Free middle turbinate mucosal graft reconstruction after primary endoscopic endonasal pituitary surgery.

The objective is to assess whether free middle turbinate (FMT) graft reconstruction, after endoscopic endonasal pituitary surgery, combines an acceptably low post-operative cerebrospinal fluid (CSF) leak rate with acceptable rhinological morbidity. This study identified 50 patients who underwent endoscopic endonasal pituitary surgery by the senior author in our teaching hospital between May 2011 and June 2012. FMT graft reconstruction was used in 32 cases. 18 patients were judged pre-operatively as not suitable for FMT reconstruction according to a novel skull base reconstructive algorithm. Outcomes examined were: length of inpatient stay; post-operative CSF leak rate; volume of gross tumour resection; and rhinological morbidity. The rhinological morbidity was measured by the completion of the 22 item sinonasal outcome test (SNOT-22) questionnaire by all 32 patients at 6 weeks and 6 months post-surgery. 32 patients were included in the study. 9 patients had functioning microadenomas and 23 macroadenomas. The median inpatient stay was 2 days. There were no post-operative CSF leaks. The rate of gross tumour resection, confirmed on post-operative MRI, was 87.5 %. The mean SNOT-22 score was 31.9 at 6 weeks and 23.4 at 6 months post-operation-a statistically significant drop. The use of the FMT graft in the reconstruction of the sella defect after endonasal endoscopic pituitary surgery provides a robust dural repair with an acceptable rhinological morbidity profile. FMT grafting as part of a defined skull base reconstructive algorithm results in a CSF leak rate of zero and allows early patient discharge without the need for nasal packing or lumbar drains.

Can early second-look tympanoplasty reduce the rate of conversion to modified radical mastoidectomy?

CONCLUSIONS: Combined approach tympanoplasty (CAT) allows for successful treatment of cholesteatoma with rates of recurrent and residual disease comparable to open mastoid surgery. Early timing of second-look procedures allows easier removal of any recurrent or residual disease, which reduces the conversion rate to open mastoidectomy. OBJECTIVES: The aims of the study were to report the rates of recurrent and residual cholesteatoma following primary CAT surgery and to report the rate of conversion to a modified radical mastoidectomy. METHODS: This was a retrospective review of a single surgeon series between 2006 and 2012. RESULTS: In total 132 second-look operations were undertaken, with a mean interval between primary surgery and second-look procedures of 6 months. The rate of cholesteatoma at second-look surgery was 19.7%, which was split into residual disease (10.6%) and recurrent disease (9.09%). New tympanic membrane defects with cholesteatoma were considered as recurrent disease. Residual disease was defined as cholesteatoma present behind an intact tympanic membrane. The majority of recurrent and residual disease was easily removed at second look (73.1%). Only four cases were converted to a modified radical mastoidectomy (3%) and three cases required a third-look procedure.

An assessment of the validity of tympanometry compared to myringotomy performed under a nitrous oxide-free general anaesthetic.

To assess the validity of tympanometry as a test for the presence of middle ear effusion using a 'gold-standard' of myringotomy performed after a nitrous oxide-free general anaesthetic, we performed a prospective validity study comparing tympanometry traces obtained immediately pre-operatively from patients undergoing grommet insertion, with the otomicroscopic findings at myringotomy. Nitrous oxide was omitted from the anaesthetic gaseous mixture as it has been reported to displace middle ear effusions. One hundred and seventy-two patients (aged 1.5-15 years) with a clinically assessed 3 month history of middle ear effusion were included in the study. Sensitivity and specificity of a Jerger classification Type B tympanometric trace for the presence of middle ear effusion were 0.73 and 0.84, respectively. We conclude that tympanometry is a valid test in assessing the presence of middle ear effusion compared to a 'gold standard' of myringotomy performed after a nitrous oxide-free general anaesthetic.

Middle meningeal artery hemorrhage: an incorrect name.

Extradural hemorrhage is most commonly assumed to result from a middle meningeal artery rupture. This article challenges that assumption. The meningeal vasculature of 29 cadaveric specimens was examined macroscopically and microscopically at the level of the greater wing of the sphenoid bone and foramen spinosum. It was observed that the middle meningeal artery is accompanied by a pair of dural sinuses throughout the majority of its course, thus making exclusively arterial rupture an anatomical improbability. Furthermore, as these dural sinuses pass caudally through the foramen spinosum with the middle meningeal artery, they were seen to diverge to form a plexiform arrangement around the artery. This has not been reported before.