Tarek Khrais

Endoscopic surgery for malignant tumors of the sinonasal tract and adjacent skull base: a 10-year experience.

Background The increasing expertise in the field of transnasal endoscopic surgery recently has expanded its indications to include the management of sinonasal malignancies. We report our experience with the endoscopic management of nasoethmoidal malignancies possibly involving the adjacent skull base. Methods A retrospective analysis was performed of patients treated by an exclusive endoscopic approach (EEA) or a cranioendoscopic approach (CEA) from 1996 to 2006 managed by two surgical teams at the Departments of Otorhinolaryngology of the University of Brescia, and the University of Pavia/Insubria-Varese, Italy. Results One-hundred eighty-four patients were considered eligible for the present analysis. An EEA was performed in 134 patients and the remaining 50 patients underwent the CEA. The most frequent histotypes encountered were adenocarcinoma (37%), squamous cell carcinoma (13.6%), olfactory neuroblastoma (12%), mucosal melanoma (9.2%), and adenoid cystic carcinoma (7.1%). Overall, 86 (46.7%) patients received some form of adjuvant treatment. The patients were followed up for a mean of 34.1 months (range, 2-123 months). The 5-year disease-specific survival was 91.4 ± 3.9% and 58.8 ± 8.6% (p = 0.0004) for the EEA and CEA group, respectively. Conclusion To the best of our knowledge, this is the largest series reported to date of malignant tumors of the sinonasal tract and adjacent skull base treated with pure endoscopic or cranioendoscopic techniques. A 5-year disease-specific survival of 91.4% and 58.8% for the EEA and the CEA groups, respectively, seem to indicate that endoscopic surgery, when properly planned and in expert hands, may be a valid alternative to standard surgical approaches for the management of malignancies of the sinonasal tract.

Hearing Preservation Surgery in Vestibular Schwannoma: The Hidden Truth

To compare the results of hearing preservation surgeries using different approaches — the enlarged middle cranial fossa approach and the retrosigmoid approach — and different classification systems, stressing the importance of preserving “normal hearing,” we performed a retrospective case review in a tertiary care medical center. The charts of 107 patients with vestibular schwannoma who underwent tumor resection were reviewed. Hearing preservation was reported according to 2 different classification systems: the modified Sanna classification and the classification of the American Academy of Otolaryngology—Head and Neck Surgery. The facial nerve results were graded according to the House-Brackmann scale. The hearing preservation rates differed markedly depending on the classification used. We conclude that hearing preservation in acoustic neuroma is a more difficult proposition than most surgeons appreciate, especially in terms of serviceable hearing.

Nerve origin of vestibular schwannoma: a prospective study.

OBJECTIVE The origin of vestibular schwannoma has always been a matter of debate. The aim of our study was to identify the nerve origin of this tumour. STUDY DESIGN Prospective case review. This study was conducted at Gruppo Otologico, a private referral centre for neurotology and skull base surgery. METHODS A total of 200 cases of vestibular schwannoma were included in the study. All the tumours were removed surgically utilising the translabyrinthine approach. The origin of the tumour was sought at the fundus of the internal auditory canal. RESULTS A total of 200 consecutive cases was included in the study. The origin of the tumour was limited to one nerve at the fundus in 152 cases (76 per cent). Out of these cases, the tumour originated from the inferior vestibular nerve in 139 cases (91.4 per cent), from the superior vestibular nerve in nine cases (6 per cent), from the cochlear nerve in two cases (1.3 per cent) and from the facial nerve in two cases (1.3 per cent). CONCLUSION The vast majority of vestibular schwannomas originate from the inferior vestibular nerve; the incidence of involvement of this nerve increases as the tumour size increases. An origin of vestibular schwannoma from the inferior vestibular nerve can be considered as one of the explanatory factors for the poor functional outcome of the extended middle cranial fossa approach, and probably accounts also for the better hearing preservation rate reported in some series for the retrosigmoid approach.

Surgical removal of jugular paragangliomas after stenting of the intratemporal internal carotid artery: a preliminary report.

Objective: Jugular paragangliomas with extensive involvement of the internal carotid artery (ICA) represent a true challenge for surgeons, especially in the presence of inadequate collateral circulation through the circle of Willis. The aim of our study is to present a preliminary report of our experience with the surgical removal of three such cases using the stenting of the ICA as the method of choice for protecting and preserving the integrity of the artery.

Auditory brainstem implant in a child with severely ossified cochlea.

Objective: The hearing outcome after implanting a severely ossified cochlea has always been less satisfactory than implanting a patent one. The aim of our study is to present a case where brainstem implantation was successfully performed as an alternative to cochlear implantation in a child with bilateral severe ossification of the cochlea.

Inner Ear Extension of Vestibular Schwannomas

Objective Inner ear extension of vestibular schwannomas (VSs) is a rare finding but has important clinical implications. This report reviews the treatment options and presents the experience of the Gruppo Otologico, Piacenza, Italy, in this field.

Hearing preservation surgery in vestibular schwannoma

OBJECTIVES To study the effect of pre-operative hearing level and tumour size on the hearing outcome of hearing preservation surgery for vestibular schwannoma. STUDY DESIGN AND SETTING A review of literature conducted at Gruppo Otologico, a tertiary referral centre for neurotology and skull base surgery. RESULTS A total of 1993 patients in 16 publications addressing the topic of hearing preservation surgery in vestibular schwannoma were analysed. The American Academy of Otolaryngology-Head and Neck Surgery hearing classification system was the classification upon which we based our analysis. CONCLUSION Defining hearing preservation as class-A hearing, there was a strong inverse relationship between pre-operative hearing and post-operative hearing levels and between tumour size and post-operative hearing levels.

Management of Temporal Bone Hemangiomas

Temporal bone hemangiomas are rare tumors that require a high degree of clinical suspicion on the part of the otolaryngologist to be diagnosed early. The purpose of this report is to present 10 histologically confirmed cases of hemangiomas located within the temporal bone treated at the Gruppo Otologico of Piacenza-Rome, Italy. A short review of the literature is also presented. The symptomatology of these extraneural vascular tumors depends on their location. Tumors located within the internal auditory canal present mainly with hearing loss, while a facial nerve deficit is the predominant symptom in geniculate ganglion tumors. The treatment modality is also dependent on the location of the tumor, as well as the clinical features and tumor size. The final facial nerve outcome is directly affected by the duration of the facial nerve deficit, and so the treatment should not be delayed once the diagnosis is made.

Canalplasty for severe external auditory meatus exostoses.

Exostoses of the external auditory meatus is a well known condition which infrequently requires surgical correction. However, the stenosis caused by severe exostosis can affect quality of life considerably and may require surgical intervention. Canalplasty, in such a situation, is a valid and effective management option. In our series the commonest indication for surgery was recurrent otitis externa. The detailed surgical technique is described and a retrospective analysis of 65 such procedures is presented. There were only two significant complications, both post-operative stenosis, requiring further corrective surgery. In conclusion, canalplasty for the exostosis of the external auditory meatus is a safe surgical option.

Atlas of microsurgery of the lateral skull base

1. Operating Room Setup 2. Special Considerations in Skull Base Surgery 3. Radiology of the Lateral Skull Base 4. Introduction to Lateral Skull Base Surgery 4.1 Classification of Lateral Skull Base Approaches 4.2 Surgical Anatomy 5. The Translabyrinthine Approaches 5.1 The Enlarged Translabyrinthine Approach 5.2 The Enlarged Translabyrinthine Approach with Transapical Extension 5.3 Brain Stem Implantation 6. The Transcochlear Approaches 6.1 The Transotic Approach 6.2 The Modified Transchochlear Approache, Types A-D 7. The Middle Fossa Approaches 8. Approaches to the Jugular Foramen 8.1 Type A Infratemporal Fossa Approach 8.2 Type B Petro-occipital Transsigmoid Approach 9. Approaches to the Infratemporal Fossa 9.1 Type B Infratemporal Fossa Approach 9.2 Type C Infratemporal Fossa Approach 9.3 The Group of Preauricular Transzygometic Approaches 9.3.1 Type D Infratemporal Fossa Approach 9.3.2 Preauricular Infratemporal Transzygometic Approach 9.3.3 Preauricular Frontotemporal Orbitozygometic Approach 10. The Retrosigmoid Retrolabyrinthine Approach 11. The Extreme Lateral Approach 12. Combined Approaches 13. Decision-making in Skull Base Surgery 14. General Principles of Embolization in Skull Base Tumors 15. Management of the Internal Carotid Artery in Skull Base Surgery