Cerebrospinal fluid leak of the fallopian canal.

Spontaneous cerebrospinal fluid (CSF) leaks from the fallopian canal are extremely rare, as only a few cases have been reported in the world literature. We describe a case of spontaneous CSF otorrhea through an enlarged geniculate fallopian canal. The patient was a 45-year-old woman who presented with a history of CSF rhinorrhea and otorrhea from the right ear. Myringotomy and tube insertion revealed CSF otorrhea. Contrast-enhanced computed tomography revealed that the geniculate fossa was smoothly enlarged (demonstrating remodeling of bone). A middle fossa craniotomy with temporal bone exploration was performed. Intraoperative inspection detected the presence of a fistula secondary to a lateral extension of the subarachnoid space through the labyrinthine segments of the fallopian canal. We discuss the management of this unusual finding, which involves sealing the fistula while preserving facial nerve function.

Endolymphatic sac shunt, labyrinthectomy, and vestibular nerve section in Meniere's disease.

Medical treatment for Meniere's disease is effective in controlling vertigo for approximately 85% of patients. However, when disabling vertigo continues, surgical therapy is indicated. Several surgical approaches are performed to control the symptoms of peripheral vestibular disorders refractory to medical measures, each procedure having many technical variations. Surgery is usually reserved for patients with disabling vertigo. Here, the authors discuss surgical options for vertigo control in Meniere's disease and review the literature on outcomes of these management options. The authors discuss endolymphatic sac shunt (ie, endolymphatic mastoid shunt), vestibular nerve section, cochleosacculotomy, and labyrinthectomy. When looking at data based on patient ratings, the authors find that surgery improves vertigo in endolymphatic sac shunt, vestibular nerve section, and labyrinthectomy groups and improves imbalance for the endolymphatic sac shunt and vestibular nerve section groups. Labyrinthectomy and translabyrinthine vestibular nerve section both offer excellent control of intractable vertigo. However, patients undergoing translab yrinthine vestibular nerve section are more likely to show improvement in imbalance and functional disability. This outcome is more likely for diagnoses other than Meniere's disease. There are potential prognostic factors that can be helpful in the preoperative or postoperative counseling of patients undergoing surgical treatment of vertigo. Patients who rate themselves as more disabled before surgery are less likely to achieve the best outcomes. Several other factors, such as duration of disease, contralateral tinnitus, eye disease, and allergy, may play a role.

Transcochlear approach to cerebellopontine angle and clivus lesions: indications, results, and complications.

OBJECTIVES: Evaluate transcochlear (TC)/transotic (TO) approaches surgery for midline intradural lesions arising from the clivus and cerebellopontine angle masses arising anterior to the internal auditory canal. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral neurotologic practice. PATIENTS/INTERVENTION: Forty patients who underwent TC/TO approach surgery. Patients were grouped by whether the facial nerve was mobilized (TC, n = 15) or not (TO, n = 25). MAIN OUTCOME MEASURES: Indications, postoperative outcomes, and complications including tumor removal and facial nerve status (House-Brackmann grade). RESULTS: Forty percent of all TC patients were meningiomas, whereas 36% of all TO patients were cochlear neuromas. The remainder included tumors associated with NF2, acoustic tumors, malignancies, and other lesions. Complete removal was achieved in 92.5% of tumors. Of all patients, 42% and 55% had normal facial nerve function at the time of hospital discharge and follow up, respectively. Moreover, 22% underwent a facial nerve reanastomosis procedure. Early and late complications occurred in 11 and 14%, respectively. There was one surgery-related death. Complications included cerebrospinal fluid leak (9%) and unsteadiness (9%). CONCLUSION: The TC and TO approaches provide access to midline intradural lesions, intradural petroclival tumors, and cerebellopontine angle tumors and cholesteatomas arising anterior to the internal auditory canal, without using brain retractors. Total tumor removal, including its base and blood supply, is possible. Facial weakness is frequent when the facial nerve is rerouted, but excellent facial nerve results are accomplished with the TO approach. With these approaches, recurrence israre when all tumor has been removed. Their safety and efficacy encourage their use in extensive lesions.

[Surgical treatment of temporal, tympanic and jugular paragangliomas. Indications and surgical technique]. / Tratamiento quirúrgico de los paragangliomas temporales timpánicos y yugulares. Indicaciones y técnica quirúrgica.

Today's imaging studies accurately delineate the extent of glomus tumors of the temporal bone. Microsurgical techniques allow total removal of even the largest tumors with acceptable morbidity. While surgical management is the principal treatment of glomus tumors, stereotactic fractionated radiation therapy may be used as an alternative treatment when there is a risk of cranial neuropathy with surgical management. We should be aware of the full range of management options and base treatment choice on the age and medical condition of the patient and location and size of the tumor.

Tratamiento quirúrgico de los paragangliomas temporales timpánicos y yugulares. Indicaciones y técnica quirúrgica / Surgical treatment of temporal, tympanic and jugular paragangliomas. Indications and surgical technique

Actualmente, los estudios por imagen permiten conocer con precisión la extensión de los tumores glómicos del hueso temporal. Las técnicas de microcirugía permiten una extirpación completa de grandes tumores, con una morbilidad aceptable. Si bien estamos a favor del abordaje quirúrgico como tratamiento principal en los tumores glómicos, el tratamiento con radiación estereotáxica focalizada puede emplearse como tratamiento alternativo, cuando el riesgo de neuropatía craneal con cirugía sea alto. Debemos conocer todas las opciones terapéuticas y realizar nuestra elección sobre la base de la edad y el estado de salud del paciente, así como de la localización y el tamaño del tumor (AU)

Today’s imaging studies accurately delineate the extent of glomus tumors of the temporal bone. Microsurgical techniques allow total removal of even the largest tumors with acceptable morbidity. While surgical management is the principal treatment of glomus tumors, stereotactic fraction atedradiation therapy may be used as an alternative treatment when there is a risk of cranial neuropathy with surgical management. We should be aware of the full range of management options and base treatment choice on the age and medical condition of the patient and location and size of the tumor (AU)

Persistent dizziness after surgical treatment of vertigo: an exploratory study of prognostic factors.

OBJECTIVE: Persistent vertigo and imbalance can occur after surgery for vertigo regardless of surgical approach. This study explored for factors affecting outcome of vertigo surgery. STUDY DESIGN: Patient survey and chart review. SETTING: Tertiary referral neurotologic private practice. PATIENTS/INTERVENTION: Of 111 patients (57.7% female; mean age, 52.3 yr), 59 underwent vestibular nerve section (middle fossa, retrolabyrinthine, and translabyrinthine), 25 underwent transmastoid labyrinthectomy, and 27 underwent endolymphatic sac shunt. Eighty-three percent had Ménière's disease. Mean follow-up was 4.3 years. MAIN OUTCOME MEASURES: Primary outcomes included American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) vertigo score and class, number of spells per month, current and change in AAO-HNS disability rating, vertigo and imbalance severity ratings, and frequency of imbalance. RESULTS: Three preoperative factors were consistently related to outcome: AAO-HNS disability rating, imbalance frequency rating, and duration of first symptom ([rho] = 0.19-0.51; all p's < 0.05). Greater disability and more frequent imbalance related to poorer outcome, but longer duration of disease related to better outcome. Presurgery vertigo characteristics were generally not related to outcome. Ménière's patients were more likely to have improvement in imbalance, as were those with no other significant disease and no allergy. The presence of tinnitus in the contralateral ear was associated with poorer outcomes, including a lower rate of results of Classes A and B (p = 0.023). Vertigo as a first symptom and the presence of eye disease also showed relationships to poorer outcome. CONCLUSION: Those rating themselves as more disabled before surgery are less likely to achieve the best outcomes, whereas frequency and severity of preoperative vertigo are not predictive. Several possible prognostic factors were identified that warrant future prospective study.