Prognostic factors of facial nerve function after vestibular schwannoma removal via translabyrinthine approach.

BACKGROUND: Prediction of facial function is a major concern when proposing surgery for patients with vestibular schwannoma (VS). AIMS/OBJECTIVES: To evaluate postoperative facial function of patients who underwent operation of VS via a translabyrinthine approach (TL), and to analyze factors that influence facial functions. MATERIAL AND METHODS: A total of 91 VS patients, who were operated via a TL approach, between March 1997 and December 2016, were analyzed. Demographics, tumor-related factors, and operative findings were collected. Facial function was assessed according to the House-Brackmann (HB) grading system before surgery, immediately after surgery, and 1-, 3-, 6-months, and 1 year after surgery. RESULTS: In cases of patients that had a tumor that extended to the CPA, an unsatisfactory facial outcome was noted in 12 (30.0%) patients. FN outcomes after tumor removal depend on tumor size (p = .040). Among FN-related factors, only the FN recovery timing was correlated with facial outcomes (p = .030). Univariable and multivariable analysis revealed that tumor size and the timing of FN recovery were significant as favorable prognostic factors for good facial outcomes. CONCLUSIONS AND SIGNIFICANCE: Tumor size and the FN recovery timing are significant prognostic factors of facial outcome in VS patients who underwent operations via a TL approach.

Framingham Risk Score as a Prognostic Predictor of Sudden Sensorineural Hearing Loss: A Preliminary Study.

OBJECTIVES/HYPOTHESIS: Predicting the prognosis of idiopathic sudden sensorineural hearing loss (ISSHL) remains challenging. This investigation aimed to apply Framingham Risk Scores (FRS) to assess the combination of prognostic factors following ISSHL and investigate the predictive role of FRS in patients with multiple comorbidities including hypertension, diabetes, and hyperlipidemia. STUDY DESIGN: Retrospective study. METHODS: Twenty-one patients presenting with unilateral idiopathic sudden sensorineural hearing loss and multiple comorbidities were surveyed. Framingham Risk Score was calculated, and patients were assigned into high-risk (FRS ≥20%) and low-risk (FRS <20%) groups. Mean pure tone audiometry (PTA) threshold of both groups and hearing outcomes following established criteria were investigated. All patients were treated with the same protocol of oral methylprednisolone. RESULTS: Overall successful recovery rate (complete + marked recovery) was 23.81%. The mean PTA threshold of the low-risk group showed significant improvement (mean PTA ± standard error, SE: pretreatment, 73.23 ± 11.80; posttreatment, 54.89 ± 10.25, P = .002), while the high-risk group did not show significant improvement in mean PTA threshold (mean PTA ± SE: pretreatment, 71.94 ± 11.77; posttreatment, 68.89 ± 12.81, P = .73). CONCLUSION: Framingham Risk Scores may be useful in predicting outcomes for ISSHL patients with multiple comorbidities.

Temporal Lobe Retraction Provides Better Surgical Exposure of the Peri-Geniculate Ganglion for Facial Nerve Decompression via Transmastoid Approach.

PURPOSE: For the exposure of the labyrinthine segment of the facial nerve, transmastoid approach is not usually considered due to being situated behind the superior semicircular canal. To obtain a better view and bigger field for manipulation in the peri-geniculate area during facial nerve decompression, retraction of temporal lobe after bony removal of tegmen mastoideum was designed via transmastoid approach. MATERIALS AND METHODS: Fifteen patients with traumatic facial paralysis [House-Brackmann (HB) grade IV-VI], 3 patients with Bell's palsy (HB grade V-VI), and 2 patients with herpes zoster oticus (HB grade V-VI) underwent facial nerve decompression surgery between January 2008 and July 2014. In all patients, we performed temporal lobe retraction for facial nerve decompression via the transmastoid approach. Patients were examined using pre operative tests including high-resolution computed tomography, temporal magnetic resonance imaging, audiometry, and electroneurography (degenerative ratio >90%). Facial function was evaluated by HB grading scale before and 6 months after the surgery. RESULTS: After the surgery, facial function recovered to HB grade I in 9 patients and to grade II in 11 patients. No problems due to surgical retraction of the temporal lobe were noted. Compared to the standard transmastoid approach, our method helped achieve a wider surgical view for improved manipulation in the peri-geniculate ganglion in all cases. CONCLUSION: Facial nerve decompression via the transmastoid approach with temporal lobe retraction provides better exposure to the key areas around the geniculate ganglion without complications.

How to Avoid Facial Nerve Injury in Mastoidectomy?

Unexpected iatrogenic facial nerve paralysis not only affects facial disfiguration, but also imposes a devastating effect on the social, psychological, and economic aspects of an affected person's life at once. The aims of this study were to postulate where surgeons had mistakenly drilled or where obscured by granulations or by fibrous bands and to look for surgical approach with focused on the safety of facial nerve in mastoid surgery. We had found 14 cases of iatrogenic facial nerve injury (IFNI) during mastoid surgery for 5 years in Korea. The medical records of all the patients were obtained and analyzed injured site of facial nerve segment with surgical technique of mastoidectomy. Eleven patients underwent facial nerve exploration and three patients had conservative management. 43% (6 cases) of iatrogenic facial nerve injuries had occurred in tympanic segment, 28.5% (4 cases) of injuries in second genu combined with tympanic segment, and 28.5% (4 cases) of injuries in mastoid segment. Surgeons should try to identify the facial nerve using available landmarks and be kept in mind the anomalies of the facial nerve. With use of intraoperative facial nerve monitoring, the avoidance of in order to avoid IFNI would be possible in more cases. Many authors emphasized the importance of intraoperative facial nerve monitoring, even in primary otologic surgery. However, anatomical understanding of intratemporal landmarks with meticulous dissection could not be emphasized as possible to prevent IFNI.

Quality of life differences in patients with right- versus left-sided facial paralysis: Universal preference of right-sided human face recognition.

INTRODUCTION: We investigated whether experiencing right- or left-sided facial paralysis would affect an individual's ability to recognize one side of the human face using hybrid hemi-facial photos by preliminary study. Further investigation looked at the relationship between facial recognition ability, stress, and quality of life. MATERIALS AND METHODS: To investigate predominance of one side of the human face for face recognition, 100 normal participants (right-handed: n = 97, left-handed: n = 3, right brain dominance: n = 56, left brain dominance: n = 44) answered a questionnaire that included hybrid hemi-facial photos developed to determine decide superiority of one side for human face recognition. To determine differences of stress level and quality of life between individuals experiencing right- and left-sided facial paralysis, 100 patients (right side:50, left side:50, not including traumatic facial nerve paralysis) answered a questionnaire about facial disability index test and quality of life (SF-36 Korean version). RESULT: Regardless of handedness or hemispheric dominance, the proportion of predominance of the right side in human face recognition was larger than the left side (71% versus 12%, neutral: 17%). Facial distress index of the patients with right-sided facial paralysis was lower than that of left-sided patients (68.8 ± 9.42 versus 76.4 ± 8.28), and the SF-36 scores of right-sided patients were lower than left-sided patients (119.07 ± 15.24 versus 123.25 ± 16.48, total score: 166). CONCLUSION: Universal preference for the right side in human face recognition showed worse psychological mood and social interaction in patients with right-side facial paralysis than left-sided paralysis. This information is helpful to clinicians in that psychological and social factors should be considered when treating patients with facial-paralysis.

Cochlear Implantation for Profound Hearing Loss After Multimodal Treatment for Neuroblastoma in Children.

OBJECTIVES: Neuroblastoma (NBL) predominantly affects children under 5 years of age. Through multimodal therapy, including chemotherapy, radiotherapy, surgery, and peripheral blood stem cell transplantation, the survival rate in patients with NBL have improved while treatment-related complications have also increased. Treatment-related ototoxicity, mainly from cisplatin, can result in profound hearing loss requiring cochlear implantation (CI). We analyzed the effectiveness and hearing preservation of CI recipients who had treated with multimodal therapy due to NBL. METHODS: Patients who received multimodal therapy for NBL and subsequent CIs were enrolled. A detailed review of the perioperative hearing test, speech evaluation, and posttreatment complications was conducted. Speech performance was analyzed using the category of auditory performance (CAP) score and the postoperative hearing preservation of low frequencies was also compared. Patients who were candidates for electro-acoustic stimulation (EAS) used an EAS electrode for low frequency hearing preservation. RESULTS: Three patients were identified and all patients showed improvement of speech performance after CI. The average of CAP score improved from 4.3 preoperatively to 5.8 at 1 year postoperatively. Two patients who were fitted with the Flex electrode showed complete hearing preservation and the preserved hearing was maintained over 1 year. The one remaining patient was given the standard CI-512 electrode and showed partial hearing preservation. CONCLUSION: Patients with profound hearing loss resulting from NBL multimodal therapy can be good candidates for CI, especially for EAS. A soft surgical technique as well as a specifically designed electrode should be applied to this specific population during the CI operation in order to preserve residual hearing and achieve better outcomes.

Clinical effectiveness of wireless CROS (contralateral routing of offside signals) hearing aids.

This study evaluated the clinical effectiveness of wireless contralateral routing of offside signals hearing aids (CROS) in patients with severe to profound unilateral sensorineural hearing loss (USNHL). Twenty-one patients with USNHL were enrolled in this prospective study. The change of subjective satisfaction was evaluated using three questionnaires (K-HHIE, K-IOI-HA, K-SSQ). Changes in objective measurements were evaluated with sound localization test (SLT) and hearing in noise test (HINT). These tests were performed at pre-CROS fitting, 2 and 4 weeks after use of CROS. Subjects were grouped according to the age: young (<40 years) vs. old (≥40 years) group. The average K-HHIE and K-SSQ scores significantly improved with the use of CROS. SLT result revealed that hit rate and error degree improved in the young group and lateralization ability improved in both groups. In quiet environments, the reception threshold for speech also indicated a significant benefit in the young group. When the noise was presented to the normal ear, HINT revealed benefit of CROS, while loss of performance with CROS use was significant when noise was presented to the impaired ear. Wireless CROS provided increased satisfaction and overall improvement of localization and hearing. Although true binaural hearing cannot be obtained, CROS is a practical option for rehabilitation of USNHL.

Questionnaire evaluation of sequelae over 5 years after parotidectomy for benign diseases.

The aim of this study was to evaluate long-term (more than 5 years) quality of life issues after parotidectomy for the treatment of benign disease. A questionnaire survey was performed after institutional review board approval, on patients who had undergone any type of parotidectomy for benign salivary diseases. Fifty-three patients were surveyed at more than 5 years (the long term group) and 39 patients at 1-2 years after surgery (the control group). The questionnaire included the items on self perception of known sequelae. Descriptive and comparative analyses were performed to determine major sources of discomfort and changes in sequelae over time. Possible factors that contribute to sequelae were also analysed for significance. Frey's syndrome was identified as the most serious self-perceived sequela, and resulting discomfort worsened with time (P=0.01). Scores for other sequelae were similar in the two study groups. Subjective perception of Frey's syndrome was significantly different (P<0.001) according to the extent of surgery, and it was most serious in total parotidectomy cases, even from 1 year postoperatively. Of the sequelae of parotidectomy for benign diseases, Frey's syndrome was of greatest concern to patients, even at more than 5 years postoperatively. Therefore, additional measures which prevent or ameliorate Frey's syndrome are likely to improve long-term quality of life after parotidectomy.

Low power radiofrequency ablation for symptomatic microcystic lymphatic malformation of the tongue.

Although many head and neck surgeons agree that complete surgical excision is the treatment of choice for lymphatic malformation, the infiltrating nature of microcystic lymphatic malformations and the involvement of vital structures of the head and neck make total removal nearly impossible in most cases. Recently radiofrequency ablation was introduced for the treatment of microcystic lymphatic malformations of the oral cavity; it destroys lesion tissues at low temperature (40-70 degrees C) with minimal damage to adjacent structures. However, high energy (800-1200 J) and general anesthesia for radiofrequency ablation can hinder the easy and repetitive application of radiofrequency to patients. To overcome this limitation of radiofrequency ablation for microcystic lymphatic malformations, we used the same technique with a lower power (6 W, less than 100 J per site) radiofrequency ablation in an office-based setting under local anesthesia in a child with a microcystic lymphatic malformation of the whole tongue, that was associated with recurrent bleeding and swelling. The repetitive low power energy radiofrequency ablation of the microcystic lymphatic malformation of the tongue was safe and effective; it provided the patient with symptomatic relief without recurrence at follow-up. Therefore, our modification of radiofrequency ablation of the microcystic lymphatic malformations could be technically feasible and easily applicable; our result suggests that it can be a useful alternative treatment option to relieve symptoms from microcystic lymphatic malformation of the oral cavity.

Changes of maxillary sinus volume and bony thickness of the paranasal sinuses in longstanding pediatric chronic rhinosinusitis.

OBJECTIVES: To evaluate the chronic bony changes in the paranasal sinuses of longstanding chronic rhinosinusitis (CRS) in pediatric patients and to compare them with normal controls. STUDY DESIGN: A single-institution retrospective analysis. METHOD: Thirty 15- and 16-year-old children with longstanding CRS, for more than 2 years, despite maximal medical treatment and had a Lund CT score over 20 were enrolled as the CRS group. They were compared with 45 age and gender matched randomly selected normal controls without CRS. No enrolled patient had a history of nasal or adenoid surgery. The volume of the maxillary sinus was measured using a three-dimensional CT reconstruction program (V-works 4.0). The bony thickness of the maxillary (MS) and ethmoid sinuses (ES) and the middle turbinate (MT) was measured and compared. In addition, we evaluated the effect of disease duration on the sinus volume and bony thickness. RESULTS: The mean volume of the MS was 22.5+/-4.4 cm(3) in the normal group and 20.0+/-4.1 cm(3) in the CRS group; this difference was statistically significant (p=0.02). However, there was no correlation found between the disease duration and maxillary sinus volume (r=-0.07, p=0.69). The mean thicknesses of the bony walls were 1.0+/-0.4 mm (MS), 0.8+/-0.4 mm (ES) and 1.8+/-0.5 mm (MT) in the normal group and 1.2+/-0.3 mm (MS), 1.2+/-0.4 mm (ES) and 2.4+/-0.5 mm (MT) in the CRS group; these differences were significant (p<0.01). In addition, the bony thickness of the ES was significantly correlated with the duration of symptoms (r=0.44, p=0.03). CONCLUSION: The volume of the maxillary sinuses decreased and the bony thickness of the paranasal sinuses increased with longstanding pediatric CRS.

Pediatric sialolithiasis: what is different from adult sialolithiasis?

OBJECTIVE: To investigate the clinical characteristics of pediatric sialolithiasis, which are distinct from those of adult sialolithiasis. METHODS: A total of 210 patients with sialolithiasis confirmed by surgical treatment were enrolled in the study from Samsung Medical Registry (1995-2005). Twenty-nine were pediatric patients (age < or =18 years) and 181 adult patients (age >19 years). Comparison of pediatric and adult sialolithiasis was performed in terms of subject characteristics, clinical manifestations, salivary calculi characteristics, treatment modalities and outcomes. RESULTS: Postprandial recurrent swelling was the most frequent complaint in pediatric sialolithiasis patients, as similar as in adult patients. However, duration of symptoms was shorter in pediatric patients (mean 14.1 months versus 30.7 months, P=0.003). Most calculi were less than 1cm in pediatric patients (93.1%), compared to 56.3% of the adult patients (P=0.001). The calculi were located more in the distal duct (62.0%) than in proximal duct and gland in the pediatric patients, whereas 44.7% in the adult patients (P=0.038). CONCLUSION: Because of large proportion of relatively small and distal sialolithiasis in pediatric patients, bimanual careful palpation of the oral cavity is mandatory to diagnostic approach for children suspicious of sialolithiasis. These findings also suggest that intra-oral approach is effective treatment procedure for most of sialolithiasis in children.