Middle ear meningiomas

Meningiomas arising in or presenting as middle ear lesions are relatively uncommon. This study retrospectively reviews the clinicopathologic features of six meningiomas arising in or extending into the middle ear. The patients comprise five women and one man ranging in age from 45 to 67 years (median, 55 years) at the time of surgery. Five tumors arose in the posterior fossa or temporal bone region and one tumor arose from the auditory canal itself. Three tumors arose on the right side and three on the left. Duration of symptoms before surgery involving the middle ear was known in five patients and ranged from 2 to 13 years (median, 10 years). Symptoms at presentation included gait or balance problems (n = 3), chronic otitis media (n = 2), diplopia (n = 2), hearing loss (n = 2), pain (n = 1), aural polyp (n = 1), and tinnitus (n = 1). Histologically, all six tumors resembled a syncytial (meningotheliomatous) meningioma. Psamomma bodies were noted in two tumors and two tumors demonstrated mild nuclear pleomorphism. None of the tumors demonstrated histologic features of atypical meningioma. Follow-up information was available in five patients. Four patients had prior surgery for removal of posterior fossa temporal bone meningiomas and developed recurrences involving the auditory canal 60 to 84 months after surgery. At the time of most recent follow-up examination, three patients were alive with evidence of tumor (65, 112, and 214 months), one patient was alive with no evidence of tumor (99 months), one patient died in the postoperative period of sepsis and pneumonia following resection of a middle ear recurrence (64 months), and one patient was lost to follow-up analysis. Meningiomas arising in or extending to the middle ear canal are unusual. They more commonly arise in woman and in most cases involve extension of intracranial/cranial tumors into the canal.     

颅中窝的应用测量研究

本研究以人类学骨胳测量法测量了100具成人颅底的颅中窝侧部,包括深径、矢状径、横径和骨结构间径等15项。各矢状径约略分别代表了颅中窝侧部外侧、中间和内侧1/3份的前后距离,各横径约相当于颅中窝侧部前、中、后1/3份的左右距离。统计学分析显示,除S_3径外,所有测量值均为右侧值大于左侧值,其中10项侧差显著或十分显著。而右侧深径、矢状径和横径之间的相关,也较左侧者多且突出。说明颅中窝的两个侧部是不对称的,以右侧部为大。本文就这些结果的理论和实践意义进行了讨论。     

The anatomical relationship of the middle ear and the jugular bulb

The authors have studied the relationship of the superior jugular bulb with the cavity of the middle ear through the examination of 200 temporal bones. It was observed that the jugular fossa presents a prominence in the tympanic cavity in 54 (27%) cases, and was also found dehiscenses on the osseous wall which protects the bulb (in 2 cases) and absolute absence of this wall in one case. It was verified the variability of the degree of exposure of both, the hypotympanum and the fossula of the cochlear fenestra by the prominence of the jugular fossa.     

Corneal Perforation with Preseptal Cellulitis in a Patient with Acute Lymphocytic Leukemia

We report a case of corneal perforation with preseptal cellulitis in a patient with acute lymphocytic leukemia (ALL). A 17-yr-old female patient who was undergoing combination chemotherapy for ALL was referred due to upper lid swelling and pain in the right eye for 2 days. Visual acuity in the right eye was 20/20. Initial examination showed no abnormal findings, other than swelling of the right upper eyelid. Computed tomography showed a finding of preseptal cellulitis. Microbiologic study of bloody and purulent discharge revealed Serratia marcescens. Corneal melting and perforation with iris prolapse were detected in the right eye on the 16th day. Emergent tectonic keratoplasty was performed. Seven months after surgery, visual acuity in the right eye was 20/300, and the corneal graft was stable.     

Anatomical Variations of the Intrapetrous Portion of the Facial Nerve

The intrapetrous facial nerve has the second longest intraosseous course of all cranial nerves, after the mandibular nerve. But it is by far the most complex considering the anatomical structures closely related to it. The auditory and vestibular portions of the inner ear, the dura of the middle fossa and posterior fossa, the sigmoid sinus and jugular bulb, and the internal carotid artery are close enough to merit attention. This article includes an anatomical study on 100 temporal bones with anatomical references as seen from the middle fossa and from the transmastoid approaches that may help identifying the facial nerve and protecting surrounding structures. Anatomical variability was present and noteworthy when considering the venous drainage system through the temporal bone and the mastoid pneumatization. The distance from the geniculate ganglion to the hiatus falopii offered the highest variability with a range of 0 to 7.75 mm and a mean of 3.30 mm. The geniculate ganglion was dehiscent in 20.8% of the specimens and the superior semicircular canal was spontaneously blue-lined in 27% of the cases. Through the transmastoid approach, the highest variability was found regarding the distance between the vertical portion of the facial nerve and the jugular bulb (range from 1.5 to 10.0 mm), the sigmoid sinus (range from 0 to 13.25 mm) and the internal carotid artery (range from 6.0 to 15.0 mm). This study highlights the importance of the relative variability of the facial nerve to other surrounding structures within the petrous portion of the temporal bone. Anat Rec, 302:588–598, 2019. © 2018 Wiley Periodicals, Inc.     

Landmarks for the greater petrosal nerve

The anatomy of the greater petrosal nerve while within the middle cranial fossa is lacking in the English literature and must be well understood by the surgeon who operates in this area. Twenty-two sides from six female and five male cadavers were examined. Measurements were made between the greater petrosal nerve as it coursed through the middle cranial fossa and surrounding structures such as the arcuate eminence and lateral wall of the middle cranial fossa. Mean distances from the arcuate eminence to the hiatus of the greater petrosal nerve into the middle cranial fossa measured 17.5 mm (SD = 2.2). The length of this nerve within the middle fossa was approximately 10 mm (SD = 2). From the lateral wall of the middle fossa to a midpoint of the greater petrosal nerve mean distances measured 39 mm (SD = 2.4). The mean distance from the foramen spinosum to the exit of this nerve inferior to the trigeminal ganglion measured 7 mm (SD = 1.8). These measurements will hopefully aid the surgeon who wishes to expose or avoid the greater petrosal nerve within the middle cranial fossa.     

High and dehiscent jugular bulb: clear and present danger during middle ear surgery

Purpose

Internal jugular vein is anatomic continuation of cranial dural sinuses in the neck region. During the course of skull base the first enlarged segment of jugular vein is described as jugular bulb. The aim of this study is to evaluate the jugular bulb abnormalities and define the risk of high and dehiscent jugular bulb injury during middle ear surgery.

Methods

This is a retrospective radiologic study of 1,010 patients (2,020 temporal bones) with various ear symptoms who had high resolution temporal bone computed tomography scans between 2007 and 2011.

Results

High jugular bulb was seen in 308 (15.2 %) temporal bones. Jugular bulb dehiscence was encountered in 153 (7.5 %) temporal bones. High jugular bulb and jugular bulb dehiscence were more common in the right ears and females. Forty-one (2 %) temporal bones revealed high and dehiscent jugular bulb which can be vulnerable during middle ear surgery. High and dehiscent jugular bulb was more common in the right ears and males. Male predominance becomes more significant in the left ears. Of the 308 temporal bones with high jugular bulb, 87 (28.2 %) also had coexisting carotid canal dehiscence.

Conclusion

High and dehiscent jugular bulb is an important anatomic variation that can result in catastrophic outcomes during middle ear surgery. Our series show that 2 % of patients can be considered in the “high-risk” group. Precise assessment of the preoperative computed tomography scans by both the radiologist and the ENT surgeon is of utmost importance. Preoperative awareness will minimize morbidity and mortality.     

颅前窝的应用测量

作者在100具中国成年人颅标本上,就颅前窝进行了矢状径、左右径和斜径测量,所用测点除额颧点外,全部为颅骨内面的骨结构。研究发现,颅前窝右半侧在矢状径和额颧点一正中平面间径两方面,十分明显地大于左半侧;右半侧矢状径与宽径的相关系数,有显著或高度显著意义;而小翼后缘外侧点一正中平面间径的平均值,为左半侧大于右半侧。因此,颅前窝的左、右半侧,在形态学测量上是不对称的。本文讨论了颅前窝、颅中窝中间部的分界问题,并联系颅脑关系和临床应用作了初步分析。     

The meningo-orbital foramen in a Scottish population

The meningo-orbital foramen is a small opening in the orbit lateral to the lateral end of the superior orbital fissure. It is widely reported to contain an orbital branch of the middle meningeal artery. The foramen may be single or multiple and may occur in the posterosuperior part of the lateral orbital wall or in the posterolateral part of the orbital roof. There is a lack of clarity in the literature as to whether foramina occurring in the orbital roof are the same entity as those occurring in the lateral wall. The disposition of the lesser wing of the sphenoid at the anterior limit of the middle cranial fossa makes it difficult to see how a foramen communicating with the anterior cranial fossa could transmit a branch of the middle meningeal artery. Our study contained 16 meningo-orbital foramina in the orbital roof that would transmit a fine probe. Fourteen of these passed into canals that tracked posteriorly in the bone to open into the middle cranial fossa close to the lateral extremity of the superior orbital fissure. The other two of these foramina communicated with the anterior cranial fossa and both were associated with a more posterior foramen that communicated with the middle cranial fossa. We hope this study clarifies an issue with relevance to surgery in the anterior cranial fossa.     

颞骨岩部的应用解剖

在２０个成人福尔马林固定的尸体头标本上，对４０侧颞骨岩部的表面及内部结构进行显微解剖研究。发现表面结构与内部结构间有恒定的空间位置关系，可以通过表面标志定位内剖结构，并提出了颞骨岩部水平段颈内动脉和耳蜗定位第三角，对指导临床手术有重要价值。     

颅中窝径路内耳道手术有关的应用解剖

本文在100侧颞骨上,对颅中窝径路的内耳道手术中内耳道定位的方法.进行了解剖学的观察和测量,提出利用岩浅大神经、面神经管裂孔、岩浅大神经沟与面神经管迷路段的夹角(平均为97.3°),及内耳道底投影点至面神经管裂孔的距离等,作为内耳道定位的主要解剖标志和参考数据.该法比磨出上半规管透明线为标志优越.     

The middle cranial fossa approach: an anatomical study

Hearing preservation surgery has become an option for an increasing number of patients with vestibular schwannomas due to diagnosis at an earlier stage. The middle cranial fossa approach represents one such surgical approach for resection of vestibular schwannomas with hearing preservation. We have undertaken an anatomical study of the middle cranial fossa approach to the internal auditory meatus using 20 fresh temporal bones. By simulating the surgical approach it was possible to analyze critically two of the main recognized subapproaches to the internal acoustic meatus. The results confirmed that the angle subtended by the facial nerve and "blue-lined" semicircular canal was much less than 60 degrees but equally important was the degree of individual variability. Furthermore the roof of the geniculate fossa was not infrequently dehiscent. The distance measured from the inner table of the craniotomy to the superior semicircular canal was on average 22 mm, similar to previous reports and utilized by some in their approach in this challenging surgery. From this anatomical study it appears that safe dissection of this area is facilitated by observing the more acute angle between the facial nerve and superior semicircular canal and by taking advantage of the relationship between the inner table and important landmarks.     

Morphology of the olfactory fossa – A new look

IntroductionThe olfactory fossa is a depression in the anterior cranial cavity whose floor is the cribriform plate of the ethmoid bone. This delicate bony plate separates the anterior cranial fossa from the nasal cavity.MethodsWe studied the morphology of the olfactory fossa in 32 dry skulls, derived from North India, of undetermined sex, using a hydroxyphilicsiloxane based gel. Molds of the olfactory fossa and adjacent cranial fossa were made and measurements of length, width, depth and angle of embankment (angle between the lateral wall of the olfactory fossa and the medial part of the anterior cranial fossa) were done on them and their coronal sections.ResultsThe average length of the olfactory fossa was 2.11 cm. The average width was 0.39 cm and the mean angle of embankment was 130.5°. According to the measured depth, the incidence of Keros’ type I (1–3mm) was 23.44%, type II (4–7mm) – 70.83% and type III (8–16mm) – 5.73%. Type III was more frequent on the left side. The fossa in north India is deeper in the middle than its anterior and posterior ends. It had a narrow anterior and broad posterior end (54.69%). There were no overall significant differences between the right and left side for the various morphometric parameters.DiscussionThis study provides baseline morphometric data of the olfactory fossa in the North Indian population and this knowledge may help the radiologists to analyze scans of this region and minimize complications associated with surgeries in this delicate area.     

The clinical and radiological status of contralateral ears in unilateral cholesteatoma patients

Purpose

To evaluate the clinical and radiological features and the risk of middle ear disease in the contralateral ears of unilateral cholesteatoma with clinical and radiological assessment.

Methods

Fifty-two patients with unilateral cholesteatoma and 30 control subjects underwent otoscopic and audiologic examination. Temporal bone computed tomography was performed to evaluate the pneumatization of the temporal bones, the status of anterior epitympanic space and eustachian tube. Then, the parameters of the temporal bone pneumatization were calculated.

Results

28 % of the contralateral ears in the cholesteatoma patients showed abnormal tympanic membrane findings. In the audiologic examination, 10 % of the contralateral ears showed moderate hearing loss and 3 % showed severe hearing loss. Aeration areas were 1.81 ± 1.01, 2.50 ± 1.31 and 4.49 ± 1.45 cm², aeration ratios were 24, 28 and 42 %, in cholesteatoma, contralateral and control ears, respectively. Development of the anterior epitympanic space and eustachian tube patency was reduced in contralateral ears relative to control ears.

Conclusions

The degree of temporal bone pneumatization, eustachian tube function, and development of the anterior epitympanic space are significantly decreased in the contralateral ears of unilateral cholesteatoma patients, and there is an increased risk of middle ear diseases. Continuous monitoring of the contralateral ear is crucial for early detection and optimal treatment of middle ear disease.     

颅中窝脑静脉的显微解剖与影像学观察

目的通过颅中窝脑静脉的显微解剖、影像学观察及其对照研究,为经翼点和经眶颧手术人路中脑静脉的保护提供形态学基础。方法分别对30例（60侧）颈内静脉灌注蓝色乳胶的成人尸头湿标本、36例（60侧）DSA静脉相、25例（50侧）CT静脉造影（CTV）和25例（50侧）MR静脉造影（MRV）图像进行观测。结果以显微解剖观测结果作为评价标准,DSA、CTV和MRV分别能够观察到70％、52％和42％的颅中窝脑静脉;根据颅中窝静脉注入硬脑膜窦处位置的不同,其分为海绵窦型、蝶顶窦型、蝶岩窦型和岩上窦型,各型脑静脉能被影像学手段区分;影像学观测到的大脑中浅静脉数目和分型与显微解剖相比较,差异无统计学意义。结论术前影像学检查有助于经翼点和经眶颧手术入路的设计和术中脑静脉的保护。     

Neuroendocrine adenoma of the middle ear with extension into the external auditory canal

We report a case of middle ear adenoma (neuroendocrine adenoma of the middle ear) protruding into the external ear canal. The patient was a 65-year-old man with hearing alterations and a headache in whom an otoscopy disclosed a sessile, pea-sized, brown-reddish, focally bleeding mass located in the posterior-superior aspect of the right external auditory canal. Histopathologically, there was a neoplasm composed of closely packed, sometimes back-to-back glandular structures formed by small uniform cuboidal or cylindrical cells. Small solid islands were also present. Following the histopathologic examination, a high resolution computed tomography was performed showing an extensive osteolytic defect mostly involving the mastoid air cells of the mastoid process with a partial destruction of the middle ear cavity. This defect was filled with a mass-like lesion with the density of soft tissue which bulged to the external auditory canal. Histopathologic examination of the mass in the middle ear cavity revealed findings identical to those seen in the original biopsy, confirming diagnosis of middle ear adenoma extending into the external ear canal. Keywords: skin - external auditory canal - neuroendocrine adenoma of the middle ear - carcinoid tumor.     

颞骨手术相关的面神经临床解剖学研究

目的探讨颞骨手术中面神经的解剖学特点及手术中的定位方法。方法 (1)在15例尸头标本上(30侧)模拟完壁式乳突根治术,面神经隐窝入路,面神经减压手术,迷路下入路,颅中窝入路内耳道等手术,观察面神经形态及其与周围结构的关系;(2)30例干颞骨标本采用断面方法观察面神经管与周围主要结构之间的关系。结果 (1)面神经垂直段中点距离乙状窦前壁(6.42±2.65)mm,距离颈静脉球外侧壁(3.58±1.33)mm。(2)面神经隐窝外侧气房明显存在者86.67%(26例),不明显者13.33%(4侧),面神经隐窝外侧气房可以定位面神经与面神经隐窝。(3)在外半规管中后1/3交点下方(1.70±0.33)mm可定位面神经锥段,向下与二腹肌嵴前端连线是面神经垂直段位置。(4)膝神经节位于匙突前(2.48±0.23)mm。(5)弓状隆起外侧端前方是内耳道底位置,岩浅大神经方便定位面神经迷路段。结论利用面神经与周围结构的关系,根据面神经走行特点及面神经管周围颜色、骨质改变在颞骨部位手术中能够快速准确的定位面神经,同时也可以将面神经作为其它手术的重要标志。     

2型糖尿病患者功能磁共振成像的局部脑区活动时空四维一致性

目的:利用功能磁共振成像（fMRI）及临床资料研究2型糖尿病（T2D）患者脑功能及血糖指标改变状况。方法:采集T2D患者（34例）及健康被试（37例）的fMRI信号,计算局部脑区神经活动时空四维一致性指标（FOCA）,采集被试者临床实验室检查信息,并分析二者的相关性。结果:与健康对照组相比,T2D患者的FOCA值在左侧颞中回、右侧颞上回显著降低,在右侧小脑显著增加。左侧颞中回的FOCA值与空腹血糖指标、餐后血糖指标呈现显著的负相关。结论:T2D患者会出现右侧小脑、右侧颞上回、左侧颞中回等脑区自发神经活动的紊乱,且左侧颞中回的活动异常与T2D患者空腹及餐后2 h血糖水平等指标具有相关性。     

侧颅底冠状位组织学与CT断层的对照

目的 制作颞骨火棉胶冠状位断层连续薄层切片,获取数字化图片库。方法 用2例尸头标本进行螺旋CT扫描后制作断层标本火棉胶包埋后,用大型轮式切片机沿冠状位切片,厚度100μm,每片均摄影并保存于计算机。选取代表性层面的胶片进行HE染色。将断层照片与HE染色照
片和CT片进行对照观察,对代表性层面结构特点进行描述。结果 共获取侧颅底数字化连续冠状位薄层断面标本数据集 2套。断层图像分辨率1920×2560像素,结构毗邻关系显示清晰。与HE照片和CT片进行对照观察,可以更清楚地定位断层结构。结论 火棉胶包埋技术是制作颞骨大切
片,获取高分辨率的数字化图片数据集的理想方法。冠状位对听小骨、Prussak‘s间隙、颈静脉窝、耳蜗与中颅窝的关系,颈内动脉升段及膝部、面神经垂直段、内听道与中颅窝的关系等显示较佳。     

Synovial chondromatosis of the temporomandibular joint with extension to the middle cranial fossa

A rare case of synovial chondromatosis with extension to the middle cranial fossa is reported. Synovial chondromatosis, a benign disorder characterized by multiple cartilaginous, free-floating nodules that originate from the synovial membrane is not exclusive to the temporomandibular joint (TMJ). This condition is commonly seen in the axial skeleton and can involve multiple joints. In this case, synovial chondromatosis of the TMJ led to complete bony erosion of the glenoid fossa extending into the middle cranial fossa. Although plain radiographs showed the involvement of the joint, Computed Tomography (CT) and Magnetic Resonance Imaging (MRI) provided more detailed information about the lesion in all three dimensions. This case demonstrates the value of CT and MRI in both the diagnosis and treatment planning. A review of previously reported cases of synovial chondromatosis with cranial extensions is included.