Conservative facial nerve management in jugular foramen schwannomas.
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Facial Nerve↗
Biomedical subjects
M Falcioni
Publications and source records attributed to M Falcioni.
[Treatment of residual acoustic neurinomas].
Generally the main objective of acoustic neurinoma (AN) surgery is to totally remove the tumor associated with minimum morbidity. Nevertheless, in some cases residual tumor fragments are intentionally or accidentally left in place. These residues can lead to new growth. The present study provides a retrospective analysis of 14 cases of residual AN have undergone surgery at the Otology Group in Piacenza from 1987 to 1999. All these patients had previously undergone at least one retrosigmoidal exeresis although only one had been performed at the Otology Group. All patients except 1 were affected by anacusia at the time of surgery. The list of post-operative deficits included 2 hemipareses, 3 irreversible facial paralysis with consequent corneal opacity in 2 cases, 1 dysmetria and 1 paralysis of the abducent nerve. The patients had also undergone the following additional treatments: 1 emergency revision to drain a cerebellar hematoma, 3 ventricle-peritoneal derivations, 1 double application of stereotactic radiotherapy and 2 surgical procedures for facial plasty. Ten cases underwent the revision surgery at the Otologic Group using a translabyrinthine approach and 4 using a transcochlear approach. Tumor removal was deemed complete in all cases. The sole post-operative complications were a subcutaneous hematoma at the point where abdominal fat was removed and a temporary paralysis of the abducent nerve. Post-operative hospitalization was an average of 6.9 days. Analysis of the results showed that AN must be operated at selected centers in order to reduce the post-operative neurological deficit and the percentage of residual tumor. It also indicated that the retrosigmoid approach has a higher risk of accidentally leaving tumor residues than the other approaches. Finally, in the presence of a residual AN, the translabyrinthine approach offers the greatest advantages.
Adult↗
Complications and their management in tympanomastoid surgery.
Chronic diseases of the ear and their surgical treatment can endanger the delicate structures of the temporal bone in close relationship with the middle ear. The experience and expertise of the otologic surgeon, based on perfect knowledge of the complex anatomy of the whole temporal bone, are unfortunately built up partly through the management of complications encountered in tympanomastoid surgery and may require knowledge of basic neuro-otologic procedures. Paralysis and paresis of the facial nerve and labyrinthine, and dural and vascular injuries may have consequences not only in the final result of surgery but also in endangering the patient's life. All major complications are discussed and some possible treatments are proposed. Minor complications affecting the temporomandibular joint, the dura, the external auditory canal, and the bony canal wall are also covered, along with some suggestions on how to keep these consequences within reasonable percentages.
Ear, Inner↗
Infratemporal fossa approaches to the lateral skull base.
The infra-temporal fossa approach is one of the lateral approaches to the skull base. It is indicated for the treatment of tumors such as glomus tumor, petrous apex cholesteatoma, chondroma, lower cranial nerve neuroma and nasopharyngeal cancer. In the present paper, we described the surgical anatomy of the lateral skull base and the indications for the infra-temporal fossa approach with its variants. We showed the hints and pitfalls in the procedures. Five illustrative cases are also presented.
Adult↗
[Facial nerve identification in the translabyrinthine approach: an alternative method].
Since the abrupt drop in the mortality rate as a result of the introduction of microsurgical dissection techniques in the treatment of acoustic neuromas, surgeons have concentrated their efforts on preserving hearing and facial nerve function. In the translabyrinthine approach, identification of the facial nerve at the fundus of the internal auditory canal is an important step for subsequent dissection. However, the identification techniques available to date carry with them some potential risk of facial nerve injury when performed by inexperienced surgeons. In addition, they are time-consuming procedures. The authors present an alternative method for identification of the facial nerve at the fundus of the internal auditory canal during the translabyrinthine approach. The superior ampullary nerve is interrupted at the superior cribrosa area where it is not in intimate relationship with the facial nerve. Medial reflection of the superior ampullary nerve and the superior vestibular nerve facilitates identification of the facial nerve and preparation of a vestibulo-facial dissection plane.
Cranial Nerve Neoplasms↗
[Intrapetrous carotid artery aneurysm].
Intratemporal carotid artery aneurysms are rare lesions, with only 54 cases reported in the literature. Their most common symptoms are pulsatile tinnitus, hearing loss and signs of Eustachian tube obstruction. In case of aneurysm rupture, bleeding may be so profuse as to require emergency legation of the common carotid in the neck. Arteriography is the diagnostic gold standard for this disorder. Successful treatment usually involves selective aneurysm embolization or carotid closure with detachable balloons. The authors report a new case of intratemporal carotid artery aneurysm previously treated with selective embolization. To avoid the risk of aneurysm recanalization and/or infection through the external auditory canal, middle ear obliteration and blind-sac closure of the external canal were performed in this case.
Aged↗
No cerebrospinal fluid leaks in translabyrinthine vestibular schwannoma removal: reappraisal of 200 consecutive patients.
OBJECTIVE: The objective of this study was to validate measures taken to reduce the number of cerebrospinal fluid (CSF) leaks after removal of vestibular schwannomas to 0. STUDY DESIGN: This study was a retrospective case review. SETTING: The study was conducted at an otology/neurotology tertiary referral center (Gruppo Otologico, Piacenza, Italy). PATIENTS: Three hundred thirty-one vestibular schwannoma patients were studied. INTERVENTIONS: The enlarged translabyrinthine approach (TLA) was used in all cases, with a number of modifications in the last 200 patients. It was extended in 22 patients with blind sac closure of the external meatus, removal of the posterior bony canal wall, and obliteration of the Eustachian tube and middle ear. MAIN OUTCOME MEASURES: Whether patients had a leak through the wound, the nose (rhinoliquorrhea), or the ear (otoliquorrhea) was assessed. RESULTS: In an early group, the percentage of CSF leaks was 6.9%. On the basis of the evaluated causes, as time went by, technical modifications evolved. They consisted of 1) the total conservation of the fascioperiosteal flap, 2) obliteration of all petrosal cells possibly communicating with the middle ear, 3) removing the incus in a correct way, 4) closing the attic with periosteum, 5) obliterating the surgical cavity, leaving strips of abdominal fat with their medial ends inside the cerebellopontine angle, 6) suturing the musculo-periosteal layer in a correct way, and 7) fixing the skin flap to the underlying surface. The application of these modifications resulted in a total absence of CSF leaks in 200 consecutive patients thereafter. Also, no cases of meningitis were encountered. CONCLUSIONS: To our knowledge, this is the first series of 200 consecutive vestibular schwannoma patients operated by means of the enlarged TLA without a single CSF leak. When the appropriate measures are taken, the number of CSF leaks after removing tumors through the enlarged TLA must and can be reduced to 0.
Adipose Tissue↗
Titration streptomycin therapy in Meniere's disease: long-term results.
As soon as the use of streptomycin was started for the treatment of tuberculosis, its ototoxic effect was discovered. Initial reports demonstrated that streptomycin was successful in reducing vestibular responses while preserving cochlear activity. Streptomycin sulfate has been used for almost half a century for the treatment of vertigo in patients with Meniere's disease. At the Gruppo Otologico, Piacenza, Italy, between 1987 and 1995 we treated 16 patients with either bilateral Meniere's disease or with Meniere's disease in their only hearing ear, adopting the titration streptomycin therapy protocol of Graham et al. Three patients with follow-up periods of less than 2 years were not included in this study. The ages of the patients ranged from 36 to 64 years with a mean of 49.2 years. The patients were observed for 2 to 8.8 years. The dose of administered streptomycin varied from 14 to 49 gm. Episodic vertigo was totally relieved in all of the patients after initial treatment, whereas hearing remained the same or was improved when compared with the pretreatment levels. Five of the patients experienced recurring vertigo during a period of 4 to 24 months after initial treatment. Oscillopsia persisted in two patients and ataxia in darkness persisted in another two patients. Hearing was unchanged in 14 ears, improved in 2 ears, and worsened in 4 ears at the last follow-up evaluation. The overall outcome indicated that intramuscular titration streptomycin therapy seems to be one of the most important therapeutic options in the treatment of disabling vertigo in patients with either bilateral Meniere's disease or Meniere's disease in an only hearing ear.
Adult↗
The cochlear aqueduct: an important landmark in lateral skull base surgery.
The cochlear aqueduct (CA) is used as a landmark in lateral skull base surgery. In this study anatomic relationships between the CA and adjacent neurovascular structures were examined by dissecting 32 temporal bones. Observations of the relationship of the external opening (EO) of the CA with the ninth, tenth, and eleventh cranial nerves, inferior petrosal sinus (IPS), and intrapetrous carotid artery (ICA) were noted. In addition to the distance of the EO of the CA to the vertical portion of the ICA, the entire length of the CA and the width of the EO were also measured. The ninth nerve was the only structure lodged at the EO of the CA in 34.4% of bones. However, in 40.6% of bones only the IPS crossed the EO of the CA, although the ninth nerve was situated just anteroinferiorly in the vicinity of the EO. In 15.6% of bones it was possible to observe both the ninth nerve and the IPS crossing the EO. In 9.4% of bones the EO of the CA was found to be occupied by the tenth and eleventh nerves. It was also observed that the ICA was located anteriorly on the same sagittal plane with the EO in 15.6% of bones. It was concluded that although in 90% of cases the EO of the CA was in close relation with the ninth nerve, other structures such as the IPS, the tenth and eleventh cranial nerves, and the ICA were also at risk during drilling in this area because of their intimate relationships with the EO of the CA.
Adult↗
Myringoplasty in children: factors influencing surgical outcome.
Age, size, and site of perforation, condition of the ear, status of the contralateral ear, grafting materials, and more are considered factors influencing the success rates in myringoplasties in children. The ambivalence in results is mainly due to nonhomogeneous patient groups. In an effort to compose groups as homogeneous as possible for analysis of influencing factors, a retrospective study of 51 pediatric myringoplasty cases (51 ears) was undertaken. All patients had perforations caused by simple chronic otitis media. The overall surgical success rate was 82.3% at 18 months, and for young (5 to 10 years) and older (11 to 16 years) children it was 77.2% and 86.2%, respectively. Anterior, central, and total perforations healed without significant differences. Outcome in unilateral perforations was better than bilateral: 96.9% and 55%, respectively (p < 0.01). Discharging ears (100%) healed better compared with dry ears (75%) (p < 0.05). Analysis of the literature also revealed significant difference in success rates of discharging and dry ears: 92.5% and 80.6%, respectively (p < 0.01). We conclude that, contrary to comments in the literature, discharging ears in children favor good outcome and they should be operated on regardless of age and site of perforation. However, in bilateral perforations results may not be so rewarding.
Adolescent↗
[Coexistence of vestibular schwannoma and glomus tympanicum tumor].
Simultaneous occurrence of a vestibular schwannoma and a glomus tympanicum tumor has been reported only once in the international literature. The authors present a second case: a 72-year-old woman having a glomus tympanicum tumor and an ipsilateral lesion confined to the internal auditory canal, radiologically diagnosed as an acoustic neuroma. Due to the patient's age, symptoms, hearing threshold and the small size of both tumors the decision was made not to perform surgery. The patient will be regularly followed-up through computerized tomography and magnetic resonance imaging.
Aged↗
[Cerebrospinal fluid leak after translabyrinthine approach in acoustic neuroma excision].
Cerebrospinal fluid (CSF) leak is one of the most dangerous complications that can arise in cases of acoustic neuroma removal. It increases the risk of meningitis, requires longer postoperative recovery and often requires revision surgery. A retrospective analysis was performed on all cases of acoustic neuromas which had undergone translabyrinthine surgery at the Gruppo Otologico, Piacenza, Italy, between April 1987 and December 1997, in the aim of finding the causes of postoperative CSF leaks. The causes found were high pneumatization of the temporal bone and improper execution of some surgical steps. The technique has presently been modified on the basis of the experience gained from cases of CSF leaks. By scrupulously applying these modifications, from July 1994 to December 1997, a total of 160 patients were consecutively treated using the translabyrinthine approach without a single case of postoperative CSF leak. Routine use of this modified technique can and must lower the percentage of CSF leaks after a translabyrinthine surgery to nearly 0%.
Adolescent↗
Clinical observations on coexistence of sudden hearing loss and vestibular schwannoma.
It has long been recognized that sudden hearing loss (SHL) may be a harbinger of vestibular schwannoma (VS). Among 192 VS patients who underwent operation in the Gruppo Otologico, Piacenza, Italy, from April 1987 to October 1995, the charts of 14 (7.3%) cases with a history of SHL were examined. SHL was the first symptom in 8 (4.2%) patients. Eight (57.1%) of 14 VS cases with SHL anamnesis had reported recovery of their previous hearing either totally or partially before establishment of tumor diagnosis. Five (35.7%) cases had recurrent bouts of SHL. SHL was observed less frequently in cases with large tumors (>3 cm). However, the frequency of SHL in patients with small tumors did not differ from that of medium-sized tumors. Awareness about coexistence of SHL and VS, as well as concomitant use of auditory brain stem response and magnetic resonance imaging, is crucial to rule out the diagnosis of VS in a patient with SHL.
Adult↗
Anatomical considerations of high jugular bulb in lateral skull base surgery.
In order to study high jugular bulb management in lateral skull base surgery, an anatomical study was conducted on 30 temporal bones by examining the relationship between the internal auditory canal (IAC) and the jugular bulb. The following parameters were measured: 1) Height of the jugular bulb (H)... distance between the level of jugular bulb dome and the line passing through the confluence of the sigmoid sinus with the jugular bulb (SS-JB), 2) Mastoid length (ML)... distance between the mastoid process and middle cranial fossa dura, 3) Distance between the most inferior part of the porus acousticus and jugular bulb dome (A), 4) Distance between the porus acousticus and SS-JB (B). The jugular bulb was defined as high when it occupied more than two thirds of (B). The incidence of a high jugular bulb was 23 per cent in this study. When the jugular bulb was high, the mean (H) and (A) were 9.4 +/- 1.9 mm and 2.7 +/- 0.5 mm, respectively. (H) was higher on the right side than on the left side. No statistically significant difference was found between small and large mastoids (t-test: p > 0.05). It was concluded that when a high jugular bulb was encountered during lateral skull base surgery, the jugular bulb position allows a very small working area inferior to the IAC. In these cases, a 3 or 4 mm depression of the jugular bulb is necessary in order to expose the lower cranial nerves. This can be accomplished by lowering the jugular bulb with the technique already described.
Humans↗
[Modified Body technique in the treatment of epithympanic cholesteatoma. Otologic group, Piacenza].
The Bondy technique is a particular radical, yet conservative, treatment where the intact tympanic-ossicular system is preserved during the operation. This technique was initially introduced by Gustave Bondy in 1910 and has been used at the authors' center since December 1983 with a few modifications. In the twelve years from December 1983 to December 1995 69 cases (66 patients) were treated with this technique: 5.6% of all chronic cholesteatomatose otitis surgically treated during that period. The following indications were applied: purely epitymapnic cholesteatoma, average transmission gap equal to or lower than 25 dB and intact bone chain. During the follow-up no signs of recurrent cholestatoma were found. The average post-operative transmission gap was greater than 25 dB in only 5 of the 54 cases with at least one year of follow-up. When used in selected cases, the modified Bondy technique can be considered an excellent option in the treatment of epitympanic cholesteatoma, making it possible to maintain the good pre-operative hearing without requiring a second operation.
Adult↗
[Lateral approaches to the clivus].
Thanks to ongoing development in microsurgical techniques to treat the skull base some clivus lesions, considered inoperable until a few years ago, can now be removed with relatively low mortality and morbidity. The approaches available for the treatment of lesions in this anatomical area can be broken down into anterior and lateral. The latter offer the surgeon several important advantages such as better control over the main vascular structures and the possibility of opening the intradural space without coming into communication with the pharynx. By virtue of their extreme versatility, the lateral approaches may be used in combination in a single operation or can be performed as staged procedures. Each of the lateral routes, however, has its own advantages and drawbacks. These are presented during a brief description of each technique. The main factor in selection of approach is the anatomical limits of the approach itself. Generally speaking, the largest surgical field is offered by the most destructive approaches. Although they do cause such deficits as unilateral hearing loss, these approaches permit greatly improved control over the vital structures. Nevertheless, when such deficits exist prior to surgery, the morbidity of such approaches is negligible. The histological nature of the disease, the variable relationships with the dura, the main neurovascular structures and other factors should all be considered when deciding how to manage each case. The surgeon must, however, have the range of skills required to perform the diversity of approaches to the lateral skull base so as to provide the patient with the best possible care.
Adult↗
Broken ergodicity and glassy behavior in a deterministic chaotic map.
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Journal Article↗
Complexity of the minimum energy configurations.
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Journal Article↗