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Derald E. Brackmann, Elizabeth H. Toh. Surgical management of petrous apex cholesterol granulomas. Otol Neurotol 2002;23:529–533
Objectives: To review surgical approaches for drainage of petrous apex cholesterol granulomas, define the criteria for the selection of each approach, and identify factors affecting surgical outcome.
Study Design: Retrospective chart review and follow–up survey questionnaire.
Settings: Tertiary neurologic referral center.
Patients: Thirty–four patients who underwent surgical treatment for symptomatic cholesterol granulomas of the petrous apex, who had a minimum of 3 months of clinical follow–up care and, in some cases, postoperative radiologic follow–up studies.
Intervention: Drainage with or without removal of the cyst lining was achieved through the transcanal infracochlear, transmastoid infralabyrinthine, middle fossa, translabyrinthine, and transotic approaches. Silastic catheters were used to stent drainage sites in some cases.
Main Outcome Measures: Relief of symptoms, postoperative cranial nerve function, clinical and radiologic recurrence, and need for further surgical intervention were evaluated. Imaging studies were reviewed to determine how anatomic information influenced surgical decisions and outcome.
Results: Clinical improvement of symptoms was observed in 28 patients (82%), and recovery of cranial nerve function was observed in 8 of 9 affected individuals. Serviceable hearing was preserved in all but 1 patient. Five patients required revision surgery for recurrent symptoms and lesions. All 5 patients had undergone drainage procedures without the use of stents. The size of the lesion did not influence the surgical outcome.
Conclusions: Determination of the appropriate surgical approach to the petrous apex is based on hearing status in the affected ear and on the anatomic relationships between the lesion and the surrounding neurovascular structures. The translabyrinthine approach is useful in nonhearing ears. In hearing individuals, anatomy permitting, the transcanal infracochlear approach with stenting is the preferred approach for drainage of petrous apex cholesterol granulomas.
Chang Weon Cho, Ossama Al–Mefty. Combined petrosal approach to petroclival meningiomas. Neurosurgery 2002;51:708–718
Objective: To study the use and advantages of combining the posterior petrosal approach with the anterior petrosal approach to petroclival meningiomas.
Methods: Seven cases of petroclival meningiomas operated on via the combined petrosal approach were retrospectively analyzed. The basis on which this approach was selected was assessed, as were its benefits and risks.
Results: Gross total resection was achieved in five of the seven patients. No mortality or decrease in Karnofsky performance score was observed at the time of the last follow–up examination. Six of the seven patients had serviceable hearing before the operation. Only one patient lost hearing after the operation, and this hearing loss occurred in only one ear. Before the operation, six patients were House–Brackmann facial nerve function Grade I, and one patient was Grade II to III. At the last follow–up examination, facial nerve function was Grade I in five patients, Grade II in one patient, and Grave V in one patient. Tumors in all patients involved the cavernous sinus, Meckel's cave, petroclival junction, and middle clivus. All patients possessed a large posterior fossa component of tumor measuring an average of 3.6 × 3.5 × 4.2 cm. In four patients, the tumor was attached for the entire width of the clivus to the contralateral petroclival junction. Four patients displayed central brainstem compression. Four patients displayed bony changes at the petrous apex. All patients displayed total or partial encasement of the vertebrobasilar artery and its major branches.
Conclusion: The combined petrosal approach should be considered for patients who have a large petroclival meningioma and serviceable hearing. This approach enhances petroclival exposure and the degree of tumor resection, especially in the area of the petroclival junction, middle clivus, apical petrous bone, posterior cavernous sinus, and Meckel's cave. The combined petrosal approach also allows better visualization of the contralateral side and the ventral brainstem, which facilitates safe dissection of the tumor from the brainstem, the basilar artery, and the perforators. If a patient has an early draining bridging vein to the tentorial sinus (before it reaches the transverse–sigmoid junction) or a prominent sigmoid sinus and jugular bulb, the combined petrosal approach provides significant working space.
Hani Z. Ibrahim, Melinda S. Moir, Willard W. Fee. Nasopharyngectomy after failure of 2 courses of radiation therapy. Arch Otolaryngol Head Neck Surg 2002;128:1196–1197
Background: Recurrence of nasopharyngeal carcinoma after initial therapy has been reported to range between 18% and 54%. As an alternative to surgical salvage, patients with recurrent nasopharyngeal carcinoma are offered a second course of radiation therapy. If this second course fails, patients may be candidates for surgical resection.
Objective: To identify the effectiveness and morbidity of surgical resection of recurrent nasopharyngeal carcinoma in patients who have received 2 cycles of external beam radiation.
Design and Setting: Retrospective survey of 6 patients in a university–based practice who underwent resection of recurrent nasopharyngeal carcinoma after 2 courses of radiation therapy.
Patients: Our study group comprised 4 women and 2 men aged between 35 and 67 years. All patients underwent 2 courses of radiation with a mean total dose of 11500 rad (115 Gy) (range, 9500–13200 rad [95–132 Gyl]) delivered to the nasopharynx prior to resection. The mean duration between the second course of radiation and resection is 21 months (range, 8–52 months). The mean follow–up period is 7.2 years (range, 4.2–11.5 years).
Intervention: Nasopharyngectomy after failure of 2 courses of radiation therapy.
Main Outcome Measures: Postoperative clinical outcome and morbidity.
Results: Five years after resection, 1 patient died of disease. The remaining 5 patients (83%) are alive with no evidence of disease. Osteomyelitis is the most common complication, affecting 5 patients. Three of the 5 patients with osteomyelitis required operative debridement of the nasopharynx and split–thickness skin grafting. Other complications include oronasal fistula (2 patients), chronic otitis media (2 patients), and nasopharyngeal stenosis (1 patient).
Conclusion: Although poor wound healing is evident, the overall 5–year survival of 83% is encouraging.
Christina Bales, Mark Kotapka, Laurie A. Loevner, Mouwafak Al–Rawi, Gregory Weinstein, Robert Hurst, Randal S. Weber. Craniofacial resection of advanced juvenile nasopharyngeal angiofibroma. Arch Otolaryngol Head Neck Surg 2002;128: 1071–1078
Objective: To describe the results of a craniofacial approach to resection of stage IIIB juvenile nasopharyngeal angiofibroma, performed by an integrated skull base surgical team.
Design: A retrospective case–series review was conducted with postoperative follow–up ranging from 28 to 63 months.
Setting: Operations were performed at a tertiary medical center.
Patients: A referred sample of 5 male patients, ranging in age from 10 to 23 years (mean, 15 years).
Interventions: All patients underwent resection of nasopharyngeal angiofibromas with intracranial extension. The procedure involved an infratemporal fossa approach via zygomatic osteotomy and subtemporal craniectomy. Anterior exposure was gained through a standard facial translocation. Dissection of the cavernous carotid artery was required in 3 patients.
Main Outcome Measures: Intraoperative and postoperative morbidity.
Results: The average operating time was 12 hours 47 minutes. Estimated blood loss ranged from 700 to 1750 mL (mean, 1120 mL), with 2 patients requiring intraoperative transfusion. Patients were hospitalized for a mean duration of 5.6 days. Long–term morbidity includes facial dysesthesia, nasal crusting, and malodorous nasal discharge. No patients sustained stroke, oculomotor dysfunction, vision loss, or auditory impairment. At most recent follow–up, which ranges from 28 to 63 months, tumor recurrence has been confirmed in 1 patient.
Conclusions: A combined craniofacial approach is appropriate for juvenile nasopharyngeal angiofibroma that extends intracranially. Complete tumor removal with acceptable morbidity can be expected.
Thomas P. Nikolopoulos, Gerard M. O'Donoghue. Acoustic neuroma management: An evidence–based medicine approach. Otol Neurotol 2002;23: 534–541
Background: Partisan claims supporting the use of microsurgical resection, radiologic surveillance, and radiosurgery in acoustic neuroma management appear widely in the published literature. However, the strength of the evidence supporting these claims has not been assessed, and the management of acoustic tumors continues to be controversial.
Methods: The English–language medical literature for the past 23 years was searched for articles dealing with outcomes after acoustic neuroma management. The quality of evidence in each article was classified according to the categories of evidence as defined by a standard appraisal instrument for clinical guidelines.
Results: The search produced 111 articles reporting outcomes after acoustic neuroma management. From the 111 studies, 78 (70.3%) concerned surgery, 20 (18%) concerned radiosurgery, 9 (8.1%) concerned radiologic surveillance, and 4 (3.6%) compared different methods of management. From these studies, 95 (85.6%) represented Type III evidence, 6 (5.4%) represented Type IV evidence and in 10 (9%) a clear–cut definition between Type III and Type IV could not be made. No study was supported by Type I or Type II evidence.
Conclusions: The evidence supporting the various methods of acoustic neuroma management is of low quality (Type III or Type IV evidence). Well–designed comparisons between treatment methods do not exist, and therefore claims by clinicians favoring a particular treatment are unfounded. Better quality of evidence from large, well–designed, randomized clinical trials should now be undertaken at the points of clinical equipoise to address the true merits of each modality of acoustic neuroma management.