Endoscopic Versus Microscopic Stapedotomy: A Randomized Clinical Trial.

OBJECTIVE: To determine the outcomes and complications of endoscopic versus microscopic stapes surgery in patients with otosclerosis. STUDY DESIGN: Randomized, single-blinded clinical trial. METHODS: Patients with otosclerosis who underwent either trans-canal microscopic or endoscopic stapedotomy at a tertiary care hospital were compared. Thirty-two patients were randomly divided into two groups using blocked randomization. Group A consisted of 16 patients who underwent trans-canal microscopic stapedotomy, and group B consisted of 16 patients who underwent trans-canal endoscopic stapedotomy. Postoperative vertigo, ear pain, and complications such as tympanic membrane perforation or chorda tympani nerve injury were evaluated. Three months postoperatively, patients were assessed for dysgeusia and hearing improvement. RESULTS: The mean pre-operative air-bone gap (ABG) in the microscopic and endoscopic groups was 32.81 ± 6.82 and 30.00 ± 7.96, respectively. The mean improvement in the ABG was 25.45 ± 11.21 dB in the microscopic group and 23.21 ± 10.68 dB in the endoscopic group. Although both techniques showed improvement in auditory outcomes (p-value <0.001), there were no statistical differences between the endoscopic and microscopic groups in the pre-operative, post-operative, and mean improvement of ABG (p-value >0.05). There were no significant differences between the two methods in chorda tympanic nerve injury, vertigo scores, and the mean operating time (p-value >0.05), but the mean pain score was higher in the microscopic group (2.56 ± 1.55 in the microscopic group versus 1.31 ± 0.70 in the endoscopic group) (p-value = 0.003). CONCLUSIONS: Endoscopic stapes surgery can be a preferable alternative to conventional microscopic stapedotomy, as it yields similar hearing outcomes and lower pain scores. LEVEL OF EVIDENCE: 2 Laryngoscope, 134:2395-2400, 2024.

Bilateral Nervus Intermedius Sectioning for Geniculate Neuralgia: Case Report and Operative Video.

BACKGROUND AND IMPORTANCE: Geniculate neuralgia is a rare condition characterized by excruciating ear pain. Surgical options for geniculate neuralgia include microvascular decompression and sectioning of the nervus intermedius. We report herein a case of bilateral geniculate neuralgia treated by nervus intermedius sectioning without prior microvascular decompression. To our knowledge, this is the first report of this treatment strategy with a subsequent description of the side effects of bilateral nervus intermedius disruption. CLINICAL PRESENTATION: A 54-yr-old woman presented with bilateral geniculate neuralgia, worse on the left, refractory to medical therapy. Surgical treatment options were reviewed, including microvascular decompression and sectioning of the nervus intermedius. She opted for left nervus intermedius sectioning. The procedure was uncomplicated and no compressive vascular loop was identified during surgery. Postoperatively, she had complete symptom resolution with no discernable side effects. Three years later, the patient developed worsening geniculate neuralgia on the contralateral side. After the discussion of treatment options, she opted again for sectioning of the contralateral nervus intermedius with successful resolution of all symptoms after surgery. Following surgery, the patient identified partial impairment of lacrimation and gustation. She continued to have functional taste of the anterior two-thirds of the tongue, lacrimation, and hearing bilaterally. CONCLUSION: Bilateral sectioning of nervus intermedius may provide benefit in patients with bilateral geniculate neuralgia without egregious side effects. However, lacrimatory and gustatory alterations are a potentially significant side effect with a wide range of symptomatology.

Clinical implications of nervus intermedius variants in patients with geniculate neuralgia: Let anatomy be the guide.

Geniculate neuralgia (GN) is an uncommon, but severe, condition that is characterized by excruciating paroxysmal pain in the seventh cranial nerve's cutaneous distribution of general somatic afferent fibers carried through the nervus intermedius (NI). GN becomes a surgical disease in refractory cases of pain after exhaustive medical management. Surgical intervention in the form of microvascular decompression and nerve sectioning has been investigated with good patient outcomes. Despite this, there are limited guidelines on either technique's appropriateness in specific operative scenarios. In our 30-year experience in GNs surgical management, we have found that a detailed knowledge of the NIs anatomy, variants, and intraoperative surgical anatomic findings are the key to choosing the most appropriate intervention, and may provide the answer to why some patients fail to experience pain relief after surgery. These anatomic variants also may explain why many patients commonly do not experience side effects related to the visceral efferent and special afferent fibers after nerve sectioning.

Effects of a sensory branch to the posterior external ear canal: coughing, pain, Ramsay Hunt's syndrome and Hitselberger's sign.

BACKGROUND: A distinct nerve innervating the external auditory canal can often be identified in close relation to the facial nerve when gradually thinning the posterior canal wall. This nerve has been attributed to coughing during cerumen removal, neuralgic pain, Hitselberger's sign and vesicular eruptions described in Ramsay Hunt's syndrome. This study aimed to demonstrate the origin and clinical impact of this nerve. METHODS AND RESULTS: In patients with intractable otalgia or severe coughing whilst inserting a hearing aid, who responded temporarily to local anaesthesia, the symptoms could be resolved by sectioning a sensory branch to the posterior canal. In a temporal bone specimen, it was revealed that this nerve is predominantly a continuation of Arnold's nerve, also receiving fibres from the glossopharyngeal nerve and facial nerve. Histologically, the communicating branch from the facial nerve was confirmed. CONCLUSION: Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.

Endoscopic Anatomy of the Protympanum.

The protympanum, a final common pathway between the tympanic cavity and external environment, is gaining relevance due to the ease and completeness of visualization with angled endoscopes. Two primary conformations are described, quadrangular and triangular, and new anatomic structures such as the protiniculum, subtensor recess, and protympanic spine are defined. Surgical relevance of the protympanum is described with respect to ventilation, cholesteatoma, cerebrospinal fluid leak, otic neuralgia, and surgical access to the eustachian tube.

Intermediate nerve neuralgia can be diagnosed and cured by microvascular decompression.

Here, we present a case of a 55-year-old woman with a 10-year history of hemifacial spasm accompanied by 1-month ipsilateral paroxysmal otalgia. Magnetic resonance imaging revealed the presence of vessels around the facial nerve root. Surgical exploration via suboccipital retromastoid craniotomy showed converging compression of the facial nerve root and intermediate nerve from both sides by an anterior inferior cerebellar artery loop. The patient's hemifacial spasm and ipsilateral otalgia were completely relieved after microvascular decompression of the facial nerve root and intermediate nerve. Intraoperative findings and the postoperative result of this case confirmed that vascular compression of the intermediate nerve was the exclusive cause of paroxysmal otalgia. The presence of ipsilateral hemifacial spasm, combined with preoperative neuroimaging studies, contributed to the diagnosis of intermediate nerve neuralgia. Microvascular decompression should be considered for the management of patients with intermediate nerve neuralgia.

The nervus intermedius: a review of its anatomy, function, pathology, and role in neurosurgery.

BACKGROUND: Geniculate neuralgia, although uncommon, can be a debilitating pathology. Unfortunately, a thorough review of this pain syndrome and the clinical anatomy, function, and pathology of its most commonly associated nerve, the nervus intermedius, is lacking in the literature. Therefore, the present study aimed to further elucidate the diagnosis of this pain syndrome and its surgical treatment based on a review of the literature. METHODS: Using standard search engines, the literature was evaluated for germane reports regarding the nervus intermedius and associated pathology. A summary of this body of literature is presented. RESULTS: Since 1968, only approximately 50 peer-reviewed reports have been published regarding the nervus intermedius. Most of these are single-case reports and in reference to geniculate neuralgia. No report was a review of the literature. CONCLUSIONS: Neuralgia involving the nervus intermedius is uncommon, but when present, can be life altering. Microvascular decompression may be effective as a treatment. Along its cisternal course, the nerve may be difficult to distinguish from the facial nerve. Based on case reports and small series, long-term pain control can be seen after nerve sectioning or microvascular decompression, but no prospective studies exist. Such studies are now necessary to shed light on the efficacy of surgical treatment of nervus intermedius neuralgia.

A novel technique of otic barotrauma management using modified intravenous cannulae.

This article provides the first detailed description and systematic evaluation of the management of otic barotrauma using modified intravenous cannulae. A 24-gauge IC cannula was modified as a tool for tympanostomy tube placement and middle ear ventilation. The medical records of 271 ears of 156 adult patients (median age 49 years) who underwent this procedure were reviewed retrospectively. Hundred and ninty-one tubes were placed for otalgia because of hyperbaric oxygen therapy, 58 tubes were inserted for air travel prophylaxis and 22 tubes were placed for management of otic barotrauma post-flight. All the patients who had this procedure for prophylaxis experienced regular otic barotrauma symptoms during air travel prior to tube placement. All patients were reviewed 6 weeks (range 2-9 weeks) post-procedure. This technique of otic barotrauma management worked effectively in 99 % of treated patients. On follow-up, 88 % of tubes were found to be extruded and non-extruded tubes were removed in clinic without any anaesthesia. 99.6 % of tympanic membrane had healed completely and spontaneously without sequelae. Given the safety, effectiveness, low risk of complications associated with this novel tympanostomy technique, it provided a simple yet effective therapeutic option for the management of otic barotrauma. Finally, this technique can be easily applied in all health settings as it only requires medical supplies readily available in hospitals, therefore there is no additional cost.

Diagnosis and treatment of giant cell granuloma of the temporal bone: Report of eight cases.

UNLABELLED: Abstract Conclusions: It is impossible to make a diagnosis of temporal giant cell granuloma (GCG) before operation because of nonspecific clinical and imaging feature. Surgery is the first-line choice of treatment. OBJECTIVE: To evaluate the diagnosis and treatment of temporal GCG. METHODS: Eight patients with GCG receiving treatment in the Chinese PLA General Hospital between 2001 and 2010 were recruited for the study. These patients' clinical features, imaging and histopathological findings, types of surgery, and results of follow-up evaluations were noted. RESULTS: The group was made up of four males and four females, with a median age of 37 years (range 21-50 years). Four patients had a granuloma on the left side and four on the right of the head. The median duration of the disease was 21 months (range 5-60 months). All patients, except one referred to us for recurring disease, were managed in our hospital. The main symptoms were: hearing loss (n = 5), tinnitus (n = 4), otalgia (n = 3), dizziness (n = 2), and local masses (n = 2). Radiological examination of the masses revealed erosion of the temporal bone and base of the skull. There was no definitive diagnosis in any of the patients before surgery. All patients had surgical treatment, six of them by middle cranial fossa approach and two by combined cranio-auricular approach. Surgical complications included partial facial paralysis (three cases) and cerebral edema (one case) but they resolved soon after surgery. One patient was lost to follow-up, but the other seven were followed up over a mean period of 24 months; none has reported a recurrence.

Microvascular decompression may be an effective treatment for nervus intermedius neuralgia.

OBJECTIVE: To report microvascular decompression as a possible effective treatment for patients with nervus intermedius neuralgia, and to contribute to the literature regarding both this syndrome and this specific form of treatment. METHOD: Case report of a patient with intermedius neuralgia. The main complaint was severe otalgia in the area innervated by the nervus intermedius, possibly caused by neurovascular compression of the nervus intermedius by the anterior inferior cerebellar artery. Microvascular decompression was undertaken, with good results. RESULTS: Post-operatively, the patient felt immediate and total relief of her otalgia, with normal facial nerve function and no otological morbidity. One year post-operatively, she was still free from otalgia. CONCLUSION: Patients with nervus intermedius neuralgia who do not respond to medical treatment may benefit from microvascular decompression.

Accessory tragus in the middle ear: A rare congenital anomaly.

OBJECTIVE: We present a very interesting and extremely rare case of an accessory tragus in the middle ear. METHOD: Case report and review of literature. RESULTS: Accessory tragus is not an uncommon congenital malformation of the external ear. The exact prevalence of accessory tragus as an isolated physical finding is unknown but it has been estimated to be 1.7:1000. There are many case reports on accessory tragus but there is no report of accessory tragus being found in the middle ear in English literature. We report the presentation and discuss the radiology and histopathology findings of this interesting case. CONCLUSION: To our knowledge, this is the first one to be reported in the English literature.

Sectioning the sensory auricular branch of the facial nerve to treat recalcitrant otalgia.

OBJECTIVE: To present a new surgical approach to treat idiopathic neuralgia of the sensory auricular branch of the facial nerve. PATIENTS: : Three patients with chronic ear pain resistant to medical therapy. INTERVENTION: Sectioning of the sensory auricular branch of the facial nerve along its course at the posterior wall of the external auditory canal by a retroauricular mastoidectomy approach. MAIN OUTCOME MEASURES: Resolution of otalgia. RESULTS: All the patients were relieved of their pain at their first follow-up visit, and they have remained symptom-free. The patients were followed at least for 1 year. CONCLUSION: The surgical treatment of idiopathic otalgia should be reserved for patients in whom medical treatment has failed. Finding the exact location of the ear pain is of utmost importance for a favorable outcome after surgery. If the origin of the otalgia is found to be the sensory auricular branch of the facial nerve, the section of this nerve offers favorable outcomes with no morbidity.

Geniculate neuralgia: long-term results of surgical treatment.

A rare cause of otalgia is geniculate neuralgia. In its most typical form, it is characterized by severe paroxysmal neuralgic pain centered directly in the ear. The pain can be of a gradual onset and of a dull, persistent nature, but occasionally it is sharp and stabbing. When the pain becomes intractable, an operation to surgically excise the nervus intermedius and geniculate ganglion via the middle cranial fossa approach is indicated. The purpose of this article is to review the long-term outcomes in 64 patients who were treated in this manner. Findings indicate that excision of the nervus intermedius and geniculate ganglion can be routinely performed without causing facial paralysis and that it is an effective definitive treatment for intractable geniculate neuralgia.

Síndrome otálgico por hiperflacidez timpánica (SOHITIM) / Otalgic syndrome for timpanic hyperflaccid

Se describe un síndrome otálgico causado por hiperflacidez de la membrana timpánica, al someterse a cambios barométricos. La hiperflacidez timpánica, la cual carece en cierta parte de la capa de tejido fibroso, el cual establece la apropiada tensión del tímpano, y al no estar presente, permite la distensión súbita de la membrana timpánica, provocando molestias dolorosas al paciente, cuando éste realiza vuelos en avión, al viajar por tierra ascendiendo montañas, o bajando a valles; igualmente al hacer natación sumergiéndose a cierta profundidad; también puede causar el dolor cuando el paciente realiza la prueba de valsalva

Effect of artificial airway on ear complications from hyperbaric oxygen.

Hyperbaric oxygen treatment is associated with an increased risk of barotrauma to the tympanic membrane and middle ear. An artificial airway may compromise normal eustachian tube function and equilibration of middle ear pressures. This retrospective study was designed to evaluate the risk of middle ear complications in 267 patients receiving hyperbaric oxygen (HBO) therapy and to compare those with and without artificial airways. Charts of all patients were reviewed for middle ear and tympanic membrane complications and myringotomy tube placement. Eighteen of the 267 patients had artificial airways. Seventeen (94%) of these 18 patients developed middle ear or tympanic membrane complications, and 11 (61%) required tympanostomy tubes for pain, hemotympanum, or serous otitis. In contrast, 114 (45.8%) of the 249 patients without airways developed ear complications, and 53 (21.3%) required tympanostomy tubes. These results suggest that patients with an artificial airway who are receiving HBO therapy are at greater risk for developing tympanic membrane and middle ear complications than nonintubated patients. Similarly, patients with artificial airways receiving HBO frequently require placement of tympanostomy tubes.

Geniculate neuralgia: the surgical management of primary otalgia.

Intractable, unexplained deep-ear pain presents a rare, albeit significant problem in otolaryngological and neurosurgical practice. The authors review their experience with 18 cases of primary otalgia during the past 15 years. A total of 31 surgical procedures were performed. Seventeen patients had sequential rhizotomies and one patient had microvascular decompression alone. Based on the clinical diagnosis, the nerves sectioned were singly or in combination: the nervus intermedius (14 patients), geniculate ganglion (10 patients), ninth nerve (14 patients), 10th nerve (11 patients), tympanic nerve (four patients), and chorda tympani nerve (one patient). Microvascular decompression of the involved nerves was undertaken in nine patients, in whom vascular loops were discovered. Adhesions (six patients), thickened arachnoid (three patients), and benign osteoma (one patient) were other intraoperative abnormalities noted. The overall success of these procedures in providing pain relief was 72.2%, and the mean follow-up period was 3.3 years (range 1 month to 14.5 years). There was no surgical mortality. Expected side effects were: decreased lacrimation, salivation, and taste related to nervus intermedius nerve section, and transient hoarseness and diminished gag related to ninth and 10th nerve section. Four patients developed sequelae consisting of sensorineural hearing loss, vertigo, and transient facial nerve paresis. One patient had a cerebrospinal fluid leak and another developed aseptic meningitis as postoperative complications. Except when primary glossopharyngeal neuralgia is the working diagnosis, a combined posterior cranial fossa-middle cranial fossa approach is recommended for adequate exploration and/or section of the fifth, ninth, and 10th cranial nerves as well as the geniculate ganglion and nervus intermedius.