Preoperative antibiotics and steroids in vestibular schwannoma excision

Antibiotic Use in Lateral Skull Base Surgery: A Survey of the North American Skull Base Society

Objectives Antibiotic use in lateral skull base surgery (LSBS) has not been thoroughly investigated in the literature. There is wide variability in antibiotic use and insufficient data to guide management. This study aims to describe the factors and patterns influencing antibiotic use in LSBS among the membership of the North American Skull Base Society (NASBS).

Design An online-based survey was designed and distributed to the membership of the NASBS. Data was analyzed using bivariate analysis and logistic regression modeling.

Setting Online-based questionnaire.

Participants NASBS membership.

Main Outcome Measures Use of intraoperative antibiotics and use of postoperative antibiotics.

Results The survey response rate was 26% (208 respondents). Of the 208 total respondents, 143 (69%) respondents performed LSBS. Most respondents are neurosurgeons (69%) with the remaining being otolaryngologists (31%). The majority of respondents (79%) are fellowship-trained in skull base surgery. Academic or government physicians make up 69% of respondents and 31% are in private practice with or without academic affiliations. Bivariate analysis showed that practice setting significantly influenced intraoperative antibiotic use (p = 0.01). Geographic location significantly affected postoperative antibiotic use (p = 0.01). Postoperative antibiotic duration was significantly affected by presence of chronic otitis media, cerebrospinal fluid leak, and surgeon training (p = 0.02, p = 0.01, and p = 0.006, respectively). Logistic regression modeling showed that the motivation to reduce infection significantly impacted postoperative antibiotic use (p = 0.03).

Conclusion This study demonstrates significant variations in intraoperative and postoperative antibiotic use in LSBS among the NASBS membership. Appropriate guidelines for optimal perioperative antibiotic use patterns should be determined with randomized studies in the future.

Betamethasone-enhanced vein graft conduit accelerates functional recovery in the rat sciatic nerve gap

PURPOSE

The objective of the study was to assess the effect of topically administered betamethasone on peripheral nerve regeneration and functional recovery after sciatic nerve transection in the rat.

MATERIALS AND METHODS

Forty-five healthy male white Wistar rats were divided into 3 experimental groups (n = 15), randomly. In the treatment group, a 10-mm sciatic nerve defect was bridged by use of an inside-out vein graft filled with 10 μL betamethasone (0.1 mg/kg) (IOVG/BETA group). In the control group, the vein was filled with phosphate-buffered saline solution alone (IOVG group). In the sham surgery group, the sciatic nerve was exposed with no further deleterious manipulations (SHAM group). Each group was subdivided into 3 subgroups of 5 animals each, and the regenerated nerve fibers were studied 4, 8, and 12 weeks after surgery.

RESULTS

Functional study confirmed faster recovery of regenerated axons in the IOVG/BETA group than in the IOVG group (P < .05). Gastrocnemius muscle mass in the IOVG/BETA group was found to be significantly greater than that in the IOVG group (P < .05). Morphometric indices of the regenerated fibers showed that the number and diameter of the myelinated fibers were significantly higher in the IOVG/BETA group than in the control group (P < .05). By use of immunohistochemistry, the location of reactions to S-100 in IOVG/BETA was clearly more positive than that in the IOVG group.

CONCLUSIONS

When loaded in a vein graft, betamethasone resulted in improvement of functional recovery and quantitative morphometric indices of sciatic nerve. Topical application of this readily available agent offers the benefit of cost savings, as well as avoiding the complications associated with systemic administration.

The efficacy of corticosteroids in postparotidectomy facial nerve paresis

OBJECTIVE

To determine whether the administration of perioperative corticosteroids is effective in ameliorating facial nerve paresis after parotidectomy.

STUDY DESIGN

Prospective, randomized, double-blinded, placebo-controlled clinical trial at a university medical center.

METHODS

Patients scheduled for parotidectomy and who met inclusion criteria were invited to enroll in the protocol. They were stratified according to the anticipated surgery (superficial or total parotidectomy) and then received one of two doses of dexamethasone (0.51 or 1.41 mg/kg divided into three doses) or placebo solution immediately preoperatively and then every 8 hours for 16 hours postoperatively. The facial nerve was graded for proportion (percentage) of function at each of the four major regions (frontal, orbital, midface and upper lip, and lower lip). The early postoperative function and rate of return of function were compared among the treatment groups.

RESULTS

Forty-nine patients were enrolled and evaluated (18 in the control group, 16 receiving low-dose dexamethasone, and 15 receiving high-dose dexamethasone). No therapeutic advantage of dexamethasone treatment could be appreciated with respect to the degree of early postoperative nerve function (81.3% for control patients vs. 69.5% for dexamethasone-treated patients [ =.239]). Similarly, the median time to recovery of complete facial nerve function was 60 days in the control group and was 150 days in the dexamethasone-treated patients.

CONCLUSIONS

Dexamethasone administration in patients undergoing parotidectomy is not justified. Despite the relatively modest risk profile of dexamethasone, we were unable to demonstrate any benefit in patients who were treated with either low-dose or high-dose steroids compared with placebo-treated patients in a randomized, controlled trial.

Implementation of a clinical pathway in management of the postoperative vestibular schwannoma patient

OBJECTIVE

The purpose of the study was to evaluate the effectiveness of a new clinical pathway in management of patients with postoperative vestibular schwannoma. The impact on duration of hospitalization and quality of care was evaluated.

STUDY DESIGN

The study was a retrospective review of 59 consecutive patients undergoing surgical intervention for vestibular schwannoma between January 1995 and July 1999.

METHODS

A new clinical pathway for management of postoperative vestibular schwannoma patients was implemented at The California Ear Institute at Stanford (Palo Alto, CA) in January 1995. All patients undergoing surgical intervention subsequent to initiation of the pathway were included in the study. Data including surgical approach, patient age, sex, and tumor size were included. Duration of hospitalization and postoperative complications were recorded. During the same time period, data for patients undergoing radiation therapy for vestibular schwannomas were evaluated for length of hospital stay and in-hospital complications. Data were compared with norms recorded in the literature for duration of hospitalization and complications following surgical intervention.

RESULTS

Fifty-nine patients underwent 35 middle fossa approaches and 24 translabyrinthine approaches to their tumors. The average patient age was 53 years; there were 34 female and 25 male patients. The average length of hospital stay was 3.83 days (SD = 1.4 days) with a range from 2 to 10 days. Postoperative complications were observed in 19% of patients, including eight (13%) cerebrospinal fluid (CSF) leaks, two requiring lumbar drains (3.4%); one hematoma (1.6%), one postoperative fever (1.6%), and one dural tear with associated hyponatremia (1.6%). These results compared favorably with previously recorded average hospital stays of 5.95 to 9.5 days 1,5-7 and CSF leak complication rates of 7% to 15%.9,10

CONCLUSIONS

Implementation of a clinical pathway for management of the patient with postoperative vestibular schwannoma improves efficiency of patient care, allowing decreased duration of hospitalization. This goal is achieved without increasing complication rates and, in our experience, actually improving the quality of clinical care. The cost-effectiveness of clinical pathways may become increasingly important in a managed care-driven environment.

Role of topical steroids in reducing dysfunction after nerve injury

OBJECTIVE

To determine the efficacy of topical dexamethasone in reducing nerve dysfunction after axonotmesis injury.

STUDY DESIGN

A three-armed, blinded study including sham, control, and test groups was designed using the rat sciatic nerve crush injury model.

METHODS

Twenty-two rats were randomly assigned to a control group or a topical steroid group. A standardized sciatic nerve crush injury was performed under sterile conditions on each animal. A separate group of five rats underwent a sham operation to isolate the crush injury as the source of postoperative dysfunction in the control and steroid groups. All animals underwent walking track analysis with calculation of the sciatic functional index (SFI) before surgery and through the postoperative recovery period. Dexamethasone saturated Gelfoam was placed at the site of injury in the topical steroid group. The functional performance of each group was compared throughout the recovery period.

RESULTS

No morbidity associated with topical application of steroids at the injury site was noted. The topical steroid group had improved recovery at postoperative days 14, 18, and 22. This difference was statistically significant at day 14. At the termination of the study, there was a clear trend toward superior recovery for the steroid group compared with controls (90% vs. 73%), but this difference did not reach statistical significance.

CONCLUSIONS

Clinical use of topical steroids to reduce postoperative nerve dysfunction warrants further study.