Combination of ionomer cement and bone graft for ossicular reconstruction

The aim of this study was to investigate the efficacy of the reconstruction of large ossicular chain defects with a combination of ionomer cement and an autogenous cortical bone graft. Different individual solutions are described if at least the handle of the malleus is present: restoration of a large defect of the long process of the incus, formation of the incus body and the long process, and replacement of the missing superstructure of the stapes with a short bone graft standing on the footplate. In a unique case, total reconstruction of the malleus handle was carried out. In further cases where the malleus and the incus were absent, the missing superstucture of the stapes was replaced by a bone graft fixed to the remnant of the anterior crus, supplemented with a cortical bone PORP. Between 1993 and 2005, 84 patients underwent middle ear operations with the use of ionomer cement. In 16 ears (9 males, 7 females), a combination of ionomer cement and autogenous cortical bone graft was used for ossicular reconstruction, with a documented follow-up of at least 6 months to 7 years. All operations were performed under general anesthesia. The components of the cement were mixed by hand and transferred to the bare bone surface with a curved needle. Complex structures were built up step by step. In seven cases, the tympanic membrane was simultaneously reconstructed. The postoperative air–bone gap was < 20 dB in 11/16, 68% of the cases. No columella rejection occurred. The reconstructed malleus handle is still intact, though the hearing has deteriorated. The audiological results are encouraging and a further prospective study is under design in order to analyze the efficacy of the combination of ionomer cement and an autogenous cortical bone graft for ossicular reconstruction. The simultaneous reconstruction of the superstructure of the stapes and the long process of the incus or the whole incus makes PORPs or TORPs superfluous, if at least the handle of the malleus is present.     

New guidelines for endoscopic localization of the anterior ethmoidal artery: a cadaveric study

OBJECTIVES: To determine objective data to improve the methods of identification of the anterior ethmoidal artery during endoscopic dissection. STUDY DESIGN: Cadaveric dissection of adult human heads. METHODS: A 0 degrees, 4-mm rigid endoscope was used to guide uncinectomy and frontoethmoidectomy. The location of the anterior ethmoidal artery was first determined visually and then confirmed by passing a needle through the anterior ethmoidal foramen from the orbit into the nose in all cases. The distances were endoscopically measured using a simple ruler between two nasal landmarks and the anterior ethmoidal artery. RESULTS: Fifty-six nasal fossae in 28 cadavers were dissected endoscopically. The median distance between the artery and the "axilla" formed by the anterior attachment of the middle turbinate to the lateral nasal wall was 20 mm (range, 17-25 mm), irrespective of the side. The measurement differed by less than 2 mm between the sides in the same individual. The median distance between the artery and the "axilla" formed by the medial and lateral crura of the lower lateral cartilage (superomedial edge of the nostril) was 62 mm (range, 55-75 mm) for both sides. The artery was found to be in direct alignment with the two "axillae" formed by the middle turbinate and the nostril edge. CONCLUSIONS: The distance between the ethmoidal artery and the axilla of the middle turbinate showed the least intraindividual and interindividual variations. The tip of the endoscope (or the ruler) points directly at the anterior ethmoidal artery in the fovea ethmoidalis when its edge is aligned with the two nasal landmarks. These simple guidelines can aid the identification of the artery in endoscopic frontoethmoidectomy.     

Simple bone cyst: report of cases and proposal for a minimal surgical intervention

Simple bone cyst (SBC) is an intraosseous pseudocyst that appears as a radiolucent lesion, frequently observed among young patients. In this article we report six cases of SBC and propose a protocol for minimal surgical intervention in the management of this condition. No history of trauma was reported. All patients underwent a minimal bone intervention procedure to perforate the cortical bone and stimulate blood clot formation. Complete healing and no recurrence were observed after 1-year follow-up. This treatment shows advantages such as the establishment of a definitive diagnosis and low invasiveness, particularly in pediatric patients.     

The perichondrial cutaneous graft: a facial reconstructive option for the ages (ages 1 week to 94 years)

Objectives/Hypothesis: The perichondrial cutaneous graft (PCCG) possesses unique characteristics that make them a propitious reconstructive option in facial plastic surgery. The PCCG is easily harvested from the conchal bowl. Notable characteristics are that it does not contract, unexcelled color match for resurfacing facial skin, and minimal donor site morbidity. This free graft frequently offers an expeditious solution to an otherwise more complicated reconstructive effort. Study Design: Retrospective review of an academic otolaryngology and facial plastic surgery practice. Methods: Patients requiring head and neck reconstruction for cutaneous deficiencies were studied. The PCCG is harvested from the anterior conchal bowl. This is technically easy, and the perichondrium is tightly adherent to the dermis in this area. The donor site is closed by resecting a fenestra of conchal cartilage and rotating a posterior auricular interpolated island flap into the defect (the “flip‐flop‐flap”). The posterior auricular defect is easily closed in a linear fashion. The main outcome measures were cosmetic result, graft survival, donor site morbidity, and complications. Results: There are 406 PCCGs in our series. Patients ranged in age from 7 days to 94 years. There were 170 grafts used for trauma and 236 used for reconstruction after skin cancer resection. Over the past 30 years in observing these grafts, there are no contractions noted in infants and children, growth with maturity is noteworthy. Cosmesis is excellent and in most cases superior to other skin grafting techniques. We have had four total failures and six partial losses of less than 30% for the PCCG. All complete failures were in patients with a smoking history. Conclusions: The PCCG is a very reliable flap for reconstruction of facial defects. It has been used in elderly and heavy smoking patients with minimal complications, attesting to its viability. The graft provides excellent cosmesis and it is an expeditious alternative to commonly used local flaps. It is especially useful in pediatric patients because the graft actually expands with growth. This is in contrast to the disadvantages of split thickness and full thickness skin grafts that predictably contract with maturity. Local flaps often lack adequate laxity for common implementation and make the PCCG a propitious choice in the pediatric patient.     

The potential of a plastination specimen for temporal bone surgery

Objective: The benefits of plastination specimens in temporal bone surgery (TBS) were evaluated. Methods: A formalin-preserved human temporal bone was drilled and dissected with the middle cranial fossa approach or the translabyrinthine (or transcochlear) approach. The specimen was thereafter subjected to silicon impregnation. Results: The flexibility of the dura mater after plastination was maintained, and not only bony structures such as the auditory ossicles and semicircular canals but also soft tissues such as the facial nerve, internal carotid artery and the sinus attached to the dura mater were easily discriminated. Conclusion: The technique furnishes a persistently dry, odorless and durable specimen that allows handling and may serve as the most ideal specimen for anatomical learning of various approaches of TBS.     

The navigation-controlled drill in temporal bone surgery: a feasibility study

Background: This study examines the feasibility of a navigation‐controlled (NC) drill for surgery on the petrosal bone in an experimental environment. According to the principle of NC, the drill is to be switched off automatically once the borders of the workspace are exceeded during a mastoidectomy. Materials and Methods: The registration is based on an optical navigation system with navigation software (MiMed). As surgery engine, the Unidrive‐system (Karl Storz GmbH & CO. Kg, Tuttlingen, Germany) was integrated. The definition of the workspace was performed manually in axial computed tomography (CT) slices of the petrosal bone phantom. The mastoidectomy on the model was accomplished in three runs with 10 trial surgeons altogether (5 experienced [exp.] in otologic (ear) surgery, 5 inexperienced [nonexp.]). During each run, the following were logged: the total length of time for the procedure as well as the number and extent of injuries to the risk structures (facial nerve, horizontal semicircular canal, sigmoid sinus). The resultant petrosal bone cavities were measured on the CT. Results: The time for the segmentation of the workspace for the mastoidectomy amounted to 17 minutes. The mean value of the drilling (e.g., milling) performance ranges from 6.61 mm³/s (group 1 [nonexp. + NC]), 9.62 mm³/s (group 2 [exp. w/o NC]), to 10.08 mm³/s (group 3 [exp. + NC]). The relative deviation to the segmented volume amounts to +7.4% (794.3 mm³) for group 1, –39.9% for group 2, and –34% (3,647.0 mm³) for group 3. In the groups with NC guidance of the drill, no damage to a risk structure could be logged. In the group of exp. ear surgeons without NC assistance, one injury to the facial nerve in the petrosal bone phantom occurred. Discussion: The results that follow prove the fundamental feasibility of an NC drill for surgery of the petrosal bone using the example of the simple mastoidectomy in the laboratory test. When using NC, tissue resection is faster, more precise, and has fewer related complications than the same procedure without. The results offer a very promising basis for the introduction of a newly conceived system to the procedure of NC surgery on the petrosal bone. The device configuration used here was originally conceived for NC guidance of a shaver in functional endoscopic sinus surgery. Individual errors will have to be mitigated through the new version of the control unit presently in development.     

Interlocking calvarial bone grafts: a solution for the short, depressed nose

OBJECTIVES/HYPOTHESIS: In patients severely affected with collapse of the nose, deprojection and upward rotation of the nasal tip are commonly seen. Traditional maneuvers to derotate and project the tip may be insufficient, because of the natural tendency of the nasal skin/soft tissue envelope to pull the tip in a cephalic and posterior direction. If the forces of scar contracture can be resisted, the tip and dorsum should remain adequately positioned. STUDY DESIGN: Retrospective chart review of 20 cases. METHODS: Using an open rhinoplasty approach, two strips of calvarial bone are fitted together in a tongue-in-groove fashion, and esthetics are analyzed. Rotation and projection are altered as indicated. A screw inserted at the indicated level along the caudal bone graft acts to prevent retrodisplacement of either the dorsal or caudal strut as scarring occurs. RESULTS: The procedure has been used in 20 patients. Two patients had displacement of the dorsal bone graft. Two patients have been lost to follow-up. Follow-up in the remainder has ranged from 6 weeks to 4 and a half years. All have maintained adequate tip and dorsal projection without excess upward tip rotation. Bone grafts have undergone minimal resorption. CONCLUSION: The interlocking calvarial bone graft technique stabilizes the nasal tip and dorsum in such a way that resists the forces of contracture and provides improved esthetics and function.     

Saphenous vein graft for bypass of the external carotid artery to supraclinoid internal carotid artery using a modified technique: An anatomical and technical study

Objective—To investigate the use of a saphenous vein graft for bypass of the external carotid artery (ECA) to supraclinoid internal carotid artery (ICA) when the proximal middle cerebral artery (MCA) is not suitable for a bypass procedure.

Material and Methods—Five adult cadaver sides were used. Dissection required a frontotemporal craniotomy and a zygomatic arch osteotomy, with a hole being opened 2–3 mm lateral to the foramen rotundum extradurally. The ECA was found easily via a second incision in the cervical region. The ophthalmic segment of the ICA was exposed by removal of the anterior clinoid process intradurally. After the dura over the hole was opened, the 7–8-cm long bypass graft was passed just behind the mandibula and through the hole inside the dura to reach the ICA. The ECA was then transected proximal to the occipital artery (OA) branch and the distal side of the vein graft was anastomosed end-to-end with the ECA and end-to-side with the supraclinoid ICA.

Results—The mean diameter of the ECA proximal to the OA was 3.75±0.4 mm (range 3.35–4.15 mm) and that of the supraclinoid ICA was 3.4±0.5 mm (range 2.9–3.9 mm). The mean length of the venous graft was 7.5±0.5 cm (range 7–8 cm).

Conclusion—When high blood flow is needed and the proximal MCA is not suitable for a bypass, the bypass described herein may be an alternative to a superficial temporal to MCA bypass as well as to extracranial carotid artery to MCA or ICA bypasses, which both need long vein grafts.     

A technique for temporal bone sections using non-decalcified frozen guinea pig cochleas: a study of succinic dehydrogenases

Summary We have developed a technique for sectioning temporal bones and have studied non-decalcified frozen guinea pig cochleas to localize succinic dehydrogenases. The technique is simple and practicable. The 6m sections used preserve both fine cochlear structure and satisfactory histochemical localization for identifying the succinic dehydrogenases. The technique can also be extended to immunological test, detecting transmitters and investigating enzymes in the cochlea. Offprint requests to: Fusheng Yang     

软腭平面手术联合舌骨悬吊术治疗阻塞性睡眠呼吸暂停综合征效果的Meta分析

目的 系统评价软腭平面手术联合舌骨悬吊术治疗伴有舌平面阻塞的阻塞性睡眠呼吸暂停综合征( OSAS )患者的疗效。 方法 采用计算机检索维普、中国知网和Pubmed数据库,按纳入与排除标准选择文献,根据MINORS评价条目评价文献质量,最后提取数据进行定性描述,采用RevMan 5.3软件进行Meta分析。 结果 共纳入13项研究,共310例患者。病情均为中至重度,随访时间均≥3个月。所选取病例11项为自身前后对照病例,2项为随机对照研究。按照MINORS评价条目评分,2项为低质量研究(总分0~12分),2项为高质量研究(总分19~24分),余下9项为中质量研究(总分13~18分)。11项研究分析了术后呼吸暂停指数(AHI)变化,漏斗图示2项研究位于漏斗底部、不对称,提示存在发表偏倚。2项研究分析了呼吸紊乱指数(RDI)变化。13项研究分析了最低动脉血氧饱和度(LSaO₂),漏斗图示4篇文献位于漏斗底部、不对称,提示存在发表偏倚。术后AHI、RDI、LSaO₂均较术前改善,AHI 总效应量为45.61,95% CI( 42.48,48.73),P<0.001;RDI总效应量为35.26, 95% CI( 22.47,48.04),P<0.001;LSaO₂总效应量为-20.16,95% CI(-24.99,-15.33),P<0.001。Meta分析异质性较高,依次逐个剔除纳入研究进行敏感性分析时,剔除林凌等研究后异质性降低,其他文献则无实质性改变。 结论 软腭平面手术联合舌骨悬吊术治疗OSAS的研究多为自身前后对照病例,样本量少,质量中等居多;软腭平面手术联合舌骨悬吊术可显著降低伴有舌平面阻塞的OSAS患者的AHI、RDI及提高LSaO₂,但需更多证据证实手术效果。     

Superficial temporal artery graft for bypass of the maxillary to proximal middle cerebral artery using a transantral approach: an anatomical and technical study

Conclusion. Using a transantral approach, we examined a new bypass of the maxillary artery (MA) to proximal middle cerebral artery (MCA). The caliber of the MA was suitable to provide sufficient blood flow. The length of the graft was shorter and it had a straighter course in the new technique than in previously described techniques. Objective. To examine a new bypass of the MA to proximal MCA using a transantral approach as an alternative to other forms of anterior circulation bypass surgery. Material and methods. The method was applied to five adult cadavers bilaterally. The MA and its branches were easily found after removal of the posterior sinus wall using a transantral approach. Then, a hole was created in the sphenoid bone 5–6?mm lateral to the posteroinferior edge of the superior orbital fissure extradurally. After the carotid and sylvian cisternae had been opened, the M2 segment of the MCA was exposed. The MA was transected just before the origin of the descending palatine artery branch. After opening the dura over the hole, the MA was passed through the hole to reach the intracranial cavity. The proximal side of the superficial temporal artery graft was anastomosed end-to-end with the MA and the distal side was anastomosed end-to-side with the M2 segment of the MCA. Results. The mean caliber of the MA was 2.4±0.3?mm before the origin of the descending palatine artery branch. The mean caliber of the largest trunk of the M2 segment of the MCA was 2.3±0.3?mm. The average length of the graft was 24±3?mm.     

The growth rate and size of the mastoid air cell system and mastoid bone: a review and reference

This review suggests a reference to the postnatal growth of mastoid air cells and bone. Information was retrieved from studies having large consecutive age groups, in order to reveal a development pattern. Data regarding origin, gender, and antibiotic treatment was investigated as well. Most measurements were obtained by planimetry. Assessment of the various data sources suggested the antrum to be well developed at birth (1–1.5 cm²), the mastoid cells to be about 3.5–4 cm² at 1 year, followed by a linear growth till the age of 6 (1–1.2 cm²/year), having a slower increment up to adult size at puberty (~12 cm²). The mastoid bone expansion is about 0.6–0.9 cm/year in length and width and 0.4 cm/year in depth in the first year, followed by half that rate until the age of 6–7. At puberty there was a slower sprout reaching adult size. Different ethnic groups share similar mastoid aeration and bone growth patterns. There were no differences between mastoid aeration measured at the pre-antibiotic era and after its widespread use. In conclusion, there are three distinguishable phases of mastoid pneumatization from birth till reaching final size. Bone and air cell compartments share a similar growth pattern; bone expansion lags behind aeration. Antibiotic treatment for otitis may have no impact upon mastoid aeration.