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ABSTRACT: Determine the prevalence of carotid artery injury (CAI) in patients with basilar skull fractures and describe significant demographic and radiographic risk factors for CAI.
From January 2004 to December 2008, medical records of 1,279 consecutive adult patients treated for basilar skull fractures at a tertiary care academic hospital were retrospectively reviewed. Diagnostic angiography was performed in 112 patients because of concern for CAI. Computed tomographic studies of the head and cranial base were reviewed for evidence of pneumocephalus, petrous carotid canal fractures, and sphenoid bone fractures.
Mean age of patients undergoing angiography was 38.7 years, and 85 patients (75.9%) were male subjects. Thirty-five (50%) of 70 discrete cerebrovascular injuries on angiography involved the carotid canal. The prevalence of CAI in patients with basilar skull trauma was 2.0%. CAI was associated with female sex (p = 0.001), whereas lower Glasgow Coma Scale score approached statistical significance (p = 0.07). Sensitivity and specificity of the 3 computed tomographic findings individually were 44% to 68% and 41% to 67%, respectively. With all 3 findings concurrently, 85% specificity and 80% negative predictive value for CAI were obtained, although sensitivity declined.
The frequency of CAI in patients with basilar skull fractures was higher than that in those without basilar skull involvement. Female sex was strongly associated with CAI. The intimate anatomic relationship between the carotid artery and the cranial base posit substantial diagnostic and therapeutic challenges for the contemporary cranial base surgeon, and thus, understanding the epidemiology and risk factors for CAI is of paramount importance.
Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 07/2011; 32(5):882-6. · 1.44 Impact Factor
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ABSTRACT: To better understand the drainage patterns of the 3 largest superficial anastomotic veins (SAVs), namely, vein of Labbé (VL), the vein of Trolard (VT), and the superficial sylvian vein (SSV). To assess the dominance of the VL in the superficial cortical venous system, because this vein may be encountered in neurotologic surgery and its interruption may result in a venous infarct of the temporal lobe.
The database of the radiology department at the University of Cincinnati was used to identify all patients who underwent a diagnostic angiographic study between September 1, 2009, and January 1, 2010. Studies were excluded if there were intracranial masses or vascular lesions. Angiograms were assessed for the presence of the VL, VT, and SSV, as well as vessel dominance, determined by their relative calibers.
A total of 101 patients (81%) underwent bilateral and 48 unilateral angiography, for a total of 250 studies. Mean age was 55 years (range, 16-83 yr). Seventy-seven patients (53%) were females. The most common pattern observed was the presence of all 3 SAVs (78%). The VL was absent or poorly developed in 34 studies (14%) and was the dominant superficial vein in 51 (20%), of which 28 (55%) occurred on the right.
Considerable variability is demonstrated in the drainage patterns of the SAVs. Care should be taken in neurotologic surgery to avoid injuring the VL because this may represent the single dominant drainage pathway of the lateral surface of the temporal lobe in a large number of patients.
Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 06/2011; 32(6):1012-6. · 1.44 Impact Factor
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ABSTRACT: Temporal bone fractures (TBFs) are a frequent manifestation of head trauma. We investigated the prevalence of concurrent intracranial injuries (ICIs) and cervical spine injuries (CSIs) in a series of patients with TBFs and attempted to identify significant associations between current TBF classification systems and either ICI or CSI.
Retrospective case series with chart review.
The records of all patients ≥18 years of age diagnosed with a basilar skull fracture, including TBF, at a level I trauma center from 2004 to 2009 were reviewed. Patient demographics, mechanism of injury, and Glasgow Coma Scale (GCS) scores were collected. Imaging studies were reviewed to classify TBF using the traditional longitudinal-transverse-mixed and otic capsule-sparing versus -involving systems and identify concurrent ICI and CSI.
Of 1,279 patients, 202 (15.8%) met inclusion criteria. There were 160 (79.2%) males. Sixteen (7.9%) patients had bilateral TBFs. Falls (n = 66, 32.7%) represented the most common mechanism for TBF. Longitudinal (n = 96, 44.0%) and otic capsule-sparing (n = 209, 95.9%) fractures were the most prevalent subtypes. There were 184 (91.1%) patients who sustained ICI and 18 (8.9%) who demonstrated CSI. Longitudinal, transverse, mixed, otic capsule-sparing, or otic capsule-involving TBF subtypes had no statistically significant associations with mechanism of injury, GCS score, or concomitant ICI or CSI.
More than 90% of patients sustaining TBF presented with concomitant ICI, and 9% sustained CSI. Current TBF classification systems do not correlate with these outcomes. A more sophisticated, multidisciplinary classification system encompassing radiographic and clinical findings may better predict neurologic, neuro-otologic, and skull base complications.
The Laryngoscope 05/2011; 121(5):929-32. · 1.75 Impact Factor
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The Laryngoscope 03/2011; 121(3):574-6. · 1.75 Impact Factor
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ABSTRACT: Temporal bone imaging in children has several inherent limitations. Computed tomography has the disadvantage of ionizing radiation, possible sedation, cost and accessibility. Magnetic resonance imaging has most of these disadvantages, with the exception of radiation, and provides bone images of limited resolution. Recent advances in ultrasound have led to its increased application in numerous medical fields. The purpose of this study was to investigate the ability of four-dimensional ultrasound (4DUS) to image middle ear ossicles in vitro and determine if this technology should be adapted for future clinical use.
Thirty cadaveric ossicles (10 malleus, 10 incus, and 10 stapes) were randomized and measured by two evaluators under a microscope. The ossicles were then immersed in a cold water bath and imaged, randomized, and measured using four-dimensional ultrasound by the same two evaluators. A separate cadaveric temporal bone, modified to allow the ultrasound probe to rest on the tympanic membrane, was imaged to visualize the ossicles in situ and evaluate whether or not the tympanic membrane and malleus would impede visualization of more medial structures.
Microscopic measurements were: malleus (h=8.0 mm+/-0.32, w=2.7 mm+/-0.20), incus (h=6.8 mm+/-0.41, w=5.3 mm+/-0.46), stapes (h=3.5 mm+/-0.34, w=2.4 mm+/-0.17). Inter-rater reliability was 0.8. Measurements were in agreement with previously published values. Ultrasound measurements were: malleus (h=8.0 mm+/-0.51, w=2.9 mm+/-0.27), incus (h=6.8 mm+/-0.49, w=5.5 mm+/-0.42), stapes (h=3.6 mm+/-0.41, w=2.5 mm+/-0.19). Inter-rater reliability was 0.7. Mean intra-class correlation coefficient for microscopic and ultrasound measurements was 0.7. Images of the ossicular chain in continuity in the temporal bone specimen were not as clear as images of individual ossicles that were disarticulated and imaged under water.
4DUS provides reasonable images of ossicles disarticulated and mounted in underwater medium. However, images of the intact ossicular chain in a modified cadaveric temporal bone were not as clear, making interpretation difficult. Further investigation into the development of a thinner ultrasound probe that can pass through the external auditory canal and into overcoming limitations of air in the middle ear cleft are warranted. This could allow for a clinically relevant, faster, lower cost and lower risk alternative to current imaging techniques.
International journal of pediatric otorhinolaryngology 09/2010; 74(9):1028-33. · 0.85 Impact Factor
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ABSTRACT: Ewing's sarcoma, which accounts for 6 to 9% of malignant bone neoplasms in children, typically affects the trunk and long bones and less often affects the skull (i.e., maxilla, frontal, parietal, ethmoid, temporal bones). Adding to literature of five previously reported cases, we now describe the case of the oldest child, a 16-year-old boy, with a primary Ewing's sarcoma of the petrous temporal bone. When this patient presented after 1 week of right-sided facial paralysis and new-onset headache, imaging studies showed a mass that originated in the right petrous temporal bone. During biopsy and surgical excision, the mass was found to involve the facial nerve, which then required nerve grafting. Postoperatively, he then underwent radiotherapy with both induction and adjuvant chemotherapy. Although an uncommon tumor of the temporal bone, physicians should consider Ewing's sarcoma in the differential diagnosis of children and adolescents who present with facial nerve paralysis.
Skull Base 05/2010; 20(3):213-7. · 0.66 Impact Factor
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ABSTRACT: 1) To define the surgical anatomy and dimensions of the infracochlear approach to the petrous apex through the use of high-resolution computed tomography and 2) use of digitized images of cadaveric temporal bones for computer simulation of infracochlear access using the Ohio Supercomputer Center/Ohio State University temporal bone simulator.
The petrous apex is a surgically challenging area to access. Many routes have been described and used successfully in clinical practice. However, these routes have not been defined with the aim of application in computer-assisted surgery. The infracochlear approach, due to its access via a transcanal route, affords the opportunity for its potential application in minimally invasive computer-assisted surgery.
High-resolution computed tomographic scans were performed on 102 cadaveric skulls (204 temporal bones). Standard measurements were taken using an open-source picture archiving and communication system software of the maximum height, width, and depth of the infracochlear approach. In addition, the maximum diameter of a circular fenestration that could be created in the infracochlear space without breaching the basal turn of the cochlea, internal carotid artery, or the jugular bulb was used to simulate a drill path. In addition, 5 temporal bone specimens (3 left, 2 right) underwent high-resolution computed tomography, with the digitized images being used to create simulated temporal bones for infracochlear surgical access; the transcanal infracochlear approach was then performed by the same surgeon on the cadaveric bone.
The mean height, width, and depth of the infracochlear space in temporal bones with nonpneumatized petrous apices were 7.2 +/- 0.4, 9.4 +/- 0.8, and 17.5 +/- 1.0 mm, respectively. Corresponding dimensions in pneumatized petrous apices were 7.6 +/- 0.4, 10.1 +/- 1.1, and 18.6 +/- 0.8 mm, respectively. The mean diameter of the circular fenestra in the nonpneumatized petrous apices was 5.1 +/- 0.4 compared with 5.7 +/- 0.6 mm in pneumatized petrous pieces. This was statistically significant (unpaired t test; p value = 0.04). The time to perform a simulated infracochlear approach to the petrous apex ranged from 3.1 to 12.6 minutes (mean, 6.1 minutes). The time to perform the same approach on the cadaveric bone ranged from 4.32 to 14.1 minutes (mean, 9.3 minutes).
Temporal bones with pneumatized petrous apices have an overall larger infracochlear space. The mean diameter of a circular infracochlear path that would avoid damage to vital structures was sufficiently large in both pneumatized and nonpneumatized petrous apices to have a potential application as a safe approach in computer-assisted surgery. Such an application is feasible with mating of a robotic system with computed tomographic- or magnetic resonance imaging-guided imagery, which is the next phase of this study.
Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 04/2010; 31(3):419-23. · 1.44 Impact Factor
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ABSTRACT: Comparison of audiometric outcomes between patients with definite Meniere's disease who underwent endolymphatic mastoid sac surgery (EMSS) following failed medical therapy and patients who underwent medical therapy only.
Retrospective chart review of 456 consecutive patients between 1997 and 2006.
Outcome measures were changes in pure-tone average (PTA), word recognition score (WRS), and speech reception threshold (SRT).
Of 58 qualified patients, 29 who underwent EMSS after failing medical therapy showed a 4 dB decrease in PTA, a 2% increase in WRS, and a 2 dB decrease in SRT. Twenty-nine patients treated with medical therapy only demonstrated a 1 dB PTA increase, 2% WRS improvement, and 2 dB SRT improvement. No significant difference was noted between the medically and surgically managed patients in terms of changes in PTA (P = .34) or WRS (P = .95) after treatment. Of all patients in the study, 60% had no clinically significant change in hearing, whereas 24% improved and 16% worsened. The distribution of post-treatment hearing changes between the medical and surgical groups was statistically insignificant (P = .17).
The changes in PTA and WRS among patients with Meniere's disease managed with medical therapy or EMSS were not statistically significant. Although performing EMSS to treat the vertigo of Meniere's disease does not appear to be associated with an increased risk of deteriorating auditory function after treatment, surgery also does not confer an increased likelihood of stabilizing or improving hearing.
The Laryngoscope 03/2010; 120(3):591-7. · 1.75 Impact Factor
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Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 03/2010; 32(2):e9-10. · 1.44 Impact Factor
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ABSTRACT: Use of hydroxyapatite cement has been advocated for closure of transpetrosal defects to decrease the incidence of cerebrospinal fluid leaks. We previously identified delayed extrusion of this cement as a significant complication associated with this closure technique and now update our long-term experience.
In our retrospective review, we identified 1231 patients who underwent transpetrosal procedures by our multidisciplinary cranial base team between 1984 and 2005. Of the subgroup of 177 patients who had hydroxyapatite cement used during the closure of the procedure, 13 patients (7.3%) experienced delayed extrusion of hydroxyapatite cement.
Extrusion occurred in 3 patients within 12 months and in 10 patients within 68 to 140 months. Twelve patients presented with draining fistulae and concomitant Staphylococcus aureus infection; 1 patient presented asymptomatically with a large temporal lobe abscess identified on surveillance magnetic resonance imaging. All 13 patients underwent reoperation, including 1 who underwent a second procedure.
Delayed extrusion of hydroxyapatite cement resulted in significant morbidity to our patients and often presented in an indolent manner. We recommend serial examination and imaging studies in patients who have had transpetrosal closures with hydroxyapatite cement. Because of the complication rates associated with hydroxyapatite cement, we have discontinued its use.
Neurosurgery 04/2009; 64(3):527-31; discussion 531-2. · 2.79 Impact Factor
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ABSTRACT: In the past few years, otologists have been seeing an increasing number of patients with vestibular disorders due to migraine-associated vestibulopathy. This article reviews some of the latest developments in the understanding of this disease process, specifically its incidence, symptoms, diagnosis, and treatment.
Migraine-associated vestibular symptoms may include episodic true vertigo, movement-provoked dysequilibrium, imbalance/unsteadiness, and complaints of lightheadedness. The pathophysiology of migraine-associated vestibulopathy is not completely understood; however, both peripheral and central deficits have been observed. Although the International Headache Society classification does not include migraine-associated vestibulopathy as a subclassification of migraine, there is emerging evidence to support this development, which should then lead toward improved diagnosis and treatment. Currently, migraine-associated vestibulopathy is still considered a diagnosis of exclusion.
Treatment of migraine-associated vestibulopathy is effective and includes lifestyle changes, such as reducing triggers that increase susceptibility to migraines (e.g. stress, poor diet, nicotine, or irregular sleep patterns), prophylactic and abortive medications, vestibular therapy, or a combination of these. Further research is needed to better understand migraine-associated vestibulopathy and improve treatment.
Current opinion in otolaryngology & head and neck surgery 11/2008; 16(5):412-5.
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ABSTRACT: To determine whether aeration of surgically treated petrous apex cholesterol granulomas (PA CG) has any correlation with resolution of symptoms.
Retrospective chart review.
Twenty-six patients with a petrous apex cholesterol granuloma during a 16-year period were reviewed.
Seventeen of 26 (65%) patients underwent surgical intervention. Preoperative symptoms included headache, facial weakness/twitching or numbness, vertigo, hearing loss, vision changes, and tinnitus. Postoperative symptoms resolved in 9 of the 16 patients (56%). Three patients had a postoperative headache. Facial nerve dysfunction persisted or recurred in four patients. One patient was lost to follow-up. Thirteen patients had postoperative imaging. All 13 (100%) patients demonstrated stable or increased size of PA CG with no evidence of aeration. Revision surgery was performed in four patients (25%) for facial nerve symptoms or persistent headaches.
The extent of PA CG aeration on postoperative imaging had no correlation to symptom resolution or cyst enlargement. Revision surgery should not depend on imaging alone but primarily on patient symptoms and physical exam.
Otolaryngology Head and Neck Surgery 05/2008; 138(4):518-22. · 1.72 Impact Factor
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ABSTRACT: This article reviews the literature on vestibular-evoked myogenic potential testing, a short latency electromyogram evoked by high acoustic stimuli and recorded via surface electrodes over the sternocleidomastoid muscle. Applications and refinements of this technique are described for different pathologies and in adults and children.
Various techniques for electrode placement have been described to elicit a vestibular-evoked myogenic potential response, which has been clinically investigated in normal individuals, under pathological conditions, and in adult and pediatric patients. As vestibular-evoked myogenic potential amplitude is linearly related to the level of background activity of the sternocleidomstoid muscle, maintaining steady contraction of the muscle can be challenging in some patients.
Vestibular-evoked myogenic potential testing may provide additional information about the vestibular system and allow site of lesion testing (e.g. saccule and inferior vestibular nerve) in patients of all ages. Its role has yet to be defined in the diagnosis and treatment of common vestibular disorders, including Meniere's disease, vestibular neuronitis, labyrinthitis, and other diseases. Further research is needed to support its clinical usefulness in patients with balance disorders, to optimize patient selection, and to establish its cost effectiveness.
Current Opinion in Otolaryngology & Head and Neck Surgery 11/2007; 15(5):330-4. · 1.83 Impact Factor
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ABSTRACT: Objective: The middle cranial fossa approach has been used to explore and decompress the facial nerve in patients with Bell's 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.
The Laryngoscope 04/2007; 117(5):872 - 875. · 1.75 Impact Factor
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Skull Base Surgery 04/2007; 17(2):141-3. · 0.66 Impact Factor
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ABSTRACT: : To review the long-term results of hydroxyapatite closure of transpetrosal defects.
: Retrospective chart review.
: One hundred seventy-seven patients were followed for more than 5 years. After surgical management by way of transpetrosal routes, hydroxyapatite was placed after medial wound closure with abdominal fat and before a three-layered lateral soft tissue closure.
: Among this group of patients, three (1.7%) cerebrospinal fluid (CSF) leaks were encountered. None of these required re-operation. Delayed extrusion of hydroxyapatite with concomitant superficial wound infections have occurred in seven (4%) patients. All required operative re-intervention.
: Hydroxyapatite has proven to be an effective material in the closure of skull base defects. Nevertheless, delayed extrusion of this agent can occur, resulting in the potential for morbidity and the need for operative re-intervention.
The Laryngoscope 11/2006; 116(10):1817-9. · 1.75 Impact Factor
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ABSTRACT: 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.
Otolaryngologic Clinics of North America 09/2006; 39(4):699-712, vi. · 1.65 Impact Factor
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Ontology & Neurotology 10/2005; 26(5):1041-4. · 1.90 Impact Factor
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ABSTRACT: We discuss the first reported case of a chronic leukemia involving the external auditory canal.
Case report and review of the literature (Medline, 1962-2003).
An adult man in good health came to receive medical attention because of a sensation of aural fullness. Radiologic and physical examination demonstrated an ovoid soft tissue mass of the lateral external auditory canal that, after biopsy and flow cytometry studies, was found to be T-cell prolymphocytic leukemia. The patient presented with minimal disease in a highly symptomatic location, allowing early initiation of therapy and extending his life by nearly four times the average life expectancy for this aggressive chronic leukemia.
Lymphomas of the external auditory canal are extremely rare neoplasms. Only a few cases have previously been reported, and all of the previous reports involve acute leukemias. This report indicates that chronic leukemias can present with otologic manifestations such as an external auditory canal mass.
Ontology & Neurotology 12/2004; 25(6):1006-8. · 1.90 Impact Factor
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ABSTRACT: A pseudomeningocele results from the escape of cerebrospinal fluid through a dural defect with trapping of subarachnoid fluid in surrounding soft tissue. The present study evaluates the incidence of pseudomeningocele following neurotologic procedures and delineates an algorithm for management.
A retrospective review of 375 consecutive patients undergoing neurotologic procedures at a single institution identified 17 patients with the postoperative complication of pseudomeningocele.
The incidence of pseudomeningocele formation was 4.5% in the present study. Fourteen pseudomeningoceles resolved with nonoperative management including pressure dressing, bed rest, and lumbar spinal drainage. Three patients failed nonoperative management and required surgical procedures for resolution. All patients ultimately had resolution of their pseudomeningocele.
Skull-base pseudomeningoceles occur as a complication following neurotologic procedures and can cause complications as they enlarge. The majority of these cases can be dealt with in a nonsurgical manner, but those failing to respond to conservative management should be considered for surgical intervention.
Otolaryngology Head and Neck Surgery 10/2004; 131(3):253-62. · 1.72 Impact Factor
