Synthetic temporal bone CT generation from UTE-MRI using a cycleGAN-based deep learning model: advancing beyond CT-MR imaging fusion.

OBJECTIVES: The aim of this study is to develop a deep-learning model to create synthetic temporal bone computed tomography (CT) images from ultrashort echo-time magnetic resonance imaging (MRI) scans, thereby addressing the intrinsic limitations of MRI in localizing anatomic landmarks in temporal bone CT. MATERIALS AND METHODS: This retrospective study included patients who underwent temporal MRI and temporal bone CT within one month between April 2020 and March 2023. These patients were randomly divided into training and validation datasets. A CycleGAN model for generating synthetic temporal bone CT images was developed using temporal bone CT and pointwise encoding-time reduction with radial acquisition (PETRA). To assess the model's performance, the pixel count in mastoid air cells was measured. Two neuroradiologists evaluated the successful generation rates of 11 anatomical landmarks. RESULTS: A total of 102 patients were included in this study (training dataset, n = 54, mean age 58 ± 14, 34 females (63%); validation dataset, n = 48, mean age 61 ± 13, 29 females (60%)). In the pixel count of mastoid air cells, no difference was observed between synthetic and real images (679 ± 342 vs 738 ± 342, p = 0.13). For the six major anatomical sites, the positive generation rates were 97-100%, whereas those of the five major anatomical structures ranged from 24% to 83%. CONCLUSION: We developed a model to generate synthetic temporal bone CT images using PETRA MRI. This model can provide information regarding the major anatomic sites of the temporal bone using MRI. CLINICAL RELEVANCE STATEMENT: The proposed algorithm addresses the primary limitations of MRI in localizing anatomic sites within the temporal bone. KEY POINTS: CT is preferred for imaging the temporal bone, but has limitations in differentiating pathology there. The model achieved a high success rate in generating synthetic images of six anatomic sites. This can overcome the limitations of MRI in visualizing key anatomic sites in the temporal skull.

Deep learning reconstruction for high-resolution computed tomography images of the temporal bone: comparison with hybrid iterative reconstruction.

PURPOSE: We investigated whether the quality of high-resolution computed tomography (CT) images of the temporal bone improves with deep learning reconstruction (DLR) compared with hybrid iterative reconstruction (HIR). METHODS: This retrospective study enrolled 36 patients (15 men, 21 women; age, 53.9 ± 19.5 years) who had undergone high-resolution CT of the temporal bone. Axial and coronal images were reconstructed using DLR, HIR, and filtered back projection (FBP). In qualitative image analyses, two radiologists independently compared the DLR and HIR images with FBP in terms of depiction of structures, image noise, and overall quality, using a 5-point scale (5 = better than FBP, 1 = poorer than FBP) to evaluate image quality. The other two radiologists placed regions of interest on the tympanic cavity and measured the standard deviation of CT attenuation (i.e., quantitative image noise). Scores from the qualitative and quantitative analyses of the DLR and HIR images were compared using, respectively, the Wilcoxon signed-rank test and the paired t-test. RESULTS: Qualitative and quantitative image noise was significantly reduced in DLR images compared with HIR images (all comparisons, p ≤ 0.016). Depiction of the otic capsule, auditory ossicles, and tympanic membrane was significantly improved in DLR images compared with HIR images (both readers, p ≤ 0.003). Overall image quality was significantly superior in DLR images compared with HIR images (both readers, p < 0.001). CONCLUSION: Compared with HIR, DLR provided significantly better-quality high-resolution CT images of the temporal bone.

Analysis of Cochlear Morphology for Cochlear Implantation Using Three-Dimensional Reconstruction of Computed Tomography Images.

INTRODUCTION: Preoperative evaluation of cochlear morphology is important for successful cochlear implantation. This study analyzed the cochlear canal by three-dimensional reconstructions of temporal bones using computed tomography (CT). METHODS: Fifty temporal bones from 25 patients aged 42-74 years were evaluated. The inner spaces of the bony cochlea were reconstructed using a surface rendering technique on the CT images. Eight angular points (P0-P7) every 90° were selected from 0° to 630° from the center of the round window using the reconstructed cochlear canal images. The radius (R) and thickness (T) of the cochlear canal at each point were measured. The cochlear canal length (CoCL) was estimated using an equation based on the radius at each point. The cochlear width and height based on multiplanar CT images were also measured and compared with the length and volume of the cochlear canal. RESULTS: The mean CoCL from 0° to 630° was 31.5 mm, and the cochlear volume was 55.9 mm3. The CoCL to P7 was correlated with the cochlear volume (r = 0.77), coiling ratios (R4/R0, r = 0.47; R5/R1, r = 0.384), cochlear width (long) (r = 0.539), cochlear height (r = 0.385), and total thickness at each point (r = 0.475). The cochlear volume was correlated with CoCL (630°) (r = 0.77), coiling ratio (R4/R0, r = 0.367), cochlear width (long) (r = 0.616), cochlear height (r = 0.447), and total T (r = 0.566). CONCLUSION: Preoperative evaluation using three-dimensional reconstruction can elucidate the size and shape of the cochlear canal before cochlear implantation.

A 3D and Explainable Artificial Intelligence Model for Evaluation of Chronic Otitis Media Based on Temporal Bone Computed Tomography: Model Development, Validation, and Clinical Application.

BACKGROUND: Temporal bone computed tomography (CT) helps diagnose chronic otitis media (COM). However, its interpretation requires training and expertise. Artificial intelligence (AI) can help clinicians evaluate COM through CT scans, but existing models lack transparency and may not fully leverage multidimensional diagnostic information. OBJECTIVE: We aimed to develop an explainable AI system based on 3D convolutional neural networks (CNNs) for automatic CT-based evaluation of COM. METHODS: Temporal bone CT scans were retrospectively obtained from patients operated for COM between December 2015 and July 2021 at 2 independent institutes. A region of interest encompassing the middle ear was automatically segmented, and 3D CNNs were subsequently trained to identify pathological ears and cholesteatoma. An ablation study was performed to refine model architecture. Benchmark tests were conducted against a baseline 2D model and 7 clinical experts. Model performance was measured through cross-validation and external validation. Heat maps, generated using Gradient-Weighted Class Activation Mapping, were used to highlight critical decision-making regions. Finally, the AI system was assessed with a prospective cohort to aid clinicians in preoperative COM assessment. RESULTS: Internal and external data sets contained 1661 and 108 patients (3153 and 211 eligible ears), respectively. The 3D model exhibited decent performance with mean areas under the receiver operating characteristic curves of 0.96 (SD 0.01) and 0.93 (SD 0.01), and mean accuracies of 0.878 (SD 0.017) and 0.843 (SD 0.015), respectively, for detecting pathological ears on the 2 data sets. Similar outcomes were observed for cholesteatoma identification (mean area under the receiver operating characteristic curve 0.85, SD 0.03 and 0.83, SD 0.05; mean accuracies 0.783, SD 0.04 and 0.813, SD 0.033, respectively). The proposed 3D model achieved a commendable balance between performance and network size relative to alternative models. It significantly outperformed the 2D approach in detecting COM (P≤.05) and exhibited a substantial gain in identifying cholesteatoma (P<.001). The model also demonstrated superior diagnostic capabilities over resident fellows and the attending otologist (P<.05), rivaling all senior clinicians in both tasks. The generated heat maps properly highlighted the middle ear and mastoid regions, aligning with human knowledge in interpreting temporal bone CT. The resulting AI system achieved an accuracy of 81.8% in generating preoperative diagnoses for 121 patients and contributed to clinical decision-making in 90.1% cases. CONCLUSIONS: We present a 3D CNN model trained to detect pathological changes and identify cholesteatoma via temporal bone CT scans. In both tasks, this model significantly outperforms the baseline 2D approach, achieving levels comparable with or surpassing those of human experts. The model also exhibits decent generalizability and enhanced comprehensibility. This AI system facilitates automatic COM assessment and shows promising viability in real-world clinical settings. These findings underscore AI's potential as a valuable aid for clinicians in COM evaluation. TRIAL REGISTRATION: Chinese Clinical Trial Registry ChiCTR2000036300; https://www.chictr.org.cn/showprojEN.html?proj=58685.

Gun shot injuries to the temporal bone: Anatomic predictors of mortality.

PURPOSE: To explore anatomic predictors of mortality from gunshot wounds involving the temporal bone. METHODS: A retrospective search of radiology reports was performed for all patients with CT reports suggestive of gunshot wounds (GSW) to the TB (2000-2020). All cases were reviewed by the senior author to confirm injury to the temporal bone. Detailed demographic and radiographic data were collected. MAIN FINDINGS: A total of 120 patients met inclusion criteria. The majority of patients were male (n = 101) and the average age was 32.9. The squamosa was the most commonly involved subsite (n = 90), followed by the mastoid (n = 43). Squamosal entry site had the highest associated mortality (89.7 %). For those with known disposition, 65.8 % (79 of 120) expired on the same hospital admission. Inpatient otolaryngology consultation was noted in 18.3 % (n = 22) of patients, with poor outpatient follow-up. CONCLUSIONS: This series represents the largest survey of GSW to the temporal bone to date. Although associated mortality is high and outpatient follow-up poor, otolaryngologists should be aware of associated morbidities to facilitate both inpatient and subsequent outpatient management.

3D printed temporal bones for preoperative simulation and planning.

OBJECTIVE: Demonstrate the utility of 3D printed temporal bone models in individual patient preoperative planning and simulation. METHODS: 3D models of the temporal bone were made from 5 pediatric and adult patients at a tertiary academic hospital with challenging surgical anatomy planned for cochlear implantation or exteriorization of cholesteatoma with complex labyrinthine fistula. The 3D models were created from CT scan used for preoperative planning, simulation and intraoperative reference. The utility of models was assessed for ease of segmentation and production and impact on surgery in regard to reducing intraoperative time and costs, improving safety and efficacy. RESULTS: Three patients received cochlear implants, two exteriorization of advanced cholesteatoma with fistulas (1 internal auditory canal/cochlea, 1 all three semicircular canals). Surgical planning and intraoperative referencing to the simulations by the attending surgeon and trainees significantly altered original surgical plans. In a case of X-linked hereditary deafness, optimal angles and rotation maneuvers for cochlear implant insertion reduced operating time by 93 min compared to the previous contralateral side surgery. Two cochlear implant cases planned for subtotal petrosectomy approach due to aberrant anatomy were successfully approached through routine mastoidectomy. The cholesteatoma cases were successfully exteriorized without necessitating partial labyrinthectomy or labyrinthine injury. There were no complications. CONCLUSION: 3D printed models for simulation training, surgical planning and use intraoperatively in temporal bone surgery demonstrated significant benefits in designing approaches, development of patient-specific techniques, avoidance of potential or actual complications encountered in previous or current surgery, and reduced surgical time and costs.

Intratemporal facial nerve neurofibroma causing facial paralysis in an infant: Case report and review of the literature.

This article describes the first recorded case of intratemporal neurofibroma in an infant. A literature review of all other existing cases of intratemporal neurofibroma is performed, finding that the majority of cases involve multiple segments and can be found in the mastoid segment most often. Most common symptoms described included facial paralysis, otalgia, and conductive hearing loss, respectively.

Audiometric outcomes following surgery for spontaneous temporal bone cerebrospinal fluid leaks - A single institution study.

PURPOSE: To assess the audiometric outcomes following surgical repair of spontaneous temporal bone cerebrospinal fluid otorrhea and compare different surgical approaches. MATERIALS AND METHODS: Retrospective review of adults (≥18 years old) who underwent repair of spontaneous CSF leak between 2011 and 2022. Audiometric outcomes were compared across the three surgical groups: transmastoid, middle cranial fossa and combined. RESULTS: Thirty-nine patients (40 ears) met the inclusion criteria (71.8 % females; mean age 59.77 +/- 12.4). Forty-two percent underwent transmastoid, 12.5 % middle cranial fossa and 45 % transmastoid-middle cranial fossa. Four patients (10 %) had recurrence, 3 in the transmastoid group and 1 in the combined approach. The mean change in air-bone gap (ABG) for all patients (postoperative-preoperative) was -7.4 (paired t-test, p-value = 0.0003). The postoperative ABG was closed in 28 (70 %) ears (postoperative ABG ≤ 15). The mean change in pure tone average (PTA) for all patients (postoperative-preoperative) was -4.1 (paired t-test, p-value = 0.13). The mean change in word recognition scores (WRS) for all patients (postoperative-preoperative) was -3 (paired t-test, p-value = 0.35). On multivariable analysis (controlling for site and reconstruction material), there was no significant difference in ABG, PTA and WRS change between surgical groups. CONCLUSIONS: Transmastoid, middle cranial fossa and combined approaches are all effective in treatment of spontaneous CSF leaks and all showed mean decrease in post-operative ABG. Transmastoid approach showed the greatest decrease in ABG and PTA (although middle cranial fossa approach shows the greatest decrease, when excluding profound hearing loss in a patient with superior canal dehiscence). Further studies comparing audiometric outcomes are needed.

A new 3D-printed temporal bone: 'the SAPIENS'-specific anatomical printed-3D-model in education and new surgical simulations.

PURPOSE: Otology and neuro-otology surgeries pose significant challenges due to the intricate and variable anatomy of the temporal bone (TB), requiring extensive training. In the last years 3D-printed temporal bone models for otological dissection are becoming increasingly popular. In this study, we presented a new 3D-printed temporal bone model named 'SAPIENS', tailored for educational and surgical simulation purposes. METHODS: The 'SAPIENS' model was a collaborative effort involving a multidisciplinary team, including radiologists, software engineers, ENT specialists, and 3D-printing experts. The development process spanned from June 2022 to October 2023 at the Department of Sense Organs, Sapienza University of Rome. Acquisition of human temporal bone images; temporal bone rendering; 3D-printing; post-printing phase; 3D-printed temporal bone model dissection and validation. RESULTS: The 'SAPIENS' 3D-printed temporal bone model demonstrated a high level of anatomical accuracy, resembling the human temporal bone in both middle and inner ear anatomy. The questionnaire-based assessment by five experienced ENT surgeons yielded an average total score of 49.4 ± 1.8 out of 61, indicating a model highly similar to the human TB for both anatomy and dissection. Specific areas of excellence included external contour, sigmoid sinus contour, cortical mastoidectomy simulation, and its utility as a surgical practice simulator. CONCLUSION: We have designed and developed a 3D model of the temporal bone that closely resembles the human temporal bone. This model enables the surgical dissection of the middle ear and mastoid with an excellent degree of similarity to the dissection performed on cadaveric temporal bones.

The clinical availability of facial nerve enhancement in temporal bone MRI for the patients of idiopathic acute peripheral facial palsy.

PURPOSE: This study is to evaluate the duration of facial nerve enhancement in gadolinium-enhanced temporal bone MRI after the onset of acute facial palsy. METHODS: Gd-enhanced MRI imagines were examined in 13 patients with idiopathic acute facial palsy within 14 days after the onset. The degree of facial nerve function was measured according to the House-Brackmann (H-B) grading system at their first visit at outpatient clinic. The follow-up MRI was taken about 16.5 months (7-24 months) after onset of disease. The degree of facial nerve enhancement was measured with signal intensity (SI) which was quantitatively analyzed using the region-of-interest (ROI) measurements for each segment of the facial nerve. SI was statistically analyzed by comparing SI values of contralateral site and ipsilateral site using the paired t test with SPSS program. RESULTS: The gadolinium enhancement was statistically increased at labyrinthine segment and geniculate ganglion area of facial nerve at initial temporal bone MRI. The gadolinium enhancement was statistically decreased at all the segments of facial nerve except tympanic segment (p < 0.05) at follow-up MRI. CONCLUSIONS: The facial nerve enhancement in Gd-enhanced MRI images prolonged more than 21 months of the onset. The newly developed pathologic lesions of acute facial palsy especially occur at the site of labyrinthine and geniculate ganglion.

Questioning the value of stalk drilling after external auditory canal osteoma excision: case series, literature review, and meta-analysis.

OBJECTIVES: To question the value of drilling the site of the stalk ("insertion site" or "stalk" drilling) of a pedunculated external auditory canal osteoma (EACO) in reducing recurrence. DATA SOURCES: A retrospective medical chart review of all patients treated for EACO in one tertiary medical center, a systematic literature review using Medline via "PubMed", "Embase", and "Google scholar" search, and a meta-analysis of the proportion for recurrence of EACO with and without drilling. RESULTS: The local cohort included 19 patients and the EACO origin was the anterior EAC wall in 42% and the superior EAC wall in 26%. The most common presenting symptoms were aural fullness and impacted cerumen (53% each), followed by conductive hearing loss (42%). All patients underwent post-excision canaloplasty, and one sustained EACO recurrence. Six studies suitable for analysis were identified (63 EACOs). Hearing loss, aural fullness, otalgia, and cerumen impaction were the most common clinical presentations. The most common EACO insertion site was the anterior EAC wall (37.5%), followed by the superior EAC and posterior walls (25% each). The inferior EAC wall was least affected (12.5%). There was no significant difference in recurrence between EACOs whose stalk insertions were drilled (proportion 0.09, 95% confidence interval [CI] 0.01-0.22) to the ones whose insertion was not drilled (proportion 0.05, 95% CI 0.00-0.17). The overall recurrence proportion was 0.07 (95% confidence interval 0.02-0.15). CONCLUSION: EACO insertion site drilling does not reduce recurrence and should be avoided in the absence of a definite pedicle projecting to the EAC lumen.

Impact of virtual reality training on mastoidectomy performance: a prospective randomised study.

PURPOSE: The opportunities for surgical training and practice in the operating room are in decline due to limited resources, increased efficiency demands, growing complexity of the cases, and concerns for patient safety. Virtual reality (VR) offers a novel opportunity to enhance surgical training and provide complementary three-dimensional experience that has been usually available in the operating room. Since VR allows viewing and manipulation of realistic 3D models, the VR environment could enhance anatomical and topographical knowledge, in particular. In this study, we explored whether incorporating VR anatomy training improves novices' performance during mastoidectomy over traditional methods. METHODS: Thirty medical students were randomized into two groups and taught mastoidectomy in a structured manner. One group utilized a VR temporal bone model during the training while the other group used more traditional materials such as anatomy books. After the training, all participants completed a mastoidectomy on a 3D-printed temporal bone model under expert supervision. Performance during the mastoidectomy was evaluated with multiple metrics and feedback regarding the two training methods was gathered from the participants. RESULTS: The VR training method was rated better by the participants, and they also needed less guidance during the mastoidectomy. There were no significant differences in operational time, the occurrence of injuries, self-assessment scores, and the surgical outcome between the two groups. CONCLUSION: Our results support the utilization of VR training in complete novices as it has higher trainee satisfaction and leads to at least as good results as the more traditional methods.

Association of the superior semicircular canal and tegmen tympani dehiscences and its relationship with the pneumatisation of the temporal bone.

PURPOSE: To analyse the degree of pneumatisation of the temporal bone when there is an association between dehiscence of the superior semicircular canal and dehiscence of the tegmen tympani. MATERIALS AND METHODS: We analysed a retrospective CT study of 124 selected cases. A single inclusion criterion was applied: the presence of a dehiscence of the tegmen tympani. On the other hand, the degree of temporal pneumatisation was assessed by axial and coronal planes, and has been divided into the following grades O, I, II and III, according to the status and relationship of the mastoid, the bony labyrinth, the petrous segment of the carotid canal and sigmoid sinus. RESULTS: Of the 124 cases studied, 35 (28.2%) presented both dehiscences. In 26 of the 35 (47.3%), grade II pneumatisation, 4 (14,8%), grade I, and 5 (11,9%) grade III was observed, with a statistically significant relationship (p < 0.001). On the other hand, we did not find a significant relationship when relating both dehiscences in any age or sex group. However, when relating the degree of pneumatisation to sex, among those with grade III pneumatisation, the proportion of men (52.4%) was significantly higher than that of women (47.6%) (p = 0.017). CONCLUSION: We have detected a statistically significant relationship between the coexistence of grade II pneumatisation and the presence of both dehiscences in the temporal bone.

Applicability of ChOLE staging to preoperative HRCT temporal bone in chronic otitis media with cholesteatoma.

PURPOSE: Chronic otitis media with cholesteatoma is a frequent disease entity in otology, requiring surgery in overwhelming majority of cases. Despite the huge burden there is no established grading system available to assess the severity and extent of disease preoperatively until date. Aim of our study is to assess the applicability of ChOLE staging to preoperative HRCT temporal bone in Chronic otitis media with cholesteatoma. METHODOLOGY: Patients clinically diagnosed as COM with cholesteatoma, who underwent preoperative HRCT temporal bone imaging and mastoid exploration at our tertiary care centre were included. Preoperative radiology was assessed and a radiological ChOLE (r-ChOLE) was given by radiologist. This was then compared with the postop ChOLE. RESULTS: 21 patients were included in the study. Data was linear and normally distributed (Shapiro wilk test). Pearson's product-moment correlation used to see relationship between radiological and postop Total score showed strong statistically significant positive correlation with correlation coefficient (r) of 0.977. Paired t test showed p value was 0.329 (p > 0.05) suggesting no significant difference between radiological and postop Total scores. Cohen kappa test of agreement was applied. It revealed an overall strong agreement (p < 0.001). CONCLUSION: ChOLE staging may be extended to preoperative HRCT of temporal bone in COM with cholesteatoma (rCHOLE). A preoperative radiological staging will help in better prioritizing, planning and execution of tympanomastoid surgeries.

Changes in paranasal sinus volumes, temporal bone pneumatization, internal acoustic canal and olfactory cleft dimensions over the centuries: a comparison of skulls from different epochs in Anatolia.

OBJECTIVES: Investigating changes in temporal bone pneumatization (TBP) and paranasal sinus volumes (PSV) across different eras may help understanding not only changes in skull anatomy but also pathophysiology of chronic otitis media and sinusitis, respectively, which are common health problems. METHODS: Eight skulls from the second century AD, 20 skulls were from the 10th-11th centuries AD, 20 skulls from the 16th-19th centuries AD, and 60 contemporary skulls were included in this cross-sectional observational study. Using computerized tomography (CT) scans, the PSV were calculated by multiplying the height, width, and antero-posterior distance of the sinuses. TBP was divided into three types. Internal acoustic canal (IAC) length and width, and olfactory cleft (OC) width were measured. RESULTS: No statistically significant differences were found between the paranasal sinus (frontal, maxillary, and sphenoid) volumes between the groups. However, TBP decreased statistically significantly over time on both sides of the skulls (p = 0.001). The contemporary IAC and OC measures were found to be significantly lower on both sides compared to the skulls from the other three eras (p < 0.001 for both). CONCLUSIONS: Although no significant change was observed in PSV, decreases were evident in TBP, OC width and IAC length and width over time. It appears a fair inference that changes in size of OC and IAC might be another indication of the fact that olfaction and hearing were more vital for survival in old eras. Since we do not know incidence of chronic ear problems in old eras, we cannot speculate outcome of increased TBP in terms of developing chronic ear diseases. On the contrary, increased TBP was likely to play a protective role in traumas in old ears. Additionally, the environmental influences may be crucial role in the development of paranasal sinuses.

The endoscopic transcanal approach to the internal auditory canal: an anatomic study.

PURPOSE: The internal auditory canal (IAC) plays a key role in lateral skull base surgery. Although several approaches to the IAC have been proposed, endoscope-assisted transcanal corridors to the IAC have rarely been studied. We sought to provide a step-by-step description of the transcanal transpromontorial approach to the IAC and analyze anatomic relationships that might enhance predictability and safety of this approach. METHODS: Ten cadaveric specimens were dissected and the extended transcanal transpromontorial approach to the IAC was established. Various morphometric measurements and anatomic landmarks were reviewed and analyzed. RESULTS: The proposed technique proved feasible and safe in all specimens. There was no inadvertent injury to the jugular bulb or internal carotid artery. The chorda tympani, a key landmark for the mastoid segment of the facial nerve, was identified in all dissections. The spherical recess of the vestibule and middle turn of cochlea are important landmarks for identification of the labyrinthine segment of the facial nerve. Identification of all boundaries of the working area is also essential for safe access. Among various morphometric measurements, the modiolus-IAC angle (≈ 150°) proved particularly consistent; given its ease of use and low variability, we believe it could serve as a landmark for identification and subsequent dissection of the IAC. CONCLUSIONS: The extended transcanal transpromontorial approach to the IAC is feasible and safe. Relying on anatomic landmarks to ensure preservation of the involved neurovascular structures is essential for a successful approach. The modiolus-IAC angle is a consistent, reproducible landmark for IAC identification and dissection.

Success and safety of endoscopic versus microscopic resection of temporal bone paraganglioma: a meta-analysis.

PURPOSE: Temporal bone paraganglioma (TBP) are the most common tumors of the middle ear. They pose a challenge in otologic surgery due to their extensive vascularity and intricate location within the middle ear. This meta-analysis aimed to compare the safety and efficacy of two surgical approaches, microscopic middle ear surgery (MMES) and endoscopic middle ear surgery (EMES), in the resection of TBP. METHODS: Eligible studies published after 1988 were identified through systematic searches of "PubMed", "Scopus" and "Google Scholar". Retrospective studies and randomized/non-randomized control trials reporting on surgical approaches for TBP with a minimum of five adult patients were included. RESULTS: A total of 595 records were initially identified. After removing 229 duplicates, 349 articles were excluded based upon article subject, title and abstract. Following the review of full texts, 13 articles were assessed for eligibility. The pooled analysis included a total of 529 ears, with a complication rate of 7.8% for EMES and 14.2% for MMES. Subgroup differences indicated no significant variation between the two methods (p = 0.2945). CONCLUSION: Both EMES and MMES demonstrated favorable surgical outcomes with low complication rates for TBP resection. These findings suggest that EMES is a safe and effective method for TBP resection and one that is comparable to MMES. Since the risk of bleeding is significant in these tumors, a third-hand technique, endoscopic bipolar cautery or laser-assisted hemostasis should be considered. Conversion to MMES is another option when visibility is critically affected by bleeding.

Integration of 3D-printed middle ear models and middle ear prostheses in otosurgical training.

BACKGROUND: In otosurgical training, cadaveric temporal bones are primarily used to provide a realistic tactile experience. However, using cadaveric temporal bones is challenging due to their limited availability, high cost, and potential for infection. Utilizing current three-dimensional (3D) technologies could overcome the limitations associated with cadaveric bones. This study focused on how a 3D-printed middle ear model can be used in otosurgical training. METHODS: A cadaveric temporal bone was imaged using microcomputed tomography (micro-CT) to generate a 3D model of the middle ear. The final model was printed from transparent photopolymers using a laser-based 3D printer (vat photopolymerization), yielding a 3D-printed phantom of the external ear canal and middle ear. The feasibility of this phantom for otosurgical training was evaluated through an ossiculoplasty simulation involving ten otosurgeons and ten otolaryngology-head and neck surgery (ORL-HNS) residents. The participants were tasked with drilling, scooping, and placing a 3D-printed partial ossicular replacement prosthesis (PORP). Following the simulation, a questionnaire was used to collect the participants' opinions and feedback. RESULTS: A transparent photopolymer was deemed suitable for both the middle ear phantom and PORP. The printing procedure was precise, and the anatomical landmarks were recognizable. Based on the evaluations, the phantom had realistic maneuverability, although the haptic feedback during drilling and scooping received some criticism from ORL-HNS residents. Both otosurgeons and ORL-HNS residents were optimistic about the application of these 3D-printed models as training tools. CONCLUSIONS: The 3D-printed middle ear phantom and PORP used in this study can be used for low-threshold training in the future. The integration of 3D-printed models in conventional otosurgical training holds significant promise.

3D 4K Exo-Endoscopic Temporal Bone Dissection: A Novel Approach for Sharing the Anatomy.

BACKGROUND: Temporal bone dissection is overwide recognized as an ideal training method for otologic surgeons. The knowledge of temporal bone anatomy and especially of the course of infratemporal facial nerve is pivotal in practice. The 3D exoscope is an innovative and promising tool, that was recently introduced in ear surgery. METHODS: A high-definition 3D exoscope (3D VITOM®) mounted on the VERSACRANETM holding system (Karl Storz) was used to perform two temporal bone dissection, with the aim to study the anatomy of infratemporal facial nerve. The 3D endoscope (TIPCAM®1 S 3D ORL, Karl Storz) was used in combination to provide a close-up high-quality view and to provide a different angle of view on fine anatomical relationships. RESULTS: The high-definition 3D exoscope allowed to conduct the dissection with high quality visualization and to share the same surgical field with trainees. Moreover, it showed a high interchangeability with the 3D endoscope. CONCLUSIONS: 3D 4 K Exo-endoscopic temporal bone dissection seems to have benefits in terms of educational purpose, especially concerning anatomy understanding. The superiority in teaching value of this tool should be further investigated in cohort studies.

Role of surgery along with antimicrobials in refractory skull base osteomyelitis-A prospective observational study.

INTRODUCTION: Study aimed to ole of surgery along with antimicrobials to improve clinical outcomes in treating refractory cases of skull base osteomyelitis (SBO). METHODS: A prospective observational study in a tertiary care centre with 70 SBO patients meeting eligibility criteria. The study population comprised 35 patients refractory to systemic antimicrobials of at least 4 weeks duration who later underwent surgery in addition to medication (surgical group). They were compared with a medical group that responded to medications alone. The outcome variables studied were the resolution of clinical features (pain, discharge, radiology, and inflammatory markers), culture yield, and total duration of treatment. RESULTS: According to our study, relief of pain was faster in the surgical group (1.66 against 4.57 months) with statistical significance (p < 0.001). Relief of symptoms (p < 0.001), radiological improvement (p = 0.001), and normalising of inflammatory markers (p < 0.001) were better in the surgical group than in the medical group. The duration of treatment was an average of 9.2 months in the surgical group compared to 11.3 months in the medical group (p = 0.019). Microbial culture from deep tissue sampling was positive in 24 surgical patients (68.57%). CONCLUSIONS: The treatment response in selected patients of refractory SBO who underwent surgery along with antimicrobials was better than the group who responded to antimicrobials alone. Surgery provided higher microbial yield resulting in culture-specific antimicrobials. The surgical group observed faster relief of symptoms, reduced hospital stay, and total treatment duration.