Microendoscopic Surgery of Middle Ear and Petrous Bone: Benefits Analysis.

OBJECTIVES: Endoscopy has become routinely used in middle ear surgery. The aim of this study is to analyze where this tool may complement the traditional microscopic approach. This is a retrospective study done in single tertiary hospital. METHODS: We reviewed 342 middle ear/petrous bone surgical procedures performed between 2005 and 2015. Only cases in which both microscopic and endoscope-assisted techniques were used have been included. Sixty-six patients received this double-technique surgery: 51 (77.2%) had middle ear/mastoid and petrous bone cholesteatomas (46 middle ear and mastoid and 5 acquired/congenital petrous bone cholesteatomas), 5 (7.5%) had glomus tympanicum tumors (GTT), 4 (6%) had an ossicular chain dislocation, 3 (4.5%) had purulent chronic otitis media, 2 (3%) had tympanosclerosis, and 1 (1.5%) had an ossicular chain malformation. RESULTS: The endoscope was helpful to remove disease remnants not accessible by microscope in 41 (62%) of the cases; 37 (90%) were cholesteatomas, 3 (7%) were GTT, and only 1 (3%) was an open tympanosclerosis. In the remaining 25 (37.8%) cases, the endoscope was useful only to visualize the cavity since the microscope had already been successful in removing the entire lesion. CONCLUSIONS: The endoscopy can add valuable information and support to the usual microscope approach alone. The consensus of a single best technique does not yet exist, but the physician should choose the best modality or combination of modalities in order to cure the patient and prevent any possible complications or recurrence of the pathology.

The multiplanar analysis of the retromandibular vein in surgical planning for parotid gland tumors.

OBJECTIVE: To analyze the effectiveness of the multiplanar analysis of the retromandibular vein in establishing the position of the parotid gland tumor and its relationship with the facial nerve, together with the most common radiological criteria (facial nerve line, Utrecht line, retromandibular vein and parapharyngeal space variations) using the magnetic resonance imaging. STUDY DESIGN: Retrospective study SETTING: Tertiary Academic Hospital SUBJECTS AND METHODS: 128 preoperative magnetic resonances were analyzed to study preoperative tumor location (medial or lateral to the expected course of the facial nerve) based on comparison between the radiological criteria and the surgical findings. RESULTS: FN line had the lowest accuracy at 77%, whereas the retromandibular vein achieved 85% accuracy and the UT line achieved accuracy of 93%. The retromandibular vein could not be identified in 11 cases (9%). The multiplanar evaluation of the retromandibular vein allowed us to identify it on almost all MR images (99% of cases) and reach 87% of accuracy. The parapharyngeal space evaluation achieved 92% of accuracy. In the subgroup of 66 cases where the neoplasms were strictly related to the main trunk, where the surgery entailed manipulation if situated laterally to the tumor, the multiplanar evaluation of the retromandibular vein reached 98% of accuracy and UT line achieved 94%. CONCLUSIONS: The multiplanar modality, combined with the evaluation of the parapharyngeal space, is effective in helping the surgeon to achieve accurate planning: it enables the tumor to be located and the facial nerve course predicted with a good precision.

Surgical management of parapharyngeal space tumors: The role of cervical and lateral skull base approaches.

We conducted a retrospective study to analyze the role of the cervical and lateral skull base approaches in the surgical excision of parapharyngeal space (PPS) tumors. Our study population was made up of 34 patients-15 males and 19 females, aged 13 to 73 years (mean: 50.6)-who had presented to us with a PPS tumor during a 9-year period. The 34 cases included 23 benign tumors and 11 malignancies. The 23 benign tumors consisted of 11 pleomorphic adenomas, 5 schwannomas, 2 paragangliomas, 2 Warthin tumors, 1 oncocytoma, 1 hamartoma, and 1 osteochondroma. The 11 malignancies included 3 cases of recurrent nasopharyngeal carcinoma, 2 cases of mucoepidermoid carcinomas, and 1 case each of carcinoma ex pleomorphic adenoma, liposarcoma, lymph node metastasis from nasopharyngeal carcinoma, lymph node metastasis from follicular thyroid carcinoma, rhabdomyosarcoma, and cranial nerve (CN) X neurofibrosarcoma. Among the benign tumors, 14 were removed via the transparotid approach, 3 via the transcervical approach, 3 via the transcervical-transparotid approach, 2 via the petro-occipital-trans-sigmoid approach, and 1 via the Fisch type A infratemporal fossa approach. During postoperative follow-up, 5 of the 23 patients with a benign tumor exhibited facial nerve paresis, 2 developed CN IX to XII palsy, and 1 each developed Frey syndrome and CN X palsy. In the malignant tumor group, 4 of the 11 patients were treated via the transcervical-transparotid approach, 3 via the Fisch type C infratemporal fossa approach, 3 via the transcervical-transmandibular approach, and 1 via the transcervical-lateral petrosectomy approach. The neural deficits observed during the postoperative period were more extensive among the patients with a malignant tumor. We conclude that the transparotid and transcervical approaches were adequate for excising most benign tumors. For malignant tumors, large tumors, and tumors with skull base involvement and transcranial extension, the transparotid-transcervical, transcervical-transmandibular, infratemporal fossa, and petro-occipital-trans-sigmoid approaches were necessary.

Treatment of endolymphatic sac tumour (Papillary adenocarcinoma) of the temporal bone.

AIM: To define a better treatment of sporadic endolymphatic sac tumours (ELST) analysing our experience and literature available data. BACKGROUND: ELST can arise as sporadic case (rare) or as a part of von Hippel-Lindau (VHL) disease. It is a low grade malignancy with local spread by continuity. MATERIALS AND METHODS: we described our experience with 7 cases with up to date follow up. RESULTS: Five cases were free of disease after first surgical procedure. One case had recurrence in the temporal lobe after 12 years. One case had two surgical procedures followed by irradiation and died five years after radiotherapy with a slow disease progression. CONCLUSION: With increasing expertise in the skull base surgery, complete tumour excisions are achieved in majority of the more recent cases and appear to be the treatment of choice. External irradiation is also used as palliative measures with doubtful effectiveness. Some recent reports showed encouraging results with gamma knife radiosurgery.

Orbital exenteration: our experience.

INTRODUCTION: We reviewed our experience of the multidisciplinary collaboration between ophthalmologists, head and neck surgeons, neurosurgeons, radiologists and oncologists in the management of extensive tumors treated by orbital exenteration at the Humanitas Research Institute, Milan, Italy, over the past 10 years. METHODS: This is a retrospective cohort study of all patients who underwent orbital exenteration between March 2005 and August 2014 at the Humanitas Research Institute. The 10-year cohort of exenterated patients was identified through operating room notes using the clinical code set of the International Classification of Diseases, 10th revision (ICD-10). RESULTS: A total of 26 patients were identified, including 19 (73.1%) males. The median age was 65.5 years (range 37-87). Eighteen (69.2%) patients had major skin cancers extending to the orbit. Patients were divided into 2 cohorts: cohort 1 comprising patients with sinus or craniofacial cancers requiring orbital exenteration, and cohort 2 comprising patients with advanced periorbital skin cancers. The two cohorts were well matched for sex, age at surgery, degree of invasion, extension of surgical removal, necessity of adjuvant radiotherapy, reconstruction processes, and rehabilitation. CONCLUSIONS: In our experience patients never died of the primary lesion but because of the occurrence of other problems. So we encourage local surgical radicality.