Nael M. Shoman

Do contemporary temporal bone fracture classification systems reflect concurrent intracranial and cervical spine injuries

Temporal bone fractures (TBFs) are a frequent manifestation of head trauma. We investigated the prevalence of concurrent intracranial injuries (ICIs) and cervical spine injuries (CSIs) in a series of patients with TBFs and attempted to identify significant associations between current TBF classification systems and either ICI or CSI.

Double-barrel stenting in infracochlear approach for drainage of petroux apex cholesterol granulomas.

INTRODUCTION Cholesterol granulomas (CGs) are benign, cystic lesions that typically present in an air cell tract of a pneumatized petrous apex (PA). Two theories have been proposed to explain their pathophysiology. The classic theory relates to an obstructive process that precludes the normal aeration of an apex air cell, resulting in a vacuum phenomenon; the subsequent negative pressure leads to an effusion. If hemorrhage then occurs, the poorly absorbed blood is broken down and a subsequent local inflammatory response ensues. The second theory proposes bone marrow exposure in a well-pneumatized PA as the initiating event (possibly congenital), with a subsequent subacute hemorrhage and a giant cell inflammatory response. Although initially silent, enlargement of CGs eventually encroaches on surrounding cranial nerves, resulting in myriad symptoms including hearing loss, dizziness, facial weakness, and diplopia. The mainstay of management remains surgical treatment to reduce pressure-induced symptoms, typically consisting of drainage of the lesion. Anterior and lateral skull base routes have been used to access the PA. Selection of a specific approach depends not only on the hearing status of the patient but also on the temporal bone pneumatization pattern, anatomy of the internal carotid artery, and location of the jugular bulb. Given the tendency for recurrence, stenting has been used by some surgeons in the hopes of ensuring long-term success. The goal of this article is to describe the technique used in our institution to drain CGs via the infracochlear approach with the use of a double-barreled angiocatheter sheath as a stent to optimize adequate drainage and reduce the incidence of recurrence.

Intravascular papillary endothelial hyperplasia of the internal auditory canal

Intravascular papillary endothelial hyperplasia (IPEH), also known as Massons tumor, is a rare vascular lesion characterized by intravascular proliferation of endothelial‐lined papillae and a propensity for manifestation in the head and neck. Signs and symptoms associated with IPEH generally occur due to compressive effects of the lesion on adjacent structures. A rare instance of IPEH occurring in the internal auditory canal is presented herein. Clinical presentation, radiographic and pathologic findings, and management strategies are discussed.

Analysis of carotid artery injury in patients with basilar skull fractures.

Objectives: Determine the prevalence of carotid artery injury (CAI) in patients with basilar skull fractures and describe significant demographic and radiographic risk factors for CAI. Study Design: From January 2004 to December 2008, medical records of 1,279 consecutive adult patients treated for basilar skull fractures at a tertiary care academic hospital were retrospectively reviewed. Diagnostic angiography was performed in 112 patients because of concern for CAI. Computed tomographic studies of the head and cranial base were reviewed for evidence of pneumocephalus, petrous carotid canal fractures, and sphenoid bone fractures. Results: Mean age of patients undergoing angiography was 38.7 years, and 85 patients (75.9%) were male subjects. Thirty-five (50%) of 70 discrete cerebrovascular injuries on angiography involved the carotid canal. The prevalence of CAI in patients with basilar skull trauma was 2.0%. CAI was associated with female sex (p = 0.001), whereas lower Glasgow Coma Scale score approached statistical significance (p = 0.07). Sensitivity and specificity of the 3 computed tomographic findings individually were 44% to 68% and 41% to 67%, respectively. With all 3 findings concurrently, 85% specificity and 80% negative predictive value for CAI were obtained, although sensitivity declined. Conclusion: The frequency of CAI in patients with basilar skull fractures was higher than that in those without basilar skull involvement. Female sex was strongly associated with CAI. The intimate anatomic relationship between the carotid artery and the cranial base posit substantial diagnostic and therapeutic challenges for the contemporary cranial base surgeon, and thus, understanding the epidemiology and risk factors for CAI is of paramount importance.

Contemporary angiographic assessment and clinical implications of the vein of labbé in neurotologic surgery.

Background: To better understand the drainage patterns of the 3 largest superficial anastomotic veins (SAVs), namely, vein of Labbé (VL), the vein of Trolard (VT), and the superficial sylvian vein (SSV). To assess the dominance of the VL in the superficial cortical venous system, because this vein may be encountered in neurotologic surgery and its interruption may result in a venous infarct of the temporal lobe. Methods: The database of the radiology department at the University of Cincinnati was used to identify all patients who underwent a diagnostic angiographic study between September 1, 2009, and January 1, 2010. Studies were excluded if there were intracranial masses or vascular lesions. Angiograms were assessed for the presence of the VL, VT, and SSV, as well as vessel dominance, determined by their relative calibers. Results: A total of 101 patients (81%) underwent bilateral and 48 unilateral angiography, for a total of 250 studies. Mean age was 55 years (range, 16-83 yr). Seventy-seven patients (53%) were females. The most common pattern observed was the presence of all 3 SAVs (78%). The VL was absent or poorly developed in 34 studies (14%) and was the dominant superficial vein in 51 (20%), of which 28 (55%) occurred on the right. Conclusion: Considerable variability is demonstrated in the drainage patterns of the SAVs. Care should be taken in neurotologic surgery to avoid injuring the VL because this may represent the single dominant drainage pathway of the lateral surface of the temporal lobe in a large number of patients.

The challenges of starting a cochlear implant programme in a developing country.

Purpose of reviewDeafness is indeed a silent disability in many parts of the world, and the majority of people who have hearing impairment live in developing countries. With rising economy and developing nations becoming hub of industrialization, hearing loss may increase in these countries. In this review, the authors have elected to focus the discussion on India to frame the challenges of cochlear implants in a developing country. This article reviews the common causes of hearing loss, the challenges faced by those with hearing impairment and why the penetration of these devices is low and also reviews some reasons for the inability of the government to support the implant programme in India. Recent findingsEarly identification of hearing is crucial towards ensuring appropriate hearing rehabilitation; it is, however, challenged by various factors, including public awareness, absence of a national new born screening programme, accessibility to diagnostic centres, availability of trained personnel and equipment and patient affordability.Cochlear implants are a proven auditory rehabilitative option for individuals with severe to profound sensorineural hearing loss, who otherwise do not benefiting from hearing aids. Nevertheless, only a small percentage of these individuals receive cochlear implants, and cost remains a leading prohibitive factor, particularly in developing countries. For example, in India, the personal average annual income is well below US

Contemporary Neuroradiographic Assessment of the Cochleo-Carotid Partition.

2000, whereas these devices cost between

Radiographic Assessment and Surgical Implications of Arcuate Eminence Pneumatization.

12 000 and

Vein of Labbe Radiographic Anatomy Surgical Implications

25 000, exclusive of hospital and staff fees. Hence, the technology is virtually unavailable to the masses. SummaryTo overcome the cost limitation of those who would benefit from cochlear implants countries such as India and China have started to develop their own indigenous implants.

Management of Acoustic Neuroma with Contralateral Ménière's Disease

Purpose: The cochleo-carotid partition (CCP) describes the intimate anatomic relationship between the petrous carotid artery and the cochlear basal turn. This partition bears significant surgical and unique clinical relevance. The purpose of this paper is to radiographically assess the CCP and discuss its clinical implications. Methods: A total of 155 consecutive fine-cut temporal bone CT scans were retrospectively reviewed, and study scans were digitally analyzed in both axial and coronal views. The shortest distance between the petrous carotid canal and the cochlear basal turn was measured. Results: In all, 310 temporal bones were studied, with a mean CCP of 1.9 mm (range 0.2-8.5, SD 1.1). The following CCP measurements were obtained: ≤1.0 mm [n = 46 (14.8%)]; 1.1-2.0 mm [n = 161 (51.9%)]; 2.1-3.0 mm [n = 29 (9.4%)], and ≥4.0 mm [n = 12 (4.2%)]. One temporal bone (0.3%) had complete CCP dehiscence. There was a positive correlation between each patients right and left CCP measures (p < 0.005) and a significant negative correlation between CCP grade and age (p = 0.027). Conclusions: The CCP is a narrow anatomic confinement measuring ≤2 mm in 66.7% of patients. Potential implications of the CCP include iatrogenic risks, its possible function as a third inner ear window in patients with audiovestibular symptoms, and pathophysiology of new-onset tinnitus following cochlear implantation.