Renewed Concept of Mastoid Cavity Obliteration with the Use of Temporoparietal Fascial Flap Injected by Injectable Platelet-Rich Fibrin after Subtotal Petrosectomy for Cochlear Implant Patients

Background: The subtotal petrosectomy procedure may be useful for cochlear implantation in selected patient groups. Although it is highly effective, complications can arise, which may have economic implications for the patient due to the high cost of the device. Therefore, several authors have attempted to identify the most effective concept for obliteration. Methods: We present a pilot descriptive study of application techniques for obliterating cavities after subtotal petrosectomy using a temporoparietal fascial flap (TPFF) modified with injectable platelet-rich fibrin (IPRF+) for three cochlear implant (CI) patients. Results: Our concept preserves important anatomical structures, such as the temporalis muscle, which covers the CI receiver-stimulator. Injection of IPRF+ also increases the available tissue volume for obliteration and enhances its anti-inflammatory and regenerative potential. Conclusions: To the best of our knowledge, the use of TPFF for filling the cavity has not been adopted for CI with SP and for blind sac closure. Our literature review and our experience with this small group of patients suggest that this procedure, when combined with IPRF+ injections, may reduce the risk of potential infection in the obliterated cavity, particularly when used with CI. This technique is applicable only in cases when the surgeons are convinced that the middle ear cavity is purged of cholesteatoma.

Allergic Fungal Otomastoiditis: A Case Report

Otomastoiditis caused by an allergic reaction to fungi in the middle ear is rare, with only four cases reported in the English literature. We report the case of a patient with allergic fungal otomastoiditis. A 28-year-old man presented with otalgia, hearing loss, and vertigo. Exploratory tympanotomy revealed mucin with a peanut butter-like consistency and containing eosinophils and Candida parapsilosis, but no evidence of direct tissue invasion by fungi. The patient was treated with a combination of surgery and medication. Subtotal petrosectomy was finally performed to remove the middle ear mucosa and separate the middle ear from the external environment. Short-term prednisolone and long-term fluconazole were administered without satisfactory therapeutic results. The inflammatory condition has improved but continues without complete remission. Allergic fungal otomastoiditis is an extremely rare condition that may share pathophysiological features with allergic fungal rhinosinusitis, so a thorough examination combining bacterial cultures, histopathological examination with fungal staining, and serum antigen-specific immunoglobulin E against multiple fungi is essential. Optimal treatment probably comprises appropriate surgery and long-term administration of systemic corticosteroids. Definitive diagnostic criteria and therapeutic strategies need to be established, based on the accumulation of similar cases.

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.

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.

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.

A Giant Congenital Mastoid Cholesteatoma With Extension to the Occipital Condyle

A congenital mastoid cholesteatoma (CMC) is a keratinizing epithelium originating from embryological epithelial tissue of the mastoid. It is often not diagnosed until it becomes large because of its rarity and indolent nature. Although there are a few reports on giant CMC, its exact extensions have not been well described, and detailed information regarding surgical methods is lacking, especially in giant CMC involving the occipital condyle and the middle and posterior cranial fossae. In this article, we report a case involving a 70-year-old woman with a giant CMC that extended inferiorly to the occipital condyle. The CMC eroded the middle and posterior cranial fossae, sigmoid sinus plate, and fallopian canal of the facial nerve. For complete removal, we used a subtotal petrosectomy in conjunction with an exposure of the cranial cervical junction and a wide decompression of the suboccipit. The boundaries of exposure were similar to those of a petro-occipital transsigmoid approach which is usually used for management of tumor involving the jugular foramen. The wide exposure allowed for complete removal of the lesion without any complications. Thus, we recommend this surgical approach for management of the giant CMC involving the occipital condyle and the middle and posterior cranial fossae.

Impact of occlusive material and cochlea-carotid artery relation on eustachian tube occlusion in subtotal petrosectomy

OBJECTIVE

To evaluate the success rate of eustachian tube (ET) occlusion in subtotal petrosectomy relative to the occlusive material used and to the varying protympanum anatomy, by means of standardized alignment of the cochlea-carotid artery relation on computed tomography images.

PATIENTS AND METHODS

All cases of subtotal petrosectomy carried out by the same surgeon at a tertiary care referral center were retrospectively evaluated. Only cases with available computed tomography prior to second stage cochlear or middle ear implantation were included. The occlusive material was either muscle tissue or oxidized regenerated cellulose in combination with bone wax. On 3D multiplanar image reconstruction, the varying topographic interrelation of the cochlea and the petrous carotid artery was measured and categorized into two groups: detachment or overlapping.

RESULTS

In 9 (31%) of the 29 included cases there was insufficient occlusion of the ET. In none of these cases was an infection of the fat filling in the obliterated cavity observed during the implantation procedure on second stage (average 10 months interval). The failure rate of both occlusion materials was almost the same (using muscle tissue, in 4 (33.3%) of 12 or oxidized regenerated cellulose, in 5 (29.4%) of 17 cases). It was also similar for both materials in each of the anatomic variation groups.

CONCLUSIONS

An incomplete occlusion of the ET alone does not appear to lead to an infection of the obliterated cavity. Autologous muscle tissue and oxidized regenerated cellulose had similar rates of ET occlusion failure. The topographical variance of the protympanum appears to have no direct influence on the success of the ET occlusion.

Subtotal Petrosectomy With Preservation of Chorda Tympani for Petrous Bone Cholesteatoma: Case Report

A petrous bone cholesteatoma (PBC) is a rare epidermoid cyst of the petrous portion of the temporal bone. The main treatment is subtotal petrosectomy (SP), which generally involves sacrificing the chorda tympani. We report a case of extensive supralabyrinthine PBC in an elderly patient undergoing hemodialysis that was treated by SP with anatomical preservation of the chorda tympani. To the best of our knowledge, preservation of the chorda tympani during SP has not been previously reported. For maintenance of postoperative taste and appetite, preservation of the chorda tympani is a meaningful maneuver whenever possible.

[Subtotal petrosectomy - indications, surgical technique, experiences in Pécs]

Introduction: Subtotal petrosectomy (STP) has been known for decades and it is considered being on the borderline between ear and skull-base surgery. Due to its excessive radicalism and adverse effects on hearing, it has been a forgotten surgical technique until recently. Over the last decade, due to its many benefits and the ability to combine it with modern hearing rehabilitation methods, STP has reappeared, providing a definitive solution to a number of problematic middl-ear disorders. Aim: In our retrospective clinical study, we wanted to highlight the effectiveness of STP, analyzing the efficiency of this surgery for the first time in domestic patient records, and to report our own experiences to date. Method: We processed data from 45 surgeries on our 44 patients. In addition to presenting the various surgical indications, we review the steps of the operation, analyze the audiological results, including the various methods of hearing rehabilitation, and also analyze the complications that have occurred. Our results are also summarized in the light of international professional literature. Results: Of our 44 patients, 23 were female and 21 were male. Patients had a mean age of 44.6 ± 20.5 years and a mean follow-up of 23 ± 16 months. Of our patients, 25 (57%) had undergone at least two previous unsuccessful ear operations, and 6 (14%) had deafness before surgery. The most common indication was chronic otitis media with cholesteatoma. 13 patients underwent 14 cochlear implantations (23%), in addition 6 patients received bone anchored hearing aids (BAHA) (14%), and 2 patients (5%) underwent VSB (Vibrant Soundbridge) placement against the round window membrane. Complications occurred in 11 of our patients, the most common of which was cerebrospinal fluid leak (5 cases, 11%) and wound dehiscence (3 cases, 7%). Data from 3 patients were available for processing the audiological results. Conclusion: STP is an extremely favorable surgical solution for a number of middle-ear pathologies that have previously caused major problems. The main reason for its growing popularity is that it can be combined with a number of modern, effective methods of hearing rehabilitation. Orv Hetil. 2020; 161(14): 544-553.

Facial nerve reconstruction following radical parotidectomy and subtotal petrosectomy for advanced malignant parotid neoplasms

Introduction:

To describe the oncological management and functional outcome of patients with advanced parotid malignant tumors undergoing facial nerve reconstruction after radical parotidectomy and subtotal petrosectomy.

Materials and Methods:

A combined approach was used to treat advanced stage parotid malignancies with intrapetrous involvement of the facial nerve main trunk or abutment on the stylomastoid foramen. Patients underwent facial nerve rehabilitation with cable graft reconstruction or with static techniques.

Results:

Six patients were included. All patients had Stage IV disease and underwent surgical treatment using a combined approach. Three patients underwent facial-nerve cable graft technique and three patients underwent static techniques to rehabilitate facial nerve function. Five patients received adjuvant treatment with radiotherapy and/or chemotherapy. The mean follow-up was 27.5 months, with a minimum of 7 months and a maximum of 8 years. Four patients remain disease-free, with an overall survival rate of 66%. Among the patients undergoing dynamic reconstruction, first signs of recovery were established at 6 months of follow-up. All patients achieved a House-Brackmann score of III-IV within the first two postoperative years.

Conclusions:

When possible, facial nerve grafting is the preferred method of facial nerve rehabilitation in an advanced stage parotid tumors. A multidisciplinary approach allows better functional and oncological outcomes.

Treatment outcomes of temporal bone osteoradionecrosis

OBJECTIVE

To investigate the clinical relevance of the classification systems used for temporal bone osteoradionecrosis (ORN) and to define a treatment protocol for temporal bone ORN.

STUDY DESIGN

Retrospective case series.

SETTING

Amsterdam, department of otorhinolaryngology and head and neck surgery.

SUBJECTS AND METHODS

Classification of temporal bone ORN was performed through use of clinical data and radiologic imaging. Outcomes of conservative and surgical treatment were investigated and compared for different grades of ORN.

RESULTS

Of the 49 ears included in this study, 35 were primarily treated conservatively. At start of conservative treatment, 23 were classified as a localized and 8 as a diffuse form of ORN; 4 could not be classified. There was a significant difference in clinical outcome between the localized and diffuse forms of ORN (χ(2) = 5.862, P = .015), and mastoid air cell destruction on preoperative computed tomography scan was found to be a significant predictor for a negative outcome of conservative treatment (χ(2) = 4.34, P = .037). Fourteen ears with diffuse ORN were primarily treated surgically, and 11 were secondarily treated surgically following a period of conservative treatment. Twenty-two patients were treated with subtotal petrosectomy, of which 20 were cured. Three patients were treated with canal wall down mastoidectomy, and 2 had recurrence of disease.

CONCLUSION

Ramsden's classification system is clinically relevant in predicting conservative treatment outcomes. Mastoid air cell destruction on computed tomography differentiates between the localized and diffuse forms of ORN. Given our results and experience with treating temporal bone ORN, we propose a treatment protocol.

Subtotal petrosectomy and cerebrospinal fluid leakage in unilateral anacusis

Objective This study presents a group of patients experiencing recurrent cerebrospinal fluid (CSF) leakage associated with ipsilateral anacusis who underwent subtotal petrosectomies with the goal of stopping the CSF leak and preventing meningitis. Materials and Methods Eight patients with CSF leakage were enrolled: three patients with giant vestibular schwannomas had CSF leakage after gamma knife failure and subsequent removal via a retrosigmoid approach; two patients had malformations at the level of the inner ear with consequent translabyrinthine fistulas; two had posttraumatic CSF leakages; and one had a CSF leakage coexisting with an encephalocele. Two patients developed meningitis that resolved with antibiotic therapy. Each patient had preoperative anacusis and vestibular nerve areflexia on the affected side. Results The patients with congenital or posttraumatic CSF leaks had undergone at least one unsuccessful endaural approach to treat the fistula. All eight patients were treated successfully with a subtotal petrosectomy. The symptoms disappeared within 2 months postoperatively. No meningitis, signs of fistula, or other symptoms occurred during the follow-up. Conclusion A subtotal petrosectomy should be the first choice of treatment in patients with recurrent CSF leakage whenever there is associated unilateral anacusis.