The Bonebridge active bone conduction system: a fast and safe technique for a middle fossa approach

AbstractBackgroundThe transmastoid pre-sigmoid approach is always the preferred choice for implantation of the Bonebridge active bone conduction system in patients with a normal anatomy. When an anatomical variant exists or a previous surgery has been performed, a retrosigmoid approach or middle fossa approach can be performed.MethodsThe preferred surgical technique for a middle fossa approach is described. A 14 mm drill head (Neuro Drill) was used to create the bed at the squamous portion of the temporal bone. Surgical time and complication rate were analysed.ResultsThe surgical time was shorter than 30 minutes in all cases, and only 14 seconds were needed to create a 14 mm bone bed. No complications were observed during the follow-up period (6–45 months).ConclusionUse of the Neuro Drill for the middle fossa approach is an easy technique. It significantly decreases the surgical time, without increasing the complication rate.

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A Rapid and Safe Middle Fossa Approach to the Geniculate Ganglion and Labyrinthine Segment of the Facial Nerve

Ear Nose & Throat Journal ◽

10.1177/014556130208100509 ◽

2002 ◽

Vol 81 (5) ◽

pp. 320-326 ◽

Cited By ~ 12

Author(s):

Ricardo Ferreira Bento ◽

Rubens Vuono de Brito ◽

Tanit Ganz Sanchez

Keyword(s):

Facial Nerve ◽

Geniculate Ganglion ◽

Middle Fossa ◽

Cochlear Function ◽

Surgical Time ◽

Anatomic Landmarks ◽

Middle Fossa Approach ◽

Surgical Access ◽

Safe Technique ◽

Internal Acoustic Canal

The middle fossa approach provides neurotologic surgical access to lesions of the geniculate ganglion and the labyrinthine portion of the facial nerve as well as to the internal acoustic canal, and therefore helps preserve cochlear function. Although this approach is widely used, surgeons are still not certain which anatomic landmarks are best to locate the facial nerve and internal acoustic canal without causing labyrinthine damage. The purpose of this article is to describe a fast and safe technique to expose the geniculate ganglion and the labyrinthine portion of the facial nerve in two structures of the middle ear: the cochleariform process and the tympanic portion of the facial nerve. We prospectively evaluated 32 patients who underwent surgical facial nerve exploration via the middle fossa approach. Our goal was to determine the incidence of intraoperative difficulties and complications; we found none, and hearing levels could not be maintained in only one of the 32 patients. Our technique allowed us to decompress the first genu and the labyrinthine segment of the nerve. It also allowed us to reach and manipulate its tympanic segment in a very short amount of surgical time.

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Complications in Treatment of 31-A Fractures with Trochanteric Gamma Nail (TGN) Versus Gamma3 Nail (G3N) - A Review of 217 Cases

The Open Orthopaedics Journal ◽

10.2174/1874325001610010389 ◽

2016 ◽

Vol 10 (1) ◽

pp. 389-395 ◽

Cited By ~ 3

Author(s):

R. Schupfner ◽

L.T. Käsmann ◽

W. Wagner ◽

A.P. Schulz

Keyword(s):

Complication Rate ◽

Statistical Significance ◽

Gamma Nail ◽

Consecutive Series ◽

Related Complication ◽

Surgical Time ◽

Adequate Treatment ◽

Femur Fractures ◽

Two Generations

Introduction:The aim of this study was to clinically evaluate two generations of intramedullary gamma-nail used in the treatment of 31-A femur fractures.Materials and Methods:In two consecutive series, 117 trochanteric gamma nails (TGN) and 100 Gamma3 nails (G3N) were implanted for the treatment of inter- and subtrochanteric fractures between 2009 and 2011. Clinical and radiological follow-up examinations were assessed. An analysis of surgical time, hemoglobin drop and complications were performed.Results:Average surgical time, fluoroscopy time, haemoglobin drop and length-of-stay (LOS) were similar in both groups. No significant differences were found in surgery-related complications like wound hematomas (p=0,59), abscesses (p=0,38), wound infections (p=0,69) and Cut-outs (p=0,69) between the two groups. The cumulative surgery-related complication rate was higher in the TGN group compared to the G3N group (13,68%vs.8%) but this did not reach statistical significance (p=0,2).Conclusion:Our findings suggest that both TGN and G3N allow adequate treatment of trochanteric fractures with an acceptable complication rate.

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Hearing Preservation Using the Middle Fossa Approach for the Treatment of Vestibular Schwannoma

Neurosurgery ◽

10.1227/neu.0b013e31823110f1 ◽

2011 ◽

Vol 70 (2) ◽

pp. 334-341 ◽

Cited By ~ 26

Author(s):

Joe Walter Kutz ◽

Tyler Scoresby ◽

Brandon Isaacson ◽

Bruce E. Mickey ◽

Christopher J. Madden ◽

...

Keyword(s):

Facial Nerve ◽

Vestibular Schwannoma ◽

Academic Medical Center ◽

Hearing Preservation ◽

Middle Fossa ◽

Middle Fossa Approach ◽

Class A ◽

Facial Function ◽

Grade Iii

Abstract BACKGROUND: The incidence of small vestibular schwannomas in patients with serviceable hearing is increasing because of the widespread use of MRI. The middle fossa approach provides the patient with an opportunity for tumor removal with hearing preservation. OBJECTIVE: To determine the rate of hearing preservation and facial nerve outcomes after removal of a vestibular schwannoma with the use of the middle fossa approach. METHODS: A retrospective case review at a tertiary, academic medical center was performed identifying patients from 1998 through 2008 that underwent removal of a vestibular schwannoma by the middle fossa approach. Preoperative and postoperative audiograms were compared to determine hearing preservation rates. In addition, facial nerve outcomes at last follow-up were recorded. RESULTS: Forty-six patients underwent a middle fossa craniotomy for the removal of a vestibular schwannoma. Of the 38 patients that had class A or class B hearing preoperatively, 24 (63.2%) retained class A or B hearing and 29 (76.3%) retained class A, B, or C hearing. When tumors were 10 mm or less in patients with class A or B preoperative hearing, 22 of 30 patients (73.3%) retained class A or B hearing. When the tumor size was greater than 10 mm in patients with class A or B preoperative hearing, 2 of 8 patients (25%) retained class A or B hearing. At most recent follow-up, 76.1% of patients had House-Brackmann grade I facial function, 13.0% had House-Brackmann grade II facial function, and 10.9% had House-Brackmann grade III facial function. CONCLUSION: Hearing preservation rates are excellent using the middle fossa approach, especially for smaller tumors. No patient experienced long-term facial nerve function worse than House-Brackmann grade III.

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Middle Fossa Approach for Facial Nerve Schwannoma Aiming for Functional Improvement: 2-Dimensional Operative Video

Operative Neurosurgery ◽

10.1093/ons/opz178 ◽

2019 ◽

Vol 18 (5) ◽

pp. E167-E168

Author(s):

Ken Matsushima ◽

Michihiro Kohno ◽

Hitoshi Izawa ◽

Yujiro Tanaka

Keyword(s):

Facial Nerve ◽

Facial Palsy ◽

Tumor Resection ◽

Nerve Fibers ◽

Middle Fossa ◽

Tumor Removal ◽

Middle Fossa Approach ◽

Brainstem Response ◽

Facial Nerve Schwannoma

Abstract The treatment paradigm of skull base surgery has been changed from radical tumor resection to maximal tumor removal while giving priority to functional preservation. Facial nerve schwannoma is one of the representative disorders of this type of paradigm shift.1 This video demonstrates facial nerve schwannoma surgery through the middle fossa approach, aiming for improvement of facial function. A 33-yr-old woman presented with gradually worsening facial palsy (House-Brackmann grade IV), dizziness, and nausea. Neuroimaging revealed a growing tumor involving the geniculate ganglion, and extending to the middle fossa, internal acoustic meatus, and cerebellopontine angle. The nerve-sparing surgery through the left middle fossa approach was performed under detailed neuromonitoring including the evoked facial electromyograms and auditory brainstem response. The facial nerve fibers were involved within the tumor mass and the plane between the tumor and facial nerve could not be identified as seen in most cases of such large facial nerve schwannomas. But sufficient tumor removal with facial nerve preservation was achieved owing to continuous facial monitoring.2 The patient had no new neurological deficits. Her facial palsy has been gradually improving, now at grade III, without any signs of tumor regrowth during the 10 mo of follow up after the operation. Careful follow up is being continued to survey the possible tumor recurrence. The video was reproduced after informed consent of the patient.

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A comparison of the Ameroid constrictor versus ligation in the surgical management of single extrahepatic portosystemic shunts

Journal of the American Animal Hospital Association ◽

10.5326/15473317-37-4-390 ◽

2001 ◽

Vol 37 (4) ◽

pp. 390-396 ◽

Cited By ~ 45

Author(s):

ST Murphy ◽

GW Ellison ◽

M Long ◽

J Van Gilder

Keyword(s):

Complication Rate ◽

Surgical Techniques ◽

Portosystemic Shunt ◽

Comparable Efficacy ◽

Surgical Time ◽

Postoperative Complication Rate ◽

Surgical Ligation ◽

Portosystemic Shunts ◽

Occlusion Technique

Twenty-two dogs were managed surgically for a single extrahepatic portosystemic shunt; 12 with surgical ligation and 10 with an Ameroid constrictor. Utilization of the Ameroid constrictor significantly decreased surgery time to approximately half that of the ligation technique. A decreased intraoperative and postoperative complication rate was noted with the Ameroid constrictor group. Follow-up evaluation demonstrated comparable efficacy when comparing surgical techniques. The Ameroid constrictor offered a surgical occlusion technique for management of a single extra-hepatic portosystemic shunt that was equally effective to ligation while shortening surgical time and minimizing the risks that are commonly associated with ligation of the shunting vessel.

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Active Transcutaneous Bone Conduction Implant: Audiometric Outcomes Following a Novel Middle Fossa Approach With Self-Drilling Screws

Otology & Neurotology ◽

10.1097/mao.0000000000002597 ◽

2020 ◽

Vol 41 (5) ◽

pp. 605-613 ◽

Cited By ~ 1

Author(s):

Lauren Siegel ◽

Peng You ◽

Kim Zimmerman ◽

Lorne Parnes ◽

Sumit K. Agrawal

Keyword(s):

Bone Conduction ◽

Middle Fossa ◽

Middle Fossa Approach ◽

Bone Conduction Implant

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Middle fossa approach for a pediatric facial nerve meningioma

Journal of Neurosurgery Pediatrics ◽

10.3171/2020.5.peds2034 ◽

2020 ◽

Vol 26 (5) ◽

pp. 578-582

Author(s):

Robert C. Rennert ◽

Danielle M. Levy ◽

Jillian Plonsker ◽

Jeffrey A. Steinberg ◽

Rick A. Friedman ◽

...

Keyword(s):

Facial Nerve ◽

Cerebellopontine Angle ◽

Pediatric Patients ◽

Middle Fossa ◽

Facial Weakness ◽

Total Resection ◽

Who Grade ◽

Middle Fossa Approach ◽

Pathological Analysis

Pediatric cerebellopontine angle (CPA) meningiomas are extremely rare and are usually treated with a retrosigmoid surgical approach or radiation. The authors present the use of a middle fossa approach for the treatment of a symptomatic CPA meningioma in a 22-month-old female. The patient initially presented at 17 months with isolated progressive, long-standing right-sided facial weakness. MRI demonstrated a 5.0 × 5.0–mm right CPA lesion just superior to the cisternal segment of cranial nerve (CN) VII, which demonstrated growth on interval imaging. At 22 months of age she underwent a successful middle fossa craniotomy, including wide exposure of the porus acusticus, allowing for a gross-total resection with preservation of CNs VII and VIII. Pathological analysis revealed a WHO grade I meningioma. The patient remained neurologically stable on follow-up. The middle fossa approach can be used to safely access the CPA in properly selected pediatric patients.

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Alternative Inverted Middle Fossa Approach in Bonebridge Surgery. Technique, Results and Complications

International Archives of Otorhinolaryngology ◽

10.1055/s-0040-1715152 ◽

2020 ◽

Author(s):

Mario E. Zernotti ◽

Maria F. Di Gregorio ◽

Máximo Zernotti

Keyword(s):

Bone Conduction ◽

Similar Rate ◽

Treacher Collins Syndrome ◽

Middle Fossa ◽

Aural Atresia ◽

Middle Fossa Approach ◽

Mixed Hearing Loss ◽

Novel Approach ◽

Surgical Options ◽

Canal Wall Down

Abstract Introduction The transmastoid approach is the most recommended technique to Bonebridge surgery, while in patients with bad anatomy or in the canal wall down technique, retrosigmoid or Middle Fossa Approaches are the alternative surgical options. Objective To describe a novel alternative approach called inverted middle fossa approach (IMFA) and its technique and audiological outcomes. Methods Seven patients submitted to the IMFA were included. All patients presented conductive and mixed hearing loss with bone thresholds of the audiogram > 40 dB. The audiological test was conducted pre- and postoperatively. Results A total of 5 males and 2 females, aged 13,8 years old (range 6–25 years old) were studied. The average follow-up was of 20 months (12 to 32 months). All patients presented aural atresia, except one with severe osseous-fibrous dysplasia of the temporal bone. Two patients showed bilateral compromise, three patients had associated Goldenhar and Treacher Collins syndrome. On the preoperative audiograms, air conduction (AC) thresholds showed a PTA4 (0.5, 1, 2 and 4 kHz) of 66.7 dB (standard deviation [SD] = ± 7.8), while the bone conduction thresholds reached an average of 11.2 dB (SD = ± 6.9). The postoperative thresholds did not change, and additional sensorineural damage was not observed before activation. Four weeks after surgery, all the patients were fitted with the external processor. The postoperative audiological aided exam showed AC PTA 4 thresholds of 18.9 dB (SD = ± 5.9). Conclusion The IMFA allows the nearest position of the microphone to the external auditory canal. The technique is a suitable option to the 3 classical approaches with similar rate of audiological results. More investigation is needed to determine the benefit of the novel approach compared with the others.

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