Facial Dehiscence Research Articles

English

OBJECTIVE: The aim of this study to evaluate the incidence and localization of facial nerve dehiscence in patients undergoing middle ear surgery. MATERIALS AND METHODS: A retrospective study done at our ENT center consists of 103 patients undergoing various middle ear surgery. The patients who have been operated in our ENT center for middle ear problems in last 3 years were enrolled for the study. Among 103 patients, 35 were women, 68 were men with age ranging from 7 to 59. STATISTICAL TOOL: proportion and percentage, Chi square test. Statistical method analyzed by Graph Pad Instat software. RESULTS: Facial nerve dehiscence occurred in 15 (14.5%) of 103 patients. Involvement of tympanic segment more common than other segments. CONCLUSION: Conclusively, one out of every 10 surgical cases may have dehiscence of the facial canal which has to be always keeping in mind during surgical manipulation of the middle ear. Facial nerve is most vulnerable structure in middle ear and that should be dealt carefully to avoid complications.

Analysis of differences in facial nerve dehiscence and ossicular injury in chronic otitis media and cholesteatoma

Conclusion: Facial nerve dehiscence (FND) and ossicular injury occurred more frequently in patients with cholesteatomatous than non-cholesteatomatous otitis media. Objective: FND and ossicular injury commonly occur intraoperatively in patients with otitis media, both with and without cholesteatoma. This study was designed to analyze differences in FND and ossicular injury between patients with cholesteatomatous and non-cholesteatomatous otitis media. Methods: Patients who underwent tympanomastoidectomy due to otitis media from January 2010 to July 2012 were analyzed retrospectively. Clinical features (age, sex, bacteria, and severity of preoperative hearing loss) and intraoperative findings (FND and state of ossicular injury) were compared in patients with cholesteatomatous and non-cholesteatomatous otitis media. Results: Of 212 patients with otitis media, 148 (69.8%) had non-cholesteatomatous and 64 (30.2%) had cholesteatomatous otitis media. Of these groups, 88.6% and 88%, respectively, had positive bacterial cultures. Facial nerve dehiscence was detected in 41 patients (27.7%) with non-cholesteatomatous and 41 (64.0%) with cholesteatomatous otitis media. Dehiscence of the tympanic segment was most frequently observed in both groups. Ossicular injury was detected in 52 (35.1%) and 51 patients (78.1%), respectively. Erosion was most frequent in the incus, followed by the stapes and malleus.

Outcomes, Complications and Management of the Congenital Aural Atresia Surgery

Congenital aural atresia is characterized by aplasia of the external auditory canal (EAC), often associated with abnormalities of the auricula (microtia), the middle ear, and, occasionally, the inner ear structures. The aim of this study is to evaluate the surgical challenges, complications and long term results of congenital aural atresia(CAA) surgery. Records of 103 patients who underwent surgery because of congenital aural atresia were reviewed between 1992 and 2012 in a tertiary referral center. Audiological and surgical events were observed. Surgical technique, incision type, graft material and long term results were noted. Postoperative visit records and audiograms were investigated. Many types of ossicular chain abnormalities such as absence of an ossicle, deformity of an ossicle or ossicular block were observed. Facial canal dehiscence or abnormal location of the facial nerve was seen in 33.9% of patients. Closure of the air-bone gap (ABG) to 30 dB or less at short-term follow-up occurred in 63.1% of patients. Major complications were as follows: restenosis of the external ear canal, hearing loss, facial paralysis, iatrogenic cholesteatoma and perforation of the graft. The air-bone gap cannot be totally closed in all aural atresias, and there is also the chance of sensorineural type hearing loss. Success of the surgery depends on accompanying abnormalities like unexpected route or dehiscence of facial nerve, status of the ossicular chain and middle ear cleft and surgical techniques. Long term results of congenital aural atresia surgery are encouraging and promising.

Comparison of Preoperative Temporal Bone CT with Intraoperative Findings in Patients with Cholesteatoma.

Cholesteatoma is traditionally diagnosed by otoscopic examination and treated by surgery. The necessity for imaging in an uncomplicated case is controversial. This study was planned to investigate the usefulness of a preoperative high-resolution computed tomography (HRCT) scan in depicting the status of middle ear structures in the presence of cholesteatoma and also to compare the correspondence between pre- and intraoperative CT findings in patients with cholesteatoma. This prospective descriptive study was performed from January 2009 to May 2011 in 36 patients with cholesteatoma who were referred to the Kashani and Al-Zahra Clinics of Otolaryngology. Preoperative high-resolution temporal bone CT scans (axial and coronal views) were carried out and compared with intraoperative findings. Evaluation of 36 patients and their CT scans revealed excellent correlation for sigmoid plate erosion, widening of aditus, and erosion of scutum; good correlation for erosion of malleus and tegmen; moderate correlation for lateral canal fistula (LCF) and erosion of mastoid air cells; and poor correlation for facial nerve dehiscence (FND), incus, and stapes erosion. A preoperative CT scan may be helpful in relation to diagnosis and decision making for surgery in cases of cholesteatoma and ossicular erosion. The CT scan can accurately predict the extent of disease and is helpful for detection of lateral canal fistula, erosions of dural plate, and ossicular erosions. However it is not able to distinguish between cholesteatoma and mucosal disease, facial nerve dehiscency, incus, and stapes erosion.

Negotiating the severely resorbed extraction site: a clinical case report with histologic sample.

The treatment of an infected socket with a severe facial dehiscence/ fenestration defect presents a therapeutic dilemma to the dental team. Both implant-supported restoration and fixed partial denture are viable options to restore function and occlusion, each with its benefits and disadvantages. In the present case report, a multi-stage regenerative approach was selected to enable implant-supported single crown. The first phase of the treatment after extraction of the maxillary central incisor was the stabilization of the blood clot with a collagen plug. Six weeks later, the surgical site was re-entered and the socket was grafted with biphasic calcium sulfate (BCS). Six months later, a dental implant was placed and a core biopsy taken. However, the central portion of the facial defect demonstrated only partial regeneration resulting in exposure of six implant threads. Freeze-dried bone allograft (FDBA) and a collagen membrane were utilized to augment the ridge and cover the exposed threads. The histology of the bone core showed a complete resorption of the grafted material with the presence of new woven bone throughout the specimen. Clinically, complete defect regeneration and augmentation of the alveolar ridge were attained after 4 months. Thus, the clinician should consider the pros and cons of this regenerative approach along with other more conservative treatment alternatives when dealing with similar cases.

Pedicle Connective Tissue Graft With Novel Palatal Tunneling

Introduction: Implant esthetics can be compromised with a lack of hard and/or soft tissue in the anterior maxilla. Soft‐tissue augmentation is often a crucial step in optimizing esthetic outcomes. Palatal pedicle soft‐tissue grafts present a versatile option and have a high survival potential. This case series presents a pedicle connective tissue graft technique with novel palatal tunneling as an additional tool for implant site development. It has multiple indications, including complete socket closure, augmentation of soft‐tissue volume, enhancement of gingival papillae, and treatment of peri‐implant defects.Case Series: In the first case, the pedicle graft was performed to achieve soft‐tissue closure over a socket preservation site that was fully dehisced on the facial aspect. This procedure allowed for protecting the bone graft and developing the soft tissue for implant placement 4 months later. The second case was more challenging because of an ankylosed maxillary central incisor presenting with a severe gingival discrepancy. After tooth extraction and hard‐tissue reconstruction, a pedicle graft was used at the time of implant placement to augment the soft tissue over the facial dehiscence of the implant in combination with a bone graft.Conclusions: The novel palatal tunneling in this technique improved the positioning of the pedicle graft at the recipient site. It also preserved the integrity of the mucosa palatal to the defect site by minimizing the protuberance that resulted at the site of pedicle rotation. Soft‐tissue height and volume were found to be increased.

Long‐term Safety of Tympanomastoid Obliteration for Children with Suppurative Cholesteatomatous Ears

Objectives: Analyze long-term prognosis and safety in children with suppurative cholesteatomatous ears following tympanomastoidectomy with cartilage obliteration. Methods: During a 30-year period (1982-2012), the medical records of children (≤18 years) with cholesteatomas after primary tympanomastoidectomies with cartilage obliteration were analyzed. The recidivism rates were calculated using Kaplan-Meier survival analysis. Potential predictors of recidivism were entered into a Cox’s regression model as covariates for multivariate analysis. These factors were sex, tympanomastoid obliteration, eardrum perforation, ossicular destruction, facial nerve dehiscence, history of ventilation tube insertion, craniofacial abnormality, surgical technique, and extent of disease. Results: Among a total of 150 cholesteatomatous ears in 146 children, there were 95 discharging ears (63%) in 94 children. Among the 95 discharging ears, tympanomastoidectomy was performed with cartilage obliteration (CO group) in 77 ears (81%) and without cartilage obliteration (WO group) in 18 ears (19%). The mean follow-up period was 11.6 ± 8.1 years. Recidivism was observed in 16 years in the CO group (12 recurrent and 4 residual) and 4 in the WO group (2 recurrent and 2 residual). The 10-year cumulative recidivism rates were comparable between CO and WO groups (19% vs. 25%, P = 0.762, log-rank). Multivariate analysis indicated that tympanomastoid obliteration was not a negative predictor of recidivism ( P = 0.760), while surgical technique (canal wall up vs. down; hazard ratio = 5.86, P = 0.011) was a significant predictor. Major long-term complications were not observed. Conclusions: This study provides long-term evidence supporting the safety, feasibility, and effectiveness of tympanomastoid cartilage obliteration for children with suppurative cholesteatomatous ears.

Clinical and Radiographic Predictors of Lateral Semicircular Canal Fistula

Objectives: Lateral semicircular canal fistula (LSCCF) may occur in as many as 10% of patients with cholesteatoma. Despite improvements in diagnostic imaging, reliable preoperative identification of LSCC remains elusive. Our objective is to explore preoperative clinical variables and intraoperative findings in order to identify factors associated with the presence of LSCCF. Methods: A retrospective matched cohort study was conducted. All patients with LSCCF, determined by intraoperative diagnosis, that had preoperative temporal bone computed tomography (CT) available for review were identified. Subjects were matched to patients without LSCCF according to age, gender and year of surgery. Associations between LSCCF and preoperative vertigo, fistula test results, sensorineural hearing loss (SNHL), stapes superstructure erosion, facial nerve and dural dehiscence, and preoperative radiographic findings were evaluated. Results: Eighty-three patients with LSCCF met inclusion criteria and were matched to subjects without labyrinthine fistula. Patients with LSCCF more commonly had stapes superstructure erosion (34 vs 15, P < .001), facial nerve dehiscence (55 vs 10, P < .0001), and dural dehiscence (29 vs 4, P < .0001) compared to subjects without LSCCF. The presence and severity of preoperative SNHL, vertigo, and fistula test results were unreliable predictors of LSCCF. Furthermore, of those patients with LSCCFs, only 28% were identified on pre-operative CT. Conclusions: Preoperative variables including SNHL, vertigo, fistula test results as well as preoperative temporal bone CT were not reliable predictors of LSCCF. However, intraoperative findings including stapes superstructure erosion, facial nerve and dural dehiscence were found to be associated with LSCCF and should raise suspicion of disease.

Post-traumatic Immediate onset Facial Palsy-delayed Exploration with Complete Recovery

ABSTRACTPost-traumatic immediate onset facial palsy is well-documented clinical entity. However, it is usually described in transverse fracture of temporal bone requiring early surgical intervention. Here we report a case of immediate onset facial palsy following longitudinal fracture of temporal bone in a 50-year-old male patient who presented to us 6 months after the closed head trauma. Electroneurography and electromyography showed complete nerve degeneration. Facial palsy was completely recovered after delayed reconstruction almost 7 months after the onset. Here longitudinal fracture of temporal bone caused pressure over the incus which in turn had pressed over the dehiscent facial nerve in its tympanic segment up to the second genu thereby resulted in immediate onset facial palsy.How to cite this articleKulkarni AS, Karnik P, Nataraj U. Post-traumatic Immediate onset Facial Palsy-delayed Exploration with Complete Recovery. Int J Head Neck Surg 2013;4(3):148-151.

Computed Tomography in Chronic Suppurative Otitis Media: Value in Surgical Planning

The present study was conducted prospectively to evaluate how accurately high resolution computed tomography scanning could define the extent and severity of the underlying disease in patients with chronic suppurative ear disease, thus, helping convert a surgical exploration into a planned procedure. Sixty adult consecutive cases of chronic suppurative otitis media underwent a detailed high resolution computed tomography by a single radiologist. The recorded radiological findings in various heads were then compared to the surgical findings during mastoid exploration of these patients by a single otologist and the two statistically compared. The presence and distribution of soft tissue in the middle ear cleft and mastoid could confidently be predicted using this modality. The malleus, body and short process of incus were well visualized, but not the long process of incus and the stapes suprastructure. Lateral semicircular canal fistulae could be demonstrated with an acceptable degree of accuracy. It was possible to detect facial nerve dehiscence and defects in tegmen tympani in significant number of cases although, statistical values were low for these structures. High resolution scanning is a modality which can accurately image the pathological anatomy in unsafe chronic suppurative otitis media. Otologists should use it more often, especially in complicated cases as an adjunct to better preoperative assessment, and thus, the surgical outcome. Its accuracy is likely to improve with larger studies and better experience, wherein its routine use may become justifiable.

Clinical Indications for Modified Radical Mastoidectomy

Objective: To establish clinically derived indications for modified radical mastoidectomy in the setting of cholesteatoma. Method: We performed a retrospective review of 223 patients who underwent 265 operations for cholesteatoma in a single tertiary pediatric otolaryngology practice. Clinical characteristics of patients who underwent modified radical mastoidectomy were compared to those who underwent simple mastoidectomy or atticotomy. Results: Of the 265 procedures, 10% were modified radical mastoidectomy. Congenital cholesteatoma was more common in the the canal-wall-up group, while recurrent cholesteatoma was more common in those who had a canal-wall-down procedure. The Mills score for those who had a modified radical mastoidectomy was significantly higher than those who underwent canal-wall-up procedures (4.9 vs 3.2, P < .05). Furthermore, extremely poorly pneumatized mastoids and facial nerve dehiscence were both more common in the group who underwent modified radical mastoidectomy. Conclusion: Posterior wall preservation or reconstruction is possible in the large majority of cases. Severity of Mills score correlated well with the need for a canal-wall-down procedure. This was further reflected by the fact that this group had a higher incidence of facial nerve dehiscence due to cholesteatoma.

Fallopian Canal Stapedotomy in Congenital Stapes Fixation with Aberrant Facial Nerve

Congenital stapes ankylosis is reported to have an occurrence rate of 3% to 4%, and it represents 20% to 35% of ossicular malformations. Surgical treatment of congenital stapes ankylosis is described to be satisfactory in the large majority of the case series reported in the literature. In these cases, special attention should be paid to exclude any aberrations of the course of the facial nerve, which have been demonstrated to be frequently associated with congenital middle ear malformations. We describe a case of congenital stapes ankylosis associated with a previously unreported facial nerve abnormality, characterized by the presence of an empty fallopian canal in combination with a dehiscent facial nerve running over the footplate and almost totally covering it.

Facial Nerve Dehiscence and Cholesteatoma

We evaluated the incidence of facial nerve dehiscence in a group of patients with cholesteatoma who underwent otologic surgery. We performed a retrospective study in a tertiary referral hospital of 336 patients (298 adults, 38 children) with cholesteatoma who underwent surgery in the years 1998 to 2008. Using intraoperative findings, we assessed the incidence of facial nerve dehiscence in a group of patients with cholesteatoma. We quantified, in adult versus pediatric patients and in primary versus revision surgeries, the occurrence of facial nerve dehiscence, the predisposed anatomic sites, and the coexistence of semicircular canal fistula. In a selected group of 67 patients, preoperative 0.55-mm collimation computed tomography (CT) scans were compared with the intraoperative findings. The frequency of facial nerve dehiscence in this group of patients was 27.1%. The dehiscence was detected in 29.5% of the adults, but in only 7.8% of the patients 16 years and younger. Dehiscence was present in 42.3% of the patients who underwent revision surgery. The most common site of dehiscence (92.3%) was the tympanic segment. The sensitivity and specificity of CT were 69% and 87%, respectively. Dehiscence of the facial nerve was found in 27.1% of patients with cholesteatoma, with a significant difference between patients of pediatric and adult ages. A dehiscent facial nerve was more commonly seen during revision surgery and more frequent in patients older than 16 years. The site of dehiscence most frequently involved by cholesteatoma was the tympanic segment. The presence of a semicircular canal fistula increases the risk of facial nerve dehiscence. Finally, the results of preoperative CT scans are encouraging for the use of CT in predicting facial nerve dehiscence.

Minimally Invasive Approach to Pancreatic Necrosectomy

Conventional open surgery for infected pancreatic necrosis is associated with significant surgical morbidity, that is, wound complications, facial dehiscence, and intestinal fistulae. In recent years, there has been interest in attempting to reduce this surgical morbidity by adopting a number of minimally invasive approaches. Fifteen patients with pancreatic necrosis underwent pancreatic necrosectomy by minimally invasive surgery (11 men, 4 women; age group: 25-64 years, mean age: 46 years). Apache II scores ranged from 5 to 14. Pancreatic necrosectomy was performed by laparoscopic transperitoneal approach in 12 patients (transmesocolic, 4 patients; transgastrocolic, 6 patients; and gastrohepatic omentum, 2 patients), by retroperitoneal approach in 2 patients, and by a combination of methods in 1 patient (endoscopic transgastric drainage followed by laparoscopic intracavity necrosectomy). Relook laparoscopy was done in 5 patients to assess for residual necrosis. All the patients tolerated the procedure well, and there was no mortality. Two of them had pancreatic fistula, which eventually responded to conservative treatment. Three patients were converted to open necrosectomy because of bleeding or difficulty to access the area of necrosis. The mean operating time was 120 ± 10 minutes. There were no postoperative complications related to the procedure itself, such as major wound infections, intestinal fistulae, or postoperative hemorrhage. Postoperative computed tomographic scans confirmed adequacy of debridement. The average length of hospital stay after surgery was 14 days. Minimally invasive necrosectomy is technically feasible and a body of evidence now suggests that acceptable outcomes can be achieved. There are no comparisons of results available, either with open surgery or among different minimally invasive techniques.

Congenital Familial Fixation of the Malleus

We present a familial association of radiographically and surgically demonstrated mallear fixation with concurrent stapedial abnormality and dehiscence of the facial nerve in a father and son, including history, physical findings, surgical findings, radiologic analyses, and a literature review. A 12-year-old boy presented with long-term left-sided conductive hearing loss, and was found to have mallear fixation and a dehiscent facial nerve on a computed tomographic (CT) scan of the temporal bone. Release of the malleus was performed at surgery, revealing hypermobility of the remaining ossicular chain. A repeat CT scan of the temporal bone showed successful release of the mallear head. The patient's father later presented with bilateral hearing loss, and a CT scan of the temporal bones showed bilateral osseous fixation of the mallear head to the tegmen and bilateral facial nerve dehiscences. He underwent right middle ear exploration, but release of the malleus was not performed because of the risk to the dehiscent facial nerve. The stapes crurae were found to be filiform at surgery. This is the first reported familial association of mallear fixation. Mallear fixation with facial nerve dehiscence and an abnormal stapes occurring in a parent and his child is interesting embryologically, and suggests that these anomalies may be genetically linked.

Complete Obstruction of the Stapes Footplate by a Dehiscent Facial Nerve in Stapedectomy

Complete Obstruction of the Stapes Footplate by a Dehiscent Facial Nerve in Stapedectomy

Another Cause for Conductive Hearing Loss With Present Acoustic Reflexes

There are numerous potential causes of conductive hearing loss (HL). It is important to obtain a thorough history and perform a complete examination, including audiometric testing and radiographic evaluation when necessary. In this report, we present a patient with an intact tympanic membrane, no history of ear disease or trauma who as an adult developed progressive, conductive HL because of an anomalous course of a dehiscent facial nerve. In the patient with a conductive HL and at least partially intact reflexes, superior semicircular canal dehiscence, fracture of the stapes superstructure proximal to the tendon, other third window phenomena, and now dehiscence of the facial nerve resulting in decreased mobility of the ossicular chain must be considered.

Incidence of fallopian canal dehiscence at surgery for chronic otitis media

The objectives of this study were to determine the incidence and locations of dehiscence of the fallopian canal (FC) in patients undergoing surgery for different middle ear pathologies and to describe the findings that will aid in pre-operative prediction of dehiscence. Charts and operative details of the 118 ears managed with canal wall-down and 147 ears managed with canal wall-up tympanomastoidectomy performed by a single surgeon were retrospectively reviewed. The distribution of the diagnoses for ears that were operated was as follows: 118 ears cholesteatoma, 42 ears adhesive otitis, 23 ears tympanosclerosis, and 82 ears chronic otitis media. The presence and the location of facial nerve dehiscence after exenteration of the disease as well as the presence of any coexisting inner ear fistula and dural defect were noted. FC dehiscence was observed in 56 of the cases. The incidence of dehiscence was highest among ears with cholesteatoma (n = 44, P < 0.05). Adults and also male patients in the study had significantly higher incidence of dehiscence compared to pediatric (P < 0.05) and female (P < 0.01) patients. The most common location for dehiscence was the tympanic segment which was significantly higher than the other locations (P < 0.01). Among the ears with FC dehiscence, labyrinthine fistula presence was seen in ten ears which was also significant (P < 0.001). Patients with dural exposure were 12.06 times more likely to have FC dehiscence than those without dural exposure. The incidence of FC dehiscence was 1.26 times higher in revision operations, but the difference was not significant (P > 0.05). An otologic surgeon should be more careful while performing operation for cholesteatoma in an adult and male patient because of the high incidence of dehiscence observed in these ears. Presence of lateral semicircular canal fistula and erosion of the bony tegmen should also be considered as a clue for the presence of dehiscence before surgery. Operation of these ears should be performed by experienced surgeons in otology.

Bilateral Stapedectomy: Association between First- and Second-Ear Surgical Findings and Their Effects on the Second-Ear Outcome

We assessed the association between first-ear and second-ear surgical findings in patients undergoing second-ear stapedectomy for bilateral otosclerosis and the impact of such findings on the audiometric outcome of the second ear. A retrospective chart review of all stapedectomy patients who underwent stapes surgery by one of two surgeons in a single tertiary referral institution from 1962 to 2001 was performed, and those patients who underwent bilateral stapedectomy were identified. Patient demographic data, surgical findings, procedure performed, and preoperative and postoperative audiometric data were recorded. A total of 459 patients (918 ears) underwent bilateral stapedectomy for bilateral otosclerosis during the study period, of whom 426 had complete data for analysis. The finding of a white or obliterated footplate in the second ear was significantly higher if the first ear had this disease manifestation (p < .001, chi2 test). The association between a second drill-out's being performed and a drill-out in the first operation was significant (p < .001, chi2 test). Statistical analysis identified that those who underwent a drill-out procedure had a 2.9-fold increase in unsuccessful outcome in comparison to those who did not have a drill-out (odds ratio, 2.89; 95% confidence interval, 1.41 to 5.89). Facial nerve anomalies were infrequently encountered, affecting only 23 patients, of whom 3 had bilateral abnormalities. The finding of an overhanging or dehiscent facial nerve in the second ear was significantly more likely if such an abnormality was identified during the first procedure (23% versus 2.5%; p = .005, Fisher's exact test). Second-ear hearing results are poorer in those who require a drill-out of this ear, and this is more likely to be required if a drill-out was required in the first ear, regardless of a successful outcome of the first procedure. Patients should be aware of the reduced likelihood of success in these cases and be counseled regarding risks and benefits of second-ear surgery based, in part, on the findings from the first ear. This study confirms that bilateral advanced footplate obliteration and overhanging or dehiscent facial nerves may be anticipated in patients found to have these abnormalities during first-ear stapedectomy.

Chronic Ear Surgery in Irradiated Temporal Bones

To analyze outcomes of chronic ear surgery in patients with irradiated temporal bones. Retrospective case review. Fifteen patients who received radiation involving the temporal bone underwent 21 surgical procedures from 1977 to 1997. Intraoperative findings, long-term complications, and hearing outcomes were analyzed. Over 50% of cases involved abnormal intraoperative findings including facial nerve dehiscence, labyrinthine fistulas, or dural exposure. Audiologic data revealed that these patients suffered from conductive, mixed, and sensorineural hearing loss. Long-term complications included tympanic membrane perforation and recurrent cholesteatoma. All patients had dry, non-draining ears at the end of the study. Irradiated temporal bones present difficult intraoperative anatomy and often require multiple procedures to cure otologic disease. Although radiation significantly reduces vascularity and hampers healing, vascularized reconstruction flaps are not necessary for good outcomes.