Increased prevalence of aspiration pneumonitis in spontaneous cerebrospinal fluid leaks

BACKGROUND

Aspiration pneumonitis (AP) secondary to cerebrospinal fluid (CSF) leak is underestimated and rarely discussed. This study aimed to evaluate the association between AP and CSF leaks.

METHODS

Clinical and surgical characteristics of CSF leak patients with and without AP between January 2010 and December 2022 were included and compared.

RESULTS

This study included 159 patients, 16 with CSF otorrhea and 143 with CSF rhinorrhea. Among them, 40 (25.2%) had AP. Bilateral pneumonitis was identified in 32 cases, of which 11 showed severe pneumonitis in the right upper lung lobe. Twenty-one (52.5%) asymptomatic and 19 (47.5%) symptomatic cases were documented. The major clinical manifestations included cough (n = 19, 47.5%) and expectoration (n = 9, 22.5%). The prevalence of pneumonitis was significantly higher in the spontaneous group than in the traumatic group. High-flow CSF leak was associated with AP (42.5% vs. 16.8%, p = 0.001). No significant differences were identified in defect locations between patients with and without AP. Patients with pneumonitis had a higher prevalence of meningitis (32.5% vs. 12.6%, p = 0.003). Multiple logistic regression results revealed that meningitis, spontaneous and high-flow CSF leaks are independent factors for AP occurrence. Both the CSF leak and pulmonary complications resolved following successful surgical repair.

CONCLUSIONS

AP secondary to CSF leaks is frequently underdiagnosed, with a higher incidence identified in spontaneous cases. The occurrence of AP was associated with high-flow CSF leak.

KEY POINTS

A pneumonitis rate of 25.2% in cerebrospinal fluid (CSF) leak patients was reported for the first time. A higher prevalence of aspiration pneumonitis was identified in spontaneous CSF leak. Meningitis, spontaneous and high-flow CSF leaks are independent factors for aspiration pneumonitis occurrence.

Management and outcome of pediatric skull base fractures

OBJECTIVE

The management of skull base fractures in the pediatric age group continues to be a major challenge even for experienced multidisciplinary teams. This retrospective study was undertaken at a tertiary care academic hospital to evaluate the management and outcome of pediatric skull base fractures.

METHODS

Retrospective analysis covering a period of 13.5 years (from 1996 to 2009) and 63 patients (mean age 10.7 years; range 1-18 years) was performed.

RESULTS

A road traffic accident was the most frequent etiological factor (38%). The most common skull base fracture type was temporal bone fracture (64%). Longitudinal temporal fractures were observed in 45% and transversal in 23% of these patients; in 10 cases (25%) the fracture was comminuted or mixed type. A fracture involving the spheno-ethmoidal complex was the second most common type of basilar skull fracture (41%) followed by fracture through the orbital bone (35%). Forty-three percent of the patients had a concomitant intracranial injury. Early neurological deficits were diagnosed in 21 patients (33%) and 10 patients (16%) had permanent neurological deficits. One patient died after 1 week of intensive care treatment. Fifty-four patients (86%) were discharged home and 8 patients (13%) were discharged for further rehabilitation. Glasgow Coma Scale score of 8 or lower correlated with moderate to poor outcome.

CONCLUSIONS

We conclude that skull base fracture is a rare injury in childhood. Mortality is uncommon, but this trauma is commonly associated with intracranial injury. Early neurological deficits are caused by traumatic brain injury and were observed in one-third of the patients. However, only less than one-sixth suffered from permanent neurological or neuropsychiatric disorders.

Complications in retrosigmoid cranial nerve surgery

CONCLUSIONS

Although microvascular decompression (MVD), facial nerve splitting (FNS) and neurectomy procedures were safe treatments for hemifacial spasm (HFS), trigeminal neuralgia (TN) and glossopharyngeal neuralgia (GPN) in retrosigmoid cranial nerve surgery, fatal and severe complications may occur. It is essential to pay great attention to the entire procedure to avoid these complications.

OBJECTIVE

To report the complications of cranial nerve surgery via the retrosigmoid approach.

PATIENTS AND METHODS

We reviewed 516 cases of cranial nerve surgery via the retrosigmoid approach for HFS, TN and GPN. There were 208 cases of HFS, of which 117 cases underwent FNS alone and 91 cases underwent combined MVD and FNS. There were 273 cases of TN treated by MVD and selective neurectomy. There were 35 cases of GPN treated by neurectomy.

RESULTS

Of the cases with complications, two (0.4%) died. Hearing impairment ranging from mild to severe occurred in 31 (6.0%) patients; 4 of these (0.8%) presented total hearing loss. Postoperative cerebrospinal fluid leakage occurred in 29 (5.6%) cases.

Tacrolimus: A New Option in Therapy-Resistant Chronic External Otitis

OBJECTIVE

To evaluate the efficacy of the novel topical immune modulator tacrolimus in chronic uninfectious otherwise therapy-resistant external otitis (EO).

STUDY DESIGN

Prospective clinical study.

PATIENTS AND METHODS

There were 53 patients aged 5 to 83 years. An ear wick containing 0.1% tacrolimus ointment (Protopic) was inserted into the external auditory canal every 2nd to 3rd day. Altogether, the wick was changed three times. The pre-, intra- and posttherapeutic state of the clinical parameters otalgia, edema, otorrhea, erythema, pruritus, and desquamation was rated by means of a 6-point score system. Treatment efficiency was evaluated on the basis of follow-up investigations at 3-month intervals, a standardized findings sheet, and photograph documentation.

RESULTS

The short-term results showed a clear improvement in 85% of the patients and significant reductions of the severity levels for all clinical parameters investigated (P < .001). Concerning the long-term results, a one-time treatment cycle led to complete healing in 46% of the patients throughout a follow-up of 10 to 22 months. Of the patients, 54% had recurrent EO events with significantly extended mean symptom-free intervals. Reapplied tacrolimus treatment patterns attenuated the relapsing course of disease and significantly reduced the number of EO episodes. Within the observation period, no relevant side effects were observed, except for a local feeling of heat, occasional skin burning, and itching.

CONCLUSIONS

The topical application of 0.1% tacrolimus ointment in the outer ear canal appears to be an effective and well-tolerated new option in corticosteroid-free treatment of chronic therapy-resistant EO.

Otorrhoea is a marker for symptomatic disease in HIV-infected children

BACKGROUND

Chronic otorrhoea occurs commonly in HIV-infected children. However, there are few data on incidence and severity.

OBJECTIVE

To document the prevalence of otorrhoea in the clinic attendees.

METHODS

A retrospective chart review was done of all HIVI infected children seen at the Family Clinic for HIV from 1 February 1997 to 31 December 2001, a period preceding widespread availability of antiretrovirals. Otorrhoea was classified into two groups, viz. group 1 (mild): an episode lasting less than 1 month, and group 2 (severe): an episode lasting more than 1 month or more than 1 episode of otorrhoea. The clinical and immune stages of the children were noted.

RESULTS

Of 326 children seen during the study period, 104 (32%) had otorrhoea. Forty-five (13.8%) had mild and 59 (18.1%) severe otorrhoea. Two hundred and eighty-eight (88.6%) had either Centers for Disease Control stage B or C disease. The median CD4 percentage in children with otorrhoea was 17.5% (8.3-23%) versus 21% (14-28%) in those without otorrhoea (p=0.004). The odds ratio (OR) of children in stage B or C not having severe otorrhoea was 0.1 (0.01 - 0.72, p = 0.013). The OR for immune class 2 or 3 without severe otorrhoea was 0.39 (0.18 - 0.85, p = 0.021).

CONCLUSIONS

Otorrhoea contributes to the morbidity of HIV infection in children. It is a marker for symptomatic disease and CD4 depletion and should be included in clinical classifications.

Surgical approaches and complications in the removal of vestibular schwannomas

Vestibular schwannomas are benign tumors that usually originate from the balance portion of cranial nerve VIII. The treatment options currently available for vestibular schwannomas include observation with serial imaging, stereotactic radiation, and microsurgical removal. Although the ultimate goal in treatment of vestibular schwannomas is preservation of life, the best option for each patient depends on symptoms, tumor size, tumor location, and the patient's general health and age. Surgical exposure of the cerebellopontine angle for removal of vestibular schwannomas can be performed safely via a translabyrinthine, retrosigmoid, and middle fossa approach. Each approach has its advantages and disadvantages. The goal of surgery is complete eradication of tumor with preservation of hearing and facial nerve function when possible.

Tympanic membrane perforation among adults in West Africa

CONTEXT

The knowledge of variations of the tympanic membrane (TM) perforations with the climatic changes in the West African subregion would help clinicians in its prevention and management.

OBJECTIVE

To analyze the pattern of clinical presentations and associated features of TM perforation in adults in West Africa.

DESIGN

A prospective study.

SETTING

Tertiary referral centre, University hospital.

PATIENTS OR OTHER PARTICIPANTS

Thirty-five (35) consecutive adults with TM perforations during a 1-year period had clinical evaluation of each TM using head mirror, video otoscopy, and micro-otoscopy.

MAIN OUTCOME MEASURES

Clinical presentations and associated features of TM perforations.

RESULTS

Thirty-five patients, 20 (57%) men and 15 (43%) women, with 42 perforated TMs were examined. Twenty-eight (80%) patients had unilateral perforations. Infection was responsible for 90.5% of cases, and trauma was responsible for the rest. Locations of perforations were central (29; 69.1%), anteroinferior (4; 9.5%), posteroinferior (4; 9.5%), anterosuperior (3; 7.1%), and posterosuperior (2; 4.8%). The sizes of the perforations ranged from 1.2 to 83.2%. Large sizes of 25% and more were found to occur in humid and wet seasons, and also, clinical presentations of otorrhea (65.6%), otalgia (51.5%), tinnitus (37.1%), and ear itching (34.4%) seemed to worsen.

CONCLUSION

Most TM perforations result from infection and are preventable via appropriate health education. Posterosuperior perforation is rare, and this is probably one of the factors making choleasteatoma uncommon in West Africa. Approximately 83.3% of TM perforations measure more than 25% in size and appear during the wet humid season of the year. These findings are important for both local and foreign otolaryngologists who may be practicing in this subregion of the world.

Ciprofloxacin/dexamethasone drops decrease the incidence of physician and patient outcomes of otorrhea after tube placement

OBJECTIVE

To evaluate ciprofloxacin 0.3%/dexamethasone 0.1% (CIPRODEX, Alcon, Ft. Worth, TX) for the prevention of early post-operative otorrhea following TT placement.

METHODS

This was a single-center, randomized, evaluator-blinded, parallel-group study. Two hundred children undergoing bilateral TT placement were categorized as having unilateral ("wet/dry"), bilateral ("wet/wet"), or no ("dry/dry") effusion at the time of surgery. All patients received Ciprodex or no treatment for 5 days post-operatively and returned at 2 weeks.

RESULTS

Physician-observed otorrhea was reported in 5 (4.95%) patients receiving Ciprodex and 39 (39.39%) patients receiving no treatment (p<0.0001). Treatment decreased otorrhea in all groups, while the greatest benefit was observed in patients with bilateral effusion (93% reduction). Ciprodex treatment also decreased the rate of clinically diagnosed otitis media (OM) and effusion following TT placement (p< or =0.0006).

CONCLUSION

Ciprodex reduced early post-operative otorrhea, clinically diagnosed OM and effusion following TT insertion. The greatest reduction in otorrhea was observed in patients with bilateral effusion at the time of surgery.

Congenital Cholesteatoma: Risk Factors for Residual Disease and Retraction Pockets-A Report on 117 Cases

OBJECTIVES

To define predictors of residuals and retraction pockets (RP) in children operated on for congenital cholesteatoma (CC).

DESIGN AND SETTING

Retrospective review (1996-2005), academic center.

PATIENTS

One hundred seventeen patients treated for CC corresponding to modified Derlacki's criteria were included (median age, 6.5 yr). No case of RP at time of diagnosis, with a mean follow-up of 2.5 years after last surgery.

MAIN OUTCOME MEASURES

Clinical and surgical data influencing outcome. Multivariate analysis.

RESULTS

Two groups were defined after CC removal: group I (12 cases), no second look required and no case of subsequent re-intervention; group II (105 cases), planned second look always performed (mean delay, 12.1 mo), no difference of sex ratio (M/F = 2). Group I patients were younger than in group II (3.3 vs. 5.9 yr, P < .001). All of them had a normal contralateral eardrum and a disclosure of CC by routine examination (vs. 19% in group II, P < .001). In group I, the mass occupied one or two anterior quadrants (41.6% and 58.4%, respectively) versus more than two quadrants in 46.6% in group II. Residuals and RP rates were 41% and 15%, respectively (only in group II). Predictors for residuals were atticotomy (odds ratio [OR] 2.9, 95% confidence interval [CI] 1.3-6.7) and destruction of stapes (OR 4.3, 95% CI 1.7-10.5). Predictors for RP were eustachian tube extension (OR 6.8, 95% CI 1.7-26.8) and nonreconstructed atticotomy (OR 5.9, 95% CI 1.1-30.9).

CONCLUSIONS

Young children with small CC had no recurrences. Residuals were more frequent in case of atticotomy and stapes destruction. RP occurred especially in cases of eustachian tube extension and if cartilage tympanoplasty was not performed. Tympanic and canal wall reinforcement should be considered in extensive CC.

Post-tympanostomy tube otorrhea: a meta-analysis

INTRODUCTION

Post-tympanostomy tube otorrhea is the most common complication of tympanostomy tube placement. The incidence of this problem varies from 3.4% to 74%. Trials that study post-tympanostomy tube otorrhea may involve valid randomization "by patient" or "by ear." In an attempt to define "best practice," we conduct a meta-analysis to quantify the benefit of using topical prophylactic antibiotic drops in the postoperative period. We then compare our findings with previous results found in the literature.

METHODS

We selected randomized studies for which antibiotic drops had been used for at least 48 hours after tympanostomy tube insertion. Nine studies, 3 "by ear" and 6 "by patient," met our inclusion criteria. The odds ratio and 95% confidence intervals were calculated for each to conduct the meta-analysis.

RESULTS

Overall, prophylaxis appears to be effective at reducing the incidence of post-tympanostomy tube otorrhea. The odds ratios for all studies were less than 1.0. However, none of the 3 "by ear" studies and only 3 of the 6 "by patient" studies were statistically significant. The mean odds ratio was 52%, suggesting that prophylaxis may reduce the incidence of post-tympanostomy tube otorrhea by half.

CONCLUSION

This meta-analysis suggests that routine post-tympanostomy tube prophylaxis is beneficial, but this finding is dependent on selection criteria used.

EBM RATING

A-1a.

Water Precautions and Tympanostomy Tubes: A Randomized, Controlled Trial

OBJECTIVES/HYPOTHESIS

The objective was to determine whether there is an increased incidence of otorrhea in young children with tympanostomy tubes who swim and bathe without water precautions as compared with children who use water precautions in the form of ear plugs.

STUDY DESIGN

Prospective, randomized, investigator-blinded, controlled trial.

METHODS

Two hundred one children (age range, 6 mo-6 y) who had undergone bilateral myringotomy and tube insertion were randomly assigned into one of two groups: swimming and bathing with or without ear plugs. Children were seen monthly for 1 year and whenever there was intercurrent otorrhea.

RESULTS

Ninety children with and 82 children without ear plugs returned for at least one follow-up visit. Mean (SD) duration of follow-up was 9.4 (4.1) months for the children with ear plugs and 9.1 (4.4) months for the children without ear plugs. Forty-two children (47%) who wore ear plugs developed at least one episode of otorrhea, as compared with 46 (56%) who did not use ear plugs (logistic regression adjusting for stratification variables, P = .21). The mean (SD) rate of otorrhea per month was 0.07 (0.31) for the children who wore ear plugs as compared with 0.10 (0.31) for the children who did not wear ear plugs (Poisson regression adjusting for stratification variables, P = .05).

CONCLUSION

There is a small but statistically significant increase in the rate of otorrhea in young children who swim and bathe without the use of ear plugs as compared with children who use ear plugs. Because the clinical impact of using ear plugs is small, their routine use may be unnecessary.

Ventilation tubes in infants increase the risk of otorrhoea and antibiotic usage

1) PROBLEM/OBJECTIVE: The effect of ventilation tubes on acute otitis related symptoms (otorrhoea, earache, and fever) and on antibiotic usage was investigated in children with persistent otitis media with effusion, as part of a multicenter, randomised, controlled clinical trial. 2) METHODOLOGY: One hundred-eighty-seven children were randomly placed into either a watchful waiting group (WW group) (n = 94) or a group treated with ventilation tubes (VT group) (n = 93). Both groups were followed for 12 months. Data were collected from parental reports and from medical files kept by the attending ENT-surgeons. 3) RESULTS: There were significant differences in the reported frequency of otorrhoea (but not of earache or fever) between both groups during follow-up, i.e. children in the VT group had more episodes of otorrhoea than the children in the WW group (p < 0.003). As a consequence, children in the VT group had been prescribed antibiotics more often. 4) CONCLUSIONS: Young children treated with ventilation tubes due to persistent otitis media with effusion have a higher risk of developing otorrhoea because of the tubes, and they have a higher risk of needing treatment with antibiotics.

Does ENT outpatient review at 1-week post ventilation tube insertion improve outcome at 1 month in paediatric patients?

The aims of this study were to see if ENT review at 1 week following ventilation tube insertion in paediatric patients reduced the complication rate and the number of consultations with the general practitioner in the first postoperative month. Sixty-six children were prospectively randomized into two follow-up groups: group A was reviewed at 1 week and 1 month and group B at 1 month only. There was no statistically significant difference in postoperative otorrhoea (P = 0.59), ventilation tube patency (P = 0.44), ventilation tube extrusion rate (P = 0.64) and number of consultations with the general practitioners (GP) for postoperative otorrhoea (P = 0.19) between the two groups at 1 month. In conclusion, there seems to be no advantage with early postventilation tube insertion review as it does not reduce complications or decrease the GP consultation rate.

[Basilar skull fractures: clinical and prognostic aspects]

The incidence of basilar skull fractures and their clinical and prognostic aspects were studied in victims with varying severity of brain injury. Of 947 cases, 449 (46%) patients were diagnosed as having basilar skull fracture and 181 (18.6%) had basal spinal fluid leakage. The frequency of fractures and basal spinal fluid leakage increased in proportion to the severity of brain injury. The above 14-day history of spinal fluid leakage was an absolute indication for surgical fistula closure.

Management of cerebrospinal fluid leak associated with craniomaxillofacial trauma

PURPOSE

The management of persistent, post-traumatic cerebrospinal fluid (CSF) rhinorrhea and otorrhea remains a surgical challenge. Repair of CSF leaks has evolved from that of an intracranial approach to one that is primarily extracranial and endoscopic. The purpose of this retrospective analysis is to determine the incidence of persistent CSF rhinorrhea and otorrhea and assess the clinical outcomes of patients presenting to a level 1 trauma center with posttraumatic CSF leaks who were managed by both surgical and nonsurgical means.

PATIENTS AND METHODS

The records of all patients with basilar skull fractures and/or severe facial trauma presenting to a major level 1 trauma center from 1991 to 2001 were reviewed. Patients diagnosed with CSF otorrhea or rhinorrhea, who had not undergone an intracranial procedure, elevation of depressed skull fractures, or received a ventriculostomy, were identified and their demographics recorded. For purposes of statistical comparison, patients were divided into 2 groups: "leak" and "no leak." All patients in the leak group were initially observed for a period of 7 to 10 days. Persistent CSF leaks were managed by CSF diversion via lumber drainage for 5 to 7 days. Extracranial repair was performed only if lumbar drainage failed to resolve the leak.

RESULTS

Seven hundred thirty-five patients were identified who met the criteria for inclusion in the study. Thirty-four patients (incidence, 4.6%) were identified with CSF leak presenting as otorrhea (n = 25 [75.8%]) or rhinorrhea (n = 9 [26.5%]), which was diagnosed by clinical, laboratory, or radiographic examination (average age, 28.2 years; age range, 2 to 80 years; 23 males and 11 females). All patients in this study experienced successful resolution of CSF otorrhea or rhinorrhea by using a variable combination of observation, CSF diversion, and extracranial repair. There were no complications or cases of meningitis. Twenty-eight patients (84.6%) experienced uncomplicated resolution of the leak without treatment in 2 to 10 days. Persistent CSF leak, defined by drainage greater than 7 days after injury, was identified in 6 patients (incidence, 0.8%), all except 1 who underwent CSF diversion via a lumbar drain for a period of 5 to 10 days. Two of these patients were treated successfully; the remaining 4 patients required surgical procedures.

CONCLUSIONS

Post-traumatic CSF leaks are uncommon and will usually resolve without surgical intervention. Successful management in refractory cases often involves a combination of observation, CSF diversion, and/or extracranial and intracranial procedures.

Vestibular schwannoma surgery outcomes: our multidisciplinary experience in 400 cases over 17 years

OBJECTIVES/HYPOTHESIS

The aim of the study was to evaluate the incidence of short- and intermediate-term postoperative complications after vestibular schwannoma surgery.

STUDY DESIGN

Retrospective review in a tertiary referral center.

METHODS

In 400 patients who underwent surgical removal of vestibular schwannoma from 1984 to 2000,symptoms, preoperative evaluation, surgery, and postoperative complications were analyzed using standardized grading systems.

RESULTS

One hundred ninety-four men and 206 women had an operation. Mean age was 53.9 years (age range, 11-78 y). Tumor size according to Koos stage was stage 1 in 39 cases, stage 2 in 122 cases, stage 3 in 87 cases, and stage 4 in 152 cases. Preoperatively, 7.5% of patients had facial nerve dysfunction. Surgical approaches were translabyrinthine in 229 patients, widened retrolabyrinthine in 128 cases, suboccipital in 42 cases, and transotic in 1 case. Mortality was 0.5%. Facial nerve was transected in 15 cases (3.7%) and immediately repaired in 5 cases. A delayed hypoglossal-to-facial nerve anastomosis was performed in 12 cases. At 1 year, House-Brackmann grade in 70.7% of patients was 1 to 2; in 24.3%, 3 to 4; and in 5%, 5 to 6. Poor facial nerve outcome was correlated with tumor size, preoperative irradiation, and nerve dysfunction and was not correlated with the approach used. Most patients had postoperative dizziness, and 30% still had vestibular disturbances after 1 year. Nine patients (2.2%) had a cerebrospinal fluid rhinorrhea, and 24 had a cerebrospinal fluid wound leak (6%). Twenty-two patients (5.5%) had postoperative meningitis. Two patients had a cerebellopontine angle hemorrhage, and three a brainstem infarct.

CONCLUSION

Transpetrosal approaches (translabyrinthine, widened retrolabyrinthine) are safe for vestibular schwannoma removal, and rates of postoperative complications and sequelae are decreasing.

Perioperative Complications in Acoustic Neuroma (Vestibular Schwannoma) Surgery

OBJECTIVE

Retrospective study and review of the complications other than those related to the facial nerve and hearing, encountered in acoustic neuroma surgery. Also, an evaluation of hospital stay and its relation with various factors.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary neurotologic and skull base referral center.

PATIENTS

A series of 707 patients who underwent surgical removal of acoustic neuroma from April 1987 to December 2001.

INTERVENTIONS

The surgical approaches used were the enlarged translabyrinthine approach, the enlarged middle fossa approach, and the retrosigmoid approach. In a small number of cases, the operations were performed through other approaches.

MAIN OUTCOME MEASURES

The duration of hospital stay and appearance of complications in the perioperative period along with their management. Results related to the facial nerve and hearing were not considered in this study.

RESULTS

The most frequent complication was abdominal subcutaneous hematoma (site of fat harvest), which occurred in 23 patients (3.2%). Cerebrospinal fluid leak was present in 20 patients (2.8%), 15 of whom needed revision surgery. Other complications included VIth cranial nerve dysfunction in 12 cases (1.68%), subdural hematoma in 3 cases (0.4%), cerebellopontine angle hematoma in 4 cases (0.6%), cerebellar edema in 2 cases (0.28%), brainstem hematoma in 1 case (0.14%), transitory aphasia in 1 case (0.14%), and lower cranial nerve dysfunction in 1 case (0.14%). Mortality occurred in only one case (0.14%). Medical complications seldom occurred. The postoperative hospital stay ranged from 2 to 36 days, with an average of 6.4 days. The overall hospital stay diminished over time from 10.2 days in 1987 to 1990, to 4.9 days in 2001. There was a significant relation between hospital stay and tumor size, approach used, and presence/absence of complications.

CONCLUSIONS

Perioperative complications in acoustic neuroma surgery do exist, but this study demonstrated how low the incidence is. The authors believe that the low percentage of complications is mainly attributable to the majority of operations being carried out in specialized clinics, where they are considered routine operations. They believe that following individualized approaches, depending on tumor size and on the preoperative function of the cranial nerves, is the proper way to reach a significant reduction in complications while maintaining a high percentage of total tumor removal. The results of this study, considered as a basis of comparison with other studies, will certainly be useful in preoperative patient counseling.

The Incidence of Cerebrospinal Fluid Leak after Vestibular Schwannoma Surgery

OBJECTIVE

To review the incidence of cerebrospinal fluid leak after vestibular schwannoma removal reported in the literature.

DATA SOURCES

MEDLINE and PubMed literature search using the terms "acoustic neuroma" or "vestibular schwannoma," and "cerebrospinal fluid leak" or "cerebrospinal fluid fistula" covering the period from 1985 to the present in the English language literature. A review of bibliographies of these studies was also performed.

STUDY SELECTION

Criteria for inclusion in this meta-analysis consisted of the availability of extractable data from studies presenting a defined group of patients who had undergone primary vestibular schwannoma removal and for whom the presence and absence of cerebrospinal fluid leakage was reported. Studies reporting combined approaches were excluded. No duplications of patient populations were included. Twenty-five studies met the inclusion criteria.

DATA EXTRACTION

Quality of the studies was determined by the design of each study and the ability to combine the data with the results of other studies. All of the studies were biased by their retrospective, nonrandomized nature.

DATA SYNTHESIS

Significance (p < 0.05) was determined using the chi2 test.

CONCLUSIONS

Cerebrospinal fluid leak occurred in 10.6% of 2,273 retrosigmoid surgeries, 9.5% of 3,118 translabyrinthine surgeries, and 10.6% of 573 middle fossa surgeries. The type of cerebrospinal fluid leak was not associated with surgical approach. Meningitis was significantly associated with cerebrospinal fluid leak (p < 0.05). Age and tumor size were not associated with cerebrospinal fluid leak.

Complications of otitis media before placement of tympanostomy tubes in children

OBJECTIVES

To report the incidence of short-term complications from otitis media in children before placement of tympanostomy tubes (TTs) and to compare children treated according to the Agency for Health Care Policy and Research guidelines with those who were treated earlier or later than recommended.

DESIGN

Retrospective outcomes review.

PATIENTS

Subjects were children aged 10 or younger who had TTs inserted at a tertiary care county hospital from January 1, 1999, to December 31, 2000. Exclusion criteria included prior TT placement, any concurrent head and neck procedure, and craniofacial defects.

INTERVENTION

Tympanostomy tube placement.

MAIN OUTCOME MEASURES

Any occurrences of otorrhea, tympanic membrane perforation, tinnitus, antibiotic reactions, speech or language delay, febrile seizures, or meningitis before placement of TTs documented in the county hospital records were recorded as complications. Hearing loss was considered separately.

RESULTS

Of 147 children who met our criteria, 81 (55.1%) had 1 or more complications from otitis media before placement of TTs. Fifty-five (37.4%) had 2 to 6 complications documented. Adverse reactions to antibiotics were the most common complication, reported in 34 (23.1%).

CONCLUSIONS

Most children in this county hospital experienced short-term complications of otitis media before receiving TTs. Even the children treated "on time" according to the guidelines from the Agency for Health Care Policy and Research experienced complications; however, adherence to the guidelines had no significant effect on complications.

Management of cerebrospinal fluid leaks involving the temporal bone: report on 92 patients

OBJECTIVE

To investigate the success of different surgical and nonsurgical techniques in the management of cerebrospinal fluid otorrhea or otorhinorrhea.

STUDY DESIGN

Retrospective case analysis.

METHODS

Ninety-two patients with confirmed diagnosis of cerebrospinal fluid otorrhea or otorhinorrhea treated at our institution between 1976 and 1998 were followed up long-term by retrospective chart review and patient interviews.

RESULTS

Conservative treatment was successful in most cases of cerebrospinal fluid otorrhea or otorhinorrhea resulting from head injury (26 of 29 patients). In contrast, surgical intervention was required in all but 1 of 53 patients with cerebrospinal fluid otorrhea or otorhinorrhea caused surgically. The primary operative success rate was 76.9%. When relapse occurred, the interval ranged from 0 days to 24 months (mean interval, 3.9 mo; median, 1.3 mo). All leaks requiring surgery eventually were closed successfully. Surgical results were chronologically dependent. Before 1989, 11 failures occurred in 37 primary procedures. After 1989, only 4 failures occurred in 28 primary procedures. Of seven patients undergoing primary dural closure alone, three (43%) had recurrence of the leak. Closure rates were highest among patients in whom a multilayer technique for leak closure was used: combining a primary graft or sealing material such as bone wax, free muscle, or fascia for closure of the defect with additional autologous free grafts or allogenic materials. This resulted in a 2-year closure rate of 100% compared with a 2-year rate of 75.4% for patients whose primary closure was supported by a single layer of autologous or allogenic material (P =.034). Fibrin glue with primary closure alone did not have additional benefit. Postoperative meningitis occurred in two patients and was treated without sequelae.

CONCLUSIONS

Conservative treatment should be reserved for cerebrospinal fluid otorrhea or otorhinorrhea resulting from head injury. Postoperative and nontraumatic cerebrospinal fluid otorrhea or otorhinorrhea should have early operative intervention. A multilayer technique combining allogenic materials with free autologous grafts is recommended.

Incidence of cerebrospinal fluid leak after microsurgical removal of vestibular schwannomas

OBJECTIVES

Cerebrospinal fluid (CSF) leak still remains an unresolved problem after microsurgical removal of vestibular schwannomas (VS).

METHODS

14 (6%) Cases of cerebrospinal fluid rhinorrhea and 3 cases with subcutaneous retro-auricular CSF collection, occurring in a series of 224 patients operated on by the senior author (JMG) on VS between 1989-2000 via the suboccipital retrosigmoidal approach were studied retrospectively. Prophylaxis of CSF leak was usually attempted by packing the unroofed posterior wall of internal acoustic meatus with muscle. The mastoid air cells were packed first with collagen then with muscle and bone dust.

RESULTS

All CSF leaks were diagnosed within 2-7 days after surgery. We found no relation to tumour size. Treatment was initiated in all patients with continuous external lumbar cerebrospinal fluid drainage (CELCFD) for 7 days. In 11 cases with CSF rhinorrhea and all cases with retro-auricular CSF collection, the CSF leak was stopped. However, in 3 cases the CSF leak persisted despite the lumbar drain. These patients were operated on again with sealing the IAM and the mastoid cells again with muscle and collagen. No recurrence of CSF leak was noted after the second operation. There was no case of late onset CSF leak during the follow-up of one year.

CONCLUSION

Although CSF leak is a common complication (6%) after vestibular schwannoma removal, aggressive treatment is required only in a few cases (1%). Most of the cases are successfully treated by (CELCFD). The suboccipital approach offers an advantage of opening only a part of mastoid air cells, which are in our opinion the second most common site of CSF leakage.

Translabyrinthine approach for the management of large and giant vestibular schwannomas

BACKGROUND

The removal of large vestibular schwannomas through the translabyrinthine approach is still controversial.

MATERIALS AND METHODS

A retrospective review was performed of 81 patients (58 men and 23 women) with vestibular schwannomas 3 cm or greater, who underwent tumor removal via the translabyrinthine approach between 1985 and 2000. The mean tumor size was 3.7 +/- 0.81 cm, and the mean age of the patients was 47 +/- 16.1 years. The largest tumor was 6 cm. All surgical procedures were performed in collaboration with a neurosurgery team.

RESULTS

Total tumor removal was accomplished in 77 cases (95.1%). The facial nerve was preserved anatomically in 69 (85.2%) of the patients. In 4 patients, divided nerves were repaired by primary anastomosis. Facial nerve function was assessed immediately after surgery and 1 year or more after discharge. Good function (House-Brackmann facial nerve Grade I or II) was present in 45% of patients and acceptable function (Grades I-IV) in 80% of patients 1 year after resection of the tumor. Cerebrospinal fluid leakage occurred in 12 patients (17%), meningitis developed in 3 patients (4%), and 1 patient experienced a stroke immediately after surgery. There were no deaths caused by surgery in this series.

CONCLUSION

The translabyrinthine approach offers an excellent anatomical view of the cerebellopontine angle and a direct approach to the tumor with functional preservation of the facial nerve. Total removal is accomplished in most cases, with minimum incidence of morbidity and no incidence of mortality.

Acoustic neuroma--treatment modalities. Surgery, gamma-knife or observation?

We present our results of 211 patients with acoustic neuroma over a period of 10 years, 1988-97. We operated on 100 and 111 had Gamma-knife (GK) treatment (69 were available to follow-up). The results are excellent for surgery on small and intracanalicular tumours. In tumours of the same size, surgery and GK treatment give comparable, but somewhat different, results. In the GK group of 54 primary treated patients, 3 patients had to be operated on and another 4 developed hydrocephalus. A group of 35 acoustic tumours was observed for more than 3 years. Nineteen did grow (54%). Hearing was unchanged in 23%. We performed surgery in 11 patients and gave 2 patients GK treatment because of tumour growth of > 2 mm in diameter a year. We conclude that either treatment is effective for small and medium-sized acoustic neuromas. Hearing preservation was best in the GK-treated group (80%), compared to only 12.5% in the group operated via the suboccipital route. Larger tumours and most medium-sized tumours should be operated, as should smaller tumours with persistent symptoms of vertigo and pain. Medical contraindications to surgery or reluctance to undergo surgery make GK treatment a good alternative. Treatment of residual tumours with the GK could also be a solution to a difficult problem.

Cerebrospinal fluid leak after acoustic neuroma surgery: influence of tumor size and surgical approach on incidence and response to treatment

OBJECT

The aims of this study were to review the incidence of cerebrospinal fluid (CSF) leakage complicating the removal of acoustic neuroma and to identify factors that influence its occurrence and treatment.

METHODS

Prospective information on consecutive patients who underwent operation for acoustic neuroma was supplemented by a retrospective review of the medical records in which patients with CSF leaks complicating tumor removal were identified. This paper represents a continuation of a previously published series and thus compiles the authors' continuous experience over the last 24 years of practice. In 624 cases of acoustic neuroma the authors observed an overall incidence of 10.7% for CSF leak. The rate of leakage was significantly lower in the last 9 years compared with the first 15, most likely because of the abandonment of the combined translabyrinthine (TL)-middle fossa exposure. There was no difference in the leakage rate between TL and retrosigmoid (RS) approaches, although there were differences in the site of the leak (wound leaks occurred more frequently after a TL and otorrhea after an RS approach, respectively). Tumor size (maximum extracanalicular diameter) had a significant effect on the leakage rate overall and for RS but not for TL procedures. The majority of leaks ceased with nonsurgical treatments (18% with expectant management and 49% with lumbar CSF drainage). However, TL leaks (especially rhinorrhea) required surgical repair significantly more often than RS leaks. This has not been reported previously.

CONCLUSIONS

The rate of CSF leakage after TL and RS procedures has remained stable. Factors influencing its occurrence include tumor size but not surgical approach. The TL-related leaks had a significantly higher surgical repair rate than RS-related leaks, an additional factor to consider when choosing an approach. The problem of CSF leakage becomes increasingly important as nonsurgical treatments for acoustic neuroma are developed.

Retrospective analysis of surgical outcome, symptom changes, and hearing improvement following myringoplasty

This study examines the surgical and audiologic results of myringoplasty and what factors affect these outcomes. It also examines whether patients experience any improvement in their main symptoms following surgery. This was a retrospective analysis of case notes, patient questionnaires, and audiograms of all patients undergoing myringoplasty between 1990 and 1995 at Walsgrave Hospital, Coventry, UK. Overall success of myringoplasty for consultants was 81% and for trainees was 79%, with an overall success rate of 86% in children. Posterior and inferior perforations had a 90% success rate for repair, compared to only 67% of anterior perforations. There was a statistically significant reduction in air-bone gaps following myringoplasty, and the majority of patients felt that their ears were drier and had improved hearing. Myringoplasty is a successful procedure in the hands of consultants and trainees alike. The results are satisfactory enough to justify surgery purely for deafness and also in symptomatic children. There is a strong correlation between surgical success and resolution of symptoms and generally a satisfactory improvement in hearing.

Otorrhea after grommet insertion for middle ear effusion in patients with nasopharyngeal carcinoma

PURPOSE

To document the incidence of complications after myringotomy and grommet insertion in patients with nasopharyngeal carcinoma. The focus is on the incidence of otorrhea and perforation. The possible risk factors for these conditions and treatment response were studied.

MATERIALS AND METHODS

We reviewed the records on 206 ears of 163 patients who suffered from nasopharyngeal carcinoma and underwent myringotomy and grommet insertion in a 7-year period. The follow-up period ranged from 4 weeks to 78 months (median, 9 months).

RESULTS

The overall incidence of otorrhea in these ears was 38%. Patients with nasopharyngeal carcinoma (NPC) had a significantly high incidence of postoperative discharge (chi2 test, P<.0001) compared with other patients who underwent myringotomy and grommet insertion. The mean interval between myringotomy and otorrhea was 19.8 weeks. Forty-seven per cent of the ears with a discharge developed otorrhea within 1 month. In 42%, the otorrhea responded to treatment and the ears became dry. After extrusion of the grommet, 29% of those ears with otorrhea ended with an eardrum perforation, and 24% of the ears showed recurrent effusion.

CONCLUSIONS

For patients with NPC who underwent myringotomy, there was a significant risk of otorrhea (49%) and persistent perforation (29%), and these complications were difficult to manage. We conclude that myringotomy and grommet insertion should not be routinely offered to NPC patients with middle ear effusion.

Early postoperative otorrhea after tympanostomy tube placement: a comparison of topical ophthalmic and otic drops

In a retrospective review of the incidence of early postoperative otorrhea, we compared cortisporin otic suspension with sulfacetamide/prednisolone ophthalmic drops and found them to be approximately equally effective. The beneficial effect of topical otic and ophthalmic antibiotic drops after tympanoplasty tube placement has already been well documented. It is therefore suggested that the potentially more comfortable and theoretically less ototoxic ophthalmic drop be used to decrease the incidence of early postoperative otorrhea.

Antimicrobial activity of silastic tympanostomy tubes impregnated with silver oxide. A double-blind randomized multicenter trial

OBJECTIVE

To test the null hypothesis that impregnation of tympanostomy tubes with silver oxide did not alter the rate of postintubation otorrhea.

DESIGN

Multicenter, double-blind, randomized clinical trial.

OUTCOME MEASURE

Rates of postoperative otorrhea during a 1-year study in ears implanted with Silastic tubes compared with contralateral, identical tubes impregnated with silver oxide.

SETTING AND PARTICIPANTS

Eight sites in the United States, 125 children aged 1.5 months to 12 years who had bilateral otitis media with effusion or bilateral recurrent acute otitis media.

RESULTS

The overall incidence of postoperative otorrhea was 9.78% in the control ears and 5.08% in the ears with silver oxide-impregnated tubes (P = .01), but no effect was seen during the immediate postoperative period. Granulation tissue was seen adjacent to the tube during two visits in the ears with standard tubes (0.54%) and during two visits in the ears with experimental tubes (0.53%); cholesteatomas did not occur in either group.

CONCLUSION

Silastic tubes impregnated with silver oxide seem to diminish the incidence of postoperative otorrhea in ears requiring long-term ventilation.

Post tympanostomy otorrhea

Myringotomy with placement of ventilation tubes is the most common pediatric otolaryngologic procedure in the United States. Otorrhea is generally recognized as the most common complication of this procedure. The current study is a three-year prospective evaluation of post tympanostomy otorrhea to determine what variables might be associated with otorrhea. Analysis of patients from a predominantly rural population is presented.

A clinicopathological study of collagen sponge as a dural graft in neurosurgery

There is frequently a need for dural grafts to cover defects resulting from retraction, shrinkage, or excision following neurosurgical procedures. Several materials have been evaluated both experimentally and clinically, and then discarded. Collagen, in its various forms, continues to be an area of intense interest. In this study the authors examined the suitability of collagen sponge to effect dural repair. In a 5-year clinical study 102 collagen sponge implants were examined macroscopically and histologically. Graft encapsulation, neomembrane formation, delayed hemorrhage, and foreign body reactions were not found. The porous nature of the collagen sponge encouraged fibroblastic ingrowth and dural repair. Meningocerebral adhesions were present in 11 patients, all of whom had required significant cortical resection or had pia-arachnoid disruption during the initial surgery. Inflammatory cells were seen only in response to infection. Postoperative cerebrospinal fluid leaks developed in only three of 67 patients who underwent an intradural posterior fossa procedure. In a prospective arm of the study involving 459 patients, the wound infection rate using collagen sponge was 6.1%, which compared favorably (p = 0.67) with the 5.7% rate in a similar group of 637 patients in whom collagen sponge had not been used.

Enlargement of the cochlear aqueduct: fact or fiction?

Enlargement of the cochlear aqueduct (CA) is often mentioned in the otologic literature, usually in its purported association with sensory hearing loss, stapes gusher, and transotic cerebrospinal fluid leak. In CT scans of 100 ears, the diameter of the CA medial aperture was found to be highly variable, ranging from 0 to 11 mm, with a mean of 4.5 mm. In contrast, the otic capsule segment was very narrow in every case. It could be visualized in only 56% of cases, none of which exceeded 2 mm in diameter. Several published reports of supposed CA enlargement presented images of a dilated medial aperture that was well within the range of normal variability according to the present study. In a thorough review of the literature on radiology of the CA, we were unable to find a single published image that convincingly demonstrated enlargement of the otic capsule portion. As radiographic CA enlargement has not been convincingly reported to date, it appears to be an exceedingly rare or perhaps even nonexistent malformation. It is important to recognize than even a radiographically normal CA may be hyperpatent. It is theoretically possible for increased fluid flow to result from either deficiencies in intraluminal membrane baffles or subtle canal enlargement beneath the resolution limits of CT scanning. However, as fluid flow through a tube is regulated by its narrowest point, it is extremely improbable that stapes gusher, transotic CSF leak, and vigorous perilymphatic fistula are generated by the CA when CT scans show any portion of it to be very narrow. A substantial body of evidence points to a deficient partition between the internal auditory canal and inner ear as causative in such cases. We propose that the criteria for the diagnosis of CA enlargement on high-resolution CT scan be a diameter exceeding 2 mm throughout its course from the posterior fossa to the vestibule.

Defect reconstruction and cerebrospinal fluid management in neurotologic skull base tumors with intracranial extension

Intracranial extension (ICE) is the spread of tumor into the subarachnoid space through dura or along cranial nerve roots. The single-stage removal of the skull base tumor with its ICE has been confounded by cerebrospinal fluid management and defect reconstruction. The purpose of this report is to review a current protocol for managing the cranial base tumor and its ICE as a unit. The ventricular shunting paper of 1987 is retracted. All tumors were managed at a single stage. Defect reconstruction was size dependent. Ninety-eight neurotologic skull base tumors with ICE were managed from 1971 to 1991. The new protocol was initiated in 1987. Results specific to this group are highlighted. For glomus tumors, cerebrospinal fluid leak rates have been dramatically reduced overall from 14.5% to 4%. The leak rates for nonglomus tumors, overall, have improved slightly. Complications are discussed. The development of this surgical approach protocol improves the functional outcome in patients of surgeons who aspire to disease "cure" rather than "control."

Cerebrospinal fluid fistula: frequency in head injuries

The authors present 11,074 patients with head trauma managed in the Xoco and Juarez Hospitals from Mexico City, from 1980 through 1990. They report a frequency of cerebrospinal fluid fistulas in 1.3% of head trauma: 55% were anterior fossa fistulas and 39% middle fossa fistulas. The most common symptoms and the treatment are presented.

Basal skull fractures. A prospective study of 100 consecutive admissions

A prospective study of 100 consecutive patients with basal skull fracture admitted to the University Hospital, Kuala Lumpur between July 1986 and October 1988 was carried out to study its epidemiological pattern, clinical and radiological presentations, mechanisms of injury, time interval between accidents and neurosurgical referrals, complications and outcomes. Two-thirds of the patients were between 20 and 50 years old and 79% were male. Half of the injured were motorcyclists and 22% were pedestrians. Three-quarters of the patients were seen within an hour after injury. Thirty-two patients had intracranial haematomas: 14 subdural, 9 extradural and 9 intracerebral. Three patients developed meningitis (two after operations) and six developed epilepsy. Eighteen patients died, but good recovery resulted in 70 patients at follow-up of 1 to 28 months. A small subgroup of 15 patients with severe ear and nose bleeding as a result of basal venous sinus tear died within a few hours despite aggressive resuscitation, probably due to underlying severe brain stem injury. The implication of the high incidence of basal skull fractures in motorcyclists, despite the enforcement of crash helmets is discussed, with possible mechanisms proposed.

Postoperative complications in acoustic neuroma surgery by the extended middle cranial fossa approach

The complications of acoustic neuroma (AN) surgery by the extended middle cranial fossa approach were studied in 160 cases. Death during surgery occurred in 3 cases (1.9%); 2 of these involved large tumors and the third was a case of recurrence. Transient temporal lobe symptoms were seen in 24 cases (15.3%); the average tumor diameter in these cases was 36.0 mm. Beside symptoms of 7th and 8th nerve disturbance, hemiparesis was seen 7.6%; 3rd, 4th, and 6th cranial nerve symptoms in 7.0%; and cerebellar symptoms in 7.6% of the patients. The incidence of these disturbances increased with tumor size. Cerebrospinal fluid (CSF) leakage occurred in 20.4% of the cases and this necessitated surgical treatment in 5% of the cases.