Clinical practice guideline on the management of vestibular schwannoma.

INTRODUCTION: Vestibular schwannoma (VS) is the most common tumour of the cerebellopontine angle. The greater accessibility to radiological tests has increased its diagnosis. Taking into account the characteristics of the tumour, the symptoms and the age of the patient, three therapeutic strategies have been proposed: observation, surgery or radiotherapy. Choosing the most appropriate for each patient is a frequent source of controversy. MATERIAL AND METHODS: This paper includes an exhaustive literature review of issues related to VS that can serve as a clinical guide in the management of patients with these lesions. The presentation has been oriented in the form of questions that the clinician usually asks himself and the answers have been written and/or reviewed by a panel of national and international experts consulted by the Otology Commission of the SEORL-CCC. RESULTS: A list has been compiled containing the 13 most controversial thematic blocks on the management of VS in the form of 50 questions, and answers to all of them have been sought through a systematic literature review (articles published on PubMed and Cochrane Library between 1992 and 2023 related to each thematic area). Thirty-three experts, led by the Otology Committee of SEORL-CCC, have analyzed and discussed all the answers. In Annex 1, 14 additional questions divided into 4 thematic areas can be found. CONCLUSIONS: This clinical practice guideline on the management of VS offers agreed answers to the most common questions that are asked about this tumour. The absence of sufficient prospective studies means that the levels of evidence on the subject are generally medium or low. This fact increases the interest of this type of clinical practice guidelines prepared by experts.

Traqueotomía en pacientes COVID-19: un procedimiento necesario de alto riesgo. Experiencia de dos centros / Tracheotomy in patients COVID-19: A necessary high risk procedure. Two center experience

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Utilidad diagnóstica de la densidad ósea de la cápsula laberíntica en el diagnóstico de la otosclerosis por tomografía de alta resolución / Diagnostic utility of labyrinth capsule bone density in the diagnosis of otosclerosis with high resolution tomography

OBJETIVO: El objetivo de este estudio es comparar la densidad ósea alrededor de la cápsula ótica en pacientes otosclerosos con un grupo control y encontrar el límite de densidad ósea a partir del cual podemos diagnosticar la enfermedad. MATERIAL Y MÉTODOS: Se realizó un estudio retrospectivo de casos y controles. La densidad ósea en unidades de Hounsfield (HU) de 28 oídos otosclerosos fue comparada con la densidad de 33 cápsulas no otoscleróticas. La densidad fue medida en 8 áreas de interés (ROI) donde normalmente se encuentran los focos otoscleróticos. Adicionalmente se realizó la densidad media de estas regiones (PROMED). Además, se calcularon las curvas ROC de cada ROI y la densidad media (PROMED). RESULTADOS: Todas las densidades radiológicas en HU de cada ROI y la densidad media en pacientes otosclerosos fueron menores en comparación con los oídos no otosclerosos. El área bajo la curva ROC de cada ROI y la densidad media mostraron que las áreas con mayor rendimiento diagnóstico fueron la densidad media, la fissula antefenestram y la región precoclear, con valores de corte de 1.980, 1.750 y 2.114 HU, respectivamente. CONCLUSIÓN: La densidad media de la cápsula ótica (PROMED), la densidad en fissula antefenestram (ROI 1) y en la región precoclear (ROI 3) parecen ser los parámetros más útiles para realizar el diagnóstico de otosclerosis

OBJECTIVE: The aim of this study is to compare the bone density around the otic capsule in otosclerotic patients with a control group, and find the cut-off values of bone density from which we can diagnose the disease. MATERIAL AND METHODS: A retrospective case-control study was performed. Bone densities in Hounsfield units (HU) from 28 otosclerotic ears were compared to the densities of 33 non otosclerotic capsules. These densities were measured in eight regions of interest (ROI) where the otosclerotic foci are usually found. The mean density of these regions (PROMED) was taken. Furthermore, the ROC curves of each ROI and the mean density (PROMED) were calculated. RESULTS: All radiological densities in HU of each ROI and the mean density in otosclerotic patients were lower compared to non otosclerotic ears. The area under the ROC curve of each ROI and the mean density showed that the areas with greater accuracy for the diagnosis of otosclerosis were mean density, the fissula ante fenestram, and precochlear region, with cut-off values of 1980 HU, 1750 HU and 2114 HU, respectively. CONCLUSION: The mean density of the otic capsule (PROMED), the density in the fissula ante fenestram (ROI 1) and in the precochlear region (ROI 3) seem to be the most useful parameters to make a diagnosis of otosclerosis

Diagnostic utility of labyrinth capsule bone density in the diagnosis of otosclerosis with high resolution tomography. / Utilidad diagnóstica de la densidad ósea de la cápsula laberíntica en el diagnóstico de la otosclerosis por tomografía de alta resolución.

OBJECTIVE: The aim of this study is to compare the bone density around the otic capsule in otosclerotic patients with a control group, and find the cut-off values of bone density from which we can diagnose the disease. MATERIAL AND METHODS: A retrospective case-control study was performed. Bone densities in Hounsfield units (HU) from 28 otosclerotic ears were compared to the densities of 33 non otosclerotic capsules. These densities were measured in eight regions of interest (ROI) where the otosclerotic foci are usually found. The mean density of these regions (PROMED) was taken. Furthermore, the ROC curves of each ROI and the mean density (PROMED) were calculated. RESULTS: All radiological densities in HU of each ROI and the mean density in otosclerotic patients were lower compared to non otosclerotic ears. The area under the ROC curve of each ROI and the mean density showed that the areas with greater accuracy for the diagnosis of otosclerosis were mean density, the fissula ante fenestram, and precochlear region, with cut-off values of 1980HU, 1750HU and 2114HU, respectively. CONCLUSION: The mean density of the otic capsule (PROMED), the density in the fissula ante fenestram (ROI1) and in the precochlear region (ROI3) seem to be the most useful parameters to make a diagnosis of otosclerosis.

Patient-Related Benefits for Adults with Cochlear Implantation: A Multicultural Longitudinal Observational Study.

OBJECTIVES: To assess subjectively perceived, real-world benefits longitudinally for unilateral cochlear implant (CI) recipients in a multinational population treated routinely. To identify possible predictors of self-reported benefits. DESIGN: This was a prospective, multicenter, repeated-measures study. Self-assessment of performance at preimplantation and postimplantation at 1, 2, and 3 years using standardized, validated, local language versions of the Speech, Spatial, and Qualities of Hearing Scale (SSQ), and the Health Utilities Index Mark 3 (HUI3) was performed. Outcomes were analyzed using a longitudinal mixed-effects model incorporating country effect. Patient demographics were explored for associations with change over time. SUBJECTS: Two hundred ninety-one routinely treated, unilateral CI recipients, aged 13-81 years, from 9 clinics across 4 countries. RESULTS: Highly significant improvements were observed for all outcome measures (p < 0.0001). Postimplantation, mean outcome scores remained stable beyond 1 year, with notable individual variability. A significant association for one or more outcomes with preimplantation contralateral hearing aid use, telephone use, age at implantation, implantation side, preimplantation comorbidities, dizziness, and tinnitus was observed (p < 0.004). CONCLUSIONS: Longitudinal benefits of CI treatment can be measured using clinically standardized self-assessment tools to provide a holistic view of patient-related benefits in routine clinical practice for aggregated data from multinational populations. Self-reported outcomes can provide medical-based evidence regarding CI treatment to support decision-making by health service providers.

Tratamiento de las hipoacusias mixtas severas a profundas con el BAHA Cordelle II / Treatment of severe to profound mixed hearing loss with the BAHA Cordelle II

Objetivo: Evaluar el rendimiento auditivo del BAHA Cordelle II en el tratamiento de pacientes afectados de hipoacusias mixtas de severas a profundas bilaterales. Material y método: Estudio retrospectivo de 12 pacientes afectados de hipoacusia mixta de severa a profunda, con audiometría tonal liminar, logoaudiometría y encuesta subjetiva antes y después de la implantación de un BAHA Cordelle II (Cochlear®).Resultados: La ganancia promedio con el BAHA en campo libre de todos los pacientes en las frecuencias conversacionales (0,5 a 4 khz) fue de 43, 51, 47 y 44 dB, respectivamente. Se obtuvo un sobre cierre del umbral diferencial auditivo (UDA) en todas las frecuencias en 10 de los 12 pacientes. La logoaudiometría pasó de un 85% de discriminación máxima promedio a 83 dB a un 96% a 62 dB. Los cuestionarios subjetivos mostraron un alto grado de satisfacción del uso del BAHA, si bien su rendimiento disminuyó en ambiente ruidoso y con el viento. La inmensa mayoría de usuarios utilizan el BAHA a lo largo de todo el día. Conclusiones: El BAHA Cordelle II (Cochlear®).es una buena alternativa en el tratamiento de los pacientes afectados de una hipoacusia mixta de severa a profunda bilateral. Su mínimo riesgo de laberintización, su alta previsibilidad de resultados, su cirugía fácil y muy reglada, la anestesia habitualmente local y el cierre del UDA en casi todas frecuencias son sus mayores ventajas. Los dispositivos activos de oído medio representan otra alternativa más compleja, aunque sus indicaciones específicas no están aún bien definidas por la falta de experiencia mundial. Cuando la inteligibilidad del paciente es muy pobre se debe considerar, como mejor alternativa, la indicación de un implante coclear (AU)

Goals: Evaluation of the audiological outcome and subjective satisfaction of BAHA Cordelle II in the treatment of patients with severe to profound bilateral mixed hearing loss. Material and method: Retrospective study of 12 patients suffering a severe to profound bilateral sensorineural hearing loss, using pure tone audiometry (PTA), speech audiometry and subjective evaluation before and after the implantation of a BAHA Cordelle II (Cochlear®). Results: The average gain in conversational frequencies (0.5 to 4 kHz) with BAHA in free field was 43, 51, 47 and 44 dB, respectively. We observed a GAP over closure in 10 of the 12 patients. Speech audiometry improved from 85% at 83 dB of maximum discrimination to 96% at 62 dB. The subjective evaluation questionnaires showed great satisfaction with a slight decrease in noisy or windy environments. The great majority of our patients used the BAHA device throughout the entire day. Conclusions: The BAHA Cordelle II (Cochlear®) is a good option in the treatment of severe to profound bilateral mixed hearing loss. Its best advantages are a low risk of labyrinthization, high result predictability, easy and step-by-step surgery, no need for general anaesthesia, and the GAP over closure in all frequencies. Active middle ear devices represent another alternative, but specific indications have not been defined yet because of low universal experience. When the intelligibility of the patient is poor, cochlear implantation should be considered (AU)

[Treatment of severe to profound mixed hearing loss with the BAHA Cordelle II]. / Tratamiento de las hipoacusias mixtas severas a profundas con el BAHA Cordelle II.

GOALS: Evaluation of the audiological outcome and subjective satisfaction of BAHA Cordelle II in the treatment of patients with severe to profound bilateral mixed hearing loss. MATERIAL AND METHOD: Retrospective study of 12 patients suffering a severe to profound bilateral sensorineural hearing loss, using pure tone audiometry (PTA), speech audiometry and subjective evaluation before and after the implantation of a BAHA Cordelle II (Cochlear(®)). RESULTS: The average gain in conversational frequencies (0.5 to 4kHz) with BAHA in free field was 43, 51, 47 and 44dB, respectively. We observed a GAP over closure in 10 of the 12 patients. Speech audiometry improved from 85% at 83dB of maximum discrimination to 96% at 62dB. The subjective evaluation questionnaires showed great satisfaction with a slight decrease in noisy or windy environments. The great majority of our patients used the BAHA device throughout the entire day. CONCLUSIONS: The BAHA Cordelle II (Cochlear(®)) is a good option in the treatment of severe to profound bilateral mixed hearing loss. Its best advantages are a low risk of labyrinthization, high result predictability, easy and step-by-step surgery, no need for general anaesthesia, and the GAP over closure in all frequencies. Active middle ear devices represent another alternative, but specific indications have not been defined yet because of low universal experience. When the intelligibility of the patient is poor, cochlear implantation should be considered.

Reimplantación coclear en el mismo oído: hallazgos, peculiaridades de la técnica quirúrgica y complicaciones / Cochlear reimplantation in the same ear: Findings, peculiarities of the surgical technique and complications

Introducción: Los implantes cocleares son, por diversos motivos, dispositivos electrónicos perecederos y, en ocasiones, han de reemplazarse. La técnica quirúrgica de reimplantación coclear, si bien no difiere substancialmente de la implantación virgen, si tiene unas peculiaridades características. En este artículo se analizan estas peculiaridades, no solo desde el punto de vista técnico, si no también respecto a las complicaciones que genera y el rendimiento funcional auditivo que consigue. Objetivos: Descripción detallada de los hallazgos operatorios, las peculiaridades de la técnica quirúrgica y las complicaciones generadas en el proceso de reimplantación coclear. Evaluación del rendimiento auditivo funcional del paciente reimplantado. Material y método: Revisión descriptiva retrospectiva de 34 reimplantaciones en el mismo oído, realizadas en nuestro servicio durante el periodo entre 1993 y 2008 en 27 pacientes en un hospital terciario por el mismo equipo de cirujanos. Los implantes reemplazados fueron 2 Ineraid® (Smith & Nephew Richards), 23 Laura® (Philips Hearing Implants), 8 Nucleus 24K® (Cochlear Corp.) y un Clarion® (Advanced Bionics). Resultados: La tasa de reimplantación por paciente en el mismo oído fue del 18,5%. La causa más frecuente de reimplantación en nuestra serie fue el fallo interno del implante (14 casos). Otras causas fueron la substitución por actualización tecnológica (7 casos), malposición del haz de electrodos (8 casos), necrosis/infección del colgajo cutáneo con exposición del implante (3 casos) y por último traumatismos externos (2 casos). Los hallazgos operatorios más significativos fueron la reosificación parcial de la mastoidectomía, la ausencia de osificación de la timpanotomía posterior y la permeabilidad de la espira basal de la cóclea cuando esta alojaba el haz de electrodos. En 25 pacientes, se consiguió una reintroducción completa del haz de electrodos y en 2 pacientes una introducción parcial. La tasa de complicaciones generadas fueron, tanto cuantitativamente como cualitativamente, comparables a la tasa de implantación en el oído virgen, salvo cuando el implante original fue del tipo Ineraid. Conclusiones: La técnica quirúrgica de reimplantación y de multirreimplantación tiene peculiaridades específicas en cado uno de sus pasos, pero, en términos generales, tiene una complejidad parecida a la implantación de oídos vírgenes y se asocia a una tasa de complicaciones similar. La introducción del nuevo haz de electrodos es sencilla y completa en la inmensa mayoría de casos, dado que la cóclea permanece permeable, siempre y cuando aloje al haz de electrodos; en caso contrario, tiene tendencia a reosificarse. El rendimiento auditivo esperable del nuevo implante está en consonancia con sus prestaciones. Si son iguales a las del implante substituido, el rendimiento auditivo del implantado es similar, y si son mejores, también lo es su rendimiento, excepto en oídos con grandes periodos de deprivación auditiva (AU)

Introduction: Cochlear implants are, for many reasons, expirable electronic devices and occasionally may have to be replaced. The surgical cochlear reimplantation technique is not substantially different from the initial implantation but does have some peculiarities. These peculiarities are analyzed in this paper not only from the point of view of surgical technique but also with respect to the complications involved and the functional auditive outcome obtained. Objectives: An accurate description of the surgical findings, peculiarities of the surgical technique and complications found during the process of cochlear reimplantation. An evaluation of the audiometric functional outcome of the reimplantation. Material and method: A descriptive retrospective review of 34 reimplantations in the same ear, carried out at our department during the period between 1993 and 2008, in 27 patients in a tertiary hospital by the same team of seniors surgeons. The cochlear implants replaced were 2 Ineraid ® (Smith & Nephew Richards, TN), 23 Laura ® (Philips Hearing Implants), 8 nucleus 24K ® (Cochlear Corp., Englewood, CO), 1 Clarion r (Advanced Bionics, Sylmar, CA). Results: The rate of reimplantation in the same ear was 18.5% per patient. The most frequent reason in our series was internal failure of the device (14 cases). Other causes were substitution for a technological update (7 cases), misplacement of electrodes (8 cases), necrosis/infection of the skin flap with exposure of the implant (3 cases) and external injuries (2 cases). The most important surgical findings were partial mastoidectomy reossification, absence of ossification in the posterior tympanostomy and the permeability of the basal turn of the cochlea when it housed the electrodes. A complete reintroduction of the electrodes was achieved in 25 patients and a partial one in 2 patients. The rate of complications generated was similar in reimplantation and in virgin ear implantation, except for when the original implant was an Ineraid device. Conclusions: The surgical technique of reimplantation and multireimplantation technique has characteristic peculiarities at each step, but in general terms, its complexity is similar to that of implantation in virgin ears and the rate of complications is also similar. The introduction of the new electrodes is simple and complete in the immense majority of cases, given that the cochlea remains permeable, as long as it houses the electrodes; otherwise it tends to become reossified. The functional auditory outcome of the new implant is in relation with its capacities. If they are equal to those of the initial implant then the auditory outcome will be similar and if they are better, then so will the outcome be, with the exception of ears with long periods of auditive deprivation (AU)

[Cochlear reimplantation in the same ear: Findings, peculiarities of the surgical technique and complications]. / Reimplantación coclear en el mismo oído: hallazgos, peculiaridades de la técnica quirúrgica y complicaciones.

INTRODUCTION: Cochlear implants are, for many reasons, expirable electronic devices and occasionally may have to be replaced. The surgical cochlear reimplantation technique is not substantially different from the initial implantation but does have some peculiarities. These peculiarities are analyzed in this paper not only from the point of view of surgical technique but also with respect to the complications involved and the functional auditive outcome obtained. OBJECTIVES: An accurate description of the surgical findings, peculiarities of the surgical technique and complications found during the process of cochlear reimplantation. An evaluation of the audiometric functional outcome of the reimplantation. MATERIAL AND METHOD: A descriptive retrospective review of 34 reimplantations in the same ear, carried out at our department during the period between 1993 and 2008, in 27 patients in a tertiary hospital by the same team of seniors surgeons. The cochlear implants replaced were 2 Ineraid (Smith & Nephew Richards, TN), 23 Laura (Philips Hearing Implants), 8 nucleus 24K (Cochlear Corp., Englewood, CO), 1 Clarion (r) (Advanced Bionics, Sylmar, CA). RESULTS: The rate of reimplantation in the same ear was 18.5% per patient. The most frequent reason in our series was internal failure of the device (14 cases). Other causes were substitution for a technological update (7 cases), misplacement of electrodes (8 cases), necrosis/infection of the skin flap with exposure of the implant (3 cases) and external injuries (2 cases). The most important surgical findings were partial mastoidectomy reossification, absence of ossification in the posterior tympanostomy and the permeability of the basal turn of the cochlea when it housed the electrodes. A complete reintroduction of the electrodes was achieved in 25 patients and a partial one in 2 patients. The rate of complications generated was similar in reimplantation and in virgin ear implantation, except for when the original implant was an Ineraid device. CONCLUSIONS: The surgical technique of reimplantation and multireimplantation technique has characteristic peculiarities at each step, but in general terms, its complexity is similar to that of implantation in virgin ears and the rate of complications is also similar. The introduction of the new electrodes is simple and complete in the immense majority of cases, given that the cochlea remains permeable, as long as it houses the electrodes; otherwise it tends to become reossified. The functional auditory outcome of the new implant is in relation with its capacities. If they are equal to those of the initial implant then the auditory outcome will be similar and if they are better, then so will the outcome be, with the exception of ears with long periods of auditive deprivation.

[Revision of carcinomas in paranasal sinuses]. / Revisión de los carcinomas de senos paranasales.

The annual incidence rate for paranasal sinus cancer is quite low in Europe at approximately 1 case a year per 100 000 inhabitants. The most frequent site is the maxillary sinus; in some countries such as Spain, however, carcinomas of the ethmoidal sinus complex are more prevalent. Squamous cell carcinoma is the most frequent histological type and adenocarcinoma is the one with the best prognosis. In general terms, the association of surgery and radiotherapy continues to be the optimal therapeutic option. The inclusion of an endoscopic endonasal approach for the treatment of these lesions must be considered in very selective cases. Most authors currently accept invasion of the fat and muscles of the orbital apex and infiltration of the conjunctiva and/or sclera as an absolute indication for orbital exenteration. Lymph node involvement at diagnosis or in the course of the disease is infrequent, so prophylactic lymph node treatment would therefore not be indicated.

Revisión de los carcinomas de senos paranasales / Revision of carcinomas in paranasal sinuses

Los carcinomas de senos paranasales presentan una incidencia baja, aproximadamente un caso al año cada 100.000 habitantes entre la población europea. La localización más frecuente es el seno maxilar, aunque en algunos países como España los carcinomas de etmoides son el grupo más numeroso. El tipo histológico más frecuente es el carcinoma escamoso, y el adenocarcinoma es la variante histológica con mejor pronóstico. En términos generales, la combinación de cirugía y radioterapia sigue siendo la modalidad terapéutica óptima. La inclusión del abordaje endonasal endoscópico en el tratamiento de estas lesiones debe considerarse en casos muy seleccionados. Actualmente, la mayoría de los autores acepta como indicaciones para llevar a cabo una exenteración orbitaria la invasión de la grasa, la musculatura y el ápex orbitario y la infiltración de la conjuntiva y/o esclerótica. La afección ganglionar en el momento del diagnóstico o durante el curso de la enfermedad es poco frecuente, lo que justificaría no tratar las cadenas ganglionares de manera profiláctica

The annual incidence rate for paranasal sinus cancer is quite low in Europe at approximately 1 case a year per 100 000 inhabitants. The most frequent site is the maxillary sinus; in some countries such as Spain, however, carcinomas of the ethmoidal sinus complex are more prevalent. Squamous cell carcinoma is the most frequent histological type and adenocarcinoma is the one with the best prognosis. In general terms, the association of surgery and radiotherapy continues to be the optimal therapeutic option. The inclusion of an endoscopic endonasal approach for the treatment of these lesions must be considered in very selective cases. Most authors currently accept invasion of the fat and muscles of the orbital apex and infiltration of the conjunctiva and/or sclera as an absolute indication for orbital exenteration. Lymph node involvement at diagnosis or in the course of the disease is infrequent, so prophylactic lymph node treatment would therefore not be indicated