A Rare Case of Post Inflammatory Lateral Stenosis of External Auditory Canal and It's Management with Review of Literature.

Acquired external auditory canal stenosis is a challenging condition to treat and can affect any age group. Post inflammatory lateral canal atresia is uncommon. This article focuses on a 2 year old child who presented with hearing loss with history of otitis externa. The lateral part of Auditory Canal was completely stenosed. He underwent debrider assisted endoscopic ear surgery and stenting, and a patent External Auditory Canal with normal hearing was achieved.

Cross-sectional area of the ulnar nerve after decompression at the cubital tunnel.

UNLABELLED: A total of 48 patients undergoing surgical decompression of the ulnar nerve at the cubital tunnel between February 2010 and May 2013 were retrospectively studied to determine changes in the cross-sectional area of the nerve by the technique of neurosonography. The mean follow-up was 46 months. Post-operative follow-up examination of the cross-sectional area of the ulnar nerve showed a slight reduction in the mean value from 13.8 mm(2) (pre-operative) to 12.9 mm(2) (post-operative). Of the 48 patients, 36 showed a reduction in the cross-sectional area. No correlation was detected between the clinical and sonographic outcomes. Ultrasound seems to be of limited value in the post-operative assessment of patients with entrapment neuropathy of the ulnar nerve. LEVEL OF EVIDENCE: IV.

[Microneurovascular facial reanimation via the masseteric nerve: reconstruction alternative for long-standing facial palsy]. / Mikroneurovaskuläre Gesichtsreanimation über den N. massetericus : Rekonstruktionsalternative bei lang bestehender Fazialisparese.

BACKGROUND: The aim of the study was to retrospectively analyze the functional outcomes of microneurovascular facial reanimation using the masseteric innervation. PATIENTS AND METHODS: Seventeen patients with irreparable facial paralyses resulting from benign lesions involving the facial nuclei (n=14) or Möbius syndrome (n=3) were treated with free muscle flaps for oral commissural reanimation using ipsilateral masseteric innervation and using temporalis muscle transfer for eyelid reanimation. The results were analyzed by a commissural excursion (CE) index and a patient self-evaluation score. The presence of synkinesis was documented. Follow-up ranged from 8 to 48 months (mean 26.4 months). RESULTS: Normalization of the CE index could be observed in 8 out of 17 patients (47%), an improvement in 7 out of 17 (41%) and failure in 2 out of 17 (12%). A natural smiling response was observed in 10 out of 17 (59%) patients. Patient self-evaluation scores were a level higher than objective indices. CONCLUSIONS: Innervation of free muscle flaps with the masseteric nerve for oral commissure reanimation might play an important role in patients with long-standing facial palsy (as in Möbius syndrome). Synkinesis persists for long periods after surgery. However, most of the patients had learned to express their emotions by overcoming this phenomenon. Despite hypercorrection or inadequate correction, patients evaluate themselves favorably.

Outcomes of surgical resection of large solitary hemangioblastomas of the craniocervical junction with limitations in preoperative angiographic intervention: report of three cases.

INTRODUCTION: Hemangioblastomas of the central nervous system may occur sporadically, or in association with von Hippel-Lindau (vHL) disease. The treatment of large solitary hemangioblastomas of the posterior cranial fossa mandates a combination of angiographic intervention and surgery. However, large tumors may derive their vascularity from major cerebellar vessels, which can make their embolization hazardous. AIM: To describe the surgical outcomes of three cases of large hemangioblastomas with compression of the medulla oblongata, where the potential for preoperative embolization was extremely limited. CASES: Three patients (all males; 68, 36 and 38 years) presented with a history of chronic headache and caudal cranial nerve deficiencies. Diagnostic imaging showed large vascular lesions (4 x 3, 4 x 5 and 5 x 5 cm) at the craniocervical junction, compressing the brainstem. There were no concomitant findings associated with vHL disease. TREATMENT: Staged treatment was administered. Preoperative embolization was attempted at first. One patient (68 yrs) showed a PICA occlusion and associated cerebellar infarction after embolization; embolization was deemed hazardous in the other two. In the second phase, the lesions were removed via a midline suboccipital approach with resection of the arch of altas. Complete removal was possible in all three cases. POSTOPERATIVE COURSE AND FOLLOW-UP: The caudal cranial nerve deficiencies deteriorated soon after surgery in all three patients. A tracheotomy was required in two patients, which was removed uneventfully during the rehabilitation phase. Ventriculo-peritoneal shunts were implanted in two patients. MRI follow-up three (1 case) and four years (2 cases) after surgery showed no relapse. The Karnofsky Index scores were 80, 70 and 90 in the three patients aged 68, 36 and 38, respectively. CONCLUSION: Total microneurosurgical removal of large hemangioblastomas at the craniocervical junction with limited preoperative embolization (associated with morbidity) should be seriously considered. Although the early outcome is not encouraging, the long-term outcomes seem favorable.

Primary aspergillosis of the sphenoid sinus with pituitary invasion - a rare differential diagnosis of sellar lesions.

Aspergillosis belongs to the group of mycotic diseases of paranasal sinuses. The invasive forms, and particularly the fulminant forms, are potentially fatal. Isolated aspergillosis of the sphenoid sinus or the clivus is a difficult diagnosis, since the often misleading clinical manifestations of this rare disease develop late. These patients become apparent by neurological signs such as cavernous sinus syndrome, pseudotumor of the pituitary or the orbit. Diagnosis is often made intra-operatively or on histological examination. We report a case of invasive aspergillosis uniquely involving the sellar area revealed by clinical features suggesting a pseudotumor of the pituitary. Although such lesions are almost always seen in immune suppressed subjects, in our case, the patient was immune competent and had no past history of sinusitis.The question of whether, and when to perform limited or extensive surgery remains an issue for discussion, owing to the rarity of this disease honed by lack of experience. It depends on several factors: the kind of disease, the immunity, the subtype of invasive fungal sinusitis and the degree of tissue invasion.

The transaxillary approach in the treatment of thoracic outlet syndrome: a neurosurgical appraisal.

OBJECT: Different surgical approaches are available for the treatment of thoracic outlet syndrome (TOS). Our aim is to describe the transaxillary approach from a neurosurgical perspective, and to present the results in 15 patients. METHODS AND RESULTS: Fifteen patients (6 m and 9 f; mean age 44 yrs) were treated for neurogenic TOS. Four patients (26.7 %) demonstrated a cervical rib. The rest did not show a diagnosable bony anomaly (73.3 %). Provocative tests were neurologically positive in all patients (100 %); 4 patients additionally demonstrated vascular symptoms (26.7 %). Six patients demonstrated ulnar nerve F-wave latency (40 %). The transaxillary approach was used in all patients. In three patients with cervical ribs (20 %), an additional ventral approach was utilized. 14 patients remain symptom-free at a mean follow-up period of 24 months (93.4 %). One complained of pain recurrence at nine months after surgery and was treated conservatively (2(1/2) yrs). One patient developed pneumothorax after surgery (6.7 %). Four patients reported on numbness of the lateral thoracic wall, due to stretch injury of the intercostobrachial nerve that lies along the approach corridor (26.7 %). CONCLUSION: The transaxillary approach is one of several described surgical options for the treatment of TOS. It lies along a natural corridor and is non-muscle splitting. Although it requires a deep surgical corridor, the transaxillary approach allows definitive treatment of both bony and soft-tissue components causing TOS, provided the anatomical boundaries are recognized and respected. A persistent cervical rib, however, calls for an additional ventral approach. The complications are minimal and the results are predominantly acceptable.

The diaphragma sellae meningioma -- a rare differential diagnosis of non-functioning pituitary adenoma.

It is important to differentiate the rare Diaphragma sellae meningioma from the quite common hormonally inactive pituitary adenoma, especially with regards to the surgical approach. The differentiation could, however, be problematic. We report the case of a 66-year-old woman with a Diaphragma sellae meningioma, which became apparent through a visual field and visual acuity disorder. Successful radical tumor extirpation was achieved via the transsphenoidal approach, since the space-occupying lesion was initially thought to be a hormonally inactive pituitary macroadenoma. However, histological investigation confirmed a meningioma. A careful retrospective analysis of the MRI revealed the possibility of a meningioma having been overlooked, since not all distinguishing features of this lesion were manifested. These criteria, as well as the principles of the surgical approach for treating sellar space-occupying lesions are discussed.

The venous flaps: an experimental study of the microvascular architecture, the area of perfusion and their correlation.

The aim was to compare the various modes (cephalic, caudal and bidirectional input) of venous-flap perfusion and to relate the area perfused to the microvascular architecture of the venous flaps. Thirty-three flaps harvested from the forearm and dorsal foot regions of 12 fresh cadavers were divided into four groups: Group 1, cephalic input (n = 12); Group 2, caudal input (n = 11); Group 3, bidirectional input (n = 13 - converted from either Group 1 or Group 2); and Group 4, a control group made up of traditional arterial free flaps (n = 10). Perfusion was carried out using a cocktail of vital dye and Roentgen contrast medium, so that the flaps could be studied both for area of perfusion and by microangiography. Perfusion in Groups 1 and 2 was carried out with increasing numbers of injected veins. The numbers of contrasted vessels in the microangiograms were counted and correlated with the areas of perfusion. Statistical comparisons were made between the different groups, between the test groups and the control group, and between the flaps from different anatomical locations. The bidirectional-input flaps showed statistically significantly larger areas of perfusion than both the caudal-input and the cephalic-input groups. The perfusion areas of the cephalic-input flaps were larger than those of the caudal-input flaps. The control flaps had the largest area of perfusion. Forearm flaps had larger areas of perfusion than dorsal foot flaps. There was a significant correlation between the area perfused and the number of vessels contrasted in all the venous flaps, with a significant increase in perfusion area with increasing numbers of veins.

Sensory recovery after reconstruction of defects of long fingertips using the pedicled V flap.

The pedicled V-flap technique was used to repair varying degrees of injury to the fingertip in 29 patients. The technique is described, together with the results of static two-point discrimination tests 1 month and 3 months after surgery. The sensation in the flaps reached near-normal levels after 3 months in all patients. Although statistically significant, the difference in the results at 1 month and 3 months postoperatively was minimal.

Usefulness of 3-D reconstructed images of the human cerebral cortex for localization of subdural electrodes in epilepsy surgery.

Three-dimensional (3-D) images of 14 patients, in whom subdural electrodes were implanted for epilepsy surgery evaluation, were produced by fusing computerized tomography (CT) scans and magnetic resonance images (MRI) to determine the exact location of the electrodes. In 25% (198 of 806) of the subdural electrodes an exact location for resection strategy was not evident from the X-rays. The location of these electrodes ('doubtful location', DL) was compared to the 3-D images. Intraoperative inspection served as the gold standard. Concordance score was defined as good for 75-100% concordance, moderate for 50-75%, and poor for less than 50% concordance of the DL electrodes to the intraoperatively determined location. A comparative analysis of the 3-D images and X-ray films showed a highly significant difference (P < 0.0002) in favor of 3-D images. The concordance score for the DL electrodes in the 3-D images was good in 93% of the patients and moderate in 7%. In contrast, the concordance score was good in only 7% of the patients for the two-dimensional (2-D) skull films, moderate in 57%, and poor in 36%. Interobserver reliability was better for 3-D images (93%) than for the 2-D X-rays (43%). These findings suggest that 3-D images aid preoperative planning for resective epilepsy surgery.

Influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism.

OBJECT: The indications for cranioplasty after decompressive craniectomy are cosmetic repair and, mainly, restoration of cerebral protection. Although neurological improvement after cranioplasty is repeatedly noted, the reasons for this remain unclear. Few observations concerning the impact of cerebrospinal fluid hydrodynamic and/or atmospheric pressure have been published during the last decades. Relevant data concerning the cerebrovascular reserve (CVR) capacity and cerebral glucose metabolism before and after cranioplasty have been lacking until now. To gain further insight, this study was undertaken to investigate the impact of cranioplasty on indices of cerebral blood flow regulation and metabolism. METHODS: Thirteen patients in whom extensive craniectomies had been performed underwent a meticulous study of blood flow velocities in the middle cerebral artery (MCA) and extracranial internal carotid artery (ICA), as assessed by transcranial Doppler ultrasonography during postural maneuvers (supine and sitting positions) and during stimulation with 1 g of acetazolamide for the interpretation of CVR capacity. Twelve patients underwent 18-fluorodeoxyglucose positron emission tomography. These measurements were obtained before and 7 days after cranioplasty. Cranioplasty improved preoperative differences in MCA blood flow velocities when comparing those in the injured with those in the uninjured hemisphere. Similarly, cranioplasty resolved decreases in extracranial ICA blood flow in the injured hemisphere that were induced by postural changes, which was a constant finding prior to this procedure. More strikingly, however, the CVR capacity, which was severely impaired in both hemispheres, increased significantly after the procedure. Metabolic deficits, which were observed in the injured hemisphere, were found to improve after reimplantation of the skull bone flap. CONCLUSIONS: Cranioplasty appears to affect postural blood flow regulation, CVR capacity, and cerebral glucose metabolism markedly. Thus, early cranioplasty is warranted to facilitate rehabilitation in patients after decompressive craniectomy.

Transcallosal interforniceal-transforaminal approach for removing lesions occupying the third ventricular space: clinical and neuropsychological results.

OBJECTIVE: The present study was undertaken to describe the clinical and prospective neuropsychological results for our group of 30 patients who were treated using a transcallosal interforniceal-transforaminal microsurgical approach. METHODS: The transcallosal interforniceal and transcallosal-transforaminal approaches were used to treat 30 patients with space-occupying lesions located in the anterior part of the third ventricle. We used a modified anterior transcallosal microsurgical approach, as described recently. The patients underwent extensive, pre- and postoperative, prospective neuropsychological testing, using a specially designed test battery. RESULTS: Twenty-three of 30 patients (77%) experienced excellent clinical outcomes (Glasgow Outcome Scale Grade V). The surgical procedures described in this report did not themselves impair attentional function. In both the early and late postoperative neuropsychological testing sessions, deficits in verbal memory were only rarely observed and were not noted to be correlated with the surgical procedures. The most relevant neuropsychological results for individual patients are reported in detail. CONCLUSION: The approach described here can be successfully used for the resection of various space-occupying lesions in the anterior part of the third ventricle. The anatomic landmarks we recently defined and described (for example, the midline vessel on the trunk of the corpus callosum, to direct the callosotomy) guide the surgical path. Furthermore, we recommend the use of neuropsychological test batteries for both scientific and rehabilitative purposes.

Foreign-body reaction to silastic burr-hole covers with seroma formation: case report and review of the literature.

Because silastic material is one of the most commonly used biomaterials in modern medicine, the biocompatibility of these implants is still a source of long standing controversy. Though several studies have established silastic material as biologically inert, numerous authors have repeatedly described characteristic pathological tissue responses to silicone and its elastomeres. We report a case of foreign-body reaction to silastic burr-hole cover with successive formation of a seroma following resection of an olfactory groove meningioma. Within 30 days postoperatively, the patient developed a marked bulge in the glabbelar region. Histopathological examination revealed a seroma-like lesion obviously caused by a chronic inflammatory allergic reaction to the silastic burr-hole cover. Although the silicone-induced tissue damage clinically shows a wide variability and a conclusive model of pathogenesis is presently not available, the histopathological findings in some patients, in the form of granulomatous lesions and inflammatory cell response, might partly be due to an immunological reaction. Such a reaction has been previously described both clinically and experimentally, as detected in our patient. In addition, a review of the literature is given.

Closure of recurrent frontal skull base defects with vascularized flaps -- a technical case report.

Techniques for vascularized reconstruction of the anterior cranial fossa floor defects causing recurrent cerebrospinal fluid fistula are discussed in this report. The closure employs the use of local random- or axial-pattern vascularized flaps in simple cases. In complicated cases (for instance, status after repeated exploration) the tissue of the cranial base is severely compromised and shows low potential for healing. Non-vascularized grafts only add avital scars to the already present ones leading to recurrent fistulas. Free vascularized flaps show more mechanical strength and less scar contraction, resistance to infections and survive better in a compromised surrounding, thus leading to long term sealing in such cases. The technical issues of vascularized closure of defects of the frontal skull base are discussed in this report.

The influence of cranioplasty on postural blood flow regulation, cerebrovascular reserve capacity, and cerebral glucose metabolism.

The indications for cranioplasty after decompressive craniectomy are cosmetic repair and, mainly, restoration of cerebral protection. Although neurological improvement after cranioplasty is repeatedly noted, the reasons for this still remain unclear. Few observations concerning the impact of CSF hydrodynamic and/or atmospheric pressure were published during the last decades. Relevant data concerning the cerebrovascular reserve capacity and cerebral glucose metabolism before and after cranioplasty have been lacking until now. To gain further insight, the present study was undertaken to investigate the impact of cranioplasty on indices of cerebral blood flow regulation and metabolism. Thirteen patients in whom extensive craniectomies had been performed underwent a meticulous study of blood flow velocities in the middle cerebral artery (MCA) and extracranial internal carotid artery (ICA), as assessed by transcranial Doppler (TCD) ultrasonography during postural maneuvers (supine and sitting positions) and during stimulation with 1 g of acetazolamide for the interpretation of cerebrovascular reserve (CVR) capacity. Twelve patients underwent 18-fluorodesoxyglucose positron emission tomography. These measurements were made before and 7 days after cranioplasty. Cranioplasty improved preoperative differences in MCA blood flow velocities when comparing the injured with the noninjured hemisphere. Similarly, cranioplasty resolved decreases in extracranial ICA blood flow in the injured hemisphere that were induced by postural changes, which was a constant finding prior to this procedure. More strikingly, however, the CVR capacity, which was severely impaired in both hemispheres, significantly increased after the procedure. Metabolic deficits, which were observed in the injured as compared with the noninjured hemisphere, were found to improve after reimplantation of the skull bone flap. Cranioplasty appears to affect postural blood flow regulation, CVR capacity, and cerebral glucose metabolism markedly. Thus, early cranioplasty is warranted to facilitate rehabilitation in patients after decompressive craniectomy.