Recess Approach Research Articles

One-stage coclear implantation via a facial recess approach in children with otitis media with effusion

ObjectiveTo investigate surgical indications, operative techniques, complications and auditory and speech rehabilitation for cochlear implant (CI) in children with otitis media with effusion (OME). Material and methodsThis is a retrospective review of records of 24children with bilateral profound sensorineural hearing loss and OME who were implanted during January 2011 to November 2014 in the Department of Otorhinolaryngology and Head and Neck Surgery at the PLA Hospital, using one-stage implantation via the facial recess approach and round window insertion. The incus was removed in 8 cases during the implantation procedure. Local infiltration of dexamethasone and adrenaline in the middle ear was also performed. Postoperative complications were examined. Preoperative and postoperative questionnaires including Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR), and the Meaningful Auditory Integration Scale (MAIS) were collected. ResultsAll electrodes were implanted successfully without any immediate or delayed complications. Inflammatory changes of middle ear mucosa with effusion were noted in all implanted ears. The scores of post-implant CAP and SIR increased significantly in all 24 cases (t = −25.95 and −14.09, respectively for CAP and SIR, p < 0.05). ConclusionsOne-stage CI via the facial recess approach with round window insertion is safe and effective in cochlear implant candidates with OME, as seen in the 24 children in our study who achieved improved auditory performance and speech intelligibility after CI.

Development of a Temporal Bone Model for Transcanal Endoscopic Ear Surgery.

Transcanal endoscopic ear surgery (TEES) is being increasingly used in chronic ear disease for cholesteatoma removal and middle ear reconstruction, reducing the need for a postauricular incision and mastoidectomy. However, TEES is a challenging technique even for the most experienced otologist, requiring one-handed dissection using angled instrumentation. We have therefore developed a high-fidelity dissection model incorporating key aspects of TEES and cholesteatoma removal to facilitate the acquisition of these skills. Artificial cholesteatoma was implanted into middle ear spaces of a human temporal bone via a facial recess approach. A pilot study was conducted whereby surgeons endoscopically elevated a tympanomeatal flap with artificial bleeding and removed artificial cholesteatoma with angled instrumentation. Surgeons were uniformly satisfied with the experience and felt it would translate into improved performance in the operating room. This study suggests that the TEES dissection model could become an integral tool in the training of emerging TEES techniques.

Promising new baseflow separation and recession analysis methods applied to streamflow at Glendhu Catchment, New Zealand

Abstract. Understanding and modelling the relationship between rainfall and runoff has been a driving force in hydrology for many years. Baseflow separation and recession analysis have been two of the main tools for understanding runoff generation in catchments, but there are many different methods for each. The new baseflow separation method presented here (the bump and rise method or BRM) aims to accurately simulate the shape of tracer-determined baseflow or pre-event water. Application of the method by calibrating its parameters, using (a) tracer data or (b) an optimising method, is demonstrated for the Glendhu Catchment, New Zealand. The calibrated BRM algorithm is then applied to the Glendhu streamflow record. The new recession approach advances the thesis that recession analysis of streamflow alone gives misleading information on catchment storage reservoirs because streamflow is a varying mixture of components of very different origins and characteristics (at the simplest level, quickflow and baseflow as identified by the BRM method). Recession analyses of quickflow, baseflow and streamflow show that the steep power-law slopes often observed for streamflow at intermediate flows are artefacts due to mixing and are not representative of catchment reservoirs. Applying baseflow separation before recession analysis could therefore shed new light on water storage reservoirs in catchments and possibly resolve some current problems with recession analysis. Among other things it shows that both quickflow and baseflow reservoirs in the studied catchment have (non-linear) quadratic characteristics.

The sensitivity and accuracy of a cone beam CT in detecting the chorda tympani.

The facial recess approach through posterior tympanotomy is the standard approach in cochlear implantation surgery. The size of the facial recess is highly variable, depending on the course of the chorda tympani. Despite their clinical importance, little is known about the sensitivity and accuracy of imaging studies in the detection of the chorda tympani. A total of 13 human temporal bones were included in this study. All of the temporal bones were submitted to a cone beam CT (Accuitomo, Morita, Japan). The multi-planar reconstruction images were rotated around the mastoid portion of the facial nerve to locate the branches of the facial nerve. A branch was diagnosed as the chorda tympani when it entered the tympanic cavity near the notch of Rivinus. The distance between the bifurcation and the tip of the short crus of the incus was measured. In all temporal bones, the canal of the chorda tympani or the posterior canaliculus was detected. In the CT-based evaluation, the average distance from the bifurcation to the incus short crus was 12.6 mm (8.3-15.8 mm). The actual distance after dissection was 12.4 mm (8.2-16.4 mm). The largest difference between the distances evaluated with the two procedures was 1.1 mm. Cone beam CT is very useful in detecting the course of the chorda tympani within the temporal bone. The measured distance is accurate.

Cochlear implantation in 21 patients with common cavity malformation

Conclusion: The facial recess approach is preferred in common cavity (CC) malformation with an incomplete basal turn, and the transmastoid single-slit labyrinthotomy approach in classic CC malformation. Patients with CC benefit from cochlear implantation (CI) over time, but the audiological and speech development is poorer than in cases with normal cochleas. Objectives: To discuss the surgical aspects and performance of CI in 21 patients with CC malformation. Methods: Twenty-one CC malformations were classified into 2 types: classic CC malformation and CC malformation with an incomplete basal turn. Twenty-one patients without inner ear malformation were set as the control group. Thus, data for 42 patients were analyzed. Results: The facial recess approach was used in 3 patients with CC malformation with an incomplete basal turn, and the transmastoid single-slit labyrinthotomy approach in 18 patients with classic CC malformation. After follow-up for 36 months, the average free-field hearing threshold was higher, and the scores for the CAP, SIR, IT-MAIS, and closed-set/open-set auditory speech perception tests were lower than in the control group (p < 0.05).

A Case of Removal of Medial Maxillary Intraosseous Hemangioma through an Intranasal Endoscopic Prelacrimal Recess Approach

Currently, most sinonasal lesions are treated using a transnasal endoscopic approach, but some areas of the maxillary sinus, such as the prelacrimal recess, may not be visualized and accessible. To overcome these limitations, several surgical techniques have been used, such as the Caldwell-Luc procedure and endoscopic medial maxillectomy. The intranasal endoscopic prelacrimal recess approach (PLRA) is a novel technique to address maxillary sinus lesions. We have successfully applied this approach to manage a bony lesion of the maxilla.

Predictors of round window accessibility for adult cochlear implantation based on pre-operative CT scan: a prospective observational study.

BackgroundCochlear implantation has become a mainstream treatment option for patients with severe to profound sensorineural hearing loss. During cochlear implant, there are key surgical steps which are influenced by anatomical variations between each patient. The aim of this study is to determine if there are potential predictors of difficulties that may be encountered during the cortical mastoidectomy, facial recess approach and round window access in cochlear implant surgery based upon pre-operative temporal bone CT scan.MethodsFifty seven patients undergoing unilateral cochlear implantation were analyzed. Difficulty with 1) cortical mastoidectomy, 2) facial recess approach, and 3) round window access were scored intra-operatively by the surgeon in a blinded fashion (1 = “easy”, 2 = “moderate”, 3 = “difficult”). Pre-operative temporal bone CT scans were analyzed for 1) degree of mastoid aeration; 2) location of the sigmoid sinus; 3) height of the tegmen; 4) the presence of air cells in the facial recess, and 5) degree of round window bony overhang.ResultsPoor mastoid aeration and lower tegmen position, but not the location of sigmoid sinus, are associated with greater difficulty with the cortical mastoidectomy. Presence of an air cell around the facial nerve was predictive of easier facial recess access. However, the degree of round window bony overhang was not predictive of difficulty associated with round window access.ConclusionCertain parameters on the pre-operative temporal bone CT scan may be useful in predicting potential difficulties encountered during the key steps involved in cochlear implant surgery.

Positive Outcomes and Surgical Strategies for Bilateral Cochlear Implantation in a Child with X‐Linked Deafness

Objectives: (1) Recognize that bilateral cochlear implantation (CI) in X-linked deafness is surgically feasible and safe. (2) Recognize that improvement in hearing as well as language acquisition is an achievable goal. Methods: This is a retrospective case review at a tertiary care center of one patient who presented with bilateral profound sensorineural hearing loss at age 6 months. He lacked auditory brainstem responses in both ears and was confirmed to have congenital X-linked deafness secondary to POU3F4 gene mutation. Because of lack of benefit from amplification, he underwent bilateral CI in a staged fashion at 12 (right ear) and 15 months (left ear) of age. Results: The patient underwent transmastoid-facial recess approach and received Nucleus Freedom implants (Cochlear Ltd) in both ears, utilizing perimodiolar electrodes. High-flow gushers were encountered bilaterally and resolved with temporalis muscle plugs. C-arm fluoroscopy was used during insertion of electrodes in both ears. Follow-up data were available for 12 months. No complications were encountered, including no postoperative CSF leakage or facial stimulation. Postoperative audiograms in aided conditions showed hearing thresholds &lt;40 dB. At 11 months following activation of his second CI, he scored in the normal range for his chronological age on standardized language measures, the Receptive Expressive Emergent Language Test-3 and the Preschool Language Scale-5. Conclusions: With careful preparation and the assistance of intraoperative fluoroscopy, cochlear implantation in patients with congenital X-linked deafness can be done safely. Performing bilateral CI followed by dedicated auditory-verbal rehabilitation may allow patients to trend toward normal language development.

A combination of modified transnasal endoscopic maxillectomy via transnasal prelacrimal recess approach with or without radiotherapy for selected sinonasal malignancies.

An external approach for resection of sinonasal tumors is associated with increased morbidity. Therefore, we employed a modified transnasal endoscopic maxillectomy combined with pre and/or postoperative radiotherapy for early stage maxillary carcinomas. It aims to evaluate our early experience with endoscopic resection of selected malignant sinonasal tumors. The medical and radiology records of patients who underwent endonasal endoscopic resection of malignant sinonasal tumors between 2008 and 2012 were retrospectively reviewed. Ten cases of selected malignant tumor were performed to resect by modified transnasal endoscopic maxillectomy. All the patients were without evidence of disease at a mean follow-up of 26.8 months. No major complications were recorded. The mean hospitalization stay was 6.6 days. In very carefully selected cases of malignant tumors, modified transnasal endoscopic maxillectomy is acceptable. The postoperative complication rate is low, cosmetic outcome is excellent and patients do not require a long hospitalization.

Contemporary Changes with the Use of Facial Nerve Monitoring in Chronic Ear Surgery

There is a growing trend for the routine use of the facial nerve monitor (FNM) in chronic ear surgery. We aimed to examine current patterns in the use of FNMs in chronic ear surgery. Descriptive design (survey). Academic health center. A 10-question survey was designed to identify level of training, scope of practice, specific otologic surgeries where monitoring was most used, and the opinion of respondents regarding the use of FNMs as standard of care for chronic and/or middle ear surgery. A randomized list of 2000 board-certified members of the American Academy of Otolaryngology-Head and Neck Surgery was generated. One thousand subjects received a mailed survey with a self-addressed return envelope and 1000 subjects received an emailed survey through Surveymonkey.com. There were 359 (36%) surveys returned by mail and 258 (26%) surveys returned electronically. Forty-three percent of respondents were in private practice, and 31% were fellowship trained in otology/neurotology. Sixty-five percent used a FNM in their training and 95% had regular access to a FNM. Revision mastoid surgery, cholesteatoma, canal wall down mastoidectomy, and facial recess approach were the settings where a FNM was most used. Forty-nine percent of respondents felt that a FNM should be used as the standard of care in chronic ear surgery; this represents an increase from 32% in a similar study done approximately 10 years ago. There is a growing trend for routine facial nerve monitoring in the setting of chronic ear surgery.

Scala tympani cochleostomy survey: a follow-up study.

To reassess cochleostomy techniques among North American cochlear implant surgeons after a 6-year period of widespread education and research on the topic. Prospective cohort study. A multiple-choice survey of cochlear implant techniques was distributed to surgeons attending the William House Cochlear Implant Study Group in 2006 and 2012. This survey contained questions regarding routine surgical access and cochleostomy techniques. Responses were anonymous, and >50% were repeat respondents. Statistical analysis sought changes in technique in the past 6 years. Comparisons between 2006 and 2012 responses revealed no significant changes in the proportion of surgeons identifying the facial nerve or chorda tympani. By contrast, respondents in 2012 were more likely to drill off the round window niche overhang (P < .001), use a round window insertion (P < .001), or make a smaller cochleostomy (P = .003). In two images of a transfacial recess approach, there was a significant increase in the proportion choosing an inferior or anterior cochleostomy site over a superior location (image 1, 76% in 2006 to 92% in 2012, P = .003; image 3, 78% to 90%, respectively, P = .044). This repeat survey documents a change in practice among cochlear implant surgeons. Specifically, scala tympani access techniques now appear to be more consistent with known anatomical relationships in the round window region. These findings may have resulted from the concerted education and research efforts over the past 6 years.

Novel en-bloc resection of locally advanced hilar chulangiucarcinuma: the Rex recess approach

Loco-regional recurrence after potentially curative resection remains a problem in hilar cholangiocarcinoma. Hilar dissection risks local spillage of tumor cells leading to suboptimal disease free survival. We have developed a new technique of radical resection for hilar cholangiocarcinoma based on the distinctive anatomy of the Rex recess of the liver, which has been assessed in two patients with locally advanced hilar cholangiocarcinoma. This technique included a right hepatectomy with en-bloc resection of the hepatoduodenal ligament and portal venous reconstruction to the left portal vein at the Rex recess. Both patients had R0 resection and have been disease-free for 26 and 38 months, respectively.

Removal of Schwannoma in the pterygopalatine and infratemporal fossa via endoscopic prelacrimal recess approach

To sum up and analyze the results of surgical removal of Schwannoma in the pterygopalatine and infratemporal fossa (PPF and ITF) through postero-lateral wall via prelacrimal recess approach (PLRA). The surgical technique and indications were presented and discussed. Six patients aged from 29-59 year-old with Schwannoma in the PPF and ITF, who received the tumor resection via PLRA under endoscope, were enrolled in this paper. Three were female and 3 were male. All of them received preoperative CT and MRI. The PPF and ITF were approached via prelacrimal recess endoscopically under general anesthesia. Schwannoma was histopathologically confirmed after surgery. The postoperative periodical CT and MRI follow up was conducted. The tumors were removed completely in these 6 patients. No recurrence was found during 19.3 months follow up on the average. Three patients had obvious numbness in the V2 innervation area 1 or 2 weeks after operation and disappeared afterwards. Only 1 patient had mild altercation numbness at the end of follow up. Schwannoma involved PPF and ITF can be removed endoscopically via PLRA. The lateral wall of nasal cavity might be kept intact. It is a novel minimally transnasal invasive approach to PPF and ITF with less damage and complications.

Scala Tympani Cochleostomy Survey: A Follow‐up Study

Objectives: Reassess cochleostomy techniques among North American cochlear implant surgeons after a 6-year period of widespread education and research on the topic. Methods: A multiple-choice survey of cochlear implant techniques was distributed to surgeons attending the William House Cochlear Implant Study Group in 2006 and 2012. This survey contained questions regarding routine surgical access and cochleostomy techniques. Responses were anonymous and more than 50% were repeat respondents. Statistical analysis sought changes in technique in the last 6 years. Results: Comparisons between 2006 and 2012 responses revealed no significant changes in the proportion of surgeons identifying the facial nerve or chorda tympani. By contrast, respondents in 2012 were more likely to drill off the round window-niche overhang ( P &lt; 0.001), use a round window insertion ( P &lt; 0.001), or make a smaller cochleostomy ( P = 0.003). In two images of a trans-facial recess approach, there was a significant increase in the proportion choosing an inferior or anterior cochleostomy site over a superior location (Image1-76% in 2006 to 92% in 2012 ( P = 0.003), Image 3 78% to 90%, respectively ( P = 0.044). Conclusions: This repeat survey documents a change in practice among cochlear implant surgeons. Specifically, scala tympani access techniques now appear to be more consistent with known anatomical relationships in the round window region. These findings may have resulted from the concerted education and research efforts over the last six years.

Intranasal endoscopic prelacrimal recess approach to maxillary sinus

Background The inferior turbinate (IT) and nasolacrimal duct (NLD) are often sacrificed while managing the diffuse lesion of maxillary sinus (MS). We report a new approach to MS without ablation of NLD and IT. Methods This retrospective study enrolled 19 hospitalized patients (aged from 42 to 68 years) who underwent endoscopic sinus surgery between 2003 and 2008. Twelve patients had inverted papilloma (IP), two had nasal polyps, two had Kubo's postoperative cyst of MS, one had recurrent bone cyst of maxilla, one had dentigerous cyst and one had bleeding of internal maxillary artery secondary to Caldwell-Luc operation respectively. Two IP patients were excluded from this group since the follow-up time was less than 12 months. The NLD was dissected after removing the anterior bony portion of nasal lateral wall. The prelacrimal recess approach (PLRA) to MS was established when IT-NLD flap was raised medially. The flap was repositioned when MS lesion was removed. Results All the 17 patients had unilateral lesions. Ten MS IP patients were at the T3 Krouse stage. The follow-up ranged from 7 to 60 months. No recurrence was seen in 16 patients. Only one IP patient had a local recurrence in MS. All of them had no any complications. Conclusion The diffuse or severe diseases of MS may be the potential indications for PLRA.

Transcanal approach for implantation of a cochlear nerve electrode array

To evaluate a transcanal approach for placement of a stimulating electrode array in the cochlear nerve. Prospective cadaveric temporal bone study. Ten human cadaveric temporal bones were dissected. Both a facial recess approach with mastoidectomy and a transcanal approach using the novel technique were performed in each bone. A middle fossa dissection of the internal auditory canal was performed to confirm the position of the electrode in the cochlear nerve. The transcanal approach offered a direct approach to the cochlear nerve in all 10 bones. The procedure was quicker than the facial recess approach and did not endanger the facial or chorda tympani nerves. Inspection of the medial end of the internal auditory canal confirmed correct placement of the electrode in the cochlear nerve. In contrast, anatomical constraints, specifically the position of the facial nerve, blocked access to the cochlear nerve by the facial recess approach in three of the specimens to achieve the exposure to place the electrode at a perpendicular angle to the cochlear nerve. Sacrifice of the chorda tympani was necessary in five of the seven bones in which the cochlear nerve could be accessed. The transcanal approach offers a simpler, safer approach for cochlear nerve implantation compared to the facial recess approach. This approach can be accomplished in less time and avoids the hazards of dissection around the facial nerve. Use of the proposed approach will facilitate development of intraneural stimulation for an improved auditory prosthesis.

Laser Doppler Vibrometry measurements of human cadaveric tympanic membrane vibration

ObjectiveTo determine the feasibility of measuring tympanic membrane (TM) vibrations at multiple locations on the TM to differentiate normal eardrums from those with associated ossicular pathologies.DesignCadaveric human temporal bone study.SettingBasic science laboratory.MethodsA mastoidectomy and facial recess approach was performed on four cadaveric temporal bones to obtain access to the ossicles without disrupting the TM. Ossicles were palpated to ensure normal mobility and an intact ossicular chain. Laser Doppler Vibrometry (LDV) measurements were then taken on all four TMs. LDV measurements were repeated on each TM following stapes footplate fixation, incudo-stapedial joint dislocation, and malleus head fixation.Main outcome measuresLDV measurements of TM vibration at the umbo, the lateral process of the malleus, and in each of the four quadrants of the TM.ResultsThe best signal-to-noise ratios were found between 2 and 4 kHz, at the umbo, the anterior superior quadrant, the anterior inferior quadrant, and the posterior inferior quadrant. Since our goal was to assess the ossicular chain, we selected the TM locations closest to the ossicular chain (the umbo and lateral process of the malleus) for further analysis. Differences could be seen between normals and the simulated ossicular pathologies, but values were not statistically significant.ConclusionsLDV measurements are technically challenging and require optimization to obtain consistent measurements. This study demonstrates the potential of LDV to differentiate ossicular pathologies behind an intact tympanic membrane. Future studies will further characterize the clinical role of this diagnostic modality.

Trudności diagnostyczne towarzyszące utajonemu zapaleniu wyrostka sutkowego – opis przypadku

IntroductionComplications of acute otitis media have decreased in frequency because of the broad use of antibiotics. On the other hand, antimicrobial agents may sometimes not prevent the complication but only obscure the presentations making the signs and symptoms less obvious. In latent mastoiditis, the patient typically lacks the classic symptoms and the tympanic membrane can seem to be normal if the middle-ear infection has resolved but there is an obstruction of the aditus ad antrum. At this stage, the infection can develop into another intratemporal or intracranial complications. Case reportA long way to establish the diagnosis of latent mastoiditis in 32-year-old woman is described. ConclusionsAlthough relatively uncommon, latent mastoiditis still remains one of the potential consequences of otitis media. Myringotomy, tympanostomy tube insertion or mastoidectomy with large facial recess approach to middle ear have to be considered to prevent further possible complications.

The Round Window

To demonstrate that the round window insertion (RWI) for cochlear implantation with multichannel electrodes is a reliable, safe, and effective technique. Retrospective case review. Academic tertiary referral center. One hundred thirty consecutive cochlear implants (72 female and 58 male subjects) performed from August 2009 to August 2011. Devices included 83 Cochlear, 40 Med El, and 7 Advanced Bionics (AB) cochlear implants. Subsequent to a full audiometric assessment, patients underwent a mastoidectomy with facial recess approach whereby the primary surgical objective was to perform a RWI. When the surgeon was unable to access the round window safely, a cochleostomy was performed anterior and inferior to the round window. Postoperative performance was measured with Hearing in Noise Test, the Consonant-Nucleus-Consonant test, and/or the Arizona Biomedical Sentences test. Surgical feasibility of reliably performing a RWI, reason for cochleostomy, postoperative complications, and audiometric performance. In 111 (85.4%) of 130 procedures, a RWI was performed; in 19 (14.6%), a cochleostomy was readily performed by the same approach. Reasons for creating a cochleostomy included facial nerve and jugular bulb location. There were no major postoperative complications in either group and 13 total minor complications. There was no statistically significant difference in postoperative complications or in audiometric performance between the 2 groups. The RWI may offer several advantages over a cochleostomy, and it seems to be a reliable, safe, and effective technique for cochlear implantation with today's cochlear implant electrodes. Further studies would be necessary to verify these findings for broad application to the cochlear implant patient population.

Serious Complications during Aural Impression-Taking for Hearing Aids: A Case Report and Review of the Literature

Complications during aural impression-taking for hearing aids are relatively rare. We present a case to highlight the need for vigilance when taking an aural impression and review the literature to identify other cases in order to assess the range of complications encountered and the sequelae of this potentially serious problem. We present a case report and a review of the literature. The most common complication was the entry of mold material into the middle ear cavity. This frequently occurred in patients with a preexisting perforation of the tympanic membrane, although traumatic perforation occurred in 5 cases. Spread of the mold material within the middle ear cavity was frequently extensive, with 46% of cases involving the eustachian tube. There were 6 cases of ossicular chain involvement: encasement of the ossicles in 5 and extensive ossicular erosion in 1. The extent of the surgical procedures performed varied widely, ranging from simple removal of the foreign body in the mastoid cavity to tympanomastoidectomy with a facial recess approach and ossiculoplasty. In 50% of cases, the patient recovered without any complication. However, further hearing loss was observed in 36% of cases. When mold material is impacted in the ear canal and visualization of the middle ear is obscured, we advise against simple piecemeal removal. Such cases are best managed by an experienced otologist.