Maurizio Falcioni

Perioperative complications in acoustic neuroma (vestibular schwannoma) surgery.

Objective: Retrospective study and review of the complications other than those related to the facial nerve and hearing, encountered in acoustic neuroma surgery. Also, an evaluation of hospital stay and its relation with various factors. Study Design: Retrospective case review. Setting: Tertiary neurotologic and skull base referral center. Patients: A series of 707 patients who underwent surgical removal of acoustic neuroma from April 1987 to December 2001. Interventions: The surgical approaches used were the enlarged translabyrinthine approach, the enlarged middle fossa approach, and the retrosigmoid approach. In a small number of cases, the operations were performed through other approaches. Main Outcome Measures: The duration of hospital stay and appearance of complications in the perioperative period along with their management. Results related to the facial nerve and hearing were not considered in this study. Results: The most frequent complication was abdominal subcutaneous hematoma (site of fat harvest), which occurred in 23 patients (3.2%). Cerebrospinal fluid leak was present in 20 patients (2.8%), 15 of whom needed revision surgery. Other complications included VIth cranial nerve dysfunction in 12 cases (1.68%), subdural hematoma in 3 cases (0.4%), cerebellopontine angle hematoma in 4 cases (0.6%), cerebellar edema in 2 cases (0.28%), brainstem hematoma in 1 case (0.14%), transitory aphasia in 1 case (0.14%), and lower cranial nerve dysfunction in 1 case (0.14%). Mortality occurred in only one case (0.14%). Medical complications seldom occurred. The postoperative hospital stay ranged from 2 to 36 days, with an average of 6.4 days. The overall hospital stay diminished over time from 10.2 days in 1987 to 1990, to 4.9 days in 2001. There was a significant relation between hospital stay and tumor size, approach used, and presence/absence of complications. Conclusions: Perioperative complications in acoustic neuroma surgery do exist, but this study demonstrated how low the incidence is. The authors believe that the low percentage of complications is mainly attributable to the majority of operations being carried out in specialized clinics, where they are considered routine operations. They believe that following individualized approaches, depending on tumor size and on the preoperative function of the cranial nerves, is the proper way to reach a significant reduction in complications while maintaining a high percentage of total tumor removal. The results of this study, considered as a basis of comparison with other studies, will certainly be useful in preoperative patient counseling.

Myringoplasty in Children: Factors Influencing Surgical Outcome

Age, size, and site of perforation, condition of the ear, status of the contralateral ear, grafting materials, and more are considered factors influencing the success rates in myringoplasties in children. The ambivalence in results is mainly due to nonhomogeneous patient groups. In an effort to compose groups as homogeneous as possible for analysis of influencing factors, a retrospective study of 51 pediatric myringoplasty cases (51 ears) was undertaken. All patients had perforations caused by simple chronic otitis media. The overall surgical success rate was 82.3% at 18 months, and for young (5 to 10 years) and older (11 to 16 years) children it was 77.2% and 86.2%, respectively. Anterior, central, and total perforations healed without significant differences. Outcome in unilateral perforations was better than bilateral: 96.9% and 55%, respectively (p < 0.01). Discharging ears (100%) healed better compared with dry ears (75%) (p < 0.05). Analysis of the literature also revealed significant difference in success rates of discharging and dry ears: 92.5% and 80.6%, respectively (p < 0.01). We conclude that, contrary to comments in the literature, discharging ears in children favor good outcome and they should be operated on regardless of age and site of perforation. However, in bilateral perforations results may not be so rewarding.

Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review

Temporal bone meningoencephalic herniation is a rare condition with potentially dangerous complications. The aim of this study is to analyze the pathogenesis, clinical presentation, surgical treatment, and postoperative outcome of 133 cases of surgically confirmed temporal bone meningoencephalic herniations. A review of the literature is also presented.

Surgical Management of Jugular Foramen Schwannomas With Hearing and Facial Nerve Function Preservation: A Series of 23 Cases and Review of the Literature

Objective: Schwannomas of the jugular foramen are rare lesions and controversy regarding their management still exists. The objective of this retrospective study was to analyze the management and outcome in a series of 23 cases collected at a single center.

Surgical management of jugular foramen meningiomas: a series of 13 cases and review of the literature.

Objective: Primary meningiomas occurring within the jugular foramen are exceedingly rare lesions presumed to originate from arachnoid‐lining cells situated within the jugular foramen. The objective of this study is to analyze the management and outcome in a series of 13 primary jugular foramen meningiomas collected at a single center.

Facial nerve tumors

Objective To evaluate the surgical results in primary facial nerve (FN) tumors. Study Design Retrospective case review. Setting Private neuro-otological and skull-base tertiary referral center. Patients Twenty eight consecutive patients affected by primary FN tumors that underwent surgery between December 1990 and February 2001. Interventions The lesions were removed through a variety of surgical approaches, depending on tumor location and extension, as well as preoperative hearing. In one case, partial removal was performed. Main Outcome Measures Preoperative and postoperative FN function; preoperative and postoperative hearing level; and postoperative complications. Results Based on histologic examination, tumors were distributed as follows: 18 schwannomas, six hemangiomas, two meningiomas, and two neurofibromas. Tumor location varied, with lesions distributed along the entire length of the nerve. Facial dysfunction was the most frequently recorded symptom, followed by hearing loss. Only five patients presented a preoperative grade 1 facial function. In the remaining patients of the group, the facial deficit lasted from 2 to 120 months, with a mean of 31.2 months. Anatomic integrity of the nerve was preserved in 4 cases; all others required a nerve interruption followed by reconstruction using a sural nerve graft. The complications recorded were: one cerebrospinal fluid leak, one postoperative retraction pocket, and one external auditory canal wall resorption requiring a surgical revision. Preoperative hearing remained unchanged in 8 out of the 15 patients in whom a hearing preservation procedure was attempted. In 25 cases, a follow-up of equal to or longer than 1 year was available, with the FN functions: two grade 1, eight grade 3, nine grade 4, three grade 5, and three grade 6. Patients with a preoperative deficit lasting more than 1 year demonstrated the worst recovery. Conclusions Primary FN tumors are rare lesions that include different histologic types. FN deficit represents the most common symptom, but it is not present in all cases. A conservative strategy is often adopted in presence of a normal preoperative facial function. When surgical management is selected, the decision on surgical approach to use depends on tumor size and location, as well as on preoperative hearing. FN integrity may be spared in rare occasions, but more frequently nerve reconstruction is required. Final facial function recovery is mainly dependent on the preoperative presence of FN deficit and its duration.

Meningoencephalic herniation into the middle ear: A report of 27 cases

Meningoencephalic herniation into the middle ear is a rare and potentially life‐threatening condition that may require prompt surgical intervention. Preoperative diagnosis is based on a high index of suspicion. Sometimes, however, meningoencephalic herniation is discovered during surgery. High‐resolution computed tomography and magnetic resonance imaging should be performed to confirm the diagnosis and to evaluate the extension of the herniated tissue. This article discusses the diagnostic approach, management strategy, and surgical technique used in 27 patients with meningoencephalic herniation. In an attempt to avoid infective complications, the authors used the middle cranial approach in patients with large herniations.

The Role of Subtotal Petrosectomy in Cochlear Implant Surgery-A Report of 32 Cases and Review on Indications

Objective To report and review 32 cases of subtotal petrosectomy (SP) in cochlear implant (CI) surgery and to define the indications and contraindications for this procedure Study Design Retrospective case review + case reports. Setting Tertiary skull base center. Patients Cochlear implant database: 32 subtotal petrosectomies in 31 patients. Interventions Subtotal petrosectomy with blind sac closure of the external auditory canal, closure of Eustachian tube, and abdominal fat obliteration in combination with cochlear implantation. Results Indications for SP in CI surgery were as follows: chronic otitis media (n = 4), previous radical cavity (n = 13), previous subtotal petrosectomy (n = 4), ossification of the cochlea (n = 5), malformation of the inner ear (n = 2), and temporal bone fracture (n = 4). One patient was simultaneously bilaterally implanted; 2 cases were revisions. All procedures were performed in 1 stage. In 2 cases, complications were encountered (6%), one of which lead to reoperation (3%). None of the patients was explanted. Conclusion Subtotal petrosectomy combined with cochlear implantation is a procedure required in specific situations and lowers the risk of repetitive ear infections, CSF leakage, and meningitis by closing off all connection with the external environment. Additionally, it gives excellent visibility and access in difficult anatomy or in drill-out procedures. The complication rate of 6% is comparable with normal cochlear implantation. Preservation of residual hearing can be considered the only absolute contraindication as an open external meatus is necessary for use of electroacoustic stimulation. Risks of the SP+CI procedure are infection of the abdominal fat, breakdown of the blind sac closure, and entrapped cholesteatoma. Follow-up with CT imaging is therefore mandatory.

Outcomes of facial nerve grafting in 155 cases: predictive value of history and preoperative function.

Objective: To investigate the factors that were effectual on the recovery of the facial nerve functions after repair with grafting. Study Design: Retrospective case review. Setting: Private neuro-otologic and cranial base quaternary referral center. Patients: One hundred ninety-four patients underwent facial nerve grafting during lateral cranial base surgery between July 1989 and December 2009. The mean age of the patients was 44.1 ± 15.8 years (range, 2-79 yr). There were 94 male and 100 female patients. Facial nerve functions were normal in 89 patients, whereas facial nerve paresis or paralysis was present for a mean duration of 25.4 months (range, 1-600 mo) in the rest of the patients. Main Outcome Measure: Final facial nerve motor function. Results: Best outcome, which was Grade III according to House-Brackmann scale, was achieved in 105 of 155 patients with a follow-up of 1 year or longer (67.7%). Final result was grade IV in 23 (14.8%), grade V in 8 (5.2%), and grade VI in 19 patients (12.3%). Preoperative deficit duration was found to be the only significant factor that affected the prognosis (p = 0.027). Receiver operating characteristic curve analysis revealed that the most critical time for recovery to grades III and IV function is 6 months (p < 0.001). Conclusion: A number of factors were implicated to affect the success rate of facial nerve grafting, but only the duration of preoperative facial nerve deficit was found to be significant. Thus, timely management of facial nerve problems is critical for achieving optimal results.

Balance impairment after acoustic neuroma surgery.

Objective: The aim of this study was to assess the incidence of balance problems after acoustic neuroma surgery, evaluating whether disequilibrium is disabling. Study Design: Retrospective observational study. Setting: Rehabilitation center. Patients: A group of 386 patients who underwent acoustic neuroma surgery. Interventions: Patients were selected from a population of 459 subjects who had undergone surgery for acoustic neuroma. Mean Outcome Measures: The Dizziness Handicap Inventory, The Activities-specific Balance Confidence Scale (ABC), and a specific questionnaire on oscillopsia. Results: The specific questionnaire emphasized that 39 patients (10.10%) perceived disequilibrium as disabling, and the oscillopsia handicap score result was moderate in 73.32% of the sample, mild in 21.50%, and severe in 5.18% of patients. The Dizziness Handicap Inventory and ABC scales revealed the presence of handicap and disability due to disequilibrium and the influence of some variables such as sex and a higher oscillopsia handicap score. Dizziness Handicap Inventory and ABC scores were higher in symptomatic patients. Conclusion: Disequilibrium influences handicap and disability after acoustic neuroma surgery. This symptom is also present after several years since surgery, and some patients perceived disequilibrium as disabling.