Antonio De la Cruz

Congenital aural atresia surgery: long-term results.

OBJECTIVES The study goal was to evaluate the stability of hearing results from short- to long-term follow-up in patients who underwent surgery for congenital aural atresia. We also reviewed complications such as external auditory canal stenosis, lateralization and perforation of the tympanic membrane, sensorineural hearing loss, and facial palsy. METHODS We conducted a retrospective chart review of 116 patients who underwent congenital aural atresiaplasty between 1985 and 2002 at the House Ear Clinic. There were 116 atretic ears. Complication rates and short- and long-term (up to 13.6 years) hearing results were evaluated for primary and revision cases. RESULTS Closure of the air-bone gap (ABG) to 30 dB or less at short-term follow-up occurred in 58.5% of primary surgeries and 56% of revisions. The long-term postoperative ABG was 30 dB or less in 50.8% of the primary cases and 39.1% of the revisions. Paired comparison analysis found no significant change in ABG from short- to long-term follow-up for either primary or revision cases. Soft tissue stenosis was seen in 8% of primary surgeries and 3.4% of revisions. Ossicular chain refixation was seen in 11.5% and 6.9% of primary and revision surgeries, respectively. There were no dead ears. CONCLUSION Atresiaplasty surgery in individuals with congenital aural atresia can yield reliable, lasting hearing results with a low incidence of complications.

Surgery of the Skull Base: Transcochlear Approach to the Petrous Apex and Clivus

The Transcochlear approach is described for resection of lesions arising anterior or medial to the internal auditory canal as well as for those arising directly from the clivus. Through an extended complete mastoidectomy the facial nerve is totally decompressed and rerouted posteriorly from the stylomastoid foramen to the internal auditory canal. The fallopian canal, promontorium, and cochlea are removed anteriorly and medially as far as the internal carotid artery, obtaining exposure to a triangular area limited by the superior petrosal sinus, inferior petrosal sinus, carotid, and internal auditory canal, giving adequate exposure to the structures of the clivus and the midline (basilar artery, vertebral arteries, and the sixth cranial nerves).

Advances in Congenital Aural Atresia Surgery: Effects on Outcome

OBJECTIVES: To compare modifications in the surgical technique of congenital aural atresia (use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks) by examining hearing results and complications before and after initiation of these changes. STUDY DESIGN AND SETTING: Retrospective chart review of patients who underwent congenital aural atresiaplasty between 1985 and 2002 in a tertiary referral neurotologic private practice. Complication rates and hearing results were compared before (n = 36) and after (n = 80) modifications in the surgical technique. RESULTS: Closure of the air-bone gap to 30 dB or less at short-term follow-up occurred in 63.1% of surgeries performed after modifications in the surgical technique and 44.5% of surgeries performed before these changes. The long-term postoperative air-bone gap was 30 dB or less in 50.0% of the surgeries performed after and 47.1% of the cases performed before the changes in surgical technique. Soft tissue stenosis and bony growth of the external auditory canal were seen in 3.8% of surgeries performed after and 13.9% of surgeries performed before the surgical technique changes. Ossicular chain refixation occurred in 3.8% of surgeries performed after and 25.0% of surgeries performed before such changes. There were no dead ears and no facial palsies. CONCLUSION: The use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks, as a group, has helped to improve hearing results and decrease the incidence of complications in congenital aural atresia surgery. SIGNIFICANCE: Refinements in surgical techniques can lead to measurable improvements in outcome in atresiaplasty.

Single vertical incision for Baha implant surgery: preliminary results.

Objectives: A single vertical skin incision with subcutaneous tissue removal is a cosmetic alternative for Baha implant placement. We aimed to determine the preliminary complication rate using a 4-cm vertical skin incision. Study Design: Retrospective review. Subjects and Methods: Vertical incision Baha implant placements from January 2006 to August 2007 were reviewed. Complications including skin irritation, skin overgrowth, and implant extrusion were tallied. A total of 71 patients underwent surgery, with a mean follow-up time of 7 months. Results: There were five minor complications (three cases of skin irritation, one wound infection requiring oral antibiotics, one postoperative hematoma) and seven major complications (one case of irritation requiring abutment removal, six cases of skin overgrowth or infection requiring flap revision), for a total complication rate of 16.9 percent. Conclusions: A single vertical incision for Baha implant placement has a complication rate similar to that of traditional dermatome use in this preliminary study. Patients with thick scalps or risk factors for hypertrophic scarring may require longer abutments.

Tympanosclerosis: Long-Term Hearing Results after Ossicular Reconstruction:

OBJECTIVE: The study goal was to analyze long-term hearing results and factors likely to affect outcome after ossicular reconstruction in patients with tympanosclerosis, particularly tympanosclerotic stapes fixation. METHODS: We conducted a retrospective chart review of the past 10 years. The short- and long-term (up to 9 1/2 years) hearing results of first-stage and second-stage operations for middle ear tympanosclerosis in 203 consecutive patients, performed in a tertiary referral otologic private practice, are presented. There were 160 tympanoplasties and 43 tympanoplasties with mastoidectomy performed, with ossicular fixation secondary to tympanosclerosis in 135 cases. Of these 203, 42.9% were primary cases, with the majority being planned second-stage or revision procedures. RESULTS: The average preoperative air-bone gap (ABG) was 30.9 dB. The average short-term postoperative ABG was 17.4 dB with closure of the ABG within 20 dB in 64.6%. The success rate (ABG ≤ 20 dB) for patients with ossicular fixation was 65.3%. Partial sensorineural hearing loss occurred in 1.0% of the patients, and none experienced profound sensorineural hearing loss (dead ears). There was no statistically significant change from short-term to long-term follow-up in either ABG or air PTA, with mean differences of only 0.3 and 2.0 dB, respectively. The mean time to the last follow-up was 1.6 years. CONCLUSION: Ossicular reconstruction in individuals with tympanosclerosis can yield satisfactory, lasting hearing results with a low incidence of complications and no dead ears.

Transcochlear approach to cerebellopontine angle and clivus lesions: indications, results, and complications.

Objectives: Evaluate transcochlear (TC)/transotic (TO) approaches surgery for midline intradural lesions arising from the clivus and cerebellopontine angle masses arising anterior to the internal auditory canal. Study Design: Retrospective chart review. Setting: Tertiary referral neurotologic practice. Patients/Intervention: Forty patients who underwent TC/TO approach surgery. Patients were grouped by whether the facial nerve was mobilized (TC, n = 15) or not (TO, n = 25). Main Outcome Measures: Indications, postoperative outcomes, and complications including tumor removal and facial nerve status (House-Brackmann grade). Results: Forty percent of all TC patients were meningiomas, whereas 36% of all TO patients were cochlear neuromas. The remainder included tumors associated with NF2, acoustic tumors, malignancies, and other lesions. Complete removal was achieved in 92.5% of tumors. Of all patients, 42% and 55% had normal facial nerve function at the time of hospital discharge and follow up, respectively. Moreover, 22% underwent a facial nerve reanastomosis procedure. Early and late complications occurred in 11 and 14%, respectively. There was one surgery-related death. Complications included cerebrospinal fluid leak (9%) and unsteadiness (9%). Conclusion: The TC and TO approaches provide access to midline intradural lesions, intradural petroclival tumors, and cerebellopontine angle tumors and cholesteatomas arising anterior to the internal auditory canal, without using brain retractors. Total tumor removal, including its base and blood supply, is possible. Facial weakness is frequent when the facial nerve is rerouted, but excellent facial nerve results are accomplished with the TO approach. With these approaches, recurrence israre when all tumor has been removed. Their safety and efficacy encourage their use in extensive lesions.

Lateral extent of internal auditory canal involvement by acoustic neuromas: A surgical-radiologic correlation

The sensitivity of gadolinium-enhanced magnetic resonance imaging (MRI) is such that inflamed areas of individual nerves can be visualized. Given this, might the lateral extent of an acoustic neuroma in the internal auditory canal be inaccurately depicted by MRI with gadolinium contrast due to variable enhancement in inflamed neural tissues? The authors studied the correlation between preoperative MRI and intraoperative observation of the lateral extent of tumor in the internal auditory canal (IAC) of 82 patients with acoustic neuromas. The surgeon made a visual determination of tumor extent when the lateral-most aspect of the tumor was exposed. The radiologist, blind to surgical findings, noted the degree of extension into the IAC based on the MRI. The majority (83%) of the tumors involved the lateral third and fundus of the IAC. Agreement between scans and surgical findings was excellent for tumors extending into the lateral third of the IAC, with a test sensitivity of 94 percent and a positive predictive value of 98.5 percent. Knowledge of the accuracy of MRI in demonstrating extent of tumor in the IAC is important in making decisions regarding surgical approach.

Single Vertical Incision for BAHA: Preliminary Results

Objective A single vertical skin incision with subcutaneous tissue undermining is a cosmetic alternative to standard dermatome skin graft elevation for bone anchored hearing aid (BAHA) placement. A vertical incision minimizes alopecia and simplifies wound closure, while maintaining thin skin flaps. We aimed to determine the preliminary complication rate using a 4cm skin inicsion with 4⋉4 cm of subcutaneous tissue removal. Methods A retrospective chart review of patients undergoing BAHA placement from January 2006 to August 2007 was performed. This search was filtered to include only vertical incision BAHA patients. Complications including skin irritation or infection, skin overgrowth, and implant extrusion were tallied. Pertinent patient risk factors were identified. 71 patients underwent vertical incision surgery, with a mean followup time of 6.8 months. 50 patients had sensorineural hearing losses and 21 had conductive hearing losses. Results No patient had spontaneous extrusion of the titanium abutment. There were 5 minor complications (skin irritation 3, wound infection requiring oral antibiotics 1, postoperative hematoma 1) and 7 major complications (irritation requiring abutment removal 1, skin overgrowth or infection requiring flap revision 6). Total complication rate was 16% and major complication rate was 9.8%. Conclusions A single vertical incision for BAHA placement has a similar complication rate to traditional dermatome use in this preliminary study, though more follow-up is necessary to identify cases of late skin overgrowth. Patients with thick scalps or risk factors for hypertrophic scarring may require placement of longer abutments.

Miniseminar: Bone-anchored hearing AIDS (BAHA) in children

Abstract BAHA is today a well-accepted treatment modality in adults and it has received FDA approval for use in children above the age of 5 years. The educational objectives of this miniseminar are to present the current status of the use of BAHA in children. The panel will discuss:(1) indications and contraindications; (2) selection of patients; (3) surgical procedure; (4) handling of complications; and (5) postop treatment. In the panel there are surgeons with extensive experience in the treatment of children with external ear canal atresia. Topic to be discussed include when an ear canal reconstruction should be recommended and when a BAHA may be a better alternative. The recommendation of timing between BAHA vs external ear reconstruction/implant retained auricular prosthesis will be covered. The use of BAHA in single-sided conductive loss and experience with bilateral BAHA in children will also be discussed together with the special surgical considerations in children. The panelists will present their view on how to handle the soft and thin bone in the mastoid of the child and how to proceed if the dura of the middle cranial fossa is exposed; the wall of the sigmoid sinus is damaged; or if the air-cells of the mastoid process are entered. Additionally, how to increase bone volume with the use of membrane technique will be described. The importance of soft tissue handling during surgery and pointers and pitfalls will be discussed. The seminar will also cover postop and follow-up routines.

Miniseminar: Contemporary management of otosclerosis

revised protocol with images taken at 15 mts, 30 rots, 60 mrs, and 120 mts was used. Two of 3 nonvisualized parathyroid adenomas were localized by this technique, thereby increasing the sensitivity of the test. These localized adenomas were confirmed at the time of neck exploration. Conclusion: We suggest that all patients with a high degree of suspicion for a parathyroid adenoma and nonvisualization of adenoma on a standard sestamibi scan undergo a reduced time window sestamibi scanning, which includes single view scans at 15 mts, 30 rnts, 45 mts, and 120 mts and tomograms at 60 mts to increase the sensitivity of the localizing scan from 96% to 98%.