[Intracranial otogenic complications: inspite of therapeutic progress still a serious problem]

BACKGROUND

High-imaging modalities, antibiotics and improved microsurgical procedures have decreased morbidity and mortality of intracranial otogenic complications in the western hemisphere nowadays. However, they do occur and the resulting mortality is still about 10%.

PATIENTS AND RESULTS

We report our experiences with 22 patients, who were treated for intracranial otogenic complications (15 x meningitis, 5 x brain abscess, 1 x subdural empyema, 1 x Gradenigo's syndrome) due to cerebrospinal fluid leak in 2 patients, chronic otitis in 9 patients (5 with cholesteatoma), acute otitis media in 11 patients, between 1981 and September 1999. Five patients with acute otitis media have had predisposing anatomic pathology: 1 x inner ear malformation, 1 x status after duraplasty, 2 x dura-brain-prolapse due to temporal bone fractures and 1 x dura-brain-prolapse after antrotomy. Streptococcus pneumoniae was a common cause of intracranial-complicating acute otitis media (64%). Residual neurologic impairment was noted in 3 patients at the time of discharge. 3 patients (13.6%) died due to the otogenic intracranial complication.

CONCLUSION

Otogenic intracranial complications are potentially life threatening conditions. Early diagnosis is essential to allow appropriate antimicrobial and surgical treatment. The necessity of close cooperation between otorhinolaryngologist, pediatrician, neurologist, radiologist and neurosurgeon is stressed.

[Endonasal endoscopic surgery of maxillary sinus mucoceles after Caldwell-Luc operation]

BACKGROUND

Mucoceles of the maxillary sinus after Caldwell-Luc procedure develop by entrapment of mucosa. Specially mucoceles far laterally were being revised by a second transoral approach. This procedure carries the risk of damaging the infraorbital nerve. In addition the problem of scarring at the bottle neck between the lateral recessus and the nasal cavity with reclosure remains.

METHODS AND PATIENTS

In 3 patients with a mucocele of the maxillary sinus 4-25 years after Caldwell-Luc operation an endonasal endoscopic opening of the mucocele was performed. In addition a silicon spacer was placed for 6 months.

RESULTS

Twelve to fifteen months postoperatively all 3 patients still had an uneventful maxillary sinus according to the data of endoscopy, computer-tomographic or MRI-examination.

CONCLUSIONS

The endoscopic approach and the long standing placement of a splint seems to be a valuable alternative to a renewed somewhat risky Caldwell-Luc approach.

Osteoplastic frontal sinus surgery with fat obliteration: technique and long-term results using magnetic resonance imaging in 82 operations

OBJECTIVE

To evaluate the intraoperative and late complications of osteoplastic sinus surgery with fat obliteration with long-term magnetic resonance imaging (MRI) follow-up.

METHODS

The operative records of all patients who underwent osteoplastic frontal sinus surgery with fat obliteration between January 1, 1986 and December 31, 1997 were reviewed and the postoperative clinical course and magnetic resonance imaging (MRI) scans were analyzed if available. MRI analyses revealed that changes in the distribution of fatty and fibrous tissue, the development of necrosis or oil cysts, recurrences, inflammatory complications, and mucoceles were time-dependent occurrences.

RESULTS

Eighty-two operative records were evaluated and 59 patients were followed 1 to 12 years after surgery. Eighty-six MRI scans in 51 patients were available for analysis. The most frequent intraoperative complications were exposure of orbital fat (19.5%), unintentional fracture of the anterior wall (19.5%), incorrect placement of the anterior wall (17%), and dural injury (9.8%). Persistent changes of the frontal contour (embossment, depression) occurred in 10.2% and the esthetic result was unfavorable in 5.1% of the cases. Mucoceles could be detected in 5 of 51 cases (9.8%). The amount of adipose tissue detectable in the last scan was less than 20% in the majority of cases (53%), and more than 60% in only 18% of the cases. The amount of adipose tissue decreased significantly with time (the median half-life was 15.4 mo).

CONCLUSIONS

Osteoplastic frontal sinus surgery with fat obliteration is very useful and successful in patients in whom the frontal sinus is not accessible via an endonasal approach or the natural drainage cannot be reestablished. MRI is currently the most valuable diagnostic tool to evaluate the frontal sinus after obliteration with adipose tissue. The method has some limitations with regard to detection of small recurrent mucoceles and differentiating vital adipose tissue from fat necroses in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary.

Packing and stents in endonasal surgery

Nasal packing is used primarily to control bleeding in epistaxis and after surgical procedures to the nose such as septoplasty, turbinate and paranasal sinus surgery. It is also used for internal stabilisation after operations involving the cartilaginous-bony skeleton of the nose. Apart from haemostasis, packing is used to prevent synechiae or restenosis, particularly after surgery. Generally accepted standards regarding the materials which should be used for packing, how long the packing should be left in place or the indications for nasal packing are lacking (Egelund and Jeppessen, 1992; Hosemann, 1996; Weber et al., 1996b). For example, many authors do not use packing at all provided that there is no heavy bleeding during or after the operation. Of those who use packing, some remove it on the day of the operation, others up to 5 days postoperatively (for overview see Weber et al., 1996b). Most publications describe experience with packing materials developed or preferred by the authors. Results of comparative studies on the nature and duration of packing are listed in Table 1. The currently available materials are reviewed and their respective properties, indications and risks are outlined.

[Cranialization of the frontal sinus. Indications, technique and results]

The osteoplastic frontal sinus surgery with obliteration of the sinus has been established in the therapy of frontal sinus diseases that can not be drainaged permanently or healed through an endonasal access. The obliteration of the frontal sinus is endangered in cases of multiple fracturing of the posterior frontal sinus wall or if it has been destroyed by an inflammatory process. In these problematic cases obliteration bears the danger of complications and cranialization of the frontal sinus is therefore the method of choice. We review 8 patients who were operated on using the cranialization technique. Indications for surgery were a combined fracture of the anterior and posterior frontal sinus wall (3), a pyocele of the frontal sinus with extensive destruction of the posterior wall (4) and a large osteoma of the posterior frontal sinus wall (1). The frontal sinus was exposed through a coronal incision, the mucosa and the posterior wall were completely removed and the frontal sinus obliterated with fat tissue. The anterior sinus wall was replaced after obliteration of the sinus or reconstructed with calvarian bone transplants. The follow up period was 1.8 years (11 months to 8 years). All patients underwent postoperatively a clinical ENT-examination and radiological assessment by CT-Scan or MRI. The overall functional and esthetic outcome was excellent. There were no serious complications nor any recurrence. The cranialization of the frontal sinus is a reliable and safe variation of the classical osteoplastic frontal sinus surgery with fat obliteration.

[What is the value of the Denecke surgical therapy concept in deglutition disorders?]

BACKGROUND

Denecke developed 1957 a surgical strategy consisting of three or four operative steps for rehabilitation of patients with unilateral paralysis of IXth and Xth cranial nerve. These four steps are the following: myotomy of the cricopharyngeal muscle, resection of the paralyzed pharyngeal wall, medialization of the paralyzed vocal cord and fixation of the soft palate to the posterior pharyngeal wall which can be facultative.

PATIENTS AND METHODS

For the first time we have reviewed patients operated on with the Denecke operation in a retrospective study. The surgical results should be analyzed to deduce some parameters for surgical indication.

RESULTS

16 patients were reviewed in regard to nourishment status, situation of tracheostomy, former pneumonias, classification of Miller and Eliachar for aspiration and subjective evaluation. The follow-up was 21 +/- 16 months postoperatively. In 8 cases surgical intervention was successful. In 2 additional cases the results were partially satisfying.

CONCLUSIONS

The surgical procedure of Denecke was successful for improving substantially nourishment and aspiration status of considerably reduced patients in about 50% of the reviewed cases. Preoperative cinematography of swallowing, manometry and an interdisciplinary approach are required to clearly define the indications for surgical intervention.

[Chronic inflammation of the petrous bone with fatal outcome]

We report the case of a 44-year-old woman, suffering from lethal cerebritis of the temporal lobe caused by an unusual chronic otitis media with granulations. A chronic inflammatory process of the left temporal bone had affected the patient over a period of 4 years. This had started with mastoiditis accompanied by a lesion of the dura mater, leading to labyrinthitis, encephalitis and cerebellar abscess. The patient's symptoms persisted, especially vertigo and uncertainty, and then deteriorated acutely. MRI showed otogenic cerebritis. Intracranial bleeding from vasculitis had worsened the patient's condition, finally resulting in the patient's death. This case impressively demonstrates that a cerebral abscess can cause acute worsening of general complaints associated with ear disease and results in a fatal outcome at any stage.

["Fuldaer ventilation surgery"--a surgical concept in severe ventilation disorders of the middle ear]

BACKGROUND

This report presents the long-term results of a special surgical technique in cases of persistent severe dysfunction of the Eustachian tube.

PATIENTS AND METHODS

We performed this operation on 16 patients (18 ears) between 1982 and 1997. Almost all patients had undergone previous surgery. This included myringotomies and tube insertions, adenoidectomies, tonsillectomies, myringoplasties and mastoidectomies, sinus surgeries, and an operation on a cleft palate. The concept developed by one coauthor (Draf) combines different methods to improve ventilation of the middle ear and protect the eardrum against partial vacuum. The concept combines mastoidectomy, posterior tympanotomy, and removal of the incus and the head of the malleus with an interposition of the incus. The tympanic membrane is then stabilized with a cartilage-perichondrium graft, and a tube is placed leading from the tympanic cavity to the nose (Wright-tube). A T tube may also be used. The procedure was varied slightly on occasion depending on intraoperative findings.

RESULTS

Thirteen patients (15 ears) were available for audiometry at a minimum of 5 months after surgery until 14 years (mean duration of 6.2 years). We compared preoperative and postoperative air-bone gaps. They were measured for the three speech frequencies (500, 1000, and 2000 Hz) at 5 dB intervals. The average preoperative air-bone gap was 25.7 dB versus 18.2 dB postoperatively. This represents an improvement of 7.5 dB. Seven of fifteen ears required revision. Six ears required one revision procedure each (three for cholesteatoma, one for myringitis, one for discharge due to a narrow external auditory meatus, and one for mastoiditis). Another patient required three revision procedures (one for mastoiditis and the other two for cholesteatoma).

CONCLUSION

This concept can help prevent cholesteatoma and improve hearing in more than 50 per cent of severe cases of dysfunction of the Eustachian tube.

[Nuclear magnetic resonance tomography after fatty tissue obliteration of the frontal sinus]

BACKGROUND

The osteoplastic flap procedure with fat obliteration has been hailed as the gold standard of definitive frontal sinus procedures for chronic inflammatory disease. The value of magnetic resonance imaging (MRI) in postoperative follow-up has not yet been sufficiently examined.

METHODS

All postoperative MRI scans performed in patients undergoing surgery between January 1, 1986, and December 31, 1996 were evaluated. The outcome parameters were time-dependent changes in the distribution of fatty or connective tissue and development of necroses or oil cysts, as well as recurrences, inflammatory complications, or mucoceles.

RESULTS

Sixty-eight operations were performed in the specified period and a total of 73 postoperative MRI scans from 45 operations were available for evaluation. In 16 cases, between two and five MRI scans were available. The individual time between surgery and the last MRI scan ranged from two weeks to 130 months with an average of 30.1 months. We found four mucoceles 34, 49, 106, and 130 months, respectively. Three of the mucoceles were diagnosed on the first postoperative MRI scan. In the fourth case the mucocele had not been seen on the previous scan. The amount of adipose tissue depictable on the last scan was less than 20% in the majority of cases (58%) and more than 60% in only 18% of cases, although in the latter group the time between surgery and MRI was less than 7 months in half the cases.

CONCLUSIONS

MRI is the most valuable diagnostic tool after frontal sinus obliteration using adipose tissue. Despite the good soft tissue differentiation, the method has some limitations with regard to detection of small recurrent mucoceles and differentiation between vital adipose tissue and fat necrosis in the form of oil cysts. In these difficult cases, long-term MRI follow-up is necessary for definitive evaluation. We therefore recommend MRI 1, 2, and 5 years after osteoplastic frontal sinus surgery with obliteration.

Experiences with endonasal surgery in angiofibroma

Surgery is the most common treatment for angiofibromas, but the approach is still a major point of discussion. Five cases of angiofibroma with typical localisation were treated surgically by an endonasal approach at the Fulda Academic Teaching Hospital from 1994 to 1997. This article presents an analysis of the clinical findings, computer tomography and magnetic resonance imaging, preoperative embolization, operative technique and complications. Endoscopic and radiologic follow-up ranging from 5 to 39 months excluded any residual tumour or recurrence. The endonasal microendoscopic approach with adequate preoperative embolization should be considered as an useful technique for removing tumours with considerable size without using an external incision.

[Bone neogenesis in a rare space-occupying lesion of the inner ear canal]

Hemangiomas of the skull base are rare neoplasms and are easily misdiagnosed as acoustic neuromas when occurring in the internal auditory canal. Among these tumors, ossifying hemangiomas are characterized histologically be newly formed bone tissue within their substance. We describe a 26-year old female patient who presented with left-sided sensorineural hearing loss and tinnitus. T2-weighted magnetic resonance imaging demonstrated a bright space-occupying lesion of the internal auditory canal with extension to the geniculate ganglion. Bony erosions of the internal auditory canal were proved by high-resolution computed tomography. A hemangioma was suspected preoperatively and was resected via a middle cranial fossa approach. Histologically, new bone formations were found in a cavernous hemangioma. In general, radiologic findings can suggest a hemangioma of the internal auditory canal and help to differentiate it from acoustic neuroma. Based on the histological findings of intratumoral bone formation, the hemangioma in our patient was classified as an ossifying hemangioma. However, reactive bone formation at the borders of a tumor in the internal auditory canal can also be mistaken as new intratumoral bone formation.

Videoendoscopic analysis of nasal steroid distribution

Topical corticosteroids are one of the main pillars in the treatment of nasal polyps. The exact topography of their intranasal deposition has not yet been adequately visualised. The intranasal distribution of a 1% sodium fluorescein solution applied with original Pulmicort Topinasal (budesonide) metered pump bottles was analysed by videoendoscopy. The study group included eight healthy subjects and ten patients who had undergone endonasal sinus surgery. Videoendoscopy was performed in the study group within the first minute after application of the fluorescein solution. Additionally the deposition pattern of Pulmicort Topinasal was analyzed using a nasal model. The examination showed that the majority of the substance is deposited on the anterior portion of the nasal septum and the head of the inferior turbinate. Only a small fraction actually reaches the middle meatus. The distribution is improved by application during the decongested phase of the nasal cycle, after use of vasoconstricting nasal drops and maintaining a spraying angle of 45 degrees upwards. The development of new delivery techniques and systems could improve the efficacy of intranasally administered corticosteroids and reduce the complication rate.

Conductive hearing loss in Beckwith-Wiedemann syndrome

Beckwith-Wiedemann syndrome is a rare genetic overgrowth syndrome presenting with organomegaly, abdominal wall defects, macroglossia, and postnatal hypoglycemia. Head and neck manifestations of this abnormality include flame nevus of the forehead and characteristic sulci of the ear lobe. We present a 7-year-old child with Beckwith-Wiedemann syndrome and a rare finding of conductive hearing loss on both sides due to congenital malleus and stapedial fixation. Small fenestra stapedotomy and mobilization of malleus fixation in the epitympanum improved the child's hearing. The bony fixation of the malleus and stapes is explained as atavism of the processus anterior mallei and peripheral lamina stapedialis in embryological development.

Surgical experience and complications during endonasal sinus surgery

OBJECTIVE/HYPOTHESIS

The introduction of optical aids for endonasal sinus surgery has not produced the expected drop in the rate of serious intraoperative complications.

STUDY DESIGN/METHODS

1. Retrospectively, consecutive procedures of different surgeons were analyzed in regard to major complications (periorbital injury, orbital lesion, dural injury, endocranial lesion, damage to the internal carotid artery). The chronological distribution was transformed into a personal learning curve. 2. From our own experience and as surveyors, we analyzed the experiences of surgeons having encountered severe complications and compared them with the above-mentioned learning curve.

RESULT

In total, 1,500 operations carried out by five surgeons with 16 serious complications were assessed. For the learning curve, the following stages were defined. stage I: greatest risk of complication, with dural injury (1st to 30th operation); stage II, slighter risk of complication, with frequent periorbital injuries (31st to 180th operation); and stage III, least risk, corresponding to an experienced surgeon. Serious complications occur most frequently among experienced surgeons.

CONCLUSION

The beginner enjoys the most effective type of assistance, in the form of personal guidance of an experienced surgeon who is constantly present during the first 30 operations, and who should then be readily available during the next 70 operative procedures. The use of multimedia software appears to be helpful, though its actual value still remains to be determined. The experienced surgeon in particular must be willing to exercise repeated self-criticism to keep his or her rate of complications to a minimum.

Obliteration of the frontal sinus--state of the art and reflections on new materials

Despite increasing advances in endonasal frontal sinus surgery, obliteration of the frontal sinus is necessary in some cases for definitive clearing frontal sinus pathology. Reviewing the literature and considering pathophysiological aspects, successful obliteration of the frontal sinus depends on the complete removal of the mucosa and a sufficient closure of the nasofrontal duct, but not on the material used for obliteration, if special considerations are taken into account and foreign materials are avoided. Complete removal of the mucosa has to include removal of the inner bony cortex of the frontal bone. Occlusion of the nasofrontal duct is achieved with a sufficiently fixed fibrous layer.

An unusual cavity within the styloid process

A rare case of an unusual sinus within the styloid process is described. The radiological appearance of this malformation is presented with CT-scans and a hypothesis for its development is presented. The malformation is designated as "Recessus processus styloidei" and this entity is considered to be a dysgenesis of the second branchial arch.

Unusual sinus of the styloid process

The case of a 50-year-old man with an unusual sinus of the styloid process is presented. This anomaly caused recurrent otorrhea and repeated neck inflammation. The sinus was identified in the upper part of the styloid process and was resected completely as definitive treatment. Since the styloid process is formed by mesenchymal tissue of the second branchial arch, lack of chondrification and ossification was presumed to be the cause of the sinus found in the patient. In case of direct communication between the styloid process cavity and the middle ear space the term "styloid process recess" is suggested. This recess can act as a possible source for recurrent middle ear infections and neck inflammations.

Detection of an occult transclival cerebrospinal fluid fistula by CT and MRI

We describe an unusual occult transclival cerebrospinal fluid (CSF) fistula to the sphenoid sinus demonstrated by MRI. CT was performed because of a posterior cerebral infarct caused by cardiac arrhythmia. Axial sections showed fluid in the sphenoid sinus. High-resolution scans revealed a bony defect 3 mm in diameter of the posterior wall of the sphenoid sinus, and MRI showed a transclival CSF fistula. This occult lesion was confirmed by surgery and duraplasty was successfully performed via an endonasal approach.

[Regional muscle flap-plasty and adjuvant measures for rehabilitation of the paralyzed face]

BACKGROUND

The loss of facial nerve activity reduces the quality of life in regard to functional disturbances and to the appearance of the patient. As far as possible a reconstruction of the facial nerve should be advocated. Only this procedure allows the natural variety of differentiated facial expression. If reconstruction of the facial nerve is not indicated or turns out to be unsatisfactory, a dynamic muscle transposition should be considered.

PATIENTS AND METHODS

The patient records of the ENT-Departments in Fulda for the period from 1988 to 1995 and in Mönchengladbach from 1993 to 1995 were reviewed to survey the experience of secondary plastic rehabilitation of the paralysed face. Our special interest focussed on the oral region with dynamic muscle transfer. The techniques leading to rehabilitation of the lid region were included in this study.

RESULTS

Transfer of the temporalis muscle was performed 12 times and a masseter muscle flap 4 times to rehabilitate the oral region. Static rehabilitation (canthoplasty, tarsorrhaphy) of the lid was performed 8 times, implantation of a gold weight in the upper lid 5 times and dynamic rehabilitation of the lid region with a temporalis muscle transposition once.

CONCLUSIONS

Rehabilitation of the oral region is best managed with a temporalis muscle flap because of its favourable vector of tension and its broad, flat form. Masseter muscle transposition is particularly indicated if a temporalis muscle transfer is not possible or if resection of the facial nerve because of malignancy of the parotid gland has to be performed and nerve reconstruction is not advisable.