Chemically assisted dissection by means of mesna in cholesteatoma surgery.

OBJECTIVE: To investigate whether the use of mesna (sodium 2-mercaptoethanesulfonate), a mucolytic agent capable of breaking disulfur bonds, reduces the frequency of residual cholesteatoma in canal wall up tympanomastoidectomy. STUDY DESIGN: Retrospective study. SETTING: Tertiary care otology and skull base centers. PATIENTS: Two hundred fourteen patients operated on by means of canal wall up tympanomastoidectomy for a middle ear cholesteatoma. INTERVENTIONS: Planned staged canal wall up tympanomastoidectomy. In the study group, the cholesteatoma removal was performed with the support of chemically assisted dissection by using mesna. In the control group, the dissection of the disease was performed by means of a traditional mechanical technique alone. MAIN OUTCOME MEASURES: Prevalence of residual cholesteatoma at the second-stage operation in the 2 groups of study. RESULTS: One hundred eight patients were treated with the ancillary use of mesna and one hundred six without chemically assisted dissection. A residual cholesteatoma was found in 12 (11.1%) of the 108 patients treated with chemically assisted dissection and in 26 (24.5%) of the 106 patients treated with mechanical dissection. After adjusting for potential confounders, CADISS procedure was associated with a significantly lower risk of having residual cholesteatoma (OR, 0.39; 95% CI, 0.18-0.84, p = 0.02). CONCLUSION: This study showed that chemically assisted dissection by using mesna represents a valid support in reducing the frequency of residual disease in cholesteatoma surgery.

Cochlear effects of intraoperative use of Mesna in cholesteatoma surgery.

BACKGROUND AND AIM OF THE WORK: Mesna is thiol compound proposed as chemical dissector in otolaryngologic surgery. The aim of this study was to address the issue of possible ototoxicity from topical administration of MESNA into the middle ear during otologic surgery. METHODS: Audiological findings of patients (n=55) who underwent canal wall up tympanomastoidectomy with the ancillary use of Mesna in 1-year period were retrospectively reviewed. We identified another set of 51 patients who had undergone otologic surgery without the use of Mesna to serve as a control group. Preoperative and postoperative mean bone conduction thresholds were calculated and compared between the two groups for the frequencies of 500,1000,2000, and 3000; 4000 and 8000 Hz were further analyzed to search for high-frequency sensorineural hearing loss. RESULTS: Fifty-five patients were operated on with the ancillary use of Mesna and 51 underwent surgery with traditional mechanical dissection alone. When mean preoperative bone conduction values were compared with postoperative values, no significant differences were found for any of the frequencies tested in both groups. Analyzing changes in bone conduction at 4000 and 8000 Hz a slight worsening was observed in both groups. CONCLUSIONS: We found no difference in hearing thresholds between the treatment and control groups. Thus, the results of this study confirmed data obtained in laboratory animal models demonstrating that intraoperative use of Mesna in middle ear surgery is safe and does not lead to ototoxic effects.

Facial nerve outcome after vestibular schwannoma surgery: our experience.

In this study we evaluate the postoperative facial nerve function after vestibular schwannoma (VS) surgery and analyze the factors that cause it. We included 97 consecutive patients undergoing surgical excision of sporadic unilateral VS. Patient and tumor characteristics, surgical approaches, facial nerve function, extent of tumor removal, perioperative complications are all analyzed through standardized systems. Four different surgical approaches are used: translabyrinthine, retrolabyrinthine, retrosigmoid, and middle cranial fossa. Anatomic preservation of the facial nerve is achieved in 97% of patients. The incidence of postoperative facial palsy is found to be statistically correlated to tumor size, but not to the surgical approach used and to extent of tumor penetration in the internal auditory canal. A significant improvement of the short-term facial nerve outcome is detected in patients undergone simultaneous intraoperative electromyography (EMG) and pneumatic facial nerve monitoring. Complete tumor excision is achieved in 94% of cases. Complication rates are excellent and no deaths are reported. Short- and long-term facial nerve outcome is good and comparable with those of other series reported in literature. In VS surgery both EMG and pneumatic facial nerve monitors should be simultaneously used. Further investigations are desirable to improve the facial outcome respecting the oncological radicality.

Isolated fracture of the malleus handle: a video clip.

Isolated malleus fracture is a rare clinical entity, and usually the handle of the malleus is involved. We report a video, to our knowledge the first in the literature, of a diagnostic otoscopy of a malleus fracture showing the movement of a left fractured malleus handle during a Valsalva maneuver (see the video online at www.laryngoscope.com).

Management of acoustic neuromas in the elderly: retrospective study.

The wide availability of gadolinium-enhanced magnetic resonance imaging (MRI-Gd) has led to the discovery of an increasing number of small and less symptomatic acoustic neuromas in elderly patients. We conducted a retrospective study in order to obtain data on outcomes and complications associated with different management strategies that would be useful in establishing a management guideline. We identified 44 patients aged 65 to 77 years with acoustic neuromas who had been managed with either surgery or simple observation with MRI-Gd imaging. Of the entire group, 36 patients had tumors larger than 1 cm, and they underwent surgery (most via the translabyrinthine approach). Complete removal of the tumor was achieved in 34 of these patients (94.4%). At the 1-year follow-up, grade VI facial nerve paralysis was evident in only two of 35 evaluable patients (5.7%). Postsurgical complications occurred in five patients (13.9%), including one death. The remaining eight patients had tumors 1 cm or smaller, and they were managed with periodic MRI-Gd scanning. At the 5-year follow-up, no tumor growth was seen in six of these patients. The other two patients exhibited a tumor growth rate of less than 2 mm per year. No patient in the observation group required surgical intervention.

Multichannel cochlear implantation in radical mastoidectomy cavities.

OBJECTIVE: We report on our experience in cochlear implantation in patients with radical mastoidectomy cavities. Study Design, Setting, and Methods: Retrospectively, records of patients from the Department of Otolaryngology, University of Parma between December 1991 and March 2000 were reviewed, and 6 postlingually deafened adults who received a cochlear implant in a radical cavity were identified. Speech performances were evaluated in terms of bisyllabic word and sentence recognition and common phrase comprehension. RESULTS: To date, with a follow-up of 1 to 9 years, no patient has experienced extrusion of electrodes or other local or intracranial complications. Mean bisyllabic word and sentence recognition scores were 74% and 80%, respectively. Mean comprehension score for common phrases was 86%. CONCLUSION: By obliterating and isolating the radical mastoidectomy cavity from the outer environment, patients who previously had undergone radical surgery of the middle ear can be safely implanted with satisfactory hearing results.

Results of the MXM Digisonic auditory brainstem implant clinical trials in Europe.

OBJECTIVE: To assess the potential benefit of the MXM auditory brainstem implant for patients with neurofibromatosis type 2. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral centers. PATIENTS: Fourteen patients with neurofibromatosis type 2 and bilateral acoustic neuromas underwent implantation with the MXM auditory brainstem implant during surgery to remove the second-side tumor. RESULTS: There were no complications related to the auditory brainstem implantation. Auditory sensations were present for 12 of 14 patients (86%). Global results indicated an improved quality of life for the patients receiving auditory sensations, in part because of their auditory orientation within the environment. Eighty-nine percent of patients tested with an open-set sentence test demonstrated enhancement of speech understanding as a result of lip-reading improvement when auditory brainstem implant sound was combined with lip-reading. A few patients (36%) had some speech understanding in sound-only mode. One patient was able to have limited phone conversations. CONCLUSION: These results indicate that significant auditory benefit can be derived from the MXM auditory brainstem implant.