Intralabyrinthine schwannoma: Surgical management and cochlear lumen preservation.

The present video reports the surgical removal of an intralabyrinthine schwannoma. The video contains patient's medical history, preoperative radiological evaluations and detailed description of surgical steps of the procedure, consisting in labyrinthectomy, cochleostomy and insertion of a dummy electrode in the preserved cochlear lumen within the context of a subtotal petrosectomy.

Congenital Retrosigmoid Cholesteatoma: Case Series and Literature Review.

BACKGROUND: This study aimed to discuss 3 cases of congenital cholesteatoma located posterior to the sigmoid sinus, with no/minimal involvement of mastoid, and compare them with cases presented in the literature to better define this rare entity. METHODS: Retrospective chart analysis of 3 congenital cholesteatomas located posterior to the sigmoid sinus treated surgically in 2 skull-base centers and literature review. Though congenital cholesteatoma can arise outside the middle ear, only a few cases presenting in the retrosigmoid occipital bone have been described earlier. RESULTS: In all 3 patients, there was a delay in the presentation, as symptoms were nonspecific or lacking, leading in 1 case to severe complications. Computed tomography and magnetic resonance imaging, especially diffusion-weighted imaging scans, allowed accurate diagnosis and surgical planning. Surgery happened to be challenging due to the tight adherence of the cholesteatoma to the thinned dural surface. Complete excision was achieved in all the cases. CONCLUSION: Congenital cholesteatoma located posterior to the sigmoid sinus is a rare entity and is even more exceptional after a critical review of the literature. Complete excision is quintessential to prevent intradural extension or infection. The most important surgical issue is the management of the posterior fossa dura and the sigmoid sinus. We recommend meticulous dissection with slow peeling of the epithelial lining from the dura. Bipolar coagulation of the dura may help in avoiding recidivism. Moreover, cerebrospinal fluid (CSF) leak during dissection has to be avoided as long as possible, because the loss of tension of the already thinned dura makes its peeling particularly difficult.

Current trends on subtotal petrosectomy with cochlear implantation in recalcitrant chronic middle ear disorders.

Objective: To establish the safety and effectiveness of subtotal petrosectomy with cochlear implantation in patients affected by chronic middle ear disorders to refractory to previous surgical treatments. Methods: A multicentre, retrospective study was conducted on patients affected by recalcitrant chronic middle ear disorders who underwent cochlear implantation in combination with subtotal petrosectomy. Patients' details were collected from databases of 11 Italian tertiary referral centres. Additionally, a review of the most updated literature was carried out. Results: 55 patients were included with a mean follow-up time of 44 months. Cholesteatoma was the most common middle ear recurrent pathology and 50.9% of patients had an open cavity. 80% of patients underwent a single stage surgery. One case of explantation for device failure was reported among the 7 patients with post-operative complications. Conclusions: Subtotal petrosectomy with cochlear implantation is a benchmark for management of patients with recalcitrant chronic middle ear disorders. A single stage procedure is the most recommended strategy. Optimal follow-up is still debated. Further studies are required to investigate the role of this surgery in paediatric patients.

Revision cochlear implant surgery for clinical reasons.

Objective: To report the authors' experience in a series of patients treated with cochlear implant (CI) revision surgery due to medical problems. Methods: Revision CI surgeries performed in a tertiary referral centre for medical reasons not related to skin conditions were reviewed; patients were included if device removal was required. Results: 17 cochlear implant patients were reviewed. The main reasons requiring revision surgery with device removal were: retraction pocket/iatrogenic cholesteatoma (6/17), chronic otitis (3/17), extrusion in previous canal wall down procedures (2/17) or in previous subtotal petrosectomy (2/17), misplacement/partial array insertion (2/17) and residual petrous bone cholesteatoma (2/17). In all cases surgery was performed through a subtotal petrosectomy. Cochlear fibrosis/ossification of the basal turn was found in 5 cases and uncovered mastoid portion of the facial nerve in 3 patients. The only complication was an abdominal seroma. A positive difference was observed between the number of active electrodes and comfort levels before and after revision surgery. Conclusions: In CI revision surgeries performed for medical reasons, subtotal petrosectomy offers invaluable advantages and should be considered as first choice during surgical planning.

Management of complicated temporal bone fracture.

The current video presents the surgical management of a complicated temporal bone fracture. The video contains patient's medical history, preoperative radiological evaluations, and detailed surgical approach to manage the disease. The current video presents the surgical management of a complicated temporal bone fracture. The video contains patient's medical history, preoperative radiological evaluations, and detailed surgical approach to manage the disease.

Management of cochlear fistula and the role of hearing: a five-case report.

OBJECTIVE: Cochlear fistula (CF) is a rare finding, usually associated with extensive middle ear cholesteatoma. There is agreement on the fact that removing the cholesteatoma matrix on a CF exposes the ear to a high risk of sensorineural hearing loss or dead ear. The aim of the study is to describe the presentation, possible treatment strategies and related outcomes for patients with CF in chronic otitis media (COM). METHODS: The study considers a retrospective case series of patients with CF diagnosis supported by CT-scan and intraoperative/otoscopic evidence. RESULTS: Five cases of CF were identified, 4 associated with cholesteatoma and 1 associated with non-cholesteatomatous COM. Two patients presenting with anacusis underwent a subtotal petrosectomy. Two patients with useful hearing underwent a radical mastoidectomy in order to preserve the cholesteatoma matrix on the promontorium. One patient with good hearing and COM was treated conservatively. CONCLUSIONS: Conservative management should be considered for rare cases of CF in COM with residual hearing. Matrix preservation through radical/modified radical mastoidectomy is strongly advised in the presence of useful preoperative bone conduction. Subtotal petrosectomy should be considered the preferred option in presence of cholesteatoma with preoperative profound hearing loss.

Capillary Venous Malformation With Secondary Aneurysmal Bone Cyst of Temporal Bone.

Aneurysmal bone cysts (ABCs) arising from vascular malformation are extremely rare, and none have been reported in the literature in English till now. We report a very rare case of secondary ABC of left temporal bone in a 5-year-old Caucasian boy who presented with a left sudden facial palsy associated with a painless non-tender mass of the left temporo-parietal region. The computed tomography (CT) and magnetic resonance imaging (MRI) features were suggestive of ABC secondary to a capillary venous malformation, with concurrent involvement of the squamous, mastoid, and petrous portions of the temporal bone. Surgical resection was performed. On follow-up, the patient was found to be doing well.

Giant Epidermoid Cyst of Posterior Fossa-Our Experience and Literature Review.

INTRODUCTION: Intracranial epidermoid cysts are the most frequent congenital intracranial lesion. They rare and benign tumors that can present in different clinical situations depending on location and extension of the disease. Diagnosis is obtained with radiological imaging with RM and non-enhanced TC as elective investigating methods. Elective treatment is surgery, based on total/subtotal excision sparring healthy neurovascular structures, considering the benign nature of this lesion. CASE REPORT: In this study we present the case of a 79-year-old woman affected by recidivist epidermal cyst of the posterior fossa. Clinical presentation was characterized by positional subjective vertigo, intense headache localized in the right part of the head increased by Valsalva maneuver and retroarticular subcutaneous swelling. Radiological investigation found a giant epidemoid cyst of the posterior fossa (8,4 x 4,8 x 5,8 cm), treated with surgery. In the postoperative, the patient was fine and no neurological deficit has been encounterd. REVIEW: In this study, we present a review of the literature regarding giant epidermoid cysts of posterior fossa. Only 11 cases were reported before ours, which actually is one of the largest ever described.

Bedside Surgical Tracheostomy in the Intensive Care Unit during Covid-19 Pandemic.

OBJECTIVES: To describe Otolaryngologists' perspective in managing COVID-19 patients with acute respiratory distress syndrome (ARDS) requiring tracheostomy in the ICUs during the pandemic peak in a dramatic scenario with limited resources. SETTING: Tertiary referral university hospital, regional hub in northern Italy during SARS CoV 2 pandemic peak (March 9th to April 10th, 2020). METHODS: Technical description of open bedside tracheostomies performed in ICUs on COVID-19 patients during pandemic peak with particular focus on resource allocation and healthcare professionals coordination. A dedicated "airway team" was created in order to avoid transportation of critically ill patients and reduce facility contamination. RESULTS: During the COVID-19 pandemic, bedside minimally invasive tracheostomy in the ICU was selected by the Authors over conventional surgical technique or percutaneous procedures for both technical and operational reasons. Otolaryngologists' experience derived from direct involvement in 24 tracheostomies is reported. CONCLUSIONS: Tracheostomies on COVID-19 patients should be performed in a safe and standardized setting. The limited resources available in the pandemic peak required meticulous organization and optimal allocation of the resources to grant safety of both patients and healthcare workers.

Mastoid Dermoid Cyst.

A case of mastoid dermoid cyst (DC) was presented, and differences with cases of other temporal bone DCs were analyzed. The mastoid DC was also compared with mastoid congenital cholesteatoma. We reported a case of a patient with mastoid DC, evaluating her clinical, radiological, and surgical findings. A review of the literature was performed to compare our findings with those reported. The preoperative radiological evaluation prompted us to plan a surgical approach to the lesion, suspecting the presence of a mastoid congenital cholesteatoma. The surgical findings were in line with the presence of a mastoid DC. Only two cases reported in the literature presented features that fulfilled the criteria of a true mastoid DC. A DC confined to the mastoid region is an extremely rare clinical entity, with asymptomatic and slow growth. Preoperative radiological differentiation between congenital cholesteatoma and DCs with atypical features can be difficult. However, surgical excision is the treatment of choice in both cases. Diagnosis is confirmed by the histological evaluation.

An uncommon cause of conductive hearing loss.

The current video presents the surgical management of a middle ear osteoma through a retroauricolar endocanalar approach, under local anesthesia. The video contains patient's medical history, pre-operative radiological evaluation, surgical approach to the lesion and clinical follow up.

Safety of bedside surgical tracheostomy during COVID-19 pandemic: A retrospective observational study.

Data regarding safety of bedside surgical tracheostomy in novel coronavirus 2019 (COVID-19) mechanically ventilated patients admitted to the intensive care unit (ICU) are lacking. We performed this study to assess the safety of bedside surgical tracheostomy in COVID-19 patients admitted to ICU. This retrospective, single-center, cohort observational study (conducted between February, 23 and April, 30, 2020) was performed in our 45-bed dedicated COVID-19 ICU. Inclusion criteria were: a) age over 18 years; b) confirmed diagnosis of COVID-19 infection (with nasopharyngeal/oropharyngeal swab); c) invasive mechanical ventilation and d) clinical indication for tracheostomy. The objectives of this study were to describe: 1) perioperative complications, 2) perioperative alterations in respiratory gas exchange and 3) occurrence of COVID-19 infection among health-care providers involved into the procedure. A total of 125 COVID-19 patients were admitted to the ICU during the study period. Of those, 66 (53%) underwent tracheostomy. Tracheostomy was performed after a mean of 6.1 (± 2.1) days since ICU admission. Most of tracheostomies (47/66, 71%) were performed by intensivists and the mean time of the procedure was 22 (± 4.4) minutes. No intraprocedural complications was reported. Stoma infection and bleeding were reported in 2 patients and 7 patients, respectively, in the post-procedure period, without significant clinical consequences. The mean PaO2 / FiO2 was significantly lower at the end of tracheostomy (117.6 ± 35.4) then at the beginning (133.4 ± 39.2) or 24 hours before (135.8 ± 51.3) the procedure. However, PaO2/FiO2 progressively increased at 24 hours after tracheostomy (142 ± 50.7). None of the members involved in the tracheotomy procedures developed COVID-19 infection. Bedside surgical tracheostomy appears to be feasible and safe, both for patients and for health care workers, during COVID-19 pandemic in an experienced center.

Bonebridge implantation for mixed hearing loss in a patient with Kabuki syndrome.

The high prevalence of middle ear disease with related hearing loss in Kabuki syndrome requires the diagnostic and treatment expertise of otologists. This case report describes outcomes and changes in the quality of life of a patient affected by Kabuki syndrome with a history of recalcitrant chronic otitis media and mixed hearing loss who had undergone several unsuccessful surgical procedures before solving his problems by means of subtotal petrosectomy and active middle ear implant.

Drainage of a petrous apex cholesterol granuloma through an infracochlear approach.

The current video presents the surgical management of a cholesterol granuloma of the anterior petrous apex, through the infracochlear approach. The video contains patient's medical history, pre-operative radiological evaluation, surgical approach to the lesion and radiological follow up. Surgery was conducted by an otology and skull base team in a tertiary referral center. The patient is a 49-years-old male, who was referred to our center for a four months history of right tinnitus and fullness. The clinical evaluation was unremarkable and the audiometric testing showed a right sensorineural hearing loss with normal contralateral hearing. A high-resolution CT-scan of the temporal bone was performed showing a lesion occupying the right petrous apex and eroding the cochlea. In a subsequent MRI scan, the lesion appeared hyperintense in both T1- and T2-weighted images. Those radiological features prompted us to the diagnosis of a cholesterol granuloma, and the selected treatment was a drainage via infracochlear approach. The infracochlear approach, firstly described by Giddings et al. [1] in 1991, represents a direct route to the petrous apex, that can be chosen in selected cases with favorable anatomical conditions and that allows respecting of the hearing mechanism. After surgical drainage of the granuloma, no worsening of the pure tone threshold was confirmed by the audiological evaluation. The hospital stay was uneventful and the patient was discharge one day postoperatively. One-year postoperative MRI scan showed signal reduction of the cholesterol granuloma.

Subtotal petrosectomy and cochlear implantation.

OBJECTIVE: The objective of this study is to analyse surgical outcomes in a series of patients who underwent subtotal petrosectomy in combination with cochlear implantation. METHODS: Retrospective chart review. Thirty patients (32 ears) underwent subtotal petrosectomy and cochlear implantation in one stage. Indications for subtotal petrosectomy included the following: cholesteatoma, chronic otitis media, previous canal wall-down, osteoradionecrosis, revision surgery for clinical reasons, inner ear malformations, middle ear anatomical variations and severe cochlear ossification. RESULTS: Follow-up ranged from 2 to 54 months. Only 2 complications related to the subtotal petrosectomy (1 subcutaneous abdominal haematoma and 1 subcutaneous abdominal seroma) occurred in this series. Complete electrode insertion was achieved in all but 4 cases. CONCLUSIONS: Subtotal petrosectomy is a safe procedure and can offer technical advantages in some cases of complex cochlear implantation.

Jugular Foramen Metastasis from Lung Cancer: A Case of "A Mass without His Syndrome".

Jugular foramen (JF) metastasis is rare and often presents as JF syndrome. A 73-year-old male complained of left-sided mastoid pain that irradiated to the neck since the past 3 months. Onset of facial nerve (FN) palsy and persistence of the symptomatology despite corticosteroid therapy demanded radiologic evaluation. Computed tomography and magnetic resonance imaging showed a wide osteolytic lesion of the left JF with involvement of the third segment of the FN. The patient underwent transmastoid incisional biopsy. Histopathological examination showed an adenocarcinoma that was suggested to be of respiratory origin. A primary pulmonary lesion and metastasis to other sits were detected. The patient died 1 month after the initiation of the chemotherapy. Persistent mastoid pain and progressive FN palsy must be considered indicative of JF malignant lesions. Despite early diagnosis, secondary lesions of the JF are characterized by a poor prognosis; however, accurate diagnosis may avoid unnecessary aggressive surgery.

Cochlear implantation after solid organ transplantation: long term results and review of the literature.

OBJECTIVE: To analyze rate and type of complications in cochlear implant (CI) recipients receiving immunosuppressive therapy following solid organ transplant (SOT). STUDY DESIGN: Retrospective case series. English language literature review. SETTING: Tertiary referral center. INTERVENTION: Cochlear implantation surgery following solid organ transplantation (SOT) and immunosuppressive therapy. METHODS: Data of patients who received CI after SOT and with at least one year of follow up were reviewed. Main outcome measures were the rate and type of complications, classified as major (requiring a second surgical procedure) and minor (requiring medical therapy). A search was performed in PubMed database on January 2019 using the keywords: organ transplant; cochlear implant, complications, deafness, solid organ transplant, immunosuppressive therapy. Only studies reporting on patients who have been implanted after the transplant procedure and with a follow up period of at least 1 year were considered. Final analysis was performed on pooled data. RESULTS: Four patients received CI surgery following SOT. Age at treatment ranged from 40 to 47 years (mean 44.25 years). Follow-up after implantation averaged 5.25 years (range 1-10 years), without complications. Review of the available literature on the subject yielded seven papers; a total of 26 procedures in 22 patients satisfied inclusion criteria. Pooled data from the present series and from the literature were analyzed; the global rate of complications was 16.6%, with 10% major (3 of 30 procedures) and 6.6% minor (2 of 30 procedures). The three reported cases of major complications appear unrelated to SOT. Major complications were found in one case over 16 procedures in pediatric patients (6.2%), while in adults the percentage raised to 14.3% (2/14 procedures). CONCLUSIONS: Cochlear implantation is a safe and effective intervention, even during immunosuppressive therapy after organ transplantation.

Seborrheic Keratosis or Squamous Carcinoma? Clinical Examination versus Biopsy: The Importance of Criticism.

We compare the results of clinical observation and histopathology analysis for developing a differential diagnosis of seborrheic keratosis (SK) of the external auditory canal (EAC). A 46-year-old man with a history of a recurrent lesion in the EAC underwent clinical observation of the skin lesion's appearance, computed tomography (CT) scan, magnetic resonance imaging (MRI), and several biopsies. Initially, a benign form of SK was diagnosed based on several biopsies performed over a 10-year period. The lesion's appearance was consistent with a malignant disease, which led the clinician to perform a CT scan and an MRI scan. The patient underwent partial petrosectomy to completely remove the lesion as CT and MRI scans showed an infiltrative process. Squamous carcinoma was the final histological diagnosis. The patient was disease free at 1 year of follow-up after petrosectomy. In conclusion, if there are inconsistencies between clinical observation and histological report, additional tests should be performed to exclude the malignity of a lesion.