Matthew L. Kircher

Osseointegrated Implant Applications in Cosmetic and Functional Skull Base Rehabilitation

This study discusses the indications, outcomes, and complications in patients that underwent osseointegrated implantation for skull base rehabilitation. We conducted a retrospective review of eight patients with skull base defects who had undergone implantation of a facial prosthetic retention device ± bone-anchored hearing aid at a tertiary academic referral center. Descriptive analysis of applications, techniques, outcomes, and complications were reviewed. The majority of patients were males (n = 6) with previously diagnosed skull base malignancy (n = 5) with an average age of 46 (range, 14 to 77). All patients received an implanted facial prosthetic device either for an aural (n = 7) or orbital (n = 1) prosthesis. There were only two complications that included infection (n = 1) and implant extrusion (n = 1). Osseointegrated implantation of abutments for anchoring prosthetic devices in patients for skull base rehabilitation provides an excellent cosmetic option with minimal complications.

Concurrent endoscopic sinus surgery and rhinoplasty.

Background Concerns over increased surgical risk and associated complications have been reported regarding concurrent endoscopic sinus surgery (ESS) and rhinoplasty procedures. The aim of this study was to evaluate the overall safety of these concurrent procedures in our experience. Methods A chart review was performed on 48 consecutive patients undergoing concurrent ESS and rhinoplasty between January 1998 and January 2005 with a mean follow-up of 12 months. The extent of surgical procedures, revisions required, and postoperative complications were documented. Results Thirty-one (65%) women and 17 (35%) men ranging in age from 16 to 56 years with a mean age of 37 years were included in this study. Forty-five patients (93.7%) underwent a primary rhinoplasty procedure, whereas the other three (6.3%) underwent a revision rhinoplasty. Four patients required minor rhinoplasty revision procedures for a rhinoplasty revision rate of 4/48 or 8.3%. Complications noted in three separate cases included partial nasal obstruction, pain near osteotomy site, and localized infection for a complication rate of 3/48 or 6.3%. Conclusion In this study, rhinoplasty revisions did not appear to be related to the fact that ESS was performed at the same time as rhinoplasty. In addition, the only complication possibly attributed to a combined approach was a postoperative infection that developed in an insulin-dependent diabetic patient who underwent a rhinoplasty for functional reasons. Consequently, we recommend screening patients with poor wound healing factors in addition to those with acute exacerbations of chronic rhinosinusitis or severe chronic rhinosinusitis before performing concurrent ESS and rhinoplasty. In our experience, complications noted during concurrent ESS and rhinoplasty were minor, indicating the overall safe nature of this combined procedure when performed in appropriate patients.

S205 – Neuroradiologic Assessment of Pulsatile Tinnitus

Objectives To present a neuroradiographic imaging algorithm for patients presenting with pulsatile tinnitus. Methods This was a retrospective review of patients presenting to a tertiary care academic medical center from 1993 to 2007 with a chief complaint of pulsatile tinnitus. Clinical presentation and diagnostic imaging data were analyzed. Results Of the 108 patients identified, 93 patients had subjective pulsatile tinnitus and 15 patients presented with objective pulsatile tinnitus. In patients with subjective pulsatile tinnitus, 27/93 (29%) had positive radiologic findings, with 71% of cerebral angiogram studies and 57% of MR studies revealing anatomic abnormalities responsible for the pulsatile tinnitus. In patients with objective pulsatile tinnitus, 9/15 (60%) had positive radiologic findings, with 80% of cerebral angiogram studies and 57% of MR studies revealing anatomic abnormalities responsible for the pulsatile tinnitus. Magnetic resonance sensitivity in subjective and objective pulsatile tinnitus was 67% and 57% respectively. Conclusions Magnetic resonance is an excellent first-line diagnostic imaging modality in the assessment of pulsatile tinnitus. However, regardless of the subjective or objective nature of pulsatile tinnitus, cerebral angiography should be considered in patients with a negative MR and disabling pulsatile tinnitus.

A Rat Model for Intracranial Facial Nerve Crush Injuries

Objective. (1) Explain the need for an animal model to study intracranial injuries to the facial nerve. (2) Describe various techniques attempted to identify and crush the intracranial segment of the facial nerve in a rat model. (3) Describe in detail a successful rat model of intracranial facial nerve crush injury. Study Design. Randomized controlled animal study. Setting. Animal laboratory. Subjects and Methods. Multiple attempts at surgical approaches to the cerebellopontine angle were attempted on cadaveric rats. Once a successful approach was derived, this was used on 19 live rats under anesthesia. Fourteen rats had a 1-minute facial nerve crush performed, and 5 had a sham surgery with complete surgical exposure of the facial nerve but no crush. Rats were followed for a 12-week duration evaluating immediate postoperative facial nerve function, complications, and survival. Results. All 14 (100%) rats that underwent surgery with crush injury had complete facial paralysis postoperatively. Complete facial paralysis was defined as loss of eye-blink reflex, flat vibrissae, and lack of vibrissae movement. The 5 sham surgery rats had complete facial function postoperatively. Surgery was performed by 2 separate surgeons with no difference in outcome between the 2. Complications occurred in only 1 animal (1/19, 5.3%), which was a corneal abrasion requiring sacrifice. Conclusion. Our group describes a consistent method for performing an intracranial crush injury in the rat. This new model and its applications in translational facial nerve research are promising, particularly with tumors or lesions at the cerebellopontine angle.

Inner Ear Effects of Canal Wall Down Mastoidectomy

Objective. To evaluate the inner ear effects of canal wall down (CWD) mastoidectomy without ossiculoplasty in the treatment of chronic otitis media (COM) with regard to sensorineural hearing loss (SNHL) and reported tinnitus and dizziness-related disability. Setting. Tertiary care academic medical center. Subjects and Methods. Prospective study of 86 patients treated by CWD mastoidectomy without ossiculoplasty for COM with or without cholesteatoma. Standard patient workup included preoperative audiogram and completion of 2 surveys: Dizziness Handicap Inventory (DHI) and Tinnitus Handicap Inventory (THI). Patients underwent repeat audiogram, DHI, and THI surveys at 4 to 6 months postoperatively. Preoperative and postoperative data were analyzed. Results. No significant SNHL occurred after CWD mastoidectomy. Thirteen patients (13/34 [38%]) had DHI improvement greater than 18 points, indicating a significant improvement in dizziness-related disability. Three patients developed new-onset postoperative dizziness complaints. Twenty patients (20/43 [46.5%]) had THI improvement greater than 7 points, indicating a significant improvement in tinnitus-related disability. Five patients developed new-onset postoperative tinnitus complaints. The odds ratio for improving DHI and THI scores after surgery was 6.6 (1.8 to 25.0) and 4.2 (95% confidence interval, 1.45% to 12.2%), respectively. Conclusion. In this study, CWD mastoidectomy without ossiculoplasty in the treatment of COM did not cause significant SNHL. In addition, using the DHI and THI measures, patient-perceived disability from dizziness and tinnitus, respectively, was shown to decrease after mastoid surgery.

Utility and cost analysis of cholesteatoma histopathologic evaluation.

To evaluate the correlation between the surgeons intraoperative findings and histopathologic diagnosis of cholesteatoma specimens and the associated health care cost in requesting pathologic evaluation.

Hearing Loss following Posterior Fossa Microvascular Decompression: A Systematic Review.

Objectives (1) Determine the prevalence of hearing loss following microvascular decompression (MVD) for trigeminal neuralgia (TN) and hemifacial spasm (HFS). (2) Demonstrate factors that affect postoperative hearing outcomes after MVD. Data Sources PubMed-NCBI, Scopus, CINAHL, and PsycINFO databases from 1981 to 2016. Review Methods Systematic review of prospective cohort studies and retrospective reviews in which any type of hearing loss was recorded after MVD for TN or HFS. Three researchers extracted data regarding operative indications, procedures performed, and diagnostic tests employed. Discrepancies were resolved by mutual consensus. Results Sixty-nine references with 18,233 operations met inclusion criteria. There were 7093 patients treated for TN and 11,140 for HFS. The overall reported prevalence of hearing loss after MVD for TN and HFS was 5.58% and 8.25%, respectively. However, many of these studies relied on subjective measures of reporting hearing loss. In 23 studies with consistent perioperative audiograms, prevalence of hearing loss was 13.47% for TN and 13.39% for HFS, with no significant difference between indications (P = .95). Studies using intraoperative brainstem auditory evoked potential monitoring were more likely to report hearing loss for TN (relative risk [RR], 2.28; P < .001) but not with HFS (RR, 0.88; P = .056). Conclusion Conductive and sensorineural hearing loss are important complications following posterior fossa MVD. Many studies have reported on hearing loss using either subjective measures and/or inconsistent audiometric testing. Routine perioperative audiogram protocols improve the detection of hearing loss and may more accurately represent the true risk of hearing loss after MVD for TN and HFS.

Facial Nerve Schwannomas Mimicking as Vestibular Schwannomas

Objective The objective of this study was to identify preoperative and intraoperative findings that may aid in distinguishing facial nerve schwannomas (FNS) from vestibular schwannomas (VSs), particularly in cases limited to the internal auditory canal (IAC) and cerebellopontine angle (CPA). Study Design This was a retrospective study. Setting This study was set at a Tertiary Referral Center. Patients Seventeen cases from October 2002 to July 2015 with an IAC/CPA mass presumed to be a VS who were found to have a FNS intraoperatively. Main Outcome Measures The main outcome measures included preoperative presentation, intraoperative findings, and subsequent intervention. Results Preoperative hearing loss and imbalance were seen in 70.5 and 64.7%, respectively. Suspicious intraoperative findings included: facial nerve incorporated intimately with the tumor capsule in 12 cases; spontaneous action potentials noted while drilling the bony IAC in 3 cases; and action potentials noted on stimulation of the entire tumor capsule in 10 cases. The mean long‐term facial function was House‐Brackmann grade II and the mean length of follow‐up was 4.86 years. Conclusion FNSs are rare and may be difficult to distinguish from VS preoperatively. Surgical findings that should raise concern include spontaneous action potentials during drilling the bony IAC, absence of a plane of dissection between the facial nerve and tumor, or stimulation of the tumor capsule.

Temporoparietal fascial flap repair of middle cranial fossa tegmen and dural defects

INTRODUCTION The repair of middle cranial fossa tegmen defects, encephalocele, and cerebrospinal fluid (CSF) leaks frequently involve the use of nonvascularized free tissue grafts such as fascial, cartilage, and bone grafts. A number of processes can lead to the development of tegmen and dural defects, including but not limited to cholesteatoma disease, surgical and nonsurgical trauma, and spontaneous CSF otorrhea with or without encephalocele. Success with nonvascularized free tissue graft techniques in achieving primary tegmen repair and control of CSF leak is variable, with failure rates ranging from 2.3% to 28.6%. Cases requiring revision repair or with extensive dural defects should especially consider alternative reconstructive options. In addition, nonvascularized free tissue grafts may have poor viability in an infected field, which can be encountered in cholesteatoma disease. Vascularized tissue grafts offer a robust option in the closure of a variety of skull base defects with control of CSF leak. Patel et al. described their use of the temporoparietal fascial flap in reducing CSF leak after lateral skull base tumor resections. We report our use of the temporoparietal fascial (TPF) flap in a case of middle fossa CSF otorrhea failing multiple previous repairs, and in the case of a large tegmen defect with CSF leak and temporal lobe abscess stemming from middle ear cholesteatoma disease.

Imaging case of the month: Carotid artery dissection after exercise in stylo-carotid artery syndrome.

The patient is a 41-year-old physically fit man with no significant past medical history who experienced acute onset of left-sided weakness, left-sided neglect, left visual field deficit, and dysarthria after an episode of intense exercise. He was immediately taken to the nearest emergency department where a computed tomographic scan revealed a hyperdense right middle cerebral artery (MCA) sign, and he was emergently treated with intravenous tissue plasminogen activator (t-PA) thrombolytic therapy. His physical examination improved modestly over the 1-hour infusion time, and further imaging revealed an elongated right styloid process impacting the lateral wall of the right distal internal carotid artery (ICA) (Fig. 1). At the same level, a severe ICA dissection with intraluminal clot was evident on angiography, and the patient was then treated with endovascular intraarterial t-PA. This resulted in partial right MCA recanalization with near complete resolution of intraluminal clot. The patient subsequently achieved a near complete neurologic recovery. He presented to our clinic 2 months postincident for discussion of styloid process resection. After an extensive discussion of the possible risks of the procedure with the potential for further cerebrovascular compromise, the patient elected for styloid process resection. A preoperative angiogram revealed pseudoaneurysm formation at the previous site of dissection with patency of the right ICA circulation, and it was elected to not place a carotid stent preoperatively. The operative procedure was performed in conjunction with an interventional radiologist and a neurovascular surgeon. Surgery was performed under general anesthesia with electroencephalography used throughout the case. Using fluoroscopic guidance, a catheter was advanced up to the brachiocephalic artery to provide immediate carotid occlusion in the event of intraoperative carotid rupture. A transcervical approach was used to expose the ICA at the cranial base and resect the styloid process. The patient tolerated the procedure well without any evident