Head and neck lipoblastoma in children: A case report and systematic review.

BACKGROUND: Lipoblastoma is a rare and benign tumor arising from embryonal fat cells. It develops primarily in infancy and early childhood. We present a case study of a 10-month-old child treated for an extensive tumor of the infratemporal fossa and parapharyngeal space. The systematic review of 60 reports in 80 children with lipoblastoma of the head and neck is also reported. MATERIAL AND METHODS: Systematic review of all articles included lipoblastomas of the head and neck area in children published from 1964 to 2022 in the PubMed database was conducted. Clinical presentation of extensive lipoblastoma of the head and neck in a child. RESULTS: On the basis of all inclusion criteria 83 articles were identified concerning pediatric lipoblastoma. There were 36 F (45%) and 39 M (48%), in 6 patients, (7%) gender was not specified. Ages ranged from 0mth (6h) to 15 yo (180mth). The tumor was located in the head in 22 (27%) cases, while the neck area accounted for 53 (65%) cases. General description without precise location was shown in 6 (7%) cases. All patients underwent complete surgical excision. Post surgical recurrence was noted in 6% clinical cases in the analyzed articles. CONCLUSIONS: Lipoblastoma is characterized by a rapidly growing predominantly adipose mass. The treatment of choice is complete surgical excision. In selected cases when the pathology is hard to reach, as a consequence of the extensive penetration of the mass, we recommend performing the procedure with an interdisciplinary team. Endoscopy assistance and microdebrider significantly facilitated the removal of pathology in the described advanced case of lipoblastoma. This is the only case reported in the pediatric literature of a head and neck lipoblastoma, where due to extensive involvement and location of the disease the cranial nerves V2 and inferior alveolar branch of V3 could not be spared. Long-term follow-up even to 10 years is required because there is a reported tendency for these tumors to recur.

Application of "banana cochleostomy" and looped electrode insertion for cochlear implantation in children with common cavity malformation and cystic forms of cochlear hypoplasia.

OBJECTIVES: Patients with profound hearing loss due to inner ear malformations may benefit from cochlear implantation; however, the surgery may present a substantial problem for the cochlear implant surgeon due to anatomical variations. The authors describe a new surgical and technical advancement for implantation in patients with small inner ear cavities that make the surgery easier and safer. On the basis of experience involving five consecutive surgeries performed in four patients with inner ear malformations, we present the advantages and application possibilities of the technique. METHODS: The technique does not change the surgical approach in general; however, modification of the cochleostomy shape and looping of the cochlear implant electrode enables safe advancement of the electrode with optimal positioning in the cavity. Additionally, these modifications protect against the insertion of the electrode into the internal auditory canal minimizing the risk of gushing and extracochlear stimulation. RESULTS: The present technique has been used in five cases of cystic implantable inner ear spaces in three independent institutions by different surgeons. It has proven to be a reliable, relatively easy and safe procedure performed with very good anatomic and initially functional effects (positive intraoperative neural response telemetry measurements). CONCLUSIONS: We hope that utilization of the "banana cochleostomy" and insertion of the looped cochlear implant electrode in the implantable cystic spaces of children with malformed inner ears will facilitate and simplify the surgical technique in this difficult procedure and additionally, in revision surgical cases. To our knowledge, the looped insertion and banana-shaped cochleostomy have not been reported previously.

The Petrosquamous Stalactite.

Objective To define the presence and relationship of the petrosquamous stalactite (PsS)-a condensation of the trabecular Korner's septum into a bony plate of the petrosquamous suture-to surrounding structures and understand its surgical implications. Study Design Series of cadaver dissections. Setting University of Missouri Alumni Temporal Bone and Microvascular Laboratory. Subjects and Methods Anatomic dissections were conducted on 15 consecutive formalin-preserved and frozen adult human temporal bones. A calibrated Dino-Lite Premier Digital Microscope was used to photograph dissections of each bone. Measurements were conducted with DinoCapture 2.0 software, with measurement agreement between 2 authors. Results The PsS was present in all specimens. A conserved vascular structure courses within the structure, and the superior malleolar ligament inserts on it. The mean ± SEM distances from the PsS to the tegmen tympani and incus buttress were 2 ± 0.24 mm and 4.23 ± 0.14 mm, respectively. The shortest distance from the PsS to the posterior body of the incus was 1.25 ± 0.13 mm, while the greatest distance from the posterior prominence of the PsS to the posterior body of the incus was 4.58 ± 0.25 mm. Conclusion The PsS is a consistently identifiable structure that may facilitate identification of the tegmen tympani and guide the otologic surgeon from the mastoid antrum to the incus. It is important to recognize the contribution of the PsS to the division of the epitympanic space when cholesteatoma involves the region, to avoid leaving a nidus for future disease.

Enhancement of the subtemporal approach by partial posterosuperior petrosectomy with hearing preservation.

BACKGROUND: The microsurgical management of aneurysms in the interpeduncular and ambient cisterns remains challenging. The classic subtemporal approach has several limitations. OBJECTIVE: To present a modification of this approach that allows for broader exposure with hearing preservation. METHODS: We retrospectively reviewed our clinical database between August 2007 and February 2012 for all patients who underwent a modified subtemporal partial posterosuperior petrosectomy. Clinical data, complications, and postoperative head computed tomography (CT) scans were analyzed. Improvement in the angle of view acquired by the new approach was measured using the OsiriX 3-D rendering software and was compared with that obtained from the subtemporal approach. Similar methods were used to study improvement in the angle of view in head CT scans of randomly selected control patients. RESULTS: Five patients underwent a modified subtemporal approach for posterior circulation aneurysm clipping. All patients were women with a mean age of 49.8 years. Mean aneurysm size was 5.75 mm. Mean improvement in the angle of view was 17.52° in the study group (n = 5) and 11.7° in the control group (n = 10). Hearing was completely preserved in 3 patients. One patient had a subclinical conductive hearing loss, and 1 patient was not assessed formally at follow-up, but had no hearing concerns. No neurological sequelae were recorded. CONCLUSION: Our modified subtemporal approach appears to be safe and provides an increased angle of view with minimal additional operative time and with low risk to hearing. This approach may expand this surgical corridor and reduce the need for temporal lobe retraction.

The zone-based approach for selection of tympanoplasty technique.

At the outset of surgery, the extent of a tympanic membrane defect is judged including any additional loss of area that may result from disease extirpation or removal of the mucocutaneous junction. There are, three tiers of complexity when deciding upon which technique should be used for repair. Limited central perforations are defects amenable to a standard underlay technique. The Zone Based Approach is applied for marginal perforations whereby the specific technique is selected based on the zone of the defect. The zones and specific techniques are detailed. There are however, still a significant number of patients who have scarce residual tympanic membrane, or keratin matrix adherently involving the undersurface requiring sacrifice. These situations prove poor for either standard underlay or the zone based techniques. The total tympanic membrane reconstruction (TT MR) technique was developed specifically to avoid these complications as well as facilitate extirpation of the more extensive inflammatory and neoplastic pathologies commonly encountered, yet still amenable to intact canal wall mastoidectomy approaches.

Imaging and anatomy for cochlear implants.

At a minimum, successful cochlear implantation requires that electrical impulses be delivered to a surviving spiral ganglion cell population, and that these impulses be transmitted to a functioning auditory cortex by an existent neural connection. Accordingly, imaging the auditory pathway of the implant candidate is necessary to screen for morphologic conditions that will preclude or complicate the implantation process. In addition to radiography, increasing resolution of computed tomography and magnetic resonance imaging technology has provided the clinician with more detailed information about the integrity of the auditory pathway.

Combined surgical and endovascular access of the superficial middle cerebral vein to occlude a high-grade cavernous dural arteriovenous fistula: case report.

BACKGROUND AND IMPORTANCE: High-grade cavernous sinus (CS) dural arteriovenous fistulae with cortical venous drainage often have a malignant presentation requiring urgent treatment. In the absence of a venous access to the lesion, transarterial embolization can potentially cure these lesions; however, the high concentration of eloquent arterial territories adjacent to the fistula creates a precarious risk of arterial-arterial reflux. In such cases, a combined surgical and endovascular approach may provide the least invasive option. CLINICAL PRESENTATION: We describe a patient presenting with a venous hemorrhagic infarct caused by a high-grade CS dural arteriovenous fistula (Barrow type D caroticocavernous fistula) with isolated drainage via the superficial middle cerebral vein into engorged perisylvian cortical veins. No transfemoral or ophthalmic strategy was angiographically apparent, and the posterior location of the involved CS compartment mitigated a direct puncture. The patient underwent direct puncture of the superficial middle cerebral vein via an orbitozygomatic craniotomy and the CS was catheterized under fluoroscopic guidance. The CS was coil-embolized back into the distal superficial middle cerebral vein with complete obliteration of the fistula. The patient did well with no new deficits and made an uneventful recovery. CONCLUSION: This novel combined open surgical and endovascular approach enables obliteration of a CS dural arteriovenous fistula with isolated cortical venous drainage and avoids the additional manipulation with direct dissection and puncture of the CS itself.

Modification of the orthodromic temporalis tendon transfer technique for reanimation of the paralyzed face.

OBJECTIVE: To report a modification of the temporalis tendon transfer technique used in facial paralysis where dynamic adjacent muscle transfer is determined to be the best treatment option. STUDY DESIGN: Case series with chart review. SETTING: Tertiary care teaching hospital. SUBJECTS AND METHODS: Review of 10 consecutive patients who underwent orthodromic transfer of the temporalis tendon and the attached coronoid process for the treatment of longstanding facial paralysis. Outcomes measured included patient satisfaction, measurements of oral commissure elevation with smiling, and grading of preoperative and postoperative patient photographs by objective physician observers. Reporting of complications. RESULTS: Patient satisfaction was high, with a mean score of 7.0 (possible score of 10). Four patients were graded by the observer as excellent to superb. The other 6 patients were rated as having fair to good postoperative results. Movement was identified in every patient and ranged from 2.1 to 9.3 mm, with mean movement of the oral commissure of 5.12 mm. One patient developed a seroma at the site of harvest of the fascia that was drained without further complication. CONCLUSIONS: This facial reanimation procedure is a novel modification of the temporalis tendon transfer technique in which the coronoid process is transferred in conjunction with the tendon. This technique is minimally invasive and may result in less variability of the postoperative aesthetic result. The procedure allows orthodromic action of the temporalis muscle, is relatively easy to perform, and eliminates the facial asymmetry typically produced by transfer of the origin of the temporalis muscle.

Comparison of Intraoperative Portable CT Scanners in Skull Base and Endoscopic Sinus Surgery: Single Center Case Series.

Precise and safe management of complex skull base lesions can be enhanced by intraoperative computed tomography (CT) scanning. Surgery in these areas requires real-time feedback of anatomic landmarks. Several portable CT scanners are currently available. We present a comparison of our clinical experience with three portable scanners in skull base and craniofacial surgery. We present clinical case series and the participants were from the Northwestern Memorial Hospital. Three scanners are studied: one conventional multidetector CT (MDCT), two digital flat panel cone-beam CT (CBCT) devices. Technical considerations, ease of use, image characteristics, and integration with image guidance are presented for each device. All three scanners provide good quality images. Intraoperative scanning can be used to update the image guidance system in real time. The conventional MDCT is unique in its ability to resolve soft tissue. The flat panel CBCT scanners generally emit lower levels of radiation and have less metal artifact effect. In this series, intraoperative CT scanning was technically feasible and deemed useful in surgical decision-making in 75% of patients. Intraoperative portable CT scanning has significant utility in complex skull base surgery. This technology informs the surgeon of the precise extent of dissection and updates intraoperative stereotactic navigation.

Optical cochlear implants: evaluation of surgical approach and laser parameters in cats.

Previous research has shown that neural stimulation with infrared radiation (IR) is spatially selective and illustrated the potential of IR in stimulating auditory neurons. The present work demonstrates the application of a miniaturized pulsed IR stimulator for chronic implantation in cats, quantifies its efficacy, and short-term safety in stimulating auditory neurons. IR stimulation of the neurons was achieved using an optical fiber inserted through a cochleostomy drilled in the basal turn of the cat cochlea and was characterized by measuring compound action potentials (CAPs). Neurons were stimulated with IR at various pulse durations, radiant exposures, and pulse repetition rates. Pulse durations as short as 50 mus were successful in evoking CAPs in normal as well as deafened cochleae. Continual stimulation was provided at 200 pulses per second, at 200 mW per pulse, and 100 mus pulse duration. Stable CAP amplitudes were observed for up to 10 h of continual IR stimulation. Combined with histological data, the results suggest that pulsed IR stimulation does not lead to detectable acute tissue damage and validate the stimulation parameters that can be used in future chronic implants based on pulsed IR.

CO(2) laser fiber soft cochleostomy: development of a technique using human temporal bones and a guinea pig model.

OBJECTIVE: A novel approach for creating a soft cochleostomy has been described using a handheld CO(2) laser hollow waveguide from termed in the following the handheld CO(2) laser fiber. The effects on cochlear function have been studied in an animal model and were compared to the effects of the micro drill. STUDY DESIGN: Combined human temporal bone and experimental animal study. MATERIALS AND METHODS: Four human temporal bones were used to describe the technique to create a cochleostomy using the handheld CO(2) laser fiber. A cochleostomy was made by thinning the cochlear wall with a motorized drill and by creating an opening with the CO(2) laser fiber. Eighteen guinea pigs were used to investigate the effects of the CO(2) laser and the drill on cochlear function. An electrode was placed in the round window niche to measure compound action potentials (CAPs). Baseline cochlear function was determined by recording CAP thresholds evoked by acoustic tone pips and was re-assessed during and after a cochleostomy was made. The protocol was repeated using a diamond-burr drill technique. RESULTS: The handheld CO(2) laser fiber is an ideal tool to create cochleostomies under 1 mm in diameter. In the guinea pig animal model, CAP thresholds showed little change after creating the cochleostomy at 4 W laser power setting and revealed focal threshold elevations averaging 32 dB at higher laser power settings. CONCLUSIONS: The human temporal bone study introduces a novel surgical approach for soft cochleostomies that uses both the drill and the CO(2) laser fiber. Threshold elevations, which were observed after making the cochleostomy with the laser, compared favorably to the diamond burr technique.

Prevalence of depression and antidepressant use in an otolaryngology patient population.

OBJECTIVE: To determine the prevalence of depressive diagnoses and antidepressant use in various subsets of otolaryngology patients. STUDY DESIGN: Academic practice EMR database query. SUBJECTS AND METHODS: Over 12,000 consecutive otolaryngology patients were analyzed by primary diagnosis and in three groups: Group 1 (tinnitus, vertigo), Group 2 (rhinosinusitis), and Group 3 (sleep apnea). The number with depressive diagnoses and/or those taking antidepressants was determined. RESULTS: The prevalence of any depressive diagnosis was 11 percent, and 18 percent had been prescribed antidepressants. The prevalence of depression was 13 percent, 10 percent, and 14 percent for Groups 1, 2, and 3, respectively. Antidepressants had been prescribed in 21 percent, 15 percent, and 28 percent, respectively. The primary-encounter diagnosis with the highest incidence of depression (21%) and antidepressant use (46%) was sleep apnea with insomnia. CONCLUSION: Otolaryngology patients may exhibit greater prevalence of depression than is observed in the general population (7.3%). Highest prevalence was found in patients with inner ear disease and sleep apnea. Depression may be a cause of significant comorbidity in patients with chronic otolaryngic conditions.

Quantitative evaluation of transtemporal and facial translocation approaches to infratemporal fossa.

OBJECTIVE: To compare the extent of exposure and surgical maneuverability provided by facial translocation and transtemporal approaches for access to the infratemporal fossa and anterolateral skull base. MATERIALS AND METHODS: Surgical procedures were performed on five fresh frozen adult cadavers (ten sides) with no known pathology. Facial transfacial approaches with and without a mandibulotomy and transtemporal approaches were evaluated. OBJECTIVE measures were (1) the distance from the surgical plane to designated anatomic landmarks and (2) the surgical angle of exposure. RESULTS: Distances from the surgical plane to the anatomic reference points were comparable for most of the access procedures (3 to 6 cm). The extended midfacial translocation and bilateral facial translocation approaches did, however, provide a shorter operative distance (1 to 3 cm) for access to the infratemporal fossa and contralateral structures, respectively. The transtemporal approaches facilitate a better angle of exposure (74 to 84 degrees) to the petrotemporal region, while the transfacial approaches were superior for access to the infratemporal structures. CONCLUSIONS: Based on the results, we propose a clinical algorithm for selecting a surgical approach based on the position and extent of an infratemporal or petrotemporal lesion.

[Perilymphatic fistula: diagnosis and treatment]. / Przetoka perylimfatyczna jako problem diagnostyczny i leczniczy.

INTRODUCTION: Diagnosis and management of perilymphatic fistula (PLF) is a controversial topic in the international neurotologic literature. An illustrative case of post traumatic PLF with clear surgical indications is presented. This manuscript also reviews the various clinical presentations, pathogenesis, diagnostic examinations, and management options of PLF. MATERIALS AND METHODS: Case report and literature review. RESULTS: A 40 y/o female presented with paroxysmal vertigo, imbalance and severe sensorineural hearing loss (SNHL) following minor occipital head trauma from a fall six months prior to presentation. Laboratory examination included intermittently positive fistula sign on video-nystagmography. Patient failed to respond to trials of pharmacologic treatment and bedrest and ultimately underwent surgical exploration and repair. Patient had earlobe fat placed in the round and oval windows. Postoperatively, she had prompt resolution of vestibulopathy and ultimate full return of sensorineural function. CONCLUSIONS: Patients with appropriate antecedent history demonstrating fluctuating SNHL and vestibulopathy, failing to respond to conservative medical treatments, should be considered for exploratory tympanotomy. In the absence of any other violations of labyrinthine integrity, connective tissue grafting of the round and oval windows should be performed even if no obvious flow of fluid is observed. This management protocol is safe and effective in properly selected patients.

Total tympanic membrane reconstruction: AlloDerm versus temporalis fascia.

BACKGROUND AND OBJECTIVE: Patients who require surgery for chronic otitis media with perforation and cholesteatoma frequently provide no residual tympanic membrane that is usable in grafting procedures. A novel technique of total tympanic membrane reconstruction (TTMR) is described that maximizes perforation closure rate in these situations while minimizing mucosalization, incomplete healing, and anterior blunting. The specific aim of this report is to assess the safety and efficacy of TTMR and to compare the results obtained with AlloDerm compared with temporalis fascia as a grafting material. METHODS: The records of 50 patients operated within the years 1999 and the 2004 were reviewed. TTMR with intact canal wall was performed in all cases. Both clinical and audiometric data were analyzed. RESULTS: Overall perforation closure rate was 92%. There was no statistical significance in closure rate when grafting with AlloDerm versus temporalis fascia. A statistically significant shortened healing time was observed with AlloDerm grafting. CONCLUSIONS: TTMR is a highly effective and safe technique.

Prevention and management of cerebrospinal fluid leak following vestibular schwannoma surgery.

OBJECTIVES/HYPOTHESIS: Postoperative cerebrospinal fluid (CSF) leak is reported in 2% to 30% of cases following vestibular schwannoma surgery. The authors' current surgical techniques for translabyrinthine, retrosigmoid transmeatal, and middle cranial fossa approaches have evolved from analysis of their prior experience in an effort to minimize their complication rate. The authors evaluated the efficacy of their current surgical technique in decreasing the postoperative CSF leak rate. STUDY DESIGN: Retrospective review. METHODS: The vestibular schwannoma database from the New York University Medical Center (New York, NY) neurotological service was reviewed. Data were extracted for type of approach, tumor size, and CSF leak rate. Liberal leak criteria were used. Surgical techniques and management of CSF leak were reviewed. RESULTS: Data from 215 patients who had surgery from 1995 to 2000 manifested a 6.6% CSF leak rate for primary surgeries. This compared favorably with the authors' 17% overall CSF leak rate in 555 total primary surgeries performed between 1979 and 1995. Translabyrinthine closure was performed with dural sutures used as a sling across the posterior fossa dura and abdominal fat placed as a series of corks through the sutures. Abdominal fat was used to obliterate the mastoid cavity in conjunction with aditus and mastoid obliteration. Attention must be paid to soft tissue obliteration of potentially open air cell tracts. Retrosigmoid transmeatal closure was performed with a soft tissue graft in the internal auditory canal drill-out held in position by a "saloon-door" dural flap. Bone wax was used to block perimeatal cells in all cases. Watertight dural closure was achieved with a sutured temporalis fascia graft. Abdominal fat obliteration of the mastoidectomy cavity was performed with an additional firm pressure from the "Palva" periosteal flap. Middle cranial fossa closure was performed with attention to potential air cell tracts of the internal auditory canal drill-out, as well as abdominal fat graft, tissue glue, and bone wax. Fibrin glue was used in all approaches to temporarily secure fat in situ. Management of CSF leaks starts with nonoperative measures including bed rest, oversewing of incisional wounds, and placement of a lumbar subarachnoid spinal fluid diversion drain. If these conservative measures fail, repeat exploration is necessary and is directed at identifying and corking the cell or cells (usually perimeatal or perilabyrinthine) opening directly into the posterior fossa. CONCLUSION: Evolution in surgical techniques, with particular attention to exposed air cell tracts, abdominal fat graft, and Palva periosteal flap for closure, has had a significant effect in decreasing the author's CSF leak rate after vestibular schwannoma surgery. Conservative management was successful in approximately 50% of cases. Repeat exploration, when needed, was directed at blocking the air cell tract (usually perimeatal or perilabyrinthine) responsible for the CSF leak.

Cranial nerve preservation in surgery for large acoustic neuromas.

Facial nerve outcomes and surgical complication rates for other cranial nerves were evaluated retrospectively after the resection of large acoustic neuromas. The charts of all patients who underwent surgical removal of an acoustic neuroma between 1992 and 2001 at New York University Medical Center were reviewed. Fifty-four patients with tumors measuring 3 cm or larger were included in the study. Four patients had neurofibromatosis type 2, two of whom underwent bilateral removal of acoustic neuromas. Translabyrinthine microsurgical removal of tumor was performed in 47 of 56 cases (84%). In all cases, EMG monitoring, improved sharp microdissection, and ultrasonic aspiration were employed. Facial nerve function was assessed using the House-Brackmann facial nerve grading system immediately after surgery and at follow-up visits. A House-Brackmann grade III or better was achieved in 90% of patients, and a grade II or better was achieved in 84% of patients. Ultimate facial nerve outcome was excellent after the surgical resection of large acoustic neuromas. Preoperative cranial nerve palsies also improved after surgery. The translabyrinthine approach for tumor removal is our treatment of choice for acoustic neuromas 3 cm or larger.

Fluoroscopically assisted cochlear implantation.

HYPOTHESIS: Real-time intraoperative fluoroscopy is a useful adjunct to cochlear implantation in selected cases. The advantages include the avoidance of complications such as extracochlear array placement, intrameatal array insertion, and avoidance of significant bending or kinking. This is particularly useful when implanting a severely abnormal cochlea. BACKGROUND: The technique was initially developed for laboratory study of electrode prototypes in cadaver temporal bones to evaluate insertion dynamics and mechanisms of intracochlear trauma. The technique was subsequently adapted for use in live surgeries. METHODS: Live surgeries were performed using fluoroscopic guidance on nine patients. RESULTS: Five patients were implanted with the Nucleus 24 RCS during preclinical trials. Two patients with severe cochlear malformations were implanted with a Nucleus CI24M straight array. Two patients with severe cochlear ossification were implanted with the Nucleus CI24 double array. Appropriate insertions were achieved without electrode damage in all cases. CONCLUSIONS: Intraoperative fluoroscopy is a useful adjunct to cochlear implantation, which can be performed with minimum risk to the patient and operating room staff if the outlined precautions are taken. Intraoperative fluoroscopy is indicated in cases where the intracochlear behavior of the electrode array cannot be predicted, a condition encountered when implanting new electrode designs, cases with severely malformed inner ears, or cases of severe intraluminal obstruction requiring a double-array insertion.