Update in the classification and the role of intra-arterial stenting in the management of carotid body paragangliomas.

BACKGROUND: To review the Shamblin classification of carotid body paragangliomas (CBPs) and the role of intra-arterial stenting in their surgical management. METHODS: Retrospective case series of 20 patients with 28 CBPs that were surgically resected at our center. Intra-arterial stenting was performed in Shamblin II and II classes. RESULTS: The mean follow-up was 47.8 months. Five (17.9%) tumors were Shamblin class I, 15 (53.6%) were class II, and 8 (28.6%) were class III. Thirteen (68.4%) CBPs were associated with other paragangliomas. The internal carotid artery (ICA) was stented preoperatively in eight (28.6%) cases and occluded in four (14.3%) cases. The tumor extended to the jugular foramen in six cases (21.4%). Intraoperatively, there was an ICA injury in one case of Shamblin II CBP in the present era. CONCLUSIONS: The proposed classification enables the clinician to plan the management of the ICA and the right approach. Stenting of the ICA gives a chance for complete tumor removal with arterial preservation.

Facial Nerve Outcomes Following Total Excision of Vestibular Schwannoma by the Enlarged Translabyrinthine Approach.

OBJECTIVE: To study the early and late facial nerve (FN) outcomes in different tumor classes in addition to determining the predictive factors for the same. STUDY DESIGN: A retrospective clinical study. SETTING: A quaternary referral otology and skull base center. PATIENTS AND METHODS: A retrospective study of 1983 cases of vestibular schwannomas (VSs) with preoperative normal FN function, undergoing total excision with anatomical preservation of the nerve by enlarged translabyrinthine approach (ETLA) were included. FN status was recorded postoperatively at day 1, at discharge, and at 1-year follow-up and were analyzed in different tumor sizes. RESULTS: At 1 year, 988 patients with House-Brackmann (H-B) grade I and II FN at day 1 after surgery, 958 (96.9%) maintained their status up-to 1 year. Of the 216 patients with H-B grade III at day 1 after surgery, 113 (52.3%) improved to H-B grade I and II. Similarly, of the 779 patients with H-B grade IV and VI FN function at day 1 after surgery, improvement to H-B III and H-B I and II were noted in 442 (56.7%) and 80 (10.3%) of patients, respectively. Intrameatal and extrameatal tumors upto 2 cm showed better recovery from H-B grade III to H-B I and II and from H-B grade IV and VI to H-B I and III when compared with extrameatal tumors >2 cm (p = 0.001). CONCLUSION: Tumors of smaller sizes have good immediate postoperative FN results and recover well at the end of 1 year while more than 3 cm have poor outcomes and recover poorly at the end of 1 year. When the VSs reaches more than 1 cm, the HB I and II outcomes drop significantly.

Incomplete and false tract insertions in cochlear implantation: retrospective review of surgical and auditory outcomes.

OBJECTIVES: To evaluate incidence, demographics, surgical, and radiological correlates of incomplete and false tract electrode array insertions during cochlear implantation (CI). To evaluate outcomes in patients with incomplete electrode insertion (IEI). STUDY DESIGN: Retrospective analysis. SETTING: Otology and skull base center. PATIENTS AND METHODS: Charts of 18 patients (19 ears) with incomplete or false tract insertions of the electrode array were evaluated who underwent CI, with at least 1 year follow-up (from 470 cases). Demographic findings, etiologies, pre-operative radiologic findings, operative records, post-operative plain radiographic assessment for extent of electrode insertion, and switch-on mapping were evaluated. Audiological outcomes were evaluated using maximum and last recorded vowel, word, sentence, and comprehension scores for patients with IEI. RESULTS: Incidence of insertional abnormalities was 4.25% with 17 instances of incomplete and 2 cases of insertion into superior semicircular canal. Mean age and duration of deafness were 55.18 ± 4.62 and 22.12 ± 5.71 years. Etiologies in the IEI group were idiopathic, otosclerosis, meningitis, chronic otitis media (COM), temporal bone fractures, and Neurofibromatosis-2. 29.4% cases had cochlear luminal obstruction. Mean radiological and active electrophysiological length of insertion was 20.49 ± 0.66 and 19.49 ± 0.88 mm, respectively. No significant correlation was observed between audiological outcomes and insertional length except in time to achieve maximum word scores (p = 0.04). Age at implantation had significant correlations with last recorded word and comprehension scores at mean follow-up of 42.9 months, and with time to achieve maximum auditory scores. CONCLUSIONS: IEI during cochlear implantation using straight electrodes can occur with or without cochlear luminal obstruction. Age plays an important role in the auditory rehabilitation in this patient subset.

Cochlear Implantation in Cochlear Ossification: Retrospective Review of Etiologies, Surgical Considerations, and Auditory Outcomes.

OBJECTIVES: 1) To review the surgical and auditory outcomes and complications of cochlear implantation in cases with cochlear ossification. 2) To evaluate association between the extent and etiology of ossification to outcomes. STUDY DESIGN: Retrospective study. SETTING: Otology and skull base surgery center. SUBJECTS AND METHODS: Charts of 40 patients (42 ears) with cochlear ossification undergoing cochlear implantation were reviewed. Demographic features, operative findings, auditory outcomes, and complications were analyzed. Operative findings included extent of cochlear ossification, extent of drilling required to obtain patent cochlear lumen, approach (posterior tympanotomy/subtotal petrosectomy), electrode insertion (partial/complete, scala tympani/vestibuli), and complications. Auditory outcomes were assessed over a 4-year follow-up period using vowel, word, sentence, and comprehension scores. Patients were divided into groups (otosclerotic/non-otosclerotic and round window/basal turn ossification) for comparison of auditory outcomes. Outcomes were compared with 60 randomly identified controls (adults with postlingual deafness) who underwent implantation with no cochlear ossification. RESULTS: The median age and duration of deafness of patients was 54.39 and 27.15 years, respectively. Etiology of cochlear ossification was otosclerosis in 23 of 42 ears and mixed in 19 of 42 ears (chronic otitis media, temporal bone fractures, idiopathic, meningitis, Cogan's syndrome) with exclusive round window involvement in 54.7% of cases and the rest having partial or complete basal turn ossification. 59.5% ears underwent subtotal petrosectomy for implantation. Three patients underwent scala vestibuli insertion and five had incomplete electrode insertion. Auditory outcomes were comparable in otosclerotic and non-otosclerotic cases and in round window and basal turn ossification cases. No significant differences were observed in auditory scores when compared with controls with no ossification. CONCLUSIONS: Cochlear implantation in cochlear ossification is feasible despite surgical challenges and modifications. Auditory outcomes in basal turn ossification appear to be comparable to cases with no ossification with extent of ossification having no significant association with outcomes.

Cochlear Implantation in Chronic Otitis Media With Cholesteatoma and Open Cavities: Long-term Surgical Outcomes.

OBJECTIVES: To evaluate the long-term surgical outcomes of cochlear implantation (CI) in chronic otitis media (COM) with cholesteatoma and open cavities using subtotal petrosectomy (STP). To review device explantation (DE) patients and reimplantation considerations. STUDY DESIGN: Retrospective review. SETTING: Otology and skull base center. PATIENTS AND METHODS: Charts of 35 patients (36 ears) with COM with cholesteatoma, including open cavities, who underwent CI were reviewed for surgical outcomes and DE. Patient demographics, pathologies, previous surgeries, staging of implantation, salient intraoperative findings at the time of implantation and follow-up were evaluated. Details of patients with DE were evaluated for cause, operative findings, and reimplantation considerations. RESULTS: Mean age of patients was 65.94 years. Nineteen open cavities, 11 primary cholesteatomas, 3 petrous bone cholesteatomas, and 3 atelectatic middle ears represented the pathologies with 31 patients of CI with concurrent STP and 5 patients where implantation was staged. The mean follow-up was 7.16 years ranging from 2 to 13 years. Four patients (11%) had DE due to extrusion and cavity infection with three reimplanted in same or contralateral ear. All explantations occurred within 24 months of primary implantation. No residual or recurrent cholesteatoma was observed in any of the patients during follow-up. CONCLUSION: CI is feasible in COM with cholesteatoma and open cavities with the use of STP and single-stage implantation can be performed in the absence of purulence. Despite low risk of residual cholesteatoma post meticulous disease removal, risk of DE remains, particularly in open cavity patients, and is higher than standard implantation. Reimplantation is often possible with careful considerations.

Petrous Apex Cholesterol Granulomas: Outcomes, Complications, and Hearing Results From Surgical and Wait-and-Scan Management.

OBJECTIVE: 1. To analyze the surgical outcomes in the management of petrous apex cholesterol granulomas (PACG) with a brief literature review.2. To evaluate the importance of wait-and-scan management option. STUDY DESIGN: Retrospective review. SETTING: Quaternary referral center for otology and skull base surgery. SUBJECTS AND METHODS: Charts of 55 patients with at least 12 months of follow-up were analyzed for demographic, clinical, audiometric, and radiological features. Patients were divided into surgical group (SG) (n = 31) and wait-and-scan (n = 24) (WS) group. Surgical approach was chosen as per hearing status and PACG extension and relation to nearby neurovascular structures and included either drainage by transmastoid-infralabyrinthine approach (TM-IL)/transcanal-infracochlear approach (TC-IC) or resection by infratemporal fossa type B approach (ITF-B). The combination of ITF-B with trans-otic (TO) approach or TO approach solely was used in unserviceable hearing cases. Postoperative outcomes and complications were evaluated in SG. RESULTS: Postoperative symptom relief was observed in 24 patients (77.4%). Diplopia and paresthesia recovered in each case and improvement in headache, dizziness, tinnitus, and hearing loss was observed in 87.1% cases. Serviceable hearing was preserved in 24 of 26 cases. Postoperative complication rate was 32.2% including incidences of profound hearing loss, facial nerve paresis, carotid artery injury and intraoperative CSF leaks. Revision surgery was required in 3 (9.6%) cases, after TM-IL approach. CONCLUSION: Surgical drainage is preferable to more aggressive resection procedures, with the latter reserved for recurrent lesions or lesions with severe hearing loss/involvement of critical neurovascular structures. ITF-B approach provides adequate cyst and neurovascular control for resection, while avoiding brain retraction. An initial wait-and-scan approach can be used in most patients where symptoms and imaging justify so.

Cochlear Implantation in Otosclerosis: Surgical and Auditory Outcomes With a Brief on Facial Nerve Stimulation.

OBJECTIVES: 1) To review the surgical and auditory outcomes in patients of cochlear implantation in otosclerosis. 2) To review complications and postimplantation facial nerve stimulation (FNS). 3) To compare the auditory outcomes between patients displaying cochlear ossification to the nonossified ones. STUDY DESIGN: Retrospective study. SETTING: Quaternary Otology and Skull base surgery center. SUBJECTS AND METHODS: Charts of 36 patients (38 ears) with otosclerosis undergoing cochlear implantation were reviewed from the cochlear implant database. Demographic features, operative findings, auditory outcomes, and postimplantation FNS were analyzed. Operative findings included extent of cochlear ossification, approach (posterior tympantomy/subtotal petrosectomy), electrode insertion (partial/complete, scala tympani/vestibuli), and complications. All the patients underwent implantation using straight electrodes. Auditory outcomes were assessed over a 4-year follow-up period using vowel, word, sentence, and comprehension scores. Patients were divided into two groups (with and without cochlear ossification) for comparison of auditory outcomes. RESULTS: The mean age and duration of deafness of patients was 59.72 and 28.9 years respectively. Twenty-three of 38 ears had cochlear ossification, with exclusive round window involvement in 60% of the patients, with the rest having partial or complete basal turn ossification. 36.8% ears underwent subtotal petrosectomy for cochlear ossification. One patient underwent scala vestibuli insertion and two had incomplete electrode insertion. Patients with no ossification had no intra or postoperative complications. One patient had bilateral FNS managed by alterations in programming strategy. Auditory outcomes in patients without any ossification were better than in patients with ossification, though statistically insignificant in most parameters. CONCLUSION: Cochlear implantation in otosclerosis provides good auditory outcomes, despite high incidence of cochlear ossification. Patients of FNS can be managed by alterations in programming strategy, without affecting auditory outcomes.

Extensive Allergic Fungal Rhinosinusitis: Ophthalmic and Skull Base Complications.

To review the clinical features, ophthalmic and skull base complications, radiologic correlates, surgical methods and outcomes in cases of extensive allergic fungal rhinosinusitis (AFRS). The retrospective review was carried out at a tertiary referral center and included 11 patients with extensive AFRS. Inclusion criteria were confirmed cases of AFRS with intracranial extension, gross erosion of the skull base or medial orbital wall and/or ophthalmic complications of AFRS, including visual loss. Acute bacterial or invasive fungal sinusitis and other non-AFRS sinus pathologies with orbital or skull base complications were excluded from the study. The mean age of patients was 22.7 years. Proptosis was the most common presenting feature followed by diplopia and visual loss. Four patients exhibited unilateral visual loss with one case of sudden acute onset. Intracranial extradural spread to the middle cranial fossa was observed in two cases with cavernous sinus involvement, destruction of the entire cranial base and extension to the petrous temporal bone. Ten patients exhibited co-existing orbital and skull base erosion whereas gross erosion of the lamina papyracea alone was seen in one patient. All patients underwent endoscopic sinus surgery with complete disease clearance. The minimum and maximum follow-up periods were 1 and 3 years, respectively with one documented recurrence 18 months after surgery. Visual recovery was complete after sudden vision loss whereas it was only partial or absent in patients with prolonged vision loss. Cases of extensive AFRS with ophthalmic and skull base complications pose diagnostic and therapeutic challenges and merit early intervention with long-term follow-up.

Extensive intratemporal cholesteatomas: presentation, complications and surgical outcomes.

The purpose of the study was to review the clinical features, complications, surgical management and post-operative outcomes of medially invasive extensive cholesteatomas and intracranial complications of cholesteatoma. The retrospective review was carried out at a tertiary referral center and included 20 patients presenting with extensive intratemporal cholesteatomas between 2011 and 2013. Inclusion criteria were involvement of the labyrinth, facial nerve, posterior fossa dura and intracranial complications. The mean age of the patients was 20 years. Profuse foul-smelling otorrhoea and severe otalgia/temporal headache were the most common presenting features. Intracranial complications were observed in nine patients, most commonly temporal lobe abscess; 14/20 patients exhibited profound hearing loss. One case exhibited massive labyrinthine petrous apex cholesteatoma. Labyrinthine destruction was seen in all cases of facial nerve involvement. Management of intracranial complications preceded canal wall-down mastoidectomy with or without partial labyrinthectomy and subtotal petrosectomy (transotic) with blind sac closure for petrous cholesteatoma. Facial nerve infiltration was observed in one case, whereas eight cases exhibited gross dehiscence of the fallopian canal. Disease clearance was complete in all cases with two mortalities in patients with intracranial complications. Post-operative course was uncomplicated in all other patients apart from a case of wound dehiscence. All patients remain disease free after a minimum and maximum follow-up of 6 months and 2 years, respectively. Extensive intratemporal cholesteatomas and intracranial complications caused by them continue to pose a challenge to the management of otitis media in the current era and merit early recognition, surgical management and follow-up.

Cartilage palisades in type 3 tympanoplasty: functional and hearing results.

To evaluate the functional and hearing outcomes using full thickness broad cartilage palisades for tympanic membrane reconstruction in type 3 tympanoplasty with titanium prostheses. The retrospective study performed at a tertiary referral institute included 30 patients with posterior mesotympanic retraction pockets or tympanic membrane perforations requiring tympanic membrane and type 3 ossicular reconstruction. Patients with disease extending beyond the aditus requiring canal wall down mastoidectomy were excluded. Disease removal from posterior mesotympanic and epitympanic recesses was confirmed using angled endoscopy and ossicular reconstruction was performed using titanium partial or total ossicular replacement prostheses. Tympanic membrane reconstruction was done, with or without attic reconstruction, using full thickness broad cartilage palisades harvested from the tragus with perichondrium attached laterally. Patients were assessed at 24 and 48 weeks for graft status and any evidence of implant extrusion. Hearing evaluation was done using subjective assessment and pure tone audiometry. In total, 27 out of 30 patients had intact and completely healed grafts at 48 weeks postoperatively (a success rate of 90 %) showing full union and epithelialization of palisades, and with three patients displaying small defects. The mean pure tone air bone gap pre- and postoperatively was 32.4 and 8.8 dB, respectively, with most patients reporting satisfactory postoperative hearing. No evidence of implant extrusion was found in the 48-week period. Tympanic membrane reconstruction using full thickness palisades of tragal cartilage provides good functional and hearing outcomes in type 3 tympanoplasty with titanium prostheses.

Clinical advantages of cartilage palisades over temporalis fascia in type I tympanoplasty.

OBJECTIVE: To compare the post-operative outcomes in using temporalis fascia and full thickness broad cartilage palisades as graft in type I tympanoplasty. METHODS: This study, conducted at a tertiary referral institute, included 90 consecutive patients with mucosal type chronic otitis media requiring type I tympanoplasty with a 60/30 distribution of cases with fascia and cartilage palisades, respectively. The fascia group consisted of primary cases in adults and excluded revision cases, near-total or total perforations and pediatric cases. The cartilage group included pediatric, revision cases and near-total or total perforations. The fascia group utilized the underlay technique for grafting, whereas the cartilage group used tragal full thickness broad cartilage palisades with perichondrium attached on one side placed in an underlay or over-underlay manner. Post-operative graft take-up and hearing outcomes were evaluated after 6 months and 1 year with subjective assessment and pure tone audiometry. RESULTS: The graft take-up rate was 83.3% in the fascia group and 90% in the cartilage palisade group. The mean pure tone air-bone gaps pre- and post-operatively in the fascia group were 30.43 ± 5.75 dB and 17.5 ± 6.94 dB, respectively, whereas for the cartilage group, these values were 29 ± 6.21 dB and 7.33 ± 3.88 dB, respectively. CONCLUSION: Cartilage grafting with full thickness palisades is more effective than fascia as graft material, particularly in "difficult" tympanoplasties fraught with higher failure rates otherwise.

Giant vascular hamartoma of the tongue.

We present one of the largest lingual hamartomas of the tongue base to have been reported, along with a review of the current literature and a description of the management of this case, as well as insights into the histopathology of the lesion. A 21-year-old woman presented with a mass on the base of her tongue, extending to the vallecula. The mass was found to be over 4 cm and enhancing on computed tomography. The size, vascularity, and site of the lesion merited its excision using the suprahyoid pharyngotomy approach. Histopathology confirmed the mass to be a vascular hamartoma. In reviewing the literature, we encountered 61 reported cases of lingual hamartomas, which are described with a number of pathological variants and sites of occurrence and with different methods of surgical excision. The size, vascularity, and site of the lesion we found merited a different approach from the conventional transoral approach that was used in all of the previous reports. Also, our study agrees with current world literature that histopathological examination plays an important role in the final diagnosis.

Extensive nasopharyngeal angiofibromas: the maxillary swing approach.

The objective of this study was to evaluate the efficacy and outcome using the maxillary swing approach for the management of extensive nasopharyngeal angiofibromas. A retrospective analysis in a tertiary care center revealed five cases with extensive nasal angiofibromas operated using the maxillary swing approach between 2010 and 2012. All patients had tumor extension to the lateral-most portions of the infratemporal fossa with complete occupation and destruction of the lateral wall of the sphenoid sinus causing abutment to the cavernous sinus and complete involvement of the pterygopalatine fossa and pterygoid base. One patient displayed full occupancy of the maxillary sinus as a consequence of erosion of the posterior and medial walls of the maxillary sinus, while another had severe temporal lobe compression through the roof of the infratemporal fossa. All patients underwent tumor excision using the maxillary swing approach. Patients were followed up for a minimum period of 1 year after surgery. The maxillary swing approach gave optimal exposure of the entire central skull base including the infratemporal fossa and its extreme lateral and superior aspects. Adequate tumor exposure and vascular control could be achieved in all cases resulting in complete tumor excision. The mean operative time was 4.5 h. Post-operative healing was satisfactory with palatal fistula formation in two cases and all patients remaining disease-free up to the present time. One had minimal misalignment of the halves of the upper jaw and two had epiphora, of which one required dacryocystorhinostomy. The maxillary swing is an effective approach in the management of extensive nasopharyngeal angiofibromas and leads to optimal anatomical exposure with minimal morbidity.

Endoscopic vs microscopic myringoplasty: a different perspective.

The objectives of this study were to ascertain the feasibility of transcanal endoscopic underlay myringoplasty using temporalis fascia and compare the results with microscopic myringoplasty. This prospective randomized trial included 60 patients with mucosal chronic otitis media with tympanic membrane perforations of all sizes and locations apart from posteriorly based small or moderate sized perforations. In the endoscopy group, 30 patients underwent exclusive transcanal myringoplasty using tympanomeatal flap elevation with underlay graft placement. In the microscopy group, 30 patients underwent myringoplasty using the postaural approach. Intra-operative variables compared were canalplasty and canal wall curettage for assessment of ossicular status. Graft uptake, hearing outcomes using pure tone audiometry and subjective cosmetic outcomes were assessed 24 weeks post-operatively and compared in the two groups. Resident feedback on the feasibility of endoscopic myringoplasty was obtained using a questionnaire. In the microscopy group, 5/30 patients required canalplasty due to canal overhangs and 4/30 required canal wall curettage for ossicular assessment, whereas none of the patients in the endoscopy group required these procedures. A graft uptake rate of 83.3% was observed in both groups post-operatively after 24 weeks. Mean air-bone gap pre- and post-operatively in the endoscopy group was 28.5 and 18.13 dB, respectively, whereas these values were 32.4 and 16.9 dB, respectively, in the microscopy group. Subjective cosmetic outcomes were better in the endoscopy group. Resident feedback on endoscopic myringoplasty was positive. Endoscopic myringoplasty appears to be an effective alternative to microscopic myringoplasty and results in excellent hearing with good cosmetic outcomes.