Trends in acoustic neuroma management: a 20-year review of the oxford skull base clinic.

Objective To describe the change in the management of acoustic neuromas at one United Kingdom center over a 20-year period and to compare this with what is known regarding trends in practice on a national and international scale. Design, Setting, and Participants Data was collected prospectively on all patients attending the Oxford Skull Base Clinic between 1990 and 2009. Main Outcome Measures The proportion of patients managed initially by observation versus radiotherapy versus surgery was recorded for each year. Results Significantly more patients received radiation treatment (instead of surgery) between 2000 and 2009 when compared with 1990 to 1999. Compared with national audit data, the Oxford Skull Base Clinic treats a higher proportion of patients with radiotherapy and significantly lower proportion with surgery, though the trend nationally is toward more observation and radiotherapy and less surgery. Conclusion Surgery will remain crucial in the management of some patients with acoustic neuromas (usually those with the larger tumors where radiosurgery is recognized to be less appropriate), but using current trends to predict future practice would suggest that alternative nonmicrosurgical treatment may play an increasingly important role in the future.

Parotid cancer treatment with surgery followed by radiotherapy in Oxford over 15 years.

INTRODUCTION: Primary parotid malignancies represent a rare diagnosis, making high-quality comparative research unfeasible. There is little U.K.-based evidence to guide practice. A review was therefore undertaken of a large series of patients treated by a multidisciplinary team in a National Health Service tertiary referral centre. PATIENTS AND METHODS: Retrospective patient record review at the John Radcliffe Hospital in Oxford identified 401 patients who had undergone parotidectomy between 1995 and 2010, of whom 50 subjects were given a definitive diagnosis of primary parotid malignancy, treated with surgery and postoperative radiotherapy. Case notes, histology and imaging were reviewed by the study team. RESULTS: The median follow up for the cohort was 60 months (range: 1-108 months). Facial nerve function was preserved in all patients undergoing partial or total conservative parotidectomy. Although histology showed microscopically close or positive margins in 82% of cases, all patients underwent postoperative radiotherapy and locoregional recurrence was identified in only two (4%) patients. CONCLUSIONS: The data presented demonstrate a reasonable and practical multidisciplinary approach to a complex management problem. Facial nerve sparing surgery and postoperative radiotherapy result in good control of locoregional disease.

Central or atypical skull base osteomyelitis: diagnosis and treatment.

OBJECTIVE: We report cases of central or atypical skull base osteomyelitis and review issues related to the diagnosis and treatment. METHODS: The four cases presented, which were drawn from the Oxford, United Kingdom, skull base pathology database, had a diagnosis of central skull base osteomyelitis. RESULTS: Four cases are presented in which central skull base osteomyelitis was diagnosed. Contrary to malignant otitis externa, our cases were not preceded by immediate external infections and had normal external ear examinations. They presented with headache and a variety of cranial neuropathies. Imaging demonstrated bone destruction, and subsequent microbiological analysis diagnosed infection and prompted prolonged antibiotic treatment. CONCLUSION: We concluded that in the diabetic or immunocompromised patient, a scenario of headache, cranial neuropathy, and bony destruction on imaging should raise the possibility of skull base osteomyelitis, even in the absence of an obvious infective source. The primary goal should still be to exclude an underlying malignant cause.

Malignant tumors of the ear and temporal bone: a study of 27 patients and review of their management.

OBJECTIVE: To evaluate the management of patients with malignant tumors of the ear and temporal bone. DESIGN: Retrospective analysis of data. SETTING: Radcliffe Infirmary, Oxford, United Kingdom. PARTICIPANTS: Twenty-seven patients were classified into two groups according to the site of origin of the tumor: (1) superficial (17 tumors): tumors arising from the skin of the pinna, parotid, and temporomandibular joint area; (2) deep (10 tumors): tumors arising in the ear canal and temporal bone. MAIN OUTCOME MEASURES: Treatment modality, complications, recurrence rate, disease-free interval, and survival. RESULTS: The mean follow-up period was 25 months (0 to 60), and the median overall survival 46 months (0 to 102). Complications occurred in 6 patients (22%). The 3-year survival was 38% (95% confidence interval [CI], 19 to 58%), and the 5-year survival 19% (95% CI, 3 to 35%). CONCLUSIONS: There were insufficient data to demonstrate any difference in survival or disease-free interval related to the site of tumor origin (superficial versus deep tumors). There were independent differences in survival in favor of both performing parotidectomy and using postoperative radiotherapy, but neither reached significance at the 0.05 level.

Pneumomediastinum, an unusual complication of facial trauma.

Pneumomediastinum is often an incidental finding following a blunt or penetrating trauma to the neck or chest. We report a rare case of pneumomediastinum following an isolated facial trauma that was diagnosed on imaging. We also review the clinical signs of this condition, its radiologic characteristics, and the 18 previously reported cases of pneumomediastinum following facial trauma.

Vertebral artery aneurysm causing contralateral cerebellopontine angle mass effect.

OBJECTIVE: A vertebral artery aneurysm mimicking a contralateral cerebellopontine angle tumor is described. This is only the second reported case of this in the literature. STUDY DESIGN: Case report. SETTING: Radcliffe Infirmary, Oxford, United Kingdom. PATIENT: Seventy-year-old female patient who presented with a gradually deteriorating right-sided sensorineural hearing loss and a right facial palsy. INTERVENTIONS: Magnetic resonance imaging scan and computed tomography angiography with three-dimensional reconstruction followed-up by endovascular coiling of a vertebral artery aneurysm. MAIN OUTCOME MEASURE: Deterioration in neurologic status. RESULTS: Satisfactory recovery, and at 3 months, the patient is well with no deterioration in facial nerve function. CONCLUSION: Imaging by means of computed tomography angiography complements the standard magnetic resonance imaging scan in the rare event of an aneurysm at the cerebellopontine angle. Endovascular coiling occlusion is a recognized and effective way of managing intracranial aneurysms at the cerebellopontine angle.

Minimally invasive biopsy of parasellar lesions: safety and clinical applications of the endoscopic, transnasal approach.

The base of the skull can be affected by a variety of tumours requiring a wide range of treatment modalities. In formulating a management plan, histological diagnosis can play an essential role. Existing methods of skull base biopsy, especially in the anatomically critical parasellar region, include either prolonged open skull base approaches or image-guided needle biopsies. The latter methods can be time-consuming and cannot reliably avoid surrounding critical neurovascular structures. The experience with an endoscopic, transnasal biopsy of parasellar tumours in selected patients is presented. A preliminary series of 11 patients harbouring parasellar lesions with some degree of extension to the sphenoid or maxillary sinus underwent endoscopic, transnasal biopsy. The procedure was diagnostic in all cases. There was no operative mortality and minimal morbidity only recorded. The biopsy results affected the patients' management and, based on these results, major skull base surgery was avoided in four cases. Direct endoscopic visualization prompted avoidance of a vascular catastrophe of an atypical vascular lesion. The endoscopic, transnasal biopsy appears to offer a number of advantages over existing methods in selected patients. It is minimally invasive as it employs the use of natural osseous corridors. Tissue sampling under direct visualization minimizes the risks of negative biopsies or damage to critical neurovascular structures. The use of additional imaging employed by image-guided needle biopsies in not necessary. When planning treatment of parasellar tumours, the endoscopic, transnasal route should be considered.