Piezosurgery-, neuroendoscopy-, and neuronavigation-assisted intracranial approach for removal of a recurrent petrous apex cholesteatoma: technical note.

Current approaches for resection of petrous bone cholesteatomas (PBCs), such as canal wall up (closed) and canal wall down (open) mastoidectomies, in the pediatric population present recurrence rates ranging between 17% and 70% with a high rate of postoperative complications involving hearing loss and facial nerve weakness. This technical note illustrates an alternative intracranial approach that was used in combination with the techniques of piezoelectric surgery, neuroendoscopy, and neuronavigation for safe and effective removal in a difficult pediatric case of recurrent PBC. The third recurrence of a PBC in a 14-year-old girl was diagnosed by CT and MRI. A retrosigmoid approach gave access to the petrous apex, allowing for the safe and complete removal of the lesion and decompression of the facial nerve and internal carotid artery. The intraoperative implementation of piezoelectric surgery, neuronavigation, neuroendoscopy, and neuromonitoring ensured better intraoperative visualization, safer bone removal, and preservation of nerve function, facilitating a macroscopically total resection of the pathology without additional neurological damage of the adjacent tissues. Cholesteatoma extension could be clearly verified by intraoperative neuronavigation. Neuroendoscopy and piezoelectric surgery provided good support in the safe bone removal in close vicinity to neurovascular structures and in full vision inside the cholesteatoma cavity beyond the line of sight of the microscope. Hearing and facial nerve function could be preserved. The presented intracranial retrosigmoid approach combined with multiple intraoperative assisting techniques proved to be effective for the safe and complete removal of recurrent PBC, providing excellent intraoperative visualization and the possibility of preserving cranial nerve function.

Surgical technique and results of cable graft interpositioning of the facial nerve in lateral skull base surgeries: experience with 213 consecutive cases.

OBJECTIVE The aim in this study was to review the technique and outcomes of cable graft interpositioning of the facial nerve (FN) in lateral skull base surgeries. METHODS The authors retrospectively evaluated data from patients who had undergone cable graft interpositioning after nerve sacrifice during skull base tumor removal between June 1987 and May 2015. All patients had undergone lateral skull base approaches to remove tumors at a quaternary referral center in Italy. Facial nerve function was evaluated before and after surgery using the House-Brackmann (HB) grading system. RESULTS Two hundred thirteen patients were eligible for study. The mean follow-up was 44.3 months. The most common pathology was vestibular schwannoma (83 cases [39%]), followed by FN tumor (67 cases [31%]). Facial nerve tumors had the highest incidence of nerve interruption (67 [66%] of 102 cases). Preoperative FN function was normal (HB Grade I) in 105 patients (49.3%) and mild (HB Grade II) in 19 (8.9%). At the last postoperative follow-up, 108 (50.7%) of the 213 patients had recovered to Grade III nerve function. Preoperative HB grading of the FN was found to have a significant effect on outcome (p = 0.002). CONCLUSIONS Cable graft interpositioning is a convenient and well-accepted procedure for immediate restoration of the FN. The study results, over a large number of patients, showed that the stitch-less fibrin glue-aided coaptation technique yields good results. The best possible postoperative result achieved was an HB Grade III. The chances of a good postoperative result increase when FN function is normal preoperatively. Slow-growing tumors of the cerebellopontine angle had a favorable outcome after grafting.