Characteristics and Management of Facial Nerve Schwannomas and Hemangiomas.

OBJECTIVES: To characterize facial nerve (FN) schwannomas (FNSs) and FN hemangiomas (FNHs) and their clinical features and management strategies, and to describe the results of cable nerve grafting after FN sectioning during tumor removal. METHODS: This retrospective study included 84 FNS cases and 42 FNH cases managed between July 1989 and July 2020 at a quaternary referral center for skull base pathology. Clinical details, locations, management, and results of cable nerve grafting at 1 year and during an average period of 3.12 years were evaluated. Sural nerve interpositioning was performed for patients who experienced FN paralysis for less than 1 year and underwent nerve sectioning during tumor removal. RESULTS: FNSs more often involved multiple segments compared with FNHs. The cerebellopontine angle and the mastoid segments were involved in 16 (19.1%) and 34 (40.5%) FNS cases, respectively; however, the cerebellopontine angle and the mastoid segments were involved in 0 and 7 (16.7%) FNH cases, respectively. Sectioned nerves of 99 patients (78.6%) were restored using interposition cable grafting. At the last follow-up evaluation, 56.3% of FNSs and 60.7% of FNHs attained House-Brackmann (HB) grade III. Lower preoperative HB grades were associated with poorer postoperative outcomes. For FNSs, the mean HB grades were 4.13 at 1 year postoperatively and 3.75 at the last follow-up evaluation ( p = 0.001); however, for FNHs, the mean HB grades were 4.04 postoperatively and 3.75 at the last follow-up evaluation. Therefore, extradural coaptation yielded better outcomes. CONCLUSION: FNSs can occur along any part of the FN along its course, and FNHs are concentrated around the area of geniculate ganglion. The results of cable inter positioning grafts are better in patients with preoperative FN-HB-III or less when compared with higher grades. The outcome of the interpositioning continues to improve even after 1 year in extradural coaptation.

Myiasis in Neglected Cutaneous Squamous Cell Carcinoma of the Head and Neck: Review of Management and Current Protocol Recommendations.

OBJECTIVE: To propose a first-aid management protocol for myiasis in neglected cutaneous squamous cell carcinoma (SCC) in the ED based on a recent literature review. DATA SOURCES: PubMed. STUDY SELECTION: Inclusion criteria were all series and case reports of primary/secondary cutaneous SCC with myiasis of the head and neck, including orbital SCC cases, published after 2005. DATA EXTRACTION: A total of 14 articles including 15 patients were included. DATA SYNTHESIS: Demographics, socioeconomic situation, site of the lesion, larvae species with bacterial suprainfection, and first-aid treatment options were discussed. Two representative cases are described. CONCLUSIONS: Large, ulcerated, necrotic, myiasis-burdened SCC lesions in the head and neck area present a challenge for treatment, and to date, no consensus regarding first-aid management exists. The authors' proposed four-pillar first-aid management scheme may be a valid option to rapidly improve wound condition through disinfection, pain relief, and malodor and discharge eradication as a bridge to surgery.

"Large and giant vestibular schwannomas: overall outcomes and the factors influencing facial nerve function".

(1) To study the overall outcomes of patients surgically treated for large/giant vestibular schwannomas (VSs) and (2) to identify and analyze preoperative and intraoperative prognostic factors influencing facial nerve (FN) outcome. A retrospective clinical study was conducted at a quaternary referral otology and skull-base center. A total of 389 cases were enrolled. The inclusion criteria were patients with tumor > 30 mm undergoing surgery with a minimum follow-up of 12 months. Neurofibromatosis-II, previous radiotherapy, revision surgeries, preoperative FN House-Brackmann (HB) grade > I, partial resections, incomplete records, or those lost to follow-up for a minimum period of 1 year were excluded. In addition, partial resections and cases where FN was sacrificed intraoperatively were also excluded and were analyzed separately. The mean duration of symptoms was 35.4 months, pronounced more in elderly (58.3 months) than in younger individuals (28.4 months). Mean tumor diameter was 36 mm and 52.7% was cystic. Total resection (TR), near total resection (NTR), and subtotal resections (STR) were achieved in 77.4%, 9.5%, and 13.2% of cases, respectively. Regrowth was observed only after STR (19.6%). Good (HB I-II), moderate (HB III), and poor (HB IV-VI) FN functions were observed in 36.8%, 51.7%, and 11.6% cases, respectively. Younger individuals underwent TR in 259 (86.9%) cases against 42 (46.2%) in elderly individuals. Non-total resections (NTR/STR) were performed in 49 (53.8%) cases in elderly as against 39(13.1%) in younger individuals. Good FN outcome was observed in 28 (57.1%) cases of non-total resections in elderly as against 13 (33.3%) cases in younger individuals. On multiple logistic regression analysis, size of the tumor, preoperatively prolonged duration of symptoms, profound deafness, and antero-superiorly located FN with respect to the tumor played a detrimental role in the final facial nerve outcome postoperatively. On the contrary, in large tumors (3-3.9 cm), presence of vertigo/disequilibrium had a relatively better impact on final FN outcome. Partial resections accounted for 41(7.8%) cases and FN was interrupted in 71(13.6%) cases in total. Factors detrimental to better FN outcome were giant VSs (> 4 cm), antero-superiorly located FN intratumorally, preoperatively prolonged duration of symptoms, and profound deafness. In large tumors (3-3.9 cm), presence of vertigo/disequilibrium had a better impact on FN outcome. Understandably, cases with TR in comparison with NTR/STR had worse FN outcomes. In comparison with younger patients, elderly patients underwent higher NTR/STR resulting in better FN outcomes. The above factors can be used as prognosticators for patient counseling and surgical decision making.

Inferior Turbinate Reduction: Diode LASER or Conventional Partial Turbinectomy?

Hypertrophy of inferior nasal turbinate is one of the most common causes for nasal obstruction (NO). As diode laser has proven to be as effective as any other lasers, our objective was to study various primary outcomes of its use of diode laser like improvement in NO, intraoperative bleeding, postoperative pain, and rapidity of healing. The study was undertaken to compare the various outcomes by diode laser turbinate reduction (LTR) and conventional partial inferior turbinectomy (PIT). A nonrandomized controlled trial was conducted on 2 groups: One group (30 cases) underwent LTR and PIT was performed in the other group (30 cases). The improvement in NO was measured postoperatively up to 6 months. Intraoperative bleeding was measured and postoperative pain scores were assessed each day up to fifth postoperative day. Lastly, rapidity of healing was evaluated until 6 months. Subjective relief of NO was 90.8% in LTR group, whereas it was 65% in PIT group at 6-month follow-up, which was statistically significant (P < .05). Pain scores were higher until 5 days in PIT group compared to LTR group (P = .0001). Intraoperative bleeding mean scores (milliliters) were 8.03 in LTR group compared to 23.29 in PIT group (P = .00001). Rapidity of healing was faster in LTR group with mean scores of 3.03 weeks in comparison to PIT group where it was 6.33 weeks (P = .00001). Compared to the conventional technique, the outcomes were better with diode laser and caused less morbidity.

Facial Nerve Outcomes Following Total Excision of Vestibular Schwannoma by the Enlarged Translabyrinthine Approach.

OBJECTIVE: To study the early and late facial nerve (FN) outcomes in different tumor classes in addition to determining the predictive factors for the same. STUDY DESIGN: A retrospective clinical study. SETTING: A quaternary referral otology and skull base center. PATIENTS AND METHODS: A retrospective study of 1983 cases of vestibular schwannomas (VSs) with preoperative normal FN function, undergoing total excision with anatomical preservation of the nerve by enlarged translabyrinthine approach (ETLA) were included. FN status was recorded postoperatively at day 1, at discharge, and at 1-year follow-up and were analyzed in different tumor sizes. RESULTS: At 1 year, 988 patients with House-Brackmann (H-B) grade I and II FN at day 1 after surgery, 958 (96.9%) maintained their status up-to 1 year. Of the 216 patients with H-B grade III at day 1 after surgery, 113 (52.3%) improved to H-B grade I and II. Similarly, of the 779 patients with H-B grade IV and VI FN function at day 1 after surgery, improvement to H-B III and H-B I and II were noted in 442 (56.7%) and 80 (10.3%) of patients, respectively. Intrameatal and extrameatal tumors upto 2 cm showed better recovery from H-B grade III to H-B I and II and from H-B grade IV and VI to H-B I and III when compared with extrameatal tumors >2 cm (p = 0.001). CONCLUSION: Tumors of smaller sizes have good immediate postoperative FN results and recover well at the end of 1 year while more than 3 cm have poor outcomes and recover poorly at the end of 1 year. When the VSs reaches more than 1 cm, the HB I and II outcomes drop significantly.

Temporal Bone Meningo-Encephalic-Herniation: Etiological Categorization and Surgical Strategy.

OBJECTIVE: To study the clinical presentation, intraoperative findings and surgical management in meningo-encephalic-herniation (MEH) based on the etiology. STUDY DESIGN: A retrospective clinical study and is a follow-up on the previously published report in 2009. SETTING: A quaternary referral otology and skull base center PATIENTS AND METHODS:: The inclusion criteria were intraoperatively verified MEH in patients with a minimum follow-up of 12 months, which yielded 262 operated ears. The data were extracted regarding demographics, laterality, clinical presentation, past surgeries, contralateral-ear condition, intraoperative findings, complications, recurrences, revision-surgeries, audiometric-data, and follow-up. RESULTS: The mean age at surgery was 49.7 years with the involvement of right-ear in 53.8% of patients. Lesions were categorized based on the etiology as chronic-otitis-media with/without cholesteatoma-MEH (COM/CHOL-MEH)-47.7%, iatrogenic-MEHs -20.9%; traumatic-MEHs -8% and spontaneous-MEHs -23.3%. At presentation, hearing loss (100 and 98.2%) and otorrhea (65.6 and 49.1%) were predominant in COM/CHOL-MEHs and iatrogenic-MEHs, respectively. On the other hand, meningitis (23.9 and 14.3%) and cerebrospinal fluid-leak (52.4 and 42.8%) were more pronounced in spontaneous and traumatic MEHs, respectively. Surgical approaches included 1) transmastoid, 2) middle-cranial-fossa-approach, 3) combined, and 4) middle-ear-obliteration (MEO) techniques. A total of 52.8% of COM/CHOL-MEHs and 49.1% of iatrogenic-MEHs underwent MEO. Middle-cranial-fossa approach was predominantly used in spontaneous-MEHs (52.5%) and traumatic-MEHs (38.1%). The defect was mostly single (75.2%). Smaller, multiple, bilateral lesions were more common in spontaneous-MEHs with tegmen-tympani involvement (57.4%). CONCLUSION: Incorporating etiology into MEHs is a key-step that can be used as a guidance in choosing the right surgery. MEO is a part of armamentarium, and should be used whenever needed, if the objective is performing a definitive surgery.

Cochlear Implantation in Chronic Otitis Media With Cholesteatoma and Open Cavities: Long-term Surgical Outcomes.

OBJECTIVES: To evaluate the long-term surgical outcomes of cochlear implantation (CI) in chronic otitis media (COM) with cholesteatoma and open cavities using subtotal petrosectomy (STP). To review device explantation (DE) patients and reimplantation considerations. STUDY DESIGN: Retrospective review. SETTING: Otology and skull base center. PATIENTS AND METHODS: Charts of 35 patients (36 ears) with COM with cholesteatoma, including open cavities, who underwent CI were reviewed for surgical outcomes and DE. Patient demographics, pathologies, previous surgeries, staging of implantation, salient intraoperative findings at the time of implantation and follow-up were evaluated. Details of patients with DE were evaluated for cause, operative findings, and reimplantation considerations. RESULTS: Mean age of patients was 65.94 years. Nineteen open cavities, 11 primary cholesteatomas, 3 petrous bone cholesteatomas, and 3 atelectatic middle ears represented the pathologies with 31 patients of CI with concurrent STP and 5 patients where implantation was staged. The mean follow-up was 7.16 years ranging from 2 to 13 years. Four patients (11%) had DE due to extrusion and cavity infection with three reimplanted in same or contralateral ear. All explantations occurred within 24 months of primary implantation. No residual or recurrent cholesteatoma was observed in any of the patients during follow-up. CONCLUSION: CI is feasible in COM with cholesteatoma and open cavities with the use of STP and single-stage implantation can be performed in the absence of purulence. Despite low risk of residual cholesteatoma post meticulous disease removal, risk of DE remains, particularly in open cavity patients, and is higher than standard implantation. Reimplantation is often possible with careful considerations.

Surgical Management of Intrinsic Tumors of the Facial Nerve.

BACKGROUND: Intrinsic tumors of the facial nerve are a rare entity. Dealing with this subset of tumors is challenging both in terms of decision making and surgical intervention. OBJECTIVE: To review the outcomes of surgical management of facial nerve tumors and cable nerve graft interpositioning. METHODS: A retrospective analysis was performed at a referral center for skull base pathology. One hundred fifteen patients who were surgically treated for facial nerve tumors were included. In case of nerve interruption during surgery, the cable nerve interpositioning technique was employed wherein the facial nerve palsy lasted for less than 1-yr duration. In cases of facial nerve palsy lasting for greater than 1 yr, the nerve was restituted by a hypoglossal facial coaptation. RESULTS: Various degrees of progressive paralysis were seen in 84 (73%) cases. Sixty nine (60%) of the tumors involved multiple segments of the facial nerve. Sixty-two (53.9%) tumors involved the geniculate ganglion. Seventy four (64.3%) of the cases were schwannomas. Hearing preservation surgeries were performed in 60 (52.1%). Ninety one (79.1%) of the nerves that were sectioned in association with tumor removal were restituted primarily by interposition cable grafting. The mean preoperative House-Brackmann grading of the facial nerve was 3.6. The mean immediate postoperative grading was 5.4, which recovered to a mean of 3.4 at the end of 1 yr. CONCLUSION: In patients with good facial nerve function (House-Brackmann grade I-II), a wait-and-scan approach is recommended. In cases where the facial nerve has been interrupted during surgery, the cable nerve interpositioning technique is a convenient and well-accepted procedure for immediate restitution of the nerve.

Rapidly growing cystic vestibular schwannoma with sudden onset facial palsy, ten years after subtotal excision.

An elderly male patient diagnosed with a right-sided cystic vestibular schwannoma (CVS) at our center underwent a translabyrinthine approach with a subtotal excision to preserve the facial nerve (FN). The tumor grew slowly for the first 9 years but in the subsequent 2 years grew rapidly, with the patient developing a FN paralysis. Using the previous approach, a second surgery was done and the tumor was excised, leaving behind a sheath of tumor on the facial and lower cranial nerves. This case demonstrates that CVSs show unpredictable growth patterns and need to be followed up for a longer period of time. Laryngoscope, 128:1649-1652, 2018.

Diphtheria Re-emergence: Problems Faced by Developing Countries.

In the pre-vaccination era, diphtheria was a leading cause of childhood mortality. With the introduction of routine childhood immunization, paediatric care and improved hygiene status the disease has been almost completely eradicated in many developed countries. On the contrary developing countries, still account for 80-90% of the global burden. Retrospective analysis of 52 cases of diphtheria over a period of 12 years at a tertiary referral hospital was carried out. They were analyzed for mortality and morbidity trends, immunization status, microbiological confirmation rates and antidiphtheritic serum (ADS) administration. Incidence in those over 5 years was 59.61%. Only 11.54% cases were either partially or fully immunized. The case fatality rate was 36.53%. Culture was performed only in 17 cases whereas ADS was administered in only 16 cases. In conclusion, the occurrence of diphtheria even in those immunized highlights the flaws in the present immunization program. Poor immunization coverage, lack of ADS, antibiotic resistance are the main reasons for re-emergence of diphtheria.