Pediatric cerebral cysts: comparison of early complications following fenestration versus shunting procedures.

Objective: Characterize practice patterns and acute (30-day) surgical complications following fenestration and shunt procedures for the treatment of cerebral cysts in pediatric patients.Methods: This study utilized the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Pediatric database. Patients were identified by International Classification of Disease codes for cerebral cysts and Current Procedural Terminology codes for shunting or fenestration. Demographic data, preoperative comorbidities, and postoperative complications were compared between the two procedures.Results: 741 patients were included in the data analysis, with a majority aged 4 years or younger (55.9%) and a male predominance (62.6%). Fenestration was performed in 590 (79.6%) patients. Primary shunting was performed in 151 (20.4%) patients. Patients who received shunts were more commonly aged 0-4 years and had proportionately worse preoperative health status. No statistically significant differences in postoperative complications were detected. Reoperation rate was 7.9% and 8.6% in the shunt and fenestration groups, respectively. Common reasons for reoperation were shunt revision or replacement and shunt placement after fenestration. Patients requiring shunting after a failed fenestration tended to be younger with higher American Society of Anesthesiologists (ASA) classification.Discussion: Fenestrations are performed more often than shunting. Generally, children who receive shunts are younger than those who undergo fenestration. Acute surgical risk appears to be similar for both operations.

Influence of laser-assisted cochleostomy on acoustically evoked compound action potentials in the guinea pig.

HYPOTHESIS: Making a cochleostomy with a laser can affect the inner ear function. BACKGROUND: Different types of lasers can be used to create a fenestration in the footplate of the stapes during stapedotomy. Because of variations in absorption spectra of the laser light in various tissues or fluids, each laser has its own characteristics and possible side effects. MATERIALS AND METHODS: The basal turns of the cochleae of 20 guinea pigs were fenestrated using 4 types of lasers (thulium, KTP, CO2, diode; all groups n = 4). A control group (n = 4) was included to correct for the effects of the surgery alone. At 3 different time points, acoustically evoked compound action potentials (CAPs) were recorded at 5 frequencies and at different sound pressure levels. N1-P2 amplitudes were measured, and subsequently, thresholds were calculated. A repeated measures analysis of variance was used to investigate differences between groups. RESULTS: There was a decrease in CAP amplitudes and an increase in CAP thresholds after cochleostomy with each laser. The increase in thresholds was significantly larger for higher frequencies. The thulium laser evoked the largest threshold shifts, the KTP laser the smallest with the CO2, and diode lasers in intermediate positions. Overall, there was an increase in latencies after treatment. CONCLUSION: Laser treatment on or near the cochlea can cause damage to the sensitivity of the cochlea for sound. The thulium laser seems to be the worst choice in this respect.

New macroscopic classification of stapedio-ovalar otosclerosis: a simplified rating for training in stapedotomy.

OBJECTIVE: To have a new macroscopic classification of otosclerosis based on appearance variations of the stapes footplate due to the disease and to determine if the color variations are correlated to a minor or major incidence of footplate complications. STUDY DESIGN: Retrospective study. MATERIALS AND METHODS: From January 2006 to December 2006, 106 patients affected by otosclerosis underwent surgery. Three revision procedures (1 primarily operated in our department and 2 elsewhere) were excluded from the study. We finally considered 103 surgical procedures. In all patients, the appearance of stapes footplate before removing superstructure was assessed to determine a simplified rating of stapedial otosclerosis. We then excluded from the study group 7 patients in which the footplate was not visible (obliterative otosclerosis). Finally, we considered 96 otosclerosis patients divided into 2 groups (Groups A and B) that differed only in footplate color. Group A included 74 otosclerosis patients with blue footplate (77%), and Group B included 22 otosclerosis patients with white footplate (23%). We planned a stapedotomy procedure for all patients of Groups A and B. The surgeon, anesthesia, approach, succession of surgical steps, and type of surgical instruments were the same in all patients. We estimated whether there is statistical correlation between the incidence of footplate complications (floating footplate and footplate fracture) and the color variations of the stapes footplate in Groups A and B. MAIN OUTCOME MEASURES: Color footplate, incidence of footplate complications (floating and fractures footplate). RESULTS: The visible portion of stapes footplate before removing superstructure preserves the natural blue color in all its points in 71.84% of patients (n = 74). In 21.36% of patients (n = 22), the footplate appears white in all or in most of its extent. In 6.8% of patients (n = 7), the footplate was not visible because it was covered by massive otospongiotic tissue. Comparison of incidence of footplate complications between Groups A and B showed statistical significance. The incidence of footplate complications is higher in white otosclerosis than in blue otosclerosis. CONCLUSION: Based on the appearance and, furthermore, on the color of the visible portion of stapes footplate, before removing superstructure, the authors have formulated a new classification of otosclerosis: blue otosclerosis (blue footplate), white otosclerosis (white footplate), and obliterative otosclerosis (nonvisible footplate). The advantage of this classification is that it consents, before making any manipulation on the stapes, a rapid and simple identification of the different degrees of difficulty of surgery: I degree, blue otosclerosis; II degree, white otosclerosis; and III degree, obliterative otosclerosis.

Twenty-year review of revision stapedectomy.

OBJECTIVE: To evaluate surgical findings and techniques, patient management techniques, and audiometric results of 522 revision stapedectomies. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary otologic referral center. PATIENTS: A total of 522 revision stapedectomies over a 20-year period in Warren, Ohio, and Israel. The audiologic criterion for revision was an air-bone gap greater than 20 dB over the three-frequency range 0.5 to 2 kHz. RESULTS: Of the 522 revision cases, a total of 483 patients were operated on to improve hearing. The remainder of the patients were operated on for various other noted reasons. Closure of the air-bone gap to within 10 dB was achieved in 71% of patients (343 of 483). The mean pure-tone average improvement was 17.8 dB, with an average postoperative air-bone gap of 7.3 dB. The most common surgical findings were prosthesis malfunction at the oval window, incus, or both (58%). Since beginning the use of the Argon laser for surgical problems, the success rate has increased to 80%. A subgroup of 35 Argon laser revision stapedectomies resulted in a larger hearing gain (25.2 dB) and 91.4% closure of the air-bone gap to less than 10 dB. CONCLUSIONS: More than 70% of revision stapedectomy cases for hearing improvement have had successful closure of their air-bone gap. Since the introduction of the laser 5 years ago, the success rate has increased to 80%. In those specific cases where the laser was required, the success rate increased to 91.4%. Regardless of the revision technique, hearing results were the least successful when the incus could not be used for reconstruction.

Bone wax prevents nystagmus after labyrinthine fenestration in guinea pigs.

OBJECTIVE: We examined the effect of 3 methods of closure of labyrinthine fenestrations. STUDY DESIGN AND SETTING: A guinea pig animal model was developed to examine the effect of 3 methods of closure of labyrinthine fenestrations. These methods included bone wax alone, fascia and fibrin glue, and fascia alone. Nystagmus, a reproducible sign of labyrinthine injury, was chosen as an end point for comparing materials commonly used in human ear surgery. RESULTS: Animals repaired with bone wax showed no postoperative nystagmus, whereas animals repaired with other materials or that underwent canal fenestration without repair showed 3 to 5 days of postoperative nystagmus. CONCLUSIONS: Although it is premature to extrapolate our results to human surgery, postoperative nystagmus can be eliminated in guinea pigs by sealing labyrinthine fenestrations with bone wax. SIGNIFICANCE: Given the intimate relationship between the vestibular and cochlear systems, it is possible that prevention of vestibular irritation might be associated with preservation of cochlear function.

Robot-assisted stapedotomy: micropick fenestration of the stapes footplate.

OBJECTIVE: Micropick fenestration of the stapes footplate, a difficult step in stapedotomy, was selected for trials evaluating the potential for robotic assistance (RA) to improve clinical measures of surgical performance. STUDY DESIGN: In a surgical model of stapedotomy, we measured accuracy of fenestration to a desired point location and force applied to the stapes footplate. Performance variables were measured for 3 experienced and 3 less-experienced surgeons. RESULTS: RA significantly reduced the maximum force applied to the stapes footplate. For fenestration targeting, RA significantly improved accuracy for less-experienced surgeons and significantly worsened targeting for more-experienced surgeons. CONCLUSIONS: RA significantly improves performance for micropick fenestration in a surgical model of stapedotomy. For certain tasks, RA differentially affects performance for users of different experience levels. CLINICAL SIGNIFICANCE: These are the first results showing quantitative improvements in performance during simulated ear surgery using RA and differential effects of RA on performance for users of different experience levels.

Labyrinthine fenestration in the guinea pig.

OBJECTIVE: To evaluate the auditory effects of single, double, and triple semicircular canal fenestration procedures, with and without sealing the labyrinthine defect. BACKGROUND: Violation of the inner ear remains a feared complication in otologic surgery because it commonly leads to profound sensorineural hearing loss. It has been assumed that the natural history of labyrinthine injury in the guinea pig is similar to that in human beings; however, this assumption has not been rigorously studied. DESIGN: Prospective, randomized, and controlled animal study. SUBJECTS: Sixty pigmented guinea pigs. OUTCOME: Click-evoked electrocochleographic response, with same-ear prefenestration control. RESULTS: All of the fenestration groups had elevated auditory thresholds at 1 hour when compared with controls (P < 0.01); however, this difference lost statistical significance at 1 and 4 weeks. The degree of labyrinthine injury did not correlate with the degree of hearing loss or with the incidence of anacusis. Hearing remained stable during the study period. Sealing the fenestration had no significant audiologic effect (P > 0.40). CONCLUSIONS: The guinea pig model of labyrinthine fenestration may not be representative of the human condition.

Anomalous internal carotid artery-anterior cerebral artery anastomosis associated with fenestration and cerebral aneurysm.

A 69-year-old female presented with a ruptured aneurysm at the distal tip of a fenestrated anomalous artery which originated in the ophthalmic segment of the internal carotid artery (ICA), passed between the optic nerves, ascended along the midline, and formed the fenestration before dividing into the bilateral pericallosal arteries. The anomalous artery manifested as subarachnoid hemorrhage. Four days later, she died from severe pulmonary edema. The angiographic finding was confirmed by postmortem examination. Numerous perforating vessels from the anomalous artery and the distal ICA supplied the optic nerves and chiasm. This finding supports the idea that this anomalous vessel may be an extreme developmental variation of the prechiasmal arterial plexus.

Microdrill versus perforator for stapedotomy.

The purpose of this study was to compare the hearing results of performing stapedotomy using either a microdrill or a perforator. Two groups of patients, otherwise similar, were followed up for at least 2 years after the stapedotomy. It was possible to create 0.8 mm fenestra in 91.6% of our patients. There was no significant difference between the two groups in hearing results. The results showed a continuous improvement in the first 6 post-operative months after which the hearing stabilized. In our hands, the microdrill has not proved to be more traumatic than the perforator to the inner ear.

[Suppuration of old open cavities. Radical treatment]. / Les suppurations des anciennes cavités d'évidement. Cure radicale.

The use of small, Davis-type, cutaneous grafts, enabled drying up of draining cavities where suppuration persisted despite all treatment. At the same time, hearing was improved by a cartilage arch from the septum which had vibratory and anti-retractile effects.

Histopathology of fenestration operation for otosclerosis.

The author describes the histopathology of fenestration operation in five temporal bones of the Massachusetts Eye and Ear Infirmary collection. The four subjects underwent the intervention more than 18 years before their death. One of the patients was operated bilaterally by Lempert himself in 1950. Special attention is given to the effect on hearing results of the otosclerotic disease; the condition of the middle ear, mastoidectomy cavity, and fenestra; and the lateral and posterior membranous semicircular canals. Also the patency of the three fenestrae (the oval, the round, and the new fenestra) in respect to the resulting hearing function, is considered.