Jugular Foramen Paragangliomas.

Paragangliomas are the most common tumors at jugular foramen and pose a great surgical challenge. Careful clinical history and physical examination must be performed to adequately evaluate neurological deficits and its chronologic evolution, also to delineate an overview of the patient performance status. Complete imaging evaluation including MRI and CT scans should be performed, and angiography is a must to depict tumor blood supply and sigmoid sinus/internal jugular vein patency. Screening for multifocal paragangliomas is advisable, with a whole-body imaging. Laboratory investigation of endocrine function of the tumor is necessary, and adrenergic tumors may be associated with synchronous lesions. Preoperative prepare with alpha-blockage is advisable in norepinephrine/epinephrine-secreting tumors; however, it is not advisable in exclusively dopamine-secreting neoplasms. Best surgical candidates are young otherwise healthy patients with smaller lesions; however, treatment should be individualized each case. Variations of infratemporal fossa approach are employed depending on extensions of the mass. Regarding facial nerve management, we avoid to expose or reroute it if there is preoperative function preservation and prefer to work around facial canal in way of a fallopian bridge technique. If there is preoperative facial nerve compromise, the mastoid segment of the nerve is exposed, and it may be grafted if invaded or just decompressed. A key point is to preserve the anteromedial wall of internal jugular vein if there is preoperative preservation of lower cranial nerves. Careful multilayer closure is essential to avoid at most cerebrospinal fluid leakage. Residual tumors may be reoperated if growing and presenting mass effect or be candidate for adjuvant stereotactic radiosurgery.

Trans-mastoid plugging of superior semicircular canal dehiscence: long-term follow-up.

OBJECTIVE: To evaluate the long-term outcomes of trans-mastoid plugging of superior semicircular canal dehiscence (SSCD), focusing on complicated cases. METHODS: In this cohort study, we included all patients who underwent trans-mastoid plugging of SSCD between 2009 and 2019. We evaluated the symptoms (autophony, sound-/pressure-induced vertigo, disequilibrium, aural fullness and pulsatile tinnitus) before and 1 year after surgery in the medical records. We systematically assessed the current symptoms 6.2 ± 3 years postoperative (range 2.2-12.3 years) using questionnaires sent by post and validated by telephone interviews. We also documented any complications and the need for further procedures. We compared pure tone and speech audiometry before and 1 year after surgery. Finally, the degree of mastoid pneumatisation and mastoid tegmen anatomy were reviewed on preoperative CT scans. RESULTS: We included 24 ears in 23 patients. No complications were recorded, and none required a second procedure for SSCD. Following surgery, oscillopsia and Tullio phenomena resolved in all patients. Hyperacusis, autophony, and aural fullness were also settled in all patients except one. Balance impairment persisted to some degree in 35% of patients. No deterioration over the years was reported regarding the above symptoms. On average, bone conduction pure tone average pre- and 1 year postoperative were 13.7 ± 17 and 20.5 ± 18 dB, respectively (P = 0.002). Air bone gaps were reduced from 12.7 ± 8 to 5.9 ± 6 (P = 0.001). Two patients had a significant sclerotic mastoid, three had a prominent low-lying mastoid tegmen, and two had both. Anatomy had no effect on outcome. CONCLUSION: Trans-mastoid plugging of SSCD is a reliable and effective technique which achieves long-lasting symptom control, even in cases with sclerotic mastoid or low-lying mastoid tegmen.

Long-term clinical and radiological results for fat graft obliteration in subtotal petrosectomy and cochlear implant surgery: a retrospective clinical study.

PURPOSE: The study aimed to evaluate the long-term clinical, radiological, and functional results for subtotal petrosectomy and cochlear implant surgery with closure of the external auditory canal and fat obliteration. METHODS: We retrospectively included all consecutive cases of simultaneous subtotal petrosectomy and cochlear implant surgery performed at a tertiary referral center between 2009 and 2016 using the same surgical technique. All patients underwent postoperative high-resolution computed tomography (HRCT) and annual audiological assessments. A 5-year minimum clinical, radiological, and audiological follow-up was performed. The early and late postoperative results were compared. The main outcome measures were complications, postauricular retraction, fat graft reabsorption, and audiological outcomes. RESULTS: Twenty-nine procedures performed in 23 patients (six bilateral) met the inclusion criteria. The mean age of the patients was 67 ± 13.4 years and mean follow-up duration was 7.5 ± 2 years. At follow-up, postauricular retraction was detected in 24 cases (82.8%), including five cases (17.1%) with subcutaneous protrusion of implant and array. Fat graft volume was significantly reduced at late-HRCT in terms of maximum diameter (2.24 ± 1.0 cm vs 3.69 ± 0.7 cm; p < 0.0005) and surface area (1.88 ± 1.2 vs 4.24 ± 1.6 cm2, p < 0.0005). Six patients had extracochlear electrodes at late-HRCT (3/6 had an increased number of extracochlear electrodes), with a lowering of this group's performance of - 15% (p < 0.005) in the follow-up speech comprehension test. CONCLUSIONS: Subtotal petrosectomy with cochlear implantation is an effective long-term technique in selected cases. Fat grafts showed significant reabsorption at long-term follow-up with reaeration of the middle ear spaces. Prolonged clinical and radiological follow-up is recommended for monitoring implant performances and late complications.

External auditory canal reconstruction using a novel mastoidoplasty technique during canal wall down mastoidectomy: how I do it.

BACKGROUND: While mastoid obliteration techniques have received much attention in decreasing the disadvantages associated with the resultant mastoid cavity from canal wall down procedures, techniques for an anatomically normal looking ear canal reconstruction to increase the feasibility of hearing aid fitting are less commonly discussed as an alternative. METHODS: Our mastoidoplasty technique basically utilises an inferiorly based periosteal flap with or without temporalis muscles and fascia to obliterate the epitympanum and reconstruct the external auditory canal (EAC). Stay sutures are used to keep them in place. For larger cavities, demineralized bone matrix (DBM) is used to obliterate the mastoid cavity and support the neo-EAC. CONCLUSIONS: The concept of our mastoidoplasty potentially provides a very useful alternative in recreating a near normal ear canal anatomy avoiding cavity problems as well as facilitating hearing aid fitting with canal type hearing aids after canal wall down mastoidectomy.

Interpretation of the nine-step test for Eustachian tube function should consider mastoid cavity volume.

INTRODUCTION: The modified nine-step test is a classical method for evaluating Eustachian tube function. However, clinical interpretation of the increased maximal difference in middle ear pressure (mdMEP) in the modified nine-step test is unknown. We hypothesised that the different reservoir effects of the mastoid cavity can bias the results of the modified nine-step test. METHODS: A total of 108 consecutive participants (216 ears) were retrospectively screened. Of these, 55 participants (82 ears) who met the inclusion/exclusion criteria were enrolled. The volumetric results of the mastoid cavity, parameters of the modified nine-step test (mdMEP, middle ear pressure, tympanic membrane compliance), and demographic data were analysed. RESULTS: A significant negative correlation was found between mdMEP and mastoid cavity volume (R = .467, p < .001). Ears with mdMEP >70 daPa showed poor pneumatization in the mastoid cavity, with volumes less than 3000 mm3 (10th percentile of all ears analysed). Ears with mastoid cavity volumes lower than the 25th percentile showed a significantly higher mdMEP (p < .001). Patients with mastoid cavity volumes higher than the 75th percentile were significantly younger (p < .001). Multivariate regression analysis for mdMEP showed a good fit (R = .854) using factors including middle ear pressure, admittance and, most importantly, the reciprocal of mastoid volume (Beta = 0.752, p < .001). CONCLUSIONS: The mdMEP, the main parameter of the modified nine-step test, was negatively correlated with the mastoid cavity volume. Therefore, the results of the modified nine-step test should be interpreted with consideration of mastoid cavity volume.

Anatomical variations of Koerner's septum: a computed tomography-based, single-centered study.

BACKGROUND: Koerner's septum (KS) is a bony plate located at the junction of the petrous and squamous parts of the temporal bone. The reported prevalence of KS varied between studies. KS variations are associated with various pathologies and pose difficulties during surgeries. The study aims to determine the KS frequency in Omani patients and analyze its association with sex and side. METHODS: The present study investigated the KS topography in 344 computed tomography (CT) scans of normal temporal bones of adult Omani patients at Sultan Qaboos University Hospital. The presence of KS and its parts (complete or incomplete), as well as its thickness at three anatomical landmarks were recorded. Additionally, sex and laterality differences in KS parameters were analyzed using a Chi-square test. RESULTS: The overall frequency of KS among Omani subjects was 39.5%. The complete KS was observed only in 14% of cases. The thickness of KS was 0.78 ± 0.21 mm, 0.93 ± 0.28 mm and 0.78 ± 0.21 mm at the head of the malleus (HM), the superior semicircular canal (SSC) and the tympanic sinus (TS), respectively (p < 0.01). KS was present most constantly at the level of HM (64.7%), followed by SSC (57.4%), and less constantly at the level of TS (49.3%). KS frequency was similar in both males than females (41.9% vs 37.3%), with statistically insignificant difference (p = 0.38). No side differences were observed concerning KS frequency (p = 0.955). CONCLUSION: The KS frequency in Omani subjects within the range of previously reported studies. It is incomplete in most of the cases and constantly present at the level of HM. Its thickness is more at the level of SSC.

150 years ago: Schwartze's 1873 mastoidectomy and its implementation over the following 2 years.

BACKGROUND: In 1873, Hermann Schwartze and Adolf Eysell described a new surgical technique for treating mastoid disease using a mallet, chisels, and gouges of various sizes instead of trephines or drill instruments also called "modern mastoidectomy." On the 150th jubilee of this landmark article, we pay tribute by studying the reception and implementation of mastoidectomy in the 2 years following its publication. METHODS: The commentaries published in the otological and medical literature between the second part of 1873 to the end of 1875 were studied with an emphasis on the three specialized otological journals and the otological textbooks that existed during this period. RESULTS AND CONCLUSION: The princeps paper Ueber die künstliche Eröffnung des Warzenfortsatzes ("On the artificial opening of the mastoid process") by Hermann Schwartze and Adolf Eysell published in 1873 was rapidly disseminated in the medical literature for nearly 1 year, and then entered a phase of evaluation followed by a phase of extension and implementation, before finding its definitive place in the history of mastoid process surgery.

Anatomical study of the mastoid foramina and mastoid emissary veins: classification and application to localizing the sigmoid sinus.

The mastoid foramen (MF) is located on the mastoid process of the temporal bone, adjacent to the occipitomastoid suture or the parietomastoid suture, and contains the mastoid emissary vein (MEV). In retrosigmoid craniotomy, the MEV has been used to localize the position of the sigmoid sinus and, thus, the placement of the initial burr hole. Therefore, this study aimed to examine the exact location and variants of the MF and MEV to determine if their use in localizing the sigmoid sinus is reasonable. The sample in this study comprised 22 adult dried skulls (44 sides). MF were identified and classified into five types based on location, prevalence, whether they communicated with the sigmoid sinus and exact entrance into the groove of the sigmoid sinus. The diameters and relative locations of the MF in the skull were measured and recorded. Finally, the skulls were drilled to investigate the course of the MEV. Additionally, ten latex-injected sides from human cadavers were also dissected to follow the MEV, especially in cases with more than one vein. We found that type I MFs (single foramen) were the most prevalent (50%). These MFs were mainly located on the occipitomastoid suture; only one case on the right side was adjacent to the parietomastoid suture. Type II (paired foramina) was the second most prevalent (22.73%), followed by type III (13.64%), type 0 (9.09%), and type IV (4.55%). The diameter of the external opening in a connecting MF (2.43 ± 0.79) was twice that of a non-connecting MF (1.14 ± 0.56). Interestingly, on one side, two MFs on the external surface shared a single internal opening; the MEV bifurcated. MFs followed three different courses: ascending, almost horizontal, and descending. Regardless of how many external openings there were for the MF, these all ended at a single opening in the groove for the sigmoid sinus. For cadaveric specimens with multiple MEVs, all terminated in the sigmoid sinus as a single vein, with the more medial veins terminating more medially into the sinus. Based on our study, the MF/MEV can guide the surgeon and help localize the deeper-lying sigmoid sinus. Knowledge of this anatomical relationship could be an adjunct to neuronavigational technologies.

An anatomical study of the sigmoid sinus artery: Application to the transmastoid approach.

INTRODUCTION: We aimed to investigate the morphological features of the artery that traverse the sigmoid sinus's lateral surface and to discuss this structure's clinical relevance. METHODS: Ten sides from five cadaveric Caucasian heads were used for gross anatomical dissection to investigate the morphological features of the sigmoid sinus artery (SSA), and additional five sides were used for histological observation. RESULTS: The SSA was found on eight out of ten sides (80%). The mean diameter of the SSA was 0.3 mm. The mean distance from the tip of the mastoid process to the artery was 20.3 mm. Histological observation identified extradural and intradural courses of SSA. The intradural course was further categorized into protruding and non-protruding types. In the protruding type, the SSA traveled within the dura but indented into the bone, making it more or less an intraosseous artery. In the non-protruding type, the SSA traveled within the dura but did not protrude into the bone but rather indented into the lumen of the SS. In all sections, both intradural and extradural courses were identified simultaneously. CONCLUSIONS: When the mastoid foramen is observed, it does not always only carry an emissary vein but also an artery. The SSA could be considered a "warning landmark" during bone drilling for the transmastoid approach.

The Mastoid Skin Graft: A Fast, Efficient Donor Site for Auricle Reconstruction After Mohs Surgery.

BACKGROUND: Mohs micrographic surgery has been considered the gold standard for treating nonmelanoma skin cancers. Approximately 8% to 10% of skin cancers requiring Mohs surgery occur on the auricle. Skin grafts can be used to achieve optimal functional and cosmetic results. OBJECTIVES: To describe a skin graft technique using the mastoid area as a donor site for auricular reconstruction following Mohs micrographic surgery, to achieve optimal esthetic results in functionally important areas. METHODS: This retrospective study assessed the outcomes of patients who underwent MMS in an out-patient Mohs surgery clinic from 2010 to 2021. All patients had MMS of the auricle with reconstruction using a split thickness skin graft harvested from the mastoid area. RESULTS: A total of 154 patients were included. The average lesion diameter was 13.7 mm (range 5-30 mm), excised in an average of 1.9 rounds of MMS. Skin graft success rate was 96%. Complications included one patient with a hypertrophic scar. The cosmetic appearance of the recipient site was rated as excellent by 87.5% of patients. All patients rated the cosmetic appearance of the donor area as excellent and well-concealed. CONCLUSIONS: Split thickness skin grafts harvested from the mastoid area are a quick and efficient reconstruction method for post-Mohs auricular defects.

Role of mastoid pneumatization in predicting tympanoplasty results: Will it have the same importance in different age groups?

INTRODUCTION: There are several factors that seem to affect the surgical success rate of tympanoplasty, one of them being the pneumatization of the contralateral mastoid. In the current literature, several studies have been published with classification proposals for temporal bone pneumatization pattern. This study aims to evaluate the role of mastoid air cell extension in relation to the sigmoid sinus in predicting the surgical success of tympanoplasty. MATERIAL AND METHODS: This case-control study was performed on patients diagnosed with chronic otitis media (COM) who underwent type I tympanoplasty. The study group did not close the tympanic membrane, or there was a retraction or lateralization of the graft. The control group consisted of patients with surgical success. RESULTS: No statistically significant difference was found between groups regrading age, gender, perforation side/type, previous nasal surgery, and the presence of chronic otitis media in contralateral ear. A statistically significant difference was found when groups were compared in relation to the degree of pneumatization of the contralateral ear (p = 0.046), and this relationship does not seem to be influenced by age. CONCLUSION: To predict surgical success in terms of tympanic membrane closure in tympanoplasty, classification of contralateral ear pneumatization degree using the sigmoid sinus as a reference seems to be a valid and easy to apply method, and makes it possible to restrict the evaluation of pneumatization to the mastoid, a cell complex that does not seem to change with age.

Mastoid obliteration versus canal wall down or canal wall up mastoidectomy for cholesteatoma: Systematic review and meta-analysis.

BACKGROUND: There is ongoing debate over the optimal surgical approach for cholesteatoma treatment1-5. The aim of this review was to determine whether canal-wall down with mastoid obliteration is associated with favourable outcomes compared to either canal-wall down without obliteration or canal-wall up. The primary outcome was cholesteatoma reoccurrence with secondary outcomes including otorrhoea, reoperation and patient-reported outcome measures. METHODS: Medline, Embase, Cochrane databases and clinicaltrials.gov were searched for studies reporting outcomes of patients undergoing primary CWD-MO for cholesteatoma and directly compared with CWD and CWU mastoidectomies. Data were collated and meta-analysis performed. RESULTS: 2379 patients were included from 12 studies that met the inclusion criteria. CWD-MO was found to be associated with significantly less risk of recurrence when compared to CWU (OR = 0.330 (95 % CI 0.191-0.570, p < 0.001). When compared to CWD, CWD-MO was associate with significantly lower incidence of persistent otorrhoea (OR 0.405 (95 % CI 0.232-0.706, p < 0.001) while the rates of recurrence were comparable (OR: 1.231 [95 % CI: 0.550-2.757] p = 0.613). Otorrhoea rates between CWD-MO and CWU were equivalent as was reoperation. Quality of life and hearing outcomes were variably reported. CONCLUSIONS: This systematic review demonstrates that CWD-MO technique achieves lower recurrence rates comparable to CWD approaches and superior to CWU, while offering improved long-term control of otorrhoea. The final procedural choice should be decided based on surgeon experience, skill set and individual patient factors. To address the risk of selection bias, a randomised controlled trial is needed to answer this important research question.

Modified-modified radical mastoidectomy.

PURPOSE: It is unusual to have communication from the external auditory canal (EAC) directly to the mastoid, totally sparing the tympanum. These patients need a different surgical approach, a modified canal wall-down procedure, to completely clear the disease but fully preserve the tympanum. We present one such exceptional case. CASE PRESENTATION: A 28-year-old lady presented with ear discharge for 1 year. Imaging confirmed the canal-mastoid fistula, but the entire tympanum was normal. We performed a modified-modified radical mastoidectomy. CONCLUSIONS: Canal-mastoid fistula is an infrequent entity and may be idiopathic. Despite being evident on clinical examination, imaging aids in assessing size and location of the defect. Although EAC reconstruction may be attempted, the majority require a canal wall-down procedure.

Surgical results and quality of life after subtotal petrosectomy.

PURPOSE: Few data are available regarding subjective complaints and quality of life (QoL) after subtotal petrosectomy (STP). The purpose of our study was to assess long-term surgical results after STP, and to evaluate disease-specific, patient-reported outcomes including QoL and subjective hearing. METHODS: A retrospective cohort study, including a postal survey, was performed in the Amsterdam University Medical Centers (Amsterdam UMC) location Academic Medical Centre (AMC). All patients who underwent a STP between 1990 and 2018 were included. Patient characteristics, indication for surgery, adverse events, disease recidivism, and patient-reported health outcomes were evaluated. RESULTS: 181 patients (183 ears) underwent a STP for several indications. The main indication was chronic otitis media (COM) with or without cholesteatoma (69%). In the total cohort, 8 residual cholesteatoma (5%) and 6 inclusion cholesteatoma 4% were detected. Postoperative (functional) health outcomes showed a significant negative impact on QoL in the STP cohort compared to normative data. Compared to patients without ear problems, the postoperative STP patients scored worse on almost all domains of the Chronic Ear Survey (CES) (p < 0.001). SF-36 scores of postoperative STP data showed negative Z-scores in almost all subscales, indicating lower levels of QoL compared to Dutch reference values. Most subscales of the Amsterdam Inventory for Auditory Disability and Handicap (AIADH) demonstrate a large-effect size in disadvantage of the STP cohort when compared to Dutch reference values. CONCLUSION: STP is a suitable technique to tackle severe ear disease. Despite its favourable surgical results, STP has a negative impact on several domains of patient's QoL.

Cholesteatoma surgery in the pediatric population: remaining challenges in the era of mastoid obliteration.

PURPOSE: To present the first pediatric study on the safety and efficacy of mastoid obliteration using S53P4 bioactive glass (BAG) for cholesteatoma surgery. METHODS: A single-center retrospective cohort study was conducted. Inclusion criteria were pediatric cases (≤ 18 years) and at least at least one year of follow-up including non-echo planar diffusion-weighted MRI to assess cholesteatoma recidivism. Both canal wall up (CWU) and canal wall down (CWD) procedures were evaluated. RESULTS: A total of 61 cases (56 patients) were included. Most cases had an otologic history before the development of the cholesteatoma. CWU procedure was performed in 18 cases (30%) and CWD procedure in 43 cases (70%). The cholesteatoma recidivism rate was 33% after a mean follow-up period of 58 months. Kaplan-Meier curve estimated a 5-year recidivism rate of 40%. Few complications were seen that were all minor and resolved spontaneously or after local or systemic treatment. Control of the infection (merchant grade 0-1) was achieved in 98% of the cases. Closure of the air-bone gap within 20 dB was achieved in 22% of the cases with complete audiometric evaluation. CONCLUSION: In this MRI-controlled study, we show the safety and efficacy of S53P4 BAG for mastoid obliteration in a pediatric cholesteatoma cohort. Postoperative complications were both rare and minor, and a dry ear was achieved in almost all patients. Nevertheless, persistent hearing loss and the apparent high recidivism rate reflect the challenging nature of pediatric cholesteatoma.

Mastoid obliteration with hydroxyapatite vs. bone pâté in mastoidectomy surgery performed on patients with cholesteatoma and chronic suppurative otitis media: a retrospective analysis.

PURPOSE: To compare the efficacy and safety of hydroxyapatite vs. bone pâté as obliteration material in mastoidectomy surgery for patients with chronic suppurative otitis media and cholesteatoma. METHODS: This is a retrospective, multi-center, cohort study. All patients were followed up with micro-otoscopy, audiometry, and, if indicated, MRI with diffusion-weighted imaging. The following outcome parameters were analyzed: procedure safety (wound infections and complications), cholesteatoma recidivism rates (residual/recurrent), control of infection (Merchant's scale), and hearing results (pure-tone averages at 500/1000/2000/4000 Hz). RESULTS: Eighty-three cases were included: 45 obliterated with hydroxyapatite and 38 with bone pâté, with a mean follow-up time of, respectively, 25 and 24 months. Wound infections were only detected in the bone pâté group (4.8%) and successfully treated with oral or intravenous antibiotics and surgical drainage (p = 0.026). No other major surgical complications were observed in both groups. Cholesteatoma recidivism was observed in 15% using hydroxyapatite and 12% using bone pâté (p = 0.471). Complete control of infection (Merchant 0) was achieved in 76.2% using bone pâté and 86.8% using hydroxyapatite at 12 months postoperatively (p = 0.223). All patients showed good postoperative healing without complete failure to manage infection (Merchant 3). Pre- and postoperative audiometry showed significant improvement in hearing results in both groups. No significant difference between the obliteration materials was observed. CONCLUSIONS: Evaluation of mastoid obliteration reveals that hydroxyapatite and bone pâté are safe and effective obliteration materials, with high success rates in achieving a dry ear, low recidivism rates, and good hearing outcome, respecting the short-term limitation. In addition, our study shows that hydroxyapatite results in fewer postoperative wound infections compared to bone pâté.

Vestibular and audiometric results after endolymphatic mastoid shunt surgery in patients with Menière's disease.

PURPOSE: Treatment of Menière's Disease (MD) comprises an array of both non-destructive and destructive treatment options. In patients who are therapy-refractory to non-destructive medical treatment, endolymphatic mastoid shunt surgery (EMSS) is both recommended and debated controversially. The aim of this study was to investigate safety in terms of hearing, vestibular function, complication rate, and efficacy with regards to vertigo control of EMSS in patients with MD according to the current diagnostic criteria of 2015. METHODS: Retrospective analysis of 47 consecutive patients with definite or probable MD with description of demographic parameters, pre- and postoperative MD treatment, pre- and postoperative audiometric (pure tone audiometry) and vestibular (caloric testing) results. The parameters were compared between patients with and without postoperative vertigo control. RESULTS: 31/47 patients (66.0%) had improved vertigo control postoperatively. Postoperative hearing and vestibular preservation were predominantly stable. No significant differences between patients with improved vertigo control and patients with no change or worse vertigo episodes were found. In the treatment refractory group, 4 patients required a revision EMSS and 6 a destructive MD treatment (5 gentamicin intratympanically, 1 labyrinthectomy). No peri- or postsurgical complications were reported. CONCLUSIONS: EMSS was found to be beneficial in two thirds of the patients with definite or probable Morbus Menière and a safe procedure regarding hearing and vestibular preservation with no postoperative complications. Therefore, EMSS should be considered before inducing destructive treatment options, such as intratympanic gentamicin application or labyrinthectomy.

Use of bonalive in obliterative mastoidectomy: anatomical results and clinical outcome.

PURPOSE: To investigate safety and efficacy of mastoid obliteration in canal-wall-down tympanoplasty performed for cholesteatoma using bioactive glass (BAG). The authors routinely adopt CWD tympanoplasty in case of massive cholesteatoma or revision surgery, performing obliteration with BAG to reduce the mastoid cavity and related disadvantages. We assessed anatomical results, infection control and cholesteatoma recurrence in obliterative mastoidectomy using BAG. METHODS: The authors evaluated 66 patients treated with obliterative mastoidectomy using BAG during the period 2010-2021. 48.5% of the cases had first diagnosis of cholesteatoma, 48.5% had cholesteatoma recidivisms, and two patients underwent obliteration to improve clinical outcome. BAG granules were always moistened with venous blood to enhance their adhesion and reduce the risk of dispersion. Anatomical results were evaluated in otomicroscopy and infection control was assessed during follow-up visits. Periodical otomicroscopy was performed to check recurrent cholesteatoma. MRI-DWI was indicated only in case of clinical suspect of cholesteatoma. RESULTS: Authors followed 66 patients during a mean of 23 months. No post-operative wound infections occured. The mean re-epithelialization time was 45 days. At the last visit, control of infection was achieved in 97% of patients and a clinical stable anatomical cavity in all patients. No clinical suspect for recurrent cholesteatoma was found. CONCLUSIONS: The use of bioactive glass is safe and effective as obliteration material in cholesteatoma surgery. Authors pay a particular attention to obliterate only patients without suspect of epithelial residual, to correctly calibrate the ear canal and to completely cover the granules with graft.

Efficiency of intraoperative endoscopic inspection in reducing residuals in canal-wall-up surgery for pediatric cholesteatoma involving the mastoid.

OBJECTIVE: To investigate the efficiency of additional intraoperative endoscopic inspection in reducing residual cholesteatoma in pediatric cholesteatoma involving the mastoid treated with classic canal-wall-up mastoidectomy and tympanoplasty. MATERIALS AND METHODS: 32 cases of pediatric cholesteatoma involving the mastoid were enrolled in this perspective study and treated with classic canal-wall-up mastoidectomy and tympanoplasty. Transmastoid posterior tympanotomy, atticotomy and transecting tendon of tympani tensor were conducted to achieve adequate visualization of hidden spaces in the middle ear. After complete removal of cholesteatoma, endoscopic inspection was additionally performed to check residual cholesteatoma. All cases had at least a 2-year follow-up by routine otoscopy examination, CT scan or MR imaging. Residual rates of both intraoperative and follow-up findings were used to evaluate the efficiency of the endoscopic inspection in reducing residual cholesteatoma and compared with published reports. RESULTS: The additional intraoperative endoscopic inspection did not find any residual in this case series. In the 2-year follow-up, 2 cases (2/32, 6.3%) with residual cholesteatoma and 3 cases with recurrence (3/32, 9.4%) were found. The mean duration of endoscopic inspection and microscopic procedure were 17.9 min and 93.6 min, respectively. CONCLUSIONS: This study suggested that the additional intraoperative endoscopic inspection in microscopic CWU surgery for pediatric cholesteatoma involving the mastoid had no obvious value in reducing residual cholesteatoma but took extra time.

Corticospinal and spinal excitability during peripheral or central cooling in humans.

Cold exposure can impair fine and gross motor control and threaten survival. Most motor task decrement is due to peripheral neuromuscular factors. Less is known about cooling on central neural factors. Corticospinal and spinal excitability were determined during cooling of the skin (Tsk) and core (Tco). Eight subjects (four female) were actively cooled in a liquid perfused suit for 90 min (2 °C inflow temperature), passively cooled for 7 min, and then rewarmed for 30 min (41 °C inflow temperature). Stimulation blocks included 10 transcranial magnetic stimulations [eliciting motor evoked potentials (MEPs) which indicate corticospinal excitability], 8 trans-mastoid electrical stimulations [eliciting cervicomedullary evoked potentials (CMEPs) which indicate spinal excitability] and 2 brachial plexus electrical stimulations [eliciting maximal compound motor action potentials (Mmax)]. These stimulations were delivered every 30 min. Cooling for 90 min reduced Tsk to 18.2 °C while Tco did not change. At the end of rewarming Tsk returned to baseline while Tco decreased by 0.8 °C (afterdrop) (P < 0.001). Metabolic heat production was higher than baseline at the end of passive cooling (P = 0.01), and 7 min into rewarming (P = 0.04). MEP/Mmax remained unchanged throughout. CMEP/Mmax increased by 38% at end cooling (although increased variability at this time rendered the increase insignificant, P = 0.23) and 58% at end warming when Tco was 0.8 °C below baseline (P = 0.02). Cooling increased spinal excitability but not corticospinal excitability. Cooling may decrease cortical and/or supraspinal excitability which is compensated for by increased spinal excitability. This compensation is key to providing a motor task and survival advantage.