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Objective To delineate the steps of exoscopic en bloc carotid artery–sparing total temporal bone resection for malignancies involving the temporal bone in a cadaveric model. Methods Dissections were performed on 3 right-sided (3 sides) formalin-fixed, latex-injected cadaveric specimens. An exoscopic en bloc carotid artery–sparing total temporal bone resection was performed on each cadaver. In the past 4 years, 8 patients have undergone exoscope-assisted internal carotid artery–sparing total temporal bone resection with the technique described in this report. As an example, we present a representative case of a patient in whom this technique was used. Results Exoscope-assisted en bloc total temporal bone resections were performed on 3 right-sided cadaveric specimens. The following steps were described to circumferentially expose the petrous temporal bone: infratemporal fossa exposure, temporal craniotomy for subtemporal middle fossa approach to the petrous bone, retrosigmoid craniotomy, and transjugular approach. Finally, 3 skull base osteotomies were performed to liberate anterior, medial, posterior attachments of the petrous bone for en bloc removal. Possible extensions of these dissections as indicated by tumor pathology were described. A case illustration and operative video utilizing these techniques is presented. Conclusions Exoscope-assisted en bloc carotid artery-sparing total temporal bone resection is a feasible technique for management of malignancies with temporal bone invasion.

Objective To evaluate the facial nerve function and audiological results of delayed (by at least one month after the insult) transmastoid facial nerve decompression (FND) in traumatic facial nerve paralysis (FNP). Methods Medical records of 57 patients with traumatic FNP were reviewed and surgical results of 13 patients (mean age 28.0 ± 17.67, range 3-67) undergoing transmastoid FND were analyzed. Preoperative and postoperative mean hearing thresholds were compared using 0.5, 1, 2, and 3 kHz. Facial nerve function was graded according to the House-Brackmann scale (HB) before and after surgery. HB scale results of grade III or better were accepted as good results postoperatively. Results Preoperative HB grades were V in 5 and VI in 8 patients. Twelve of 13 patients had good recovery of facial nerve function regardless of the operation timing. When mean preoperative and postoperative air-bone gap (ABG) values were compared (except the patients with total sensorineural hearing loss), the mean preoperative ABG was 33 ± 15.9 dB, and mean postoperative ABG was 17.2 ± 8.68 dB. There was a mean hearing gain of 15.8 dB after transmastoid facial nerve decompression surgery. Surgery and anesthesia-related complications were not seen in any patients. Conclusion The transmastoid route can be used safely and effectively with elimination of the risks of craniotomy and middle fossa surgery for patients with traumatic FNP. Hearing improvement can be achieved by performing ossicular chain reconstruction during decompression surgery for patients with conductive or mixed hearing loss (HL).

ObjectiveTo describe our management of implantable hearing device extrusion in cases of previous cervicofacial surgery.MethodsA review was conducted of a retrospectively acquired database of surgical procedures for implantable hearing devices performed at our department between January 2011 and December 2019. Cases of device extrusion and previous cervicofacial surgery are included. Medical and surgical management is discussed.ResultsFour cases of implant extrusion following cervicofacial surgery were identified: one involving a Bonebridge system and three involving cochlear implants. In all cases, antibiotic treatment was administered and surgical debridement performed. The same Bonebridge system was implanted in the middle fossa. The three cochlear implants were removed, and new devices were implanted in a more posterior region.ConclusionPrevious cervicofacial surgery is a risk factor for hearing implant extrusion. The middle fossa approach is the best option for the Bonebridge system. Regarding the cochlear implant, it is always suitable to place it in a more posterior area. An inferiorly based fascio-muscular flap may be a good option to reduce the risk of extrusion.

Background Subdural empyema (SDE) is a well-known entity in pediatric populations and is associated with a high rate of morbidity and mortality. Large scale evacuation of empyema, although effective, places the bone flap at risk of failure when replaced. Case Description We report the case of a 19-year-old man with a history of a shunted left middle fossa cyst presenting with a panhemispheric SDE after removal of his cystoperitoneal shunt by an outside facility. Extensive evacuation was performed via the patients prior parietal shunt incision after expansion of the preexisting burr hole. Cultures grew methicillin-sensitive Staphylococcus aureus and Propionibacterium acnes, and he was treated with long-term antibiotics. The patient had a complete recovery with persistent empyema resolution on 6-month follow-up. Conclusions Endoscopic-assisted burr hole evacuation of large panhemispheric and loculated SDE is feasible, effective, and safe. The primary advantage over conventional open evacuations is that it negates the need for a bone flap and its potential complications related to a secondary infection.

Although the possibility of spontaneous regression of intracranial arachnoid cysts (AC) during observational follow-up is widely recognized, the number of reports documenting such clinical course, often associated with the mild head trauma, is rather limited. We present a case of nearly complete resolution of the large middle fossa AC in a 5-year-old boy without any identifiable cause in 2.3 years after the initial diagnosis. It once again justifies observational strategy for AC not accompanying by mass effect and manifesting with minimal symptoms or diagnosed incidentally.

To examine whether simple mobility assessments can predict functional limitations and length of hospitalization after acoustic neuroma (AN) resection.Prospective case series.A prospective clinical study of adult patients undergoing AN resection by either the translabyrinthine, retrosigmoid, or middle fossa approach was conducted at a tertiary center. Preoperative mobility assessments included the functional gait assessment (FGA) and the 10-m walk (10 MW). Postoperatively, the Activity Measure for Post-Acute Care (AMPAC, at 48 hours), FGA, and 10 MW (at 1 week) were obtained. Demographic and medical data were collected.One hundred and thirty-eight patients were analyzed (mean age: 48.3 years, 68.8% female). Mean length of stay (LOS) was 3.1 days. The translabyrinthine approach was most commonly performed (48.6%). On regression analyses, preoperative FGA (P = 0.03) and 48-hour postoperative AM-PAC (P 0.001) independently predicted LOS, even after accounting for age, gender, body mass index, and tumor size. On receiver operating characteristic analysis, a preoperative FGA cut score of 25.5 predicted a protracted hospital stay (4 days) with a sensitivity of 77% and specificity of 50% (area under curve: 68.5).This study demonstrated that preoperative mobility assessments can predict functional limitations and LOS after AN resection. These objective tools can be used by clinicians to manage expectations and guide preoperative counseling in patients considering surgery.3 Laryngoscope, 131:644-648, 2021.

Introduction Tumors of the lateral skull base often require collaboration between neurosurgeons and neurotologists for the surgical approach. The three main transosseous surgical approaches are retrosigmoid (RS), translabyrinthine (TL), and middle fossa (MF). The literature reflects a relative paucity regarding the various closure techniques for these approaches and the postoperative complications. We have performed a systematic review comparing closure techniques from each approach. Methods A systematic review was performed using Ovid MEDLINE (1990–2016) on closure technique and postoperative complications for patients undergoing lateral skull base surgery via the TL, RS, or MF approach. Studies were included if they contained at least 10 patients, described their closure technique, and provided data on postoperative complications. Results A total of 1,403 studies were reviewed. Of these, 53 studies met inclusion criteria yielding a total of 10,466 subjects in this analysis. The average rate of cerebrospinal fluid leak was 5.3% in the TL approach, 9% in the RS approach, and 6.2% in the MF approach. There was no significant effect of various closure techniques on postoperative wound complications in the MF approach. Multiple factors were identified which affected postoperative wound complication in the RS and TL approaches. Conclusion There are a plethora of closure techniques for lateral skull base surgery. Several techniques were identified in this review that may affect the postoperative wound complication rates in lateral skull base surgery.

Objective To present surgical and audiometric outcomes of patients implanted with an active transcutaneous bone conduction implant following the novel middle fossa surgical approach with self-drilling screws. Study design Retrospective review. Setting Tertiary care center. Patients Thirty-seven adults with either conductive or mixed hearing loss that met indications for an active transcutaneous bone conduction implant were consecutively implanted from April, 2013 to May, 2018. Intervention Unilateral middle fossa implantation of an active transcutaneous bone conduction implant. Main outcome measures Patient charts were reviewed for surgical outcomes and complications over the 6-year period. Preoperative air conduction, preoperative bone conduction, and 3-month postoperative aided thresholds were recorded. Speech perception was assessed using CNC words and AzBio sentences. Pure-tone averages (PTAs; measured at 0.5, 1.0, 2.0 and 3.0 kHz), air-bone gap, and functional gain were calculated. Results Mean air conduction and bone conduction PTAs (±standard deviation) of the implanted ear were 66.8 dB (±14.9 dB) and 21.9 dB (±14.0 dB), respectively. Mean aided PTA was 26.5 dB (± 8.5 dB). The average functional gain was 40.3 dB (±19.0 dB). Favorable speech perception outcomes were observed. No complications or instances of revision surgery were reported, with a mean follow-up time of 32 months (range, 9-71 mo). Conclusions This is the first paper to describe outcomes of patients implanted with an active transcutaneous bone conduction implant via the middle fossa with self-drilling screws. Favorable surgical outcomes were observed with a follow-up of up to 6 years.

To determine the relationship, if any, between body mass index (BMI) and attenuation of the arcuate eminence (AE).Case series with chart review.Tertiary neurotologic referral center.Submillimeter distances were recorded from high-resolution temporal bone computed tomography (CT) scans of 50 patients (100 sides). The AE (defined as the superiormost location of the petrous bone over the otic capsule), the bony apex of the superior semicircular canal (SSC), and the geniculate ganglion (GG) were identified and 3-dimensional distances measured. The height of the AE relative to the bony apex of the superior semicircular canal was determined using Euclidean geometry using the fixed anatomical landmark of the GG as the origin. Correlations between AE and BMI were calculated using Pearson's, linear mixed effects, and sensitivity analysis models.The mean (SD) BMI was 30 (8.1) kg/mContrary to other structures within the lateral skull base, the relative prominence of the arcuate eminence does not correlate with BMI or any other demographic variables.

Purpose Middle fossa arachnoid cyst (MFAC) is one of the most common cranial cysts in children. The various postoperative complications following cyst fenestration are still the major concern for most surgeons. We systemically review the short-term postoperative complications in the literature and introduce our experience in preventing these complications.Methods A retrospective survey was conducted on the 38 cases of patients having MFAC (Results The overall complication rate in our series is 5.2%. Eight patients (21.1%) developed postoperative SH. One of them required reoperation. Patients who developed SH were significantly younger (4.1±1.6 versus 6.2±3.4 y.o., p=0.018). Binary logistic analysis showed that a lower age could be a risk factor for developing SH (P=0.115). No postoperative hemorrhage, cranial nerve palsy, or CSF leak was observed. In the systemic review, eighteen studies were included, comprising 649 cases of MFAC. The most common complication was SH (4.9%). The short-term postoperative complication rate between microscopic and endoscopic techniques was similar.Conclusion The complication rate in MFAC fenestration is low in children. SH is the most common postoperative complication, and it is prone to occur in young children.

Vestibular neurectomy for Meniere's disease is considered as a treatment option when conservative methods fail to control debilitating vestibular symptoms. Most common surgical approaches today consist of transtemporal supralabyrinthine (middle fossa), retrolabyrinthine and retrosigmoid craniotomies. The aim of this article is to describe the procedure of vestibular neurectomy via a retrosigmoid approach. This approach can be performed alone or in combination with a retrolabyrinthine approach and allows good exposure of the cranial nerves VII and VIII in the cerebellopontine angle.

Meniere's disease can cause debilitating dizziness and vertigo despite maximal medical management. In select patients, treatment with vestibular nerve section provides optimal outcomes for symptom control and hearing preservation. Vestibular nerve section is also indicated in other vestibular disorders, including refractory uncompensated vestibular neuritis. Surgical approaches for vestibular nerve section include the retrolabyrinthine, retrosigmoid, middle fossa, and translabyrinthine craniotomies. The advantages of the retrolabyrinthine approach include rapid access, excellent visualization of the facial and cochlear nerves, and the possibility of hearing preservation in conjunction with consistent outcomes for vestibular symptoms. In this chapter, we discuss the retrolabyrinthine approach for vestibular nerve section, providing the reader with an overview of when, why, and how to employ the technique.

BackgroundThe 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.

Background Surgical resection of vestibular schwannomas (VS) located within the internal auditory canal (IAC) is challenging, especially those located very laterally in the IAC. Various transcranial approaches have been described for resection of intracanalicular VS including retrosigmoid, translabyrinthine, and middle fossa approaches. Each approach has its indications, advantages, and limitations. The middle fossa approach (MFA) is considered by many authors as the gold standard approach for resection of small intracanalicular VS in young patients with serviceable hearing; however, there is often a limitation in complete visualization of the tumor. Methods The authors present an illustrative case to highlight the technical nuances of complementary use of endoscopy in MFA for complete resection of intracanalicular VS located at the IAC fundus, preserving preoperative hearing status and mainting intact facial nerve function. Results In our experience, the combined use of the endoscope and the microspe as described here and illustrated in our case, improves visualization of the IAC and its contents, improving ressection and outcomes. Conclusions MFA allows for a direct yet safe surgical corridor to small intracanalicular VS. The implementation of endoscopy with MFA, especially for VS located laterally in the IAC, allows for better opportunity for complete resection of the tumor with improved preservation of hearing and facial nerve function.

Petrous apex cholesterol granulomas are believed to result from blockage of the normal aeration of the petrous air cells, resulting in a repetitive cycle of mucosal engorgement, hemorrhage, and granuloma formation.1 The lesion usually progressively expands causing compressive symptoms. The thick granulomatous wall envelopes various ages of breakdown products, including a cholesterol-containing fluid, which is typically hyperintense on T1 and T2 weighted magnetic resonance imaging. Drainage procedures, regardless of the route (endoscopic, endonasal, or transtemporal), with or without stenting or marsupialization, will only temporarily drain this cholesterol-containing fluid, with consequently frequent recurrences.2-5 A total exoneration of the granuloma and obliteration of the cavity with vascularized tissue will assure a more durable outcome.1 The extradural zygomatic/middle fossa approach provides a short distance to the petrous apex and is purely extradural. By sectioning the zygoma, temporal lobe retraction is avoided.6 We present a case of a 29-yr-old male who presented in the year 2000 with progression of a left petrous apex cholesterol granuloma despite 2 previous drainage and stenting procedures. The patient consented for surgery and photo publication. Images in video at 2:41 © JNSPG, republished from Eisenberg et al1 with permission.

Background: Intracranial and central nervous system’s involvement with multiple myeloma (MM) is a clinically rare manifestation. Furthermore, the development of intracranial plasmacytoma without bone involvement is much rarer. Herein, we report the case of massive intracerebral hemorrhage form intracranial plasmacytoma that arose from the dura mater without bone involvement. Case Description: A 71-year-old woman, who had been diagnosed as MM and treated 2 years prior, developed sudden lethal intracerebral hemorrhage from the intracranial plasmacytoma. Massive hemorrhage was observed after a rapid tumor growth in the middle fossa. Immediate hematoma evacuation and tumor resection allowed the patient to avoid severe neurological deficits and lethal conditions. Conclusion: A close follow-up by neuroimaging studies is essential in cases of intracranial plasmacytoma in MM patients and early intervention with surgical resection or radiotherapy should be considered.

Background Skull base meningiomas represent a challenge for neurosurgeons, and the procedures are typically performed by experienced neurosurgeons, thus limiting resident training. A new simulation and rehearsal device can be used as an aid for senior surgeons during these operations and serve as a training tool for junior surgeons. Methods Forty patients harboring an anterior/middle fossa meningioma were recruited. Surgical Theater, a rehearsal/simulation platform, was used for preoperative planning and intraoperative 3D navigation on 20 patients (CT-MADE group), while the remaining (control group) underwent a traditional navigation. Qualitative comparisons between the 2 groups were made with regard to surgical procedure and patient outcome. Satisfaction questionnaires were completed by expert neurosurgeons and residents to assess the overall usefulness of the platform. Furthermore, the surface of the simulated craniotomy performed during the planning was compared with the one actually performed during surgery in order to evaluate the reliability of the planning. Results No differences between the 2 groups were found (surgery duration: P = 0.4; visual impairment: P = 0.56). Both residents and senior neurosurgeons enjoyed using the platform for intraoperative navigation and planning; simulated craniotomies were significantly smaller as compared with the real ones (P = 0.009), probably because it was not intuitive to depict the exact margins of the operculum with the platform. Conclusion Surgical Theater helped residents to improve their anatomic and procedural comprehension and was deemed as a useful aid to safely perform some demanding neurosurgical procedures, by both senior and junior surgeons.

Trigeminal schwannomas are rare benign tumors, it is second most common intracranial schwannomas after vestibular schwannomas. The management includes not limited to observation, stereotactic radiosurgery/radiotherapy, and/or surgical resection. Tumor size and patient clinical status are the most important factors in management.In this video, we describe the technical nuances of an extended middle fossa approach for large trigeminal schwannoma with cavernous sinus extension resection. A 44-year-old right-handed female with several months' history of progressive right facial paresthesia and pain in the distribution of V3 mainly. On physical examination, she had decreased sensation to light touch over the right V1 to V3 distribution with loss of cornel reflex. The brain MRI showed 3.5 cm bilobed mass extends from the pontine root entry zone to the cavernous sinus. Craniotomy was performed and followed by middle fossa dural peeling, peeling of temporal lobe dura away from the wall of the cavernous sinus, extradurally anterior clinoidectomy, drilling of the petrous apex, coagulation of superior petrosal sinus followed incision of the tentorium up to the tentorial notch with preservation the fourth cranial nerve, and tumor dissected away from V1 and then gradually removed from the superior wall of the cavernous sinus.The technique presented here allows for complete tumor resection, safe navigation through the relative cavernous sinus compartments, and minimizes the possibility of inadvertent injury to the cranial nerves.The postoperative course was uneventful except for right eye incomplete ptosis from the swelling. Her facial pain subsided after the surgery without any extra ocular movement impairment.The link to the video can be found at: https://youtu.be/zxi2XK2R9QU.

Surgical fenestration is widely accepted as a primary treatment for middle fossa arachnoid cysts (MFACs) in pediatric patients. However, postoperative subdural effusion and/or hydrocephalus always affect treatment outcomes. In this study, we presented our experience of treating MFACs with surgical fenestration in pediatric patients and analyzed the cases complicated by postoperative subdural effusion and/or hydrocephalus, to give insight into the clinical characteristics predisposing the complications. We retrospectively analyzed 21 pediatric cases with MFACs treated by surgical fenestration suffering postoperative subdural effusion and/or hydrocephalus in our department from November 2011 to April 2019. We reviewed the clinical characteristics and treatment outcomes. A total of 21 patients, among a total of 53 pediatric patients with MFACs treated by surgical fenestration, developed subdural effusion and/or hydrocephalus postoperatively. The mean age at the time of the initial surgery was 49 months. A total of 75% (6/8) of the patients under 2 years old and 13.3% (6/45) of the older patient group sustaining postoperative subdural effusion and/or hydrocephalus required further surgeries, respectively (Fisher’s exact test, p = 0.001). Notably, among the 21 cases with postoperative subdural effusion and/or hydrocephalus, all the 6 patients under 2 years old needed additional surgeries, while of the other 15 older patients, only 40% (6/15) needed further surgical interventions (Fisher’s exact test, p = 0.019). The immature CSF absorption in MFAC patients younger than 2 years old might predispose them to the relatively serious postoperative subdural effusion and/or hydrocephalus. For very young patients with giant MFACs, surgical fenestration might not be the best option.

Meningiomas arising from Dorello's canal1-3 are a rare disease entity often resulting in an unclear diagnosis even at the time of surgery.4,5 We present a case of a 63-yr-old man who presented with a sixth nerve palsy. He was found to have a lesion in the region of Meckel's cave on neuroimaging studies. Additionally, there were cutaneous and joint complaints that gave rise to a clinical possibility of sarcoidosis. The differential diagnosis also included meningioma or other inflammatory processes. The patient underwent a right-sided middle fossa approach and partial anterior petrosectomy (Kawase approach). Meckel's cave was opened, the tumor resected, and the petrosphenoid ligament (Gruber's) was identified. It was a meningioma. The case presentation, surgical anatomy, technique, and postoperative course and outcome are reviewed. The patient gave verbal consent for participating in the procedure and surgical video.

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.

The meningo-orbital band (MOB) is the most superficial dural band that tethers the fronto-temporal dura to the periorbita. It is usually encountered when performing a pterional or fronto-temporo-sphenoidal approach, and it disrupts surgical access to deeper regions. Our objective was to perform a detailed anatomy study and a stepwise method to successfully detach the MOB using cadaveric specimens. We used six formalin-fixed, silicone-injected cadaveric heads. On each side, we performed a pterional approach plus mini-peeling of the anterior third of the middle fossa and/or extradural anterior clinoidectomy. We also applied this technique in three clinical cases to prove its safety and efficacy. The detachment of the MOB consists in four steps, 1) detachment of the temporal and frontal dura, 2) cutting of the MOB, 3) exposure and drilling of the anterior clinoid process, and 4) pealing of the lateral wall of the cavernous sinus. Using clinical cases, we explain how to adapt the technique depending on the localization of the lesion. The detachment of the MOB is the key to safely expose the cavernous sinus and the anterior clinoid process. The authors proposed a step-by-step method for the safe and effective detachment of the MOB. It is recommended, particularly to less experienced neurosurgeons that are starting with skull base surgery, and also to experts that want to expand their knowledge.

Background Petroclival tumors and ventrolateral lesions of the pons present unique surgical challenges. This cadaveric study provides qualitative and quantitative anatomic comparison for an anterior petrous apicectomy through the transcranial middle fossa (TMF) and expanded endoscopic transsphenoidal-transclival approaches. Methods In 10 silicone-injected heads, the petrous apex and clivus were drilled extradurally using middle fossa and endonasal approaches. With in situ and frameless stereotactic navigation, we defined consistent points to compare working areas, bone removal volumes, approach angles, and surgical freedom. Results Mean exposed TMF area (21.03 ± 3.46 cm2) achieved a 44.71 ± 4.13° working angle to the brainstem between cranial nerves V and VI. Kawase's rhomboid area measured 1.76 ± 0.34 cm2, and bone removal averaged 1.20 ± 0.12 cm3 at the petrous apex. Surgical freedom on the lateral brainstem was higher halfway between cranial nerves V and VI at the center of the rhomboid compared with midline at the basilar sulcus (P Conclusions Expanded transclival anterior petrosectomy through the TMF approach provides an adequate corridor to lesions in the upper ventrolateral pons. The expanded endoscopic transsphenoidal-transclival approach better fits midline lesions not extending laterally beyond cranial nerve VI and C3 carotid when evaluating normal anatomic parameters.

The aim of this letter is to respond to a commentary on a published article on the middle fossa approach to BONEBRIDGE implantation with self-drilling screws published by the senior authors.

As one of the common neurological diseases, pediatric middle fossa arachnoid cysts(MFACs) can develop intracystic hemorrhage and subdural hematoma. Risk factors for pediatric arachnoid cyst rupture/hemorrhage is very complicated in mechanism. Although surgery is the first choice for children with MFACs and subdural hematoma, the rate of recurrence of the subdural hematoma is very high after 1 or more surgeries. Atorvastatin has proven to be a bold and safe choice in the management of subdural hematoma with mild symptoms. The present study has described a 7-year-old child with a recurrent rupture of arachnoid cyst develops into a subdural hematoma. We demonstrate that atorvastatin is safe and effective in pediatric patient who has failed surgical treatment of middle fossa arachnoid cyst and subdural hematoma. The patient received atorvastatin monotherapy, once daily for the first week, with an initial dose of 5 mg, followed by 10 mg once daily for 7 weeks. In the third month after the initial treatment, the neurological function recovered, and the hematoma completely resolved. This case report supports the concept that atorvastatin can promote the absorption of subdural hematoma.

Bone conduction implants can be used in the treatment of conductive or mixed hearing loss. The BONEBRIDGE bone conduction implant (BB-BCI) is an active, transcutaneous device. BB-BCI implantation can be performed through either the transmastoid or retrosigmoid approach with their respective limitations. Here, we present a third, novel approach for BB-BCI implantation.Describe the detailed surgical technique of BB-BCI implantation through a middle fossa approach with self-drilling screws and present preliminary audiometric outcome data following this approach.A single institution, retrospective chart review was completed for patients implanted with the BB-BCI via the middle fossa approach. Preoperative planning and modelling were performed using 3D Slicer. Audiological testing was performed pre- and post-operatively following standard audiometric techniques.Forty patients underwent BB-BCI implantation using the middle fossa approach. Modelling techniques allowed for implantation through the use of external landmarks, obviating the need for intraoperative image guidance. The surgical technique was refined over time through experience and adaptation. Mean follow-up was 29 months (range 3-71 months) with no surgical complications, favourable cosmesis, and expected audiometric outcomes. An average functional gain of 39.6 dB (± 14.7 SD) was found.The middle fossa technique with self-drilling screws is a safe and effective option for BONEBRIDGE implantation. As a reference for other groups considering this approach, an annotated video has been included as a supplement to the study.

Background Intracranial pneumocephalus is a well-known clinical entity most frequently caused by trauma and intracranial surgery. A less frequent cause of intracranial pneumocephalus is spontaneous pneumocephalus. Spontaneous pneumocephalus can have an intraventricular extension, causing tension intraventricular pneumocephalus. Case Description We present an exceptionally rare case of spontaneous otogenic intraventricular pneumocephalus in a 58-year-old female that resulted in a decline in mentation and neurologic deficit. The patient was subsequently treated with ventriculostomy and middle fossa craniotomy, with repair of a bony defect and dural closure. Conclusions This case demonstrates an unusual presentation of spontaneous intraventricular tension pneumocephalus necessitating ventriculostomy in addition to the traditional repair of a cerebrospinal fluid fistula.

Objectives To describe clinical outcomes of patients undergoing revision surgery for vestibular schwannomas. Design Retrospective case series. Setting Tertiary private neurotologic practice. Participants Patients who underwent revision surgeries for recurrent/residual vestibular schwannomas between 1985 and 2015. Main Outcome Measures Degree of resection, facial nerve function, cerebrospinal fluid (CSF) leak. Results A total of 234 patients underwent 250 revision surgeries for recurrent/residual vestibular schwannomas. Of these, 86 carried a diagnosis of neurofibromatosis type 2 (NF2). The mean number of prior surgeries was 1.26, and 197 (85%) prior surgeries had been performed elsewhere. The average age at surgery was 43. The most common approach employed at the time of revision surgery was translabyrinthine (87%), followed by transcochlear (6%), middle fossa (5%), and retrosigmoid (2%). Gross total resection was achieved in 212 revision surgeries (85%). Preoperative House–Brackmann facial nerve function was similar in non-NF2 and NF2 groups (mean: 2.7). Mean postoperative facial nerve function at last follow-up was 3.8 in the non-NF2 group and 3.9 in the NF2 group. History of radiation and the extent of resection were not associated with differences in facial nerve function preoperatively or postoperatively. CSF leaks occurred after 21 surgeries (8%), and six (2%) patients required reoperation. Conclusions This is the largest series of revision surgery for vestibular schwannomas to date. Our preferred approach is the translabyrinthine craniotomy, which can be readily modified to include the transcochlear approach for improved access. CSF leak rate slightly exceeds that of primary surgery, and gross total resection is achievable in the vast majority of patients.

Object: Arachnoid cysts are developmental space-occupying lesions filled with CSF-like content and surrounded by a membrane resembling arachnoid mater, with controversial etiology and natural history. Endoscopy has been successfully used for decades to treat a variety of pathologies within thecentral nervous system. Methods: Thirteen patients who underwent endoscopic fenestration for treatment of arachnoid cyst were selected for this study. The surgical indications and techniques were reviewed, and surgical success rates and patient outcomes were assessed. Results: Five patients had middle fossa cysts; 2 a posterior fossa cyst; 3 a quadrigeminal cistern arachnoid cyst and 3 a suprasellar arachnoid cyst. Endoscopic management consisted in a cystoventriculostomy in 8 patients and cystocisternotomy in 5 patients. There was neither mortality nor operative morbidity. Discussion: Arachnoid cysts are a relatively benign pathological entity that can be managed by performing endoscopically guided cyst wall fenestrations into the ventricular system or cerebrospinal fluid containing cisterns. Conclusion: Proper patient selection, preoperative planning of endoscope trajectory, use of frameless navigation, and advances in endoscope lens technology and light intensitycombine to make this a safe procedure with excellent outcomes.

Objective To present qualification criteria, surgery, and results of cochlear implantation via the middle fossa approach. Study design A retrospective analysis of medical charts of patients. Setting Cochlear implant program in academic medical center. Patients Six adults after middle ear surgery due to chronic otitis media with bilateral deafness or profound hearing loss. Intervention Analysis aimed to identify patients qualified for cochlear implantation via middle fossa approach and to present surgery and result. Main outcome measure Qualification criteria, details of surgery and surgical, functional and audiological results. Results Surgery was completed in four patients and in the remaining two it was stopped because of adhesions and bleeding from the dura. In three patients, there were no postoperative complications and in one individual intracranial hematoma occurred. Postoperative computed tomography showed the intracochlear position of the electrode in all the implanted patients. All of the patients use their implant for 14 to 16 hours daily. One year after the implantation, they had hearing thresholds in the sound-free field of between 25 and 45 dB sound pressure level, number recognition scores between 80 and 100% and monosyllabic words recognition between 30 and 90%. Conclusion Successful cochlear implantation via middle fossa approach results in satisfactory hearing, bringing deaf people into a hearing environment. However, this approach is technically difficult and provides the risk of intracranial complications. In our opinion this approach should be used in special cases only (e.g., postmeningitis or otosclerotis patients with obliteration of basal turn of cochlea). In analysed group it should not be considered the primary solution.