[The surgical treatment of cholesteatoma of the pyramid of the temporal bone]

This paper presents in brief the data on epidemiology, classification, diagnostics, and current tendencies in the surgical treatment of cholesteatoma of the pyramid of the temporal bone. A clinical case of diagnostics and the surgical treatment ofpetrous apex cholesteatomainthe temporal bone is described.

[FEATURES OF OTOGENIC INTRACRANIAL COMPLICATIONS AT THE PRESENT STAGE]

A retrospective analysis of treatment was made in 127 adult patients with acute and chronic otitis media complicated by suppurative-inflammatory pathology of the brain. Purulent meningitis was revealed in 52 (40.9%) of hospitalized patients. Meningoencephalitis was often diagnosed in the cases of acute otitis media (15.4%) and in cases of chronic otitis (22.7%). The otogenic brain abscess was detected in 13.5% of otitis media cases and it was noted to be twice frequent (33.3%) in cases of purulent otitis media. The patients 124 (97.6%) have been operated. An extended mastoidotomy and antromastoidotomy were performed in the acute purulent otitis media. An extended radical operation on the ear was applied in case of chronic otitis media. Performance of craniotomy and complete removal of the abscess using modern systems of neuronavigation showed a higher clinical efficacy as compared with transtemporal approach during sanitizing intervention on the ear including the opening and abscess drainage in surgery of otogenic abscesses of the brain.

Surgery of isolated malleus fixation due to tympanosclerosis

The aim of the present study was to describe our surgical approach for isolated malleus fixation in patients with tympanosclerosis and to analyze the postoperative results. A total of 30 patients presented with isolated malleus fixation were operated. The fixation was reached via canalplasty. Fixated areas were cleaned without damaging the ossicle. Pre- and postoperative audiometric results were evaluated for each patient. Improvement of the pure-tone average (PTA) by at least 10 dB and an air-bone gap (ABG) of less than 20 dB after 12 months of follow-up was accepted to indicate success. The recovery of the postoperative PTA and ABG measurements was significant. Pre- and postoperative PTA was 48.00 ± 11.86 and 24.90 ± 12.45 dB, respectively (p < 0.001). According to PTA measurements, 40-50 dB recovery was achieved in four (13.3 %) patients, 31-40 dB in six (20 %) patients, 21-30 dB in ten (33.3 %) patients, and 11-20 dB in five (16.6 %) patients, with a total success rate of 25/30 (83.2 %). Pre- and postoperative ABG levels were 38.95 ± 9.92 and 16.10 ± 7.79 dB (p < 0.001), respectively. The ABG level was between 0 and 10 dB for 8 (26.6 %) patients, and 11-20 dB for 16 (53.3 %), with a total success rate of 24/30 (80 %). In cases of isolated malleus fixation with tympanosclerosis, performing a canalplasty to clean the sclerotic plaques without damaging the normal anatomy of the ossicle system using a diamond burr is a safe surgical option that provides significant recovery in hearing levels.

Traumatic ossicular disruption with isolated fracture of the stapes suprastructure: comparison with incudostapedial joint dislocation

CONCLUSION

More severe high frequency hearing loss, especially at 8 kHz, occurs with fracture of the stapes suprastructure (SSF) compared with isolated incudostapedial joint dislocation (ISD). Successful hearing gain can be achieved in the speech range with appropriate ossicular reconstruction.

OBJECTIVES

Traumatic SSF is a rare consequence of head trauma. This study aimed to demonstrate the characteristic features of SSF compared with traumatic ISD.

METHODS

Eighteen patients who suffered from conductive hearing loss after head trauma and were operated from 2000 to 2012 were enrolled. Eight and 10 patients were confirmed to have a traumatic SSF (SSF group) and ISD (ISD group), respectively. The etiology of ossicular disruption, preoperative CT scan of the temporal bone, and intraoperative findings were retrospectively reviewed. Pre- and postoperative hearing was analyzed by both pure tone averages and thresholds at each frequency (0.5-8 kHz).

RESULTS

The most common etiologies in the SSF group were fall (n = 3) and direct ear trauma (n = 3), and for those in the ISD group, the most common etiology was traffic accident (n = 6). CT scan showed no evidence of fracture in the SSF group, whereas findings of ossicular dislocation were found in 70% of patients in the ISD group. Hearing outcomes according to the frequencies demonstrated that pre- and postoperative hearing loss at 8 kHz was more severe in the SSF group than in the ISD group. In a comparison of hearing outcomes at each frequency, the postoperative hearing threshold at 8 kHz was higher than for other frequencies. Postoperatively, 63% of the SSF group and 70% of the ISD group obtained an air-bone gap of within 15 dB.

Comparison of obliteration materials used for revision canal wall-down mastoidectomy with mastoid obliteration

AIM

To describe our surgical technique and compare the results of obliteration materials.

PATIENTS AND METHODS

Fifty patients over a 7-year period were evaluated retrospectively. Out of these 50 consecutive patients, 29 had recurrent chronic otitis media (COM) with or without cholesteatoma and 21 patients had old open cavities. Efficacy of mastoid obliteration was assessed by an electronic chart review, otoendoscopic findings, temporal bone computerized tomography (CT) images, and postoperative caloric test.

RESULTS

Among 50 patients, inferiorly-based periosteal flap was used in 25 patients (50%) and anteriorly-based periosteal flap was used in the other 25 patients. Tympanic membrane and newly-formed external auditory canal wall was intact in 48 patients (96%). The newly-formed EAC provided sufficient aeration, and satisfactory aesthetic appearance. None of our patients complained of vertigo triggered by cold air or water. There was no significant difference in the caloric test results between the operated ear and the normal ear. No difference was observed in the caloric test between the bone pate and costal cartilage groups.

CONCLUSION

Our results indicate that mastoid obliteration using autogenous bone pate or costal cartilage is helpful in improving the outcomes of revision canal wall-down mastoidectomy in patients with an old radical cavity and recurrent COM or cholesteatoma.

A clinical experience of 'STAMP' plate-guided Bonebridge implantation

Conclusion

The surface template-assisted marker positioning (STAMP) method is useful for successful Bonebridge™ (BB) implantation on a planned site while avoiding dangerous positions.

Objectives

To confirm the usefulness of the STAMP method for the safe operation of BB.

Methods

From a patient’s temporal bone CT data, a guide plate and confirmation plate were generated by the STAMP method. The guide plate is used to mark the correct place for implantation, while the confirmation plate lets us know the correct angle and depth of the hole.

Results

With the guide plate, the correct place for BB implantation was easily found. The hole was made to be an appropriate size with the confirmation plate while exposing only a small part of sigmoid sinus as simulated. Finally, the BB implant was successfully placed exactly at the planned site.

Hearing stimulation of the pediatric patient with congenital aural atresia: surgical and audiological evaluation of 38 patients

The aim of this work is to stress the importance of and discuss the timing and options for the treatment of congenital aural atresia (CAA), including non-surgical alternative treatment modalities and amplification, and to report the audiological and surgical results of a series of patients. Thirty-eight children with CAA were evaluated with regard to hearing and anatomical anomalies accompanying CAA: the state of the ossicles and the facial nerve, postoperative complications and audiological results. The ages of the patients ranged between 4 and 18 years, with a mean of 10 years. All underwent surgical treatment; 32 had unilateral atresia, while 6 had bilateral atresia. The mean follow-up duration was 7 months. The facial canal was dehiscent in 36.8% of cases. In 70.2% cases, the malleus and incus were present as an ossicular mass, fixed and attached to the atretic bone. The stapes was normal in 97.3% of the patients; in 2.7% the suprastructure was deformed. The success rate, defined as an air-bone gap of 20 dB or less, was 63.1% in this series of patients. If atresia is bilateral, very early hearing stimulation to prevent the maldevelopment of children's speech and cognitive skills is of the utmost importance. In unilateral cases, surgery may be postponed until early adulthood, when the patient is able to make his/her own decision and cooperate in the treatment and postoperative aspects.

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.

Round window reinforcement for superior semicircular canal dehiscence: a retrospective multi-center case series

PURPOSE

To evaluate the outcome of round window (RW) tissue reinforcement in the management of superior semicircular canal dehiscence (SSCD).

MATERIALS AND METHODS

Twenty-two patients with confirmed diagnosis of SSCD by clinical presentation, imaging, and/or testing were included in the study. Six surgeons at four institutions conducted a multicenter chart review of patients treated for symptomatic superior canal dehiscence using RW tissue reinforcement or complete RW occlusion. A transcanal approach was used to reinforce the RW with various types of tissue. Patients completed a novel postoperative survey, grading preoperative and postoperative symptom severity.

RESULTS

Analysis revealed statistically significant improvement in all symptoms with the exception of hearing loss in 19 patients who underwent RW reinforcement. In contrast, 2 of 3 participants who underwent the alternate treatment of RW niche occlusion experienced worsened symptoms requiring revision surgery.

CONCLUSION

RW tissue reinforcement may reduce the symptoms associated with SSCD. The reinforcement technique may benefit SSCD patients by reducing the "third window" effect created by a dehiscent semicircular canal. Given its low risks compared to middle cranial fossa or transmastoid canal occlusion, RW reinforcement may prove to be a suitable initial procedure for intractable SSCD. In contrast, complete RW occlusion is not advised.

Cochlear implantation after resection of an intralabyrinthine schwannoma

Intralabyrinthine schwannomas are rare tumors of the distal ends of the cochlear and vestibular nerve. Their presence can be debilitating secondary to symptoms of hearing loss, vertigo, tinnitus, and imbalance. Currently, treatment to restore hearing in those who have become profoundly deaf is not attempted. Additionally, resection in patients with functioning hearing is rare, as the surgery assures deafness. We report the first case demonstrating the feasibility of resection of an intralabyrinthine schwannoma with immediate cochlear implantation. This technique addresses the patients hearing status by taking into account advancing technology, allowing for an improved quality of life.

Is a redefinition of the growth criteria of vestibular schwannomas needed?

PURPOSE

The natural history of vestibular schwannomas is poorly understood. Knowledge of growth rate and growth pattern is essential because the treatment strategy is based upon these. The purpose of this study was to determine the inter- and intraobserver variability in measuring VS size.

MATERIALS AND METHODS

Two consultant neuroradiologists independently made three linear measurements (d1, d2, d3) using digital MRI scans. MRI scans from 72 patients diagnosed between 2002 and 2010 with VS were obtained. These patients had a total of 223 MRI scans. d1 (medio-lateral diameter) was made perpendicular to d2. d2 was made parallel to the posterior border of the petrous ridge, and d3 was a measure of the cranio-caudal height of the tumor.

RESULTS

Limits of Agreement ranges are larger for interobserver reliability compared to intraobserver reliability. Measurement error for all diameters (except d1, intraobserver) is greater than 2mm. d1 measurements had the least variability and d3 measurements the highest variability, both for intra and interobserver measurements.

CONCLUSIONS

The optimal method of estimating VS size needs further investigation, and measurements need to be standardized and clearly defined. d3 seems to be the most difficult diameter to measure reliably. Interobserver measurement error for all diameters is greater than 2mm. The current VS growth criterion of more than 1-2mm, used to triage patients to surgery, lies within this error range, and thus is problematic as a guide for clinical practice. We therefore suggest that the growth criterion for VS be redefined.

[Causal analysis and management strategies of cerebrospinal fluid leakage following translabyrinthine approach for acoustic neuromas]

OBJECTIVE

The purpose of the report was to investigate the causes of CSF leakage and discuss the methods for prevention and management of CSF leakage following translabyrinthine resection of acoustic neuromas.

METHODS

A retrospective review of cerebrospinal fluid leakage following translabyrinthine approach for 152 acoustic neuromas patients, from January 1983 to December 2013, was performed. The cases were divided into two groups, traditional and modified closure techniques. The incidence of CSF leakage was compared between the two groups.

RESULTS

The incidence of postoperative CSF leakage by translabyrinthine approach was 5.9% (9/152), with four cases of rhinorrhea, two case of wound leakage, one case of rhinorrhea and otorrhea, one case of otorrhea, and one case of rhinorrhea and wound leakage. The CSF leakage incidence of traditional closure technique was 14.3% (5/35); the incidence of modified closure technique was 3.4% (4/117). After introducing a modified closure technique, the incidence of the CSF leakage significantly decreased.

CONCLUSIONS

As a common complication of translabyrinthine approach, the incidence of CSF leakage is closely related to the closure technique. The incidence of the CSF leakage should decrease dramatically when adopting the modified closure technique.

[Application of modified enlarged translabyrinthine approach in the removal of vestibular schwannoma]

OBJECTIVE

To describe and analyze the surgical outcomes of modified enlarged translabyrinthine approach(ETLA), which is combined with middle ear eradication and blind sac technique.

METHODS

A retrospective study was conducted on 28 patients who underwent surgery for vestibular schwannoma (VS) via modified ETLA from Jan. 2001 to Dec. 2012. The sizes of tumors were 25-52 mm[(38.2 ± 9.1) mm (X(-) ± s)]. Main outcomes measures included the rate of total removal, the rate of cerebral spinal fluid (CSF) leakage after surgery, complications, and intraoperative anatomical preservation of facial nerve and facial nerve function.

RESULTS

Among the 28 patients who underwent modified ETLA, the rate of total removal was 100%. There was no death after surgery via modified ETLA. The rate of CSF leakage after surgery was 3.5% (1/28). The rate of intraoperative anatomical preservation of facial nerve was 89.3% (25/28).Short-term and long-term good facial nerve function rates were 25.0% (7/28) and 42.9% (12/28), respectively.

CONCLUSIONS

Modified ETLA is suitable for VS>3 cm with extension to the anterior region of cerebellopontine angle, VS involve with labyrinth part of facial nerve, high jugular bulb, proposing sigmoid sinus and highly pneumatized temporal bone. This approach can provide a wide surgical field and well prevention of CSF leakage.

Image-guided placement of the Bonebridge™ without surgical navigation equipment

PURPOSE

   Most of the current Bonebridge surgeries undergo preoperative simulation planning in a computer. However, surgeons usually use the landmarks on the bone surface to determine the location where to implant the device, using the simulation image in the computer only as a reference (conventional method). We developed an image-guided method for precisely replicating simulation surgery upon performing Bonebridge implantation.

METHODS

   Based on our previous development of the surface template-assisted marker positioning (STAMP) method for performing image-guided otologic surgery, we fabricated templates that fit only at the designated location on the patient's temporal bone surface. The Bonebridge STAMP (BB-STAMP) plate shows the exact location where to start drilling. The BB-STAMP was also combined with a perforator-guiding sleeve, so that the location, direction and depth of the cylindrical well could be precisely replicated as simulated. We also created a STAMP plate for confirmation that fits only after sufficient drilling at the correct location is finished. To evaluate the proposed methods, we performed simulation surgery on four cadaveric temporal bones and their 12 replicas (three each for four bones). The time used and the degree of mismatch between the simulated location and the drilled location were compared.

RESULTS

   A feasibility study was successfully conducted using the proposed BB-STAMP methods and the conventional method. The amount of time required for the procedure did not differ significantly between the surgical methods, although using the BB-STAMP and perforator guide was always quicker. The degree of mismatch between the simulation and resected models had tendency to be smaller when the surgery was guided by the BB-STAMP with or without a perforator guide, although the difference was not statistically significant.

CONCLUSIONS

   The proposed BB-STAMP is a promising method for replicating exactly what is performed during simulation without using a surgical navigation system.

[The problems of education in otosurgery: the current state-of-the-art]

An overview of the current problems of education in ear surgery is presented. The methods used for the purpose including the classical dissection of the temporal bone, application of synthetic and natural (animal) temporal bones are described alongside with the 3D models of the temporal bone and virtual dissection. In addition, the review covers the problem of enhancing effectiveness of the teaching methods, considers their advantages and disadvantages.

[The potential of simultaneous surgery in rhinology]

The objective of the present work was to analyse the results of simultaneous rhinosurgical interventions and substantiate the possibility of their wider application for the improvement of the outcomes of the treatment of the patients presenting with diseases of the nose and paranasal sinuses. The clinical observations of 1661 patients following rhinosurgical operations are reported. Simultaneous interventions were performed on 756 of them (45.5%); their classification and character are described. The advantages of one-step rhinosurgery are discussed, the relevance and good prospects for the more extensive application of this approach are emphasized.

Herniation of the temporomandibular joint into the external auditory canal: Our review of 13 cases

Symptomatic dehiscence of the anterior wall of the external auditory canal is only occasionally encountered during otologic surgery.

OBJECTIVE

To propose a technical answer for the reconstruction of anterior wall defects based on the size of the dehiscence.

MATERIAL AND METHODS

Retrospective study of 13 cases of dehiscence of the anterior wall (9 male and 4 female patients between 30 and 66 years) operated between 1998 and 2010. The pathologies at the cause of the dehiscence were cholesteatoma (2 cases), chronic otitis externa (3 cases), congenital dehiscence (1 case), 5 cases which appeared after a surgery mainly for exostosis (3 of them previously operated in another center) and 2 cases of accidental breach during canal calibration. The size of the defect measured during surgery was "small" (< 4 mm diameter) in 2 cases, "medium" (between 4 and 8 mm) in 8 cases and "large" in 3 (> 8 mm). The reconstruction was performed in 7 cases through the EAC and in 6 cases an anterior approach of the anterior wall of the EAC was used. In all cases, we could insert a graft anteriorly and this was held in place by the pressure exerted by the temporomandibular joint. Bone paté and temporalis fascia with in most cases a piece of cortical bone graft was used in all cases.

RESULTS

The follow up period ranged from 6 to 24 months. In 10 cases the anatomical result was perfect (in 3 cases we encountered some minor complications but with no clinical consequences). In the other three cases there was one with persistent inflammation of the external auditory canal, one case of recurrence of the lateralization of the tympanic membrane and one case which required a revision surgery.

CONCLUSION

The reconstruction and the approach are done according to the size of the defect, whether small, medium or large. Complications and revision surgeries have been minimal.

Improved intact canal wall radical mastoidectomy with sandwich graft tympanoplasty

CONCLUSIONS

The procedure maximally retains the physiological structure of the middle ear and external auditory canal, thus effectively improving the patient's hearing ability.

OBJECTIVE

We explored the clinical outcomes of treating chronic suppurative otitis media using improved intact canal wall radical mastoidectomy with sandwich graft tympanoplasty.

METHODS

We chose to perform intact canal wall radical mastoidectomy with sandwich graft tympanoplasty in patients with chronic suppurative otitis media. A total of 170 patients were included in the study. Statistical analysis was carried out using software SPSS18.0, adjusted with the chi-squared test.

RESULTS

In all, 140 cases were shown to have been treated effectively (82.35%, 140/170). The increased auditory threshold of preoperative bone conduction was not related to the duration of disease and/or the presence of cholesteatoma (p > 0.05), but was associated with ossicular chain disruption or fixation (p < 0.05), specifically the ossicular chain destruction/absorption, granulation tissue wrapping, and consequent fixation. During the procedure, the sleeve-like pedicle flap of external auditory canal and tympanic membrane is covered with graft, allowing good fixation with maintenance of the tympanic membrane's natural shape. The auditory threshold test revealed equal or above normal levels (30 dB) for 126 cases (74.12%, 126/170). The primary healing rate of tympanic membrane achieved was 96.47% (164/170).

[Reconstruction of bone defects in the earcanal with hydroxyapatite]

Traditional reconstruction methods of osseous defects within the tympanic frame, most often being the atticotomy, within the framework of chronic otitis media surgery, still do not produce stable or definitive results, usually due to displacement or partial lyse of the transplanted material (cartilage, bone ...). The reconstruction procedure with the aid of hydroxyapatite cement as presented by the authors, allows for a complete, stable and definitive reconstruction.

Efficacy of ondansetron alone and ondansetron plus dexamethasone in preventing nausea and vomiting after middle ear surgery

BACKGROUND

Post-operative nausea and vomiting is one of the most frequently occurring side effects affecting one third of the cases. Objective of the study was to compare the efficacy of ondansetron alone and ondansetron plus dexamethasone in preventing postoperative nausea and vomiting after middle ear surgery.

METHODS

This randomized controlled trial was conducted at the Anaesthesia and ENT departments of Ayub Medical College, Abbottabad from January-June 2012. Forty American Society of Anaesthesiologists (ASA) I and 2 physical status patients undergoing middle ear surgery were divided into two groups by blocked randomization. Patients in group-1 (n = 20) received ondansetron 4 mg while group-II (n = 20) received ondansetron 4 mg with dexamethasone 8 mg just before start of operation. The whole postoperative period of 24 hours was divided into two phases, early 0-6 hours and late phase 6-24 hour.

RESULTS

Nausea score and its frequency was significantly higher in Group-I (p < 0.05). Vomiting and its frequency were found more in group-I patients. In Group-II, the nausea score was significantly less (p < 0.01) at 6 and 24 hours after surgery. The total incidence of vomiting was reduced from 28% in group-1 to 6% in group-II. Rescue antiemetic requirement was significantly less (p < 0.01) in group-II.

CONCLUSION

Prophylaxis with a combination of ondansetron and dexamethasone decreased the incidence of nausea and vomiting after middle ear surgery.

Effects of endolymphatic sac decompression surgery on endolymphatic hydrops

CONCLUSIONS

The present findings suggest that complete control of vertigo after endolymphatic sac decompression surgery (ESDS) does not always depend on improved vestibular function or reduced endolymphatic hydrops. Vertigo control is, however, associated with hearing stability.

OBJECTIVE

Among surgical treatments for intractable Meniere's disease, ESDS is performed to preserve and improve inner ear function. We examined the correlation between changes in vertigo frequency and neuro-otologic function to understand the condition of the inner ear in patients whose vertigo was completely controlled after undergoing ESDS.

METHODS

This was a retrospective cross-tabulation study. Between 1997 and 2001, we treated 52 patients with intractable vertigo using ESDS and followed the patients regularly for 2 years. Postoperatively we evaluated and recorded changes in vertigo attack frequency, maximum slow phase eye velocity, worst hearing level, and glycerol test results according to modified American Academy of Otolaryngology-Head and Neck Surgery 1995 criteria.

RESULTS

We found no correlation between vertigo control and vestibular function. There was also no correlation between vertigo control and negative conversion of the glycerol test. There was a significant correlation between vertigo control and hearing control .

Clinical characteristics of spontaneous cholesteatoma of the external auditory canal in children comparing with cholesteatoma in adults

The purpose of this study was to investigate the characteristics of external auditory canal cholesteatoma (EACC) in children through evaluation of the clinical and radiologic features as well as treatment outcomes. The clinical records were retrospectively reviewed for children under 15 years of age diagnosed with spontaneous EACC between March 2004 and December 2011. The clinical data of adults diagnosed with spontaneous EACC during the same period were evaluated to compare with EACC in children. Eight patients (3 males and 5 females) with pediatric EACC and 18 patients (7 males and 11 females, 20 ears) with adult EACC were included within the boundary of the study. The mean ages were 12.4 years (age range 9-15) for pediatric EACC and 49.8 years (age range 29-79) for adult EACC patients. Follow-up periods ranged from 8 to 86 months (mean 32.5 ± 8.62) in pediatric EACC and from 6 to 72 months (mean 22.2 ± 5.36) in adult EACC. Pediatric EACC, showed involvement most commonly in the posterior wall, while the inferior wall was most commonly involved in adult EACC. Pediatric EACC tended to show a more focal involvement and was not as extensive as adult EACC. Extension into the adjacent structures was similar in both groups, but bony destruction was more common in the adult group. Two children and eight adult patients were treated with surgery, but four adult cases needed more extensive surgical treatment because their disease was widely spread to included areas such as the mastoid segment of facial nerve and the temporomandibular joint. Six pediatric cases treated with conservative management showed no progression of disease on physical examination at the last visit, but two cases of adults progressed and required canaloplasty. Pediatric EACC shows less aggressive behavior compared to adult EACC. Adequate management may work better in pediatric than in adult EACC, even though the treatment modality is conservative management.

Meningoencephalocele of the temporal bone: pictorial essay on transmastoid extradural-intracranial repair

PURPOSE

A spontaneous meningoencephalocele of the temporal bone may present with effusion in the middle ear, a cerebrospinal fluid leak, hearing loss, or rarely otitic meningitis. Repair of spontaneous encephaloceles in the temporal bone has been performed using transmastoid and transcranial middle fossa approaches or a combination of the two with varied results. The authors present a technical paper on the transmastoid extradural intracranial approach for the management of temporal lobe encephaloceles.

MATERIALS/METHODS

Case reports and cadaver dissections are used to provide a pictorial essay on the technique. Advantages and disadvantages compared with alternative surgical approaches are discussed.

RESULTS

Traditional transmastoid approaches are less morbid compared with a transcranial repair as they avoid brain retraction. However, in the past, there has been a higher risk of graft failure and hearing loss due to downward graft migration and a potential need for ossicular disarticulation. For the appropriate lesion, the transmastoid extradural intracranial approach lesion offers a stable meningoencephalocele repair without the comorbidity of brain retraction.

CONCLUSION

The authors describe a transmastoid extradural intracranial technique via case reports and cadaver dissections for the repair of spontaneous meningoencephalocele defects larger than 2 cm. This approach provides more support to the graft compared to the conventional transmastoid repair.