Frequency of cul-de-sac obliteration in surgery for pelvic organ prolapse: a retrospective analysis

INTRODUCTION AND HYPOTHESIS

We aimed to clarify the frequency of cul-de-sac obliteration in patients undergoing POP surgery.

METHODS

We retrospectively reviewed patients who underwent laparoscopic POP surgery at our hospital between April 2017 and September 2021.

RESULTS

In total, 191 cases were included in the analysis. Ten patients (5.2%) had cul-de-sac obliteration. No difference in age (73 years vs. 72 years, P = 0.99), parity (2 vs. 2, P = 0.64), or body mass index (BMI) (25.7 kg/m2 vs. 24.7 kg/m2, P = 0.34) was observed between the cul-de-sac obliteration and normal groups. No significant differences were observed in the rate of previous abdominal surgery (50.0% vs. 32.6%, P = 0.46), rate of POP - quantification system (POP-Q) ≥ 2 posterior prolapse (40.0% vs. 46.4%, P = 0.98), and effect of defecation symptoms on the prolapse quality of life (p-QOL) score (vaginal bulge emptying bowels: 2.5 vs. 3.5, P = 0.15; empty bowel feeling: 3 vs. 3, P = 0.72, constipation: 3.5 vs. 3, P = 0.58; straining to open bowels: 3.5 vs. 3, P = 0.82; empty bowels with fingers: 1 vs. 1, P = 0.55) between the cul-de-sac obliteration and normal groups. Multivariate analysis of risk factors for the cul-de-sac obliteration was performed for age, number of births, previous abdominal surgery, and presence of rectocele; however no significant risk factors were extracted.

CONCLUSION

Predicting cul-de-sac obliteration preoperatively in patients undergoing POP surgery based on age, number of previous surgeries, previous abdominal surgeries, rectocele, and defecation symptoms is difficult.

Management of frontal sinus trauma: a retrospective study of surgical interventions and complications

BACKGROUND

Frontal sinus injuries are relatively rare among facial bone traumas. Without proper treatment, they can lead to fatal intracranial complications, including meningitis or brain abscesses, as well as aesthetic and functional sequelae. The management of frontal sinus injuries remains controversial, with various treatment methods and outcomes being reported. This article describes the clinical characteristics, surgical methods, and outcomes among 17 patients who underwent surgery for frontal sinus injury and related complications.

CASE PRESENTATION

We retrospectively included 17 patients who underwent surgery for frontal sinus injury and its related complications at the Kangwon National University Hospital between July 2010 and September 2021. Among them, six underwent simple open reduction and fixation of the anterior wall, eight underwent sinus obliteration, and three underwent cranialization. Two patients who underwent sinus obliteration died due to infection-related complications. The patient who underwent cranialization reported experiencing chronic headache and expressed dissatisfaction regarding the esthetic outcomes of the forehead. Except for these three patients, the other patients achieved satisfactory esthetic and functional recovery.

CONCLUSION

Active surgical management of frontal sinus injuries is often required owing to the various complications caused by these injuries; however, several factors, including the fracture type, clinical presentation, related craniomaxillofacial injury, and medical history, should be considered while formulating the treatment plan. Surgical treatment through the opening of the frontal sinus should be actively considered in patients with severely damaged posterior wall fractures and those at risk of developing infection.

Recurrence of Cerebral Arteriovenous Malformation Following Complete Obliteration Through Endovascular Embolization

Arteriovenous malformation (AVM) recurrence after embolization was rarely reported. This study aimed to explore the potential risk factors of recurrence in angiographically obliterated AVMs treated with endovascular embolization. This study reviewed AVMs treated with embolization only in a prospective multicenter registry from August 2011 to December 2021, and ultimately included 92 AVMs who had achieved angiographic obliteration. Recurrence was assessed by follow-up digital subtraction angiography (DSA) or magnetic resonance imaging (MRI). Hazard ratios (HRs) with 95% confidence intervals were calculated using Cox proportional hazards regression models. Nineteen AVMs exhibited recurrence on follow-up imaging. The recurrence rates after complete obliteration at 6 months, 1 year, and 2 years were 4.35%, 9.78%, and 13.0%, respectively. Multivariate Cox regression analysis identified diffuse nidus (HR 3.208, 95% CI 1.030-9.997, p=0.044) as an independent risk factor for recurrence. Kaplan-Meier analysis confirmed a higher cumulative risk of recurrence with diffuse nidus (log-rank, p=0.016). Further, in the exploratory analysis of the effect of embolization timing after AVM rupture on recurrence after the complete obliteration, embolization within 7 days of the hemorrhage was found as an independent risk factor (HR 4.797, 95% CI 1.379-16.689, p=0.014). Kaplan-Meier analysis confirmed that embolization within 7 days of the hemorrhage was associated with a higher cumulative risk of recurrence in ruptured AVMs (log-rank, p<0.0001). This study highlights the significance of diffuse nidus as an independent risk factor for recurrence after complete embolization of AVMs. In addition, we identified a potential recurrent risk associated with early embolization in ruptured AVMs.

CyberKnife based fractionated stereotactic radiotherapy as an upfront treatment for cerebral arteriovenous malformation

BACKGROUND

To explore the therapeutic outcomes of CyberKnife based fractionated stereotactic radiotherapy (CKFRT) for patients with cerebral arteriovenous malformations (AVM).

METHODS

Between January 2008 and October 2020, 45 patients underwent CKFRT for cerebral AVMs as a first treatment. The delineation of AVM targets included AVM nidus. The mean target volume was 4.07 cm3, and 9 lesions (20%) were larger than 10.0 cm3. The mean marginal dose was 24 Gy (range, 20-35 Gy). CKFRT was delivered in median 3 fractions (range, 2 ∼ 5 fractions). AVM obliteration following CKFRT was confirmed by magnetic resonance imaging or angiography.

RESULTS

During a median follow-up of 47 (5-148) months, complete obliteration and partial obliteration of AVM after CKFRT were obtained in 23 (51%) and 13 (29%) patients, respectively. Median time to complete obliteration was 39 (15-63) months. The cumulative probability of complete obliteration rate at 3 years was 47%. Complete obliteration rate of AVM was associated with Radiosurgery-based AVM score, which was consisted of AVM volume, patients age, and AVM location. One (2%) patient had hemorrhage during the follow-up period.

CONCLUSIONS

CKFRT is an effective primary treatment for patients with cerebral AVMs with a low hemorrhage risk.

Correlation Between Post-Radiosurgery Perinidal Hyperintensity and AVM Obliteration Following LINAC-Based Stereotactic Radiosurgery

OBJECTIVE

We studied the correlation between new-onset perinidal hyperintensity (PH) on T2-weighted magnetic resonance imaging and obliteration of intracranial arteriovenous malformation (AVM) after stereotactic radiosurgery (SRS).

METHODS

A retrospective study of 148 patients with an intracranial AVM who underwent SRS between September 2005 and June 2018 and had ≥1 radiological follow-up (early magnetic resonance imaging) 12-18 months after SRS was performed to analyze the correlation between PH (graded from 0 to 2) and AVM obliteration.

RESULTS

Of the 148 patients, 95 were male. The mean patient age was 27.7 ± 12.4 years. Of the 148 AVMs, 105 (70.9%) were obliterated at a median follow-up of 27 months (interquartile range, 14-48 months). The cumulative 3-, 5-, 10-year obliteration rate was 51.8%, 70.8%, and 91.8%, respectively. New-onset PH was observed in 58 AVMs (39.2%; 50 obliterated and 8 not obliterated). No association was found between the pretreatment variables or dose delivered and the development of PH. Grade 2 PH was associated with the risk of symptoms developing compared with grade 1 PH (37.5% vs. 4%; P = 0.002). Symptomatic PH was more likely to develop in patients with a larger AVM (P = 0.05). On multivariate analysis, the presence of a single draining vein (odds ratio [OR], 2.9; 95% confidence interval [CI], 1.3-6.8), a lower median AVM volume (OR, 0.97; 95% CI, 0.6-0.89), a mean marginal radiation dose (OR, 1.29; 95% CI, 1.02-1.64), and the presence of PH (OR, 3.16; 95% CI, 1.29-7.71) were independent predictors of AVM obliteration.

CONCLUSIONS

The incidence of PH after SRS for AVM was 39.2%. PH was an independent predictor of AVM obliteration after SRS. Grade 2 PH and a larger AVM volume were associated with symptomatic PH.

Three-dimensional micromorphology of human midpalatal suture and pterygomaxillary articular complex

BACKGROUND

Sutures exist in the craniofacial area, and the pattern of maturation and synostosis of facial sutures is largely unknown.

METHODS

For a comprehensive understanding of the three-dimensional circummaxillary suture micromorphology, human midpalatal suture (MPS) and pterygomaxillary articular complex from eight subjects' (five males, three females, 72-88 years old) autopsies were longitudinally scanned with microcomputed tomography. Additional histology was performed for hematoxylin and eosin staining. Sutural micromorphology was assessed by interdigitation index (II), obliteration index (OI) and obliteration number. Intergroup comparisons were performed with Kruskal-Wallis and Mann-Whitney U with Bonferroni correction (α = 0.005). Correlation with anteroposterior and craniocaudal gradients was assessed with Spearman's correlation test (α = 0.05).

RESULTS

Maxillary region of MPS presented a higher II 1.50 (0.61) and obliteration number per slice 8 (9) (P < 0.005). OI was increased in palatomaxillary 35% (47%) followed by pterygopalatine suture 25% (49%) (P < 0.005). The II and OI of the MPS exhibited only a weak anteroposterior gradient, with relatively low correlations. Obliteration areas were found sporadically along the entire MPS.

CONCLUSIONS

Based on these findings, it is conceivable that the success of nonsurgical maxillary expansion largely depends on individual variations in sutural morphology and maturation rather than appliance design.

Long-Term Follow-Up of Cerebral Aneurysms Completely Occluded at 6 Months After Intervention with the Woven EndoBridge (WEB) Device: a Retrospective Multicenter Observational Study

The Woven EndoBridge (WEB) device has been widely used to treat intracranial wide neck bifurcation aneurysms. Initial studies have demonstrated that approximately 90% of patients have same or improved long-term aneurysm occlusion after the initial 6-month follow up. The aim of this study is to assess the long-term follow-up in aneurysms that have achieved complete occlusion at 6 months. We also compared the predictive value of different imaging modalities used. This is an analysis of a prospectively maintained database across 13 academic institutions. We included patients with previously untreated cerebral aneurysms embolized using the WEB device who achieved complete occlusion at first follow-up and had available long-term follow-up. A total of 95 patients with a mean age of 61.6 ± 11.9 years were studied. The mean neck diameter and height were 3.9 ± 1.3 mm and 6.0 ± 1.8 mm, respectively. The mean time to first and last follow-up was 5.4 ± 1.8 and 14.1 ± 12.9 months, respectively. Out of all the aneurysms that were completely occluded at 6 months, 84 (90.3%) showed complete occlusion at the final follow-up, and 11(11.5%) patients did not achieve complete occlusion. The positive predictive value (PPV) of complete occlusion at first follow was 88.4%. Importantly, this did not differ between digital subtraction angiography (DSA), magnetic resonance angiography (MRA), or computed tomography angiography (CTA). This study underlines the importance of repeat imaging in patients treated with the WEB device even if complete occlusion is achieved short term. Follow-up can be performed using DSA, MRA or CTA with no difference in positive predictive value.

Cholesteatoma surgery in the pediatric population: remaining challenges in the era of mastoid obliteration

PURPOSE

To present the first pediatric study on the safety and efficacy of mastoid obliteration using S53P4 bioactive glass (BAG) for cholesteatoma surgery.

METHODS

A single-center retrospective cohort study was conducted. Inclusion criteria were pediatric cases (≤ 18 years) and at least at least one year of follow-up including non-echo planar diffusion-weighted MRI to assess cholesteatoma recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were evaluated.

RESULTS

A total of 61 cases (56 patients) were included. Most cases had an otologic history before the development of the cholesteatoma. CWU procedure was performed in 18 cases (30%) and CWD procedure in 43 cases (70%). The cholesteatoma recidivism rate was 33% after a mean follow-up period of 58 months. Kaplan-Meier curve estimated a 5-year recidivism rate of 40%. Few complications were seen that were all minor and resolved spontaneously or after local or systemic treatment. Control of the infection (merchant grade 0-1) was achieved in 98% of the cases. Closure of the air-bone gap within 20 dB was achieved in 22% of the cases with complete audiometric evaluation.

CONCLUSION

In this MRI-controlled study, we show the safety and efficacy of S53P4 BAG for mastoid obliteration in a pediatric cholesteatoma cohort. Postoperative complications were both rare and minor, and a dry ear was achieved in almost all patients. Nevertheless, persistent hearing loss and the apparent high recidivism rate reflect the challenging nature of pediatric cholesteatoma.

Comparison of Outcomes of Open Mastoid Cavity- with or Without Obliteration

For a chronically discharging ear open mastoidectomy is the mainstay of treatment, however it can cause high morbidity due a large cavity and complications like discharge, vertigo and difficulty with hearing aids. To avoid such problem, obliteration of mastoid cavity is done. The objective of our study was to compare the post-operative complains, the hearing results and outcomes of open and closed mastoid cavity. The present prospective study was conducted on 40 patients having attico-antral disease in middle ear cleft. Patients were randomly divided into two groups of 20 each. Out of 40 patients, in 20 patients (Group A) mastoid obliteration was done using conchal cartilage, whereas in other 20 patients (Group B) canal wall down mastoidectomy without mastoid obliteration was done i.e.an open cavity. The patients were followed up post-operatively at 6th week, 3rd month and 6th month. Study Design: comparative study. On Pure Tone Audiometry, 13 (65%) patients with closed mastoid cavity had Air-bone Gap < 30 dB, 7 (35%) were in the range 30-60 dB as compared to open mastoid cavity where 10 (20%), 8 (40%), 2(10%) patients had ABG < 30db, 30-60 dB, and > 60 dB respectively, showing better hearing results in obliterated cavities, healing was also better. In obliterated mastoid cavities, there were very few complications of pain, discharge, and giddiness compared to open cavities. Healing as shown by epithelisation was earlier and better in obliterated cavities. Hearing results were better in mastoid cavities with obliteration compared to open cavities. Patients with obliterated mastoid cavity need less cavity care and doctor dependence.

Linac-based stereotactic radiosurgery for brain arteriovenous malformations

PURPOSE

Linac stereotactic radiosurgery (SRS) is gaining popularity as a form of radiation treatment for cerebral arteriovenous malformations (AVMs) since the theory of combined radiosurgical and endovascular treatment poses much uncertainty and due to significant technical progress for SRS. This study focuses on how to evaluate obliteration and re-bleeding rates, and to determine factors and adverse effects influencing obliteration after linac-based SRS for cerebral AVMs.

MATERIAL AND METHODS

From a statistical record of 71 patients, 31 had partial embolisation, five surgery and 29 had no prior treatment. Using Kaplan-Meier survival and life table analyses, actuarial obliteration and annual bleeding hazard rates were calculated after SRS.

RESULTS

After a follow up of 1, 2 and 3 years the actual obliteration rates were 22, 59 and 66%, respectively whereby it was noted that prior embolization had no effect on the obliteration rate. Annual bleeding hazard rates were further analyzed after stereotactic radiosurgery to be 2.1% and 1.4% for the first and second year respectively. Asymptomatic abnormalities were detected after imaging in 33.9% of patients. A dose of less than 18 Gy significantly reduced the obliteration probability.

CONCLUSION

SRS is a therapeutic option for intracerebral AVM. In general, there is a low rate of morbidity and a high probability of nidus obliteration.

LINAC stereotactic radiosurgery for brain arteriovenous malformations: An updated single centre analysis of outcomes

Arteriovenous malformations (AVM) of the brain are congenital, high pressure vascular malformations, which are at risk of haemorrhage. Stereotactic radiosurgery (SRS) can obliterate the nidus by delivering a precise high dose of ionising radiation in a single fraction. This paper updates long term AVM obliteration rates, time to obliteration and retreatment outcomes in LINAC delivered SRS treatment at the Royal Adelaide Hospital. A retrospective review of a prospectively maintained AVM SRS database supplemented by clinical case notes, patient correspondence and electronic medical records was performed. 89 AVMs received primary SRS treatment for which the crude obliteration rate was 61% (68% for 79 patients with adequate follow up). Higher marginal dose, smaller nidus size and lower Pollock-Flickinger (PF) score were significantly associated with AVM obliteration. The crude obliteration rates for patients with adequate follow-up and AVM diameter < 3 cm vs ≥ 3 cm were 76% vs 48%, respectively, and 93% with PF score < 1.0. Median time to obliteration was 36 months. Higher dose and lower PF score were associated with earlier obliteration. The crude obliteration rate after second SRS was 56% (9/16 patients) and no significant associations were found. These obliteration rates after primary and retreatment LINAC SRS are comparable to other studies. Marginal dose and PF score were the main predictors of obliteration overall as well as early (<36 months) obliteration.

Intracranial arteriovenous malformations

The treatment of arteriovenous malformations (AVMs) has evolved over the last 10 years. It is now possible to see that obliteration continues for up to 10 years and that the final obliteration rate may be between 85% and 90%. Improved imaging has made the treatment more efficient and has reduced the complications. It is possible to treat larger AVMs in a single session than was previously thought possible without increases in the complication rates. In addition, treatments of larger lesions can be staged. The use of 3D rotating angiography produces remarkable images which can be imported into GammaPlan. On the other hand efforts are ongoing to avoid the need for digital subtraction angiography, which would make the treatment a lot more comfortable.

Revision surgery for chronically discharging mastoid cavities: mastoid obliteration with canal wall reconstruction versus non-obliteration surgery

Purpose

To evaluate the surgical results of revision canal wall down (CWD) surgery for chronically discharging mastoid cavities and to compare the non-obliteration approach to mastoid obliteration with canal wall reconstruction.

Methods

This is a retrospective cohort study. All adult patients (≥ 18 years) who underwent revision surgery for chronically draining mastoid cavities between January 2013 and January 2020 were included. Primary outcome measures included the dry ear rate, complications and postoperative hearing.

Results

79 ears were included; 56 ears received revision CWD with mastoid obliteration and posterior canal wall reconstruction and 23 ears received CWD without mastoid obliteration. The dry ear rate at the most recent outpatient clinic visit (median 28.0 months postoperative) was significantly higher in the obliteration group with 96.4% compared to 73.9% for the non-obliteration group (p = .002). There were no differences in audiological outcome and incidence of complications between the two techniques.

Conclusion

We show that in our study population revision CWD surgery with mastoid obliteration and posterior canal wall reconstruction is superior to revision CWD surgery without mastoid obliteration in the management of chronically discharging mastoid cavities. In the obliteration group, a dry ear was achieved in 96.4% as this was 73.9% in the non-obliteration group. We found no differences in audiological outcome and in incidence of complications between the two techniques.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00405-021-07138-0.

Effect of Prior Embolization on Outcomes After Stereotactic Radiosurgery for Pediatric Brain Arteriovenous Malformations: An International Multicenter Study

BACKGROUND

Pediatric brain arteriovenous malformations (AVMs) are a significant cause of morbidity but the role of multimodal therapy in the treatment of these lesions is not well understood.

OBJECTIVE

To compare the outcomes of stereotactic radiosurgery (SRS) with and without prior embolization for pediatric AVMs.

METHODS

We retrospectively evaluated the International Radiosurgery Research Foundation pediatric AVM database. AVMs were categorized, based on use of pre-embolization (E + SRS) or lack thereof (SRS-only). Outcomes were compared in unadjusted and inverse probability weight (IPW)-adjusted models. Favorable outcome was defined as obliteration without post-SRS hemorrhage or permanent radiation-induced changes (RIC).

RESULTS

The E + SRS and SRS-only cohorts comprised 91 and 448 patients, respectively. In unadjusted models, the SRS-only cohort had higher rates of obliteration (68.5% vs 43.3%,  < .001) and favorable outcome (61.2% vs 36.3%, P < .001) but a lower rate of symptomatic RIC (9.0% vs 16.7%, P = .031). The IPW-adjusted rates of every outcome were similar between the 2 cohorts. However, cumulative obliteration rates at 3, 5, 8, and 10 yr remained higher in the absence of prior embolization (46.3%, 64.6%, 72.6%, and 77.4% for SRS-only vs 24.4%, 37.2%, 44.1%, and 48.7% for E + SRS cohorts, respectively; SHR = 0.449 [0.238-0.846], P = .013).

CONCLUSION

Embolization appears to decrease cumulative obliteration rates after SRS for pediatric AVMs without affecting the risk of post-treatment hemorrhage or adverse radiation effects arguing against the routine use of pre-SRS embolization. While endovascular therapy can be considered for occlusion of high-risk angioarchitectural features prior to SRS, future studies are necessary to clarify its role.

Direct N-butyl-2-cyanoacrylate injections to the head and neck for percutaneous embolized devascularization

Background:

N-butyl-2-cyanoacrylate (NBCA) has been used for vascular malformations since the 1980s; however, few studies have looked at applications, procedural techniques, and outcome throughout many institutions. Herein, we review applications, procedural techniques, previous literature, and outcomes for the use of NBCA specifically through percutaneous technique in treating head and neck vascular pathology.

Methods:

An extensive literature review using PubMed database with published literature containing “N-butyl-2-cyanoacrylate embolization,” was performed. No date restrictions were used. Cross-checking of articles was conducted to exclude duplicate articles. The articles were screened for their full text and English language availability. We finalized those articles pertaining to the topic.

Results:

The search yielded 1124 related articles. When comparing surgical resection to embolization with NBCA for cerebral AVMs, complications were similar in both groups and included hemorrhage (15%), residual AVM (6%), and cerebrospinal fluid leak (3%). Their mortality rate was 3% in both groups. Preoperative percutaneous embolization does show improved surgical outcomes.

Conclusion:

NBCA is a fast-acting liquid embolic material used in the treatment of a variety of vascular malformations and lesions of the head and neck. Investigations surrounding the use of NBCA injections as a new alternative embolic agent began in the 1980’s. Administration of NBCA has been shown to be useful in minimizing intraoperative blood loss and controlling acute hemorrhage. Performing percutaneous embolization with NBCA provides a successful alternative for surgeons when transcatheter embolization techniques may prove to be too difficult to perform. Embolization using NBCA will continue to play in integral role in the treatment of malignant lesions and vascular malformations. Continued research is warranted to improve safety, outcomes, and further develop clinical applications of NBCA.

A stepwise approach to open surgery for the frontal sinus

BACKGROUND

Despite advances in endoscopic techniques, there are still instances when the frontal sinus must be approached externally. Given its variable anatomy, the frontal sinus continues to present a challenge to the surgeon. Our rule of thumb capitalises on the consistent embryological development of the frontal sinus, aiding safe external access.

METHODS AND RESULTS

The presented stepwise approach includes trephination, fenestration, an osteoplastic flap and obliteration. The obliteration procedure has produced good results in managing those patients with disabling symptoms despite multiple endoscopic procedures.

Magnetic Resonance Perfusion Changes of Arteriovenous Malformations Treated with Stereotactic Radiosurgery

BACKGROUND

The latency period from stereotactic radiosurgery (SRS) to obliteration of arteriovenous malformations (AVM) requires continuous imaging surveillance. Magnetic resonance (MR) perfusion is promising for noninvasive monitoring of AVMs after SRS. We studied longitudinal MR perfusion changes of brain AVMs treated with SRS.

METHODS

Consecutive patients treated for brain AVMs using SRS who had MR perfusion imaging studies performed before and at least once after SRS were studied. We estimated ipsilateral/contralateral brain hemisphere ratios of MR perfusion indexes, including regional cerebral blood flow (rCBF) and relative cerebral blood volume (rCBV), in the AVM nidus, perinidal region, and remote anterior and posterior brain regions.

RESULTS

Eleven patients (6 women; median age, 21 years) underwent SRS (median prescription dose, 18 Gy; range, 12-20 Gy) for brain AVMs (median Spetzler-Martin grade 2 and median volume 4.6 mL). Before the SRS, rCBV and rCBF ratios were significantly higher in the AVM nidus compared with other investigated brain regions (P < 0.001). Median time from SRS to the first and last post-SRS MR perfusion studies was 8 and 35 months, respectively. There was a statically significant decrease of rCBV (P = 0.043) and rCBF (P = 0.036) ratios in the AVM nidus, but not other brain regions, during post-SRS follow-up.

CONCLUSIONS

There is a gradual decrease of rCBV and rCBF in the AVM nidus after SRS. MR perfusion imaging is promising for monitoring of hemodynamic changes of AVMs after SRS. Larger studies investigating clinical value of MR perfusion imaging for AVMs after SRS are warranted.

Endoscopic management of frontal sinus diseases after frontal craniotomy: a case series and review of the literature

PURPOSE

To evaluate frontal sinus complications developed after previous external craniotomies requiring frontal sinus reconstruction and their treatment with an endoscopic approach.

METHODS

We retrospectively evaluated 22 patients who referred to Sant'Orsola-Malpighi University Hospital and Bellaria Hospital (Bologna, Italy) between 2005 and 2017. All patients presented with frontal sinus disease after frontal craniotomy with sinus reconstruction performed to treat various pathological conditions. We reported our experience in the endoscopic management of such complications and we reviewed the current literature concerning the endoscopic treatment of these conditions.

RESULTS

In total, 14 frontal mucoceles, 4 cases of chronic frontal sinusitis, 2 mucopyoceles and 2 fungus ball of the frontal sinus were identified. Endoscopic surgical treatment included 7 DRAF IIa, 1 DRAF IIb, 11 DRAF III and 3 DRAF IIc (modified DRAF III) approaches. The success rate of the surgical procedure was 86% (19/22 patients). Recurrence of the initial pathology occurred in three patients (14%) requiring a conversion of previous frontal sinusotomy into a DRAF III sinusotomy.

CONCLUSION

Frontal sinusopathy can be a long-term complication following craniotomies and may lead to potentially severe pathological conditions, such as mucoceles and frontal sinus inflammation. Its management is still debated and requires recovery of the patency of nasal-frontal route. Our study confirms that the endoscopic endonasal approach may offer a valid solution with low morbidity avoiding re-opening of the craniotomic access. For selected cases, endoscopic approach could also be performed simultaneously to craniotomy as a combined surgery to reduce the risk of short- and long-term complications. Long-term follow-up is mandatory in patients with a history of opened and reconstructed frontal sinus and should include imaging and endoscopic outpatient evaluation.

The bony obliteration tympanoplasty in cholesteatoma: safety, hygiene and hearing outcome: allograft versus autograft tympanic membrane reconstruction

OBJECTIVE

To evaluate early results on hygiene, safety and functional outcome in a population undergoing a canal wall up technique with bony obliteration of the mastoid and epitympanic space (CWU-BOT) for extensive cholesteatoma, performed by a single surgeon. This study compares different techniques of tympanic membrane reconstruction, viz. allografts and autografts.

PATIENTS

A consecutive series of 61 ears with acquired cholesteatoma treated with primary or revision CWU-BOT surgery from 2009 to 2014.

INTERVENTION

Obliteration was performed by the use of cortical bone-chips and bone pâté. Patients were followed up with micro-otoscopy and MRI with diffusion-weighted imaging. Ossicular reconstruction was performed using a remodelled autologous or allogenic incus or malleus.

MAIN OUTCOME MEASURES

Residual and recurrence rate and short- and mid-term hearing outcome prior to any revision tympanoplasty were analysed, the effect of type of tympanic membrane reconstruction was considered.

RESULTS

44 Ears were primary cholesteatoma cases, 17 cases were referred for revision surgery. Mean postoperative follow up was 45 months (SD 18.08) and mean follow-up until the last non-EP DW MRI 42 months (SD 17.72). Recurrent disease was present in 3%, no residual disease was present. An AC gain was seen in 75% of all ears undergoing ossicular reconstruction.

CONCLUSION

Reproducible safety, hygiene and hearing results with limited recurrence and residual disease can be obtained by younger otologic surgeons performing the BOT-CWU for extensive cholesteatoma while using a variety of grafts for tympano-ossicular reconstruction. The tympano-ossicular allograft nevertheless shows superior hearing results when a mobile intact stapes is present.

LEVEL OF EVIDENCE

Level 4.

Subtotal Petrosectomy in Cochlear Implant Surgery: Our Experience

Aims

Subtotal petrosectomy (SP) with cochlear implant (CI) is required in certain specific situations in the management of patients who are candidates for cochlear implants. To study and review the indications, surgical issues, and complications of this procedure.

Materials and Methods

Retrospective review of all patients who underwent subtotal petrosectomy with cochlear implant during the period January 2010-December 2016 at a tertiary care and referral centre.

Results

19 patients underwent 20 subtotal petrosectomy with cochlear implant during this period. One patient had simultaneous bilateral implantation. The indications were previous mastoid cavity in 7 patients, 5 patients had chronic otitis media, inner ear malformations in 3,ossified cochlea in 3 and unfavourable anatomy in 2 patients. Fat or musculoperiosteal flaps were used to obliterate the cavity. Ninety percent of patients underwent single stage surgery and ten percent underwent two stage procedure.Complications were seen in three patients (15%).

Conclusion

SP helps in isolating the cavity from external environment after removal of disease, improves the exposure and access, reduces risk of infection and cerebrospinal fluid (CSF) leaks and facilitates CI. Meticulous surgical technique will reduce the complications and long term follow up is needed to detect entrapped cholesteatoma. Subtotal petrosectomy with blind sac closure of external ear canal is required in certain specific situations. It is a safe and effective surgery with acceptable rate of complications.

Mastoid cavity obliteration leads to a clinically significant improvement in health-related quality of life

Objective

To assess the change in health-related quality of life (HRQoL) in patients undergoing mastoid cavity obliteration.

Methods

Patients who had undergone canal wall-down mastoidectomy for chronic otitis media with creation of a persistent mastoid cavity and underwent revision tympanomastoid surgery including mastoid cavity obliteration using autologous material were included. Audiological measurements including air conduction (AC) and bone conduction (BC) pure-tone averages (PTA) and the air–bone gap (ABG) were assessed. Health-related Quality of Life (HRQoL) was assessed by the Zurich Chronic Middle Ear Inventory (ZCMEI-21) pre- and postoperatively.

Results

A total of 25 patients (16 females and 9 males; mean age 51.6 years, 14 right and 11 left ears) were included. Patients were reexamined after a mean follow-up period of 9.2 months (SD = 6.5) after obliteration of the mastoid cavity. Compared to the preoperative visit, patients showed a significantly reduced AC PTA at the postoperative visit (mean difference: − 4.1; SD = 10.4, p = 0.045). The mean ZCMEI-21 score changed from 31.7 (SD = 14.5) preoperatively to 17.4 (SD = 15.1) postoperatively (mean difference: − 14.3; SD = 19.1; p = 0.0002). The mean ZCMEI-21 score changes were neither correlated to the AC PTA shift (p = 0.60) nor to the ABG shift (p = 0.66).

Conclusions

This is the first study reporting a highly significant and clinically important improvement in HRQoL after mastoid cavity obliteration in a prospective setting. The improvement in HRQoL was not correlated to the hearing improvement. As a clinical implication, we provide evidence for a substantial subjective benefit of the surgical obliteration of a symptomatic mastoid cavity and, therefore, encourage this surgical procedure.

Mastoid Cavity Obliteration with Cartilage Graft; Evaluation of 35 Patients

OBJECTIVE

Cartilage is a rigid material that is highly resistant to infection and retraction and is tolerated well by the middle ear. The purpose of this study was to review retrospectively the results of cases of mastoid cavity obliteration with cartilage performed after canal wall down (CWD) mastoidectomy and to discuss the literature.

METHOD

Of 983 patients who underwent surgery for chronic otitis media between January 2000 and June 2012, 54 patients who underwent CWD mastoidectomy plus mastoid cavity obliteration with cartilage and who were followed up regularly were selected from the database and invited for re-evaluation. All patients who came for a follow up after the invitation were examined and their data were evaluated retrospectively.

RESULTS

Thirty-five of the patients who accepted the invitation were included in the study. All of the patients in the study underwent mastoid cavity obliteration with conchal and/or tragal cartilage grafts. The duration of follow up ranged from 21 to 41 months (average, 27.3 months). Epithelization occurred in all patients with dry cavity, except one who had residual cholesteatoma and underwent revision surgery.

CONCLUSION

The results of this study indicate that cartilage can be preferred for obliteration of mastoid cavity after CWD mastoidectomy.

18F-NaF PET/CT imaging of bone formation induced by bioactive glass S53P4 after mastoid obliteration

Purpose

Bioactive glass has been successfully used for surgical treatment of chronic infections in bone and bone cavities. Besides infection control, new bone formation is induced by the bioactive glass which is considered to have osteoconductive properties. Evaluation of postsurgical changes after bone graft surgery is generally performed with conventional radiographs or CT/MR imaging, but 18F-NaF PET/CT might be more suitable since it has a high and rapid bone uptake, accompanied by a fast blood clearance leading to a high bone to background ratio.

Case

Obliteration with S53P4 bioactive glass of the mastoid and middle ear was performed in a patient suffering from chronic otitis media. Control of the chronic otitis media was achieved, and follow-up imaging after 3 years with 18F-NaF PET/CT showed increased uptake in the obliterated cavity indicating new bone formation.

Conclusion

18F-NaF PET/CT is able to detect new bone formation after obliteration of the mastoid with S53P4 bioactive glass.

Immediate Cranioplasty for Postcranioplasty Infection in Patients with Ventriculoperitoneal Shunt

BACKGROUND

Patients with a ventriculoperitoneal (VP) shunt tend to develop epidural fluid accumulation after cranioplasty and also have a higher frequency of syndrome of the trephined after bone flap removal. Thus treatment of patients with postcranioplasty infection and a VP shunt is often challenging.

CASE DESCRIPTION

We treated 2 patients with postcranioplasty infection and a VP shunt. One patient had undergone decompressive craniectomy for cerebral hemorrhage, and the other patient had a large frontal dead space following resection of a brain tumor. Both patients were treated by immediate cranioplasty with obliteration of the epidural dead space by using a vascularized free latissimus dorsi muscle flap. In both of them, the postoperative course was uneventful without any complications.

CONCLUSIONS

Immediate cranioplasty and obliteration of the epidural dead space with a vascularized free latissimus dorsi muscle flap is an alternative for patients with postcranioplasty infection who are unfavorable candidates for temporary bone flap removal because of the risk of neurologic deterioration.

Trauma in Facial Plastic Surgery: Frontal Sinus Fractures

The optimal management of frontal sinus fractures remains controversial. Fortunately, the severity of these injuries has diminished with more stringent auto-safety regulations, changing the treatment paradigms used to repair these injuries. Appropriate patient selection and close follow-up may allow for conservative management strategies when dealing with frontal sinus fractures, largely replacing the more morbid and invasive techniques that have been the mainstay for years. Because acute and delayed sequelae can arise after the initial injury, patients should be thoroughly counseled about the importance of follow-up and the need to seek medical care if they develop any concerning signs or symptoms.

Prevention and management of gastroesophageal varices

Bleeding from gastroesophageal varices is a serious complication in patients with liver cirrhosis and portal hypertension. Although there has been significance improvement in the prognosis of variceal bleeding with advancement in diagnostic and therapeutic modalities for its management, mortality rate still remains high. Therefore, appropriate prevention and rapid, effective management of bleeding from gastroesophageal varices is very important. Recently, various studies about management of gastoesophageal varices, including prevention of development and aggravation of varices, prevention of first variceal bleeding, management of acute variceal bleeding, and prevention of variceal rebleeding, have been published. The present article reviews published articles and practice guidelines to present the most optimal management of patients with gastroesophageal varices.

Modern robot-assisted radiosurgery of cerebral angiomas-own experiences, system comparisons, and comprehensive literature overview

Cerebral arteriovenous malformations (AVMs) are rare vascular lesions potentially responsible for substantial neurological morbidity and mortality. Over the past four decades, radiosurgery has become a valid therapeutic option for many patients with small intracranial AVMs, but reports describing the use of robotic stereotactic radiosurgery (SRS) are rare. The purposes of this study are to describe the efficacy and toxicity of robotic SRS for AVMs and to review the literature. The reports of 48 consecutive patients treated with SRS were reviewed. A total dose of 18 Gy in a single fraction was prescribed to the 70% isodose line. Efficacy (i.e., total obliteration of the AVM) and toxicity were analyzed. Literature search was performed on Embase and PubMed for the terms "Radiosurgery and AVMs", "Cyberknife and AVMs" and "Radiation therapy and AVMs." The median follow-up was 41 months. The median AVM volume was 2.62 cm³. The incidence of obliteration was 59% at 3 years. Regarding toxicity, 92% of patients remained symptom-free, 66% developed radiogenic edema on MRI, and none developed radionecrosis. Forty-one patients (85%) had embolization prior to SRS. Our study was incorporated in an exhaustive review of 25 trials categorized by SRS technique. In this review, the median follow-up was 60 months. The median nidus volume was 2 cm³. The median overall obliteration rate for SRS was 68% (range 36 to 92). The median embolization rate prior to SRS was 31% (range 8.23 to 90). Compared to other studies, tolerability was excellent and the obliteration rate was acceptable but probably affected by the high embolization rate prior to radiosurgery. Our study suggests that a higher dose is feasible. A larger cohort with a longer follow-up period will be needed to confirm the safety and effectiveness, and subsequently validate different prognosis and predictive scores with this treatment modality to maximize the benefits of this technology for selected patients in the long term.

Linear Accelerator Stereotactic Radiosurgery of Central Nervous System Arteriovenous Malformations: A 15-Year Analysis of Outcome-Related Factors in a Single Tertiary Center

BACKGROUND

Linear accelerator stereotactic radiosurgery is one of the modalities available for the treatment of central nervous system arteriovenous malformations (AVMs). The aim of this study was to describe our 15-year experience with this technique in a single tertiary center and the analysis of outcome-related factors.

METHODS

From 1998 to 2013, 195 patients were treated with linear accelerator-based radiosurgery; we conducted a retrospective study collecting patient- and AVM-related variables. Treatment outcomes were obliteration, posttreatment hemorrhage, symptomatic radiation-induced changes, and 3-year neurologic status. We also analyzed prognostic factors of each outcome and predictability analysis of 5 scales: Spetzler-Martin grade, Lawton-Young supplementary and Lawton combined scores, radiosurgery-based AVM score, Virginia Radiosurgery AVM Scale, and Heidelberg score.

RESULTS

Overall obliteration rate was 81%. Nidus diameter and venous drainage were predictive of obliteration (P < 0.05), ruptured status and previous embolization were not related to rate of obliteration, and low-grade AVMs had higher obliteration rates. Posttreatment hemorrhage incidence was 8.72%; nidus diameter was the only predictor (P = 0.05). Symptomatic radiation-induced changes occurred in 11.79% of patients and were significantly associated with unruptured status (P < 0.05). Treatment success as a composite measure was obtained in 70.77% of patients. Receiver operating characteristic curves were presented for each scoring system and outcome measure; best area under the curve was 0.687 for Lawton combined score in the obliteration outcome.

CONCLUSIONS

In the long-term, linear accelerator-based radiosurgery is a useful, valid, effective, and safe modality for treatment of brain AVMs.

Comparative Evaluation of Mastoid Cavity Obliteration by Vascularised Temporalis Myofascial Flap and Deep Temporal Fascial-Periosteal Flap in Canal Wall Down Mastoidectomy

INTRODUCTION

A consensus is emerging amongst otologists that obliteration of the mastoid cavity that results after modified radical mastoidectomy is a sound option to prevent cavity related problems such as otorrhoea, infection, granulation tissue and hearing loss. A variety of techniques have been proposed to perform the obliteration.

AIM

The present study aimed to compare the conventional method of mastoid cavity obliteration by vascularised temporalis myofascial flap with deep temporal fascial-periosteal flap in canal wall down mastoidectomy.

MATERIALS AND METHODS

The prospective study (conducted between July 2012 and August 2013) randomly assigned patients with evidence of attico-antral disease to two groups (20 in each group). After canal wall down mastoidectomy, a superior based vascularised temporalis myofascial flap was used to obliterate the resultant mastoid cavity in group 1 patients and an inferior based deep temporal fascial-periosteal flap was used in group 2 patients for the cavity obliteration. They were then followed up till day 90.

RESULTS

Cavity obliteration was better in group 2 (90%) as compared to group 1 (80%). Similarly, the final status of epithelisation of cavity at 90^th day was clinically superior in patients of group 2 (85%) as compared to group 1 (75%). However, these difference were not statistically significant.

CONCLUSION

The clinical superiority of the results with temporal fascial-periosteal flap can be attributed to less frequent complications (partial obliteration and epithelisation of resultant mastoid cavities, residual perforation and persistent ear discharge) as compared to myofascial flap.

3D Computer aided treatment planning in endodontics

OBJECTIVES

Obliteration of the root canal system due to accelerated dentinogenesis and dystrophic calcification can challenge the achievement of root canal treatment goals. This paper describes the application of 3D digital mapping technology for predictable navigation of obliterated canal systems during root canal treatment to avoid iatrogenic damage of the root.

METHODS

Digital endodontic treatment planning for anterior teeth with severely obliterated root canal systems was accomplished with the aid of computer software, based on cone beam computer tomography (CBCT) scans and intra-oral scans of the dentition. On the basis of these scans, endodontic guides were created for the planned treatment through digital designing and rapid prototyping fabrication.

RESULTS

The custom-made guides allowed for an uncomplicated and predictable canal location and management.

CONCLUSION

The method of digital designing and rapid prototyping of endodontic guides allows for reliable and predictable location of root canals of teeth with calcifically metamorphosed root canal systems.

CLINICAL SIGNIFICANCE

The endodontic directional guide facilitates difficult endodontic treatments at little additional cost.

Subtotal petrosectomy and Codacs™: new possibilities in ears with chronic infection

Subtotal petrosectomy combined with obliteration of the tympanomastoid is a standard procedure to treat temporal bones in patients with radical cavity and chronic infections. Currently, patients with profound-to-severe sensorineural hearing loss are often fitted with cochlear implants. In the case of profound mixed hearing loss, active middle ear implants have been used successfully. The new Codacs™ system provides an effective treatment for patients with severe-to-profound mixed hearing loss; however, only aerated middle ears have been treated with this device. The question arises whether the Codacs™ can be implanted in patients with radical cavity or ears with chronic otorrhea. Of the 41 patients who were implanted with the Codacs™ at the department, 4 received the device after subtotal petrosectomy and obliteration with abdominal fat. Clinical and audiological results were assessed. The device was implanted without any complications in the obliterated subtotal petrosectomy. The preliminary results of the first two patients showed stable bone conduction thresholds and indicated improved speech intelligibility in quiet and noise. Implanting the Codacs™ device after subtotal petrosectomy and obliteration with abdominal fat has been proven to be a feasible and suitable procedure for patients with radical cavity or chronic otorrhea. The speech intelligibility outcome directly after activation was comparable to patients with aerated middle ears.

Significance of radiological variables studied on orthopantamogram to pridict post-operative inferior alveoler nerve paresthesia after third molar extraction

CONTEXT

Removal of impacted third molar is a procedure that is often associated with post-operative complications. The rate of complications is somewhat high because of its proximity to the vital structures. Inferior alveolar nerve paresthesia is one of the common complications of impacted their molar surgery. This is due to intimate relationship between roots of mandibular third molar and inferior alveolar canal. To access the proximity of inferior alveolar canal to third molar many diagnostic methods are suggested but in conventional radiography orthopantamogram is considered as the best. There are many findings onorthopantamogram that are suggestive of close proximity of nerve to the canal. In this study authors reviewed seven radiographic findings related to proximity of roots to the inferior alveolar nerve as seen on orthopantamogram and try to find a relationship between these radiographic variables and presence of post-operative paresthesia.

STUDY DESIGN

The study containd 100 impacted third molars need to be removed. Presence of radiographic findings on orthopantamogram were noted and analyzed, to find a relationship with occurrence of post-operative inferior alveolar nerve paresthesia.

MATERIALS AND METHODS

This study comprises of 100 impacted third molar teeth indicated for extraction. Cases were randomly selected from the patients, needs to undergo extraction of impacted mandibular third molar. After extraction cases were evaluated for occurrence of inferior alveolar nerve paresthesia. Stastical Analyisis: Data was transferred to SPss 21 software for frequency calculation, and two tailed p-values were obtained betweens these variables and post-operative paresthesia, by applying Fischer's exact test (GRAPH PAD SOFTWARE).

RESULTS

Out of seven, four radiological findings that are grooving of roots, hooked roots, bifid roots and obliteration of white line are significantly related to post-operative paresthesia while bending of canal, narrow canal and darkening of tooth roots over the canal are not significantly associated with post-operative morbidity of facial nerve.

Evaluation of using Bioglass® in obliteration of mastoid cavity

BACKGROUND

A mastoid cavity resulting from a canal wall down mastoidectomy can result in major morbidity for patients due to different open cavity problems. Mastoid obliteration with reconstruction of the bony external ear canal recreates the normal anatomy to avoid such morbidity.

METHODS

This retrospective observational study was conducted for 4 years (between 2008 - 2013) to determine if mastoid obliteration with bioactive glass (Bioglass^®) following mastoidectomy overcomes the open cavity problems or not. Patients with cholesteatoma had subjected tomastoidectomy with primary or secondary mastoid obliteration, by using bioactive glass (Bioglass^®),then our primary outcome measure.

RESULTS

Forty patients were interviewed. Forty of them were primary or secondary obliteration after canal wall down mastoidectomy of a primary cholesteatoma. The most frequent fate of obliteration or reconstruction of mastoid was Grade 1 (47.5%) then Grade 0 (30%). Postoperative hearing assessment showed that the average (mean) air conduction (0.5-4 KHz) was 31.1 dB and the average (mean) bone conduction (0.5-4 KHz) was 15.5 dB. The gain average in air conduction was 26 dB and in bone conduction it was 0.5 dB. Ear discharge was found in 36 patients (90%) preoperative and it was found only in 6 patients (15%) postoperative, in 4 patients (10%) cholesteatoma recidivism or recurrences was present.

CONCLUSION

This study shows that the bioactive glass (Bioglass^®) is one of the beat materials used in mastoidectomy with obliteration of open mastoid cavity.

LINAC radiosurgery for cerebral arteriovenous malformations: a single centre prospective analysis and review of the literature

Stereotactic radiosurgery (SRS) is a well established, minimally invasive treatment option for patients diagnosed with cerebral arteriovenous malformations (AVM). We present the experience in linear accelerator-based SRS for cerebral AVM treated over 14 years. We prospectively followed 67 patients with 69 AVM treated with SRS from 1994 to 2008, inclusive. The mean patient age was 37 years (range 7-69) with 36 women and 31 men. The median AVM size, as defined by maximal diameter, was 2.5 cm (range 0.5-4.6 cm) and the median marginal dose was 18 Gy in one fraction. The crude angiographic obliteration rate was 55% with a 3 and 5 year actuarial rate of 39% and 65%, respectively. Median time to obliteration was 4.2 years. Higher treatment dose (p<0.0001) and smaller maximal AVM diameter (p=0.002) were associated with an increased obliteration rate. There were no deaths from treatment. Post-treatment neurological complications occurred in 10 patients (15%) including hemorrhage in two. Twelve patients (18%) required a second SRS procedure. Larger AVM diameter was associated with increased odds of requiring re-treatment (p=0.02). Radiosurgery for intracerebral AVM is a non-invasive therapeutic option with low morbidity and a reasonable likelihood of nidus obliteration. Treatment dose and AVM diameter are the main determinants of obliteration.

Radiosurgical considerations in the treatment of large cerebral arteriovenous malformations

OBJECTIVE

In order to establish the role of Gamma Knife radiosurgery (GKS) in large intracranial arteriovenous malformations (AVMs), we analyzed clinical characteristics, radiological features, and radiosurgical outcomes.

METHODS

Between March 1992 and March 2005, 28 of 33 patients with large AVMs (> 10 cm(3) in nidus-volume) who were treated with GKS underwent single session radiosurgery (RS), and the other 5 patients underwent staged volumetric RS. Retrospectively collected data were available in 23 cases. We analyzed treatment outcomes in each subdivided groups and according to the AVM sizes. We compared the estimated volume, defined as primarily estimated nidus volume using MR images, with real target volume after excluding draining veins and feeding arteries embedded into the nidus.

RESULTS

Regarding those patients who underwent single session RS, 44.4% (8/18) had complete obliteration; regarding staged volumetric RS, the obliteration rate was 40% (2/5). The complete obliteration rate was 60% (6/10) in the smaller nidus group (10-15 cm(3) size), and 25% (2/8) in the larger nidus group (over 15 cm(3) size). One case of cerebral edema and two cases (8.7%) of hemorrhage were seen during the latent period. The mean real target volume for 18 single sessions of RS was 17.1 cm(3) (10.1-38.4 cm(3)), in contrast with the mean estimated volume of 20.9 cm(3) (12.0-45.0 cm(3)).

CONCLUSION

The radiosurgical treatment outcomes of large AVMs are generally poor. However, we presume that the recent development in planning software and imaging devices aid more accurate measurement of the nidus volume, therefore improving the treatment outcome.