Topographic Anatomy of the Medial Labyrinthine Wall: Implications for the Transcanal Endoscopic Approach to the Internal Auditory Canal.

HYPOTHESIS: To characterize transcanal endoscopic landmarks of the medial labyrinthine wall and correlate these with anatomical features of the fundus of the internal auditory canal (IAC). BACKGROUND: The transcanal transpromontorial approach (TTA) enables minimally invasive access to the IAC. The establishment of a landmark-based dissection technique for the approach is crucial to avoid injury to the facial nerve. METHODS: Twenty temporal bones were dissected endoscopically through the TTA. Furthermore, high-resolution computed tomography (CT) scans from ten adult normal temporal bones were analyzed and three-dimensionally reconstructed. RESULTS: A stepwise dissection technique for the TTA was demonstrated depending on a newly described landmark used in the identification of the facial nerve. The proposed landmark, which was named the intervestibulocochlear crest (IVCC), is an integrated part of the otic capsule. It can be differentiated after the excision of the lateral labyrinthine wall as a laterally based bony pyramid between the cochlea and the vestibule. Its medially directed apex blends with the central part of the falcifrom crest and points to the distal part of the meatal facial nerve. The IVCC is best detected on axial CT images at the level of the tympanic facial nerve. The union between the IVCC and the falciform crest appears radiologically as a short stem or mini-martini glass. CONCLUSION: The proposed IVCC is a novel landmark with a consistent relationship to the IAC fundus and the facial nerve. It may be utilized in conjunction with the falciform crest to identify the facial nerve during minimally invasive transcanal surgeries.

Preemptive local anesthetic infiltration reduces opioid requirements without attenuation of the intraoperative electrical stapedial reflex threshold in pediatric cochlear implant surgery.

BACKGROUND AND AIMS: Total intravenous anesthesia using remifentanil provides good surgical condition without affecting the intraoperative electrical stapedial reflex threshold (ESRT). However, remifentanil results in hyperalgesia and increases postoperative opioid requirements. Local anesthetic infiltration is alternative methods to opioid for providing analgesia. However, otologists avoids its use as it can abolish the ESRT. We investigated the effect of the preemptive local anesthetic infiltration on intraoperative ESRT and opioid requirements in pediatric cochlear implant surgery performed under TIVA. MATERIAL AND METHODS: Prospective, randomized, double-blinded, controlled study including 70 child undergoing cochlear implant under TIVA were randomly assigned to a local anesthesia (LA group, n = 35) or control (CT group, N = 35). The primary outcome was the total tramadol consumption during the first 24 h postoperative, and the secondary outcomes were time to first analgesia request, postoperative pain scores, the ESRT and, propofol and remifentanil requirements. The incidence of postoperative vomiting was recorder as well. RESULTS: The total tramadol consumption during the first 24 h after surgery was significantly less in the LA group than in CT group (8.25 [4.3] vs. 16.5 [6.57] mg, P < 0.01). The time to first analgesic request was significantly prolonged in the LA group as compared with the CT group [8 [2-12] vs. 3 [0-8] h, P < 0.01). The postoperative Faces, Legs, Activity, Cry Consolability pain scores were significantly lower in the LA group at 15 min, 30 min, 2, 4 and 6 h postoperative. Mean remifentanil infusion rate [mean (standard deviation)] was significantly higher in in the CT group than in the LA group [0.7 (0.3) vs. 0.5 (0.2) µg/kg/min; P = 0.001).The ESRT response, propofol requirements, and the incidence of postoperative vomiting had no significant differences between both groups. CONCLUSION: Preemptive local anesthetic infiltration reduced opioid requirements without attenuation of the ESRT in pediatric cochlear implant surgery performed under TIVA.

Radiological evaluation of inner ear trauma after cochlear implant surgery by cone beam CT(CBCT).

PURPOSE: Cochlear implantation (CI) has been extended to involve younger age group with higher incidence of residual hearing which increases the need of minimizing surgical inner ear trauma. Radiological evaluation for electrode position has been studied yet without assessment of inner ear trauma, our objective is radiological evaluation of post cochlear implantation inner ear trauma MATERIAL AND METHODS: 20 patients with CI for pre lingual SNHL were included in this study. Cone beam CT (CBCT) was used for evaluation of electrode position and assessment of inner ear trauma. A Neuroradiologist and an implant surgeon analyzed the relation of inserted electrode to the intra-cochlear structures, with introduction of novel radiological grading for inner ear trauma. RESULTS: The mean major cochlear diameter was 8.9 mm, the mean angular depth of insertion was 406.9944 (SD = 165.0559). Ten patients were with no cochlear trauma (grade 0), three patients were grade 1, two patients were grade 2 and five patients were grade 3 inner ear trauma. CONCLUSION: Radiological evaluation for electrode position should extend to involve assessment of inner ear trauma using relation of the implant to cochlear internal structures which could be performed by CBCT with high resolution and least metallic artifacts.

Magnesium sulphate optimises surgical field without attenuation of the stapaedius reflex in paediatric cochlear implant surgery.

BACKGROUND AND AIMS: The anaesthesia technique for paediatric cochlear implantation should be modified to achieve an optimised surgical field and allow neuromonitoring. Total intravenous anaesthesia (TIVA) provides good surgical condition without affecting intraoperative electrical stapaedial reflex threshold (ESRT). Though magnesium sulphate (MgSO4) is a cheap, readily available drug for controlled hypotension, it can decrease the amplitude of motor-evoked potentials. This study aimed to evaluate the effect of MgSO4 infusion on quality of surgical field, intraoperative ESRT, and anaesthetic requirements in paediatric cochlear implant surgery performed under TIVA. METHODS: In this randomised controlled trial, 66 children (1-6 years) undergoing cochlear implant under TIVA were randomly assigned to control group or MgSO4 group. The primary outcome was quality of surgical field, and the secondary outcomes were mean arterial blood pressure (MAP), heart rate (HR), ESRT, and the intraoperative anaesthetic requirements. The incidence of adverse events was recorded as well. RESULTS: The quality of surgical field was better in group M than group C, P < 0.02. The number of children who achieved optimum surgical conditions (scores ≤2) was significantly better in the group M (n = 23/33, 70%) compared with group C (n = 13/33, 39%), P < 0.001. MAP, HR, and anaesthetic requirements were significantly lower in group M, P < 0.05. There were no differences between both groups regarding ESRT response. CONCLUSION: Magnesium sulphate IV infusion optimised surgical field and decreased anaesthetic requirements without attenuating the ESRT in paediatric cochlear implant surgery performed under TIVA.

Congenital Cholesteatoma: The Silent Pathology.

BACKGROUND: Congenital cholesteatomas (CC) arise from epithelial remnants around the petrous bone. They enlarge gradually causing progressive destruction and functional damage to the ear and surrounding structures. Because of their insidious course, most patients are misdiagnosed and present late with complications. METHODS: This is a retrospective study of 41 cases diagnosed as CC and followed up for 2 years. All patients underwent full audiological evaluation and a radiological study (CT, MRI). RESULTS: The male:female ratio was 2.3: 1, and the mean age was 30.89 years. The mean delay before presentation was 13 months. The commonest presentations in order of frequency were: discharge (60.9%), hearing loss (51.2%), facial paralysis (31.7%) and intracranial complications (31.7%). Forty patients were treated surgically by a variety of approaches depending on the extensions and functional status. The facial nerve was decompressed in 9 cases and cable grafted in 4. Two cases underwent VII-XII anastomosis later on. CONCLUSION: CC present with a myriad of clinical manifestations and should be suspected in all patients with unexplained otological signs and symptoms. They must be completely excised and the functional status of the ear rehabilitated either immediately or later. Follow-up must be indefinite as they have a high recurrence rate.

Utility of apparent diffusion coefficient in characterization of different sinonasal pathologies.

BACKGROUND: Sinonasal lesions are a heterogeneous group of lesions that span from a tumor to tumor-like nature. Characterization of such cases preoperatively can improve the surgical control and the overall outcome of these patients. OBJECTIVE: In this prospective study, we aimed at evaluation of the role of apparent diffusion coefficient (ADC) in the differentiation between benign and malignant sinonasal lesions. SUBJECTS AND METHODS: All patients scheduled to have sinonasal surgical intervention at Ain Shams University Hospitals, Cairo, Egypt, were enrolled. Diffusion-weighted (DW) magnetic resonance imaging (MRI) with calculation of ADC were done for all cases. Radiologic findings were then compared with histologic findings, and the sensitivity, specificity, negative and positive predictive values (PPVs) of the conventional MRI, DW-MRI, and ADC value in differentiation of benign from malignant sinonasal lesions were then calculated. RESULTS: There were 59 patients with median age of 43 years old. There were 20 cases of inflammatory lesions, 16 cases of benign tumors, and 23 cases of malignant lesions. The ADC values of all cases ranged from 0.4 × 10(-3) to 2 × 10(-3) (median = 1.5 × 10(-3)). The median ADC value for the malignant lesions was 0.6 × 10(-3), whereas that for the inflammatory conditions was 1.6 × 10(-3) and that for the benign tumors was 1.5 × 10(-3) with a highly significant difference (p < .001). Analysis of the conventional MRI and DW-MRI to differentiate between malignant and benign lesions showed that the sensitivity, specificity, PPV, and negative predictive value (NPV) were 100%, 97%, 96%, and 100% and 91%, 97%, 95%, and 95%, respectively. CONCLUSION: DW-MRI did not add significantly to the information gained from conventional MRI. It should be considered complimentary only to standard MRI in uncertain cases when malignancy is still a concern.

Pediatric parapharyngeal lesions: criteria for malignancy.

INTRODUCTION: Parapharyngeal space (PPS) pediatric lesions represent a heterogeneous group of uncommon neoplasms of both benign and malignant nature. These tumors tend to be locally advanced by the time they are diagnosed; consequently, an early presumptive diagnosis of malignancy is of utmost importance. OBJECTIVE: To highlight the occurrence of malignant PPS tumors in pediatric population, to determine their incidence and to describe probable warning clues for diagnosis. PATIENTS AND METHODS: The charts of 23 pediatric patients with PPS swellings were retrospectively reviewed to analyze clinical and pathologic data. We describe possible criteria to suspect malignancy by clinical and radiological examination. RESULTS: Twenty-three patients presented with neoplastic lesions in the PPS, benign tumors in 43.5% and malignant in 56.5%. Malignancy was suspected in 13 cases according to combined clinical and radiological criteria: a painless intraoral and neck swelling in children below one year old, presentation with cranial nerve palsy, nasopharyngeal mucosal or sub-mucosal irregular lesion, the presence of multiple lymph nodes with no evidence of infection, and adjacent bony skull base destruction with intracranial extension. CONCLUSION: Occurrence of malignancy in PPS tumors in the pediatric population is not uncommon. Clinicians should deliberately look for associated secondary signs that predict malignancy. The surgeon must understand the pathological spectrum of tumors of this space and the proper use of imaging studies to make a preoperative diagnosis. This allows for planning of a sound surgical approach and a proper preoperative counseling.

Craniocaudal extension as an indication of surgical outcome in transsphenoidal surgery for pituitary adenomas.

Transsphenoidal approach is considered the treatment of choice for pituitary adenoma removal. Suprasellar extension is regarded a drawback for complete removal of these tumors through this approach. Evaluate the correlation between the preoperative radiologic craniocaudal extension on MRI of pituitary adenomas and the extent of tumor removal. A retrospective study. Tertiary care hospital. 560 patients underwent transsphenoidal removal of pituitary adenomas. The degree of removal of pituitary tumor in the follow-up imaging of the patients was correlated with the preoperative extension in mid-Coronal T1 W Gd. Tumors with suprasellar extension can be classified into: Type I tumors with extension confined to the sellar boundaries, resulted in complete removal in all cases (100%), type II tumors with suprasellar extension reaching the floor of the 3rd ventricle, resulted in complete removal in 70.2% of the cases, type III tumors with suprasellar extension above the 3rd ventricle, had only 13.5% of complete removal. Integration of radiologic findings into a scheme for the preoperative determination of possibility of total removal of the tumor through transsphenoidal approach, can give better correlation to the surgical outcome of pituitary tumors.

Laryngeal cancer in Egypt: quality of life measurement with different treatment modalities.

BACKGROUND: Quality of life (QOL) reflects the need to assess the patient's overall sense of well-being. A nonrandomized, prospective longitudinal study was conducted to evaluate QOL in Egyptian patients treated for laryngeal cancer. METHODS: In all, 60 newly diagnosed patients with laryngeal cancer were divided into 3 groups: surgical resection, radiotherapy, and combined therapy. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaires (EORTC-QLQ) were administered to the patients at 4 points: prior to treatment, during active treatment, and at 3 and 6 months after completion of treatment. RESULTS: All pretreatment scales were worse in the combined therapy group. The functional scales reached their lowest levels in all groups during active treatment. Radiotherapy group scales showed persistent slow recovery. There was striking prevalence of the financial difficulties score in all groups. CONCLUSION: QOL measurement provides information to guide clinical decision making in patients treated for laryngeal carcinoma.

Staphylococcal infection and toxin production in chronic rhinosinusitis.

BACKGROUND: The association between bacterial colonization and different forms of chronic rhinosinusitis (CRS) has not been well documented. One of the most recent hypotheses is superantigen (SA)-induced inflammation, resulting in up-regulation of lymphocytes to produce cytokines, and other inflammatory mediators that strongly modify the disease. Staphylococcus aureus, frequently encountered in nasal passages, can produce enterotoxins that can act as SAs. METHODS: A prospective case control study was performed. Sixty-four patients diagnosed with CRS (group 1), CRS with nasal polyps (CRSwNP) (group 2), and 15 control subjects were enrolled. Swabs were taken from the middle meatus of all subjects for identification of S. aureus carriers. Positive carriers were analyzed for the presence of toxic shock syndrome toxin (TSST) 1 using reverse passive latex agglutination as well as polymerase chain reaction. RESULTS: The rate of nasal carriage of S. aureus in CRS was 42.8%, that of CRSwNP was 45.4%, and that of the control group was 13.3%. The difference between both groups of CRS and the control group was found to be highly significant (p < 0.001). The detection of TSST-1 was significantly higher (p < 0.001) in both groups of CRS patients than in the control group. Finally, the difference in colonization of TSST-1 was highly significant (p < 0.001) between the CRS group 1 and CRSwNP group 2 patients. CONCLUSION: Identifying SAs and understanding how they elicit the pathogenic condition in CRS will be central in revealing ways to ameliorate their effects and properly treat these conditions.

Complications of suppurative otitis media: still a problem in the 21st century.

The purpose of this study was to review the incidence of complicated suppurative otitis media in 10 years at a tertiary referral university hospital. During this period, 3,364 patients with suppurative otitis media (acute and chronic) were admitted to the department. The number of patients presenting with complications was 422 (12.54%). The ratio of extracranial to intracranial complications was nearly 1:1. The most frequent extracranial complication was mastoiditis while the most frequent intracranial one was lateral sinus thrombophlebitis. Multiple complications may present in the same patient. The onset of complications was insidious and 96% of the patients were already aware of their disease. There were 6 mortalities (1.42%), and additional morbidity was recorded in 16 patients (3.79%). Changes in the clinical picture should always alert the physician to the onset of a complication. Complications tended to occur in young patients from a lower socioeconomic class and without sex preponderance. Physicians should be aware of the continuing incidence of complications and the subtleness of their onset and investigate patients for the presence of more than one complication.

Anatomic Variations of the Sphenoid Sinus and Their Impact on Trans-sphenoid Pituitary Surgery.

INTRODUCTION: The trans-sphenoid access to the pituitary gland is becoming the most common approach for pituitary adenomas. Preoperative evaluation of the anatomy of the sphenoid sinus by computed tomography (CT) scan and magnetic resonance imaging (MRI) is a routine procedure and can direct the surgical decision. PURPOSE: This work determines the incidence of the different anatomical variations of the sphenoid sinus as detected by MRI and CT scan and their impact on the approach. METHODS: The CT scan and MRI of 296 patients operated for pituitary adenomas via a trans-sphenoid approach were retrospectively reviewed regarding the different anatomical variations of the sphenoid sinus: degree of pneumatization, sellar configuration, septation pattern, and the intercarotid distance. RESULTS: There were 6 cases with conchal pneumatization, 62 patients with presellar, 162 patients with sellar, and 66 patients with postsellar pneumatization. There was sellar bulge in 232 patients, whereas this bulge was absent in 64 patients. There was no intersphenoid sinus septum in 32 patients, a single intersphenoid septum in 212 patients, and an accessory septum in 32 patients. Intraoperatively, the sellar bulge was marked in 189 cases and was mild in 43 cases. DISCUSSION: The pattern of pneumatization of the sphenoid sinus significantly affects the safe access to the sella. A highly pneumatized sphenoid sinus may distort the anatomic configuration, so in these cases it is extremely important to be aware of the midline when opening the sella to avoid accidental injury to the carotid and optic nerves. The sellar bulge is considered one of the most important surgical landmarks, facilitating the access to the sella. The surgical position of the patient is also a crucial point to avoid superior or posterior misdirection with resultant complications. It is wise to use extreme caution while removing the terminal septum. CONCLUSION: Different anatomical configurations of the sphenoid sinus can seriously affect the access to the sella via the nose. The surgeon should be aware of these findings preoperatively to reach the sella safely and effectively.

Non-intubation traumatic laryngotracheal stenosis: management policies and results.

Traumatic laryngotracheal stenosis (LTS) is increasing in clinical practice. Causes include external trauma, post-intubation, and iatrogenic injuries. It is a complex problem and many patients undergo multiple procedures to achieve a stable and well-protected airway with adequate voice. We present our experience at Ain-Shams University Hospitals on 15 patients followed-up for 7 years. All patients had traumatic LTS excluding post-intubation injuries. Patients were aged 4-58 years. Nine were the victims of road traffic accidents; five were occupational trauma victims; and one tried to commit suicide by strangulation. The patients underwent a total of 53 procedures (mean 3.5 per patient). A total of seven laryngotracheal reconstruction, six partial cricotracheal resection, and four laser recanalization with stenting were performed. Six patients have mean follow-up of 26.5 months (3-60 months). Six patients had normal speech (GRBAS 0-5), three had a moderate degree of voice disturbance (GRBAS 5-10), and five had severe dysphonia (GRBAS > 10). As regards tolerance for daily activities, we used a modification of the McMaster University asthma quality of life questionnaire [Rea et al. Eur J Cardiothorac Surg 22(3):352, 2002] (using the activities and emotional scores total 112). Four patients could perform above the 90th percentile; all the remaining patients were above the 50th percentile. No patient was totally handicapped as a result of their airway problem and they could tend for their basic activities. The aim of this work is to demonstrate that non-intubation traumatic LTS is a complex problem that usually needs a longer time for reconstruction and a different way of approach. However, most of the patients can be finally rehabilitated with a stable, protected airway and adequate voice albeit at the price of a prolonged series of interventions and a long follow-up.

Prognostic value of telomerase and DNA ploidy in laryngeal carcinoma.

Prognosis of carcinoma of the larynx is currently based on the morphologic analysis of the tumor extent, differentiation grading and type of microscopic invasion. The DNA ploidy status and the cell proliferation activity may give complementary information about the prognosis. Telomerase may be used as a measure of tumor proliferation. The aim of this work was to investigate the probable application of telomerase as a measure of cell immortalization as well as DNA ploidy as a measure of cell proliferation in the prognosis of patients with laryngeal carcinoma. The work was carried out as a prospective observational study that included 35 patients with laryngeal carcinoma who were treated surgically at Ain Shams University Hospitals, Cairo, Egypt. Flowcytometric analysis and biochemical assay of telomerase using human Telomerase Reverse Transcriptase (hTERT) mRNA assay by RT-PCR in resected specimens were done. The proliferative indices in different parts of the tumor were found to be significantly different from each other, with those of tumor edges being the highest. The ploidy status at the edge of the tumor was significantly different between surviving and non-surviving patients, while the tumor core proliferative index was found to be significantly lower in patients without recurrence than those with recurrence. A gradient of telomerase levels was noticed, with levels from tumor cores being the highest followed by tumor edges, resection margins and the lowest levels in lymph nodes. Multivariate analysis showed hTERT levels in tumor edges to significantly affect survival. Both Flowcytometric parameters and telomerase activity may be useful as a prognostic factor for survival in patients with laryngeal carcinoma. Telomerase activity may be used for biologic demarcation for conservational laryngeal surgery, as well as a 'spectral' marker.