Adenoidectomy for middle ear disease in cleft palate children: a systematic review.

PURPOSE: Cleft palate children have a higher incidence of otitis media with effusion, more frequent recurrent acute otitis media episodes, and worse conductive hearing losses than non-cleft children. Nevertheless, data on adenoidectomy for middle ear disease in this patient group are scarce, since many feared worsening of velopharyngeal insufficiency after the procedure. This review aims at collecting the available evidence on this subject, to frame possible further areas of research and interventions. METHODS: A PRISMA-compliant systematic review was performed. Multiple databases were searched with criteria designed to include all studies focusing on the role of adenoidectomy in treating middle ear disease in cleft palate children. After duplicate removal, abstract and full-text selection, and quality assessment, we reviewed eligible articles for clinical indications and outcomes. RESULTS: Among 321 unique citations, 3 studies published between 1964 and 1972 (2 case series and a retrospective cohort study) were deemed eligible, with 136 treated patients. The outcomes were positive in all three articles in terms of conductive hearing loss improvement, recurrent otitis media episodes reduction, and effusive otitis media resolution. CONCLUSION: Despite promising results, research on adenoidectomy in treating middle ear disease in the cleft population has stopped in the mid-Seventies. No data are, therefore, available on the role of modern conservative adenoidectomy techniques (endoscopic and/or partial) in this context. Prospective studies are required to define the role of adenoidectomy in cleft children, most interestingly in specific subgroups such as patients requiring re-tympanostomy, given their known risk of otologic sequelae.

Isolated olfactory cleft involvement in SARS-CoV-2 infection: prevalence and clinical correlates.

PURPOSE: Smell alterations are a symptom of COVID-19 and have been associated with olfactory cleft mucosal thickening (OCMT). Although their pathogenesis is unclear, evidences link them to viral neuroinvasive potential. This study aims at estimating the prevalence of OCMT in CT scans of COVID-19 patients and investigating its clinical correlates. METHODS: In a single-institution retrospective cross-sectional study, we included all patients hospitalized for COVID-19 undergoing head CT scan for any reason. Exclusion criteria were history of recent head trauma or chronic rhinosinusitis; opacification > 2 mm in any sinonasal space other than the olfactory cleft; CT performed during/after invasive ventilation or feeding via nasogastric tube. We recorded the prevalence of OCMT and related it to age, sex, need for invasive ventilation during hospital stay, outcome, length of hospital stay, diffusion of lung SARS-CoV-19 lesions and outcome. RESULTS: 63 eligible patients were identified (39 male, 24 female; median age 77.82 ± 17.77 years). OCMT was identified in 16 patients (25.4%; 95% CI 15.3-37.9%). Patients with OCMT had longer hospital stays (median 16 ± 4 vs. 9 ± 14.5 days, p = .009, Mann-Whitney U test) and required invasive ventilation more frequently than patients without mucosal thickening (OR 4.89, 95% CI 0.96-24.89, p = .063, Fisher's test). No other difference was observed. CONCLUSION: OCMT affects nearly one in four patients hospitalized for COVID-19. It is associated with a worse disease course irrespective of age, sex and diffusion of lung lesions, although with no direct effect on survival.

Giant cell tumors of the skull base: case series and current concepts.

OBJECTIVE: To study the clinical features, tumor characteristics and outcomes of giant cell tumors (GCTs) in the skull base based on long-term follow-up. We also report the largest series of GCTs in the temporal bone and the lateral skull base. MATERIALS AND METHODS: A retrospective study was conducted of all GCTs managed at the Gruppo Otologico, a quaternary referral skull base institute, in Italy from 1993 to 2013. The clinical features, investigations, surgical management and follow-up were recorded. The surgical approaches used were infratemporal fossa approach (ITFA) type B and D and middle cranial fossa (MCF) approaches. RESULTS AND OBSERVATIONS: A total of 7 patients with GCTs of the skull base were treated at our institution. The principal complaints were hearing loss reported in 6 (85.71%) patients, tinnitus in 5 (71.43%) and swelling in 3 (42.9%). Pure-tone audiometry showed conductive hearing loss in 5 (71.43%) patients. High-resolution CT scan and MRI with gadolinium enhancement were done in all patients. Radiology showed involvement of the ITF and middle ear in 6 (85.71%) patients each, temporomandibular joint in 4 (57.14%) patients, invasions of the squamous part of the temporal bone, mastoid, MCF and greater wing of sphenoid in 3 (42.9%) patients each and the petrous bone in 2 (28.6%) patients. ITFA type B was applied as an approach for tumor removal in 5 (71.43%) patients, including a case where an additional MCF approach was employed, and ITFA type D and the transmastoid approach were applied in 1 (14.3%) patient each. Total tumor removal and successful cure was achieved in 6 (85.71%) patients. Subtotal removal leading to recurrence and eventual mortality was the result in 1 (14.3%) patient. CONCLUSIONS: A thorough knowledge of the anatomy of the skull base and the various skull base approaches is necessary to tackle GCTs. ITFA type B and D combined with MCF approaches provide good exposure of the tumor with minimal postoperative sequelae and good locoregional control. Recurrence due to either subtotal removal or suboptimal treatment may have disastrous consequences for the patient.

The effects of tympanomastoid paragangliomas on hearing and the audiological outcomes after surgery over a long-term follow-up.

The primary goals of surgery of tympanomastoid paragangliomas (TMPs) are tumor eradication and hearing preservation. Though the surgical management of TMPs has been dealt with widely in the literature, the effects of TMPs themselves on preoperative hearing and the audiological outcomes after surgery have not been analyzed in detail. This article comprehensively evaluates the preoperative hearing and the long-term hearing outcomes after surgery of TMPs. This study is based on a study population of 145 patients which is the largest reported in the literature. The surgical approaches for all patients with TMPs were formulated according to an algorithm developed by the authors. Complete tumor removal with excellent hearing results can be achieved by approaching the tumor classes by the right surgical technique. TMPs could possibly induce sensorineural hearing loss in higher frequencies, and future studies could be directed towards this.

Management of vagal paragangliomas including application of internal carotid artery stenting.

BACKGROUND: The primary treatment of vagal paraganglioma (VP) includes 'wait and scan', surgery and radiotherapy. OBJECTIVES: To present the clinical findings, surgical treatment including application of internal carotid artery (ICA) stenting to facilitate surgery, and complications, as well as to review the literature and to discuss the decision-making process in the management of VP cases based on our experience and the literature. DESIGN: A retrospective case review of 22 cases with VP. SETTING: Quaternary neurotologic and skull base referral center. MATERIAL AND METHODS: The retrospective chart review identified 22 patients presenting with VP. Our indication for surgery was VP in younger patients, irrespective of the existence of vocal cord paralysis. Preoperative endovascular management of the ICA included permanent balloon occlusion (PBO) and stenting. The transcervical approach and the infratemporal fossa approach type A (ITFA) were used. RESULTS: Fifteen cases had multicentric paragangliomas, 5 cases bilateral tumors, 3 cases a genetic mutation, and 2 cases a positive family history. The most common symptoms were hoarseness, tinnitus and hearing loss. The surgical approaches commonly employed for excision were the transcervical approach (9 cases) and the ITFA (12 cases), whereas 1 case did not have surgery. Three cases had PBO and 7 had intracarotid stent insertion. Gross total removal was achieved in 19 cases, and 1 case had a recurrence. Eighteen cases had no dysphagia or were well compensated after surgery. There were no significant complications noted in our series. CONCLUSIONS: In younger patients with VP, surgery should be recommended. The proper preoperative endovascular intervention and surgical approach facilitates gross total tumor removal. In the management of bilateral or familial paragangliomas, careful and appropriate decision making is essential.

Vertebral artery involvement by tympanojugular paragangliomas: management and outcomes with a proposed addition to the fisch classification.

OBJECTIVES: To present the management and outcomes of cases of tympanojugular paraganglioma (TJP) with vertebral artery (VA) involvement, and to propose the addition of the new 'V' category to the Fisch classification. MATERIALS AND METHODS: Retrospective analysis of data from a quaternary neuro-otologic and skull base referral center. We studied 230 TJP patients to identify the cases with VA involvement and present their management, surgical findings and outcome. RESULTS: Out of 230 patients, 8 patients were found to have VA involvement by TJP. The extradural artery was involved in 1 patient and the intradural VA was involved in 6 patients. The intradural and extradural VA were simultaneously involved in 1 patient. Seven of the 8 patients underwent surgery. In 2 patients, preoperative occlusion was performed (1 with balloon, 1 with coils). In 5 of these 7 patients, the tumor was successfully separated from the VA by microdissection with or without endovascular intervention. In another patient, the tumor together with the involved VA was removed. Of 7 patients who had surgery, 1 patient did not undergo endovascular intervention and had subtotal tumor removal from the VA. There were no serious complications in removing the tumor from around the VA. CONCLUSION: Although uncommon, the intradural or extradural VA can be involved by TJP. To avoid vascular accidents, the VA should be thoroughly evaluated at the planning stage. We advocate that the addition of a 'V' category would help to identify patients who need individualized VA management as part of a complete surgical evaluation.

Surgical management of vestibular schwannoma in elderly patients.

This study aimed to evaluate surgical results of vestibular schwannoma in elderly patients using a retrospective study in a Quaternary Neurotology and Skull Base Referral Center setting. The data of 232 elderly patients (above 65 years) operated on for vestibular schwannoma in the period between April 1987 and July 2009 were reviewed. Most patients were operated on via translabyrinthine approach (TLA) using transapical extension for large tumors. Other approaches used were retrosigmoid, middle cranial fossa, and transcochlear. Total tumor removal was achieved in the majority of cases, while planned subtotal removal was used in specific occasions. Postoperative complications included facial nerve palsy, other cranial nerves injury, persistent instability, intracranial hemorrhage, CSF leak, meningitis, and death. Patients were followed after surgery for tumor regrowth or occurrence of complications. The results showed low rate of morbidity and mortality. Despite that complete removal is the main target of the surgery; adoption of subtotal removal in selected cases can improve postoperative facial nerve results and reduce the duration of surgery.

Otoneurological management of petrous apex cholesterol granuloma.

OBJECTIVE: The aim of the study is to review the management of petrous apex cholesterol granuloma. The surgical approaches for drainage or total removal and the wait and see policy were analyzed, and outcomes were evaluated. METHODS: Retrospective charts of 27 patients managed for petrous apex cholesterol granuloma with a minimum follow-up of 12 months were analyzed in a quartenary skull base center. Presenting symptoms and signs were recorded, and radiologic imaging was evaluated. Management options included wait and see policy and surgery by several approaches. RESULTS: The mean age of patients affected by the lesion was 38.8 years. The mean follow-up was 56.7 months. Patients complained of hearing loss, vertigo, tinnitus, diplopia, hemifacial spasm, trigeminal neuralgia, and facial paresthesia. Twelve patients were managed by wait and see policy, and in this category, only one lesion showed growth during the follow-up. Depending upon size and location, 15 patients were surgically treated by infralabyrinthine approach (9 patients), infratemporal type B approach (3 patients), combined infratemporal type B transotic approach (2 patients), and transotic approach (1 patient). One recurrence was recorded during the follow-up. CONCLUSIONS: Radiologic evaluation is required for diagnosis and management. Patients with good hearing can be treated by infralabyrinthine approach. Infratemporal fossa type B approach is advocated in patients with extensive disease and internal carotid artery involvement. Wait and see policy is recommended for asymptomatic cases. Drainage and permanent ventilation are the goals of treatment. Complete removal is indicated in selected cases where placement of drainage tube is not feasible.

Combined endovascular-surgical management of the internal carotid artery in complex tympanojugular paragangliomas.

The infratemporal fossa approach described by Fisch overcame most of the factors that had previously prevented the total removal of tympanojugular paragangliomas (TJP). The remaining problem has been infiltration of the internal carotid artery (ICA) for which there has been no entirely satisfactory solution. At the least, severe encasement risks the possibility of an arterial rupture at surgery. In order to reduce this risk, preoperative endovascular interventions have been employed-mainly balloon occlusion, with or without arterial bypass. Recently, intra-arterial stents to reinforce the encased segment of the ICA have been introduced. This study evaluates our experience with 20 patients affected by TJP in which the ICA has been subjected to preoperative interventions. Ten patients underwent a preoperative balloon occlusion and the other 10 patients had their ICAs reinforced with stents. Problems that arose during embolization necessitated that one patient with a stent required ligation of their ICA. No other problems were encountered during endovascular treatment or surgical resection. In one patient with a stent, it was impossible to establish a cleavage plane between their recurrent tumour and the ICA. These early results are encouraging and suggest that intra-arterial stents have a part to play in the surgical management of large TJPs.

Nonvascular lesions of the jugular foramen: the gruppo otologico experience.

Tumors other than paragangliomas in the jugular foramen are uncommon. Of these, schwannomas and meningiomas predominate. Little clinical data are available in the literature on these tumors at this site. The purpose of this article is to review our experience at the Gruppo Otologico of the management of these tumors. A retrospective series is presented of 32 consecutive patients affected by jugular foramen schwannomas and meningiomas in which their clinical and radiological signs, together with surgical techniques and outcomes, were reviewed. A single-stage resection was possible for the majority of patients when the petro-occipital trans-sigmoid (POTS) approach was used. This allowed resection of both intra- and extradural components of the tumor with hearing preservation and avoidance of facial nerve transposition. No deaths occurred. Lower cranial nerve palsies constituted the major cause of morbidity, but none of the patients required an adjunctive procedure such as vocal cord medialization, tracheostomy, or percutaneous gastrostomy.

Revision glomus tumor surgery.

The infratemporal fossa approach type A is the best way to deal with recurrent tympano-jugular paragangliomas because facial nerve rerouting is fundamental to reaching the area of the internal carotid artery, where recurrence is likely to occur. Preservation of lower cranial nerve function is not feasible when there is tumor infiltration of the medial wall of the jugular bulb; any attempt at nerve dissection increases the risk of leaving some tumor remnants. Correct management of the internal carotid artery, including preoperative stent insertion or permanent preoperative balloon occlusion, is usually a fundamental step when dealing with these highly vascularized lesions. Because of the tumor tendency to infiltrate the bony structures, aggressive drilling of the temporal bone is also advised, especially at the level of the petrous apex. Patients affected by uncontrolled recurrences still die of this disease.

Lateral skull base approaches in the management of benign parapharyngeal space tumors.

OBJECTIVE: To evaluate the role of lateral skull base approaches in the management of benign parapharyngeal space tumors and to propose an algorithm for their surgical approach. METHODS: Retrospective study of patients with benign parapharyngeal space tumors. The clinical features, radiology and preoperative management of skull base neurovasculature, the surgical approaches and overall results were recorded. RESULTS: 46 patients presented with 48 tumors. 12 were prestyloid and 36 poststyloid. 19 (39.6%) tumors were paragangliomas, 15 (31.25%) were schwannomas and 11 (23%) were pleomorphic adenomas. Preoperative embolization was performed in 19, stenting of the internal carotid artery in 4 and permanent balloon occlusion in 2 patients. 19 tumors were approached by the transcervical, 13 by transcervical-transparotid, 5 by transcervical-transmastoid, 6, 1 and 2 tumors by the infratemporal fossa approach types A, B and D, respectively. Total radical tumor removal was achieved in 46 (96%) of the cases. CONCLUSION: Lateral skull base approaches have an advantage over other approaches in the management of benign tumors of the parapharyngeal space due to the fact that they provide excellent exposure with less morbidity. The use of microscope combined with bipolar cautery reduces morbidity. Stenting of internal carotid artery gives a chance for complete tumor removal with arterial preservation.

Management of jugular paragangliomas: the Gruppo Otologico experience.

OBJECTIVE: The objective of this study was to review the outcome of surgical management in patients of jugular paragangliomas. STUDY DESIGN: We conducted a retrospective case review. SETTING: Tertiary care otology and skull base center. MATERIALS AND METHODS: Fifty-five patients with the diagnosis of a jugular paraganglioma (Fisch Class C and D Glomus Jugulare) were managed over a period of 15 years. All patients with adequate follow up and complete records (53 cases) were reviewed with emphasis on the results of surgical management and the factors influencing them. INTERVENTION: All 53 patients were managed with a view to surgically extirpate the tumor. The primary approach was the infratemporal fossa approach-Type A used in the majority of the patients. In eight cases, the procedure was staged owing to the presence of large intracranial extension. Three patients required additional procedures to ameliorate the after-effects of lower cranial nerve resection. RESULTS: Gross total tumor removal was achieved in 49 patients. There were five cases of recurrence. Coupled with the residual tumors in five patients, the surgical control achieved was 83%. There was no perioperative mortality. There were two cases of postoperative cerebrospinal fluid leak, both of which required surgical exploration and closure. The facial nerve was resected in seven patients. The overall preservation rate of clinically uninvolved lower cranial nerves was 75%. CONCLUSIONS: The low level of complications along with a high surgical control achieved makes surgery the primary mode of treatment in the vast majority of these tumors, regardless of the size and location.

Anterior and Posterior Facial Nerve Rerouting: A Comparative Study.

The infratemporal fossa type A (IFT-A) and the modified transcochlear approach are used to remove glomus jugular tumors type C and petroclival tumors extending to the prepontine cistern, respectively. Anterior rerouting is a key step in IFT-A, whereas the modified transcochlear approach involves posterior rerouting. The aim of this study was to analyze facial nerve function after application of the two procedures. One year after surgery, anterior rerouting was associated with excellent to good outcomes (grade I to III) in 94 % of the cases, while posterior rerouting was associated with good outcomes (grade III) in 70 % of the cases.

Facial reanimation after facial nerve injury using hypoglossal to facial nerve anastomosis: the gruppo otologico experience.

To evaluate the results of facial nerve reanimation after facial nerve injury by means of hypoglossal to facial nerve anastomosis. Retrospective case review. Private neuro-otologic and cranial base quaternary referral center. Sixty patients underwent hypoglossal to facial nerve anastomosis for facial nerve reanimation between April 1987 and December 2010. Only forty patients completed a minimal follow up of 24 months at the time of evaluation and were included in the study population. Facial nerve paralysis was present for a mean duration of 11.3 months (range 2-42 months) and all the patients had a HB grade VI prior their surgery. Final facial nerve motor function. The most common cause of facial paralysis was vestibular Schwannoma surgery. All the patients achieved a postoperative HB grade III or IV after a mean follow-up time of 20 months. The facial movements were detected after a period that ranged from ranged from 5 to 9 months. Only 4 patients suffered from difficulties during eating and drinking and three of them had associated lower cranial nerve deficit. Despite the various techniques in facial reanimation following total facial nerve paralysis, the end to end of hypoglossal to facial nerve anastomosis remains one of the best treatments in cases of viable distal facial stump and nonatrophic musculature.

Oncologic outcome in surgical management of jugular paraganglioma and factors influencing outcomes.

BACKGROUND: The purpose of this study was to identify the factors that may influence the management outcome in patients with jugular paragangliomas. METHODS: The surgical records of 121 cases of jugular paraganglioma (Fisch classifications C and D) were reviewed. RESULTS: The average follow-up was 88 months. Intracranial extension (ICE; Fisch classification De and Di) constitutes 55.4% of the cases. Two cases had a malignant jugular paraganglioma. Complete tumor resection was achieved in 81.8% of the cases, and there was evidence of recurrence in 4.0% from this group. Surgical tumor control was achieved in 96% of cases. Perioperative complications consisted mainly of cerebrospinal fluid leakage in 1.6% of the cases. The lower cranial nerve (CN) was preserved in 63% of the patients mainly in the cases without ICE. CONCLUSION: The infratemporal fossa approach type A allows for complete tumor resection with low perioperative morbidity and recurrence rates. The significant influential factors were the severity of ICE and internal carotid artery involvement.

Chondroblastoma of the temporal bone.

Chondroblastomas are highly destructive tumors that are derived from immature cartilage cells. The occurrence of this tumor in the temporal bone or skull base is uncommon. Approximately 70 cases have previously been reported, several of which have involved the temporomandibular joint (TMJ). We report here the case of a 67-year-old woman who presented with right-sided mixed hearing loss, a right external auditory canal mass, ear fullness, otalgia, blood-stained otorrhea, and pain around the TMJ, associated with difficulty in opening the mouth. CT and MRI revealed a mass involving the TMJ, infratemporal fossa, and pterygopalatine fossa. The patient underwent tumor resection via an infratemporal fossa approach type B. Gross total tumor removal was achieved, with no facial nerve paralysis or other complications observed after surgery. No recurrence or residual tumors were observed on CT and MRI, even after 7.5 years of follow-up. We conclude that temporal bone chondroblastomas are extremely rare and aggressive, but the outcome after appropriate surgical treatment is favorable. From the review, it may be particularly important to deal with tumors that involve the TMJ, which could affect the long-term outcomes, as well as tumor recurrence.

Management of complex tympanojugular paragangliomas including endovascular intervention.

OBJECTIVES/HYPOTHESIS: To identify complex cases of tympanojugular paraganglioma (TJP) and to analyze their management and surgical outcome. To present strategy and guidelines on how to deal with the perioperative complicating factors. STUDY DESIGN: Retrospective analysis. METHODS: We retrospectively studied 212 TJP patients to identify the complex cases and analyzed their management and surgical outcome. The criteria for complex TJP are: 1) very large size; 2) large intradural extension (IDE); 3) extension to the cavernous sinus, foramen magnum, and clivus; 4) significant involvement of the internal carotid artery (ICA); 5) a solitary ICA on the lesion side; 6) involvement of the vertebral artery; 7) dominant or unilateral sigmoid sinus on the lesion side; 8) bilateral or multiple paragangliomas; and 9) recurrence. RESULTS: Sixty patients were classified as complex. Forty-five patients had tumors with IDE. Twenty patients with tumor involving ICA underwent preoperative endovascular intervention. Two patients had a solitary ICA and two others unilateral sigmoid sinus on the lesion side. Thirteen patients had multicentric tumors, and three patients had bilateral ones. The main procedure was the infratemporal fossa approach type A. Total removal was achieved in 46 patients, and five of them experienced recurrence. CONCLUSIONS: It is essential to carefully investigate the hemodynamics of the brain in planning surgery. A proper preoperative endovascular intervention facilitates gross total tumor removal. In bilateral paragangliomas, lower cranial nerves' function should be preserved at least unilaterally. Staged removal is recommended for a tumor with a large intradural component.

Intratympanic gentamicin: a 1-day protocol treatment for unilateral Meniere's disease.

PURPOSE: The objective of this study was to assess the usefulness of low-dose intratympanic gentamicin administration in patients with Meniere's disease (MD). MATERIALS AND METHODS: We carried out a retrospective review of the charts of 55 patients with definite MD in accordance with the AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) Diagnostic Scale who were treated at Gruppo Otologico (Piacenza, Rome, Italy). The treatment protocol consisted of 3 intratympanic injections of gentamicin at a 12-hour interval between each administration. RESULTS: Results were resumed in accordance with AAO-HNS criteria and showed complete control of vertigo spells in 60% (class A), good control in 16% (class B), moderate control in 4% (class C), poor control in 16% (class D), and no control in 4% (class E) of the patients. Audiological assessment showed unchanged thresholds in 61%, improvement in 22%, and worsening in 17% of the cases. CONCLUSION: Administration of gentamicin is a good alternative to medical and surgical procedures in the treatment of intractable MD. One-day treatment allows for adequate control of vertigo attacks without compromising hearing and quality of life and with reduced costs.