Endoscopic Spring-Mediated Distraction for Unilambdoid Craniosynostosis

Calvarial Vault Remodeling Technique for Lambdoid Craniosynostosis

SUMMARY

Premature fusion of the lambdoid suture is the most uncommon single-suture synostosis. It presents with a classic "windswept" appearance, a trapezoid-shaped head, and significant skull asymmetry notable for an ipsilateral mastoid bulge and contralateral frontal bossing. Because of the rarity of lambdoid synostosis, little is known about optimal techniques for its treatment. In particular, the proximity of the lambdoid suture to critical intracranial structures such as the superior sagittal and transverse sinuses represents a potential for significant intraoperative bleeding. Prior work has shown that parietal asymmetry persists after repair in these cases. In this article, the authors present a technique for the treatment of unilateral lambdoid craniosynostosis along with two representative cases. This calvarial vault remodeling technique requires the removal of both ipsilateral and contralateral parietal bones. These are moved across hemispheres and reinset on opposite sides to help correct the parietal asymmetry. Obliquely orientated barrel stave osteotomies are performed to provide a safe mechanism for correction of occipital flattening. The authors' early results show improvement in correction of volume asymmetry 1 year postoperatively relative to patients treated with prior calvarial vault remodeling techniques. The authors believe the technique presented here corrects the windswept appearance in patients with lambdoid craniosynostosis and also reduces the potential for complications. Further work will be necessary to confirm this technique's long-term efficacy in a larger cohort.

Spring-Assisted Surgery of Unilambdoid Craniosynostosis

Craniosynostosis is traditionally treated with extensive cranial vault reconstructions (CVRs). Although less invasive techniques, such as endoscopic strip craniectomy with postoperative helmet therapy, have been successful, they also present difficulties. An alternative method is distraction osteogenesis using either manually controlled devices or specially designed springs. In this study, the authors provide the first comparison of spring-assisted surgery (SAS) with CVR for the treatment of unilambdoid synostosis (ULS). Fourteen consecutive patients (8 CVR and 6 SAS) treated for ULS at Sahlgrenska University Hospital between 2005 and 2018 were included. Skull shape and deviations were evaluated using previously defined measurement points on 3-dimensional computed tomography scans preoperatively, at spring removal, and at 3 years of age. Posterior and middle cranial fossa (PCF and MCF, respectively), skull-base cant, facial twist, and mastoid bulge (MB) were measured, and clinical data were obtained from chart reviews. The results indicated that at the 3-year follow-up, PCF, MCF, and MB improved in both groups, with no significant difference in outcome observed between methods. In the SAS group, duration of operation [61±27 min (mean±SD)] and perioperative bleeding (3.5±2.8 mL/kg body weight) were both significantly lower relative to the CVR group (P<0.05). These findings showed that both SAS and CVR resulted in similar improvements in treating ULS, although neither produced complete normalization of skull shape. The results suggest that early diagnosis and operation allow less extensive SAS to be performed without adversely affecting the results.

Management of Sagittal and Lambdoid Craniosynostosis: Minimally Invasive Approaches

The resurgence of strip craniectomies began in the mid-1990s with advances in surgical technique and anesthesia coupled with the critical observation that earlier interventions benefitted from an easily molded skull. Jimenez and Barone's pioneering introduction of endoscopic approaches to strip craniectomies coupled with postoperative helmeting in newborns and young infants and Claes Lauritzen's introduction of spring-mediated cranioplasty began the era of minimally invasive approaches in the surgical correction of craniosynostosis. This article provides technical descriptions of these treatment modalities, a comparative literature review, and our institutional algorithms for the correction of sagittal craniosynostosis and unilambdoid craniosynostosis.

Comparison of endoscopic and microscopic tympanoplasty in patients with chronic otitis media

BACKGROUND

To compare the results between type I tympanoplasty performed with transcanal endoscopic ear surgery (TEES) and microscopic ear surgery (MES) for treatment of chronic otitis media in a homogenous group of patients.

METHODS

A retrospective study was performed in our department between January 2011 and January 2016 to review primary type I tympanoplasty cases with a subtotal perforation, an intact ossicular chain, a dry ear for at least 1 month, normal middle ear mucosa, and a follow-up period of at least 6 months post surgery. The adoption of TEES or MES was divided temporally (before and since 2013). TEES was undertaken in 224 patients (224 ears) and MES in 121 patients (121 ears).

RESULTS

The successful graft take rate was 94.64% (212/224) in the TEES group and 90.91% (110/121) in the MES group (P = 0.239). The improvements in the air conduction levels between the 2 groups were not statistically different at 1, 3, or 6 (> 6) months (P > 0.05) after surgery. The improvements in the air-bone gaps were not significantly different between the 2 groups (P > 0.05). The average hearing gains in the TEES group 6 (and > 6) months post surgery were 11.85 ± 5.47 dB, which was better than 10.48 ± 5.18 dB in the MES group (P = 0.031). The use of medical resources was lower in the TEES group than in the MES group regarding the average operating time (49.22 ± 8.24 min vs 81.22 ± 14.73 min, respectively; P < 0.0001). Patients receiving MES had a significant higher incidence of the wound problems (ear pain, numbness around the ears, and wet ear; P < 0.05).

CONCLUSION

TEES for type I tympanoplasty seems to achieve a shorter operative time and ideal tympanic membrane healing rate and hearing results in patients with chronic otitis media.

Management of Lambdoid Craniosynostosis: A Comprehensive and Systematic Review

BACKGROUND

Craniosynostosis is a condition characterized by the premature fusion of 2 or more skull bones. Craniosynostosis of the lambdoid suture is one of the rarest forms, accounting for 1-4% of all craniosynostoses. Documented cases are separated into simple (single suture), complex (bilateral), and associated with adjacent synostoses ("Mercedes Benz" Pattern) or syndromes (i.e., Crouzon, Sathre-Chotzen, Antley-Bixler). This condition can manifest phenotypic deformities and neurological sequelae that can lead to impaired cognitive function if improperly treated or left undiagnosed. Preferred surgical techniques have varied over time but all maintain the common goals of establishing proper head shape and preventing of complications that could contribute to aforementioned sequelae.

SUMMARY

This comprehensive review highlights demographic distributions, embryological development, pathogenesis, clinical presentation, neurological sequelae, radiologic findings, surgical techniques, surgical outcomes, and postoperative considerations of patients with lambdoid craniosynostosis presentation. In addition, a systematic review was conducted to explore the operative management of lambdoid craniosynostosis using PubMed, Embase, and Scopus databases, with 38 articles included after screening. Key Messages: Due to a low volume of published cases, diagnosis and treatment can vary. Large overlap in presentation can occur in patients that display lambdoid craniosynostosis and posterior plagiocephaly, furthering the need for comprehensive analysis. Possessing the knowledge and tools to properly assess patients with lambdoid craniosynostosis will allow for more precise care and improved outcomes.