Facial Canal Research Articles

Imaging re-evaluation of the tympanic segment of the facial nerve canal using cone-beam computed tomography compared with multi-slice computed tomography.

This study aims to evaluate the imaging findings of cone-beam computed tomography (CBCT) in displaying subtle structures of the tympanic segment of the facial nerve canal in human cadaver heads compared with multi-slice computed tomography (MSCT). Between January 2017 and July 2017, images of the tympanic segment of the facial nerve canal acquired from 73 human cadaver ears by both CBCT and MSCT were prospectively studied. Then, images of the lateral and inferior walls of the tympanic segment were scored using standard imaging slices through a four-point rating scale. Subsequently, the detailed findings of these two imaging modalities were recorded and compared, including interruptions of the bony walls, thread-like bony tubes connected with the walls, and separations in the cavity. The Wilcoxon signed-rank test was used to investigate the differences between scores derived by CBCT and MSCT. The mean score in the inferior and lateral walls by CBCT were significantly higher than that by MSCT (P = 0.000-0.005), which ranged from 2.0 (1.5, 2.5) to 3.5 (3.0, 4.0), and from 1.5 (1.0, 2.0) to 3.5 (2.5, 4.0), respectively. The interruption of the walls was most common at the anterior part of the inferior wall (38/73 cases). Furthermore, thread-like bony tubes were evident in 18 ears, which connected with the anterior part of the inferior wall (18/73 cases). Moreover, separation was found in 22 ears in the posterior part (22/73 cases). CBCT can readily demonstrate subtle imaging findings of the tympanic segment of the facial nerve canal.

Facial canal dehiscence in patients with cholesteatoma: concordance between intraoperative inspection, computed tomography and neurophysiological findings.

To assess the diagnostic capacity of intraoperative neurophysiological monitoring with respect to "gold standard" microscopic findings of facial canal dehiscence in middle ear cholesteatoma surgery. We carried out a retrospective cohort study of 57 surgical interventions for cholesteatoma between 2008 and 2013 at Hospital Universitario de Canarias, Spain. Each patient underwent preoperative computed tomography (CT), intraoperative neurophysiological monitoring and intraoperative inspection of the facial nerve during microsurgery. Diagnostic concordance on the presence/absence of facial canal dehiscence was assessed in 54 surgical interventions. Presence of facial canal dehiscence. Of 57 interventions, 39 were primary surgeries; 11 (28.2%) showed facial canal dehiscence. and 18 were revision surgeries; 6 (33.3%) showed facial canal dehiscence. The facial nerve was not damaged in any patient. Facial canal dehiscence was observed in 17 (29.82%) interventions. We used intraoperative microscopic findings as the gold standard. Neurophysiological study showed a sensitivity of 94.1, specificity 97.3, positive predictive value (PPV) 57.8 and negative predictive value of 97.2. CT showed a sensitivity of 64.7, specificity 78.4, PPV 57.8 and negative predictive value of 82. Our neurophysiological study showed greater sensitivity and higher PPV than CT for the detection of facial canal dehiscence. We found no relationship between disease progression time and the presence of facial canal dehiscence.

Percutaneous Threshold of Facial Nerve Stimulation Predicts Facial Canal Dehiscence

ABSTRACTIatrogenic facial nerve (FN) injury is one of the most feared complications of otologic surgery. Dehiscence of the bony covering of the FN within the temporal bone increases FN vulnerability to accidental injury. High-resolution computed tomography (HRCT) of the temporal bone is used preoperatively to assess middle ear and mastoid anatomy; however, it is unreliable for detecting facial canal dehiscence. In this study, our aim was to determine if preoperative percutaneous FN stimulation could predict middle ear facial canal dehiscence. Between January 2015 and February 2017, we performed preoperative HRCT and percutaneous FN stimulation on adult patients who underwent otologic surgery at our institution. Stimulation was performed with a monopolar probe placed on the skin over the stylomastoid foramen. Electrical stimuli ranged from 0 to 40 milliamperes (mA). Recordings were made from ipsilateral facial muscles. Dependent variables included threshold to compound muscle action potential (CMAP), threshold to maximum amplitude of CMAP, and maximum amplitude of CMAP for each muscle. A retrospective chart review was performed. Seventy patients met inclusion criteria. Of the 24 with an intraoperatively confirmed dehiscence, 10 were identified preoperatively by the attending surgeon on HRCT. Averages of the lowest recorded threshold to CMAP (5.1mA v. 9.1mA), and an average of the threshold to CMAP (8.9 mA. 11.8 mA) of dehiscent versus non-dehiscent nerves were significantly different (p < .05). In conclusion, percutaneous FN stimulation is a simple and cost-effective tool that can give the surgeon important preoperative information about FN anatomy.

Usefulness of High Resolution Computed Tomography scans in depicting the status of the middle ear structures

Background: Prior to surgery it is very important that the surgeon is fully aware, and he should have the clear picture as to the extent of the disease and the nature of the disease to give satisfactory surgical outcomes for the patient. HRCT (High resolution computed tomography) is one such guiding tool for the surgeon. The objective was to study usefulness of HRCT scan in attico-antral disease in depicting the status of the middle ear structures.Methods: A total of 30 patients were studied. HRCT temporal bone was performed by using SIEMENS EMOTION 16 slice CT machine in axial plane and coronal images were reformatted. Findings of HRCT temporal bone were recorded. Findings of mastoid exploration surgery were recorded. Report of HRCT of temporal bone was correlated with surgical findings and tabulated using percentages.Results: Surgery showed cholesteatoma in 26 (86.6%) patients. Epitympanum was involved in 29 (96.6%) patients in HRCT and 30 (100%) patients at surgery. Extension beyond middle ear cleft was seen in 4 (13.3%) patients in HRCT and 5 (16.6%) patients at surgery. Tympanic segment of facial canal was the most commonly involved, showing erosion in 10 (33.3%) patients in HRCT and 12 (40%) patients at surgery. Lateral SCC was the most commonly involved in bony labyrinth seen in 4 (13.3%) patients in both HRCT and surgery. Erosion of dural plate was seen in 6 (20%) patients in HRCT whereas 9 (30%) patients showed dural plate erosion at surgery.Conclusions: HRCT of temporal bone plays a promising role in pre-operative assessment of cholesteatoma as it depicts the extent of the disease and integrity of most of the middle ear structures.

A Clinico-Radiological Study: Veria Technique of Cochlear Implant-A Study of 50 Cases.

Main limitation of classical technique is limited access to cochlea in terms of cochlear rotations and related structures, thus causing difficulty in electrode insertion. Veria technique allows full access to cochlea after raising tympanomeatal flap. To our best knowledge this is first clinic-radiological study for Veria technique studying distance between tympanic segment of facial nerve and posterior wall of external auditory canal (EAC) demonstrating facial nerve safety. Prospective study was done on 50 patients having bilateral sensori-neural hearing loss. Patients underwent cochlear implant surgery irrespective of age and gender. Preoperative high-resolution computed tomography temporal bone and magnetic resonance imaging head was done, distance between tympanic segment of facial nerve and posterior wall of EAC and basal turn angle were measured. Intraoperative NRT followed by orbito-meatal X-ray was done in post operative period. 25 (50%) were male, 25 (50%) female. 35 patients (70%) showed that the distance between tympanic segment of facial nerve and posterior wall of EAC was more than 3mm with mean 4.41mm (± 0.63 SD). Distance calculated was greater in older age group than younger group. Patient having inner ear malformation, mean was 3.96mm (± .44 SD). Whereas patients having acquired disease, mean distance was 4.30mm (± .47 SD). On gender comparison of basal turn angle score, no significant difference was observed male (54.34° ± 4.48°) versus female (55.66° ± 4.15°) (p = 0.282). Mean of basal turn angle (BTA) in ≤ 5years age group was 54.89° ± 3.65°, in 6-10years age group was 55.21° ± 5.23° and in age group ≥ 11years was 54.93° ± 4° with no significant difference in mean value between the groups (p = 0.282). High jugular bulb was seen in 4 patients (2 in right side, 2 in left side), hypoplastic jugular bulb was seen in 10 patients (9 in left, 1 in right), otosclerosis in 2 patients. Veria technique is safe for facial nerve, as preoperatively distance between tympanic segment of facial nerve and posterior canal wall can be identified. It is suitable method for rotated cochlea (identified preoperatively through BTA) and deformed cochlea as it offers a wide visibility and accessibility as compared to posterior tympanotomy approach. BTA and distance between posterior canal wall of EAC and tympanic segment of facial nerve should be done in all cases to see any cochlear rotation and feasibility of surgery.

Assessment of Mass Effect Sign at High-Resolution Computed Tomography in Prediction of Cholesteatoma.

The aim of this study was to assess the accuracy of mass effect sign in the diagnosis of cholesteatoma at high-resolution computed tomography (HRCT). This prospective study included 32 ears in 24 patients with chronic otitis media who underwent HRCT of the temporal bone. Otoscopic and operative notes were recorded. Image analysis was done both qualitatively and quantitatively. In the qualitative analysis, mass effect was evaluated visually by comparing both ears together in 4 certain anatomical sites. Ossicular erosions, erosion of tegmen tympani, erosion of tympanic segment of facial nerve canal, and the presence of lobulated nondependent opacity were also evaluated. In the quantitative analysis, we calculated the difference between the distances of the described anatomical sites in both ears. Qualitative analysis of mass effect sign showed 97.1% accuracy in detecting cholesteatoma. Ossicular erosions showed 69.2% accuracy in the diagnosis of cholesteatoma. In the quantitative analysis, we found that the cutoff point of 0.45 mm in the difference of aditus measure between both ears showed 85.3% accuracy in differentiating cholesteatoma from otitis media. The cutoff point of 0.75 mm in the differences in supratubal measure showed 86.1% accuracy. The cutoff point of 0.45 mm in the medial to incus measure showed 100% accuracy. High-resolution computed tomography is highly valuable for the detection of mass effect sign, which has great importance in diagnosing cholesteatoma.

A cross sectional study to assess the role of preoperative HRCT temporal bone in CSOM: a comparison between middle ear surgeries with and without pre-op HRCT

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Importance of HRCT before middle ear surgery is proved by many published articles but most of the studies were done without evaluating the accuracy of clinical judgment at the same time.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; All the patients of CSOM in whom the middle ear surgery was planned were included in the study. Total number of sample size was 80 patients. Group A: 20 patients in which HRCT temporal bone was indicated as a routine evaluation before middle ear surgeries. Group B: 60 patients in which HRCT temporal bone was not indicated. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Maximum 43.75% (35) patients belong to 21 to 30 yrs. F: M is 1.5:1. Unilateral ear disease is more common (62.5%). 41.8% had mucosal type while 16.25% had squamosal type of COM. 77.5% ears found to have hearing loss. Conductive hearing loss was the most common (43.13%). HRCT in comparison with Intra-op had Kapa value of 1 (Aditus blockage &amp;amp; Tegmen erosion), 0.6 (sinus plate erosions), 0.5 (malleus, Incus, stapes erosions), 0.48 (Ossicular chain status), 0.46 (Scutum erosion), 0.4 (LSC fistula) and 0.3 (fallopian canal erosions. Clinical judgment in comparison with intra-op had kapa value of 1 (stapes erosion), 0.96 (aditus blockage), 0.79 (Incus erosion), 0.78 (malleus erosion) and 0.76 (ossicular chain status).&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Clinical judgment is as good as or even better than CT in presuming/detecting at least individual ossicular erosions, ossicular chain status, aditus blockage and HRCT temporal bone should be reserved for high risk and complicated cases.&lt;/p&gt;

Analysis on outcomes of facial paralysis complicated by middle ear cholesteatoma

Background: The prognostic factors of facial paralysis complicated by middle ear cholesteatoma (MEC) are largely unknown due to limited reports and smaller sample size.Objectives: This study aimed to analyze prognostic factors of postoperative outcomes of facial paralysis complicated by MEC.Material and methods: Clinical data of 48 patients (48 ears) with facial paralysis complicated by MEC were retrospectively reviewed and analyzed. The outcomes of facial paralysis were compared between different groups.Results: All the eight cases (100%) with intact fallopian canal had complete recovery of facial paralysis after surgery, while only 52.5% cases (21/40 cases) with fallopian canal damage achieved good recovery, with significant difference (p < .05). For subgroup analysis of the 40 cases with damaged fallopian canal, the good recovery rate of facial paralysis in shorter duration group (≤2 months) was higher compared to longer duration group (>2 months) (81.0% versus 21.1%; p < .05). Moreover, the good recovery rate of facial paralysis in moderate facial paralysis group (grade II–IV) was higher compared to severe facial paralysis group (grade V–VI) (82.4% versus 30.4%; p < .05).Conclusions and significance: The outcomes of facial paralysis complicated by MEC were associated with fallopian canal integrity, duration and severity of facial paralysis.

Middle Ear Osteoma Causing Mixed Hearing Loss: A Case Report

Osteomas of the middle ear are rare benign tumors. Their consequences and symptoms are due to their specific location, such as the promontory or the epitympanum and their contact with the facial nerve, the semicircular canal, the ossicles, and the oval or round windows. We report a very unusual case of middle ear osteoma (MEO) in a 23-year-old male patient causing a right mixed hearing loss by contacting and overwhelming the incus and stapes. The lesion was also closely attached to the tympanic portion of the fallopian canal. Since the stapes was not clearly visible behind the lesion, careful observation was preferred to surgery owing to the high risk of inner ear damage and facial palsy with removal of the lesion. MEOs are rarely situated at this critical site. Regular clinical and computerized tomography monitoring is warranted to check their growth. This case also supports the etiological theory of chronic middle ear inflammation causing osteomas.

Morphological analysis of sigmoid sinus anatomy: clinical applications to neurotological surgery

ObjectivesThe primary objective of this study was to use high-resolution micro-CT images to create accurate three-dimensional (3D) models of several intratemporal structures, and to compare several surgically important dimensions within the temporal bone. The secondary objective was to create a statistical shape model (SSM) of a dominant and non-dominant sigmoid sinus (SS) to provide a template for automated segmentation algorithms.MethodsA free image processing software, 3D Slicer, was utilized to create three-dimensional reconstructions of the SS, jugular bulb (JB), facial nerve (FN), and external auditory canal (EAC) from micro-CT scans. The models were used to compare several clinically important dimensions between the dominant and non-dominant SS. Anatomic variability of the SS was also analyzed using SSMs generated using the Statismo software framework.ResultsThree-dimensional models from 38 temporal bones were generated and analyzed. Right dominance was observed in 74% of the paired SSs. All distances were significantly shorter on the dominant side (p < 0.05), including: EAC – SS (dominant: 13.7 ± 3.4 mm; non-dominant: 15.3 ± 2.7 mm), FN – SS (dominant: 7.2 ± 1.8 mm; non-dominant: 8.1 ± 2.3 mm), 2nd genu FN – superior tip of JB (dominant: 8.7 ± 2.2 mm; non-dominant: 11.2 ± 2.6 mm), horizontal distance between the superior tip of JB – descending FN (dominant: 9.5 ± 2.3 mm; non-dominant: 13.2 ± 3.5 mm), and horizontal distance between the FN at the stylomastoid foramen – JB (dominant: 5.4 ± 2.2 mm; non-dominant: 7.7 ± 2.1). Analysis of the SSMs indicated that SS morphology is most variable at its junction with the transverse sinus, and least variable at the JB.ConclusionsThis is the first known study to investigate the anatomical variation and relationships of the SS using high resolution scans, 3D models and statistical shape analysis. This analysis seeks to guide neurotological surgical approaches and provide a template for automated segmentation and surgical simulation.

Duplicated Internal Auditory Canal: High-Resolution CT and MRI Findings.

ObjectiveTo summarize the high-resolution computed tomography (HRCT) and magnetic resonance imaging (HRMRI) features of duplicated internal auditory canals (DIACs).Materials and MethodsEar HRCT data of 64813 patients with sensorineural hearing loss (SNHL), obtained between August 2009 and November 2017, were reviewed. Among these patients, 12 (13 ears) were found to have DIACs, 9 of whom underwent HRMRI. Their images were evaluated by two otoradiologists.ResultsThe rate of occurrence of DIAC among SNHL patients was 0.019% (12/64813). The internal auditory canals of 13 ears were divided into double canals by complete (n = 6) and incomplete (n = 7) bony septa, with varied orientations ranging from horizontal to approximately vertical. All of the anterosuperior canals extended into the facial nerve (FN) canal, except for 1, which also extended to the vestibule. The posteroinferior canals ended in the cochlea and vestibule, except for 2, which also connected to the FN canals. Magnetic resonance images revealed that 77.8% (7/9) and 22.2% (2/9) of vestibulocochlear nerves (VCNs) were aplastic and hypoplastic, respectively. Furthermore, 88.9% (8/9) of FNs were normal, except for 1, which was hypoplastic. All of the affected ears also had other ear anomalies: a narrow, bony cochlear nerve canal was the most common other anomaly, accounting for 92.3% (12/13). Malformations of other systems were not found.ConclusionDouble-canal appearance is a characteristic finding of DIAC on HRCT, and it is usually accompanied by other ear anomalies. The VCN usually appears aplastic, with a normal FN, on HRMRI.

Clinical and diagnostic observations of a complicated course of chronic otitis media, cholesteatoma in children

Formation of labyrinth fistulas and destruction of the facial nerve canal in children with middle ear cholesteatoma is rare. Data of children with cholesteatoma of the middle ear, operated in the ENT department of MONIKI, is analyzed. Several clinical observations of multiple-aged patients with the presence of cholesteatoma intra-temporal complications are presented. The preoperative computer tomography made it possible to diagnose the presence of the labyrinth fistula and the destruction of the facial nerve channel, which was confirmed intraoperatively.

Recurrent facial nerve baroparesis in a military diver: a case report

Middle ear barotrauma is common in diving. However, facial nerve baroparesis is a relatively rare complication. A dehiscent facial nerve canal may be a predisposing factor to developing this complication. Although there is an increasing number of facial baroparesis cases in the literature, they are likely still under-reported. In order to avoid unnecessary recompression treatments or detrimental effects to a professional diver's career, it is important to consider this in the differential diagnosis while evaluating dive injuries. This case report describes recurrent facial baroparesis in a military diver, which manifested on contralateral sides of his face. His initial presentation was misdiagnosed as an arterial gas embolism, which led to recompression treatment and a cardiac procedure. Upon recurrence about one year later, a complete work-up was done, which included an ENT evaluation and a CT scan. Imaging demonstrated a predisposing anatomic variant bilaterally. His symptoms resolved quickly and spontaneously both times, and he has been able to return to diving.

Preoperative temporal bone HRCT and intra-operative findings in middle ear cholesteatoma: a comparative study

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Middle ear cholesteatoma is a potentially dangerous condition owing to the varied extra-cranial as well as intra-cranial complications, it can be associated with. Clinical suspicion and otologic examination sufficiently identifies the pathology but its entire extent and spread is delineated by HRCT examination only, which is presently the ‘Gold Standard’. In this study we tried evaluate the efficacy of HRCT temporal bone in depiction of extent of pathology in cases of cholesteatoma of middle ear and we tried to verify the findings on HRCT imaging with intra-op findings.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; A prospective observational study comprising of 50 patients suspected of middle ear cholesteatoma was carried out at a tertiary care hospital in Lucknow, India. Pre-op evaluation with bilateral temporal bone HRCT imaging followed by suitable surgery was performed. Important pre-operative HRCT and intra-operative surgical findings were correlated for statistical significance. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Mesotympanum involvement (96%) was the most common HRCT finding as far as location and extent were concerned and incus erosion (70%) was the most common bony complication. A high sensitivity and specificity (82% -100%) of HRCT was found in detection of Erosion of scutum, tegmen tympani and incus. For findings such as stapes erosion and facial canal erosion on HRCT, a sensitivity of 68.4% and 50% respectively was found when compared to intra-op findings.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; HRCT temporal bone is a useful tool in pre-operative delineation of the extent of cholesteatoma and the recognition of its manifestations and complications. It can help the operating surgeon in appropriate surgical planning.&lt;/p&gt;

Middle ear structure and transcanal approach appropriate for middle ear surgery in rabbits.

The current study aimed to investigate the middle ear structure and surgical approach appropriate for middle ear surgery in rabbits. A total of eight healthy New Zealand rabbits (16 ears) were dissected under a surgical microscope. The dimensions of the auditory canal and the middle ear were measured. In the present study, the transcanal surgical approach to the middle ear in rabbits was performed without complications, the anatomical landmarks in the auricle and the external auditory canal were apparent, no large vessels were present in the surgical zone and the bleeding was minor. Furthermore, the surgical procedure did not require removal of large bone sections of the external auditory canal. Additionally, the constitution of the ossicular chain, the leverage ratio of the ossicular chain and the constitution of ligaments and muscles in rabbits were similar to humans. Otherwise, the facial nerve canal in rabbits was more prominent compared with humans and the mobility of pars flaccida in rabbits was more noticeable compared with humans. The results of the current study indicate that the transcanal surgical approach was suitable to study the middle ear in rabbits. Furthermore, the rabbit middle ear may be used as a model for ossicular surgery and facial nerve research.

Prevalence of Radiographic Cochlear–Facial Nerve Dehiscence

To determine the prevalence of radiographic cochlear-facial nerve dehiscence (CFD). Retrospective radiological study. Two tertiary-referral centers. Two hundred six temporal-bone computed tomography (CT) scans (405 total ears) of otology/neurotology patients from two academic institutions between the years 2014 and 2017. Diagnostic. The cochlear-facial nerve partition width (CFPW) was measured on coronal CT sections and defined as the shortest distance between the cochlear basal turn and facial nerve (FN) labyrinthine segment. We used logistics regression analyses to determine positive predictors for radiographic evidence of CFD. The overall prevalence of radiographic CFD was 5.4% (22/406 ears). 9.2% of patients (19/206) had CFD. Of these 19 patients, only one patient had mixed hearing loss that could not be explained by any other vestibular or auditory etiology. Three out of 206 patients had dehiscence in both ears (1.4%). The average CFPW was 0.6 ± 0.2 mm, and fallopian canal width was 1.1 ± 0.02 mm (n = 405). Older age, use of traditional CT scans, and thinner CT slice thickness were significant predictors for radiographic CFD. The radiographic prevalence of CFD is higher than what is reported in histologic studies, and may over-estimate the true prevalence of CFD. The clinician should keep this in mind when considering this as potential cause for third-window symptoms.

Facial canal dehiscence rate: a retrospective analysis of 372 chronic otitis media cases

This study aimed to investigate the rate and location of facial canal dehiscence (FCD) observed during surgery for chronic otitis media (COM) with or without cholesteatoma. Operative details of 1296 patients who underwent chronic otitis media surgery from January 2000 to January 2017 by the same surgeon were included in this retrospective study focusing on intraoperative observations of FCD. Because of the type of the surgery, the Fallopian canal could not be seen completely, so 924 of the cases which only involved performing a tympanoplasty were not included in the study. A total of 372 patients (196 males and 176 females) who had a canal wall down (CWD) or canal wall up (CWU) mastoidectomy were included in the study. A CWD mastoidectomy was performed on 250 patients, while 122 patients underwent a CWU mastoidectomy. The prevalence of FCD was 11.29% (42/372 patients). The dehiscence was more common in patients with cholesteatoma (n = 37; 88.1%) than those with non-cholesteatoma (n = 5; 11.9%). The tympanic segment (n = 32; 76.19%) was the most common location for FCD. When we compared the ossicular erosion results of the cases that had FCD, erosion in three ossicles together was more statistically significantly frequent than the other possibilities. It is possible to see FCD because of COM, especially with cholesteatoma. FCD is most commonly seen around the oval window. If stapes or all three ossicles are eroded, the surgeons must be more careful regarding FCD to be more effective in preventing facial nerve damage.

Fallopian Canal Meningocele with Spontaneous Cerebrospinal Fluid Otorrhea: Case Report and Systematic Review of the Literature

To present a case of spontaneous cerebrospinal fluid (CSF) otorrhea from a fallopian canal meningocele involving the geniculate fossa and review all cases of fallopian canal CSF leak reported in the literature with discussion of management and outcomes. A 53-year-old woman with history of morbid obesity and hypertension presented to a tertiary care referral center with unilateral high-volume CSF otorrhea. High-resolution temporal bone computed tomography demonstrated significant dilatation of the geniculate fossa. Rates of postoperative facial paralysis and refractory CSF leak were reported for the present case and prior cases reported in the literature. Locations of fallopian canal dehiscence, surgical approaches, techniques for packing dehiscence, rates of postoperative facial paralysis and CSF leak, and revision procedures were reported for the present case and 14 cases in the literature. The present case involved dehiscence of the geniculate fossa that was approached via combined transmastoid-middle cranial fossa exploration with facial nerve monitoring. The area of dehiscence was carefully packed with temporalis fascia, muscle, and artificial dural substitute overlay to repair the CSF leak without injuring the facial nerve. Postoperatively, no facial weakness was noted; however, right-sided high-volume CSF otorrhea persisted. After discussing treatment options, the patient underwent subtotal petrosectomy and blind-sac closure of the external auditory canal the following day. This successfully resolved the CSF leak without causing facial nerve weakness. Fallopian canal meningocele is an exceedingly rare cause of CSF otorrhea. Successful repair requires precise packing of the dilated facial canal to occlude the leak without injuring the facial nerve. For refractory CSF leak, subtotal petrosectomy and closure of the external auditory canal warrants consideration.

Jugular Bulb Anatomy for Lateral Skull Base Approaches.

This study was designed to define the detailed anatomical relations of the jugular bulb with the facial nerve, sigmoid sinus, otic capsule, and internal acoustic canal allowing the safe management of the jugular bulb. Thirty-five formalin-perfused cadaveric temporal bones that had well mastoid and petrous pneumatization without any neurovascular variations on computed tomography scan were selected for the study. The bones were dissected via translabyrinthine approach. The dome of the jugular bulb was located under the facial nerve in 21 of the cases (60%), in the mastoid cavity in 8 of the cases (22.9%), and in the tympanic cavity in 6 of the cases (17.1%). Significant difference was observed only between the temporal bones in which the dome of the jugular bulb was located in the mastoid cavity and under the facial nerve with regard to the mastoid cortex-lateral semicircular canal measurement (P = 0.04). Because of the high variability of the position of the dome of the jugular bulb, the precise knowledge of the relations of the jugular bulb and the preoperative radiologic verification of possible variations are essential to avoid the problems associated with its position and to decide the approach individually.

Anomalies of the facial nerve: a surgeon’s nightmare

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; Most of the anomalies of the facial nerve have been encountered during otological surgery or dissection of the temporal bones. ENT surgeons are taught from a nascent stage to always be wary of an anomalous facial nerve during otological surgery. Today’s surgeon is assisted with high definition imaging and nerve monitoring; yet iatrogenic facial palsy still is encountered even today.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; This study was conducted in a select population of patients who reported with aural symptoms with an aim to see the number of facial nerve anomalies one encounters during aural surgery. The filter applied was no patient with congenital anomaly was considered and patients with squamous COM were also excluded. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Almost 4.5% of the patients subjected to surgery had varying kinds of facial nerve anomaly, the most common being dehiscence of the fallopian canal.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Facial nerve anomalies are not so uncommon as one expects it to be. So it is mandatory that every ENT surgeon should be well versed with facial nerve anatomy and be wary of any structural anatomical abnormality, and irrespective of the experience it pays to be extra cautious when operating on the ear because in the event of damage to the facial nerve the patient has to carry the stigma of a facial deformity for his/her life.&lt;/p&gt;