Preoperative Diagnosis of Warthin Tumors Combining Cytological, Clinical and Ultrasonographic Information within a Multidisciplinary Approach in a Lump Clinic.

(1) Background: Warthin tumors account for about 20% of all benign salivary tumors, approaching 50% if we consider only the parotid gland. Wait and see is considered a reasonable option, but the diagnosis should be certain. Diagnosis can be based on morphological and cytological data, but the sensitivity of the fine needle aspiration cytology (FNAC) is not absolute, with a high rate of non-diagnostic findings in the event of a Warthin tumor, hindering the counseling and therapeutic decisions. The aim of the study is to evaluate the reliability of FNAC and its combination with anamnestic, clinical, and ultrasonographic data in diagnosing Warthin tumors. (2) Methods: A total of 413 patients affected by masses within the major salivary gland and managed between 2017 and 2022 at our institution have been included in the present retrospective study. Each patient underwent fine needle aspiration biopsy (FNAB) with a subsequent cytological diagnosis; successively, for each patient, the clinician (otolaryngologist) and the histopathologist discussed the combination of cytological (even non-diagnostic), clinical, and ultrasonographic data in order to make a "multiparametric" diagnosis. A total of 214 cases were subsequently submitted to surgical resection and had a final histopathology report, to which the cytological and the multiparametric diagnoses can be compared. We extracted all the patients with a cytological, multiparametric, and/or histological diagnosis of Warthin tumors in order to assess the sensitivity and specificity of FNAC and of multiparametric analysis in diagnosing Warthin tumors in case of a major salivary gland mass. (3) Results: One hundred thirty-two cases had a cytological, multiparametric, and/or histological diagnosis of Warthin tumors. FNAC displays a sensitivity of 68.4% and a specificity of 98.7% in diagnosing Warthin tumors. The multiparametric evaluation allowed a considerable improvement in sensitivity (92.9% vs. 68.4%), minimizing the number of non-diagnostic results and preserving at the same time a similar value of specificity (95.5% vs. 98.7%). Notably, none of the patients with a cytological or multiparametric diagnosis of Warthin were affected by a malignant lesion in the final histopathological report. (4) Conclusions: In the case of Warthin tumors, a multiparametric evaluation encompassing anamnestic, clinical, and cytological data is effective in reducing the number of non-diagnostic reports and can safely guide the management of a tumor (e.g., antibiotic treatment of infectious complications, assign a low priority to surgery, even consider observation avoiding surgery) which is absolutely benign and can be associated with no clinically relevant issues.

CNAP To Predict Functional Cochlear Nerve Preservation in NF-2: Cochlear Implant or Auditory Brainstem Implant.

The ideal management of bilateral vestibular schwannomas (VSs) involves complete tumor resection with preservation of hearing in at least one ear. While auditory brainstem implants (ABIs) have represented a significant advance in the management of neurofibromatosis type 2 (NF-2) patients, hearing rehabilitation is far from ideal. More recently, cochlear implantation has been used in selected cases of NF-2, following tumor removal, where the patient is left with bilateral profound hearing loss but with anatomical continuity of the cochlear nerve. In selected cases, cochlear implant (CI) has given superior results to ABI. The Gruppo Otologico experience in managing NF-2 patients consists of 29 patients treated between December 1996 and December 2007 out of a total of 1723 VSs. Thirty-nine tumors have been removed, with 10 patients having had bilateral tumor removed. Ten ABIs have been implanted and 5 CIs placed. We present a case that illustrates some of the difficulties encountered in the management of NF-2 VS and provides a basis for discussion of a technique to assist intraoperative decision-making to achieve optimal hearing rehabilitation. In the setting of a negative fast auditory brainstem response (ABR), but preserved cochlear nerve action potential (CNAP), the option of a CI can be considered. However, where the fast ABR and the morphology and amplitude of the CNAP are significantly degraded at the brainstem, the placement of an ABI should be strongly considered at the time of tumor removal. This technique must be further evaluated, but it represents an adjunct in this difficult area for the neurotologist. To this end we propose that a multicenter trial be undertaken to further elucidate the role of intraoperative monitoring to determine the functional preservation of the cochlear nerve.

Salivary gland choristoma of the middle ear.

Choristoma of the middle ear is a rare condition characterized by the presence of normal salivary gland tissue in the middle ear space. Salivary gland choristomas are benign lesions that are frequently associated with ossicular chain and facial nerve anomalies. Total surgical excision is indicated when there is no risk of damaging the facial nerve. We describe a new case of salivary gland choristoma of the middle ear, and we discuss the etiology, histologic features, and management of such lesions. Our patient was a 22-year-old woman in whom we surgically removed a whitish retrotympanic mass. Intraoperatively, we also detected an ossicular chain malformation. Histologic examination of the choristoma revealed the presence of salivary gland tissue. Furthermore, the lesion contained an extensive and previously undescribed component: a well-defined pseudostratified respiratory-type epithelium, similar to that of a normal eustachian tube. Ten months after removal of the choristoma, we surgically repaired the ossicular chain anomalies. No recurrence was noted on follow-up.

Facial nerve function after vestibular schwannoma surgery.

OBJECT: The object of this study was to evaluate long-term postoperative facial nerve (FN) function in patients undergoing vestibular schwannoma (VS) surgery. METHODS: The authors retrospectively reviewed the clinical course of patients affected by isolated VSs with normal preoperative FN function, with no previous surgical or radiotherapeutic treatment, and who underwent surgery between 1987 and 2007. Facial nerve function was clinically evaluated according to the House-Brackmann (HB) scale. The minimum postoperative follow-up was 12 months. RESULTS: Among the 1550 patients surgically treated at the authors' center, 1151 matched inclusion criteria for the present study. The FN was anatomically interrupted in 48 cases (4.2%), and 51 patients (4.4%) underwent subtotal tumor removal and were considered separately. Among the 1052 patients with anatomically preserved FNs and total tumor removal, 684 (65%) enjoyed postoperative HB Grade I or II and 309 (29.4%) enjoyed Grade III, with the remaining 59 cases (5.6%) suffering unsatisfactory results (HB Grades IV-VI). As expected, FN function results deteriorated in cases of larger tumors. CONCLUSIONS: The main factor influencing postoperative FN function was tumor size. Although there was a progressive deterioration in FN function outcome in relation to tumor size, a cutoff point between satisfactory and unsatisfactory results could be identified at around 2 cm in maximum extrameatal tumor diameter, with the "optimal size" for surgery identified at < 1 cm. This finding emphasizes the importance of an early diagnosis and should be kept in mind when selecting the correct timing for VS removal. For small lesions, the results following a middle cranial fossa approach were significantly worse as compared with those following the translabyrinthine and retrosigmoidretrolabyrinthine approaches.

Middle ear and mastoid glomus tumors (glomus tympanicum): an algorithm for the surgical management.

OBJECTIVE: Glomus tumors are slow-growing benign lesions and represent the most common primary neoplasms of the middle ear. The objective of the present study is to report our surgical strategy in the management of glomus tympanicum tumors. METHODS: Between December 1988 and July 2008, 68 patients with histologically confirmed glomus tympanicum tumor underwent surgical treatment. The follow-up of the series ranged from 6 to 194 months (mean, 33.4 months). RESULTS: Distribution of tumors according to Fisch and Mattox classification was as follows: type A, 44 cases (64.7%); type B, 24 cases (35.3%). All of the 44 Class A tumors were safely removed via either a stapedectomy-type transcanal approach or a retroauricolar-transcanal approach. Five patients with Class B tumors were operated on through a transmastoid approach. Nineteen patients with larger Class B tumors underwent a subtotal petrosectomy with blind sac closure of the external auditory canal and middle ear obliteration. Gross total tumor removal was achieved in all 68 cases. In one case (1.4%) there was recurrence after 9 years, for which the patient was re-operated. No residual/recurrence has been detected on computed tomography in the rest of the patients. CONCLUSION: Surgical excision of glomus tympanicum tumors is a safe procedure, allowing total tumor removal with minimal morbidity, a low recurrence rate, and a low complication rate.

Management of meningoencephalic herniation of the temporal bone: Personal experience and literature review.

OBJECTIVES/HYPOTHESIS: Temporal bone meningoencephalic herniation is a rare condition with potentially dangerous complications. The aim of this study is to analyze the pathogenesis, clinical presentation, surgical treatment, and postoperative outcome of 133 cases of surgically confirmed temporal bone meningoencephalic herniations. A review of the literature is also presented. STUDY DESIGN: Retrospective case series (quaternary referral otology and skull base center). METHODS: This study is based on the analysis of the collected data of 133 cases of temporal bone meningoencephalic herniations surgically treated from 1984 to 2006. The follow-up ranged from 12 to 204 months with a mean of 38.4 months. RESULTS: Meningoencephalic herniations were divided into four etiologic groups: spontaneous (24.8%), secondary to chronic otitis media (21.8%), iatrogenic (45.9%), and posttraumatic (7.5%). Different surgical techniques were used for treatment: transmastoid approach (27.8%), middle cranial fossa approach (27.8%), combined technique (transmastoid plus minicraniotomy, 3%), and middle ear obliteration with blind sac closure of the external auditory canal (41.4%). CONCLUSIONS: Temporal bone meningoencephalic herniations are potentially life threatening, and surgery must take place expeditiously. The choice of the most appropriate surgical approach must be based on the localization and size of the herniated tissue, preoperative auditory function, the presence of active infection, intraoperative cerebrospinal fluid leak, and concomitant pathology.

Chondrosarcomas of the jugular foramen.

OBJECTIVES/HYPOTHESIS: Chondrosarcomas of the jugular foramen are extremely rare tumors. Our review of the literature revealed eleven previously reported cases. The aim of this study is to describe the presenting symptoms, radiographic findings, operative procedures, and postoperative outcome of five histologically confirmed cases of chondrosarcomas arising from the jugular foramen. A review of the literature is also presented. STUDY DESIGN: Retrospective study of an quaternary referral otology and skull base private center. METHODS: Five cases of surgically treated and pathologically confirmed jugular foramen chondrosarcomas were identified. The follow-up of the series ranged from 23 to 42 months (mean, 32.8 +/- 7.7 months). RESULTS: A single stage procedure was adopted in all the cases. Two patients underwent type A infratemporal approaches, one patient underwent a transotic approach extending to the neck with ligature of the internal jugular vein, one patient underwent a petro-occipital transigmoid approach, and one patient underwent a combined petro-occipital transigmoid-transotic approach. Gross total tumor removal was achieved in all patients. The most common complications were lower cranial nerve deficits. To date, no recurrence or residual tumors have been observed at radiological controls. CONCLUSIONS: We believe that the primary treatment for chondrosarcomas of the jugular foramen is gross total surgical resection of the tumor. It is our philosophy to reserve postoperative radiotherapy for patients with histologically aggressive tumors, as well as in cases with subtotal resection and recurrent tumors.