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Common otology viva topics
Published in Joseph Manjaly, Peter Kullar, Advanced ENT Training, 2019
Surgery to decompress the facial nerve must expose both the perigeniculate region and the mastoid segment. The transmastoid/supralabyrinthine approach is often used. This approach avoids intracranial exposure and avoids sacrifice of sensorineural hearing; however, it generally requires dislocation of the incus and ossicular reconstruction. Therefore, this approach is ideal in otic capsule sparing fractures with ossicular discontinuity and a well-aerated mastoid. If the patient has any contralateral hearing loss, or the anatomy is not conducive to supralabyrinthine exposure, a middle cranial fossa approach is preferred. The translabyrinthine approach is most often used in otic capsule disrupting fractures.
Surgical Management of Vestibular Schwannoma
Published in John C Watkinson, Raymond W Clarke, Christopher P Aldren, Doris-Eva Bamiou, Raymond W Clarke, Richard M Irving, Haytham Kubba, Shakeel R Saeed, Paediatrics, The Ear, Skull Base, 2018
Shakeel R. Saeed, Christopher J. Skilbeck
The facial nerve is displaced from its normal position by the tumour, but in the majority of cases it is displaced in a fairly predictable way. It runs along the anterosuperior quadrant of the meatus as far as the porus where it is displaced to a variable extent anteriorly and/or superiorly before turning down over the front of the tumour to the brainstem, which it joins just above the pontomedullary junction. Thus in the translabyrinthine approach the tumour is usually between the surgeon and the facial nerve. However, this is not always the case. There are occasions when the facial nerve is rotated backwards in the meatus and comes to lie on the posterior surface of the tumour. This may occur if the tumour arises on the cochlear nerve. It may on occasion be displaced down to the floor of the meatus and run in a more inferior position to the brainstem. If the tumour turns out to be a meningioma, the relationship of the nerve to the tumour may be variable, and it commonly runs over the posterior surface of the tumour. It is therefore essential to establish the relationship of the nerve to the tumour before any tumour is removed. At the lateral end of the meatus the SVN has already been identified. The exposed intrameatal portion of the tumour should be closely examined, both visually and using the facial nerve monitor, to be sure that the nerve has not been displaced on to the posterior surface. Assuming this is negative the nerve should then be sought in front of the SVN both visually and with the monitor. The routine identification of Bill’s bar, the vertical crest separating the SVN from the facial nerve, has been abandoned by many surgeons now that reliable monitoring is in use in every case, but it may be useful to do so in cases of doubt. Access to the anterosuperior part of the meatus may be helped by careful debulking of the tumour in the lower half of the meatus.
Clinical features and treatment of endolymphatic sac tumor
Published in Acta Oto-Laryngologica, 2020
Seong Hoon Bae, Seung-seob Kim, Sang Hyun Kwak, Jin Sei Jung, Jae Young Choi, In Seok Moon
All patients with ELST underwent surgical intervention; three patients had no evidence of the disease (NED) and two were alive with disease (AWD). Early surgical excision seems to be a treatment of choice, considering the destructive nature of ELST. Given that recurrence is not rare, a complete excision of the tumor is recommended; however, this is not easy to accomplish. Translabyrinthine approach is recommended for a good surgical view to achieve complete excision of the tumor. Stereotactic radiosurgery was recommended in case of recurrence or incomplete resection. There were studies that reported on treating an incompletely resected tumor less than 3 cm with stereotactic radiosurgery, and producing several encouraging results [10,11]. Recently, a systematic review reported that 31 out of 46 ELSTs (67.4%) were controlled after primary or combined radiation therapy during a median follow-up of 36 months [12]. In this study, a complete resection could not be achieved in Patient 5, due to the severe extension of the tumor. The tumor was extended to the left sphenoid wing, severely compressing the brain stem, implying stage 4 [13]. The suggested treatment option was a staged operation, and GSK was chosen instead of secondary operation after discussion with the patient and the attendant medical team. Consequently, the intracranial portion and the mastoid portion of ELST were removed, but the tumor on the sphenoid wing and deep petrous bone remained for GSK treatment.
Transmastoid trans-facial canal approach to facial nerve tumors
Published in Acta Oto-Laryngologica Case Reports, 2020
Colin E. McCorkle, Bryan K. Ward, C. Matthew Stewart
For patients with intact preoperative hearing and a schwannoma or venous malformation at the geniculate ganglion or IAC, the traditional middle cranial fossa approach spares the ossicular chain and vestibular function, but requires temporal lobe retraction and risks intracranial hemorrhage, meningitis, and cerebrospinal fluid (CSF) leak. A translabyrinthine approach is used for patients with nonfunctional preoperative hearing and a lesion in the labyrinthine or meatal segment, and allows easy access to the geniculate ganglion and IAC but disrupts vestibular function and has similar risks to a middle cranial fossa surgery. Even tumors located primarily in the mastoid segment can be a conundrum. Traditionally, a positive margin found in the mastoid segment from perineural ACC or SCC invasion has left treatment teams with two options: adjuvant radiation therapy or a more aggressive surgical approach tracing the tumor proximally, but risking hearing and vestibular function [13,14]. Transcanal endoscopic approaches have also recently been developed [15]. This approach is useful for lesions contained within the suprageniculate fossa; however, the head of the malleus and incus must be removed followed by ossiculoplasty. Similar to other endoscopic approaches, limitations include lack of depth perception and one-handed tumor dissection [16].
The role of subtotal petrosectomy in cochlear implant recipients: Our preliminary results
Published in Acta Oto-Laryngologica Case Reports, 2020
Evgenia Chetverikova, Priit Kasenõmm
STP enabled full exposure of the cochlea and to perform safe drill-out procedure for intracochlear tumor removal. CI was simultaneously performed and electrode was inserted into partially drilled cochlea. That was the only way to provide hearing rehabilitation to this patient, because she rapidly lost hearing in the right ear after radiotherapy for vestibular schwannoma in the right CPA. Due to failure of radiotherapy and loss of hearing, the translabyrinthine approach was performed to remove schwannoma from the right CPA. Translabyrinthine approach was preferred due to unserviceable hearing and the size of the tumor (3 cm). Combining translabyrinthine approach with CI was not considered because cochlear nerve was not preserved. The patient has low WRS score probably as a consequence of too aggressive cochlea drill-out procedure. One of the possibilities to preserve more cochlea would have been pushing tumor out in a retrograde way from the medial turn. Another option to rehabilitate hearing is this patient is auditory brainstem implantation, because cochlear nerve is still intact in the left. However, CI was our first choice because literature shows its superiority over auditory brainstem implantation regarding hearing results [19].