Anomalías congénitas nasales: Estudio retrospectivo y revisión de la literatura / Congenital Anomalies of the Nose: retrospective study and literature review

INTRODUCTION. Congenital malformations occur in 1 in 5,000 to 40,000 live births. They present as a morphological abnormality of the nasal pyramid or as a picture of moderate to severe nasal obstruction. OBJECTIVE. Evaluate the etiology, associated comorbidities, management and mortality of congenital malformations of the nose in neonates and infants. MATERIALS AND METHODS. Cross-sectional retrospective descriptive study, 105 medical records were reviewed, of which 26 corresponded to patients with congenital nasal malformations, at the Carlos Andrade Marín Specialty Hospital in Quito - Ecuador, between January 2009 and May 2022; the tabulation and analysis of data was carried out in the Excel program. The patients were classified according to Losee et al. in 4 types: hypoplasia, hyperplasia, clefts and tumors RESULTS. Nasal anomalies occurred in males in 73.07%, all presented nasal obstruction, the diagnosis was made by flexible nasofibroscopy; in 42.3% of the cases, the evaluation was complemented with computed tomography. The most frequent congenital pathology was stenosis - choanal atresia with 53.8%, followed by craniofacial clefts with 15.39%. In 42.3% of the cases there was an association with genetic syndromes, neurological, ocular and intestinal pathology. 69.23% of the patients received clinical treatment with nasal lavages, nasal corticosteroids and positive pressure by cannula, while 30.77% were resolved surgically, being: 2 unilateral choanal atresia, 1 middle fossa stenosis, 4 cleft lip and palate and 1 encephalocele. Mortality was 7.69% CONCLUSION. Hypoplasias and clefts are the predominant pathologies, flexible nasal nasofibroscopy is the diagnostic test of choice. The clinical treatment was successful in the initial management in 69.23% of cases. Surgery was performed for the repair of facial clefts; being the hypoplasias or masses managed by endoscopic approach.

INTRODUCCIÓN. Las malformaciones congénitas se presentan en 1 de cada 5.000 a 40.000 nacidos vivos. Se presentan como una anomalía morfológica de la pirámide nasal o como un cuadro de obstrucción nasal moderada a severo. OBJETIVO. Evaluar la etiología, comorbilidades asociadas, manejo y mortalidad de las malformaciones congénitas de nariz en neonatos y lactantes. MATERIALES Y MÉTODOS. Estudio descriptivo retrospectivo transversal, se revisaron 105 historias clínicas de las cuales 26 correspondieron a pacientes con malformaciones congénitas nasales, en el Hospital de Especialidades Carlos Andrade Marín de Quito - Ecuador, entre enero de 2009 a mayo de 2022; la tabulación y análisis de datos se realizó en el programa Excel. Los pacientes fueron clasificados según Losee et al. en 4 tipos: hipoplasia, hiperplasia, hendiduras y tumores. RESULTADOS. Las anomalías nasales se presentaron en el sexo masculino en el 73.07%, el motivo de consulta fue la obstrucción nasal, el diagnóstico se realizó mediante nasofibroscopía flexible; en el 42,3% de los casos se complementó la evaluación con tomografía computarizada. La patología congénita más frecuente fue la estenosis - atresia de coana con un 53,8%, seguida de hendiduras craneofaciales con un 15.39%. En el 42.3% de los casos existió asociación con síndromes genéticos, patología neurológica, ocular e intestinal. El 69,23% de los pacientes recibió tratamiento clínico con lavados nasales, corticoides por vía nasal y presión positiva por cánula, mientras que el 30,77% se resolvió quirúrgicamente, siendo: 2 atresia unilateral de coana, 1 estenosis de fosa media, 4 hendiduras labio palatinas y 1 encefalocele. La mortalidad fue del 7,69%. CONCLUSIÓN: Las hipoplasias y las hendiduras son las patologías que predominaron, la nasofibroscopia flexible nasal es el examen diagnóstico de elección. El tratamiento clínico fue exitoso en el manejo inicial en el 69,23% de casos. La cirugía se realizó para la reparación de hendiduras faciales; siendo las hipoplasias o masas manejadas por abordaje endoscópico.

Giant Cell tumor of the Zygomatic Arch in a Pediatric Patient: Rare Case Report / Tumor de Células Gigantes do Arco Zigomático em um Paciente Pediátrico: Relato de Caso Raro / Tumor de Células Gigantes del Arco Cigomático en un Paciente Pediátrico: Informe de un Caso Raro

Introduction: A giant cell tumor (GCT) is a rare tumor, usually benign, which can be locally aggressive, with an almost unknown incidence in the skull. Case report: Case report of a pediatric patient diagnosed with Ewing's sarcoma (ES) and later GCT when sought medical care for an increased volume in the zygomatic arch and the right preauricular region. Imaging exams showed an expansive lesion in the zygomatic and squamous portion of the right temporal bone, with an extradural intracranial component in the middle fossa, with no evidence of infiltration. From the anatomopathological view, fusocelullar neoplasia was seen. The CD68 marker was positive and the S100 marker was negative. Tumor resection by microsurgery was performed. The patient remains in follow-up, with imaging exams at neurosurgery and orthopedics, the latest magnetic resonances of the skull showing a reduction in the size of the lesion. In addition, the patient did not submit to adjuvant therapy and is currently without complaints. Conclusion: This is an important case due to its rarity and clinical data that contributes for the understanding of the pathologies presented, allowing that, in the future, new studies are able to optimize the treatment, and the prognosis for these patients

Introdução: O tumor de células gigantes (TCG) é raro, geralmente benigno, e pode ser localmente agressivo, com incidência quase desconhecida no crânio. Relato do caso: Paciente pediátrico com diagnóstico de sarcoma de Ewing (SE) e posteriormente de TCG, quando procurou atendimento médico por conta do aumento de volume em arco zigomático e região préauricular à direita. Os exames de imagem evidenciaram lesão expansiva em porção zigomática e escamosa do osso temporal à direita, com componente intracraniano extradural em fossa média, sem evidências de infiltração. Do ponto de vista anatomopatológico, observou-se neoplasia fusocelular. O marcador CD68 foi positivo e o marcador S100, negativo. Realizouse microcirurgia para ressecção do tumor. O paciente permanece em acompanhamento com exames de imagem nos serviços de neurocirurgia e ortopedia, com as últimas ressonâncias magnéticas de crânio mostrando redução no tamanho da lesão. Além disso, não realiza terapia adjuvante e atualmente não apresenta queixas. Conclusão: Este é um caso importante em razão da sua raridade e dos dados clínicos que agregam informações sobre as patologias apresentadas, permitindo que, no futuro, novas pesquisas possam otimizar o tratamento da referida neoplasia e o prognóstico desses pacientes

Introducción: El tumor de células gigantes (TCG) es un tumor raro, generalmente benigno, que puede ser localmente agresivo, con una incidencia casi desconocida en el cráneo. Relato del caso: Paciente pediátrico diagnosticado con sarcoma de Ewing (SE) y posteriormente con TCG, cuando procuró atención médica por aumento de volumen en arco cigomático y región preauricular derecha. Los exámenes de imagen mostraron una lesión expansiva en la porción cigomática y escamosa del temporal derecho, con componente intracraneal extradural en la fosa media, sin evidencias de infiltración. Desde el punto de vista anatomopatológico, se observó neoplasia fusocelular. El marcador CD68 fue positivo y el marcador S100 negativo. Se realizó microcirugía para resecar el tumor. El paciente permanece en seguimiento con exámenes de imagen en los servicios de neurocirugía y ortopedia, con las últimas resonancias magnéticas de cráneo mostrando una reducción en el tamaño de la lesión. Además, no se somete a terapia adyuvante y actualmente no tiene quejas. Conclusión: Este es un caso importante por su rareza y datos clínicos que agregan informaciones sobre las patologías presentadas, permitiendo, en el futuro, nuevas investigaciones para optimizar el tratamiento de la neoplasia referida, y el pronóstico de estos pacientes

Condylar Dislocation for Intracranial Fossa: a Review of the Last 10 Years

The displacement of the mandibular condyle into the cranial fossa is an uncommon event; when it occurs, there is a need for immediate and multidisciplinary surgical intervention. Due to its rare advent, there is still no consolidated service dynamics, as this condition has not yet been described in a sedimented way in the literature databases. In the present article, we performed a literature review of condylar dislocation for the intracranial fossa described in the past 10 years in the PubMed and Lilacs search databases.

Ossification of the roof of the porus trigeminus with duplicated abducens nerve / 대한해부학회지

Ossification of parts of the intracranial dura mater is common and is generally accepted as an age-related finding. Additionally, duplication of the abducens nerve along its course to the lateral rectus muscle is a known, although uncommon anatomical variant. During routine cadaveric dissection, an ossified portion of dura mater traveling over the trigeminal nerve's entrance (porus trigeminus) into the middle cranial fossa was observed unilaterally. Ipsilaterally, a duplicated abducens nerve was also observed, with a unique foramen superolateral to the entrance of Dorello's canal. To our knowledge, there has been no existing report of a simultaneous ossified roof of the porus trigeminus with an ipsilateral duplicated abducens nerve. Herein, we discuss this case and the potential clinical and surgical applications. We believe this case report will be informative for the skull base surgeon in the diagnosis of neuralgic pain in the frontomaxillary, andibular, orbital, and external and middle ear regions.

Foramen venoso órbito cavernoso: foramen de Warwick / Cavernous orbital venous foramen: Warwick´s foramen

El foramen de Warwick o foramen venoso órbito cavernoso, es un foramen inconstante del ala mayor del esfenoides, situado entre la fisura orbitaria superior y el foramen rotundo. Comunica la órbita con la fosa craneal media y/o con la fosa pterigopalatina y permitiría el paso de la vena oftálmica inferior. La presencia del foramen venoso órbito cavernoso varía entre el 0,38 % y el 0,74 %. Se describe con forma redondeada o crescéntica (semilunar), unilateral o bilateral. El objetivo de este trabajo fue evidenciar la presencia y las características de foramen venoso órbito cavernoso en cráneos secos de individuos adultos chilenos de ambos sexos. Se analizaron 138 cráneos de individuos adultos y de ambos sexos, en búsqueda del foramen venoso órbito cavernoso para determinar la frecuencia, localización, forma, tamaño, orientación y distancias con respecto a la fisura orbitaria superior y el foramen rotundo. Los forámenes encontrados fueron fotografiados, explorados y medidos. La presencia del foramen venoso órbito cavernoso fue del 2,17 % de la muestra, encontrándose en forma unilateral (1,45 %) y bilateral (0,17 %). Con forma redondeada en 3 casos y semilunar en 1 caso. Con orientación hacia la órbita (2 casos) y hacia la fosa pterigopalatina (2 casos). También se evidenció que cuando está presente el foramen venoso órbito cavernoso, la separación entre la fisura orbitaria superior y el foramen rotundo es mayor que en su ausencia. Nuestro estudio demuestra la presencia del foramen venoso órbito cavernoso en la población chilena, con una frecuencia más alta que la observada en otras poblaciones. La localización, orientación y formas coinciden con la literatura, pero difiere en el tamaño (en forámenes redondeados). También pudimos determinar que la fisura orbitaria superior y el foramen rotundo tienden a encontrarse más cercanos en ausencia del foramen venoso órbito cavernoso y por lo tanto más distante cuando esta estructura está presente. Este hecho no está descrito en la literatura. Los resultados de este estudio son importantes para la anatomía, oftalmología, traumatología, imagenología, cirugía e identificación humana. Finalmente y en virtud de la TAI, proponemos llamar a este foramen, foramen venoso órbito cavernoso.

The Warwick's foramen or cavernous orbital venous foramen, is an inconstant foramen from the greater wing of the sphenoid bone, located between the superior orbital fissure and the rotundum foramen. It connects the orbit with the middle cranial fossa and/or with the pterygopalatine fossa and allows for the passage of the inferior ophthalmic vein. The presence of the cavernous orbital venous foramen varies between 0.38 % and 0.74 % in human skulls. It is described as having a rounded or crescentic (semilunar), unilateral or bilateral shape. The objective of the present work was to demonstrate the presence and characteristics of the cavernous orbital venous foramen in dry skulls of Chilean adult individuals of both sexes. One hundred and thirty-eight adult skulls of both sexes were analyzed in search of the cavernous orbital venous foramen to determine the frequency, location, shape, size, orientation and distances with respect to the superior orbital fissure and the rotund foramen. Found foramina were photographed, explored and measured. The cavernous orbital venous foramen was present in 2.17 % of the sample, and was both unilateral (1.45 %) and bilateral (0.17 %). It had a rounded and lunate shape in 3 and 1 cases, respectively. Moreover, it was orientated towards the orbit (2 cases) and towards the pterygopalatine fossa (2 cases). It was also evidenced that when the cavernous orbital venous foramen is present, the separation between the superior orbital fissure and the rotund foramen is greater than in its absence. Our study demonstrates the presence of the cavernous orbital venous foramen in the Chilean population, with a higher frequency than described previously. The location, orientation and observed forms agree with the literature, but differ in size (in rounded shape foramen). We could also determine that the superior orbital fissure and the rotundum foramen tend to be closer in the absence of the cavernous orbital venous foramen and, therefore, are more distant when this structure is present. This fact is not described in the literature. The results of this study are important for anatomy, ophthalmology, traumatology, imaging, surgery and human identification. Finally, and by virtue of the International Anatomical Terminology (IAT), we propose to call this structure the cavernous orbital venous foramen.

Calcium pyrophosphate dihydrate deposition disease in the temporomandibular joint: diagnosis and treatment / 대한악안면성형재건외과학회지

BACKGROUND: Calcium pyrophosphate dihydrate deposition disease (CPDD) is a rare disease in the temporomandibular joint (TMJ) space. It forms a calcified crystal mass and induces a limitation of joint movement. CASE PRESENTATION: The calcified mass in our case was occupied in the left TMJ area and extended to the infratemporal and middle cranial fossa. For a complete excision of this mass, we performed a vertical ramus osteotomy and resected the mass around the mandibular condyle. The calcified mass in the infratemporal fossa was carefully excised, and the segmented mandible was anatomically repositioned. Scanning electronic microscopy (SEM)/energy-dispersive X-ray spectroscopy (EDS) microanalysis was performed to evaluate the calcified mass. The result of SEM/EDS showed that the crystal mass was completely composed of calcium pyrophosphate dihydrate. This result strongly suggested that the calcified mass was CPDD in the TMJ area. CONCLUSIONS: CPDD in the TMJ is a rare disease and is difficult to differentially diagnose from other neoplasms. A histological examination and quantitative microanalysis are required to confirm the diagnosis. In our patient, CPDD in the TMJ was successfully removed via the extracorporeal approach. SEM/EDS microanalysis was used for the differential diagnosis.

Modified Orbitozygomatic Approach without Orbital Roof Removal for Middle Fossa Lesions

OBJECTIVE: The purpose of the present study was to describe an OrBitoZygomatic (OBZ) surgical variant that implies the drilling of the orbital roof and lateral wall of the orbit without orbitotomy.METHODS: Design : cross-sectional study. Between January 2010 and December 2014, 18 patients with middle fossa lesions underwent the previously mentioned OBZ surgical variant. Gender, age, histopathological diagnosis, complications, and percentage of resection were registered. The detailed surgical technique is described.RESULTS: Of the 18 cases listed in the study, nine were males and nine females. Seventeen cases (94.5%) were diagnosed as primary tumoral lesions, one case (5.5%) presented with metastasis of a carcinoma, and an additional one had a fibrous dysplasia. Age ranged between 27 and 73 years. Early complications were developed in four cases, but all of these were completely resolved. None developed enophthalmos.CONCLUSION: The present study illustrates a novel surgical OBZ approach that allows for the performance of a simpler and faster procedure with fewer complications, and without increasing surgical time or cerebral manipulation, for reaching lesions of the middle fossa. Thorough knowledge of the anatomy and surgical technique is essential for successful completion of the procedure.

Total Transcanal Endoscopic Facial Nerve Decompression for Traumatic Facial Nerve Palsy

A few approaches can be used to decompress traumatic facial nerve paralysis including the middle cranial fossa approach or transmastoid approach depending on the site of injury. In some specific situation of treating traumatic facial nerve palsy whose injured site was confined from the geniculate ganglion to the second genu, transcanal endoscopic approach for facial nerve decompression can be used. We performed two cases of total endoscopic transcanal facial nerve decompression in patients with traumatic facial nerve palsy. After a six month follow-up, both patients showed improvement in facial function by 2 grades according to House-Brackmann grade system. In terms of treatment outcomes, total transcanal endoscopic facial nerve decompression for traumatic facial nerve palsy is an alternative for lesions limited to the tympanic segment I, and has an advantages of being minimally invasive and is cosmetically acceptable without an external scar or bony depression due to drilling.

Modified Orbitozygomatic Approach without Orbital Roof Removal for Middle Fossa Lesions

OBJECTIVE: The purpose of the present study was to describe an OrBitoZygomatic (OBZ) surgical variant that implies the drilling of the orbital roof and lateral wall of the orbit without orbitotomy. METHODS: Design : cross-sectional study. Between January 2010 and December 2014, 18 patients with middle fossa lesions underwent the previously mentioned OBZ surgical variant. Gender, age, histopathological diagnosis, complications, and percentage of resection were registered. The detailed surgical technique is described. RESULTS: Of the 18 cases listed in the study, nine were males and nine females. Seventeen cases (94.5%) were diagnosed as primary tumoral lesions, one case (5.5%) presented with metastasis of a carcinoma, and an additional one had a fibrous dysplasia. Age ranged between 27 and 73 years. Early complications were developed in four cases, but all of these were completely resolved. None developed enophthalmos. CONCLUSION: The present study illustrates a novel surgical OBZ approach that allows for the performance of a simpler and faster procedure with fewer complications, and without increasing surgical time or cerebral manipulation, for reaching lesions of the middle fossa. Thorough knowledge of the anatomy and surgical technique is essential for successful completion of the procedure.

A Statistical Analysis of Superior Orbital Fissure Width in Korean Adults using Computed Tomography Scans

BACKGROUND: The superior orbital fissure is a small area that connects the middle cranial fossa and the orbit. Many studies have measured the size of the superior orbital fissure. However, there is no standard value for the size of the superior orbital fissure. Therefore, we conducted this study to provide the average size of the superior orbital fissure in Korean adults. METHODS: We measured the widths of the superior orbital fissures of 142 patients using computed tomography scans. Because the width of the superior orbital fissure varies at different locations, we measured the superior orbital fissure width at the level of the optic canal. RESULTS: In the males, the width of the superior orbital fissure on both sides was 3.79±0.93 mm, and these values were 3.79±0.96 mm for the left side and 3.783±0.92 mm for the right side. In the females, the widths of the superior orbital fissures were 3.62±1.35 mm on the left side, 3.69±1.18 mm on the right side, and 3.65±1.26 mm across both sides. CONCLUSION: There were no significant differences between the males and females or between the left and right sides. The present study suggests that we may accept the hypothesis that a congenitally narrow superior orbital fissure may be a risk factor for the superior orbital fissure syndrome. Surgeons should take precaution with patients who have narrow superior orbital fissures during the perioperative period.

Frontotemporal Dermoid Cyst with Sinus Tract in a Child

PURPOSE: To report the treatment results of a frontotemporal dermoid cyst with a cutaneous fistula and sinus tract that caused recurrent periorbital cellulitis in a child. CASE SUMMARY: A 4-year-old girl who presented with left orbital swelling and tenderness visited our hospital. She had a cutaneous fistula with a small amount of purulent discharge at the left frontotemporal area. Orbital computed tomography scans showed a well-defined low density lesion in the fronto-zygomatic suture, and there was a bony defect in the left greater wing of the sphenoid bone of the orbit. Orbital magnetic resonance imaging showed a cutaneous fistula and sinus tract that extended into the middle cranial fossa. The patient was treated with intravenous antibiotics until the inflammation was resolved. Surgery was performed to remove the dermoid cyst with sinus tract. After surgery, there was no evidence of recurrence, and complications included neurologic and ophthalmic symptoms. CONCLUSIONS: Orbitofacial lesions, particularly frontotemporal cutaneous fistulas that present with recurrent discharge, should be regarded with suspicion in cases of deep extended dermoid cysts with sinus tract. Additionally, imaging tests should be carefully conducted before surgery.

Temporal Bone Meningocele Presenting as a Pulsatile Mass of the External Auditory Canal / 대한이비인후과학회지

Meningocele is a protrusion of meninges through a defect in the skull base. It is a rare but potentially life-threatening condition requiring surgery. We present a case of 59-year-old woman complaining of persistent otorrhea of the right ear and a pulsating cystic mass occupying the external auditory canal in her right ear. The patient had undergone right canal wall up mastoidectomy and tympanoplasty about 30 years ago. Radiological evaluations revealed a bony defect at the tegmen tympani and tegmen mastoideum, with a cystic mass filling this defect and the external auditory canal, suggesting temporal bone meningocele. The meningocele was resected and the bony defect of tegmen was successfully repaired via combined transmastoid and middle cranial fossa mini-craniotomy approach.

Nontraumatic Intracystic Hemorrhage of Arachnoid Cyst: CT and MR Findings

Arachnoid cysts (AC) are intraarachnoidal cerebrospinal fluid collections, and account for 1% of all intracranial space-occupying lesions. Intracystic hemorrhage of the AC can occur spontaneously, but this is an extremely rare event. Herein, we present a case of hemorrhagic AC in a nontraumatic patient in the left middle cranial fossa. We also performed relevant literature review on this disease.

Teratoma congénito gigante de la órbita: reporte de caso / Giant congenital orbital teratoma: Case report

Los teratomas son tumores compuestos de tejidos derivados de las tres capas germinales que pueden localizarse en las gónadas o extragonadales. Los de localización orbitaria son infrecuentes y generalmente se presentan en recién nacidos sanos produciendo proptosis. Los autores presentan el caso de un recién nacido con gran teratoma orbitario congénito que invadía las estructuras intraoculares y que se extendía hasta la fosa cerebral media a través del vértice de la órbita. Se describen las características clínicas, los hallazgos radiológicos, el abordaje quirúrgico, la descripción histopatológica y el tratamiento adyuvante con quimioterapia recibido por el paciente.

The teratomas are tumors composed of tissues derived from all three germ layers which can be located in the gonads and extragonadal. The orbital location are rare and usually occur in healthy newborns producing proptosis. The authors present the case of a newborn with congenital orbital teratoma large invading intraocular structures and extending to the middle cranial fossa through the apex of the orbit. Clinical features, radiological findings, surgical approach, histopathologic description and adjuvant chemotherapy received by the patient are described.

Clinical analysis of 38 cases of petrous apex cholesteatoma / 临床耳鼻咽喉头颈外科杂志

OBJECTIVE@#To explore the clinical characteristics, diagnosis method and treatment of petrous apex cholesteatoma.@*METHOD@#A retrospective analysis was taken with respects to the clinical characteristics, diagnosis and surgical management of 38 patients who underwent surgery for petrous apex cholesteatoma in our department.@*RESULT@#(1)31 patients had unilateral hearing loss and facial paralysis of different degree, 27 patients were firstly characterized with hearing loss, and followed by facial paralysis. 6 cases had facial paralysis as the main performance. (2)17 patients had syndrome of tinnitus, and 15 patients had syndrome of vertigo and 4 cases of severe pain of ear. (3)All patients had petrous bone destroy with high resolution CT scan, while MRI suggests the presence of pathological changes in petrous apex. (4)All patients were taken surgeries to remove the lesion, and translabyrinth approach was chosen for 23 patients, middle cranial fossa approach is 12, while 3 case has choose endoscopic approach. 8 cases were operated with facial nerve decompression. 7 cases was taken end to end anastomosis. 3 cases of great auricular nerve transplantation. There is no recurrence in follow-up of 1 years to 2 years.@*CONCLUSION@#The clinical manifestations of petrous apex cholesteatoma lack specificity, and high resolution CT and MRI has important value in the diagnosis of petrous apex cholesteatoma. The strategy of surgical operation should be taken according to the classification, location of petrous apex cholesteatoma as well as hearing level and facial nerve function with patients.

A Case of Vestibular Schwannoma with Acute Spontaneous Vertigo / 대한이비인후과학회지

Vestibular schwannoma (VS) is a rare benign tumor arising from the vestibular portion of the 8th cranial nerve. Patients with VS complain of diverse symptoms, such as asymmetrical hearing loss, tinnitus, vertigo, and unsteadiness. The most common symptom of VS is unilateral and gradual loss of hearing, which may also be associated with tinnitus. We experienced an unusual case of 62-year-old woman, who presented with acute vertigo without any typical otologic symptoms of hearing loss and tinnitus. Because of the unusual symptom, the patient was initially diagnosed with vestibular neuronitis. However, atypical nystagmus was presented after head shaking test. Internal auditory canal MRI scanning confirmed the diagnosis of VS. We removed the patient's VS by middle cranial fossa approach. We present this case with a review of relevant peer-reviewed medical articles and literature.

A Case of Recurred Cholesteatoma Removal via Middle Cranial Fossa Approach / 대한이비인후과학회지

Cholesteatoma is a benign disease but it has an aggressive feature that may lead to serious conditions. Many strategies have been introduced for the treatment cholesteatoma, yet no definite single method has been established: it should be treated respectively regarding the completion of cholesteatoma, conservation of tympanic mucosa, proper ventilation of middle ear and preservation of hearing. A 25-year old patient visited our clinic for right-sided facial paralysis of 5 days. The patient underwent canal wall down mastoidectomy 10 years ago due to cholesteatoma and a few revision surgeries under local anesthesia for recurrence. Pre-operative temporal bone CT showed suspected recurred cholesteatoma in internal auditory canal and labyrinthine segment of facial nerve nearby. The patient underwent a removal of cholesteatoma via middle cranial fossa approach. This case report is a successful completion of recurred cholesteatoma, for which no recurrence is shown. Facial nerve function is improved at postoperative 1 year.

Descompressão dos segmentos timpânico e labiríntico do nervo facial via fossa craniana média / Decompression of the tympanic and labyrinthine segments of the facial nerve via middle cranial fossa

Introdução: A paralisia facial periférica caracteriza-se pela interrupção, definitiva ou temporária, do funcionamento da musculatura facial. Decorre de lesão ou mau funcionamento das fibras do nervo facial. É uma enfermidade que causa enorme impacto estético e funcional. O topodiagnóstico e o tratamento da paralisia facial periférica pode requer abordagem médica e fonoaudiológica; ser exclusivamente medicamentoso ou associado à terapia de reabilitação, ou ainda, medicamentoso e cirúrgico, seguido da reabilitação da mímica facial. A via FCM tem sido usada para a descompressão do NF quando a audição precisa ser preservada. Esse acesso pode ser realizado de forma isolada, ou combinado à via transmastóidea. Objetivo: Descrever uma técnica inovadora para a descompressão do nervo facial via fossa craniana média que permite a exposição direta dos segmentos labiríntico e timpânico do nervo facial, com a preservação da função da orelha interna. Métodos: Vinte cabeças extraídas de cadáveres adultos de ambos os gêneros, sem sinais de malformação, traumatismo, doença ou manipulação cirúrgica prévia foram usados neste estudo. Os pontos de referência utilizados foram a artéria meníngea média, o nevo petroso superficial maior, a eminência arqueada, o seio petroso superior, e o plano meatal seguido no ápice petroso a partir da sua porção mais anterior e medial. Foi feita a dissecação do plano meatal, com visualização do meato acústico interno, seguido no ápice petroso a partir da sua porção mais anterior e medial até a região do gânglio geniculado. Foi aberto o tégmen timpânico e identificada a porção timpânica do nervo facial. A dissecação seguiu no sentido retrógrado da porção timpânica do nervo facial em direção ao gânglio geniculado, até a sua porção labiríntica. A aracnoide do meato acústico interno era aberta, e depois de identificado o nervo facial, a bainha deste nervo era aberta em extensão exposta. Resultados: As distâncias médias, entre o canal semicircular...

Background: Peripheral facial palsy is characterized by the permanent or temporary interruption of the functioning of the facial muscles. The middle cranial fossa (MCF) approach has been used for the decompression of the facial nerve (FN) when hearing needs to be preserved. In this work, we describe an innovative technique for the decompression of the FN through the MCF approach that allows the direct exposure of the labyrinthine and entire tympanic segment of the FN, with the preservation of inner ear function. Methods: Twenty cadavers heads were used in this study. The reference landmarks used were the middle meningeal artery, the greater superficial petrosal nerve, the arcuate eminence, the inferior petrosal sinus and the meatal plane following the petrous apex from its most anterior and medial portion. Results: The tympanic segment of the FN presented, on average, a total length of 11 ± 0.67mm to the right, and 11.5 ± 0.60mm to the left. The longitudinal lengths of bone window in the tegmen tympani were 16.8±1.67mm to the right, and 16.8 ± 1.20mm to the left. The cross-sectional lengths of the bone window in the tegmen tympani were 5.5 ± 1.20mm and 5.0±1.75mm to the right and left sides, respectively. The average value of elliptical area formed by the longitudinal and transversal lengths of the bone window made in the tegmen tympani were 72.5 ± 22.5mm2 to the right, and 65.9 ± 30.3mm2 to the left. Conclusion: The proposed technique can be used for the surgical decompression of the tympanic, labyrinthine and meatal segments of the FN through the MCF, without imposing a risk to hearing, in addition to reducing the surgical time and the risk to patients.

Anatomical Factors Influencing Pneumatization of the Petrous Apex

OBJECTIVES: Aim of the present study was to define the relationship between petrous apex pneumatization and the nearby major anatomical landmarks using temporal bone computed tomography (CT) images. METHODS: This retrospective, Institutional Review Board-approved study analyzed CT images of 84 patients that showed normal findings bilaterally. Pneumatization of the petrous apex was classified using two methods. Eight parameters were as follows: angle between the posterior cranial fossa and internal auditory canal, Morimitsu classification of anterior epitympanic space, distance between the carotid canal and jugular bulb, distance between the cochlear modiolus and carotid canal, distance between the tympanic segment and jugular bulb, high jugular bulb, distance between the vertical segment and jugular bulb, and distance between the lateral semicircular canals and middle cranial fossa. RESULTS: There was a significant difference in Morimitsu classification of the anterior epitympanic space between the two classification methods. Poorly pneumatic upper petrous apices were distributed uniformly in three types of Morimitsu classification, but more pneumatic upper petrous apices were found more often in anterior type. Lower petrous apex was well pneumatized regardless of the types of anterior epitympanic space, but the largest amount of pneumatization was found more frequently in the anterior type of anterior epitympanic space. CONCLUSION: This study showed that there was no reliable anatomic marker to estimate petrous apex pneumatization and suggests that the pneumatization of the petrous apex may be an independent process from other part of the temporal bone, and may not be influenced by the nearby major anatomical structures in the temporal bone. In this study, the anterior type of anterior epitympanic space was found to be closely related to more well-pneumatized petrous apices, which implies that the anterior saccule of the saccus medius may be the main factor influencing pneumatization of the petrous apex.

Surgical anatomy, technique and application of endoscopic endonasal transpterygoid approach in skull base surgery / 中华耳鼻咽喉头颈外科杂志

<p><b>OBJECTIVE</b>To identify the landmarks of transpterygoid approach and to report its application in a series of cases.</p><p><b>METHODS</b>Two silicon-injected adult cadaveric heads(4 sides) were dissected by performing an endoscopic endonasal transpterygoid approach after CT scanning for imaging guidance. High-quality pictures were obtained. This approach was used to treat twelve patients with skull base lesions including 3 spontaneous cerebrospinal fluid (CSF) leaks in the lateral recess of the sphenoid sinus, 2 neurofibromas and 2 Schwannomas involving the pterygopalatine fossa and infratemporal fossa, 1 dermoid cyst involving the middle fossa and infratemporal fossa, 1 invasive fungal sinusitis invading the middle fossa base, 1 basal cell adenoma in the upper parapharyngeal space, 1 chondrosarcoma in the parasellar region and 1 adenoid cystic carcinoma. Clinical records were reviewed.</p><p><b>RESULTS</b>In terms of approach dissection, important landmarks, such as the sphenopalatine foramen and artery, vidian canal and nerve, foramen rotundum and maxillary branch of trigeminal nerve, foramen ovale and mandibular branch of trigeminal nerve, as well as pterygoid segment of Eustachian tube were identified. In terms of clinical data, three patients with spontaneous CSF leak underwent repair. Six patients with benign lesions underwent complete tumor resection. In the patient with invasive fungal disease, thorough debridement was undertaken and antifungal drug was administered for one month. For these benign skull base lesions, there was no recurrence during the follow-up period. In the patient with chondrosarcoma, most of the tumor was removed in the first operation, and was followed by two endoscopic operations because of fast growth of the tumor. Final control was achieved with chemotherapy and radiation. In the patient with adenoid cystic carcinoma, tumor recurred five years after surgery, and was reoperated.</p><p><b>CONCLUSION</b>An understanding of the landmarks of the transpterygoid approach is paramount for surgically dealing with disease located within and adjacent to the region of the pterygoid process of the sphenoid bone. The endoscopic endonasal transpterygoid approach is feasible and safe in selected patients with skull base lesions.</p>