Henrique Faria Ramos

Study of the nasoseptal flap for endoscopic anterior cranial base reconstruction

Measure the dimensions of the nasoseptal (NS) flap and the anterior skull base (ASB) defect. Verify whether the flap is sufficient to cover the defect. Study the anatomy of the septal artery (SA).

Hearing preservation using topical dexamethasone alone and associated with hyaluronic acid in cochlear implantation

Abstract Conclusion: Topical dexamethasone associated with hyaluronic acid in cochlear implant surgery demonstrated a statistically significant difference in the preservation of low-frequency thresholds when compared with topical dexamethasone alone and a control group. Topical dexamethasone alone was not superior in hearing preservation when compared to the control group. Objective: To compare the effects of topical dexamethasone alone and associated with hyaluronic acid intraoperatively in hearing preservation in cochlear implantation. Methods: Eighteen severely to profoundly hearing-impaired adult patients with measurable hearing were divided into three groups preoperatively: cochlear implantation as a control group (group 1), cochlear implantation using topical dexamethasone intraoperatively (group 2), and cochlear implantation using topical dexamethasone associated with hyaluronic acid intraoperatively (group 3). Preimplant and postimplant low-frequency pure-tone averages (PTAs) were calculated from unaided audiograms at 125, 250, and 500 Hz. Results: The mean changes in the low-frequency PTA comparing postoperative against preoperative thresholds were 28.03 ± 6.77 dB in group 1, 30 ± 14.53 dB in group 2, and 7.23 ± 6.12 dB in group 3. There was statistical difference when comparing group 3 with groups 1 and 2 using one-way ANOVA (p = 0.002) followed by Scheffé post hoc test.

Evaluation of residual hearing in cochlear implants candidates using auditory steady-state response.

Abstract Conclusion: The correlations between behavioral and auditory steady-state response (ASSR) thresholds were significant at 500, 1000, 2000, and 4000 Hz. ASSR presented high sensitivity and specificity in the detection of residual hearing in cochlear implant candidates when compared with warble-tone audiometry. Objectives: To assess residual hearing in cochlear implant candidates by comparing the electrophysiological thresholds obtained in dichotic single-frequency ASSR with behavioral thresholds at 500, 1000, 2000, and 4000 Hz. Methods: This was a comparative study between ASSR and warble-tone audiometry thresholds in 40 cochlear implant candidates (80 ears) before cochlear implantation with bilateral severe-to-profound sensorineural hearing loss. Results: Thresholds were obtained in 62.5% of all frequencies evaluated in warble-tone audiometry and in 63.1% in the ASSR. ASSR sensitivity was 96% and specificity was 91.6%. Mean differences between behavioral and ASSR thresholds did not reach significance at any frequencies. Strong correlations between behavioral and ASSR thresholds were observed in 500, 1000, and 2000 Hz and moderate in 4000 Hz, with correlation coefficients varying from 0.65 to 0.81. On 90% of occasions, ASSR thresholds were acquired within 10 dB of behavioral thresholds.

Juvenile Nasopharyngeal Angiofibroma with intradural extension

Senior Associate Professor of Otorhinolaryngology - Medical School of the University of Sao Paulo.Hospital das Clinicas da Faculdade de Medicina da Universidade de Sao Paulo (HC-FMUSP).Send correspondence to: Henrique Faria Ramos - Av. Dr. Eneas Carvalho de Aguiar, 255 6o andar. Sao Paulo - SP, Brazil. CEP: 05403-000.E-mail: henriquefariaramos@terra.com.brPaper submitted to the BJORL-SGP (Publishing Management System – Brazilian Journal of Otorhinolaryngology) on July 15, 2010; and accepted on October 01, 2010. cod. 7211

Endoscopic anatomy of the approaches to the sellar area and planum sphenoidale

UNLABELLED The productive work between otolaryngologists and neurosurgeons has resulted in the emergence of endoscopic endonasal skull base surgery. The goal of the present study is to describe the endoscopic anatomy of the endonasal approach to the sellar region and planum sphenoidale, highlighting the key points of the surgical approach and the neurovascular landmarks. METHOD Descriptive study of the endoscopic endonasal dissection of 9 fresh cadavers with exposure of the anatomic structures. RESULTS The endoscopic endonasal ethmoidectomy and sphenoidotomy allows an expanded access to the sellar area and planum sphenoidale. The surface anatomy of the sphenoid sinus is easily identifiable and provides safe landmarks, guiding the intracranial dissection. CONCLUSION The endoscopic endonasal approach to the skull base by the ENT and neurosurgeon is feasible, but it requires adequate anatomical knowledge and endoscopic skills for its realization, which can be obtained by practicing in cadavers.

Case reportAcquired stenosis of external auditory canal secondary to paraneoplastic manifestation of renal cancerEstenose adquirida do conduto auditivo externo secundária a manifestação paraneoplásica de câncer renal

Male, 56, presenting with an ulceration on the right auricular concha for 45 days, with poor response to topical and systemic antibiotics, associated with otorrhea, hearing loss, otalgia and fever. Otoscopy revealed an ulcerated lesion in the auricle and edema of the EAC, preventing appropriate visibilization of the tympanic membrane. Computed tomography (CT) of the temporal bones (Fig. 1A) showed obliteration of the EAC without regional bone involvement. Due to the possibility of malignant external otitis, the patient was treated with Piperacillin and Tazobactam for 21 days. The lesion improved after two weeks, evolving to scar stenosis of the EAC. The patient was discharged after 21 days with antibiotic therapy (Ciprofloxacin 750 mg, 21 days) and office follow-up for possible surgery for stenosis correction. After 3 months, the patient presented with severe bilateral otalgia associated with otorrhea, and necrosis of the auricular concha, tragus and intertragic incisure

Superior Turbinectomy: Role for a Two-surgeon Technique in Endoscopic Endonasal Transsphenoidal Surgery—Technical Note

We describe a practical technique of superior turbinectomy followed by posterior ethmoidectomy as a less invasive procedure for two-surgeon technique on endoscopic endonasal transsphenoidal surgery. After identification of the superior turbinate and the sphenoid ostium, the inferior third portion of the superior turbinate was coagulated and resected. This partial superior turbinectomy procedure exposed the posterior ethmoidal sinus. Resection of the bony walls between the sphenoid and posterior ethmoid sinuses provided more lateral and superior exposure of the sphenoid sinus. This technique was performed in 56 patients with midline skull base lesions, including 49 pituitary adenomas and 7 other lesions. Meticulous manipulation of instruments was performed in all cases without surgical complications such as permanent hyposmia/anosmia or nasal bleeding. Our findings suggested that the partial superior turbinectomy followed by retrograde posterior ethmoidectomy is a simple and safe technique providing a sufficient surgical corridor for two-surgeon technique to approaching midline skull base regions, mainly involving pituitary adenomas.

Are auditory steady-state responses a good tool prior to pediatric cochlear implantation?

INTRODUCTION ASSR allow frequency-specific evaluation in intensities up to 120dB HL and detection of residual hearing in patients with severe-to-profound hearing loss. AIM to compare ASSR thresholds and behavioral test results in children with suspected severe-to-profound hearing loss. METHODS Cross sectional study to compare ASSR and behavioral responses (VRA or audiometry) in 63 pediatric cochlear implant candidates (126 ears) aged between 6 and 72 months. We included children with normal otomicroscopy, absent responses to click-ABR and otoaccoustic emissions. We excluded children with inner ear malformations, auditory neuropathy spectrum disorder or who did not complete VRA or achieve EEG noise<30nV during the ASSR test. Air-conduction ASSR stimuli were continuous sinusoidal tones presented at 0.5, 1, 2 and 4kHz starting at 110dB HL. Behavioral thresholds were acquired with warble tones presented at 0.5, 1, 2 and 4kHz in each ear through insert or head phones at maximum presentation level of 120dB HL. RESULTS Behavioral thresholds were obtained in 36.7% (185/504) of all frequencies in all subjects, 9% in intensities >110dB HL. Among 504 ASSR measurements, 53 thresholds were obtained (10.5%). Overall 89.5% of the tested frequencies did not show any response at 110dB HL. Most responses were at 500Hz. Mean differences between behavioral and ASSR thresholds varied from 0.09 to 8.94dB. Twenty-seven comparisons of behavioral and ASSR thresholds were obtained: 12 at 0.5kHz, 9 at 1kHz, 5 at 2kHz and 1 at 4kHz. Absent responses were observed in both tests in 38.1% at 0.5kHz, 52.4% at 1kHz, 74.6% at 2kHz and 81.0% at 4kHz. Specificity was>90% at 1, 2 and 4kHz. In ears with no behavioral response at 120dB HL all ASSR thresholds were in the profound hearing loss range, 90% of them were ≥110dB HL. CONCLUSION Among 63 pediatric CI candidates, absent responses to high-intensity ASSR was the major finding (specificity>90%) predicting behavioral thresholds in the profound hearing loss range. These findings can be helpful to confirm the decision for cochlear implantation.

Are Auditory Steady-State Responses Useful to Evaluate Severe-to-Profound Hearing Loss in Children?

Objective. To evaluate Auditory Steady-State Responses (ASSR) at high intensities in pediatric cochlear implant candidates and to compare the results to behavioral tests responses. Methods. This prospective study evaluated 42 children with suspected severe-to-profound hearing loss, aged from 3 to 72 months. All had absent ABR and OAE responses. ASSR were evoked using binaural single frequency stimuli at 110 dB HL with a 10 dB down-seeking procedure. ASSR and behavioral test results were compared. Results. Forty-two subjects completed both ASSR and behavioral evaluation. Eleven children (26.2%) had bilateral responses. Four (9.5%) showed unilateral responses in at least two frequencies, all confirmed by behavioral results. Overall 61 ASSR responses were obtained, most (37.7%) in 500 Hz. Mean thresholds were between 101.3 and 104.2 dB HL. Among 27 subjects with absent ASSR, fifteen had no behavioral responses. Seven subjects showed behavioral responses with absent ASSR responses. No spurious ASSR responses were observed at 100 or 110 dB HL. Conclusion. ASSR is a valuable tool to detect residual hearing. No false-positive ASSR results were observed among 42 children, but in seven cases with absent ASSR, the test underestimated residual hearing as compared to the behavioral responses.

Expanded endonasal approach to skull base meningiomas

1Neurosurgery Division, Hospital das Clínicas, Universidade de São Paulo (USP), São Paulo SP, Brazil; 2Otorhinolaryngology Department, Hospital das Clínicas, USP, São Paulo SP, Brazil. Correspondence: Bernardo Assumpção de Monaco; Instituto Central HCFMUSP Neurocirurgia; Avenida Doutor Enéas de Carvalho Aguiar 255 / sala 5084; 05403-900 São Paulo SP Brasil; E-mail: bernardo.neuro@gmail.com Confl ict of interest: There is no confl ict of interest to declare. Received 25 February 2012; Received in fi nal form 18 September 2012; Accepted 25 September 2012.