Cervicofacial surgery and implantable hearing device extrusion: management of challenging cases.

OBJECTIVE: To describe our management of implantable hearing device extrusion in cases of previous cervicofacial surgery. METHODS: A review was conducted of a retrospectively acquired database of surgical procedures for implantable hearing devices performed at our department between January 2011 and December 2019. Cases of device extrusion and previous cervicofacial surgery are included. Medical and surgical management is discussed. RESULTS: Four cases of implant extrusion following cervicofacial surgery were identified: one involving a Bonebridge system and three involving cochlear implants. In all cases, antibiotic treatment was administered and surgical debridement performed. The same Bonebridge system was implanted in the middle fossa. The three cochlear implants were removed, and new devices were implanted in a more posterior region. CONCLUSION: Previous cervicofacial surgery is a risk factor for hearing implant extrusion. The middle fossa approach is the best option for the Bonebridge system. Regarding the cochlear implant, it is always suitable to place it in a more posterior area. An inferiorly based fascio-muscular flap may be a good option to reduce the risk of extrusion.

Pseudo mastoid obliteration with conchal cartilage may be a safe alternative technique for cochlear implantation in canal wall down mastoidectomy with large meatoplasty.

OBJECTIVE: Safe cochlear implantation is challenging in patients with canal wall down mastoid cavities, and the presence of large meatoplasties increases the risk of external canal overclosure. This paper describes our results of obliteration of the mastoid cavity with conchal cartilage as an alternative procedure in cases of canal wall down mastoidectomy with very large meatoplasty. METHODS: The cases of seven patients with a canal wall down mastoidectomy cavity who underwent cochlear implantation were retrospectively reviewed. Post-operative complications were analysed. The mean follow-up duration was 4.5 years. RESULTS: There was no hint of cholesteatoma recurrence and all patients have been free of symptoms during follow up. Only one patient showed cable extrusion six months after surgery, and implantation of the contralateral ear was needed. CONCLUSION: Pseudo-obliteration of the mastoid cavity with a cartilage multi-layered palisade reconstruction covering the electrode may be a safe alternative in selected patients with a large meatoplasty.

Endoscopic reconstruction of large anterior skull base defects with opening of the sellar diaphragm. Experience at a tertiary level university hospital.

BACKGROUND: The indications for expanded endoscopic transnasal approaches continue to increase, with more complex skull base defects needing to be repaired. This study reviews the management of large anterior skull base defects with opening of the sellar diaphragm. METHOD: A prospective analysis of endonasal endoscopic surgery carried out at Son Espases University Hospital between January 2013 and December 2018 was performed. The analysis included only the cases with a significative intra-operative cerebrospinal fluid leak. In all cases, reconstruction was performed by combining the gasket seal technique with a pedicled mucosal endonasal flap. RESULTS: Twenty-eight patients were included. The mucoperiosteal nasoseptal flap, the lateral wall flap and the middle turbinate flap were used in 13, 8 and 7 patients, respectively, combined with the gasket seal technique. One case of post-operative cerebrospinal fluid leak was observed (3.57 per cent). CONCLUSION: The combination of a gasket seal with an endonasal mucosal flap is an excellent technique for repairing large anterior skull base defects.

The Bonebridge active bone conduction system: a fast and safe technique for a middle fossa approach.

BACKGROUND: The transmastoid pre-sigmoid approach is always the preferred choice for implantation of the Bonebridge active bone conduction system in patients with a normal anatomy. When an anatomical variant exists or a previous surgery has been performed, a retrosigmoid approach or middle fossa approach can be performed. METHODS: The preferred surgical technique for a middle fossa approach is described. A 14 mm drill head (Neuro Drill) was used to create the bed at the squamous portion of the temporal bone. Surgical time and complication rate were analysed. RESULTS: The surgical time was shorter than 30 minutes in all cases, and only 14 seconds were needed to create a 14 mm bone bed. No complications were observed during the follow-up period (6-45 months). CONCLUSION: Use of the Neuro Drill for the middle fossa approach is an easy technique. It significantly decreases the surgical time, without increasing the complication rate.

[Diagnosis and treatment of chronic epiphora and recurrent dacryocystitis]. / Diagnostik und Therapie von chronischer Epiphora und rezidivierender Dakryozystitis.

The goal of this article is to highlight relevant diagnostic tools to assess chronic epiphora and recurrent dacryocystitis in order to avoid unnecessary diagnostic explorations. Probing of the canaliculi is important for the differential diagnosis of chronic epiphora. Surgical steps are detailed, such as the inferiorly based mucosal flap on the AGGER NASI, which is repositioned at the end of the surgery improving wound healing on the lateral wall. Potential complications are presented, as well as measures to avoid and to treat them. Long-term follow-up of 750 endoscopic DCR confirms the good results in more than 90% after endoscopic dacryocystorhinostomies in adults and in children.

Paediatric endoscopic sinus surgery (PESS): review of the indications.

Functional endoscopic sinus surgery (FESS) differs in children and adults. The purpose of this article is to highlight the differences by focusing on the anatomical landmarks and diagnostic and surgical peculiarities present in children. We review the indications of FESS in children, partially based on our personal experience, in order to establish a list of relative and absolute indications for the procedure. We also discuss controversies such as the overuse of FESS for chronic sinusitis and the potential postoperative alterations of pneumatization. The paper includes a retrospective study of our results with endoscopic dacryocystorhinostomy (DCR) in 31 children and the endoscopic removal of 11 juvenile angiofibromas. All patients were reviewed in the out patients clinic. Patency of DCR was evaluated by fluorescein dye application to the conjunctiva, endoscopy with a 2.7 mm rigid endoscope or by means of clinical parameters, such as tearing or recurrent dacryocystitis. For patients operated on for a juvenile angiofibroma endoscopy of the nose and MRI every 6 months for the first two years were scheduled. Functional outcome showed good overall results in 90.3% of DCR after primary surgery. The endoscopic approach to juvenile angiofibromas achieved a cure rate of 90.9% after a follow-up of at least 24 months.

[Percutaneous gastrostomy under fluoroscopic guidance. A one year experience]. / Gastrostomía percutánea bajo control fluoroscópico. Primer año de experiencia.

The nasogastric tube has traditionally been used as nutritional support for patients with head and neck cancers. We propose the percutaneous gastrostomy under fluoroscopic guidance as a part of therapy in selected patients with head and neck cancers, or in those who have chronic aspiration and dysphagia secondary to neurologic impairment. Our one-year experience with our series of nasogastric tube is reviewed.

[Preliminary functional results of tympanoplasty with palisade cartilage]. / Resultados funcionales preliminares de la timpanoplastia con cartílago en empalizada.

Total or subtotal reconstruction of the tympanic membrane with cartilage palisades counteracts the tendency to retraction observed in ears with functional problems of the tube or altered gas exchange of the mucosa, in contrast with "soft" autologous materials such as temporal fascia or perichondrium. Because of its low turnover, cartilage is more resistant to the prolonged absence of neovascularization from the periphery in (sub) total perforation making it more resistant to infection. However, the use of palisade cartilage has been questioned for the functional recuperation of the middle ear because of its rigidity and thickness. A retrospective study was made of the functional results of 148 type III tympanoplasties with partial or complete reconstruction with cartilage after a one-stage procedure. A comparison of 108 ears with a mean postoperative follow-up of 20 months and 40 ears with a mean follow-up of more than 6 months showed no statistically significant difference in the overall functional results. A "social" hearing level (GAP < 30 dB) was achieved in 83.2%: the gain was 1-30 dB in 75.6% of cases (n = 112). No statistically significant differences were found between the functional results of primary surgery and re-operation. Statistically significant differences were found in the functional results of canal wall down and canal wall up procedures.

[Indications, techniques and anatomic results of the tympanoplasty using palisade cartilage]. / Indicaciones, técnica y resultados anatómicos de la timpanoplastia con cartílago en empalizada.

One of the major unsolved problems of the middle ear is Eustachian tube disfunction and abnormalities in gas exchange through the middle ear mucosa, which produces negative pressure and may cause retraction pockets, adhesions, or atelectasis. Postoperatively, ear surgeons face a similar problem when conventional autologous material was used to reconstruct the tympanum. Sooner or later, the new tympanic membrane experience retraction, re-perforation and/or extrusion or displacement of the reconstructed ossicular chain. This paper proposes using cartilage as an alternative method of tympanic membrane reconstruction in a personal modification of Heermann's technique. The indications for the "palisade" reconstruction technique with cartilage, technical aspects, and anatomic results after an average of 20 months after surgery are discussed.