D A Moffat

Central Manchester University Hospitals NHS Foundation Trust, Manchester, England, United Kingdom

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Publications (144)183.68 Total impact

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    ABSTRACT: Objective: To determine factors affecting facial nerve outcome of vestibular schwannoma surgery. Methods: This retrospective cohort study comprised 652 patients. The outcome measure was House-Brackmann classification at two years post-operatively. Univariate and multivariate analyses were carried out to determine the factors affecting facial nerve outcome. The incidence rates of hemifacial spasm, metallic taste and crocodile tear syndrome were recorded. Results: For tumours less than 1.5 cm, 95 per cent of outcomes were normal, 100 per cent were satisfactory (House-Brackmann grades I-III) and 0 per cent were unsatisfactory (grades IV-VI). For tumours 1.5-2.4 cm, 83 per cent of outcomes were normal, 99 per cent were satisfactory and 1 per cent were unsatisfactory. For tumours 2.5-3.4 cm, 68 per cent of outcomes were normal, 96 per cent were satisfactory and 4 per cent were unsatisfactory. For tumours 3.5-4.4 cm, 52 per cent of outcomes were normal, 80 per cent were satisfactory and 20 per cent were unsatisfactory. For tumours larger than 4.4 cm, 50 per cent of outcomes were normal, 72 per cent were satisfactory and 28 per cent were unsatisfactory. Conclusion: Tumour size and operation year were significant predictors of facial nerve outcome. The surgical learning curve was steepest for the first 50 patients.
    The Journal of Laryngology & Otology 03/2014; · 0.68 Impact Factor
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    ABSTRACT: To review the treatment of squamous carcinoma of the temporal bone at a regional skull base unit for the period 1982-2012. Retrospective case review. Tertiary referral center. Sixty patients with primary squamous carcinoma of the temporal bone. Multidisciplinary team approach including surgical resection, reconstruction, and postoperative radiotherapy. Disease-specific survival, overall survival. The 5-year disease-specific survival for the whole cohort was 44% (CI, 37%-51%). Multivariable analysis revealed nodal status, poorly differentiated squamous cell histology, and carotid involvement to be poor prognostic indicators. Although the survival figures in this series are comparable with the best outcomes from other units, our experience would suggest improvements can still be achieved by reconsidering the selection of patients for neck dissection and temperomandibular joint excision in early stage disease. We also conclude that postoperative radiotherapy should be delivered to all patients, including surgical salvage cases who may have received previous irradiation. Finally, the minority of patients with poor prognostic features should be offered a more palliative therapeutic approach.
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 01/2014; · 1.44 Impact Factor
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    ABSTRACT: Objective: To review the treatment of squamous carcinoma of the temporal bone at a regional skull base unit for the period 1982-2012. Study Design: Retrospective case review Setting: Tertiary referral center Patients: Sixty patients with primary squamous carcinoma of the temporal bone Interventions: Multi-disciplinary team approach including surgical resection, reconstruction and postoperative radiotherapy Main outcome measures: Disease specific survival, overall survival Results: The five year disease specific survival for the whole cohort was 44% (CI 37-51%). Multivariable analysis revealed nodal status, poorly differentiated squamous cell histology and carotid involvement to be poor prognostic indicators. Conclusion: Although the survival figures in this series are comparable with the best outcomes from other units, our experience would suggest improvements can still be achieved by reconsidering the selection of patients for neck dissection and temperomandibular joint excision in early stage disease. We also conclude that postoperative radiotherapy should be delivered to all patients, including surgical salvage cases who may have received previous irradiation. Finally, the minority of patients with poor prognostic features should be offered a more palliative therapeutic approach.
    Ontology & Neurotology 10/2013; · 2.01 Impact Factor
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    ABSTRACT: Objectives. To analyse the long-term outcome of translabyrinthine surgery for vestibular schwannoma (VS) in neurofibromatosis type 2 (NF2). Research type. Retrospective cohort study. Setting. Two tertiary referral NF2 units. Patients. One hundred and forty eight translabyrinthine operations for patients with VS were performed. Preoperative stereotactic radiotherapy had been performed on 12(9.4%) patients. Results. Mean tumour size was 3.1 cm. Total tumour excision was achieved in 66% of cases, capsular remnants were left in 24% of cases, and subtotal excision was achieved in 5% and partial removal was achieved in 5%. The radiological residual/recurrence rate was 13.9%. The perioperative mortality was 1.6%. At 2 years postoperatively, facial function was expressed in terms of House-Brackmann score (HB): HB 1 in 53.4%, HB 1/2 in 61.3%, HB 1-3 in 83.2% and HB 4-6 in 16.8%. All nine patients who underwent surgery following failed stereotactic radiotherapy had HB 3 function or better. Among 9.5% of the cases, 14 facial nerves were lost during surgery and repaired using direct anastomosis or grafting. There was no tinnitus present preoperatively in 27% of the cases, and 22% of patients developed tinnitus postoperatively. In patients with preoperative tinnitus, 61% remained the same, 17% got it resolved and only in 21% it worsened. The preoperative hydrocephalus rate was 26%, and among 15% of the cases five ventriculo-peritoneal (VP) shunts were performed. The cerebrospinal fluid leak rate was 2.5%. Fifty-six patients underwent auditory brainstem implantation (ABI) and two patients had cochlear implant (CI) sleepers inserted. Conclusions. The management of patients with NF2 presents the clinician with a formidable challenge with many patients still presenting themselves late with the neurological compromise and a large tumour load. There is still an argument for the management by observation until the neurological compromise dictates interventional treatment particularly with the option of hearing rehabilitation with ABI or CI. The translabyrinthine approach provides a very satisfactory means of reducing the overall tumour volume.
    British Journal of Neurosurgery 03/2013; · 0.86 Impact Factor
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    ABSTRACT: Squamous cell carcinoma of the temporal bone is an uncommon tumour normally preceded by a history of inflammation within the external auditory canal or middle ear cavity. Although the human papillomavirus has been implicated in many head and neck malignancies, its role in the pathogenesis of carcinoma affecting the temporal bone has yet to be determined. Polymerase chain reaction was used to detect high risk human papillomavirus subtypes. RNA in situ hybridization, DNA sequence analysis, and p16 immunohistochemistry were employed to confirm positive samples. All specimens underwent separate investigations for the presence of latent and active Epstein-Barr virus infection or mutations within exons 5-9 of the TP53 gene. Genomic DNA was successfully extracted from 14/20 patient tissue samples, as determined by control PCR reactions. Three of these were shown to contain high risk HPV DNA (21.4%). HPV16 subtype was present in all positive cases. No significant difference in disease specific survival was detected for the papillomavirus positive group. One patient was found to have detectable Epstein-Barr virus on PCR, but this was not confirmed on subsequent analysis with immunohistochemistry or in situ hybridization. All TP53 mutations were restricted to the non-viral group. This is the first report to implicate high risk HPV16 in squamous cell carcinoma of the temporal bone by multiple analytic techniques. The study suggests the need for further investigation, and if confirmed may set the foundations for stratification of treatment according to a viral aetiology.
    Head & Neck Oncology 02/2013; 5(2):22. · 3.13 Impact Factor
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    ABSTRACT: Vestibular Schwannoma (VS) is a slow-growing, intracranial extra-axial benign tumor that develops from the vestibular nerve, or very rarely from the cochlear nerve. The tumor is located along the course of the nerve that is, between the inner ear and the brainstem in the internal auditory canal and the cerebello-pontine angle (CPA). This review summarizes the current knowledge on clinical and molecular aspects of vestibular schwannoma development with special emphasis on cellular de-differentiation of Schwann cells into plastic neural crest stem cell-like phenotype as the potentially involved cellular and molecular mechanism.
    Head & Neck Oncology 02/2013; 16(5(2)):20. · 3.13 Impact Factor
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    ABSTRACT: Vestibular schwannoma (VS) is a slow-growing, intracranial extra-axial benign tumour that develops from the vestibular nerve, or very rarely from the cochlear nerve. The tumour is located along the course of the nerve that is between the inner ear and the brainstem in the internal auditory canal and the cerebellopontine angle. This review summarizes the current knowledge on clinical and molecular aspects of VS development with special emphasis on cellular dedifferentiation of Schwann cells to plastic, neural crest stem cell-like phenotype. We also summarize the signalling cascades potentially involved in VS development and dedifferentiation of Schwann cells after injury.
    Head & Neck Oncology 01/2013; 5(2):20. · 3.13 Impact Factor
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    ABSTRACT: To assess the growth characteristics of small- to medium-sized vestibular schwannomas in patients undergoing watch, wait, and rescan management. Cohort study using prospectively collected size and tumor morphology data. Tertiary referral center for cranial base surgery. Three hundred eighty-one patients with sporadic unilateral vestibular schwannomas and 2 or more magnetic resonance scans were included. Linear measurements were used to assess tumor size. The point of growth and pattern of growth progression were assessed. Factors influencing growth were investigated. Approximately 33% of tumors demonstrated significant growth. Mean size at presentation was 9.9 mm (standard deviation [SD]. 4.8). For growing tumors, mean size at final review was 13.7 mm (SD, 4.8). This was a statistically significant increase in size (p < 0.0001). Mean annual change in size for growing tumors was 2.3 mm (SD, 2.3). 52.4% of growing tumors showed radiologically demonstrable first growth within 18 months of presentation. Approximately 7.2% of tumors showed radiologically demonstrable first growth after 5 years of follow-up. There were no demographic or morphologic predictors of growth. Tumor growth is usually slow and is most likely to occur within the first 3 years of observation. Growth may occur after five years of follow-up. A protocol for the scanning of patients is suggested based on the findings of the study.
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 06/2012; 33(6):1053-8. · 1.44 Impact Factor
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    James R Tysome, David A Moffat
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    ABSTRACT: The objective of this study is to determine whether magnetic resonance imaging (MRI) at 2 years following complete vestibular schwannoma (VS) excision using a translabyrinthine approach is sufficient to detect recurrent tumor. The study is set in a tertiary referral skull base unit. A service evaluation of a prospective database identified patients who underwent complete translabyrinthine VS excision with prospectively recorded MRI results at 2 and 5 years following surgery. The main outcome measures were evidence of tumor recurrence on MRI at 2 and 5 years after surgery. Of 314 patients in the study, all patients where MRI was reported to show no recurrence at 2 years (97%) also had no signs of recurrence on MRI at 5 years. All eight patients with MRI suspicious of recurrence (linear enhancement of internal auditory canal [IAC]) at 2 years had no progression on MRI at 5 to 15 years. One patient had evidence of definite recurrence (nodular enhancement of IAC) at 2 years, who went on to have radiosurgery at 8 years. Where patients have MRI with no linear enhancement of the IAC at 2 years, no further imaging is required. Where linear enhancement is seen, no change in enhancement at 5 years is reassuring and no further imaging is required.
    Journal of neurological surgery. Part B, Skull base. 04/2012; 73(2):121-4.
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    ABSTRACT: To report our approach to the surgical management of vestibular schwannomas (VSs) and hearing rehabilitation in neurofibromatosis Type 2 (NF2). Retrospective cohort study. Tertiary referral NF2 unit. Between 1981 and 2011, seventy-five patients were managed in our NF2 unit, of which, 58 patients are under current review. Patients who underwent VS excision were evaluated for tumor size, surgical approach, and outcomes of hearing and facial nerve function. All current patients were evaluated for NF2 mutation, hearing, and auditory implantation outcomes. Forty-four patients underwent resection of 50 VS in our unit, of which, 14% had facial neuroma excision and reinnervation during the same operation. At 12 months after surgery, facial nerve outcomes were House-Brackmann (HB) 1 in 33%, HB2 in 21%, and HB3 in 30%. Total VS resection was achieved in 78% of patients using a translabyrinthine approach. Seventy-two percent of the current patients have American Association of Otolaryngology-Head and Neck Surgery class A to C hearing (maximum speech discrimination score over 50%) in the better hearing ear, and a further 14% are full-time users of cochlear implants or auditory brainstem implants. The remaining patients have been assessed for auditory implantation. By following a policy of treating VS in NF2 patients where tumor growth is observed, complete tumor resection can be achieved through a translabyrinthine approach while achieving comparable facial nerve outcomes to published series. We advocate proactive hearing rehabilitation in all patients with timely assessment for auditory implantation to maintain quality of life.
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 02/2012; 33(3):466-72. · 1.44 Impact Factor
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    ABSTRACT: We evaluated use of the periodically rotated overlapping parallel lines with enhanced reconstruction diffusion-weighted imaging sequence, compared with conventional echo planar magnetic resonance imaging, in the detection of middle-ear cholesteatoma. Sixteen patients awaiting second-stage combined approach tympanoplasty and three patients awaiting first-stage combined approach tympanoplasty underwent magnetic resonance imaging with both (1) the periodically rotated overlapping parallel lines with enhanced reconstruction sequence (i.e. non echo planar imaging) and (2) the array spatial sensitivity encoding technique sequence (i.e. echo planar imaging). Two neuroradiologists independently evaluated the images produced by both sequences. Radiology findings were correlated with surgical findings. Seven cholesteatomas were found at surgery. Neither of the assessed imaging sequences were able to detect cholesteatoma of less than 4 mm. Rates for sensitivity, specificity, and positive and negative predictive values are presented. Decisions on whether or not to operate for cholesteatoma cannot be made based on the two imaging sequences assessed, as evaluated in this study. Other contributing factors are discussed, such as the radiological learning curve and technical limitations of the magnetic resonance imaging equipment.
    The Journal of Laryngology & Otology 11/2010; 125(4):376-80. · 0.68 Impact Factor
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    ABSTRACT: To report a rare condition affecting the temporal bone. Immunoglobulin G4 related systemic sclerosing disease is a recently described autoimmune condition with manifestations typically involving the pancreas, biliary system, salivary glands, lungs, kidneys and prostate. Histologically, it is characterised by T-cell infiltration, fibrosis and numerous immunoglobulin G4-positive plasma cells. This condition previously fell under the umbrella diagnosis of inflammatory pseudotumour and inflammatory myofibroblastic tumour. We present the case of a 58-year-old woman with multiple inflammatory masses involving the pharynx, gall bladder, lungs, pelvis, omentum, eyes and left temporal bone, over a seven-year period. We describe this patient's unusual clinical course and pathological features, which resulted in a change of diagnosis from metastatic inflammatory myofibroblastic tumour to immunoglobulin G4 related systemic sclerosing disease. We also review the literature regarding the management of inflammatory pseudotumours of the temporal bone, and how this differs from the management of immunoglobulin G4 related systemic sclerosing disease. We would recommend a full review of all histological specimens in patients with a diagnosis of temporal bone inflammatory pseudotumour or inflammatory myofibroblastic tumour. Consideration should be given to immunohistochemical analysis for anaplastic lymphoma kinase and immunoglobulin G4, with measurement of serum levels of the latter. Management of the condition is medical, with corticosteroids and immunosuppression, rather than surgical excision.
    The Journal of Laryngology & Otology 10/2010; 124(10):1106-10. · 0.68 Impact Factor
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    ABSTRACT: To measure the health-related quality of life (QoL) of patients undergoing conservative management of a vestibular schwannoma and to identify audiovestibular factors that influence health-related QoL. Cross-sectional case-control study. Adult patients undergoing conservative management of a sporadic vestibular schwannoma were identified from a prospectively updated database. Each patient was asked to complete a series of questionnaires, including the Short Form 36 health-related QoL instrument, the Hearing Handicap Inventory, the Tinnitus Handicap Inventory, and the Dizziness Handicap Inventory. The QoL data obtained were compared with UK normal data. Multiple linear regression was performed to identify audiovestibular factors influencing QoL. Of 241 patients still undergoing conservative management, 165 completed the questionnaires. The mean age was 66.6 years. Mean duration of follow-up was 5.7 years. Physical component summary scores were significantly lower than those of the normal population. Mental component summary scores were significantly above the normal population. Regression analysis showed that dizziness handicap score and age were strong predictors of physical component summary (both p < 0.0001). Dizziness handicap score and tinnitus handicap score were significant predictors of mental component summary (p = 0.0004 and p = 0.027 respectively). However, the model only explained a small amount of the data, suggesting that there may be other factors influencing QoL. Dizziness is the most significant audiovestibular predictor of QoL in patients with vestibular schwannomas. Tinnitus also has an impact on mental QoL. Hearing loss does not seem to influence QoL. Other factors such as illness perception may have an important role to play in determining QoL.
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 08/2010; 31(6):968-76. · 1.44 Impact Factor
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    ABSTRACT: The Dix-Hallpike manoeuvre is widely used in the diagnosis of positional vertigo and is regarded as safe. The manoeuvre involves a degree of neck rotation and extension, and consequently one might expect there to be some patients, particularly those with neck problems, in whom the manoeuvre is contraindicated. The term ‘neck problem’, however, encompasses a whole range of conditions, including soft tissue disorders, cervical spondylosis, prolapsed intervertebral disk, and severe rheumatoid arthritis with cervical instability. These in turn will give rise to a variety of symptoms, which will vary from minimal pain or stiffness to severe pain or complete immobility, and, in some cases, neurological deficit. Clarification is therefore needed to establish the point at which any neck pain or stiffness ceases to be a minor problem and becomes a contraindication to performing the Dix-Hallpike manoeuvre. This paper clarifies this issue by discussing the issue of absolute contraindications and proposing a simple functional assessment of neck mobility which can be performed prior to performing the Dix-Hallpike manoeuvre. Relative contraindications such as back pathology, vertebrobasilar ischaemia (posterior circulation ischaemic disease), nerve root compression and medical fitness are also discussed. La maniobra de Dix-Hallpike cs ampliamente utilizada en el diagnóstico del vértigo posicional y ha sido considerada como segura. La maniobra involucra un cierto grado de rotación y extensión del cuello, y consecuentemente uno podría esperar que existan algunos pacientes, particularmente aquellos con problemas en el cuello, para quienes dicha maniobra estariá contraindicada. El concepto de “problemas de cuello”, sin embargo, comprende un amplio rango de condiciones, incluyendo trastornos de los tejidos blandos, espondilosis cervical, discos intervertebrales prolapsados, y artritis reumatoide severa con inestabilidad cervical. Estas condiciones dan lugar a una variedad de síntomas que van desde el dolor mínimo o la rigidez, hasta el dolor sevcro o la inmovilidad total, y en algunos casos, el déficit neurológico. Se requiere, por lo tanto, una aclaración para establecer el punto en el que cualquier rigidez o dolor cervical deja dc ser un problcma menor y se convierte en una contraindicación para realizar la maniobra de Dix-Hallpike. Este trabajo aclara el asunto discutìendo las contraindicaciones absolutas y proponiendo una evaluación funcional simple de la movilidad cervical, que puede realizarse antes de ejecutar la maniobra de Dix-Hallpike. Se discuten también las contraindicaciones relativas, tales como la patología de la cspalda, la isquemia vertebrobasilar (enfermedad isquémica circulatoria posterior), la compresión de raíces nerviosas y la condición de salud.
    International Journal of Audiology. 07/2009; 42(3).
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    ABSTRACT: To determine the prevalence of Bruns' nystagmus in patients undergoing surgical treatment for unilateral sporadic vestibular schwannomas (VSs), identify the clinical characteristics of patients with Bruns' nystagmus and compare these characteristics with those of VS patients with no nystagmus and other types of nystagmus, and determine the long-term impact of having preoperative Bruns' nystagmus. A retrospective review using a prospectively updated database of patients who had undergone surgical removal of a VS. Patients were divided into 3 groups: Bruns' nystagmus, other types of nystagmus, or no nystagmus. Statistical comparison of each group was undertaken. Nine hundred eighty-four patients were included consisting of 492 men and 492 women with a mean age of 59 years (range, 11-86 yr). Bruns' nystagmus was present in 11% of patients. Bruns' nystagmus was associated with larger tumor size (p < 0.001). Beyond 3.5-cm maximum diameter, 92% of patients had nystagmus, 67% of which had Bruns' nystagmus. Preoperative balance impairment was present in 95% of patients with Bruns' nystagmus compared with 59% with no nystagmus. The balance status of all groups improved considerably postoperatively, but the patients with Bruns' nystagmus had a relatively greater improvement in balance status. Bruns' nystagmus occurs in patients with large VSs. These patients tend to have greater balance impairment pre\operatively, but after surgery, long-term balance outcomes are similar to those of patients with no nystagmus or other forms of nystagmus.
    Otology & neurotology: official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology 06/2009; 30(5):625-8. · 1.44 Impact Factor
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    ABSTRACT: Vestibular schwannomas are benign, slow-growing tumors that originate from Schwann cells lining the vestibular nerves, most commonly the superior vestibular nerve. They arise at the neurilemmal/neuroglial junction which is situated within the internal auditory canal. They have an incidence of 1 per 100,000 per year and a prevalence of around 700 per million. A case of a patient undergoing a period of observation for a vestibular schwannoma whose hearing improved despite growth of the tumor is described. This raises interesting questions regarding the pathophysiology of hearing loss in patients with vestibular schwannomas. Possible hypotheses are discussed.
    Skull Base Surgery 04/2009; 19(2):159-62. · 0.72 Impact Factor
  • Otolaryngology-head and Neck Surgery - OTOLARYNGOL HEAD NECK SURG. 01/2009; 141(3).
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    ABSTRACT: Schwannoma of the facial nerve is an extremely rare condition with an incidence far lower than that of vestibular schwannoma. We discuss the case of a woman who had been diagnosed as having vestibular schwannoma and referred to our hospital. Initially, we concurred with the diagnosis, but on reassessment of magnetic resonance imaging scans before surgery, we revised the diagnosis to facial nerve schwannoma. This allowed us to counsel the patient appropriately preoperatively regarding the expected outcome. We discuss the importance of this case and the lessons to be learned from it.
    Ear, nose, & throat journal 10/2008; 87(9):E4-6. · 1.03 Impact Factor
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    ABSTRACT: To present a case of a 60-year-old male with a history of sudden onset sensorineural hearing loss due to Churg-Strauss syndrome. The patient had a 20-year history of asthma and recurrent right otitis media and a nasal polypectomy four years prior to presenting with ear symptoms. Ear, nose and throat involvement is common in Churg-Strauss syndrome, usually manifesting as allergic rhinitis and chronic rhinosinusitis with or without polyps. Otolaryngologists play an important role in making an early diagnosis of this disease. To our knowledge this is the first case of Churg-Strauss syndrome primarily presenting with otological pathology: left sensorineural hearing loss and right otitis media.
    The Journal of Laryngology & Otology 05/2008; 122(4):425-7. · 0.68 Impact Factor
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    David Moffat, Stephen Jones, Wendy Smith
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    ABSTRACT: The goals of this retrospective case review were to analyze the long-term results of surgery for petrous temporal bone cholesteatomas and to propose a new classification system for these lesions. Patients with a surgically confirmed petrous temporal bone cholesteatoma were treated at Addenbrooke's Hospital, a tertiary referral center. Postoperative facial function, hearing, residual/recurrent cholesteatoma, and other complications were assessed in relation to preoperative signs, intraoperative findings, and surgical approach. Between 1983 and 2004, 43 patients were treated. There were no perioperative deaths. There was no long-term recurrence in 95.4% of the patients, possibly because of meticulous surgical technique, bipolar diathermy, and use of the laser to denature the cholesteatoma matrix that was adherent to the dura. At presentation, 95% of the patients had no socially useful hearing in the affected ear. Facial nerve function, however, was usually preserved. Both direct anastomosis and nerve grafting can improve facial nerve function from House-Brackmann grade VI to grade III if the palsy is not longstanding. Four patients had cerebrospinal fluid leakage; other complications were rare. The proposed classification facilitates surgical planning and predicts the postoperative outcome with regards to hearing.
    Skull Base Surgery 04/2008; 18(2):107-15. · 0.72 Impact Factor

Publication Stats

1k Citations
183.68 Total Impact Points

Institutions

  • 2010
    • Central Manchester University Hospitals NHS Foundation Trust
      Manchester, England, United Kingdom
  • 2006–2009
    • Cambridge University Hospitals NHS Foundation Trust
      • Department of Plastic and Reconstructive Surgery (Addenbrooke)
      Cambridge, England, United Kingdom
  • 2007–2008
    • Ruhr-Universität Bochum
      • Institut für Physiologie
      Bochum, North Rhine-Westphalia, Germany
    • Università degli Studi di Bari Aldo Moro
      Bari, Apulia, Italy
  • 1997–2006
    • University of Cambridge
      Cambridge, England, United Kingdom
  • 1989–1992
    • Cambridge Eco
      Cambridge, England, United Kingdom