Carlo Zini

The surgical management of childhood cholesteatoma.

The results of treatment of 124 cases of childhood cholesteatoma are reported in the present study and compared with an adult group of patients. Intact canal wall tympanoplasty was performed in over 90 per cent of cases in children and the procedure was staged in nearly 80 per cent of cases. The children had a 43.8 per cent incidence of residual cholesteatoma and an 8.8 per cent incidence of recurrent cholesteatoma in intact canal wall tympanoplasty cases. Intact canal wall tympanoplasty remains the technique of choice in our hands for the treatment of childhood cholesteatoma; pre-planned staging of the operation is mandatory for the detection and elimination of residual cholesteatoma which occurs more frequently in children.

Closed tympanoplasty in cholesteatoma surgery: long-term (10 years) hearing results using cartilage ossiculoplasty

Abstract The aim of this retrospective study was to evaluate the long-term hearing results of using costal cartilage prostheses in ossicular chain reconstruction procedures in subjects operated on for a middle ear cholesteatoma with an intact canal wall tympanoplasty. Thirty-six patients (four with bilateral disease) followed up for 10 years who underwent an ossiculoplasty with a cartilage prostheses between January 1987 and December 1989 constituted the population studied. All the subjects underwent a staged intact canal wall tympanoplasty with mastoidectomy. Ossiculoplasty with total or partial chondroprosthesis was performed during the second stage. The long-term outcome was evaluated in terms of hearing according to the guidelines of the Committee on Hearing and Equilibrium (1995), and in terms of complications (anatomical and functional). In 18 patients a partial cartilage ossicular replacement prosthesis (PORP) was used, while in 22 a total cartilage ossicular replacement prosthesis (TORP) was used. In the PORP group the mean preoperative air–bone gap (ABG) was 22.4 dB hearing level (HL); before the second stage the ABG was 37.9 dB HL, at 2 years it was 12.1 dB HL, at 5 years 15.3 dB HL and at 10 years 15.8 dB HL. In the TORP group the mean preoperative ABG was 31.6 dB HL; before the second stage the ABG was 41.1 dB HL, at 2 years it was 14.4 dB HL, at 5 years 17 dB HL and at 10 years 18.5 dB HL. In both groups the number of cases with a postoperative ABG of < 20 dB HL remained stable (P > 0.05) over time. The failure rate was 17.5%, but only in 5% of cases was a functional revision needed. No cases of extrusion of the prostheses were encountered. The use of a chondroprosthesis is associated with functional results similar to those obtained by other authors. The efficacy of the prostheses remains stable over time and is associated with a very low rate of complications and failures. In this series no extrusion occurred and in no case did an infectious disease develop after cartilage transplantation.

Results of the MXM digisonic Auditory brainstem implant clinical trials in europe

Objective To assess the potential benefit of the MXM auditory brainstem implant for patients with neurofibromatosis type 2. Study Design Retrospective case review. Setting Tertiary referral centers. Patients Fourteen patients with neurofibromatosis type 2 and bilateral acoustic neuromas underwent implantation with the MXM auditory brainstem implant during surgery to remove the second-side tumor. Results There were no complications related to the auditory brainstem implantation. Auditory sensations were present for 12 of 14 patients (86%). Global results indicated an improved quality of life for the patients receiving auditory sensations, in part because of their auditory orientation within the environment. Eighty-nine percent of patients tested with an open-set sentence test demonstrated enhancement of speech understanding as a result of lip-reading improvement when auditory brainstem implant sound was combined with lip-reading. A few patients (36%) had some speech understanding in sound-only mode. One patient was able to have limited phone conversations. Conclusion These results indicate that significant auditory benefit can be derived from the MXM auditory brainstem implant.

Chemically assisted dissection of tissues: an interesting support in abdominal myomectomy

BACKGROUND The aim of this study was to verify the efficacy of sodium-2-mercaptoethanesulfonate (mesna) in the chemical separation of tissues in abdominal myomectomies when used with the traditional mechanical separation techniques. STUDY DESIGN In a prospective, randomized study, 58 women underwent abdominal myomectomy. In 29 of these, we used mesna for highlighting and separating tissues, and in the other 29 we used saline solution for the same purposes. The variables evaluated included the number of myomas removed, the volume of the biggest myoma, and the total volume of the myomas removed in every intervention. We also recorded operating time, the length of hospital stay, the degree of procedure difficulty, perioperative blood loss, operative complications, and cost. RESULTS The operation was significantly shorter in the mesna group (p < 0.05) even though the volume and the number of myomas were larger. The degree of difficulty evaluated by the surgeon at the end of every operation was not significantly different in the two groups. The reduction in hemoglobin 24 hours after operation was significantly less in the patients treated with mesna (p = 0.006), but this difference was probably altered by the increase in hematocrit levels. CONCLUSIONS Because of its ability as a chemical dissector, mesna may be a useful aid in this type of benign gynecologic operation. Larger studies to confirm this are needed.

Prevention of Recurrent Cholesteatoma in Closed Tympanoplasty

Recurrent cholesteatoma in a series of 534 staged intact canal wall tympanoplasties performed over a 10-year period has been reviewed for the present study. Overall detected incidence of recurrent cholesteatoma is 5.2% (28 of 534 operated ears). A steady decrease of recurrent cholesteatoma was found, however, in the second period of our surgical experience (1978 to 1982) when prevention techniques were adopted in all operations, resulting in a 1.07% incidence (four of 373 operated ears). Our present policy for prevention of recurrent cholesteatoma in intact canal wall tympanoplasties with mastoidectomy includes 1) the use of plastic sheeting with thick Silastic, 2) the repair of bony sulcus defects with cartilage shavings, 3) staging of the operation with preplanned reexploration of the middle ear and mastoid, and 4) transtympanic ventilation tube insertion in cases of refractory tubal insufficiency.

Cochlear effects of mesna application into the middle ear.

ABSTRACT: Mesna (sodium 2‐mercapto‐ethane sulphonate) belongs to a class of thiol compounds that produce mucolysis by disrupting the disulphide bonds of the mucus polypeptide chains. The registered indications of mesna include the treatment of pathologies of the respiratory tract and, in oncology, the prevention of toxic lesions of the urinary tract by antineoplastic agents.

Multichannel cochlear implantation in radical mastoidectomy cavities

OBJECTIVE: We report on our experience in cochlear implantation in patients with radical mastoidectomy cavities. STUDY DESIGN, SETTING, AND METHODS: Retrospectively, records of patients from the Department of Otolaryngology, University of Parma between December 1991 and March 2000 were reviewed, and 6 postlingually deafened adults who received a cochlear implant in a radical cavity were identified. Speech performances were evaluated in terms of bisyllabic word and sentence recognition and common phrase comprehension. RESULTS: To date, with a follow-up of 1 to 9 years, no patient has experienced extrusion of electrodes or other local or intracranial complications. Mean bisyllabic word and sentence recognition scores were 74% and 80%, respectively. Mean comprehension score for common phrases was 86%. CONCLUSION: By obliterating and isolating the radical mastoidectomy cavity from the outer environment, patients who previously had undergone radical surgery of the middle ear can be safely implanted with satisfactory hearing results. Multichannel cochlear implantation (CI) is a treatment accepted worldwide for patients with total or profound deafness. In the presence of normal temporal bone anatomy, CI surgery is a safe and relatively simple procedure with a low complication rate. 1–3 However, some conditions, such as malformations of the middle or inner ear, cochlear ossification, chronic otitis media, and previous middle ear surgery, represent a technical challenge to CI surgeons. Patients with a bilateral radical mastoidectomy cavity who are otherwise suitable for implantation represent a certainly more problematic group to manage than the “standard” CI patients. Under these circumstances, various potential problems must be considered: extrusion of the electrode array by breakdown of the thin epithelial lining of the mastoid cavity, risk of recurrent cholesteatoma, and possibility of spreading of inflammation to the implant with potential labyrinthitis and meningitis. During recent years various surgical strategies have been proposed in the literature to avoid such complications. Many surgeons suggested overcoming these problems by performing an obliterative technique, 4–6 whereas others preferred to maintain the benefits of an open technique 7 or to rehabilitate the cavity 8 ; it has also been suggested that the cavity be bypassed via a middle cranial fossa approach. 9 We describe the experience at the CI Center of the University of Parma in managing 6 CI patients with radical mastoidectomy cavities.

Management of the labyrinthine fistula in cholesteatoma surgery

The presence of a labyrinthine fistula has remained one of the major problems in cholesteatoma surgery. Confronted with this problem, the surgeon may ultimately base his choice of procedure on four basic conditions: the size of the fistula, its location in the ear, the condition of the other ear, and the cochlear function. Our attitude has been changing, and currently we prefer to perform a staged closed tympanoplasty. When a closed technique is performed, we either remove the cholesteatoma matrix and then cover the fistula immediately or we leave the matrix in situ and re-explore the mastoid process 5 or 6 months later. The series consists of 88 cases out of a total of 701 patients with cholesteatoma operated on between January 1971 and June 1982. In 20 patients the matrix was left over the fistula at the first stage. The results suggest that a staged operation, i.e. closed tympanoplasty, is to be preferred even in cases with an extensive labyrinthine fistula.

Facial Nerve Outcome after Vestibular Schwannoma Surgery: Our Experience

In this study we evaluate the postoperative facial nerve function after vestibular schwannoma (VS) surgery and analyze the factors that cause it. We included 97 consecutive patients undergoing surgical excision of sporadic unilateral VS. Patient and tumor characteristics, surgical approaches, facial nerve function, extent of tumor removal, perioperative complications are all analyzed through standardized systems. Four different surgical approaches are used: translabyrinthine, retrolabyrinthine, retrosigmoid, and middle cranial fossa. Anatomic preservation of the facial nerve is achieved in 97% of patients. The incidence of postoperative facial palsy is found to be statistically correlated to tumor size, but not to the surgical approach used and to extent of tumor penetration in the internal auditory canal. A significant improvement of the short-term facial nerve outcome is detected in patients undergone simultaneous intraoperative electromyography (EMG) and pneumatic facial nerve monitoring. Complete tumor excision is achieved in 94% of cases. Complication rates are excellent and no deaths are reported. Short- and long-term facial nerve outcome is good and comparable with those of other series reported in literature. In VS surgery both EMG and pneumatic facial nerve monitors should be simultaneously used. Further investigations are desirable to improve the facial outcome respecting the oncological radicality.

Posterior canal wall reconstruction with titanium micro-mesh and bone patè.

INTRODUCTION Patients who have undergone a radical mastoidectomy may have symptoms related to the cavity itself (chronic otorrhea resistant to medical treatment, recurrent or iatrogenic cholesteatoma, granulations, dizziness, and so on), social handicaps (non-esthetic meatoplasty, impossibility to swim), or hearing problems (major conductive or mixed hearing loss, difficult or impossible hearing aid application). In all these cases, if the patient is medically fit, we suggest revision surgery. According to the age, health status, and intraoperative findings, three surgical procedures can be performed: a simple revision of the cavity, the obliteration of the cavity with blind sac closure of the external auditory canal, or the reconstruction of the middle ear (MER). MER is our preferred technique in young patients who are fit for surgery and who have good cochlear reserve. Since 1975, in the ENT Department of the University of Parma, allogenic cartilage (septal, meniscal, or costal) has been used to reconstruct the posterior canal wall (PCW) in more than 140 procedures. Over time this material, in a small number of cases, has been found to be partially or totally reabsorbed. In addition, the use of homologous grafts is still associated with risks of infectious disease, despite donors being fully screened; and it is important that the treatment and storage of the cartilage reduce the risk of transmission of viruses. Since 1995, a titanium micro-mesh has been used in 9 subjects as a variation of the technique to reconstruct the posterior canal wall. Surgical Technique The MER can be a unique or staged procedure. If staged, the first stage is performed with the patient under general anesthesia, whereas the second stage can be executed under local anesthesia.