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.

Do-It-Yourself Low-Cost Stroboscopy.

This case series tests the construction of an extremely low-cost stroboscope and assesses its strengths and weaknesses.

Should the Eigenfactor Replace the Impact Factor?: A Bibliometric Study of Plastic, Reconstructive, and Aesthetic Surgery Journals.

BACKGROUND: Despite the global acceptance of the impact factor (IF) by researchers and academic institutions as one, criticism has been voiced regarding its effectiveness in evaluating the unbiased impact of a journal. To overcome the limitations and drawbacks of the IF that were presented by the scientific community, they introduced several other citation-based bibliometric indices. METHODS: All plastic and reconstructive surgery journals were analyzed, and bibliometric indices were extracted from the relevant source. Pearson correlation coefficients were used to determine correlations between the various indices. RESULTS: All correlations in between the various bibliometric indices were found to be positively and statistically significant, ranging from moderately highly associated for the IF and Eigenfactor (r = 0.632) to very strongly associated (r = 0.962) for the IF and the Article Influence Score. CONCLUSION: In the field of plastic and reconstructive surgery, the Eigenfactor and its derivative, the Article Influence Score, could potentially serve as better indices than the IF in demonstrating the overall picture. This information is based on the inclusion of a greater number of journals in the calculation and subtraction of self-citations, without compromising their correlation with other indices.The use of Eigenfactor and other additional bibliometrics cooperatively with the IF could provide the most extensive evaluation of a journal's scientific impact.

Analysis of Prognostic Factors Impacting Pediatric Acute Mastoiditis Outcomes.

BACKGROUND: This study aimed to investigate the outcomes of pediatric patients with acute mastoiditis while examining the role of intravenous steroid therapy, patient demographics, and serum inflammatory values as prognostic factors. METHODS: This study is a single-center retrospective observational study including 73 consecutive patients treated for acute mastoiditis in the course of the 10-year study period (January 2010 to December 2019). RESULTS: Data analysis showed that patients requiring surgical treatment (14%) had a 3-fold higher C-reactive protein value at admission compared to those treated conservatively (P < .001). Receiver operating characteristic analysis revealed that a C-reactive protein cut-off of ≥98.7 had a sensitivity and specificity of 100% and 74.6%, respectively, for predicting the need for surgery (area under the curve=0.927, P < .001). The duration of symptoms before hospitalization was nearly 2 days shorter in male patients (P=.031), and the use of intravenous steroid therapy significantly shortened the length of hospitalization (P=.023), by 1.4 days on average. CONCLUSION: Intravenous steroid therapy may be useful in decreasing the length of hospital stay. Mastoiditis tends to present more severely in male patients, and monitoring C-reactive protein values during treatment correlated well with the need for surgery.

Safety of a New Sinus Irrigation Device in Rhinosinusitis: A Pilot Study.

BACKGROUND: Puncture and lavage of the paranasal sinuses, previously the primary treatment for unresponsive acute bacterial rhinosinusitis before surgery, has been abandoned due to procedural discomfort and advancements in antibiotic efficacy and endoscopic surgery. The rise in antibiotic-resistant bacteria has renewed the interest in minimally invasive sinus lavage to both avoid aggressive surgical interventions and identify appropriate antibiotic therapy. In this article, we describe the safety and feasibility of a new device in human patients and evaluate its efficacy as a treatment before the traditional sinus surgery in acute rhinosinusitis. METHODS: The device with its seeker-shaped guiding tube and rotating wire can enter the sinus cavity through the natural ostium, pulverize the inspissated mucus, and enable lavage and culture sampling without the need for sinus puncturing. It was tested in 6 patients with chronic sinusitis under general anesthesia during endoscopic sinus surgery and in additional 10 patients with maxillary acute bacterial rhinosinusitis in outpatient settings under local anesthesia. RESULTS: The device enabled rapid, efficient, and atraumatic insertion of the wire into the occluded sinuses. The rotating wire permitted pulverization of the thick mucus, which enabled irrigation without mucosal damage or adverse events. Overall, 9 of 10 patients with acute bacterial rhinosinusitis demonstrated remarkable improvements and were discharged the following day with no acute symptoms. The visual analog scale score for pain dropped from 8.9 to 0.4. The remaining one patient underwent endoscopic sinus surgery subsequently. None of the patients treated during endoscopic sinus surgery developed any adverse events.

Comparison of Lower Cranial Nerve Function Between Tympanojugular Paraganglioma Class C1/C2 With and Without Intracranial Extension: A Four-Decade Experience.

OBJECTIVE: To compare preoperative and postoperative lower cranial nerve (LCN) function between Class C1 and C2 tympanojugular paraganglioma (TJP) with/without intracranial intradural (Di)/extradural (De) extensions, according to the experience of a single surgeon over four decades. STUDY DESIGN: Retrospective review. SETTING: Quaternary referral center for otology and skull base surgery. MATERIAL AND METHODS: A chart review was conducted of all the patients operated for C1/C2 TJPs from September 1983 to December 2018. The tumors were classified as: Limited-Group (C1/C2 without Di/De extensions) and Extended-Group (C1/C2 with Di/De extensions). RESULTS: Of 159 patients, 107 (67.3%) were women; the mean age at surgery was 46.5 years. The Limited-Group (56.6%) comprised C1 (41.1%) and C2 (58.9%) tumors; the Extended-Group (43.4%) comprised C1+Di/De (14.5%) and C2+Di/De (85.5%) tumors. The prevalence of preoperative LCN palsy was 11.9 times higher in Extended than Limited tumors: 61.9% versus 4.9% (p < 0.05). The risk for postoperative LCN palsy was 4.7 times greater in Extended than Limited tumors: 29.2% versus 12.9%, p = 0.01. CONCLUSION: Especially in younger patients, complete removal of Limited C1/C2 tumors, before they extend intracranially, reduces the risk of dysfunctionality of LCNs and the burden of residual tumor. The incidence of new tumors increased over four decades. However, new-postoperative LCN palsy did not occur in any Limited C1/C2 tumors operated after the year 2000, and declined to less than 10% of Extended C1/C2 tumors.

Clinical Efficacy of Topical Nasal Pomegranate Fruit Extract for Chronic Rhinitis and Chronic Rhinosinusitis.

Objective: To evaluate the clinical efficacy of topical nasal Pomegranate Fruit Extract (PFE) for Chronic Rhinitis (CR), Chronic Rhinosinusitis with Nasal Polyposis (CRSwNP), and Chronic Rhinosinusitis without Nasal Polyposis (CRSsNP). Methods: Prospective, double-blinded, randomized study including 111 consecutive patients, between April 2012 and January 2017, afflicted by CRSwNP, CRSsNP, and CR. Patients from each group were randomly assigned to either PFE treatment or placebo twice daily for 30 days. Therapeutic efficacy was assessed by Ear Nose and Throat, blood and tomographic examinations, and the SNOT-20 questionnaire. Results: CR patients treated with PFE suffered significantly less from thick nasal discharge, difficulty falling asleep, reduced productivity, reduced concentration, and sadness (P = .004, P = .02, P = .03, P = .007 and P = .02, respectively). Conclusions: Topical nasal PFE was found to have some benefits for CR patients, however, not for CRS with or without Nasal Polyposis.

Long term outcomes of canal wall up and canal wall down tympanomastoidectomies in pediatric cholesteatoma.

Cholesteatomas in children have a more aggressive growth pattern compared to adults, which leads to a higher incidence of both residual and recurrent disease. A staged canal wall-up or a canal wall-down tympanomastoidectomy (CWUT and CWDT, respectively) is selected depending on the extent of the disease and condition of the middle ear (ME) cleft and mastoid. Endoscopic ear surgery (EES) has been recently introduced as an adjuvant tool for the treatment of this pathology even in the pediatric population. OBJECTIVES: To analyze long term outcomes of CWUT and CWDT in the pediatric population, focusing on residual and recurrence rates of cholesteatoma and hearing results. A literature review including cases treated with EES were discussed. MATERIAL AND METHODS: Pediatric patients treated for cholesteatoma involving both the ME and mastoid with a follow-up (FU) of at least 4 years were retrospectively analyzed in a quaternary referral center for otology and lateral skull base surgery. Patients were grouped according to the surgical technique (CWUT versus CWDT). Rates of residual and recurrent cholesteatoma after each surgical technique were reported and compared. Mean Air-Bone Gap (ABG) of 0.5-1-2-4 KHz was measured and reported before the first surgery and at the last post-operative FU. RESULTS: Two-hundred and thirty-six cases fulfilled our inclusion criteria. The mean FU was 100.4 ± 44.2 months (median 89 months). One-hundred and five (44.5%) cases underwent a CWUT, whereas 131 (55.5%) a CWDT. A second stage surgery was performed in 73.5% of CWUT and 58.7% of CWDT. Among the CWUT group, residual cholesteatoma occurred in 22 (21%) ears and recurrence in 24 (22.9%). Patients undergoing CWDT showed lower rates of both residual and recurrent cholesteatoma (7.6% and 2.3%, respectively). ABG improvement was noted for both groups, even though CWUT showed better post-operative hearing results. CONCLUSIONS: The CWDT technique offers a definite surgical therapy, with minimal residual and recurrence rates and audiological results comparable to the CWUT technique. EES must still prove its added benefit or equivalence to pure microscopic approaches.

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.

Management of squamous cell carcinoma of the temporal bone: long-term results and factors influencing outcomes.

OBJECTIVE: Temporal bone squamous cell carcinoma (TBSCC) is a rare, aggressive tumor. Surgery, alone or combined with radiotherapy, represent the mainstay of treatment. To report our experience in the treatment of TBSCC and evaluate the disease-specific survival, identifying the factors influencing this outcome. MATERIALS AND METHODS: A retrospective study was performed on 66 patients between 1993 and 2018. Patients were staged according to the University of Pittsburgh-modified TNM staging system. Nine cases (13.6%) were Stage I, 7 cases (10.6%) Stage II, 20 cases (30.3%) Stage III and 30 cases (45.5%) Stage IV. Twenty-four patients underwent lateral temporal bone resection (LTBR) and 42 patients underwent subtotal temporal bone resection (STBR). RESULTS: One hundred percent of Stage I and II patients showed no evidence of disease (NED) after a median follow-up of 101 months (range 1-289 months). NED resulted in 88.2% of Stage III (mean follow-up 80.3 months; range 8-257) and 46.4% of stage IV (mean follow-up 50.6 months; range 3-217). Pittsburgh Stage or involvement of mastoid, facial nerve, medial wall of the middle ear, temporomandibular joint and middle fossa dura emerged as negative prognostic factors. The highest mortality rate occurred in the first 2 years after treatment, due to local recurrence. CONCLUSIONS: Prognosis of TBSCC can be excellent in early stage tumors, employing a LTBR. In more advanced cases, prognosis is poor. STBR with adjuvant radiotherapy represents the treatment of choice, offering acceptable survival rates. Given the rarity of the pathology, many controversies still exist concerning optimal management.

Evaluation of Subtotal Petrosectomy Technique in Difficult Cases of Cochlear Implantation.

OBJECTIVES: To assess the validity of the subtotal petrosectomy (STP) technique in problematic cases of cochlear implant (CI) surgery, and review indications, outcomes, and related controversies. STUDY DESIGN: This is a retrospective review of data from a private quaternary referral center of otology and skull base surgery. PATIENTS AND METHODS: A review of patients who underwent CI with STP (STP-CI) as the leading approach was performed. Demographics, indications, surgical details, and main outcomes were evaluated. The surgeries performed were usually single-stage procedures encompassing a comprehensive mastoidectomy, blind sac closure of the external auditory canal (EAC), and mastoid obliteration with autologous fat. RESULTS: A total of 107 cases were included. Mean follow-up was 7.1 years (range 1-13 years). The most frequent indication for STP-CI was chronic otitis media with/without cholesteatoma (32.7%), followed by open mastoid cavity (26.1%), and cochlear ossification (17.7%). Other difficult conditions where STP facilitates successful implantation include inner-ear malformations, temporal-bone trauma, unfavorable anatomic conditions, and revision surgery. A planned staged procedure was performed in 3 cases. The rate of major complications was 5.6% (n = 6). Three patients developed postauricular wound dehiscence which eventually resulted in device extrusion. No cases of recurrent/entrapped cholesteatoma, EAC breakdown, or meningitis were encountered. This is the largest single-center series of STP-CI reported in the literature. CONCLUSIONS: When CI is intended in technically challenging cases or associated with a high risk of complications, STP is effective and reliable. Safe implantation and excellent long-term outcomes can be achieved provided surgical steps are properly followed. Single-stage procedures can be performed in most cases, even when there is active middle-ear disease.

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.

Cholesteatoma of the External Auditory Canal: Review of Staging and Surgical Strategy.

INTRODUCTION: External auditory canal cholesteatomas (EACC) is insidious in nature and rare entity. There are only few case series on EACCs and surgical strategy is not standardized. OBJECTIVES: 1) To elucidate etiology of EACC and cardinal features. 2) To suggest a practical staging of EACC. 3) To enumerate surgical management according to stage of EACC. STUDY DESIGN: Retrospective study in a quaternary referral center of 31 consecutive cases of EACC. RESULTS: Thirty-one patients with EACC were reviewed. Unilateral otorrhea 19 (61.2%), hearing loss 22 (70.9%), and otalgia 8 (25.8%) are cardinal symptoms. Sixteen primary and 15 secondary EACCs were treated. Bone erosion was observed in 20 cases. In the present series, stage III = 12 (38.7%), stage II = 8 (25.8%), stage I = 11 (35.4%) underwent definitive treatment by surgery. Canalplasty with reconstruction was done in 19 cases of stages I and II. Of 12 cases in stage III, 3 cases underwent canalplasty with reconstruction. Subtotal petrosectomy was done in five cases. Intact canal wall mastoidectomy with canalplasty in two cases and radical mastoidectomy in two cases. Fascia, cartilage, muscle, and bone dust were used for reconstruction. Median follow-up period was 6 years and no recurrence of cholesteatoma was observed. CONCLUSION: EACC is unique entity. Intraoperative and radiological findings assist in correct and practical staging of EACC. Late stage presentations of EACC are common. Definitive surgical treatment in our series avoided recurrence of cholesteatoma.

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.

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.

Decision Making in the Wait-and-Scan Approach for Vestibular Schwannomas: Is There a Price to Pay in Terms of Hearing, Facial Nerve, and Overall Outcomes?

BACKGROUND: The wait-and-scan modality has emerged as an important strategy in the management of vestibular schwannoma (VS) as it has been demonstrated that many tumors grow slowly or do not show any growth over long periods. OBJECTIVE: To analyze long-term outcomes of wait-and-scan in the treatment of patients with VS, discuss the factors contributing to the decision making, determine the inherent risks of the policy, and compare our results with literature. METHODS: In total, 576 patients with sporadic unilateral VS who were managed with wait-and-scan were reviewed retrospectively. Of these, a subset of 154 patients with 5-yr follow-up was separately analyzed. The tumor characteristics including patterns of growth, rate of growth, hearing outcomes, and likely factors affecting the above parameters were analyzed. RESULTS: The mean period of follow-up was 36.9 ± 30.2 mo. The mean age was 59.2 ± 11.6 yr. Thirteen different patterns of tumor growth were observed. Eighty-four (54.5%) of 154 tumors with 5-yr follow-up showed no growth throughout 5 yr. Fifty-six (36.4%) tumors showed mixed growth rates. Only 57 (37%) patients had serviceable hearing at the start of follow-up, but 32 (56.1%) maintained it at the end of follow-up. One hundred fifty (26%) of the 576 patients who failed wait-and-scan had to be taken up for surgery. CONCLUSION: While there may be no price to pay in wait-and-scan as far as hearing is concerned, this may not be the case for facial nerve outcomes, wherein the results may be better if the patients are taken earlier for surgery.

Petrous Apex Cholesterol Granulomas: Outcomes, Complications, and Hearing Results From Surgical and Wait-and-Scan Management.

OBJECTIVE: 1. To analyze the surgical outcomes in the management of petrous apex cholesterol granulomas (PACG) with a brief literature review.2. To evaluate the importance of wait-and-scan management option. STUDY DESIGN: Retrospective review. SETTING: Quaternary referral center for otology and skull base surgery. SUBJECTS AND METHODS: Charts of 55 patients with at least 12 months of follow-up were analyzed for demographic, clinical, audiometric, and radiological features. Patients were divided into surgical group (SG) (n = 31) and wait-and-scan (n = 24) (WS) group. Surgical approach was chosen as per hearing status and PACG extension and relation to nearby neurovascular structures and included either drainage by transmastoid-infralabyrinthine approach (TM-IL)/transcanal-infracochlear approach (TC-IC) or resection by infratemporal fossa type B approach (ITF-B). The combination of ITF-B with trans-otic (TO) approach or TO approach solely was used in unserviceable hearing cases. Postoperative outcomes and complications were evaluated in SG. RESULTS: Postoperative symptom relief was observed in 24 patients (77.4%). Diplopia and paresthesia recovered in each case and improvement in headache, dizziness, tinnitus, and hearing loss was observed in 87.1% cases. Serviceable hearing was preserved in 24 of 26 cases. Postoperative complication rate was 32.2% including incidences of profound hearing loss, facial nerve paresis, carotid artery injury and intraoperative CSF leaks. Revision surgery was required in 3 (9.6%) cases, after TM-IL approach. CONCLUSION: Surgical drainage is preferable to more aggressive resection procedures, with the latter reserved for recurrent lesions or lesions with severe hearing loss/involvement of critical neurovascular structures. ITF-B approach provides adequate cyst and neurovascular control for resection, while avoiding brain retraction. An initial wait-and-scan approach can be used in most patients where symptoms and imaging justify so.

Lateral skull base surgery in a pediatric population: A 25-year experience in a referral skull base center.

OBJECTIVE: To analyze the pathology and surgical outcomes of lateral skull base (LSB) procedures in a pediatric population. STUDY DESIGN: Retrospective case review in a referral skull base center. METHODS: Charts of pediatric patients who underwent defined LSB procedures from 1983 to 2015 for various pathologies were evaluated at our center. A systematic review of literature was performed and our results were compared with the literature. RESULTS: 63 patients presented with 65 diseased ears. The mean age was 13 years. 29 (44.6%) presented with hearing loss and 28 (44.4%) and chronic otorrhea. The most common pathology was petrous bone cholesteatoma (27, 42.5%) followed by vestibular schwannoma (10, 15.8%). Subtotal petrosectomy (24, 35.8%) was the most common surgical procedure followed by, transotic (18, 26.8%). The facial nerve function was preserved in 45 (67.1%) and the hearing in 28 (41.7%) cases respectively. No major complications, including mortality was encountered in our series. CONCLUSION: In rare and extensive pathologies involving the skull base in a pediatric population, the surgeon is posed with the dilemma of trying to achieve facial and hearing preservation while dealing with total tumor clearance. Mastery over LSB procedures can ensure complete disease clearance with optimal functional outcomes. LEVEL OF EVIDENCE: 2b.