Transmastoid exposure of the labyrinthine segment of the facial nerve: an anatomical study.

INTRODUCTION: Compression of the labyrinthine segment of the facial nerve by edema has been considered as an important pathology in the majority of the cases of idiopathic facial nerve paralysis. Hence, it is suggested that total decompression of the facial nerve should also include the labyrinthine segment by a middle fossa approach. However, the middle fossa approach requires craniotomy and temporal lobe retraction, which increases the morbidity. The labyrinthine segment of the facial nerve can also be reached through mastoidectomy. However, many ear surgeons are not familiar with this approach due to the lack of anatomical data on this surgical area. OBJECTIVE: To study the anatomical limitations of decompression of the labyrinthine segment via transmastoid approach. METHODS: Complete mastoidectomy was performed in six adult cadavers heads. Dissection was extended in the zygomatic root and posterior bony wall of the external auditory canal to visualize the incudomallear joint completely. The bone between tympanic segment, lateral and superior semicircular canal's ampullas and middle fossa dural plate was removed. Fine dissection was carried out over tympanic segment of the facial nerve in an anterosuperomedial direction the labyrinthine segment was reached. RESULTS: All the mastoids were well pneumatized. Distances between the labyrinthine segment and middle fossa dura, and between the labyrinthine segment and superior semicircular canal, were 2.5 and 4.5 mm on average, respectively. In addition, distances between the middle fossa dura and dome of the lateral semicircular canal, and between the middle fossa dura and tympanic segment were 4.6 mm and 4.3 mm on average, respectively. CONCLUSION: It is possible to expose the labyrinthine segment of the facial nerve through mastoidectomy by dissecting the bone in the area between the tympanic segment of the facial nerve, middle fossa dural plate and ampullary ends of the lateral and superior semicircular canals.

Transmastoid exposure of the labyrinthine segment of the facial nerve: an anatomical study,

Abstract Introduction: Compression of the labyrinthine segment of the facial nerve by edema has been considered as an important pathology in the majority of the cases of idiopathic facial nerve paralysis. Hence, it is suggested that total decompression of the facial nerve should also include the labyrinthine segment by a middle fossa approach. However, the middle fossa approach requires craniotomy and temporal lobe retraction, which increases the morbidity. The labyrinthine segment of the facial nerve can also be reached through mastoidectomy. However, many ear surgeons are not familiar with this approach due to the lack of anatomical data on this surgical area. Objective: To study the anatomical limitations of decompression of the labyrinthine segment via transmastoid approach. Methods: Complete mastoidectomy was performed in six adult cadavers heads. Dissection was extended in the zygomatic root and posterior bony wall of the external auditory canal to visualize the incudomallear joint completely. The bone between tympanic segment, lateral and superior semicircular canal's ampullas and middle fossa dural plate was removed. Fine dissection was carried out over tympanic segment of the facial nerve in an anterosuperomedial direction the labyrinthine segment was reached. Results: All the mastoids were well pneumatized. Distances between the labyrinthine segment and middle fossa dura, and between the labyrinthine segment and superior semicircular canal, were 2.5 and 4.5mm on average, respectively. In addition, distances between the middle fossa dura and dome of the lateral semicircular canal, and between the middle fossa dura and tympanic segment were 4.6 mm and 4.3 mm on average, respectively. Conclusion: It is possible to expose the labyrinthine segment of the facial nerve through mastoidectomy by dissecting the bone in the area between the tympanic segment of the facial nerve, middle fossa dural plate and ampullary ends of the lateral and superior semicircular canals.

Asymmetry, handedness and auricle morphometry / Asimetría, lateralidad y morfometría de la oreja

The aims of this study were to determine various morphometric measurements of auricle, to investigate asymmetry and its relation with handedness in both sexes. Main morphometric measurements of both auricles and hand preferences were determined on 200 male and 200 female healthy university students. All measurements of the auricles were larger in males than the corresponding ones in females and all the differences except earlobe widths were statistically significant. All measurements of left and right auricles were statistically significantly different in both sexes except earlobe length in males, and distance from the highest point of the auricle to the bottom of the intertragic notch and earlobe length in females. Auricle length and distance from the highest point of the auricle to the bottom of the intertragic notch had higher values at the left side and all other measurements were larger at the right side. There was no significant difference between the measurements of the corresponding auricles of the righthanded and lefthanded subjects. All measurements were larger at the right side except auricle length and distance from the highest point of the auricle to the bottom of the intertragic notch in righthanded and lefthanded subjects and all differences except earlobe length were significantly different in righthanded subjects as in the total population but in lefthanded subjects the difference of the auricle width was not significant, either. There was an apparent asymmetry of right and left auricles of normal people in the current study which should be taken in to consideration in plastic surgeries of the external ear, designing the ear devices and forensic applications of earprints.

El objetivo de este estudio fue determinar diversas mediciones morfométricas de la oreja, para investigar la asimetría y su relación con el uso de las manos en ambos sexos. Se realizaron mediciones morfométricas de los pabellones auriculares y las manos de 400 estudiantes universitarios (200 hombres y 299 mujeres). Todas las medidas de las orejas fueron mayores en los hombres y todas las diferencias, excepto las correspondientes al ancho del lóbulo auricular, fueron estadísticamente significativas. Todas las mediciones de los pabellones auriculares izquierdos y derechos presentaron diferencias estadísticamente significativas en ambos sexos, excepto en el caso de la longitud del lóbulo auricular en los hombres, y la distancia desde el punto más alto de la oreja a la parte inferior de la incisura intertrágica en el lóbulo auricular de las mujeres. La longitud de la oreja y la distancia desde el punto más alto de la misma a la parte inferior de la escotadura intertrágica tenían valores más altos en el lado izquierdo y todas las demás mediciones fueron más elevadas en el lado derecho. No hubo diferencia significativa entre las mediciones de las orejas correspondientes a los sujetos diestros y zurdos. Todas las mediciones fueron superiores en el lado derecho, excepto la longitud del pabellón auricular y la distancia desde el punto más alto de la oreja a la parte inferior de la incisura intertrágica en sujetos diestros y sujetos zurdos, y todas las diferencias, excepto la longitud del lóbulo auricular, fueron significativamente diferentes en los sujetos diestros como en la población total, pero en sujetos zurdos la diferencia de la anchura de la oreja no fue significativa. Se encontró una aparente asimetría en las orejas derecha e izquierda de los sujetos del presente estudio que debe tenerse en consideración en las cirugías plásticas del oído externo, para el diseño de los dispositivos de audición y para su aplicación en estudios forenses de las huellas de la oreja.

Jak-Stat signaling pathway may play a role in the pathogenesis of cholesteatoma.

PURPOSE: Jak-Stat signaling pathway is one of the major signal transduction cascades which regulates most of the cellular events such as cell proliferation, differentiation, cell migration and apoptosis. This study aims to determine the activity of Jak-Stat signaling pathway in the pathogenesis of cholesteatoma. MATERIALS AND METHODS: Cholesteatoma and skin samples were obtained from 10 patients who underwent tympanomastoidectomy for chronic otitis media with cholesteatoma. Immunohistochemical analysis of cholesteatoma and skin was performed using anti-Jak1, anti-Jak2, anti-Jak3, anti-Stat1, anti-Stat2, anti-Stat3, anti-Stat4 and anti-Stat5 antibodies. The immunoreactivities in cholesteatoma and skin were quantified using H-score measurement and statistical comparison was performed. RESULTS: Jak1, Jak2, Jak3, Stat1 and Stat3 immunoreactivities were not detected in cholesteatoma; in contrast to the skin (129.8; 226.7; 33.0; 66.4;115.9). In addition, when H-score measurements of Stat2, Stat4 and Stat5 immunoreactivities were compared between cholesteatoma (172.8; 166.7; 120.0) and skin (400.0; 284.9; 292.0), statistically significant differences were found (p<0.0001, p<0.0001, p<0.0001). CONCLUSIONS: A remarkable deficiency in the family members of Jak-Stat signaling pathway was demonstrated in cholesteatoma. Therefore, perturbations in Jak-Stat signaling pathway may play a role in the pathogenesis of cholesteatoma.

Chronic inflammation: a poor prognostic factor for endoscopic dacryocystorhinostomy.

Endoscopic endonasal dacryocystorhinostomy (En-DCR) success can be affected by many factors. In this study, we aimed to determine the effect of chronic inflammation on the surgical outcome of En-DCR. A series of 25 primary En-DCR cases and their lacrimal sac specimens were involved in the study. The surgical outcomes were assessed subjectively (satisfied and unsatisfied) and objectively (successful and unsuccessful). All the specimens were examined for the chronic inflammation related histopathological features (inflammatory cell infiltration, fibrosis and capillary proliferation) and graded according to their severity. Moreover, a "chronic inflammation score" was established to determine the intensity of chronic inflammation using the grade of histopathological features. A quantitative and statistical analysis of histopathological features and chronic inflammation were performed between patients with satisfactory and unsatisfactory outcome; and patients with successful and unsuccessful outcome. The overall success rate according to subjective and objective assessment was 60%. However, 9 of 10 patients with unsatisfactory and/or unsuccessful outcome (90%) had severe chronic inflammation of lacrimal sac. In subjective assessment, inflammatory cell infiltration (p = 0.050), fibrosis (p = 0.037), capillary proliferation (p = 0.007) and chronic inflammation (p = 0.003) had a statistically significant difference between patients with satisfactory and unsatisfactory outcome. In objective assessment, statistically significant differences were detected between patients with successful and unsuccessful outcome when they compared according to inflammatory cell infiltration (p = 0.027), capillary proliferation (p = 0.007) and chronic inflammation (p = 0.003). Chronic inflammation related histopathological features of variable degree may have a role on En-DCR outcome. Chronic inflammatory score can be used as an indicator of En-DCR success.

Surgical anatomy of the nasolacrimal duct on the lateral nasal wall as revealed by serial dissections.

The anatomy of the nasolacrimal duct (NLD) in relation with the lateral nasal wall was studied in 15 half-heads of human adult cadavers by serial photographs of the dissection of the lateral nasal wall. The aim of the study was to determine the intranasal anatomical relationships of the NLD with the lateral nasal wall for surgical reference during endoscopic dacryocystorhinostomy. Following removal of the nasal mucosa anterior to the uncinate process, the exposed bone was removed by drilling. The entire NLD was exposed intranasally. The relationships of the NLD with the maxillary sinus ostium and anterior nasal spine were determined, and the length of the NLD was measured. The morphology of the NLD opening was observed, and its distance from several landmarks were measured. There were three types of intranasal orifice: pin-point, triangular and slit-like. The NLD is located, on average, 24.6 +/- 3.56 mm posterior to the anterior nasal spine. The nearest distances between the opening of the NLD and the nasal floor and between the opening of the NLD and the most anterior attachment of the inferior nasal concha were 13.7 +/- 3.15 and 14.3 +/- 2.05 mm, respectively. The length of the NLD was 21.9 +/- 2.03 mm on average. The nearest distances between the NLD and the maxillary sinus ostium was 3.9 +/- 0.88 mm. Cadaver dissections and the photographs of the fine dissections provide a more accurate description of the lateral nasal wall anatomy. These data provide valuable anatomical information to the surgeon performing endonasal dacryocystorhinostomy.

Neural control of eustachian tube function.

OBJECTIVES/HYPOTHESIS: It has been hypothesized that middle ear pressure can be controlled by the Eustachian tube through a neuronal reflex arc in animal models. We aimed to define the role of the neuronal control mechanisms in regulating middle ear pressure in humans. STUDY DESIGN: Prospective study. METHODS: The study population consisted of 95 ears of 95 volunteers. The mechanoreceptors on the tympanic membrane and the baroreceptors in the middle ear, which are assumed to form the afferent plexus of the neuronal reflex arc, were blocked by topical administration of lidocaine hydrochloride, in various patient groups. The Eustachian tube functions forming the efferent plexus of the neuronal reflex arc were evaluated by manometric tests both before and after blocking the possible afferent plexus in each study group. RESULTS: The baroreceptors established in the tympanic plexus might possibly have an effective role in this mechanism where the mechanoreceptors on the tympanic membrane seem to have a minor effect. CONCLUSIONS: Neuronal control mechanism could play an important role in regulating Eustachian tube function in humans. Laryngoscope, 2009.

CT study on morphometry of frontal sinus.

The aim of this study was to determine the prevalence and morphological characteristics of the frontal sinus in an adult population. This study was conducted retrospectively on paranasal CT scans in the axial and coronal planes of 300 cases (123 male and 177 female). The mean age was 40.74 +/- 13.34 (range 20-83). Measurements of the width, height and anteroposterior length for each sinus and total width were obtained from CT scans. Measurements were compared statistically with relation to side and sex. The cases were divided into subgroups according to age for each sex and each measurement parameter was also compared among the subgroups. All measurements tended to be larger on the left side and were significantly larger in males than females. There was a significant difference in the anteroposterior lengths of right and left sides in both males and females and height for males and width for females. In both sexes, the highest values of measurements were usually observed at the 31-40 age group and there was a tendency to decrease with aging. The larger diameters of the left frontal sinus imply that it may be more possibly violated during surgical interventions. Morphometric features differed significantly in the two sexes at different ages and comparison with previous studies presented great regional variability. The size of the frontal sinus was seen to be related to age and sex. The knowledge provided in the present study is useful for some surgical procedures and widens the anthropometric knowledge of humanity.

The role of phonophoresis in dyshpagia due to cervical osteophytes.

OBJECTIVE: Treatment of patients with anterior cervical osteophytes causing dysphagia includes conservative treatment with anti-inflammatory drugs, muscle relaxants, antibiotics, and an appropriate soft diet. Physical therapy with its advantages may be an alternative method in the treatment, which was not reported previously. CASE DESCRIPTION: Phonophoresis therapy is applied in nine patients with dysphagia due to cervical osteophytes. RESULTS: The symptom of dysphagia regressed in various degrees in all patients after phonophoresis therapy. CONCLUSIONS: Phonophoresis might be an alternative method for the non-steroidal anti-inflammatory drug (NSAID) treatment in patients with dysphagia due to cervical osteophytes.

Elongated styloid process and cervical spondylosis.

BACKGROUND: Dysphagia, is a significant sign of many different lesions in upper digestive system especially in proximal esophagus. Tumors, gastroesophageal reflux, achalasia and extrinsic compressions are the most common causes that may lead to dysphagia in geriatric population. Cervical osteophyte induced dysphagia, is one of the uncommon reasons of dysphagia, therefore other causes of dysphagia must be excluded to establish the exact diagnosis. Eagle syndrome is one of the considerable reason which may lead to misdiagnosis in patients with cervical osteophytes. In this case report, we represent four patients who had dysphagia due to anteriorly located cervical osteophytes and evaluate the patients with special reference to Eagle syndrome. MATERIAL AND METHODS: After a detailed anamnesis and ENT examination, cervical plain radiographs in four projections and Towne radiographs were obtained for every patient. After that, magnetic resonance imaging (MRI) of cervical spine and barium swallowing studies were performed to evaluate the presence of esophageal compression. RESULTS: Eagle syndrome was excluded due to absence of other symptoms and physical signs, eventhough unilateral or bilateral elongation of styloid processes was found in all of the patients. CONCLUSION: Cervical osteophytes induced dysphagia is a rare clinical entity, diagnosis should be done by a careful examination, intensive radiologic evaluation. Moreover, all the other causes like Eagle syndrome should be excluded during the diagnosis of cervical osteophyte induced dysphagia.

Identification of unknown bodies by using CT images of frontal sinus.

The aim of the study was to define a simple system for the identification of unknown bodies by using CT images of frontal sinus and to discuss whether it was worth to add measurements to the system or not. The system was including simple features as F (presence or absence of frontal sinus), S (intersinus and intrasinus septum) and S (scalloping), and named as FSS system. Measurements selected for the study were width, height, anteroposterior length, total width of two sinuses, the distance between the highest points of the two sinuses and the distance of each sinus to its maximum lateral limit. The study was conducted retrospectively on the paranasal CT scans of 100 cases (38 male and 62 female) who had no apparent sinonasal pathology. All the features and measurements were coded according to the system defined by the authors for each case and coded formulas were compared. At least 93% of the formulas could be eliminated for a case by using FSS system. The rate of success was increased to 98% by adding measurements. Contrary to objective criteria of FSS system, measurements were prone to bias. Therefore, in practice success rate would be expected to be lower than calculated. In the study population, instead of making 100 measurements, eliminating the most of the cases with FSS system and later discriminating the rest by pattern matching was seen logical.

Effect of thermal energy produced by drilling on the facial nerve: histopathologic evaluation in guinea pigs.

The effect of thermal energy due to drilling around the facial nerve canal on the facial nerve was histopathologically evaluated in four guinea pigs. The bony canal of the facial nerve was drilled using a 3 mm diamond burr for one minute. The temperature changes on the facial nerve canal were noted before and after dissection. The temporal bones of the animals were histopathologically examined under light microscopy using haematoxylin & eosin (H&E) and solochrome cyanine staining for myelin, and immunohistochemical staining for neuronal nitric oxide synthase (nNOS). Compared to the control group, it was observed with H&E staining that there was oedema among the axonal fibres and with solochrome cyanine staining that the thickness of the myelin fibres was decreased, and that the severity and extent of nNOS activity was decreased in the axonal fibres. It was concluded that a temperature increase on the facial canal may potentially lead to inflammation of the nerve, and may also cause deterioration of nerve conduction to some extent.

Considerations of isolated destruction of the short process of the incus in a case of cholesteatoma.

Cholesteatoma occurs frequently with the destruction of the ossicles. The most commonly eroded ossicle has been reported to be the incus. Many studies report destruction of the long process and body of the incus. However, isolated erosion of the short process of the incus is an unusual finding. We present such a case with a slight conductive hearing loss that remained unchanged at 2 1/2 years postoperatively. The short process of the incus may contribute to hearing up to 10-15 dB. It is also possible that it plays a role in epitympanic aeration by supplying an attachment surface to the incudal folds.

Anatomic limitations of posterior exposure of the sinus tympani.

OBJECTIVE: The sinus tympani is a challenging area for the otologic surgeon to access and from which to remove the disease process. Recently, a posterior approach to the sinus tympani through the mastoid was proposed as an alternative technique in cases of deep sinus tympani. STUDY DESIGN AND SETTING: The posterior approach was performed by dissecting the triangular bony area formed by the facial nerve, lateral semicircular canal, and posterior semicircular canal in 8 temporal bone specimens. RESULTS: The edges of the triangle on the facial nerve and lateral semicircular canal were almost constant at 5 mm. The edge on the posterior semicircular canal was about 4 mm. CONCLUSION: It is possible to expose the sinus tympani from the posterior by careful dissection through this triangle, which has almost constant dimensions.

Hearing loss does not occur in young patients undergoing spinal anesthesia.

BACKGROUND AND OBJECTIVES: Although uncommon, hearing loss after spinal anesthesia has been described. Vestibulocochlear dysfunction after spinal anesthesia in which 22-gauge and 25-gauge Quincke needles were used was investigated to determine if needle size affected hearing. METHODS: Patients with American Society of Anesthesiologists physical status I and II, aged 20 to 40 years, who were undergoing lower extremity surgery under spinal anesthesia were randomized into 2 groups. After intravenous hydration, 3 mL of 0.5% bupivacaine was administered for spinal anesthesia, which was performed with a 22-gauge Quincke needle in group I (n=30) patients and a 25-gauge Quincke needle in group II (n=30) patients. Before surgery and 2 days after surgery, pure-tone audiometry and tympanometry were performed. Preoperative and postoperative hearing data were obtained in the right and left ears for every frequency. Headache, nausea, and vomiting and cranial nerve III, IV, V, VI, VII, and VIII function were assessed on postoperative day 2. RESULTS: Demographic data were not different between the groups. No hypoacousis was noted at any frequency during the entire testing period in either group. Two patients from group I experienced postdural puncture headache on postoperative day 3, and neither had hearing loss. No patient had cranial nerve dysfunction. CONCLUSIONS: We were unable to induce hearing loss in young patients undergoing spinal anesthesia by injecting the anesthetic with a 22-gauge or a 25-gauge Quincke needle.

Serologic examinations of hepatitis, cytomegalovirus, and rubella in patients with Bell's palsy.

OBJECTIVE: The aim of this retrospective case review was to investigate serologic evidence of cytomegalovirus, rubella virus, and hepatitis A, B, and C viruses in patients with Bell's palsy. DESIGN: A total of 24 patients with idiopathic facial paralysis, without a history of trauma, any evidence of a tumor on high-resolution computed tomographic imaging, or any otologic disease, and 33 healthy individuals as a control group were included in this study. Facial paralysis of the patient was evaluated with the House-Brackmann grading scale. Specific immunoglobulin G and M titers were determined for cytomegalovirus, rubella, hepatitis A, hepatitis B, and hepatitis C by enzyme-linked immunosorbent assay. RESULTS: Serologic positivity for hepatitis B was found in 15 of 21 Bell's palsy patients, compared with 32.1% in the control group. The difference was statistically significant. There was no difference in the prevalence of serologic positivity for cytomegalovirus, hepatitis A, and rubella between the patient and control groups. In one Bell's palsy patient, serologic evidence of recent cytomegalovirus infection was indicated by changes in antibody titers between samples taken on presentation and on the 16th day. There was no serologic evidence of hepatitis C in either Bell's palsy patients or the control group. CONCLUSION: There seems to be an association between hepatitis B and idiopathic facial paralysis. In addition, cytomegalovirus might contribute to the development of Bell's palsy in some ceases with Bell's palsy. Further studies are required to confirm these data.

Comparison of surgical outcomes in primary endoscopic dacryocystorhinostomy with and without silicone intubation.

The surgical outcome of endoscopic endonasal dacryocystorhinostomy was analyzed in 30 cases of postsaccal stenosis. Intubation with silicone tubing was used in 14 cases (46.7%) and not used in 16 cases (53.3%). Surgical success was evaluated subjectively and objectively. The patients' complaints were improved in 85.7% of cases in the intubation group, and in 81.3% of the group in which no stent was used. Postoperative endoscopic examinations revealed that the rhinostomy opening was visible in 11 cases without intubation (68.8%) and 9 cases with intubation (64.3%). Six patients in the intubation group (42.9%) had granulation tissue at the rhinostomy site. Four patients (28.6%) had complaints regarding the intubation. Considering the similar surgical success rates, and the granulation formation, patient discomfort, and cost related to intubation, we recommend endoscopic dacryocystorhinostomy without intubation as the treatment of choice in cases of chronic epiphora due to postsaccal stenosis of the lacrimal canal.

The intracranial complication of acute isolated sphenoid sinusitis.

Acute isolated sphenoid sinusitis is a rare, potentially destructive entity, which has indistinct clinical findings and non-specific symptoms. Hence, it can be easily be misdiagnosed. We present and discuss a case of an isolated sphenoiditis with intracranial complication.