Anterior petrosectomy (AP) is a commonly recognized approach for accessing tumors located in the petrous apex region. The essence of AP lies in drilling the petrous part of the temporal bone within ...the Kawase quadrangle. In our study, we conducted radiological and anatomical analyses of the structures within the petrous portion of the temporal bone, evaluating their impact on the surgical field during AP.
We conducted an analysis of 15 anatomical specimens and 20 3D reconstructions based on computed tomography scans of the middle ear. The analyzed structures included the impression of the trigeminal nerve, the groove of the greater petrosal nerve, the arcuate eminence, and the angle between eminentia arcuata and grove for greater petrosal nerve.
The mean surface area measured by radiological methods does not deviate significantly from the mean surface area measured by anatomical methods 276.265mm2 (interquartile range: 217.603–309.188) versus 233.21mm2 (interquartile range: 210.923–255.453) P = 0.051. We established a threshold 195,99mm2 for radiological determination of the surface area at which another approach should be considered. Additionally, we have developed corrections for specific radiological factors to enable a better assessment of anatomical conditions.
Our results indicate that preoperative assessment of anatomical conditions based on 3D reconstructions of computed tomography of the middle ear can be a valuable tool in preoperative planning of surgery on tumors in the petroclival region using the AP. Further studies involving a larger sample size are necessary to validate the findings of our study.
Dermoid cysts are ectodermal cysts that are rarely encountered in the Meckel’s cave. Here, we describe the case of a 33-year-old female who presented with a one-year history of facial pain. ...Neuroimaging depicted a left Meckel’s cave lesion consistent with dermoid cyst. Microsurgical resection was performed via the left extradural middle fossa approach. The cyst was completely removed. The patient reported improvement in facial pain after the surgery. Histopathology revealed a dermoid cyst. In this operative video, we demonstrate the key steps of the middle fossa approach for access to the Meckel’s cave.
Consent was obtained for the procedure and for the video recording.
The middle fossa approach is an effective option for the treatment of small (Koos grade I and II) vestibular schwannomas (VSs) when the goal is hearing preservation. The authors evaluated the rates ...of hearing preservation and examined the factors associated with improved hearing outcomes after the middle fossa approach for VSs.
In this retrospective, single-center cohort study evaluating the clinical outcomes after resection of small VSs using the middle fossa approach, consecutive adult patients (> 18 years) who underwent surgery between January 2000 and December 2021 were included. Clinical and imaging characteristics were analyzed, including baseline hearing status, duration of surgery, anesthetic parameters, and imaging characteristics of the surgically treated tumors.
Among the 131 included patients, 102 had valid and discoverable pre- and postoperative audiology assessments. The mean follow-up was 26 months (range 1-180 months). There were 85 patients with serviceable hearing preoperatively, defined as American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) class A or B, of whom 78% retained class A or B hearing at the last follow-up. Binary logistic regression demonstrated that preoperative hearing AAO-HNS class (OR 0.19, 95% CI 0.05-0.77; p = 0.02), overlap between fundus and cochlea (OR 0.32, 95% CI 0.11-0.96; p = 0.04), and duration of anesthesia (OR 0.98, 95% CI 0.97-0.99; p = 0.03) were independent predictors of hearing outcomes. Additionally, 75% of patients with high diffusion-weighted imaging signal in the tumor (p = 0.009) and 67% of patients with the tumor originating at the modiolus of the cochlea (p = 0.004) had poor hearing outcomes.
The hearing preservation rates after microsurgical resection of small VSs using the middle fossa approach are high, with 78% of patients maintaining AAO-HNS class A or B hearing. Poor hearing status at baseline, longer duration of anesthesia, and large overlap between the fundus of the internal auditory canal and the cochlea were independently associated with unfavorable hearing outcomes. Imaging characteristics can be used to stratify patients' risk of hearing loss.
Objective
Superior semicircular canal dehiscence (SSCD) represents a rare condition that may be associated to some particular symptoms as vertigo, autophony, and Tullio phenomenon. In those patients ...who present severe symptoms surgical treatment is required. Middle fossa craniotomy and transmastoid approaches are both described. Concerning repairing techniques, plugging and/or resurfacing are typically used to close the defect. Our aim was first to analyze the overall outcomes and complications of this surgery. Our second aim was to make a comparison between the different surgical modalities to investigate the eventual advantages and disadvantages.
Review Methods
A search through Ovid MEDLINE was organized in January 2015 to include all eligible articles. A statistical analysis of the obtained data was performed.
Results
Twenty studies comprising a total of 150 procedures were included. Four modalities of canal repair were described (plugging, capping, resurfacing, plugging with resurfacing). The overall rate of success resulted in 94% (95% confidence interval: 87%‐97%). No statistically significant differences were observed among the different modalities of canal repair concerning both success rate and surgical complications. Differences observed between the middle fossa approach and transmastoid approach in terms of outcome were not statistically significant.
Conclusions
This review showed that surgical treatment for SSCD represents a safe option for those patients with severe symptoms of this condition. Differences observed in terms of success rate or complications were analyzed between the different surgical techniques with results that were not statistically significant.
Level of Evidence
NA Laryngoscope, 126:1218–1224, 2016
The middle fossa approach is an excellent technique for removing appropriate vestibular schwannomas in patients with serviceable hearing. Knowledge of the intricate middle fossa anatomy is essential ...for optimal outcomes. Gross total removal can be achieved with preservation of hearing and facial nerve function, both in the immediate and long-term periods. This article provides an overview of the background and indications for the procedure, a description of the operative protocol, and a summary of the literature on postoperative hearing outcomes.
To describe postoperative hearing outcomes following transmastoid (TM) and middle cranial fossa (MCF) approaches for semicircular canal dehiscence (SSCD) repair.
Retrospective review.
Academic, ...tertiary referral center.
Adults with SSCD who underwent repair between 2005 and 2019.
Pure tone audiometry pre- and postoperatively after SSCD repair.
Change in air-bone gap (ABG) at 250 and 500 Hz, pure tone average (PTA), bone conduction (BC), and air conduction (AC) thresholds at 500, 1000, 2000, and 4000 Hz for patients undergoing TM and MCF approaches for SSCD repair.
The average change in BC PTA for patients undergoing TM (n = 26) and MCF (n = 24) SSCD repair was not significantly different between the two groups. The first and final postoperative PTAs were recorded an average of 1.7 (range 0.30-3.0) and 29.1 (range 3.5-154) months postoperatively. For patients who underwent MCF repair, the average BC PTAs increased (+) by 2.2 dB HL (p 0.43) and 0.57 dB HL (p 0.88) at the first and final audiograms respectively compared to +1.27 dB HL (p 0.53) and a decrease (-) of 0.57 dB HL (p 0.63) for the TM group. The average changes in low frequency ABG for patients undergoing MCF repair were -4.7 dB (p 0.08) and -6.9 dB (p 0.15) at first and final audiograms respectively compared to -4.9 dB (p 0.06) and -4.1 dB (p 0.36) for patients who underwent TM repair. There was a high frequency hearing loss noted at 8000 Hz for the MCF (30.0 dB ± 18.7 preop; 41.7 dB ± 21.7 postop; p 0.01) and TM (32.1 dB ± 23.2 preop; 44.3 dB ± 29.6 postop; p 0.001) groups which persisted on long term follow up.
Both TM and MCF approaches to SSCD repair can be performed with long-term preservation of hearing. ABGs were reduced in each treatment group but did not reach significance. A high frequency hearing loss (8000 Hz) may be expected with either approach.
•RS excels in small-medium VS hearing.•MF for intracanalicular, RS for larger.•Meta-analysis favors RS for VS.
Vestibular schwannomas (VS) are benign tumors arising from vestibular nerve's Schwann ...cells. Surgical resection via retrosigmoid (RS) or middle fossa (MF) is standard, but the optimal approach remains debated. This meta-analysis evaluated RS and MF approaches for VS management, emphasizing hearing preservation and Cranial nerve seven (CN VII) outcomes stratified by tumor size.
Systematic searches across PubMed, Cochrane, Web of Science, and Embase identified relevant studies. Hearing and CN VII outcomes were gauged using the American Academy of Otolaryngology-Head and Neck Surgery, Gardner Robertson, and House-Brackmann scores.
Among 7228 patients, 56 % underwent RS and 44 % MF. For intracanalicular tumors, MF recorded 38 % hearing loss, compared to RS's 54 %. In small tumors (<1.5 cm), MF showed 41 % hearing loss, contrasting RS's lower 15 %. Medium-sized tumors (1.5 cm–2.9 cm) revealed 68 % hearing loss in MF and 55 % in RS. Large tumors (>3cm) were only reported in RS with a hearing loss rate of 62 %.
Conclusively, while MF may be preferable for intracanalicular tumors, RS demonstrated superior hearing preservation for small to medium-sized tumors. This research underlines the significance of stratified outcomes by tumor size, guiding surgical decisions and enhancing patient outcomes.
We investigate the postoperative subjective and objective outcomes of different surgical treatments for superior semicircular canal dehiscence (SSCD): vestibular signs, auditory signs, vestibular ...evoked myogenic potential test, pure tone audiogram, speech audiogram, or video-nystagmography.
An electronic search performed in the PubMed, Cochrane Library, and EMBASE databases on 15th of September 2015. A systematic search was conducted. Articles were included if written in English, Dutch, German, or French language.
Original studies reporting on the pre and postoperative subjective and/or objective outcomes of surgical treatments for superior semicircular canal dehiscence were included.
The methodological quality of the studies was independently assessed by two reviewers using a constructed critical appraisal, to assess the directness of evidence and the risk of bias. The results of the pre and postoperative subjective and/or objective outcomes were extracted.
Comparative study was conducted.
Surgical treatment for SSCD is particularly effective for vestibular symptoms and there is no evidence for improvement of hearing loss after surgical treatment. Since plugging using transmastoid approach had a lower complication rate, lower revision rate, and a shorter hospital stay, this treatment is recommended in high disabled SSCD patients.
Anterior petrosectomy demands localization of the internal auditory canal (IAC) for safe bone drilling and maximum exposure. Various techniques have been described in the literature, each with ...shortcomings. We propose a new technique to localize the internal acoustic meatus (IAM) using more consistent anatomical landmarks.
The study was done in three phases. In phase-I (radiological), computed tomography scan heads of fifty patients (100 sides) were analyzed. Arcuate eminence–Greater Superficial Petrosal Nerve bifurcation angle(Garcia-Ibanez technique), Arcuate eminence–IAC angle(Fisch technique) and a new angle formed between foramen ovale (FO) and foramen spinosum (FS) line, and FS and IAM line (FO–FS-IAM angle) was measured. The mean, standard deviation, and variance were calculated. In phase-II (cadaveric), the FO-FS-IAM angle was measured on five (10 sides) dry skulls. In phase-III (clinical), the IAM was localized using the FO–FS-IAM angle in 13 patients.
The mean angle between arcuate eminence and Greater Superficial Petrosal Nerve (Garcia-Ibanez technique) was 126.20 ± 11.63°(range 106–156) with a variance of 135.20. The mean bifurcation angle was 63 ± 5.81°(range 53–78). By the Fisch technique, the mean arcuate-IAM angle was 73.5 ± 11.70°(range 51–105) with a variance of 137.18. By our technique, the mean FO–FS-IAM angle was 94.72 ± 5.89°(range 84–108). The variance was 34.73. The mean FO-FS-IAM angle on dry skulls was identical (95 ± 1.97°) to our radiological measurements. This angle was reproduced reliably in clinical cases for localizing the IAM during anterior petrosectomy.
The FO–FS-IAM angle variance was much lower than the analogous angles measured by Garcia-Ibanez and Fisch techniques, making it a more reliable and effective tool for localizing the IAM.
Display omitted
The aim of this systematic review is to analyse the role of hearing preservation surgery for vestibular schwannoma. The complications and hearing outcomes of the single surgical techniques were ...investigated and compared with those of less invasive strategies, such as stereotactic radiotherapy and wait and scan policy. This systematic review and meta-analysis was performed according to the PRISMA guidelines. All included studies were published in English between 2000 and 2022. Literature data show that hearing preservation is achieved in less than 25% of patients after surgery and in approximately half of cases after stereotactic radiotherapy, even if data on long-term preservation are currently not available.
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