Minimally invasive cochlear implantation with mastoidal three-layer flap technique.

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

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

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

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

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

Dual ectopic thyroid: report of a case.

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

Zygomatic root approach.

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

Contralateral labyrinthine concussion in temporal bone fractures.

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

Management of facial paralysis in temporal bone fractures: a prospective study analyzing 11 operated fractures.

OBJECTIVE: This study was instituted to evaluate patients operated on for traumatic facial paralysis. STUDY DESIGN: A prospective study and literature review. MATERIALS AND METHODS: Between 1996 and 2001, 10 patients with 11 temporal bone fractures resulting in facial paralysis, who were treated by surgical exploration, were handled. One patient had bilateral facial paralysis because of a bilateral temporal bone fracture. All patients had immediate facial paralysis after trauma. The sample included 7 males and 3 females, aged between 8 and 43 years. RESULTS: Of the 11 fractures, 7 (63%) were longitudinal and 4 (37%) were mixed type. There were no transverse fractures. The longitudinal fractures were operated on by the middle cranial fossa (MCF) approach, whereas the mixed fractures were operated on by using a combined approach, consisting of both MCF and transmastoid approaches. The first neurotologic examination and electrophysiological evaluation of the patients were carried out at the earliest 5 days and at the latest 50 days (mean, 25.6 days). The decision for surgery based mainly on electroneurography (ENoG) was possible only in one fracture. In the remaining 10 fractures, the decision for surgery was based mainly on the high-resolution computed tomography (HRCT), taking into account that electromyography (EMG) showed no regeneration potentials. The timing of the surgical intervention ranged from 14 to 75 days (mean, 37.9 days). During the operation, fibrosis at the geniculate ganglion was seen in 5 fractures, impingement of the facial nerve by bone spicules at the geniculate ganglion in 2 fractures, disruption or laceration at the origin of major superficial petrosal nerve also in 2 fractures, and edema around the geniculate ganglion, which is considered a mild form of injury, seen in only 2 fractures. Five fractures showed House-Brackmann (HB) grade 1, 4 patients showed HB grade 2, and 2 patients showed HB grade 3 facial recovery. There were no hearing deterioration or permanent complications related with the procedures. CONCLUSIONS: It is rarely possible to see the patients with traumatic facial paralysis in the early period and thus to perform ENoG in the critical 6 days after facial paralysis. HRCT, with the contribution of EMG and clinical judgment, has the greatest impact in decision making in patients seen late. On the basis of the facial outcomes observed in the present prospective surgical series, the recovery of satisfactory facial nerve function could be achieved, regardless of timing of surgery performed, within the first 3 months after the onset of paralysis. This study demonstrates that unless there is a disruption of the main trunk, necessitating primary end-to-end anastomosis or grafting, the type of injury does not have any clear effect on the facial outcome, as long as appropriate surgical management is applied.

An unusual cause of foreign-body sensation in the throat: corniculate cartilage subluxation.

Corniculate cartilage subluxation is a pathology that has not been reported in the medical literature. Causing vague pharyngeal symptoms, this disease entity may be overlooked or misdiagnosed as chronic nonspecific pharyngitis, globus pharyngis, or laryngopharyngeal reflux disease. A careful laryngoscopic examination is the key to detect this disorder. In this article, we present a 45-year-old patient with the complaints of foreign-body sensation in the throat, difficulty in swallowing solid food, and an urge to turn his head toward the left during the act of swallowing. His laryngeal examination revealed corniculate cartilage subluxation, and excision of the subluxated cartilage was performed by microlaryngoscopic surgery. The patient was free of his symptoms immediately after the operation and remained as such in the 6 months of follow-up.

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

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