Revision ossiculoplasty.

Although ossiculoplasty, also known as ossicular chain reconstruction (OCR), was attempted initially in the early 1900s, it was not until the 1950s that it became commonplace and relatively well understood. Since then, there have been numerous technologic advances and a gain in the understanding of ossiculoplasty. However, successful OCR with resulting long-term stability can be a daunting task. Typically, the most common condition requiring revision OCR is chronic suppurative otitis media (COM) with or without cholesteatoma. Primary and revision OCR are performed also for blunt and penetrating trauma-induced conductive hearing loss, congenital defects (eg, atresia), and benign and malignant tumors. Typically, reconstruction in ears with COM is more difficult than in ears without infection. This article discusses the key factors involved in successful revision OCR

Use of a novel ultrasonic surgical system for decompression of the facial nerve.

OBJECTIVE: The middle cranial fossa approach has been used to explore and decompress the facial nerve in patients with Bell\u27s palsy and facial nerve tumors. Unfortunately, this approach is technically challenging and has a significant risk of injury to the facial nerve and to the cochleovestibular organs. One way to minimize the risk may be with the use of the Sonopet Omni ultrasonic aspirator (Synergetics Inc., St Charles, MO) instead of an otologic drill. METHODS: In this prospective study using cadaveric temporal bones, a total of 17 temporal bone specimens were used. Seven cadaveric temporal bones were used (4-left, 3-right) for the initial feasibility study. At a second session, an additional 10 temporal bones (5-left, 5-right) underwent decompression of the facial nerve from the fundus of the internal auditory canal (IAC) to the geniculate ganglion (ie, labyrinthine segment). The average time to decompress the labyrinthine segment was measured. The temporal bones were then examined for evidence of any injury. RESULTS: None of the 17 temporal bones showed any sign of injury to the superior semicircular canal or the cochlea. However, one specimen did have penetration of the IAC dura; another specimen did have penetration of the epineurium of the facial nerve. However, in neither case was there any evidence of injury to the facial nerve itself. At the first session, the average time for decompression of the labyrinthine segment was 10 minutes and 12 seconds. At the second session, the average time for decompression was 5 minutes and 0 seconds. CONCLUSION: The ultrasonic surgical system may be used as an alternative to the surgical drill for decompression of the facial nerve. Although a learning curve does exist, as with any new surgical tool or device, our results indicate that the device can be used safely and in a reasonable amount of time. However, before proceeding with intraoperative use of this device for otologic and neurotologic procedures, familiarization is first recommended on cadaveric temporal bone specimens

Radiographic Assessment and Surgical Implications of Arcuate Eminence Pneumatization.

BACKGROUND: The middle cranial fossa (MCF) approach is a valuable yet technically challenging technique. Identification of the superior semicircular canal (SCC) using the arcuate eminence (AE) was proposed as a surface landmark. However, the AE is sometimes absent, with inconsistent relationship to the SCC. Air cells in the AE area facilitate safer identification of the SCC. The aim of this study is to determine the radiographic prevalence of AE pneumatization. METHODS: Two hundred consecutive fine-cut temporal bone CT scans were retrospectively reviewed. The region of the petrosal bone at and above the level of the SCC dome was assessed for the presence of air cells, and graded 0 (no pneumatization) to 2 (well pneumatized). RESULTS: Four hundred temporal bones were studied. The average age was 49 years (range 18-89). Of all AE assessments, 47 (12%) were nonpneumatized, 62 (15%) partially pneumatized, and 291 (73%) well pneumatized. There was no significant correlation between patient age and pneumatization grade (p = 0.72). CONCLUSION: The SCC is a valuable landmark in MCF surgery as it holds consistent relationships to adjacent critical structures. Surrounding air cells should facilitate safer initial identification of the SCC, as the AE region is well pneumatized in 73% of patients

Small Vestibular Schwannomas: Does Surgery Remain a Viable Treatment Option?

Background Surgery for small vestibular schwannomas (Koos grade I and II) has been increasingly rejected as the optimal primary treatment, instead favoring radiosurgery and observation that offer lower morbidity and potentially equal efficacy. Our study assesses the outcomes of contemporary surgical strategies including tumor control, functional preservation, and implications of pathologic findings. Design Retrospective review. Setting/Participants Eighty consecutive patients (45 women, 35 men; mean: 47 years of age). Main Outcomes Measures Approaches included retrosigmoid approach (52%), translabyrinthine (40%), and middle fossa (8%). Operated on by the same surgical team, we analyzed presentation, radiographic imaging, surgical data, and outcomes. Results At last follow-up (mean: 34 months), 95% had good facial nerve function (House-Brackmann grade I or II); 36% who presented with serviceable hearing retained it; and 93% who presented with vestibular dysfunction reported resolution. Pathology identified two grade I meningiomas. Conclusions As one of the largest contemporary surgical series of small vestibular schwannomas, we discuss some nuances to help refine treatment algorithms. Although observation and radiosurgery have established roles, our results reinforce microsurgery as a viable, safe option for a subgroup of patients