Contralateral sensorineural hearing loss after vestibular schwannoma surgery / Hipoacusia neurosensorial contralateral tras cirugía de schwannoma vestibular

Introduction: Contralateral sensorineural hearing loss (CSNHL) after vestibular schwannoma (VS) is a severe complication, especially in those cases in which hearing preservation in the operated side was not possible. There are several theories that attempt to explain this issue, but there is no established guideline of treatment. Material and methods: We report 4 patients treated in our institution who developed a severe CSNHL after surgery. Results: Of the 185 cases of VS treated with surgery, 4 patients (2.2%) developed a CSNHL after VS surgery. After medical treatment, partial recovery of hearing occurred in one patient the other 3 patients presented a well-established severe SNHL. Conclusions: Established treatment guidelines do not exist, but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful

Introducción: La hipoacusia neurosensorial contralateral (HNSC) tras cirugía de schwannoma vestibular (SV) es una complicación grave, especialmente en aquellos casos en los que la preservación de la audición del lado intervenido no fue posible. Existen varias teorías que intentan explicar este problema, pero no existe una guía de tratamiento en estos casos. Material y métodos: Presentamos los casos de 4 pacientes tratados en nuestro hospital que desarrollaron una HNSC severa tras cirugía de SV. Resultados: De los 185 casos de SV tratados con cirugía, 4 pacientes (2,2%) desarrollaron una HNSC después de la cirugía. Tras el tratamiento médico se produjo recuperación parcial de la audición en un paciente, los otros 3 pacientes presentaron una HNS severa. Conclusiones: No existen guías de tratamiento, pero se recomienda el uso de altas dosis de corticosteroides y el implante coclear en casos sin recuperación y pérdida completa de la audición

Contralateral sensorineural hearing loss after vestibular schwannoma surgery.

INTRODUCTION: Contralateral sensorineural hearing loss (CSNHL) after vestibular schwannoma (VS) is a severe complication, especially in those cases in which hearing preservation in the operated side was not possible. There are several theories that attempt to explain this issue, but there is no established guideline of treatment. MATERIAL AND METHODS: We report 4 patients treated in our institution who developed a severe CSNHL after surgery. RESULTS: Of the 185 cases of VS treated with surgery, 4 patients (2.2%) developed a CSNHL after VS surgery. After medical treatment, partial recovery of hearing occurred in one patient the other 3 patients presented a well-established severe SNHL. CONCLUSIONS: Established treatment guidelines do not exist, but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful.

Management of petrous bone cholesteatoma: open versus obliterative techniques.

The objective of this study was to expose our results in the treatment of petrous bone cholesteatomas (PBC), paying attention to diagnosis, surgical strategy, facial management, results, and recurrences. The main objective is to compare the results of obliterative and open techniques in their management concerning the recurrence rate, due to the controversy elicited on obliterative or closed techniques in large cholesteatomas. A retrospective study was performed from July 1977 to September 2007 at the Tertiary referral cranial base center. Thirty-five patients were treated for PBC through different surgical approaches, and in 25 cases (72%) the surgical cavity was obliterated with a muscle flap. Four patients (11%) had a long-term recurrence. These patients received an open technique and after surgical re-exploration using a closed technique they had no recurrence. There were no recurrences in patients who underwent an obliterative technique and they received periodic MRI controls. The facial function after surgery was acceptable (71% of patients had House-Brackmann grades I to III). PBC is a complex pathology and presents difficulties in its diagnosis and treatment. Surgical technique should be suitable for removing the pathology and preventing damage to structures such as the facial nerve or great vessels. Obliterative techniques, where possible, are at least as safe as open cavity procedures and they have fewer postoperative complications; however, regular follow-up with CT and MRI is mandatory.

[Procalcitonin plasma levels do not alter after uncomplicated skull base surgery]. / Las concentraciones de procalcitonina no se alteran en la cirugía de base de cráneo no complicada.

INTRODUCTION: Procalcitonin (PCT) is the precursor of the calcitonin hormone. Plasma concentrations of procalcitonin increase in systemic inflammation, especially when they are caused by bacterial infections. The aim of this study is to analyze and validate the baseline PCT concentrations after different types of skull base surgery and to test the hypothesis that PCT could be useful as an early marker of post-operative infectious complications, especially meningitis. MATERIAL AND METHOD: This is a prospective study of sixteen patients who underwent skull base surgery. PCT and C-reactive protein plasma levels, leukocytes and clinical symptoms were registered pre-operatively and 1, 2, and 5 days post-operatively. RESULTS: All patients had a normal post-operative course without clinical signs of infection. PCT concentrations did not increase above the normal range in any case. CONCLUSIONS: As PCT plasma concentration does not notably increase despite the inflammatory phenomena associated with uncomplicated skull base surgery, it may be possible to use PCT as an early marker for non-invasive study of post-operative infectious complications.

Las concentraciones de procalcitonina no se alteran en la cirugía de base de cráneo no complicada / Procalcitonin plasma levels do not alter after uncomplicated skull base surgery

Introducción: La procalcitonina (PCT) es el precursor de la hormona calcitonina. Las concentraciones de PCT en plasma aumentan en relación con las manifestaciones sistémicas de la reacción inflamatoria, especialmente cuando están causadas por una infección bacteriana. El objetivo de este estudio es conocer y validar las concentraciones basales de PCT alcanzadas tras diferentes tipos de cirugía de base de cráneo por si pudiese utilizarse como marcador precoz de complicaciones infecciosas, fundamentalmente meningitis. Material y método: Se realiza un estudio prospectivo sobre 16 pacientes intervenidos de base de cráneo. Se estudiaron las concentraciones de PCT, proteína C reactiva, leucocitos en sangre y síntomas clínicos en el preoperatorio y el primero, el segundo y el quinto día postoperatorios. Resultados: Todos los pacientes tuvieron un postoperatorio sin signos infecciosos generales ni fiebre. Las concentraciones de PCT no aumentaron en ningún caso por encima de los valores normales. Conclusiones: Dado que los fenómenos inflamatorios propios de las intervenciones no complicadas de base de cráneo no elevan de forma reseñable las concentraciones de PCT, se podría utilizarla para estudiar por técnicas no invasivas los casos que sí presenten complicaciones infecciosas intercurrentes

Introduction: Procalcitonin (PCT) is the precursor of the calcitonin hormone. Plasma concentrations of procalcitonin increase in systemic inflammation, especially when they are caused by bacterial infections. The aim of this study is to analyze and validate the baseline PCT concentrations after different types of skull base surgery and to test the hypothesis that PCT could be useful as an early marker of post-operative infectious complications, especially meningitis. Material and method: This is a prospective study of sixteen patients who underwent skull base surgery. PCT and C-reactive protein plasma levels, leukocytes and clinical symptoms were registered pre-operatively and 1, 2, and 5 days post-operatively. Results: All patients had a normal post-operative course without clinical signs of infection. PCT concentrations did not increase above the normal range in any case. Conclusions: As PCT plasma concentration does not notably increase despite the inflammatory phenomena associated with uncomplicated skull base surgery, it may be possible to use PCT as an early marker for non-invasive study of post-operative infectious complications

[Unusual clinical presentations of vestibular schwannomas]. / Formas clínicas inusuales de presentación de los neurinomas del acústico.

The aim of this study is evaluate the unusual ways of initial presentation of the vestibular schwannomas. We performed a retrospective study of the patients who underwent resection of acoustic neuromas on our service, including for analysis only the cases which initial symptom was not the hearing loss. Tumor size, localization, clinical presentation, and age of the patients were considered. Nine patients present with atypical symptoms. The most common complain in this group were facial paresthesias (22,2 %). None of them complained about other otological symptoms. A significant group of patients did not present with the otological symptoms classically associated with vestibular schwannoma. Clinical knowledge of these kinds of symptoms may lead to earlier detection of these lesions.

Formas clínicas inusuales de presentación de los neurinomas del acústico / Unusual clinical presentations of vestibular schwannomas

El objetivo de este estudio es mostrar las formas inusuales de presentación con que pueden manifestarse inicialmente los neurinomas del acústico. Se realiza un estudio retrospectivo de los pacientes intervenidos de neurinomas del acústico en nuestro servicio; se incluye en el análisis sólo los casos cuyo síntoma inicial no se encuadraba en la hipoacusia unilateral. Se recogen datos de tamaño tumoral, localización, forma de presentación y edad del paciente. Encontramos 9 pacientes con síntomas atípicos y sin hipoacusia, entre los que la queja más común (22,2 %) fueron las parestesias faciales. Ninguno de ellos refirió otra clínica otológica acompañante. Un grupo significativo de los pacientes de nuestro estudio no se presentó con los síntomas clásicos de los neurinomas del acústico. Que los clínicos conozcan este tipo de síntomas puede llevar al diagnóstico precoz de esta afección

The aim of this study is evaluate the unusual ways of initial presentation of the vestibular schwannomas. We performed a retrospective study of the patients who underwent resection of acoustic neuromas on our service, including for analysis only the cases which initial symptom was not the hearing loss. Tumor size, localization, clinical presentation, and age of the patients were considered. Nine patients present with atypical symptoms. The most common complain in this group were facial paresthesias (22,2 %). None of them complained about other otological symptoms. A significant group of patients did not present with the otological symptoms classically associated with vestibular schwannoma. Clinical knowledge of these kinds of symptoms may lead to earlier detection of these lesions

[Complications and sequelae in acoustic neuroma surgery]. / Complicaciones y secuelas en la cirugía de los neurinomas del acústico.

OBJECTIVE: To evaluate the complications and sequelae of acoustic neuroma surgery, according to tumour size. PATIENTS AND METHOD: A retrospective analysis of 120 patients who underwent microsurgical resection of vestibular schwannomas between November 1994 and September 2006 was undertaken. Tumour size, extent of removal, preservation of facial and cochlear nerves, complications, and sequelae were considered. The degree of hearing preservation after surgery was determined by the Gardner-Robertson classification. RESULTS: There were 39 small (<1.5 cm), 59 medium (1.5-3 cm), and 22 large tumours (>3 cm). Gross total resection was accomplished in 106 cases (88.3 %). The facial nerve was anatomically and functionally preserved in 103 cases on long-term follow-up (85.4 %). The cochlear nerve was functionally preserved (Gardner-Robertson class 1 and 2) in 54.4 % of the small tumours with useful preoperative hearing. Two patients died due to postoperative complications (mortality rate, 1.6 %), and 15 (12.5 %) developed a CSF leak. CONCLUSIONS: Despite the progress in the surgical treatment of acoustic neuromas, a considerable rate of complications and sequelae still remains. Therefore, there is a need to balance pros and cons of surgery in each patient according to the concurrent circumstances, as well as to consider other therapeutic strategies such as radiosurgery or a wait-and-see policy.

Complicaciones y secuelas en la cirugía de los neurinomas del acústico / Complications and sequelae in acoustic neuroma surgery

Objetivo: Evaluar las complicaciones y secuelas de la cirugía del schwannoma vestibular, en virtud del tamaño tumoral. Pacientes y método: Se realiza un estudio retrospectivo de 120 pacientes afectos de neurinomas del acústico, a los que se practicó resección microquirúrgica de la lesión entre noviembre de 1994 y septiembre de 2006. Se recogen datos del tamaño tumoral, la extensión de la resección, la preservación de los nervios facial y coclear, las complicaciones y las secuelas vestibulares. Se determina el grado de preservación de la audición según la clasificación de Gardner-Robertson. Resultados: Entre las citadas fechas se intervinieron en 39 neurinomas pequeños ( 3 cm). La resección total de la lesión se consiguió en 106 (88,3 %) de los 120 casos. Se alcanzó una conservación anatómica del nervio facial y funcional en el seguimiento a largo plazo en 103 (85,4 %). La función del nervio coclear se conservó (grados 1 y 2 de la clasificación de Gardner-Robertson) en el 54,4 % de los schwannomas de menos de 1,5 cm de diámetro con audición válida. Fallecieron 2 pacientes por complicaciones postoperatorias (tasa de mortalidad, 1,6 %) y en 15 (12,5 %) se desarrolló una fístula de líquido cefalorraquídeo. Conclusiones: Pese a la notable mejora en los resultados de la cirugía de los neurinomas del acústico, todavía presenta una tasa apreciable de complicaciones y secuelas. Por ello debe sopesarse en cada caso particular su realización en función de las circunstancias concurrentes y valorar la posibilidad de otras alternativas como la conducta expectante o la radiocirugía

Objective: To evaluate the complications and sequelae of acoustic neuroma surgery, according to tumour size. Patients and method: A retrospective analysis of 120 patients who underwent microsurgical resection of vestibular schwannomas between November 1994 and September 2006 was undertaken. Tumour size, extent of removal, preservation of facial and cochlear nerves, complications, and sequelae were considered. The degree of hearing preservation after surgery was determined by the Gardner-Robertson classification. Results: There were 39 small (3 cm). Gross total resection was accomplished in 106 cases (88.3 %). The facial nerve was anatomically and functionally preserved in 103 cases on long-term follow-up (85.4 %). The cochlear nerve was functionally preserved (Gardner-Robertson class 1 and 2) in 54.4 % of the small tumours with useful preoperative hearing. Two patients died due to postoperative complications (mortality rate, 1.6 %), and 15 (12.5 %) developed a CSF leak. Conclusions: Despite the progress in the surgical treatment of acoustic neuromas, a considerable rate of complications and sequelae still remains. Therefore, there is a need to balance pros and cons of surgery in each patient according to the concurrent circumstances, as well as to consider other therapeutic strategies such as radiosurgery or a wait-and-see policy

Functional significance of peripheral head-shaking nystagmus.

OBJECTIVES/HYPOTHESIS: The objective was to determine the characteristics of horizontal head-shaking nystagmus of peripheral origin and its relationship to vestibular dysfunction. STUDY DESIGN: Retrospective case series. METHODS: Eighty-three patients met the inclusion criteria of having peripheral and unilateral vestibular disease. Patients were tested with video nystagmography. Head-shaking nystagmus was performed in the horizontal plane during 30 cycles at a frequency of approximately 3 Hz. Head-shaking nystagmus was classified as monophasic or biphasic and, based on the pathological ear, as ipsilateral or contralateral related to nystagmus fast phases. The two-tailed t test, ANOVA, Mann-Whitney and chi2 tests, and lineal and polynomial regression tests were used for statistical analysis. RESULTS: Twenty-three patients showed a positive head-shaking nystagmus. All cases of head-shaking nystagmus observed were horizontal. There were four biphasic and 19 monophasic cases of head-shaking nystagmus. First phases of biphasic head-shaking nystagmus beat toward the normal ear. Eleven of the monophasic cases of head-shaking nystagmus were ipsilateral, and nine were contralateral. There was a statistically significant correlation between caloric weakness and head-shaking nystagmus. Ipsilateral head-shaking nystagmus corresponded to lower caloric asymmetries, and contralateral and biphasic head-shaking nystagmus corresponded to greater caloric weakness (P <.001). As the caloric asymmetry increased, the maximal slow-phase eye velocity of head-shaking nystagmus was greater (P =.01) and its duration shortened (P =.008). Ipsilateral responses could be distinguished from contralateral responses based on their latency (P =.03), maximal slow-phase eye velocity (P <.05), and duration (P =.02). The frequency of head-shaking nystagmus was significantly higher among older patients. There was no correlation between head-shaking nystagmus and clinical patterns. CONCLUSION: Head-shaking nystagmus of peripheral vestibular origin is a response both qualitatively and quantitatively associated with the degree of the vestibular loss.