Partial Labyrinthectomy Research Articles

P.096 Hearing preservation and quality of life outcomes in partial labyrinthectomy petrous apicectomy for microsurgical resection of large posterior fossa skullbase tumors

Background: The Partial Labyrinthectomy Petrous Apicectomy (PLPA) aims to give transpetrosal access whilst preserving hearing for challenging tumors such as petroclival meningioma. There are few studies assessing resection and morbidity and no large studies that document hearing preservation and quality of life (QOL). We present the first large series to do so. Methods: A retrospective review was performed of all PLPA cases between 2005 and 2023 at a tertiary center. Demographics, tumor characteristics, neuromonitoring, hearing and surgical outcomes were collected. QOL was measured with the 36-item short form survey (SF-36). Results: Of 73 PLPAs, data for 56 patients undergoing 57 surgeries was obtained. Petroclival meningioma (57.8%) and epidermoid tumors (21.0%) were common indications . The mean patient age and tumor size were 51.6 years and 44mm. Gross total resection was achieved in 40.3%, near total in 15.8% and subtotal in 43.8% of cases with no perioperative mortality and was not influenced by attempted hearing preservation (p=0.183). Of 39 hearing preservation cases, 27 (69.2%) were preserved, 10 (25.6%) were lost and 2 had unclear outcomes. Conclusions: Improved microsurgery and neuromonitoring during PLPA leads to decreased mortality and morbidity compared to historical cohorts while achieving a high rate of resection, hearing preservation and maintained QOL.

3D printed temporal bones for preoperative simulation and planning

ObjectiveDemonstrate the utility of 3D printed temporal bone models in individual patient preoperative planning and simulation. Methods3D models of the temporal bone were made from 5 pediatric and adult patients at a tertiary academic hospital with challenging surgical anatomy planned for cochlear implantation or exteriorization of cholesteatoma with complex labyrinthine fistula. The 3D models were created from CT scan used for preoperative planning, simulation and intraoperative reference. The utility of models was assessed for ease of segmentation and production and impact on surgery in regard to reducing intraoperative time and costs, improving safety and efficacy. ResultsThree patients received cochlear implants, two exteriorization of advanced cholesteatoma with fistulas (1 internal auditory canal/cochlea, 1 all three semicircular canals). Surgical planning and intraoperative referencing to the simulations by the attending surgeon and trainees significantly altered original surgical plans. In a case of X-linked hereditary deafness, optimal angles and rotation maneuvers for cochlear implant insertion reduced operating time by 93 min compared to the previous contralateral side surgery. Two cochlear implant cases planned for subtotal petrosectomy approach due to aberrant anatomy were successfully approached through routine mastoidectomy. The cholesteatoma cases were successfully exteriorized without necessitating partial labyrinthectomy or labyrinthine injury. There were no complications. Conclusion3D printed models for simulation training, surgical planning and use intraoperatively in temporal bone surgery demonstrated significant benefits in designing approaches, development of patient-specific techniques, avoidance of potential or actual complications encountered in previous or current surgery, and reduced surgical time and costs.

Partial Labyrinth Removal Restricted to the Superior Semicircular Canal in Focal Combined Transpetrosal Approach: Description and Illustrative Cases.

The labyrinthine structures obstruct the surgical view of the deep petroclival region in the transpetrosal approach. Historically, labyrinthectomy and removal of all 3 semicircular canals, with resultant deafness, was used in patients with ipsilateral functional hearing deficits to improve access. The advent and systematization of superior and posterior semicircular canal removal (transcrusal approach) with good rates of hearing preservation has allowed a redefinition of the possibility of partial labyrinthectomy in patients without previous hearing deficits. The present manuscript is intended to describe a technical refinement of partial labyrinthectomy during focal combined petrosectomy, offering a customization of the approach through the selective removal of the superior semicircular canal for specific types of tumors. The use of the technique is demonstrated through surgical drawings, pictures, and videos. The rationale to indicate this new approach is discussed based on clinical cases. Three illustrative clinical cases (petroclival meningiomas) are demonstrated. Functional hearing on the approach side has been preserved in all of them. The focal combined transpetrosal approach associated with the superior semicircular canal resection has been a promising surgical technique in the treatment of selected petroclival tumors. It has the potential to further decrease the risks of postoperative auditory and vestibular dysfunctions associated with labyrinthectomies.

Symptom: Vertigo After Labyrinthectomy

Symptom: Vertigo After Labyrinthectomy

Labyrinthine Fistula in Cholesteatoma Patients: Outcomes of Partial Labyrinthectomy With "Underwater Technique" to Preserve Hearing.

Labyrinthine fistula (LF) is one of the most important complications of cholesteatoma and is defined as an abnormal communication between the inner and the middle ear. This study aims to describe our experience with the partial labyrinthectomy evaluating the post-operative hearing results. Twenty-one patients who presented labyrinthine fistula in the semicircular canals were included in the present study. Hearing impairment was present in 48% of patients (10/21). A pre-operative assessment using the Gardner–Robertson hearing classification showed the following: 52%, Class I; and 48%, Class II. A post-surgical Gardner–Robertson hearing classification evidenced the following: 43%, Class I; and 57%, Class II. The presence of LF is usually considered a negative prognostic factor for hearing preservation. The key point of partial labyrinthectomy surgery is the preservation of structures, keeping them wet with Ringer's solution throughout the procedures, and not performing suction that is close to the opened LF. The bony labyrinth is drilled underwater without suction, removing the entire cholesteatoma matrix and quickly plugging the site before and after the LF. This faster plugging of the labyrinth makes it possible to preserve the peri-lymph and the endo-lymph fluid and the hearing function. This study showed that a partial labyrinthectomy is useful for maintaining serviceable hearing in patients with LF.

Hearing preservation/rehabilitation surgery for small vestibular schwannoma: preliminary experience with the presigmoid retrolabyrinthine approach

Background The presigmoid retrolabyrinthine approach (PRA) for small vestibular schwannoma (VS) has unique advantages. Combination with partial labyrinthectomy further makes up its defect of high demand for anatomy. Objective Aimed to describe our use of the PRA with partial labyrinthectomy in VS surgery. Methods We retrospectively analyzed 10 patients diagnosed with VS who underwent PRA between September 2017 and November 2020. Their perioperative data were analyzed. Results Six tumors were on the left and three were on the right. One case was due to neurofibromatosis type 2 with bilateral involvement and underwent internal auditory canal decompression by PRA without tumor removal; all other patients underwent total tumor resection. Four patients underwent cochlear implantation simultaneously because of hearing loss that was detected during surgery. Three patients underwent partial labyrinthectomy. Five patients achieved hearing preservation, and one experienced hearing improvement. One of the three patients who underwent partial labyrinthectomy maintained hearing. All patients’ pre- and postoperative facial nerve functions were House-Brackmann grade I. After a median follow-up time of 13 months, no tumors recurred. Conclusions PRA for small VS is a safe and effective surgery that can achieve facial nerve and hearing preservation. Combination with partial labyrinthectomy can also preserve hearing.

Sensorineural Hearing Loss Caused by Labyrinthine Erosion Due to a Cerebrospinal Fluid Diverticulum

To present a case of progressive sensorineural hearing loss (SNHL) caused by labyrinthine erosion secondary to expanding geniculate ganglion cerebrospinal fluid (CSF) diverticulum extending along the path of the facial nerve. Thirteen-year-old man with no past medical history or risk factors presented with unilateral progressive SNHL and no other otologic or neurologic symptoms. Audiological data as well as imaging studies including a magnetic resonance imaging (MRI) of the brain and internal auditory canal and a temporal bone computed tomography (CT) are presented. Partial labyrinthectomy, CSF leak closure, and cochlear implantation were performed. A lumbar puncture was obtained 2 months postoperatively. Closure of the CSF leak. Mastoidectomy revealed a wide area of CSF leak through the geniculate ganglion and fallopian canal with partial destruction of the superior and lateral semicircular canals by an expanding diverticulum. This is an unusual presentation of progressive SNHL due to partial labyrinthine erosion due to a meningocele of the geniculate ganglion along the fallopian canal. It is likely that the patient had a congenital open pathway through the labyrinthine segment of the facial nerve and CSF pulsations created the meningocele over a few years. This case argues for early closure of such CSF diverticula to prevent possible SNHL due to labyrinthine erosion.

Congenital Cholesteatoma in Adults-Interesting Presentations and Management.

To report a series of adult patients diagnosed with congenital cholesteatoma (CC) with respect to symptoms, different varieties of presentation, surgical findings and approach used, complications and the postoperative results. A retrospective chart review of adult cases of CC who were treated in the period from January 2014-2017 was carried out in a tertiary care center. Levenson's criteria were used for diagnosis. Diagnosis was confirmed by imaging and intraoperatively. Postoperative results and complications were also analyzed. Six adult cases of CC were studied with a mean follow up of 10months. Interesting presentations included otitis media with effusion, non-resolving facial nerve palsy, post aural discharge and meningitis. It included 3 cases of petrous apex cholesteatoma, 2 patients with cholesteatoma involving both the middle ear and mastoid and 1 patient with mastoid cholesteatoma. The operative procedures included canal wall up mastoidectomy (1 patient), atticotomy (1 patient), canal wall down mastoidectomy (1 patient), translabyrinthine and transotic excision of mass with blind sac closure (2 patients) and partial labyrinthectomy (1 patient). Complications encountered during surgery were cerebrospinal fluid leak and worsening of hearing in 2 patients and 1 patient respectively. CC can have variety of interesting presentations in adult population and they may or may not have the classical white mass behind the tympanic membrane. Appropriate individualized surgical planning and intervention gives good results.

Partial labyrinthectomy presigmoid transpetrosal resection of petroclival meningioma

A petroclival meningioma represents a challenging tumor to resect in the cerebellopontine angle and ventral to the brain stem. Multiple cranial nerves and blood vessels may be intimately involved with the tumor. A partial labyrinthectomy presigmoid transpetrosal approach can facilitate resection while preserving hearing. This approach allows for a direct line of sight along the petrous bone while sealing the canals can preserve hearing. In this video operative manuscript, we demonstrate a step-by-step illustration of a partial labyrinthectomy presigmoid transpetrosal resection of a petroclival meningioma. This approach affords the best chance of hearing preservation and an opportunity for maximum tumor resection. The video can be found here: http://youtu.be/29I4KEXz1vY .

Extensive intratemporal cholesteatomas: presentation, complications and surgical outcomes

The purpose of the study was to review the clinical features, complications, surgical management and post-operative outcomes of medially invasive extensive cholesteatomas and intracranial complications of cholesteatoma. The retrospective review was carried out at a tertiary referral center and included 20 patients presenting with extensive intratemporal cholesteatomas between 2011 and 2013. Inclusion criteria were involvement of the labyrinth, facial nerve, posterior fossa dura and intracranial complications. The mean age of the patients was 20 years. Profuse foul-smelling otorrhoea and severe otalgia/temporal headache were the most common presenting features. Intracranial complications were observed in nine patients, most commonly temporal lobe abscess; 14/20 patients exhibited profound hearing loss. One case exhibited massive labyrinthine petrous apex cholesteatoma. Labyrinthine destruction was seen in all cases of facial nerve involvement. Management of intracranial complications preceded canal wall-down mastoidectomy with or without partial labyrinthectomy and subtotal petrosectomy (transotic) with blind sac closure for petrous cholesteatoma. Facial nerve infiltration was observed in one case, whereas eight cases exhibited gross dehiscence of the fallopian canal. Disease clearance was complete in all cases with two mortalities in patients with intracranial complications. Post-operative course was uncomplicated in all other patients apart from a case of wound dehiscence. All patients remain disease free after a minimum and maximum follow-up of 6 months and 2 years, respectively. Extensive intratemporal cholesteatomas and intracranial complications caused by them continue to pose a challenge to the management of otitis media in the current era and merit early recognition, surgical management and follow-up.

Evolution of the posterior petrosal approach

In this article, the authors review the history of the posterior petrosal approach. The early foundation of the retrolabyrinthine lateral petrosectomy has its roots in the otolaryngology literature. These early approaches were limited in exposure by the tentorium superiorly and the sigmoid sinus posteriorly. Although the concept of a transtentorial approach was originally combined with a complete labyrinthectomy, Hakuba and colleagues described the expansive exposure afforded by sectioning the tentorium and superior petrosal sinus and mobilizing a skeletonized sigmoid sinus. This maneuver serves as the key step in allowing for the full, combined supra- and infratentorial exposure that the posterior petrosal approach provides. In contrast to Hakuba et al.'s approach, which used a partial labyrinthectomy, modern approaches often preserve the entire labyrinth (retrolabyrinthine approach). For added exposure, the latter can be combined with the anterior petrosal approach, allowing for the preservation of hearing and an enhanced view of the surgical target. The authors review the evolution of the petrosal approach and highlight its applicability.

Autologous Fascia Sling Technique for Dural Reconstruction Following Transtemporal Petrosectomy Approaches

Background: Reconstruction of presigmoid dural defects after transtemporal petrosectomy skull base approaches (translabyrinthine, retrolabyrinthine, partial labyrinthectomy, transpetrosal, and infratemporal fossa) is paramount to prevent CSF leakage.

Inner Ear Manipulation to Preserve Hearing in Otologic and Neurotologic Surgery

Surgical injury of the labyrinth had been generally believed to result in complete hearing loss. However, recent clinical experiences and experimental animal studies allowed surgical access to the inner ear with preservation of the cochlear function, thus providing a new gateway for the treatment of Meniere’s disease, benign paroxysmal positional vertigo and cholesteatoma, skull base tumors and acoustic neuromas. Electrophysiological experiments have shown that hearing can be preserved after semicircular canal transection, whereas wide opening of the vestibule results in hearing loss. Our clinical experiences of partial labyrinthectomy for various middle ear diseases, including labyrinthine fistula, petrous bone cholesteatomas and superior semicircular canal dehiscence syndrome are herein presented and pertinent electrophysiological research from our department is also presented and discussed.

Transcrusal approach to the retrochiasmatic region with special reference to temporal lobe retraction: an anatomical study

The retrochiasmatic region is one of the most challenging areas to surgically expose. The authors evaluated the transcrusal approach, which involves removal of the superior and posterior semicircular canal from the ampulla to the common crus, to expose the retrochiasmatic region and compared it with the retrolabyrinthine approach, both of which are a variation of the posterior petrosal approach with hearing preservation, with a special emphasis on the influence of temporal lobe retraction. Six sides of silicone-injected cadaveric heads were dissected using two approaches: the transcrusal approach and the retrolabyrinthine approach. For each craniotomy, 3 exposure parameters in the retrochiasmatic region were measured: (1) horizontal distance, (2) vertical distance, and (3) triangular area of exposure, at three different levels of temporal lobe retractions: 0, 5, and 10mm of retraction from the level of the tentorial incisura. Without temporal lobe retraction, only the transcrusal and not the retrolabyrinthine approach provided a direct exposure of the retrochiasmatic region, especially in the horizontal distance (p < 0.001). At all levels of temporal lobe retraction, the transcrusal approach provided greater exposure in the horizontal and vertical distances and in the area of exposure. Nonetheless, in the horizontal distance, the difference between the transcrusal and retrolabyrinthine approaches decreased along with increased temporal lobe retraction, and almost no difference was obtained at 10mm of retraction. Posterior petrosal approaches can provide an excellent exposure of the retrochiasmatic region. Of these two approaches, namely, transcrusal and retrolabyrinthine with hearing preservation, the transcrusal approach offers greater exposure than the retrolabyrinthine approach. The beneficial effect of partial labyrinthectomy of the transcrusal approach to the retrochiasmatic region is accentuated in the exposure of the horizontal distance with less temporal lobe retraction.

Effect of vestibular labyrinth destruction on endocochlear potential and potassium concentration of the cochlea

Partial labyrinthectomy can result in maintenance of hearing under certain circumstances, and the mechanism of the hearing impairment caused by labyrinthectomy is unclear. We hypothesized that disruption of the membranous labyrinth results in electrical leakage and electrolyte imbalance. This study investigated the change in cochlear function by measurement of endocochlear potential (EP) and potassium concentration ([K +]) caused by vestibular labyrinth destruction in the acute phase. Hartley guinea pigs underwent lateral semicircular canal (LSCC) transection with suctioning of the perilymph, ampullectomy, or destruction of the LSCC, superior SCC, and lateral part of the vestibule. The EP and [K +] were monitored using double-barreled ion-selective microelectrodes in the second turn of cochlea. The EP showed little to mild change after LSCC transectioning or ampullectomy, but declined variously and drastically after vestibulotomy. The EP did not recover but [K +] partially recovered after vestibulotomy. Disturbance of the mechanism of cochlear function caused by vestibular labyrinth destruction may involve reduction in the [K +] concentration in the endolymph.

Partial labyrinthectomy in the treatment of labyrinthine fistula: how we do it

Partial labyrinthectomy in the treatment of labyrinthine fistula: how we do it

Quantification of the presigmoid transpetrosal keyhole approach to petroclival region

Despite the presigmoid transpetrosal approach has been used by different researchers in various ways, the surgical injury rate remains high. Applying a minimally invasive keyhole idea, we devised a presigmoid transpetrosal keyhole approach (PTKA), classified and quantitatively assessed their approach to the petroclival area on a cadaver model by using a neuronavigation system. The presigmoid transpetrosal keyhole approach was divided into four increasingly morbidity-producing steps: retrolabyrinthine, partial labyrinthectomy with petrous apicectomy, translabyrinthine and transcochlear keyhole approaches. Six latex-injected cadaveric heads (twelve sides) underwent dissection in which a neuronavigation system was used. An area of exposure 10 cm superficial to a central target (working area) was calculated. The area of clival exposure with each subsequent dissection was also calculated. The retrolabyrinthine keyhole approach (RLK) spares hearing and facial function in theory but provides for only a small window of upper clival exposure. The view afforded by partial labyrinthectomy with petrous apicectomy keyhole approach (PLPAK) provides for up to four times this exposure. The translabyrinthine keyhole approach (TLK) and transcochlear keyhole approach (TCK), although producing more morbidity, add little in terms of a larger petroclival window. However, with each step, the surgical freedom for manipulation of instruments increases. The presigmoid transpetrosal keyhole approach to the petroclival area is feasible and useful. The RLK has relatively limited utility. For lesions without bone invasion, the PLPAK provides a much more versatile exposure with an excellent chance of hearing and facial nerve preservation. The TLK provides for greater versatility in treating lesions but clival exposure is not greatly enhanced. The TCK adds little in terms of intradural exposure but should be reserved for cases in which access to the petrous carotid artery is necessary.

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas: A quantitative anatomic comparison with other approaches to the same region

The partial labyrinthectomy petrous apicectomy approach to petroclival meningiomas: A quantitative anatomic comparison with other approaches to the same region

Endoscope-assisted surgery via the middle cranial fossa approach for a petrous cholesteatoma

Objective Surgical approaches to petrous cholesteatomas are the translabyrinthine–transcochlear approach, partial labyrinthectomy, and the middle cranial fossa approach. Selection of surgical approach is determined by region of cholesteatoma in the petrous bone as well as preoperative status of hearing and facial nerve function. The middle cranial fossa approach is the best approach for patient having good preoperative hearing and facial nerve function. However, application of this approach is limited for patients having relatively small petrous cholesteatomas, and sometimes difficult for patients in whom inner ear function is preserved but a cholesteatoma surrounds whole cochlea and extends to lower part of the labyrinth. In such case, we performed endoscope-assisted surgery via the middle cranial fossa approach to preserve cochlear and its function. Methods 30° and 70° rigid endoscopes were used for the operation via the middle cranial fossa. Results The inferior surface of the cochlea and the region around the internal carotid artery could be well visualized by use of endoscopy, and we succeeded in removal of petrous cholesteatoma surrounding the cochlea completely with preserving preoperative hearing. Conclusion Endoscope-assisted surgical technique that allowed safe and complete removal of a cholesteatoma extended inferior surface of coclear and around carotid artery in the petrous.

錐体部真珠腫の臨床像について―当科手術例における術式および治療成績の検討―

In this study we analyzed the clinical features and surgical treatment of petrous cholesteatoma in 9 patients (9 ears) who underwent surgery at the Jikei University Hospital. Most patients initially experienced hearing loss, then facial nerve palsy or otorrhea. Congenital cholesteatoma was diagnosed in four patients, acquired cholesteatoma in one patient, and postoperative recurrence in three patients. The proportion of cases of congenital cholesteatomas was higher than in previous reports. The area of the cholesteatoma was classified according to Dr. Sanna cases and the supralabyrinthine type in two cases. Hearing preservation surgery was performed in four patients via the middle cranial fossa approach or by partial labyrinthectomy, and the results seemed satisfactory. These results suggested that hearing preservation surgery should be adopted in every case.