T. Somers

Imaging of Intralabyrinthine Schwannomas: A Retrospective Study of 52 Cases with Emphasis on Lesion Growth

BACKGROUND AND PURPOSE: Only a few case reports and small series of intralabyrinthine schwannomas (ILSs) have been reported. The purpose of this study was to assess prevalence, MR characteristics, location, clinical management, and growth potential/patterns of ILSs in the largest series reported. MATERIALS AND METHODS: Lesion localization, MR characteristics, lesion growth, and clinical management were reviewed in 52 patients diagnosed with an ILS between February 1991 and August 2007 in 2 referral centers. The number of ILSs and vestibulocochlear schwannomas in the cerebellopontine angle/internal auditory canal was compared to assess the prevalence. RESULTS: ILSs most frequently originate intracochlearly, are hyperintense on unenhanced T1-weighted images, enhance strongly after gadolinium administration, and are sharply circumscribed and hypointense on thin heavily T2-weighted 3D images. The scala tympani is more frequently or more extensively involved than the scala vestibuli. Follow-up MR imaging, available in 27 patients, showed growth in 59% of subjects. Growth was seen from the scala tympani into the scala vestibuli and from the scala vestibuli to the saccule and vice versa. Twelve lesions were resected, and the diagnosis of ILS histopathologically confirmed. CONCLUSION: ILSs can account for up to 10% of all vestibulocochlear schwannomas in centers specializing in temporal bone imaging, grow in more than 50%, and are most frequently found intracochlearly, often anteriorly between the basal and second turn. Cochlear ILSs most often originate in the scala tympani and only later grow into the scala vestibuli. Growth can occur from the cochlea into the vestibule or vice versa through the anatomic open connection between the perilymphatic spaces in the scala vestibuli and around the saccule.

Diffusion-weighted magnetic resonance imaging of the temporal bone.

This paper summarizes the value of diffusion-weighted magnetic resonance imaging in the evaluation of temporal bone pathology. It highlights the use of different types of diffusion-weighted magnetic resonance imaging in the different types of cholesteatoma, prior to first stage surgery and prior to second look surgery. The value of diffusion-weighted magnetic resonance imaging in the evaluation of pathology of the apex of the petrous bone and the cerebellopontine angle is also discussed.

Long-term follow up after bony mastoid and epitympanic obliteration: radiological findings.

OBJECTIVEnThe canal wall up bony obliteration technique lowers the incidence of recurrent cholesteatoma, but carries the potential risk of obliterating residual cholesteatoma. The objective of this study was to report long-term follow-up radiological findings after performing a canal wall up bony obliteration technique procedure, in order to detect residual and/or recurrent cholesteatoma.nnnPATIENTSnFifty-one patients presenting with a cholesteatoma or a troublesome cavity were operated upon using the canal wall up bony obliteration technique, and were evaluated by follow-up imaging a mean of 76.4 months post-operatively (range, 53.8-113.6 months).nnnINTERVENTIONnAll patients were evaluated with high resolution computed tomography and magnetic resonance imaging (including delayed contrast, T1-weighted imaging and non-echo-planar, diffusion-weighted imaging).nnnRESULTSnImaging revealed the presence of one residual, one recurrent and one congenital petrosal apex cholesteatoma. On high resolution computed tomography, completely obliterated mastoid filled with bone was observed in 74.5 per cent (38/51) of patients, and an aerated middle-ear cavity in 64.7 per cent (33/51). High resolution computed tomography clearly detected any associated soft tissue present in the middle-ear cavity (18/51) and in the obliterated mastoids (13/51), but could not characterise this tissue. Non-echo-planar, diffusion-weighted magnetic resonance imaging clearly identified all three cholesteatomas, and differentiated them from other associated soft tissues. No cholesteatoma was found within the obliterated mastoids.nnnCONCLUSIONnLong-term follow up indicated that the canal wall up bony obliteration technique is a safe method with which to treat primary and recurrent cholesteatoma and to reconstruct unstable cavities. Soft tissue was found quite often in the middle ear and obliterated mastoids. High resolution computed tomography identified its presence but could not further characterise it. However, non-echo-planar, diffusion-weighted magnetic resonance imaging succeeded in differentiating soft tissues, enabling detection of residual or recurrent cholesteatoma after a canal wall up bony obliteration technique procedure.

Transmastoid repair of superior semicircular canal dehiscence.

Objective/Hypothesisu2003Superior semicircular canal (Sup SC) dehiscence syndrome is a rare condition, causing a variety of auditory and vestibular symptoms. The traditional surgical management is a middle cranial fossa, extradural approach to resurface the Sup SC. Recently, a transmastoid approach for plugging of the Sup SC has been developed. We present further data supporting the use of the transmastoid approach in preference to the middle fossa approach. Designu2003This is a retrospective multi-institutional case series. Methodu2003We included 10 patients in this case series from two tertiary otology institutions. Sup SC dehiscence was confirmed by correlation of clinical symptoms with positive audiometric, vestibular evoked myogenic potential, and computed tomography findings. A transmastoid approach was used for plugging of the Sup SC. Either a single fenestration was created at the site of dehiscence or separate fenestrations sited ampullopetal and ampullofugal to the dehiscence. Resultsu2003All patients who underwent this procedure had good symptom control and hearing preservation postoperatively. Conclusionu2003In patients with adequate temporal bone pneumatization, the transmastoid approach provides a safe and effective alternative to the middle cranial fossa approach. This series has demonstrated excellent symptom control and preservation of hearing with the transmastoid approach.

The Bony Obliteration Tympanoplasty in Pediatric Cholesteatoma: Long-term Safety and Hygienic Results

Objective: To present the safety and hygienic results of a 5-year longitudinal study in a pediatric population undergoing surgery for extensive cholesteatoma using a canal wall up approach with bony obliteration of the mastoid and epitympanic space. Study Design: Retrospective consecutive study. Patients: Thirty-three children (⩽18 yr) undergoing surgery for cholesteatoma (34 ears) between 1997 and 2009. Interventions: Therapeutic. Setting: Tertiary referral center. Main Outcome Measures: 1) Residual and recurrent cholesteatoma rates at 5-year postsurgery, 2) postoperative waterproofing and hygienic status of the ear, and 3) required operation rate to achieve the safety and hygienic goals. Results: At 5 years no patients were lost in follow-up. This consecutive series design is rare in chronical otitis media treatment reporting. The standard residual rate at 5 years was 5.8%, representing two residual cholesteatomas in the middle ear. The standard recurrence rate at 5 years was 2.9%, representing one recurrent cholesteatoma. At 5-year follow-up all ears were free of otorrhea and waterproof and all external ear canals were patent and self-cleaning. The operation rate to reach this safety and hygienic status was 1.5 operations per ear at 5-year follow-up. Conclusion: The use of a canal wall up approach with obliteration of the mastoid cavity and epitympanic space to surgically treat cholesteatoma in children results in low residual and recurrence rates and a high rate of trouble-free ears in the long term.

Handling an Isolated Malleus Handle Fracture: Current Diagnostic Work-up and Treatment Options.

Background: An isolated malleus handle fracture is rare and presents with vague otological symptoms. Diagnosis depends on careful history taking and otoscopic examination. Different treatment options are available. Reconstruction with hydroxyapatite bone cement is a relatively new technique. Objective: The aim of this article is to review the current diagnostic work-up and treatment options and to demonstrate our method of treatment with hydroxyapatite bone cement. Methods: Three cases, repaired with hydroxyapatite bone cement in a tertiary referral otologic center, were retrospectively analyzed. A review of the literature on diagnosis and treatment procedures was performed. Results: One fracture occurred by withdrawing a finger from the external auditory canal and 2 occurred without clear prior trauma. Our 3 cases were successfully repaired with hydroxyapatite bone cement. Conclusion: Diagnosis of an isolated malleus handle fracture still depends on careful clinical examination. In addition to pure tone audiometry, both low and higher frequency tympanometry may be useful. High resolution computed tomography with reformatting through the malleus handle is the most accurate imaging modality. Reconstruction with hydroxyapatite bone cement is reliable by restoring the original situation with only minimal manipulation and without additional ossicular interruption.

Jugular bulb diverticulum dehiscence towards the vestibular aqueduct in a patient with otosclerosis.

OBJECTIVESnTo demonstrate the need for computed tomography imaging of the temporal bone before considering revision stapes surgery in patients with recurrent or residual conductive hearing loss.nnnCASE REPORTnWe report the case of a high-riding jugular bulb with an associated jugular bulb diverticulum, which was dehiscent towards the vestibular aqueduct, in a patient with confirmed otosclerosis who did not experience hearing improvement after stapedotomy.nnnCONCLUSIONnThis case demonstrates the usefulness of temporal bone computed tomography in the evaluation of patients with otosclerosis in whom stapedotomy has not improved hearing. In such patients, revision surgery to address residual hearing loss would eventually prove unnecessary and avoidable.

Long-term Results of Troublesome CWD Cavity Reconstruction by Mastoid and Epitympanic Bony Obliteration (CWR-BOT) in Adults.

Objective: To present the long-term surgical outcome of the bony mastoid and epitympanic obliteration technique with canal wall reconstruction (CWR-BOT) in adults with an unstable cavity after previous canal wall-down surgery for extensive cholesteatoma. Study Design: Retrospective study. Interventions: Therapeutic. Setting: Tertiary referral center. Patients: Fifty consecutive adult patients undergoing a CWR-BOT between 1998 and 2009. Main Outcome Measure(s): (A) Recurrence and residual rates of cholesteatoma, (B) postoperative hygienic status of the ear, including postoperative aspect of the tympanic membrane and external ear canal integrity (EAC), (C) functional outcome, and (D) long-term safety issues. Results: (A) The percentage of ears remaining safe without recurrent or residual disease after CWR-BOT was 96% after a mean follow-up time of 101.8 months. Recurrent cholesteatoma occurred in 2% (nu200a=u200a1) and a residual cholesteatoma was detected in 2% (nu200a=u200a1) of the patients. (B) A safe dry, and trouble-free graft and selfcleaning EAC was achieved in 94%

Partielle Obliteration von Ohr-Radikalhöhlen

Die moderne operative Therapie des Mittelohrcholesteatoms hat sich von der fruheren, fast dogmatischen Anwendung entweder der 2-Wege Technik oder der Radikalhohlenoperation zu einer individualisierten Technik gewandelt, in Kenntnis der Pathomechanik (Entwicklung des Cholesteatoms aus einer Retraktionstasche) und den vielfaltigen zuverlassigen Einsatzmoglichkeiten einer Knorpelrekonstruktion der Gehorgangswande. In der modernen Ohrchirurgie kommt daher in der Mehrzahl die sogenannte Verfolgungstechnik (die transmeatale Exposition des Cholesteatomsackes ohne zwingende Mastoidektomie mit anschliesender Rekonstruktion der Gehorgangswand durch Knorpelplatten) zum Einsatz. Nur in seltenen Fallen ist noch die sogenannte 2-Wege Technik (mit Mastoidektomie) oder die Anlage einer Radikalhohle erforderlich. Auch hier hat ein Umdenken stattgefunden in Anbetracht der unertraglich hohen Rezidivraten bei der 2-Wege Technik: Sowohl die hohe Zahl der Residualcholesteatome (typischerweise im Schatten der stehengelassenen hinteren Gehorgangswand) als auch die rekurrenten Rezidive (Einsenken einer neuen Retraktion in die vormals ausgebohrte Mastoidhohle) lassen dieses Verfahren nur noch fur sehr gut pneumatisierte und mit reizloser, gasproduzierender Schleimhaut ausgekleidete Mittelohren als erfolgsversprechend erscheinen. Bei der klassischen Radikalhohlentechnik besteht trotz ihrer geringeren Rezidivrate als groser Nachteil das chronische Ohrenlaufen aufgrund der standig feuchten Hohle. Ursachlich und schon lange bekannt ist das ungunstige Beluftungsverhaltnis der hautausgekleideten grosen Hohle (zu kleine Offnung des Gehorgangs im Verhaltnis zum grosen Hohenvolumen). Eine stabile Verkleinerung der Hohle mit deutlicher Verringerung der Rezidivrate ist mit korpereigenem Knochenmehl und luckenloser Knorpelplattenabdeckung (aus dem Cavum conchae) moglich. In dem Video wird das Prinzip der Knochenmehl- und Knorpelplattenobliteration mit unserer in Dresden entwickelten Technik dargestellt und es werden einige Tipps zur Erzielung einer stabilen Hohle gegeben.

Surgical Treatment of Acquired Atresia of the External Auditory Ear Canal

Introduction u2003Acquired atresia of the external auditory canal is characterized by the formation of fibrous tissue in the medial part. The causes include chronic otitis externa, perforated chronic otitis media, postoperative or idiopathic healing problems. Acquired atresia presents with hearing loss and can be associated with otorrhea. Objective u2003We analyzed the results of surgery after six months and two years by checking (1) pre- and postoperative hearing thresholds; (2) presence of otorrhea; and (3) whether a dry and patent ear canal is achieved. Methods u2003We conducted this retrospective study at a tertiary referral center. In total, 27 ears underwent treatment with resection of the fibrotic plug followed by transplantation of a split-thickness skin graft covering the bare bone and tympanic membrane. When necessary, we combined this with a myringoplasty and a (meato-) canalplasty. Results u2003Otorrhea was present in 59.3% of the patients initially and in 14.8% at six months and 11% at two years postoperative. A dry and patent ear canal was obtained in 55.6% after six months and in 89% of the patients after two years ( n u2009=u200927). The pure tone average before surgery was 39.1 dBHL (SDu2009=u200920 dBHL), at six months 31.4 dBHL (SDu2009=u200916.4 dBHL), and at 24 months postop 30.9 dBHL (SDu2009=u200917.1 dBHL). We observed a statistically significant improvement of hearing in 63% of the patients at six months ( p u2009=u20090.005) and in 65% after two years ( p u2009=u20090.022). Conclusions u2003Treatment of acquired atresia remains a challenge. Using the appropriate surgical technique, including skin-grafting and regular postoperative check-up, rendered excellent results regarding otorrhea and a moderate improvement of hearing was achieved in 65% of the patients after two years.