Diogo Oliveira Carmo

The posterosuperior quadrant of the tympanic membrane.

Objective: To document the anatomic relationship of the posterosuperior segment of the tympanic membrane. Study Design: Point-prevalence study of postmortem material. Subjects and Materials: One hundred seventy temporal bones from adults without history of otologic pathology were studied. The anatomic details of the tympanic membrane were observed, histology was documented on 30 sectioned bones, and, with the use of the scanning electron microscope, lamina propria was studied in 40 bones. Results: We established that the posterosuperior quadrant was the largest, representing 28.7 percent of the total area of the eardrum. This feature implies that this quadrant is more likely than are the other quadrants to exhibit changes prompted by pressure challenges. We also verified that the posterosuperior part of tympanic sulcus, above the chorda tympanic nerve, lost its depth in an unexpected way in 60 percent of the cases. In association, we established that at this level there was a decrease in annulus caliber. In 25 percent of cases, by the absence of the circular fibers of lamina propria, the posterosuperior quadrant had only the radial fiber layer. Conclusions: Anatomic and morphologic details in posterosuperior quadrant were newly described and may explain the greater incidence of retraction pockets and marginal perforations that provide origin for the cholesteatoma.

Intermediate osteotomies in rhinoplasty: a new perspective

The nasal dorsum framework plays a major role in nasal and facial harmony. This study presents a new approach to an already known technique, intermediate osteotomies, which can be used routinely in patients with cosmetically unpleasant changes in eyebrow-tip line features, allowing the acquisition of a natural, aesthetically agreeable and harmonious dorsum contour, while preserving nasal function. The approach was evaluated retrospectively in 50 consecutive patients at a tertiary referral hospital. Patients were asked to complete a survey to rate their satisfaction with the cosmetic outcome on a 5-point visual analog scale (VAS) and to compare the impact of nasal obstruction on their quality of life, pre- and postoperatively, by completing the validated Nasal Obstruction Symptom Evaluation (NOSE) scale. Satisfaction was scored as excellent (satisfaction level VAS average score, 4.4), with more than 50% of the patients completely satisfied with the aesthetic result, while NOSE scale scores demonstrated preservation of nasal function postoperatively. Typical complications of the upper third of the nose following osteotomies were not observed.

Operative Interventions for Clivus Osteoradionecrosis with CSF Leak following Stereotactic Radiosurgery for Nasopharyngeal Carcinoma

Objectives: Nasopharyngeal carcinoma (NPC) local recurrence still represents a major clinical challenge and a high mortality and morbidity cause. The authors report a case of a 44-year-old male with clivus osteoradionecrosis (ORN) and dural radionecrosis who presented with cerebrospinal fluid (CSF) leak, 6 months after a boost of stereotactic radiosurgery using gamma knife for the treatment of locally recurrent NPC, following conventional external beam radiotherapy (EBRT) with chemotherapy. Methods: A direct transnasal endoscopic-assisted approach with multiple reconstructive pedicled flap technique was used to achieve watertight dural reconstruction. Results: Despite CSF leak recurrence, after the second attempt we achieved a successful clivus reconstruction using a bilateral posterior pedicle inferior turbinate flap (PPITF). The reconstruction withstood a watertight seal for 1 month, until patient death from cardiopulmonary arrest as a result of ventilator-associated pneumonia. Conclusions: We recommend an early diagnosis and surgical intervention in the setting of clivus ORN. Local debridement of necrotic bone is critical for local nasal graft adherence and survival. The evidence of dural radionecrosis is a predictor of bad prognosis. As a result, broad dural defect exposition should be the standard procedure with the use of a multi-layered technique combined with vascularized pedicle flaps regardless of the dural tear dimension.

S221 – The Postero-superior Quadrant of the Tympanic Membrane

Objectives The purpose of this study was to document the anatomic relationship of the postero-superior segment of the tympanic membrane and its clinical implications. Methods 100 temporal bones from adults without history of otologic pathology were studied. The morphological and anatomical details of the tympanic membrane were observed in 70 bones, which implied the use of macroscopic sections of the bones. The histological results were documented in 30 serially sectioned bones, stained previously with hematoxylin-eosin. Results We established that the postero-superior quadrant was the largest in size, with a mean dimension of 21.05 mm2, which represents 28.7% of the total area of the tympanic membrane. This feature implies that this quadrant is more exposed to pressure changes. We also verified that the posterosuperior part of the tympanic sulcus, above the chorda tympanic nerve, lost its depth in an unexpected way (60%) or that it gradually diminished from 0.9 to 0.5 mm until it disappeared near the posterior tympanic spine. In association, we established that at this level there was a decrease in the annulus caliber. Additionally, in 25% of cases, given the absence of the circular fibers of lamina propria, the postero-superior quadrant had only the radial fiber layer. Conclusions Anatomic and morphologic details in the postero-superior quadrant were newly described and may explain the greater incidence of retraction pockets and marginal perforations that provide the origin of cholestheatoma.

P136: The True Story of Menière’s Disease

tion. Included are case presentations of use of MDCT in superior canal dehiscence syndrome, cochlear implantation, ossicular erosion, and fixation. RESULTS: MDCT was first introduced in 1992 with a dual channel detector. However, 64-row scanners are now available as of 2003. First designed to increase scanning times and decrease slice thickness, latest generations have made great advancements in isometric imaging allowing for on-demand multiplanar reconstruction as well as increased fidelity in three dimensional reconstruction. While not well described in the literature, properties of MDCT augment our abilities to accurately diagnose otologic disease. For example, the ability to align CT images directly in the plane of the superior semicircular canal aids in finding bony dehiscences in superior canal syndrome. In addition, high-definition CT images aid in characterization of electrode array placement in cochlear implantation. Ossicular pathologies can also present a challenge to conventional imaging whereas MDCT improves diagnostic accuracy. CONCLUSIONS: Multidetector row computed tomography has increased the ability to accurately diagnose certain otologic diseases. Improvements in MDCT are changing our clinical practice.

P112: Intratemporal Facial Nerve Tumors: Management Controversies

male and 32 female) were recruited from a tinnitus clinic and underwent a detailed neuro-otological examination including otoscopy, stapedius reflexes, middle ear pressure measurements, pure tone audiometry, tinnitus pitch and loudness matches. Tinnitus severity was assessed by the Tinnitus Questionnnaire (TQ) and subjects were genotyped for two biallelic BDNF markers, an intronic A T substitution (refSNP# rs2049046), plus a functional missense variant (Val66Met, rs6265). RESULTS: When genotypes were grouped at both loci assuming dominance of the lesser alleles, no effects were observed for the intronic BDNF variant. However, carriers of the BDNF missense variant differed significantly from other subjects with regard to the prevalence of comorbid hearing impairment (p .01). In addition, tinnitus symptomatology was found to be milder in male subjects carrying the missense variant (p .05). CONCLUSIONS: This is the first study to address the participation of BDNF variants in the genetic susceptibility to chronic tinnitus. Pending replication in larger samples, a genotype-wise association with comorbid hearing impairment and, to a lesser extent, with tinnitus severity, argues in favour of a modifying role in defined tinnitus phenotypes.

P138: Treatment of Imbalance Post-Gentamicin

history, scientific discoveries and chronology of Menière’s disease and the importance of Charles Skinner Hallpike and Hugh Cairns. METHODS: The authors reviewed medical literature and medical history of Prosper Menière’s, Charles Skinner Hallpike, and Hugh Cairns. Special emphasis is given on the investigations of Hallpike on temporal bones of patient with Menière’s disease: clinical history, removal and methods of preparation of the temporal bones, and interpretation of the microscope readings. RESULTS: The observations of Hallpike on the temporal bones of patients with Menière’s disease when compared with others from normal individuals were published on 1938 and tried to explain the disease: obliteration of the endolymphatic duct, failure of re-absortion of endolymph and ionic changes, pressure increase leading to ischemia of macula and producing an attack, explanation of hearing loss and tinnitus by compression of the Corti unit. CONCLUSIONS: Through a review of medical literature the authors point out some aspects of Menière’s disease, with special interest in the thorough works of Charles Skinner Hallpike on temporal bones of patients with Menière’s disease and his explanation of Menière’s disease and attacks.

Ultracision Scissors: An Alternative Method in Tonsillectomy, 400 Cases

Abstract Objectives: To show that the ultracision curved shears for tonsillectomy is a less hemorrhagic and significantly faster and safer technique than monopolar techniques Methods: A total of 400 patients, 240 children and 160 adults, of which 86 associated with UPP were subjected to tonsillectomy with Ultacision Harmonic Scalpel curved shears shaft length 14 cm CS-14C-Ethicon Endo Surgery in the last 48 months. Results: We divided the patients into 3 groups: 240 children, 74 adults, and 86 adults with UPP. In these groups we present the (1) age distribuition, (2) operating time, (3) pain control, (4) return to work, and (5) complications. Ultracision shears are safer and permit a more blodless and significantly faster dissection in comparisson with bipolar and monopolar surgery. The tissue surrounding the capsule is conserved. The fact that there is practically no blood in the operating field gives the surgean a great sense of security and makes it possible to carry out a very accurate dissection. This combined with the inexistence of blood in the operating fiel makes it the technique of choice in the case of patients with sleep apneia with large tonsils and for UPP. Complications: 4 hemorrhages in 400 cases (1%). Conclusions: Cutting and dissecting with scissors is a very natural gesture for the surgeon. Ultracision scissors offer a safe, efficient, and clean technique that makes tonsilectomy a neat and easy surgical action. The time saving aspect is also important in surgical anaesthetic and cost effectiveness.

Tympanic insertion: an explanation for the origin of cholesteatoma

Objectives: This study on the tympanic insertion has several goals. First, we were interested in acquiring a better understanding of the morphology of the membrane. Second, we wished to correlate this to the pathologic changes which affect the membrane when the middle ear is subjected to episodic bouts of inflammatory disease. Hopefully, correlation of the anatomy and pathology will enhance both medical and surgical therapies in this area. Methods: In the morphological study 190 adult human temporal bone necropsy specimens representing both sexes were utilized. The specimens exhibited no pathological changes and were subjected to microscopic observation, histological techniques, and electronic scanning microscopy studies. Results: We divided the tympanic sulcus in three parts according to the relationships established with the cavity’s walls and external auditory canal: the anterior portion and the inferior sulcus; in these two sections the sulcus has a depth of 0.9 mm with its edges equally well defined. The posterior part of the tympanic sulcus subdivides itself in two distinct parts separated by the emerging of the chorda tympani nerve. These alterations are shown in the morphology of the edges that no longer exist or become less evident. Conclusion: In association with these deviations of the sulcus morphology we saw that there was a decrease in the annulus caliber and a smaller resistance in the structure of the lamina propria. The assemblage of all these elements contributes to the understanding of the retraction pocket physiopathology as well as the marginal perforations which are at the origin of the cholesteatoma.