystagmus that is more intense when the affected ear is uppermost. The nystagmus pattern may vary in time in the same patient, changing from apogeotropic to geotropic even in observations at short intervals. In some patients, the features indicate involvement of more than one canal, either simultaneously or in succession. It is sustained that the clinical findings can be explained by movement of endolymph caused by displacement of otoconia in the semicircular canals and that variants are due to different positions of the otoconia within the canals.

[A comparison between the "bithermal caloric test" and the "hot monothermal with simultaneous cold test"]

Hot (44) and cold (30) caloric test are the most common tool to investigate canal activity. Many authors, otherwise, have pointed out that this method is very long needing about five minutes of interval among the irrigations and that it is often troublesome for the patient that is exposed four times to a vertigo. To investigate vestibular function some of these authors tried to use the hot monothermal test alone but results were poor. The aim of this study was to propose a shorter and a less troublesome method of investigation and to introduce a new diagnostic possibility not pointed out with traditional caloric test. We have tried to determine some new reliable diagnostic criteria modifying confidential value of the hot monothermal test and considering the eventual presence of the nystagmus and its direction during the cold simultaneous test; on the basis of this results we are able to distinguish a normal vestibular function from a labyrinthine preponderance or a directional preponderance or an aspecific disfunction. When the vestibular function is normal or when there is a labyrinthine preponderance our results are in total accord with those achieved with the traditional bithermal test. Therefore we suggest to use always the hot monothermal test associated with the cold simultaneous test, performing the two cold irrigations in additions, only in the case of a directional preponderance or an aspecific disfunction.

[Diagnosis of cardiocirculatory autonomic failure by the tilting method]

The variation of SBP, DBP and HR is evaluated on tilting in a group of 34 patients affected by orthostatic hypotension versus a group of 54 healthy subjects, age and sex cross-matched. The patients affected by cardiovascular autonomic failure showed: 1) a fall of SBP greater than -19 mmHg in the 1st min; 2) a fall of the SBP average value (for 10 minutes) greater than -22 mmHg. Contrarily, the healthy subjects showed: 1) no variations of SBP values during the 1st minute and 2) a growing of SBP between the 2nd and the 10th minute; 3) a SBP average value (for 10 minutes) with a positive trend. The DBP and HR showed not differences between the groups. We suggest that the measure of SBP on standing may be considered an easy and fast method to perform a diagnosis of autonomic cardiovascular failure.

Benign paroxysmal vertigo of the horizontal canal

Over a period of 4 years we observed 15 cases of benign positional vertigo (BPV) probably caused by deposition of otoliths in the horizontal semicircular canal. Rapid rolling onto one side in recumbent position provokes a paroxysmal, purely horizontal and geotropic nystagmus which nearly always spontaneously inverts direction. Rolling the patient onto the other side provokes a left intense geotropic nystagmus. BPV is more violent but resolves more rapidly than that of the better known posterior canal positional vertigo. Sometimes both syndromes are present together.

Ophthalmoplegia plus, an electro-oculographic study

To find out whether the central structures governing conjugate eye movements are affected in ophthalmoplegia plus (OP), we conducted an electro-oculographic study in 6 patients suffering from OP with varying degrees of extraocular involvement and with mitochondrial changes in the skeletal musculature. All the patients presented alterations of the smooth pursuit and saccadic movements, of optokinetic nystagmus as well as of the vestibular reflexes and of visuovestibular interaction, thus confirming impairment of the central oculomotor structures and particularly of those of the archicerebellum and brainstem. These data suggest a supranuclear component in the pathogenesis of ophthalmoplegia and are in accord with the findings of brainstem spongiosis in OP, which in turn seem to express a multisystem pathological state of the mitochondria.