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This paper describes the construction of portals for electrode placement during cochlear implantation and emphasises the utility of pre-operative temporal bone three-dimensional computed tomography.
Temporal bone three-dimensional computed tomography was used to plan portal creation for electrode insertion.
Pre-operative temporal bone three-dimensional computed tomography can be used to determine the orientation of temporal bone structures, which is important for mastoidectomy, posterior tympanotomy and cochleostomy, and when using the round window approach.
It is essential to create appropriate portals (from the mastoid cortex to the cochlea) in a step-by-step manner, to ensure the safe insertion of electrodes into the scala tympani. Pre-operative three-dimensional temporal bone computed tomography is invaluable in this respect.
Aerosol generation during temporal bone surgery caries the risk of viral transmission. Steps to mitigate this problem are of particular importance during the coronavirus disease 2019 pandemic.
To quantify the effect of barrier draping on particulate material dispersion during temporal bone surgery.
The study involved a cadaveric model in a simulated operating theatre environment. Particle density and particle count for particles sized 1–10 μ were measured in a simulated operating theatre environment while drilling on a cadaveric temporal bone. The effect of barrier draping to decrease dispersion was recorded and analysed.
Barrier draping decreased counts of particles smaller than 5 μ by a factor of 80 in the operating theatre environment. Both particle density and particle count showed a statistically significant reduction with barrier draping (p = 0.027).
Simple barrier drapes were effective in decreasing particle density and particle count in the operating theatre model and can prevent infection in operating theatre personnel.
To depict various temporal bone abnormalities on high-resolution computed tomography in congenital aural atresia patients, and correlate these findings with auditory function test results and microtia subgroup.
Forty patients (56 ears) with congenital malformation of the auricle and/or external auditory canal were evaluated. Auricles were graded according to Marx's classification, divided into subgroups of minor (grades I and II) and major (III and IV) microtia. Other associated anomalies of the external auditory canal, tympanic cavity, ossicular status, oval and round windows, facial nerve, and inner ear were evaluated.
Minor and major microtia were observed in 53.6 and 46.4 per cent of ears respectively. Mean hearing levels were 62.47 and 62.37 dB respectively (p = 0.98). The malleus was the most commonly dysplastic ossicle (73.3 vs 80.8 per cent of ears respectively, p = 0.53). Facial nerve (mastoid segment) abnormalities were associated (p = 0.04) with microtia subgroup (80 vs 100 per cent in minor vs major subgroups).
Microtia grade was not significantly associated with mean hearing levels or other ear malformations, except for external auditory canal and facial nerve (mastoid segment) anomalies. High-resolution computed tomography is essential in congenital aural atresia, before management strategy is decided.
This study aimed to evaluate the association between cochlear nerve canal dimensions and semicircular canal abnormalities and to determine the distribution of bony labyrinth anomalies in patients with cochlear nerve canal stenosis.
This was a retrospective study in which high-resolution computed tomography images of paediatric patients with severe-to-profound sensorineural hearing loss were reviewed. A cochlear nerve canal diameter of 1.5 mm or less in the axial plane was classified as stenotic. Semicircular canals and other bony labyrinth morphology and abnormality were evaluated.
Cochlear nerve canal stenosis was detected in 65 out of 265 ears (24 per cent). Of the 65 ears, 17 ears had abnormal semicircular canals (26 per cent). Significant correlation was demonstrated between cochlear nerve canal stenosis and semicircular canal abnormalities (p < 0.01). Incomplete partition type II was the most common accompanying abnormality of cochlear nerve canal stenosis (15 out of 65, 23 per cent).
Cochlear nerve canal stenosis is statistically associated with semicircular canal abnormalities. Whenever a cochlear nerve canal stenosis is present in a patient with sensorineural hearing loss, the semicircular canal should be scrutinised for presence of abnormalities.
Necrotising otitis externa is a progressive infection of the external auditory canal which extends to affect the temporal bone and adjacent structures. Progression of the disease process can result in serious sequelae, including cranial nerve palsies and death. There is currently no formal published treatment guideline.
This study aimed to integrate current evidence and data from our own retrospective case series in order to develop a guideline to optimise necrotising otitis externa patient management.
A retrospective review of necrotising otitis externa cases within NHS Lothian, Scotland, between 2013 and 2018, was performed, along with a PubMed review.
Prevalent presenting signs, symptoms and patient demographic data were established. Furthermore, features of cases associated with adverse outcomes were defined. A key feature of the guideline is defining at-risk patients with initial intensive treatment. Investigations and outcomes are assessed and treatment adjusted appropriately.
This multi-departmental approach has facilitated the development of a succinct, systematic guideline for the management of necrotising otitis externa. Initial patient outcomes appear promising.
To investigate the prevalence of bony dehiscence in the tympanic facial canal in patients with acute otitis media with facial paresis compared to those without facial paresis.
A retrospective case–control study was conducted on acute otitis media patients with facial paresis undergoing high-resolution temporal bone computed tomography.
Forty-eight patients were included (24 per group). Definitive determination of the presence of a bony dehiscence was possible in 44 out of 48 patients (91.7 per cent). Prevalence of bony dehiscence in acute otitis media patients with facial paresis was not different from that in acute otitis media patients without facial paresis (p = 0.21). Presence of a bony dehiscence was associated with a positive predictive value of 66.7 per cent in regard to development of facial paresis. However, an intact bony tympanic facial canal did not prevent facial paresis in 44.8 per cent of cases (95 per cent confidence interval = 34.6–55.6).
Prevalence of bony dehiscence in acute otitis media patients with facial paresis did not differ from that in acute otitis media patients without facial paresis. An intact tympanic bony facial canal does not protect from facial paresis development.
To review the management of temporal bone fractures at a major trauma centre and introduce an evidence-based protocol.
A review of reports of head computed tomography performed for trauma from January 2012 to July 2018 was conducted. Recorded data fields included: mode of trauma, patient age, associated intracranial injury, mortality, temporal bone fracture pattern, symptoms and intervention.
Of 815 temporal bone fracture cases, records for 165 patients met the inclusion criteria; detailed analysis was performed on the records of these patients.
Temporal bone fractures represent high-energy trauma. Initial management focuses on stabilisation of the patient and treatment of associated intracranial injury. Acute ENT intervention is directed towards the management of facial palsy and cerebrospinal fluid leak, and often requires multidisciplinary team input. The role of nerve conduction assessment for immediate facial palsy is variable across the UK. The administration of high-dose steroids in patients with temporal bone fracture and intracranial injury is not advised. A robust evidence-based approach is introduced for the management of significant ENT complications associated with temporal bone fractures.
This study aimed to assess the potential role of pneumatisation of the mastoid and its communicating air cells in the development of middle-ear barotrauma in aircrew members.
Seventy-nine aircrew members (158 ears) underwent temporal computed tomography. All were assessed before flying by clinical examination and audiology evaluation, followed by post-flight examination to detect barotrauma.
Aircrew members’ ears were divided into 3 groups based on barotrauma and temporal bone pneumatisation: 33 ears with barotrauma and temporal bone pneumatisation of 71 cm3 or greater (group A); 12 ears with barotrauma and temporal bone pneumatisation of 11.2 cm3 or lower (group B); and 113 ears with no barotrauma (group C). Mean pneumatisation volumes were 91.05 cm3, 5.45 cm3 and 28.01 cm3 in groups A, B and C, respectively. A direct relationship was observed between volume of temporal bone pneumatisation of 71 cm3 or greater and barotrauma grade.
Pneumatisation volume of the mastoid and its communicating air cells that ranges from 11.3 cm3 to 70.4 cm3 serves as a reliable predictor of the avoidance of middle-ear barotrauma associated with flying in aircrew members who have normal resting middle-ear pressure and good Eustachian tube function.
To compare round window niche visibility as seen endoscopically during cochlear implant surgery with pre-operative high-resolution computed tomography of the temporal bone.
Nineteen patients scheduled for cochlear implantation, aged 2–20 years, were referred for computed tomography from October 2016 to March 2018. Angles were measured between the lines passing through the mid-sagittal plane and cochlear basal turn on the scans. Endoscopic round window niche visibility during posterior tympanotomy was categorised as: type I = 100 per cent, type IIa = more than 50 per cent, type IIb = less than 50 per cent or type III = 0 per cent. Pre-operative computed tomography measurements were used to predict round window niche visibility before surgery and correlated with intra-operative findings.
The mean (range) of pre-operative angles on computed tomography for endoscopic visibility types I, IIa and IIb, were 64.06° (61.16–69.37°), 63.81° (58.61–71.35°) and 56.48° (50.37–59.05°), respectively, a statistically significant finding (one-way analysis of variance test, p = 0.016).
Pre-operative high-resolution temporal bone computed tomography measurements are useful in predicting round window niche visualisation as viewed endoscopically during posterior tympanotomy. The angle was more acute in type IIb compared to type I.
The Bonebridge is an active transcutaneous bone conduction implant recommended as a surgical option for adults and children (aged 5–18 years). Successful implantation of the Bonebridge is often restricted by an insufficient amount of temporal bone to house the transducer in the paediatric patient.
Method and results
In this unique paediatric case, bilateral Bonebridge devices were implanted simultaneously in the right sinodural angle and the left middle cranial fossa.
The simultaneous implantation of bilateral Bonebridge devices was well tolerated in this paediatric patient, with significant improvement in her hearing. The middle cranial fossa is a viable option for housing the transducer.
This study gives details of a rare case of petrous apicitis that presented as Gradenigo's syndrome and was managed surgically.
This study presents a case report and review of the literature.
A four-year-old female was admitted for failure to thrive following recent sinusitis. Physical examination was positive for right sided facial pain, photophobia and right abducens nerve palsy. Subsequent magnetic resonance imaging revealed a 1.3 × 1.7 × 1.4 cm abscess encompassing the right Meckel's cave. A computed tomography scan showed petrous apicitis and otomastoiditis, confirming Gradenigo's syndrome. The patient was taken to the operating theatre for right intact canal wall mastoidectomy with myringotomy and tube placement. She was discharged on six weeks of ceftriaxone administered by a peripherally inserted central catheter line. At a two-week post-operative visit, she showed notable improvement in neuropathic symptoms.
This study presents a rare case of petrous apicitis managed surgically without the need for a craniotomy or transcochlear procedure.
The transmastoid pre-sigmoid approach is always the preferred choice for implantation of the Bonebridge active bone conduction system in patients with a normal anatomy. When an anatomical variant exists or a previous surgery has been performed, a retrosigmoid approach or middle fossa approach can be performed.
The preferred surgical technique for a middle fossa approach is described. A 14 mm drill head (Neuro Drill) was used to create the bed at the squamous portion of the temporal bone. Surgical time and complication rate were analysed.
The surgical time was shorter than 30 minutes in all cases, and only 14 seconds were needed to create a 14 mm bone bed. No complications were observed during the follow-up period (6–45 months).
Use of the Neuro Drill for the middle fossa approach is an easy technique. It significantly decreases the surgical time, without increasing the complication rate.
To recount experience with cerebrospinal fluid otorrhoea and temporal bone meningoencephalocele repair in a tertiary care hospital.
A retrospective review was conducted of 16 cerebrospinal fluid otorrhoea and meningoencephalic herniation patients managed surgically from 1991 to 2016.
Aetiology was: congenital (n = 3), post-traumatic (n = 2), spontaneous (n = 1) or post-mastoidectomy (n = 10). Surgical repair was undertaken by combined middle cranial fossa and transmastoid approach in 3 patients, transmastoid approach in 2, oval window plugging in 1, and subtotal petrosectomy with middle-ear obliteration in 10. All patients had successful long-term outcomes, except one, who experienced recurrence after primary stage oval window plugging, but has been recurrence-free after second-stage subtotal petrosectomy with middle-ear obliteration.
Dural injury or exposure in mastoidectomy may lead to cerebrospinal fluid otorrhoea or meningoencephalic herniation years later. Congenital, spontaneous and traumatic temporal bone defects may present similarly. Middle cranial fossa dural repair, transmastoid multilayer closure and subtotal petrosectomy with middle-ear obliteration were successful procedures. Subtotal petrosectomy with middle-ear obliteration offers advantages over middle cranial fossa dural repair alone; soft tissue closure is more robust and is preferred in situations where hearing preservation is not a priority.
This case report illustrates an unusual case of a dural arteriovenous fistula and an associated encephalocele presenting as otitis media with effusion.
A 53-year-old man presented with right-sided hearing loss and aural fullness of 2 years’ duration. Examination revealed ipsilateral post-auricular pulsatile tenderness. Computed tomography showed transcalvarial channels suggestive of dural arteriovenous fistula. Further magnetic resonance imaging demonstrated the presence of a temporal encephalocele herniating through the tegmen tympani defect, as well as the abnormal vascularity. Angiography confirmed a Cognard type I dural arteriovenous fistula, which is being managed conservatively. Surgical repair of the encephalocele was recommended but declined by the patient.
Dural arteriovenous fistula is an uncommon intracranial vascular malformation rarely seen by otolaryngologists, with pulsatile tinnitus being the usual presentation. To our knowledge, this is the first reported case of dural arteriovenous fistula presenting with conductive hearing loss and otalgia.
To investigate the effectiveness and usability of automated procedural guidance during virtual temporal bone surgery.
Two randomised controlled trials were performed to evaluate the effectiveness, for medical students, of two presentation modalities of automated real-time procedural guidance in virtual reality simulation: full and step-by-step visual presentation of drillable areas. Presentation modality effectiveness was determined through a comparison of participants’ dissection quality, evaluated by a blinded otologist, using a validated assessment scale.
While the provision of automated guidance on procedure improved performance (full presentation, p = 0.03; step-by-step presentation, p < 0.001), usage of the two different presentation modalities was vastly different (full presentation, 3.73 per cent; step-by-step presentation, 60.40 per cent).
Automated procedural guidance in virtual temporal bone surgery is effective in improving trainee performance. Step-by-step presentation of procedural guidance was engaging, and therefore more likely to be used by the participants.
Gorham–Stout disease of the skull is a very rare entity. It presents with gradual bone resorption, and proliferation of lymphoid and vascular channels within the bony matrix. This is often a diagnosis of exclusion confirmed with serial imaging and based on radiological evidence.
A case of Gorham–Stout disease of the temporal bone involving the temporomandibular joint, and presenting with sensorineural hearing loss and recurrent temporomandibular joint dislocation, is reported. The findings are presented and the literature on this condition is reviewed.
ENT and maxillofacial surgeons should be aware of this extremely rare cause of temporomandibular joint dislocation and ear symptoms. Imaging comprising computed tomography and magnetic resonance imaging is crucial to achieving a diagnosis, which may only become evident after repeated imaging follow up. Symptomatic treatment is advised, with the option of anti-osteoclastic medication and radiotherapy indicated for advanced cases. Surgery is only recommended for complications including involvement of neurovascular structures.
To highlight a case from 1960 connecting endolymphatic sac tumour and von Hippel–Lindau disease.
In 1960, a 24-year-old woman presented with unilateral hearing loss, pulsatile tinnitus and a mass visible on otoscopy. The patient underwent surgical biopsy, which was complicated by haemorrhage, and ultimately resulted in death. At autopsy, a destructive temporal bone neoplasm with cystic and papillary architecture was observed that had eroded into the otic capsule. Intra-abdominal lesions consistent with von Hippel–Lindau disease were also observed, and the surgeon postulated a connection between endolymphatic sac tumour and von Hippel–Lindau disease.
A review of the literature was carried out using PubMed.
Endolymphatic sac tumours are rare neoplasms of the temporal bone that can occur sporadically or as part of von Hippel–Lindau disease. The connection between endolymphatic sac tumour and von Hippel–Lindau disease was first proposed in 1988 and formalised in 1997. We believe that this case represents the first documented connection between endolymphatic sac tumour and von Hippel–Lindau disease.
Medical and educational partnerships between high- and low-resourced countries provide opportunities to have a long-term meaningful impact on medical training and healthcare delivery.
An otolaryngology partnership between Komfo Anokye Teaching Hospital in Kumasi, Ghana, and the University of Michigan Department of Otolaryngology/Head and Neck Surgery has been undertaken to enhance healthcare delivery at both institutions.
A temporal bone dissection laboratory, with the equipment to perform dedicated otological surgery, and academic platforms for clinical and medical education and residency training have been established.
This article describes the details of this partnership in otological surgery and hearing health, with an emphasis on creating in-country surgical simulation, training on newly acquired medical equipment and planning regarding the formulation of objectified metrics to gauge progress going forward.
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.
Surgeons should be aware of the posterior auricular sensory branch and its clinical implications.
Direct extension of an intracranial meningioma to involve the temporal bone is rare. Recognised sites of origin and routes of access to the middle ear and labyrinthine apparatus have been described. Direct spread through the temporal bone to primarily involve the external auditory canal has not been widely reported in the literature.
This paper discusses clinical and radiological findings in three cases of temporal bone meningioma presenting as masses within the external auditory canal.
Diagnosing temporal meningioma can be challenging because of its rarity and the often non-specific clinical and histological findings. It is important for both the surgeon and radiologist to be aware of the diagnosis and its related imaging findings in order to facilitate a timely diagnosis.