Tuncay Ulug

Dual ectopic thyroid: report of a case

Dual ectopic thyroid is very rare. We report a case of dual ectopic thyroid in the lingual and infrahyoid areas in a 20-year-old female patient with no thyroid gland in its normal anatomical location. On physical examination, there was a 7 x 5 cm anterior midline neck swelling just below the hyoid bone and a 2 x 2 cm mass in the base of the tongue. Triiodothyronine (T(3)), thyroxine (T(4)), and thyroid-stimulating hormone (TSH) levels were normal. A thyroid scan with technetium-99m sodium pertechnate confirmed dual ectopic thyroid with no iodine uptake in the normal anatomical location of the thyroid gland. The infrahyoid ectopic thyroid was surgically removed for cosmetic reasons, and the lingual thyroid, which was symptomatic, was left untouched. The importance of thyroid scanning in the evaluation of anterior midline neck swellings and treatment options are discussed.

Contralateral labyrinthine concussion in temporal bone fractures.

In this case presentation, three cases of labyrinthine concussion in the opposite ears of patients who had unilateral traumatic temporal bone fractures with facial paralysis are reported. The first patient was a 30-year-old male who had a right-sided longitudinal temporal bone fracture and labyrinthine concussion showing pure sensorineural hearing loss with a characteristic notch of 60 dB at 4000 Hz on the left side. The second patient was a 42-year-old male who had a right-sided traumatic facial paralysis owing to a mixed-type temporal bone fracture and labyrinthine concussion, demonstrating pure sensorineural hearing loss reaching its peak of 50 dB at 4000 Hz on the left. The third patient was a 19-year-old male who had a left-sided mixed-type temporal bone fracture and a right labyrinthine concussion exhibiting pure sensorineural hearing loss reaching 60 dB at 4000 Hz. For their facial paralyses, all three patients underwent middle cranial fossa or combined approach operations. The labyrinthine concussion in these patients was managed expectantly. At their 1-year follow-up, it was observed that the hearing loss owing to labyrinthine concussion persisted. Although labyrinthine concussion is not a rare complication of head injuries, it has rarely been reported in the medical literature. The main symptoms of labyrinthine concussion are hearing loss, tinnitus, and dizziness. The diagnosis mainly relies on audiometric tests, which reveal characteristic tracings reminiscent of acoustic trauma.

Bilateral traumatic facial paralysis associated with unilateral abducens palsy: a case report

Bilateral traumatic facial paralysis is a very rare clinical condition. Abducens palsy, associated with bilateral traumatic paralysis, is even rarer and has not been well described in the literature. In this report, a 24-year-old male, who developed immediate bilateral facial and right abducens paralyses following a motor vehicle accident, is presented. The patient was referred for neurotologic evaluation 22 days after the injury. Electroneurography (ENoG) demonstrated 100 per cent degeneration at the first examination and, correspondingly, electromyography showed no regeneration potentials. Using high-resolution computed tomography (HRCT), a longitudinal fracture on the right and a mixed-type fracture on the left were identified. The patient had good cochlear reserve on both sides. The decision for surgery was based not on ENoG, because of the delayed referral of the patient, but on the HRCT, which showed clear fracture lines on both sides. The middle cranial fossa approach for decompression of the right facial nerve was performed on the 55th day following the trauma, and a combined procedure using the middle cranial fossa and transmastoid approaches was applied for decompression of the left facial nerve on the 75th day following the trauma. On the right, there was dense fibrosis surrounding the geniculate ganglion and the proximal tympanic segment whereas, on the left, bone fragments impinging on the geniculate ganglion, dense fibrosis surrounding the geniculate ganglion, and a less extensive fibrotic tissue surrounding the pyramidal segment were encountered. There were no complications or hearing deterioration. At the one-year follow up, the patient had House-Brackmann (HB) grade 1 recovery on the right, and HB grade 2 recovery on the left side, and the abducens palsy regressed spontaneously. The middle cranial fossa approach and its combinations can be performed safely in bilateral temporal bone fractures as labyrinthine sparing procedures if done on separate occasions.

An unusual complication of stapes surgery: profuse bleeding from the anteriorly located sigmoid sinus

Major bleeding during stapes surgery is a rare condition. The anterior course of the sigmoid sinus is comparatively common in contracted mastoid bones, but rare in good pneumatized temporal bones. We report a case of an unusual anterior course of the vertical segment of the sigmoid sinus, which led to profuse bleeding during a stapedotomy operation. The 34-year-old female patient presented with conductive-type hearing loss in the right ear. During the operation, the unintentional sliding movement of a blunt curette caused injury to the anteriorly positioned sigmoid sinus, which was separated from the posterior wall of the external auditory canal by an extremely thin shell of bone. Profuse bleeding from the sigmoid sinus was controlled by pushing the middle part of the oxidised regenerated cellulose inside the lumen, without compromising the sinus flow. After bleeding was restrained, the stapedotomy operation was completed successfully. During the 1-year follow-up, there was neither an air-bone gap nor a sensorineural hearing loss in pure tone audiogram.

Zygomatic root approach

Conclusions. The zygomatic root (ZR) approach provides improved intraoperative exposure of the key areas around the geniculate ganglion without a craniotomy, combining the advantages of middle cranial fossa (MCF) and transmastoid extralabyrinthine (TMEL) approaches. The ZR approach may be useful in cases of traumatic facial palsy, Bells palsy, iatrogenic facial palsy, superior semicircular canal dehiscence and primary cholesteatoma. Objectives. To describe and evaluate the new ZR approach technique in the treatment of traumatic intratemporal facial nerve injuries. Patients and methods. This is a prospective clinical study of three consecutive procedures performed between July 2007 and January 2008, and a detailed discription of the surgical technique. The setting is a tertiary referral center. The patients’ age range was 3–7 years. Interventions were based on drilling the ZR area extensively, so that the perigeniculate area was exposed through the space created between the middle cranial fossa basal dura and skeletonized external auditory canal. The ZR approach can be performed as an isolated technique or can be combined with an inferior mastoidectomy protecting the bony bridge between. Results. Two patients had a mixed-type fracture and one patient had a transverse fracture. All three patients received a ZR combined approach. There was no cerebrospinal fluid leak, hearing loss, tympanic membrane perforation or meatal stenosis.

A multipurpose landmark for skull-base surgery: Henle’s spine

OBJECTIVE To determine whether Henles spine could be used as a reliable and multipurpose landmark for the other important structures of the skull base. MATERIALS AND METHODS Ninety-two specimens from 46 cadaveric adult dry skulls were studied. Two imaginary lines and a triangle were defined: a spinopterygoidal line extending from Henles spine to the root of the medial pterygoid plate, a bispinal line extending from one Henles spine to the contralateral one, and a parapetrosal triangle lying between the spinopterygoidal line, the bispinal line and the sagittal midline. The parapetrosal triangle encompasses nearly all the main structures of the skull base, including the petrosal internal carotid artery. RESULTS Along the spinopterygoidal line the distance from Henles spine to the spine of the sphenoid was found to be about 3 cm, to the foramen spinosum 3.5 cm, to the posterior and anterior margins of the foramen ovale 4 and 4.5 cm, to the root of the lateral pterygoid plate 5 cm, to the root of the medial pterygoid plate 5.5 cm, and to the vomer 6.5-7 cm. Along the bispinal line, the distance from Henles spine to the stylomastoid foramen was found to be about 1.5 cm, to the lateral and medial margins of the jugular foramen 2.5 and 3.5 cm, to the external orifice of the hypoglossal canal 4 cm, and to the foramen magnum 5 cm. CONCLUSION Henles spine with its superficial and central position can be used to localize important anatomical structures during skull-base surgery.

Minimally Invasive Cochlear Implantation with Mastoidal Three-Layer Flap Technique

Aims: To describe and evaluate a minimally invasive cochlear implantation approach using mastoidal three-layer flap (TLF) technique. Methods: We conducted a prospective clinical study at a tertiary referral center. The study population comprised 32 males and 16 females, with an age range of 1–51 years. Thirty-nine patients were operated on using the TLF technique and 9 patients were operated on using a classical cochlear implantation technique. The TLF technique was based on using the superficial musculoaponeurotic system (SMAS) as an additional, strong flap layer. The TLF, with 3 different pedicules, comprised an anteriorly based 4-cm skin flap, a superiorly based temporomastoidal flap, which included the SMAS, and an anteriorly based periostal Palva type flap in the same mastoidal area. Results: No major complications, including flap-wound problems and receiver-stimulator migration or extrusion, were encountered. The mean operation time was 66 min in the TLF population and 92 min in the classical operation population, which shows a statistically significant difference noted in the time of operation (p = 0.0001). Conclusion: The TLF cochlear implantation enables complete receiver-stimulator coverage and safe fixation without any additional procedures, while allowing reduced operation time.

An Adult Tracheocele with No Predisposing Factor

Tracheoceles are rare, and usually, they have been described as incidental findings while evaluating patients for other problems. Our patient complained of a mass located in the right supraclavicular region that got larger on coughing and straining; otherwise, he was asymptomatic. His history did not reveal any predisposing factors. Computed tomography showed an air-filled 3×2.5×2 cm mass at the level of the T2–4 vertebrae. Surgical exploration showed an air-filled mass located between the common carotid artery and trachea, communicating with the tracheal lumen via a narrow tract attached to the posterior wall of the trachea. The mass was completely resected, and the defect in the posterior wall was repaired. A literature search revealed only one tracheocele case without any predisposing factors, and our case is a new one. It is different from other tracheocele reports considering the origin side, type, and level of the lesion.