Early complications and symptoms of cerebellopontine angle tumor surgery: a prospective analysis.

UNLABELLED: Our objective is to prospectively report very early complications and outcomes of cerebellopontine angle (CPA) surgery. Between January and August 2007, 72 patients were operated on by different transpetrosal approaches in a tertiary referral center. During preoperative assessment, facial nerve function (House-Brackmann grading system), the presence of vertigo or tinnitus and caloric test results were recorded and correlated with complications and symptoms occurring daily from day (D) 1 to D 8. The overall number of complications did not differ from those of former retrospective studies; nevertheless, the prospective feature of this study prompts several comments. Even slight (grade II) preoperative facial impairments increased the risk of severe postoperative facial dysfunction. Keratitis was frequent (42%) even in patients with normal facial function. Thrombo-embolic complications only occurred after long air-travel (≥5 h). Preoperative caloric test status was predictive of postoperative vestibular disturbance occurrence. With respect to the activity recovery; younger patients (<40 years old) displayed faster central compensations than the older (>60 years old) patients. This study highlights several features that may be used for preoperative patient counseling and complication management. In particular, the practitioner has to pay attention to even minor preoperative clinical signs of facial dysfunction to properly inform the patient of facial outcome. Routine ophthalmologic evaluation should be practiced, even when facial function is normal or subnormal. LEVEL OF EVIDENCE: 1b.

Temporal breach management in chronic otitis media.

In a retrospective study performed at the Otolaryngology, Head and Neck Surgery Department, Pitié-Salpêtrière Hospital, Paris from 1991 to March 2007, we determined surgical procedures for the treatment of tegmen breaches in chronic otitis media. Forty-two cases were examined: 76% corresponded to chronic otitis media with cholesteatoma, and 24% to chronic otitis media without cholesteatoma. Twenty-eight cases were operated using a combined approach, eight cases using a single suprapetrous approach, and six cases using a transmastoid approach. A total of 33% of the cases showed a meningocele or a meningoencephalocele treated through either a combined or a suprapetrous approach. No recurrence or neural/meningeal infectious involvement was found after a mean time of 43 months in the 36 long-term follow-up cases operated through the combined or suprapetrous approaches. Two cases included in the study were a loss to follow-up. Three of the former cases had already been operated for supracentimetric fissure using lower approach. Two out of the six patients operated using lower approach presented post surgery cerebrospinal fluid otorrhea. Combined or suprapetrous approaches seem to be best adapted to the treatment of supracentimetric or recurrent tegmen breaches, as well as to the precise examination and repair of meningeal lesions. Treatment for tegmen breach can be achieved in a single intervention, even when there is an ongoing infection of the middle ear. The mastoid approach should be used only for infracentimetric defects when there is no neural/meningeal lesion.

Related timing for peripheral and central plasticity in hypoglossal-facial nerve anastomosis.

The aim of this work was to determine the role of peripheral facial muscle reinnervation in the central reorganization of the blink reflex (BR) after hypoglossal-facial anastomosis (HFA). An electrophysiological study was performed on seven patients who underwent HFA after facial nerve transection during surgery for acoustic neuroma. HFA was performed within 15 days after surgery in five patients (group 1) and later for the two others (group 2). We studied the motor responses (MR) and the BR evoked on the affected side, before and over 3 years after the HFA. The MR appeared by the third month for the first group, and by the sixth and twelfth for the second group. After 36 months, the amplitude of MR was significantly higher than its control value, showing hyperinnervation of the facial muscles. Study of the BR evoked only an R1-type blink response that was observed 4 and 6 months after the MR for groups 1 and 2, respectively. This central reorganization appeared closely correlated with muscle reinnervation and its related timing. The occurrence of peripheral nerve-muscle contacts seems to be a necessary condition for reorganization of the trigemino-hypoglossal-facial reflex.

Cerebellopontine angle lipomas: report of four cases and review of the literature.

OBJECTIVE: To define the management of internal acoustic meatus and cerebellopontine angle (CPA) lipomas according to their clinical, histological, and surgical characteristics. METHODS: We report four new cases of CPA lipomas diagnosed in the Department of Otorhinolaryngology-Head and Neck Surgery of Hôpital Pitié-Salpêtrière and review 94 cases reported previously in the literature. RESULTS: Lipomas represented 0.14% of CPA and internal acoustic meatus tumors. Localization was on the left side in 59.9%, on the right side in 37%, and bilateral in 3.1% of the patients. The diagnosis was confirmed radiologically in 33 of 98 patients, surgically in 60 patients, and by autopsy in 5 patients. The most frequent associated symptoms were of cochleovestibular origin, such as hearing loss (62.2%), dizziness (43.3%), and unilateral tinnitus (42.2%). Other associated symptoms involved the facial nerve (9%) or the trigeminal nerve (14.4%). Complete resection was performed in only 32.8% of the patients with frequent cranial nerve involvement. Frequent cranial nerve involvement was seen in 95.4% of all patients. After surgery, patient symptomatology was unchanged in 9.2% of the patients, and 50% were improved; however, new postoperative deficits occurred in two-thirds of the patients. Overall, 72.2% of the patients experienced new postoperative deficits such as hearing loss (64.8%). Preservation of hearing was possible in only 26% of the patients. Only 18% of patients were improved after surgery without any new postoperative deficits. CONCLUSION: Preoperative diagnosis of internal acoustic meatus/CPA lipomas is based on magnetic resonance imaging. The aim of surgery in these cases is not tumor removal but cranial nerve decompression or vestibular transection, and surgery is performed only in patients with disabling and uncontrolled symptoms.