Peristapedial bulb: an indicator of spontaneous CSF leak in cochlear candidates with Mondini dysplasia.

BACKGROUND: Mondini dysplasia with spontaneous cerebrospinal fluid (CSF) leak is rare in cochlear implantation (CI) candidates but lethal. Detailed evaluation and surgical intervention are needed for these patients. AIM/OBJECTIVE: To report our findings of the peristapedial bulb in computer tomography (CT) as diagnostic evidence of spontaneous CSF leak and discuss its clinical value to direct the surgical plan for patients with profound sensorineural hearing loss (SNHL) and meningitis. MATERIAL AND METHODS: A retrospective review was conducted, including patients' demographic features, radiographic examination, operation records, auditory/speech evaluation. The patients presented with a peristapedial bulb were included. RESULTS: In 2775 CI recipients, 7 out of 219 (3.2%) patients with Mondini anomaly had detectable peristapedial bulbs in HRCT, among whom 6 patients have a history of meningitis. Surgical exploration verified the radiographic findings in 6 out of 7 patients. All patients received CI and vestibular obliteration. Control of meningitis was acceptable. The threshold of hearing significantly decreased from 74.1 dB ± 6.9 dB to 37.1 ± 4.8 dB after CI and the word recognition score elevated from 21.4 ± 14.9% to 78.6 ± 9.3%. CONCLUSIONS AND SIGNIFICANCE: Peristapedial bulb is an indicator of spontaneous CSF leak in patients with profound SHNL and Mondini anomaly. Patients will benefit from CI and surgical intervention.

[The diagnostic value of labyrinthine fistula with multi-planar reconstruction in chronic otitis media by HRCT].

OBJECTIVE: To study the ability of HRCT to delineate the semicircular canals and the diagnostic value of HRCT in identifying labyrinthine fistula in chronic otitis media (COM) by means of multiplanar reconstruction. METHOD: Eighty-six patients (79 healthy ear and 93 failed ears) with chronic otitis media were scanned with HRCT, and the original data was processed with MPR. In the normal ears the semicircular canals form were individually observed and the canal geometry were compared in axial and coronal and s-MPR. In COM the destruction of the canal were observed and compared with the intraoperative findings. RESULT: The full length of horizontal semicircular canal can be displayed in some cases and the full length of the three canals can't be displayed in any single coronal image but they can be individually displayed in one image in s-MPR. In the COM, six ears labyrinthine fistula were found in the axial and five ears in coronal images; six ears were located at the horizontal semicircular canal and two ears at the superior semicircular canal in the s-MPR, which corresponded with the intraoperative findings. CONCLUSIONS: MPR can display the full path of individual semicircular canal in one image and is promising in identifying labyrinthine fistula.

[Efficacy of high-resolution CT in differential diagnosis of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows].

OBJECTIVE: To evalute the efficacy of high-resolution CT(HRCT) in differential diagnosis and treatment of chronic suppurative otitis media and cholesteatoma otitis media by soft-tissue shadows. METHODS: HRCT scanning was performed in 120 cases, 153 ears, with chronic otitis suppurative media and cholesteatoma otitis media, of which original data were processed with multi-planar reconstruction (MPR) and maximum intensity projection (MIP), the characteristics of the soft-tissue shadows' growth, window width or window leveling and bony destruction were respectively observed, as well as compared with the surgery findings. RESULTS: In 120 patients (153 ears), 109 ears were diagnosed as cholesteatoma otitis media, and 44 ears were diagnosed as chronic suppurative otitis media, among which 33 ears had granulation tissue and 11 ears had secretion. One hundred and seven ears were postoperatively diagnosed as cholesteatoma otitis media, among which 25 ears had granulation tissue. Among 46 ears of chronic suppurative otitis media, 35 ears had granulation tissue, and only 11 ears had secretion. A 98.6% diagnostic accuracy can be reached with HRCT in diagnosing cholesteatoma otitis media and chronic suppurative otitis media. The Youden's index was 0.98, 0.98 and 1.00 respectively with HRCT in diagnosing cholesteatoma, granulation tissue and secretion. CONCLUSIONS: Combination of the three different imaging methods, axial images, coronal MPR images and MIP images, can improve the efficacy of the HRCT diagnosis and definite chronic otitis media, which can be routinely used for surgery plan.

[The diagnostic value of multi-planar reconstruction in semicircular canals disease by HRCT].

OBJECTIVE: To study the diagnostic value of high-resolution computed tomography (HRCT) and multiplanar reconstruction (MPR) in assessment of semicircular canals disease. METHOD: Eighty-three patients were scanned with HRCT and the original data were processed with MPR. The semicircular canals full length was respectively observed in one image of MPR in the normal ears. The abnormal location of the canal were observed. RESULT: In one image the full length of the horizontal, superior and posterior semicircular canal can be respectively displayed in one image of MPR in normal ears. By this way ,1 superior semicircular canal dehiscence (SSCD)was found in precaution group, 1 superior and 2 horizontal semicircular canal blocked, 1 vestibular aqueduct (VA) joined into superior semicircular canal and 2 VAs joined into posterior semicircular canal and abnormity of the three semicircular canals were found in SNHL. CONCLUSION: MPR canould display the three canals full length in one picture and have a high specificity in the diagnosis of the semicircular canal abnormity.

[Diagnostic value of high-resolution computed tomography imaging in congenital inner ear malformations].

OBJECTIVE: To observe the inner ear structure with volume rendering (VR) reconstruction and to evaluate the role of high-resolution computed tomography (HRCT) in congenital inner ear malformations. METHOD: HRCT scanning was performed in 10 patients (20 ears) without ear disease (control group) and 7 patients (11 ears) with inner ear malformations (IEM group) and the original data was processed with VR reconstruction. The inner ear osseous labyrinth structure in the images generated by these techniques was observed respectively in the normal ears and malformation ears. RESULT: The inner ear osseous labyrinth structure and the relationship was displayed clearly in VR imaging in the control group,meanwhile, characters and degree of malformed structure were also displayed clearly in the IEA group. Of seven patients (11 ears) with congenital inner ear malformations, the axial, MPR and VR images can display the site and degree in 9 ears. VR images were superior to the axial images in displaying the malformations in 2 ears with the small lateral semicircular canal malformations. The malformations included Mondini deformity (7 ears), vestibular and semicircular canal malformations (3 ears), vestibular aqueduct dilate (7 ears, of which 6 ears accompanied by other malformations) , the internal auditory canal malformation (2 ears, all accompanied by other malformations). CONCLUSION: HRCT can display the normal structure of bone inner ear through high quality VR reconstructions. VR images can also display the site and degree of the malformations three-dimensionally and intuitively. HRCT is valuable in diagnosing the inner ear malformation.

[Evaluation of maximum intensity projection in HRCT in the diagnosis of the destruction of ossicular chain in chronic otitis media].

OBJECTIVE: To observe the ossicular chain structure with maximum intensity projection (MIP) and to evaluate the diagnostic value of it in the destruction of ossicular chain in chronic otitis media (COM). METHOD: Sixty-eight patients (136 ears) were scanned with HRCT. The original data was processed with MIP reconstruction technique. The images of the ossicular chain structure in normal ears were observed, while the images in suffering ears were compared with the findings in operation. RESULT: In normal ears, the ossicular chain structure was shown clearly by MIP, which can also display three-dimensional images of the ossicular chain. In the suffering ears of chronic otitis media of cholesteatoma type, granuloma type and simple type, MIP displayed the destruction of ossicular chain in 39 ears, 5 ears and 0 ear respectively, which was observed in 39 ears, 6 ears and 0 ears respectively in operation. CONCLUSION: MIP technique in HRCT can display the ossicular chain spatial structure clearly, which is very helpful to evaluate the destruction of ossicular chain in chronic otitis media (COM) and to make accurate operation plan.

[Clinical study of combined approach of tympanoplasty and mastoidectomy with close technique].

OBJECTIVE: To improve the surgery results and living quality of patients following the operation of the combined approach of tympanoplasty and mastoidectomy with close technique. METHODS: The clinical data and following-up results of 49 patients treated with combined approach of tympanoplasty and mastoidectomy with close technique and 82 patients treated with open mastoidectomy with tympanoplasty were retrospective analyzed. RESULTS: In the group treated with combined approach tympanoplasty, all patients got dry ear in 20 days and 31 patients' hearing level enhanced over 15 dB after the operation; but in the group treated with open mastoidectomy with tympanoplasty, only 13 patients got dry ear in 20 days and no patients' hearing level enhance over 15 dB after the operation. Although the recurrence rates between two groups were not significant difference, the patients of former group not only took a shorter recovery time and got a better hearing recovery, but also kept a normal external auditory meatus, at the same time, they need not to clear scab at fixed period all life long. CONCLUSIONS: When performed on carefully selected patients, combined approach tympanoplasty was a feasible surgical method to improve the surgery results and living quality of patients following the operation, however, the advanced equipment and perfect operation skill are necessary.

[Surgical approaches to the skull base neoplasms].

OBJECTIVE: To discuss the best surgical approach to the skull base neoplasms. METHODS: Retrospective analysis the 79 skull base neoplasms cases treated with surgical resection in Qilu hospital of Shandong university from 1992 to 2002. Eleven surgical approaches including midfacial degloving, frontal coronal discission, nasal eversion, maxillary swing, partial maxillary resection, total resection of orbit, mandibular swing, combination of front, temple, preauricular, post aureum, neck, and transoral approaches were used to resect the tumor which involved fossae pterygopalatine, paranasal sinuses, nasopharynx, antero, meso and posterobasilar region, lobi frontalis and lobi temporalis of cerebrum. RESULTS: Seventy-nine skull base neoplasms were totally removed and no one died from the operation. Although 5 cases complicated with cerebrospinal fluid leak and all recovered within 1 week, no serious cranium-cerebrum complication occurred. In 29 patients with benign tumor including 11 cases of meningioma, 3 cases of chondroma, 1 case of hemangio-meningioma, 1 case of cavernous hemangioma, 2 cases of osteodysplasia fibromas, 9 cases of neurofibroma, 1 case of glomus jugular tumor, 1 case of neurilemmoma, 19 have survived over 5 years and the longest one has survived over 8 years. For 50 patients with malignant tumor including 3 cases of well-differentiated squamous cell carcinoma, 17 cases of moderately differentiated squamous cell carcinoma, 11 cases of poorly differentiated squamous cell carcinoma, 1 case of undifferentiated carcinoma, 2 cases of chondrosarcoma, 5 cases of canceration of papilloma, 2 cases of adenocarcinoma, 1 case of esthesioneuroblastoma, 2 cases of malignant fibrohistiocytoma, 1 case of fibrosarcoma, 2 cases of malignant mixed tumour, 3 cases of sarcoma survival rates of 3 and 5 years were 59.2% (29/49), 38.5% (10/26) respectively. CONCLUSION: In order to resect the tumor completely and reduce the complication and malformation as far as possible, different surgical approaches must be designed according to the pathological changes characters and involved area,and the surgeon should select the shortest approach, avoid to damage the important neurovascular structure, and resect the tumor through the natural anatomy space by the shelter incision.

[Analysis of preoperative findings and ossicular condition in chronic suppurative otitis media].

OBJECTIVE: To discussion the relationship of preoperative findings and ossicular condition in chronic suppurative otitis media. METHOD: The correlation between the ossicular conditions and classification of tympanic membrane perforation, ear discharge, air conduction pure tone average, air-bone gap, pneumatization, complication, and cholesteatoma in 251 patients(288 ears) with chronic suppurative otitis media was analysed. RESULT: The air-conduction threshold and air-bone gap in patients with ossicular discontinuity are higher than that in patients with ossicular continuity. Ossicular discontinuity in patients with perforation of the pars flaccida of tympanic membrane, persistently draining ears, complications, and cholesteatoma occurred significiantly more frequently than those without these conditions. CONCLUSION: The air-conduction threshold and air-bone gap are the more reliable indications to identify the ossicular conditions in patients with chronic suppurative otitis media. There are significiant correlation between the ossicular conditions in patients with chronic otitis media and their classification of tympanic membrane perforation, ear discharge, complication, and cholesteatoma.

[Long-term results analysis of mastoidectomy for chronic otitis media].

OBJECTIVE: To study the operative indications of chronic otitis media and their long-term results. METHOD: One hundred and forty-five cases of mastoidectomy were followed for 5 years between 1995-1998. We discussed the results of recurrence and hearing level of radical mastoidectomy, canal wall up mastoidectomy (CWUM) and canal wall down mastoidectomy with mastoid obliteration (CWDM). Advantages and disadvantages were analyzed by the rate of visiting. RESULT: RM is almost invariable in hearing. There is no significant difference between CWDM [improved (10.84+/-4.63) dB HL] and CWUM [improved (10.39+/-3.93) dB HL]. The recurrence rate of RM was 11.63%, CWDM was 12.68%, but the CWUM was 22.58%. Rate of re-visiting of RM is obviously higher that of CWUM and CWDM. CONCLUSION: RM, CWUM and CWDM have all advantages, but the indication must be selected carefully. The effect of CWDM is better than that of RM and CWUM for the long-term results in these cases.

[The diagnosis and therapy for cholesterol granuloma of middle ear].

OBJECTIVE: To explore the diagnosis for cholesterol granuloma of middle ear, and discuss the effect of middle ear surgery for this disease. METHOD: The files of 18 patients (19 ears) with cholesterol granuloma of middle ear were reviewed in a retrospective study. All patients received middle ear and mastoid surgery, and all involved tissues were verified as cholesterol granuloma by pathologic examination. RESULT: The patients undergoing ventilation tube insertion were extubated 1-3 months after surgery and the eardrums healed well. The eardrums of the patients without ventilation tube insertion became normal 1-2 months after surgery. The hearing threshold after surgery of all patients improved. Beside one patients with eustachian tube obstructed had ventilation tube inserted with long term, no patient had symptoms recurred. CONCLUSION: The cholesterol granuloma of middle ear results from the bleeding, occlusion of ventilation and disturbance of drainage of the air cavity because of the middle ear inflammation. The diagnosis depends on the pathological examination. The middle ear and mastoid surgery, removing the diseased tissues completely, creating a ventilation system of mastoid-tympani-Eustachian are the key

[Clinical application of the combined presigmoid supra-infratentorial approach].

OBJECTIVE: To explore the surgical approach to the lesions of the cerebellopontine angle and the petroclival region. METHOD: Nine cases of the cerebellopontine angle or petroclival large tumors and one case of the posterior cerebral thrombotic aneurysm were treated by the combined presigmoid supra-infratentorial approach. The tumors including 3 cases of schwannomas and 6 cases of meningiomas spaned supra-infratentorium in our study. RESULT: Complete tumor removal were achieved in 6 cases, and subtotal tumor removal in 4 cases. After the operation, Cerebrospinal fluid leakage followed intracranial infection occurred in 1 case which losing follow-up. Headache and dizziness relieved in the other 9 cases. One case improved and 3 cases with no improvement after surgery among the 4 preoperative facial paralysis patients. Three cases with cerebellar symptoms were much relieved, but most deficits involving other cranial nerves preoperation did not recover. According to Samii's prognosis standard, 7 cases with good results and 1 case with common and 1 case with bad had been achieved. The hearing level had no influence in 5 cases, declined 20 dB HL in 2 cases, 30 dB HL in 1 case and 60 dB HL, in I case. CONCLUSION: The combined presigmoid supra-infratentorial approach is a direct route to the petroclival region and the cerebellopontine angle, provides a wide surgical field with less cerebellar or brain retraction, facilitates the removal of lesions and preserves the cranial nerves functions.

[The developmental expression of embryonic-neural cell adhesive molecule in human olfactory mucosa].

OBJECTIVE: To discuss the expressional features and physical function of E-NCAM (embryonic- neural cell adhesive molecule) in human fetal olfactory mucosa. METHOD: The immune expressions of E-NCAM in human olfactory mucosa at different gestational stages was detected with the technique of immunohistochemistry. RESULT: The positive expression of E-NCAM began at gestational week 14 (14W), and was localized in the cell bodied, dendrites, axis of olfactory neurons and olfactory nerve fiber bundles in lamina propria. The positive cells increased and the densities of staining of fiber bundles rose with the development of the fetus and reached the peak at 28W and decreased gradually then on. And at each stage the E-NCAM positive cells were localized at middle-lower parts of olfactory mucosa while the sustentacular cells and neurons at the top part were always E-NCAM negative. CONCLUSION: The expression features of E-NCAM are coincident with the plastict transformation of olfactory neurons. The high expression of E-NCAM at early half parts of gestation is helpful to the growth of neurons in differentiation and the down-regulation at late-half parts of gestation is helpful to the stabilization of structure of mature neurons.

[Expression of neuron-specific enolase and olfactory marker protein in the developing olfactory mucosa of human fetuses].

OBJECTIVE: To study the expression of neuron-specific enolase (NSE) and olfactory marker protein (OMP) in the developing olfactory mucosa of human fetuses. METHOD: The expression of NSE and OMP in the olfactory mucosa of 6 human fetuses (12, 16, 20, 24, 28 and 34 weeks) was studied using the technique of immunohistochemistry. RESULTS: NSE immunological positive reactions were seen in all 6 fetal mucosa from gestational 12 (G12) to G34, with plenty of positive-stained dual-pole neuron cells. At G12, the positive cells aligned tightly, the cell bodies were localized in the lower portion of olfactory epithelium and the positive-stained area occupied upper 2/3 of fetal nasal mucosa. With the development, the positive cells gradually became multilayer, but the density and the relative area of positive-cells reduced. At G34, the positive cells were located only in upper 1/3 of nasal mucosa. OMP-positive reactions were localized in a few dual-pole neurons at G12, the number was much less than NSE-positive cells in the same fetus. With the development, the OMP-positive cells gradually increased with most of the cell bodies located in the upper portion of epithelium, but number still relatively less than the NSE-positive cells at the same age. CONCLUSION: At G12, there were lots of olfactory neuron in the olfactory mucosa and only a few olfactory neurons had became mature. With the development, the olfactory epithelial area reduced but the number of mature olfactory neurons increased. At the last trimester, fetal olfactory sensor was almost matured.

[Cholesteatoma in petrous part of temporal bone].

OBJECTIVE: To explore the clinic characteristic of petrous bone cholesteatoma. METHOD: One case was treated by supra-labyrinth approach. 8 cases did by labyrinth-cochlea approach. RESULT: After 2 to 9 years follow-up in the 8 cases, no local cholesteatoma relapsion occurred. 2 cases were treated by facial nerve decompression and facial paralysis did not recover postoperatively. 1 case suffered from facial muscle movement 2 months after operation and recovered after 7 months later. 1 case still needs further follow-up with 2 months postoperatively. CONCLUSION: Proper surgical approach should be selected according to location and invasion of disease. Packing with adipose tissue and blocking the external auditory meatus are effective methods to prevent the cerebrospinal fluid leak.

[Combined frontal-preauricular-cervical approach for resection of huge transcranial lateral skull base tumors].

OBJECTIVE: To search into the appropriate approach for surgical treatment of the huge lateral skull base tumors. METHODS: The combined frontal-preauricular-cervical approach was used in two cases with huge transcranial lateral skull base tumors occupying the parapharngeal space, infratemporal fossa and middle cranial fossa. To acquire a wide surgical exposure, the flaps of orbital-zygomatic bone and the skull bone were removed, and then the mandibula was dislocated inferiorly. RESULTS: The tumors in the two cases were resected completely. The postoperative conditions of the patients were good. No cerebral spinal fluid leakage and other intracranial complications or facial morbidity were found. The occlusion was not interfered. CONCLUSION: The combined frontal-preauricular-cervical approach may provide a potential way for the surgical treatment of the large transcranial neoplasms occupying the parapharngeal space and infratemporal fossa and the middle cranial base.