Mislav Gjuric

Endonasal Endoscopic Closure of Cerebrospinal Fluid Fistulas at the Anterior Cranial Base

This study reports our indications and limits for endonasal endoscopic closure of dural defects with a cerebrospinal fluid (CSF) leak at the anterior cranial base, and demonstrates our surgical technique. Fifty-three patients with CSF rhinorrhea were reassessed for the success rate of closure of the CSF leak. Surgery was successful in 98%, and 68% of fistulas were closed endoscopically. A free graft of autogenous mucoperiosteum of the inferior turbinate was the most frequently used tissue for defect closure. The endonasal endoscopic route proved relatively safe for the closure of dural tears, irrespective of the cause, up to about 10 × 10 mm. It is characterized by minimal morbidity because of the preservation of sinus ventilation and bony structures, supraorbital nerves, and olfactory fibers. Defects larger in size, predominantly of traumatic origin, were closed via the transfacial approach. The decision on the surgical approach was additionally based on the extent of the facial soft tissue injuries and the localization of the leak.

Cranial Nerve and Hearing Function after Combined-Approach Surgery for Glomus Jugulare Tumors

In this retrospective study, oncologic and functional results of 46 patients treated for glomus jugulare tumor are reported. The standard surgical approach was the combined transmastoid-transcervical approach, modified according to the individual tumor growth, and eventually combined with a transtemporal or a suboccipital approach. Complete tumor removal resulted in a cure rate of 90%. New-onset cranial nerve palsies developed in less than 22% of patients. In 54% of cases it was possible to retain middle ear function. From a total of 12 patients with incomplete tumor removal and postoperative irradiation, progressive tumor growth was noted in 4 patients, and was controlled by salvage irradiation or surgery. Radical tumor removal by ablative surgery can be modified by efforts to reduce mutilating resections. In their place, individually tailored and combined multidirectional surgical approaches may allow total tumor removal with lower morbidity.

Experimental Sensorineural Hearing Loss Following Drill-induced Ossicular Chain Injury

In a guinea pig model, a standardized drill-induced injury to the body of the incus was applied, and the effects on hearing were characterized by electrocochleography. Drilling resulted in a threshold shift within seconds, and after 15 min it averaged 35.7 dB for clicks, 35 dB nHL for 4 kHz bursts, 36.7 dB nHL for 6 kHz bursts and 39 dB nHL for 8 kHz bursts. The deterioration of the threshold shift remained stable throughout the 5-week post-operative observation period. In five animals a disarticulation of the incudostapedial joint was performed prior to drilling, but this did not reduce the threshold shift. Caution is mandatory during drilling around an intact ossicular chain to avoid a permanent sensorineural hearing loss, and disarticulation of the incudostapedial joint prior to drilling has no protective value.

Selective Resection of the Semicircular Canals of Rabbits with Preservation of Hearing

The goal of this investigation was to develop a method of surgical removal of the semicircular canals of the rabbit without induction of auditory impairment. Four different surgical techniques were utilized: i) fenestration of the lateral semicircular canal; ii) fibrin glue perfusion of the canal following fenestration; iii) removal of the lateral semicircular canal by drilling after fenestration and fibrin glue perfusion, and iv) removal of all three canals after fenestration and fibrin gluing. Brainstem auditory potentials were recorded repeatedly for up to 3 months after operation and demonstrated preservation of hearing in all rabbits in the first group and in 78% of the second group. In the third group the potentials could be recorded in 67% of the animals and showed a 20 dB deterioration of hearing. After removal of all three semicircular canals residual hearing could be recorded in 50% of the rabbits. These animals regularly showed a 30-40 dB deterioration of hearing. A precise microsurgical technique using fibrin glue and bone chips for interruption of the peri- and endolymph flow proved crucial for hearing preservation.

Transmastoid-infralabyrinthine tailored surgery of jugular paragangliomas.

This article presents our experience with the management and outcomes of patients with sporadic glomus jugular tumors using a tailored surgical approach. We conducted a retrospective study of 49 patients with sporadic jugular paragangliomas. Thirty-eight patients (78%) were treated using the transmastoid-infralabyrinthine (TM-IL) approach, and 11 (22%) were treated with the infratemporal fossa type A (IFT-A) approach. Mean follow-up period was 8.2 years. Surgical cure was achieved in all but 6 patients using the TM-IL approach (84%) and in 8 of 11 patients with the IFT-A approach (73%). A House-Brackmann grade of I or II facial nerve function was obtained postoperatively in 84% of TM-IL cases and in 56% of the IFT-A cases. The incidence of other complications-meningitis and transient cerebrospinal fluid leak-was higher in the TM-IL group (8% and 13%, respectively) compared with the IFT-A group (0% and 9%, respectively). We concluded that the TM-IL approach with individually tailored management of the facial nerve fulfills the long-term requirements of both keeping good postoperative facial function and obtaining adequate tumor resection.

Consensus Statement and Guidelines on the Management of Paragangliomas of the Head and Neck

Paragangliomas (PGLs) of the head and neck (H&N) are uncommon tumors that either arise spontaneously or as part of an inherited syndrome. Hereditary PGL is an autosomal-dominant tumor predisposition syndrome in which an affected individual has greatly increased risk of developing PGL at any or several sites in the autonomic nervous system. The mode of inheritance for some is affected by maternal imprinting. These tumors are generally very slow growing, often taking a decade to double in size. A few are or can become malignant and can metastasize widely. Because of their site of origin, patients with these tumors may develop cranial nerve deficits that have a significant impact on their quality of life. Patients may present to specialists from widely differing disciplines, and some of these may not appreciate the full implications of their patients disease. As a result, management can become fragmented or inappropriate, and some aspects of care may even be overlooked. This article is the distillation of consensus opinion derived from current published and unpublished data in this field, with particular reference to the management of temporal bone PGLs. We propose guidelines for the management of both sporadic and hereditary PGLs. A multidisciplinary team approach to the management of this complex disorder is advocated. Progress could be made by adopting these guidelines and by widespread dissemination of standardized information. Collaborative research should be promoted with the aim of harnessing advances in molecular genetics to develop targeted therapies for patients, particularly those with hereditary PGL.

What Is the Best Tumor Size to Achieve Optimal Functional Results in Vestibular Schwannoma Surgery

OBJECTIVES To analyze our own functional results to delineate a critical vestibular schwannoma size for middle cranial fossa (MCF) surgery with the best possible outcome. STUDY DESIGN Retrospective chart review. SETTING Academic tertiary referral center. METHODS Tumors were divided into intracanalicular, tumors 1 to 5, 6 to 10, and 11 to 15 mm in the cerebellopontine angle (CPA). Patients were evaluated at 2 months, 1 year, and 5 years after surgery. RESULTS At 1 year, House-Brackmann score of I or II was obtained in 100% of intracanalicular and in 96%, 86%, and 85% with tumors up to 5, 10, and 15 mm in the CPA, respectively. Class I hearing was postoperatively preserved in 61%, 41%, 29%, and 20%, and measurable word recognition in 67%, 51%, 35%, and 21% of patients, respectively. CONCLUSION The outcome is predominantly a function of tumor size, and these changes influence MCF surgery at an earlier stage than in the translabyrinthine or retrosigmoid approach. For the facial nerve, there is a cutoff at 5-mm extracanalicular extension. Also, chances for successful hearing preservation decrease rapidly with size, and in tumors beyond 1.5 cm are below 20%. Consequently, although an expectant policy with small tumors may be reasonable in some instances, it is not so for MCF candidates.

Metastase eines spinalen myxopapillären Ependymoms im inneren Gehörgang

ZusammenfassungEpendymome sind zumeist gutartige Tumoren, die aus den die Liquorräume auskleidenden Ependymzellen entstehen. Myxopapilläre Ependymome stellen eine histologische Untergruppe der Ependymome dar, welche nur sehr selten primär intrakraniell entstehen, sondern fast ausschließlich ihren Ursprung im lumbosakralen Spinalkanal und Filum terminale haben. Histologisch sind diese nach WHO als benigne Grad-I-Tumoren definiert.Im vorliegenden Fall handelt es sich um die erstmalig beschriebene Absiedelung eines spinalen myxopapillären Ependymoms in den inneren Gehörgang. Die klinische Symptomatik und die diagnostischen Befunde gleichen denen von Tumoren anderer Histologie. Eine typische oder gar eindeutige Darstellung in der bildgebenden Diagnostik (CT, MRT) ist nicht gegeben. Der transtemporale Zugangsweg ist bei guter Exponierbarkeit des inneren Gehörgangs auch bei der hier vorliegenden Histologie zur operativen Therapie geeignet. Eine adjuvante strahlentherapeutische Behandlung ist bei inkompletter Resektion und bei Rezidivtumoren indiziert.AbstractEpendymomas are usually benign tumors of the central nervous system that derive from the ependymal cells lining liquor-filled spaces. Myxopapillary ependymomas are a variant occurring almost exclusively in the region of the cauda equina. Histologically, these tumors are benign (WHO grade I).The following case describes the first reported spread of a spinal myxopapillary ependymoma into the internal auditory canal. The symptoms and diagnostic results are similar to other tumors of this location. There are no typical findings in the diagnostic imaging (CT, MRI). The extended middle cranial fossa approach was chosen for surgical treatment. Adjuvant radiotherapy is indicated in cases of incomplete resection or recurrence.

Funktionserhaltende Chirurgie von Glomus-jugulare-Tumoren Ein realisierbares Ziel?

ZusammenfassungEine radikale Entfernung ausgedehnter Glomus-jugulare-Tumoren hinterläßt häufig schwere Einschränkungen durch Lähmungen der kaudalen Hirnnerven und die Obliteration des Mittelohrs. Die Operationsstrategie der Erlanger HNO-Klinik setzte sich zum Ziel, die postoperative Morbidität zu senken, und gleichzeitig die Sicherheit der Tumorkontrolle zu erreichen. Die vorliegende Untersuchung stellt die onkologischen und funktionellen Resultate retrospektiv an 24 Patienten mit Glomus-jugulare-Tumoren der Größen C und D dar. Der mittlere Nachbeobachtungszeitraum betrug 3,7 Jahre. Als Standardmethode der Operation diente der transmastoidale-transzervikale Zugangsweg, der je nach Wachstum des Tumors modifiziert und gegebenenfalls mit einer transtemporalen Freilegung des Felsenbeins oder mit Hilfe eines retrosigmoidalen Zugangs kombiniert wurde. Präoperativ wurde eine superselektive Embolisation, soweit möglich, ausgeführt. Eine Ergänzung mit postoperativer Strahlentherapie erfolgte in 7 Fällen. Eine Heilungsrate von 100% wurde nach vollständiger Entfernung des Tumors mit Hilfe eines multidirektionalen Vorgehens erzielt. Bei 38% dieser Patienten traten postoperativ neue Hirnnervenlähmungen auf. In 54% der Fälle konnten ein normal konturierter äußerer Gehörgang und das Mittelohr entweder erhalten oder rekonstruiert werden. Residualtumore mußten in 2 Fällen nach inkompletter Resektion und postoperativer Radiotherapie beobachtet werden. Die individuelle Anpassung des chirurgischen Vorgehens erlaubt eine funktionsschonende Therapie ausgedehnter Glomus-jugulare-Tumore. Die entsprechend der Tumorausbreitung gewählten Zugangswege und operativen Schritte gestatten vollständige Tumorresektion mit minimierter Morbidität.SummaryIn this retrospective study, oncologic and functional results of 24 patients treated for glomus jugulare tumor stages C and D are reported. The surgical approach used was a combined transmastoid-transcervical approach, which was modified according to individual tumor growth. As needed, this was combined with a transtemporal or retrosigmoid approach. Complete tumor removal resulted in a cure rate of 100%. Surgically induced cranial nerve palsies developed in 38% of the patients. In 54% of cases it was possible to retain middle ear function. Seven patients had incomplete tumor removal requiring postoperative irradiation, with tumor progression occurring in 2 patients. Radical tumor removal was modified by efforts to reduce mutilating resections. These results show that individually tailored and combined multidirectional surgical approaches can allow total tumor removal to be performed with lower morbidity.

The Value of Methylprednisolone in the Treatment of an Experimental Sensorineural Hearing Loss Following Drill-induced Ossicular Chain Injury: A Randomized, Blinded Study in Guinea-Pigs

In a previously established animal model a standardized drill-induced injury to the body of the incus was applied, and the effects on hearing were characterized by electrocochleography. In a placebo-controlled, randomized, blinded study methylprednisolone showed no protective effect in reducing or improving the auditory threshold shifts, which occurred within seconds after drilling and remained stable throughout the 5-week observation period. Therefore the otologic surgeon must pay close attention to avoiding any contact of a rotating burr with an ossicle in an intact ossicular chain.