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Wound Complications and Outcomes in Lateral Skull Base Surgery
P232
Otolaryngology– Head and Neck Surgery August 2005
Scientific Posters
idiopathic SSNHL underwent pure tone audiometry, tympanometry, evaluation of stapedial reflexes, auditory brainstem evoked response test and computer tomography or magnetic resonance imaging. Plasma samples were obtained at presentation before initiation of treatment. RNA was subjected to reverse transcriptase polymerase chain reaction (RT-PCR) using entervirus universal primers. Detection of IgM antibodies against EBV viral capsid antigen was performed by means of enzyme-linked immunosorbent assay (ELISA). Detection of CMV IgM antibodies was performed by means of enzymelinked fluorescent assay (ELFA). Results: There were 10 men and 11 women. The mean age was 54 years (range 26 to 74 years). None presented with clinical symptoms of a viral infection or with preceding upper respiratory tract infection. One patient was positive for an enterovirus infection (4.7%). Three patients (14.2%) were positive for EBV infection and no patients were positive for CMV. The prevalence of patients with positive laboratory results was lower (19%) than patients with no evidence of a viral infection (81%). In patients under 40 years old, only one patient had positive results for a viral infection, while 75% had negative results for an active infection. Conclusion: Enterovirus, EBV, and CMV are not involved in the etiology of idiopathic SSNHL in most patients, at least in Jerusalem. Further studies in larger and different epidemiological populations are required in order to verify the role of various viruses in SSNHL. P104 Relationship Between Human Cholesteatoma and Matrix-Metalloproteinase 2
P105 Delayed-Onset Facial Nerve Paresis after Acoustic Neuroma Surgery Joe Walter Kutz, MD (presenter); Jeffrey T Vrabec, MD Pearland TX; Houston TX
Objectives: Describe the incidence and characteristics of patients with delayed-onset facial nerve paresis after surgery for acoustic neuroma. Methods: Retrospective chart review of 72 consecutive patients that underwent removal of an acoustic neuroma. Facial nerve function was measured immediately post-operatively, at one week, and at four weeks. Results: Six of 37 patients (16.2%) with normal postoperative facial nerve function developed delayed-onset facial nerve paresis. The average age of patients who developed delayed facial nerve paresis was 56.7 years compared to an average age of 48.8 years in patients who did not develop delayed facial nerve paresis. Size of tumor and surgical approach did not predict the incidence of delayed-onset facial nerve paresis. All patients had an onset of facial nerve paresis between post-operative day six and 14 with an average onset of 10.3 days. Four patients developed mild facial nerve paresis (II/VI as measured by the House-Brackmann grading system). Two resolved completely with the other two patients having persistent weakness. The other two patients developed a grade V/VI facial nerve paresis. Both patients had improvement in facial nerve function, however, total recovery was not seen in either. Conclusion: Delayed-onset facial nerve paresis is a common occurrence in patients after surgery for acoustic neuroma.
Douglas Salmazo Rocha Morales, MD PhD (presenter) Sao Paolo Brazil
P106 Wound Complications and Outcomes in Lateral Skull Base Surgery Mary Margaret Beauchamp, MD (presenter); Michael Raffin, PhD; Sam J Marzo, MD Maywood IL; Maywood IL; Maywood IL
Objectives: Successful outcomes in lateral skull base surgery require an understanding of anatomy, surgical technique, patient factors, tumor factors, and wound healing. Intraoperative and postoperative complications can occur resulting in increased patient morbidity. This study looks at a series of patients undergoing lateral skull base surgery at the same institution, by the same surgical team, analyzing outcomes and various factors, which may have contributed to wound complications. Methods: A retrospective chart review of lateral skull base procedures. All patients undergoing lateral skull base procedures at a single institution between July 1999 and December 2004 were reviewed. There were sixty patients undergoing 73 procedures. Patient age, sex, medical history including co-
POSTERS
Objectives: This study is to determine whether complicating cholesteatomas (invasives) show a higher immunohistochemical expression of matrix metalloproteinase 2 (MMP2), compared to latent cholesteatomas (not causing complications). Methods: A cross-sectional study with 19 slides and paraffin blocks of cholesteatomas derived from mastoidectomies were located and processed, including eight invasive and 11 latent cholesteatomas. Immunohistochemical tecnique was empregated to MMP2. Results: The results are expressed as 0, ⫹ (to low), ⫹⫹ and ⫹⫹⫹(high) according to the quantity and color of the immunohistochemical staining of MMP2. Higher expression of MMP2 was observed in seven (87.5%) of the eight invasive cholesteatomas. With respect to latent cholesteatomas, higher expression of MMP2 was observed in 27.3% (three cases), with Fisher’s exact test indicating a significant difference (p⫽0.015). Conclusion: Invasive cholesteatomas had high MMP2 compared to latent cholesteatomas.
Otolaryngology– Head and Neck Surgery Volume 133 Number 2
P107 FLAIR Magnetic Resonance Imaging in the Evaluation of Intralabyrinthine Pathology John Butman (presenter); Hung Kim, MD Bethesda MD; Washington DC
Objectives: To demonstrate the utility of FLAIR (Fluid Attenuated Inversion Recovery) in the magnetic resonance imaging (MRI) evaluation of the inner ear. Methods: Twelve cases with abnormal signal hyperintensity in the inner ear on post contrast FLAIR MRI were identified retrospectively. FLAIR MRI was compared with T2 weighted (T2W) and pre and post-contrast T1 weighted (T1W) MRI. Correlation was made with clinical findings and audiometry. Cases included: immune-mediated inner ear disorders (IMIED) (n⫽4), radiation labyrinthitis (n⫽2), intralabyrinthine hemorrhage (n⫽3) and neoplastic labyrinthitis (n⫽3). Results: In all cases of IMIED, neoplastic labyrinthitis, and radiation labyrinthitis, hyperintense signal on post-contrast FLAIR was identified in one or both ears. In each ear with FLAIR signal abnormality, no signal abnormality was identified on T2W or on post-contrast T1W MRI. In two of the three cases of intralabyrinthine hemorrhage, hyperintensity was seen on both on FLAIR and pre-contrast TIW MRI. In one case, hemorrhage was only identified on FLAIR. In all cases, the abnormal MRI findings correlated with audiovestibular deficits in the corresponding ear. Conclusion: MRI of the inner ear relies on high resolution T2W images and post-contrast T1W images because of their capability to detection of morphologic abnormalities and neoplasms. However, the sensitivity to other inner ear pathologies is low. We have identified a number of cases in which post-contrast FLAIR demonstrates inner ear abnormalities not detect on T1W and T2W MRI. FLAIR imaging should be a valuable addition to standard MRI of the inner ear.
P108 Reversible Elevated Bone Conduction Thresholds with Middle Ear Effusions : Discussion of Cases and Pathophysiology Collin S Karmody, MD (presenter); Michael E. Dybka, PhD; Susan M. McDonald, M.A. Boston MA; Boston MA; Boston MA
Objectives: An explanation for the possible pathophysiology of reversible elevated bone conduction (BC) with middle ear effusions (MEE) will be discussed. MEE are characteristically associated with conductive hearing losses, although a temporary or permanent effect on cochlear function might occur. Arnold et.al. (1977) reported a 1-20% incidence of shifts in BC. The pathophysiology of BC shifts from MEE is not well understood, however, various theories have been presented. Paparella et. al. (1980) hypothesized that inflammatory agents transverse the round window membrane causing temporary (TTS) or permanent threshold shifts (PTS) in BC. Alternatively, Sato et.al.(1987) proposed that BC was temporarily depressed by inhibition of movements at the oval and/or round windows. Methods: A clinical and audiological study of a number of patients with MEE who displayed transient shifts in BC was examined. The type, course, and results of treatment of the MEE will be demonstrated with pre- and post-treatment audiograms. Results: Elevated BC thresholds were reversed by treatment and resolution of the MEE and some thresholds were reversed immediately after aspiration of the middle ear. Conclusion: Our findings strongly supports the theory of mechanical inhibition. Our concept is that the shift in BC thresholds is caused by a dampening effect on the round window membrane. This study demonstrates that elevated BC thresholds in MEE might be reversible with the possibility of improvement with treatment. Clinicians should be aware of this phenomenon when counseling patients about the outcome of treatment of MEE. P109 Therapeutic Efficacy of Tinnitus Retraining Therapy Sangwon Yeo (presenter); Shi-Nae Park, MD; Kyoung-Ho Park, MD; Young-Soo Park, MD PhD Seoul South Korea; Seoul South Korea; Seoul South Korea; Seoul South Korea
Objectives: Tinnitus retraining therapy(TRT), which is consist of intensive one-to-one directive counseling and sound therapy, has been presented as a good approach to tinnitus management. The purpose of this paper is to understand this therapy by showing its long term results. Methods: A total of 125 patients with tinnitus visiting Tinnitus Clinic, Kangnam St. Mary’s Hospital from May, 1999 to March, 2003, who had received TRT for their tinnitus were included for evaluation of therapeutic efficacy of TRT.
POSTERS
morbidities, chemotherapy, radiation therapy, pathology, size of defect, procedure, reconstruction method, and long term outcome were all reviewed. Results: Overall, 21% of patients had a wound complication. All patients had at least six months of follow up. Of those patients with complications, 60% had benign lesions and 40% had malignant tumors. Of these patients, 62% had a major wound complication and 38% had a minor wound complication. There were no mortalities. Fifty-four percent of patients had a late wound complication. On follow up, only two of 15 patients had a long-term non-healing wound. Conclusion: Lateral skull base surgery wound complications do occur in the early and late postoperative period. Contributing factors include a history of radiation, malignancy, size of lesion, and comorbidities. Sixty percent of patients required revision surgery. However, the majority of patient wounds healed within one to two months.
Scientific Posters P233
Otolaryngology– Head and Neck Surgery August 2005
Scientific Posters
idiopathic SSNHL underwent pure tone audiometry, tympanometry, evaluation of stapedial reflexes, auditory brainstem evoked response test and computer tomography or magnetic resonance imaging. Plasma samples were obtained at presentation before initiation of treatment. RNA was subjected to reverse transcriptase polymerase chain reaction (RT-PCR) using entervirus universal primers. Detection of IgM antibodies against EBV viral capsid antigen was performed by means of enzyme-linked immunosorbent assay (ELISA). Detection of CMV IgM antibodies was performed by means of enzymelinked fluorescent assay (ELFA). Results: There were 10 men and 11 women. The mean age was 54 years (range 26 to 74 years). None presented with clinical symptoms of a viral infection or with preceding upper respiratory tract infection. One patient was positive for an enterovirus infection (4.7%). Three patients (14.2%) were positive for EBV infection and no patients were positive for CMV. The prevalence of patients with positive laboratory results was lower (19%) than patients with no evidence of a viral infection (81%). In patients under 40 years old, only one patient had positive results for a viral infection, while 75% had negative results for an active infection. Conclusion: Enterovirus, EBV, and CMV are not involved in the etiology of idiopathic SSNHL in most patients, at least in Jerusalem. Further studies in larger and different epidemiological populations are required in order to verify the role of various viruses in SSNHL. P104 Relationship Between Human Cholesteatoma and Matrix-Metalloproteinase 2
P105 Delayed-Onset Facial Nerve Paresis after Acoustic Neuroma Surgery Joe Walter Kutz, MD (presenter); Jeffrey T Vrabec, MD Pearland TX; Houston TX
Objectives: Describe the incidence and characteristics of patients with delayed-onset facial nerve paresis after surgery for acoustic neuroma. Methods: Retrospective chart review of 72 consecutive patients that underwent removal of an acoustic neuroma. Facial nerve function was measured immediately post-operatively, at one week, and at four weeks. Results: Six of 37 patients (16.2%) with normal postoperative facial nerve function developed delayed-onset facial nerve paresis. The average age of patients who developed delayed facial nerve paresis was 56.7 years compared to an average age of 48.8 years in patients who did not develop delayed facial nerve paresis. Size of tumor and surgical approach did not predict the incidence of delayed-onset facial nerve paresis. All patients had an onset of facial nerve paresis between post-operative day six and 14 with an average onset of 10.3 days. Four patients developed mild facial nerve paresis (II/VI as measured by the House-Brackmann grading system). Two resolved completely with the other two patients having persistent weakness. The other two patients developed a grade V/VI facial nerve paresis. Both patients had improvement in facial nerve function, however, total recovery was not seen in either. Conclusion: Delayed-onset facial nerve paresis is a common occurrence in patients after surgery for acoustic neuroma.
Douglas Salmazo Rocha Morales, MD PhD (presenter) Sao Paolo Brazil
P106 Wound Complications and Outcomes in Lateral Skull Base Surgery Mary Margaret Beauchamp, MD (presenter); Michael Raffin, PhD; Sam J Marzo, MD Maywood IL; Maywood IL; Maywood IL
Objectives: Successful outcomes in lateral skull base surgery require an understanding of anatomy, surgical technique, patient factors, tumor factors, and wound healing. Intraoperative and postoperative complications can occur resulting in increased patient morbidity. This study looks at a series of patients undergoing lateral skull base surgery at the same institution, by the same surgical team, analyzing outcomes and various factors, which may have contributed to wound complications. Methods: A retrospective chart review of lateral skull base procedures. All patients undergoing lateral skull base procedures at a single institution between July 1999 and December 2004 were reviewed. There were sixty patients undergoing 73 procedures. Patient age, sex, medical history including co-
POSTERS
Objectives: This study is to determine whether complicating cholesteatomas (invasives) show a higher immunohistochemical expression of matrix metalloproteinase 2 (MMP2), compared to latent cholesteatomas (not causing complications). Methods: A cross-sectional study with 19 slides and paraffin blocks of cholesteatomas derived from mastoidectomies were located and processed, including eight invasive and 11 latent cholesteatomas. Immunohistochemical tecnique was empregated to MMP2. Results: The results are expressed as 0, ⫹ (to low), ⫹⫹ and ⫹⫹⫹(high) according to the quantity and color of the immunohistochemical staining of MMP2. Higher expression of MMP2 was observed in seven (87.5%) of the eight invasive cholesteatomas. With respect to latent cholesteatomas, higher expression of MMP2 was observed in 27.3% (three cases), with Fisher’s exact test indicating a significant difference (p⫽0.015). Conclusion: Invasive cholesteatomas had high MMP2 compared to latent cholesteatomas.
Otolaryngology– Head and Neck Surgery Volume 133 Number 2
P107 FLAIR Magnetic Resonance Imaging in the Evaluation of Intralabyrinthine Pathology John Butman (presenter); Hung Kim, MD Bethesda MD; Washington DC
Objectives: To demonstrate the utility of FLAIR (Fluid Attenuated Inversion Recovery) in the magnetic resonance imaging (MRI) evaluation of the inner ear. Methods: Twelve cases with abnormal signal hyperintensity in the inner ear on post contrast FLAIR MRI were identified retrospectively. FLAIR MRI was compared with T2 weighted (T2W) and pre and post-contrast T1 weighted (T1W) MRI. Correlation was made with clinical findings and audiometry. Cases included: immune-mediated inner ear disorders (IMIED) (n⫽4), radiation labyrinthitis (n⫽2), intralabyrinthine hemorrhage (n⫽3) and neoplastic labyrinthitis (n⫽3). Results: In all cases of IMIED, neoplastic labyrinthitis, and radiation labyrinthitis, hyperintense signal on post-contrast FLAIR was identified in one or both ears. In each ear with FLAIR signal abnormality, no signal abnormality was identified on T2W or on post-contrast T1W MRI. In two of the three cases of intralabyrinthine hemorrhage, hyperintensity was seen on both on FLAIR and pre-contrast TIW MRI. In one case, hemorrhage was only identified on FLAIR. In all cases, the abnormal MRI findings correlated with audiovestibular deficits in the corresponding ear. Conclusion: MRI of the inner ear relies on high resolution T2W images and post-contrast T1W images because of their capability to detection of morphologic abnormalities and neoplasms. However, the sensitivity to other inner ear pathologies is low. We have identified a number of cases in which post-contrast FLAIR demonstrates inner ear abnormalities not detect on T1W and T2W MRI. FLAIR imaging should be a valuable addition to standard MRI of the inner ear.
P108 Reversible Elevated Bone Conduction Thresholds with Middle Ear Effusions : Discussion of Cases and Pathophysiology Collin S Karmody, MD (presenter); Michael E. Dybka, PhD; Susan M. McDonald, M.A. Boston MA; Boston MA; Boston MA
Objectives: An explanation for the possible pathophysiology of reversible elevated bone conduction (BC) with middle ear effusions (MEE) will be discussed. MEE are characteristically associated with conductive hearing losses, although a temporary or permanent effect on cochlear function might occur. Arnold et.al. (1977) reported a 1-20% incidence of shifts in BC. The pathophysiology of BC shifts from MEE is not well understood, however, various theories have been presented. Paparella et. al. (1980) hypothesized that inflammatory agents transverse the round window membrane causing temporary (TTS) or permanent threshold shifts (PTS) in BC. Alternatively, Sato et.al.(1987) proposed that BC was temporarily depressed by inhibition of movements at the oval and/or round windows. Methods: A clinical and audiological study of a number of patients with MEE who displayed transient shifts in BC was examined. The type, course, and results of treatment of the MEE will be demonstrated with pre- and post-treatment audiograms. Results: Elevated BC thresholds were reversed by treatment and resolution of the MEE and some thresholds were reversed immediately after aspiration of the middle ear. Conclusion: Our findings strongly supports the theory of mechanical inhibition. Our concept is that the shift in BC thresholds is caused by a dampening effect on the round window membrane. This study demonstrates that elevated BC thresholds in MEE might be reversible with the possibility of improvement with treatment. Clinicians should be aware of this phenomenon when counseling patients about the outcome of treatment of MEE. P109 Therapeutic Efficacy of Tinnitus Retraining Therapy Sangwon Yeo (presenter); Shi-Nae Park, MD; Kyoung-Ho Park, MD; Young-Soo Park, MD PhD Seoul South Korea; Seoul South Korea; Seoul South Korea; Seoul South Korea
Objectives: Tinnitus retraining therapy(TRT), which is consist of intensive one-to-one directive counseling and sound therapy, has been presented as a good approach to tinnitus management. The purpose of this paper is to understand this therapy by showing its long term results. Methods: A total of 125 patients with tinnitus visiting Tinnitus Clinic, Kangnam St. Mary’s Hospital from May, 1999 to March, 2003, who had received TRT for their tinnitus were included for evaluation of therapeutic efficacy of TRT.
POSTERS
morbidities, chemotherapy, radiation therapy, pathology, size of defect, procedure, reconstruction method, and long term outcome were all reviewed. Results: Overall, 21% of patients had a wound complication. All patients had at least six months of follow up. Of those patients with complications, 60% had benign lesions and 40% had malignant tumors. Of these patients, 62% had a major wound complication and 38% had a minor wound complication. There were no mortalities. Fifty-four percent of patients had a late wound complication. On follow up, only two of 15 patients had a long-term non-healing wound. Conclusion: Lateral skull base surgery wound complications do occur in the early and late postoperative period. Contributing factors include a history of radiation, malignancy, size of lesion, and comorbidities. Sixty percent of patients required revision surgery. However, the majority of patient wounds healed within one to two months.
Scientific Posters P233