Correspondence
1 Canadian Institute for Health Information (CIHI). (2012) What factors have determined hospital expenditure trends in Canada? Hospital Cost Drivers Technical Report. 2 Pfuntner A, Wier LM & Steiner C. (2013) Costs for hospital stays in the United States, 2011. URL http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb168-Hospital-Costs-United-States-2011.jsp [accessed on 26 April 2014] 3 Schneider G.T., Christensen N. & Doerr T.D. (2009) Early tracheotomy in elderly patients results in less ventilator-associated pneumonia. Otolaryngol. Head Neck Surg. 140, 250–255
4 Organization WH. (2014) Definition of an older or elderly person. URL http://www.who.int/healthinfo/survey/ageingdefnolder/en/ [accessed on 19 April 2014] 5 Rockwood K. (1990) Delays in the discharge of elderly patients. J. Clin. Epidemiol. 43, 971–975 6 Hwabejire J.O., Kaafarani H.M., Imam A.M. et al. (2013) Excessively long hospital stays after trauma are not related to the severity of illness: let’s aim to the right target!. JAMA Surg. 148, 956–961 7 Baskin J.Z., Panagopoulos G., Parks C. et al. (2004) Clinical outcomes for the elderly patient receiving a tracheotomy. Head Neck 26, 71–75
Anatomical reposition of incus after transmastoid facial nerve decompression using bone cement: preliminary results in 17 patients Ghonim, M.R., Shabana, Y.K., Ashraf, B. & Salem, M.A. Department of ORL (Otology & Neurotology Unit), Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt Accepted for publication 24 May 2015
Dear Editor, Management of traumatic facial nerve disorders is challenging. The type, onset and localisation of the injury, and complete or partial paralysis are the main determinants of the prognosis.1 Temporal bone fractures are classified according to the axis of petrous apex into longitudinal fractures (80%) and transverse fractures (20%). More recently, another classification: otic capsule sparing (OCS) or disrupting (OCD) fractures, showed better clinical correlation.2 Surgical repair of facial nerve includes the following: decompression – decompression with end-to-end anastomosis or with nerve grafting. Transmastoid facial decompression approach can be utilised when trauma is localised to tympanic or mastoid segments. Important landmarks for this approach include the lateral semicircular canal (LSCC) and fossa incudis. The incus should be removed to decompress the tympanic segment, and this can lead to an air–bone gap (ABG) up to 60 dB.3 The aim of this study was to evaluate the efficacy of anatomical reposition of incus after transmastoid facial decompression using bone cement and evaluation of hearing.
Correspondence: B. Ashraf, Department of ORL (Otology & Neurotology Unit), Mansoura Faculty of Medicine, Mansoura University, El-Gomhoria St., Mansoura 35516, Egypt. Tel.: 0020502267011-0020502267012; Fax: 0020502267016-0020502360138; e-mail: [email protected] © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Patient and methods Ethical considerations
This study was performed fulfilling the requirements of ethical committee of ORL Department, Faculty of Medicine, Mansoura University. This is a prospective clinical study carried out at NeuroOtology Unit, Otolaryngology Department, Mansoura University, Egypt. This study was conducted on 17 patients with traumatic facial paralysis operated by transmastoid decompression approach from December 2011 to January 2014. Inclusion criteria
1 Traumatic complete facial nerve paralysis 2 Evidence of OCS fracture by HRCT Exclusion criteria
1 Sever or profound hearing loss (HL) (dead ear) The degree of facial paralysis was recorded according to House–Brackmann scale before and after the procedure.4 HRCT temporal bone and pure tone audiometry were performed for all patients; air conduction (AC), bone conduction (BC) and ABG were recorded at 0.5, 1, 2 and 4 kHz. Hearing results were reported in conformity with the American Academy of Otolaryngology Head and Neck Surgery Guidelines.5 Successful hearing was defined as a
CORRESPONDENCE: OUR EXPERIENCE
References
95
96
Correspondence
post-operative ABG within 20 dB. Patients are divided into two groups according to their hearing: group A, conductive or mixed HL, and group B, normal hearing or mild-tomoderate sensorineural HL. Surgical technique
All patients were operated with senior surgeon (Ghonim MR) using a post-auricular approach. After standard mastoidectomy, identification of the mastoid segment of facial nerve starts from digastric ridge; then, a posterior tympanotomy is made, then extended superiorly by removing its upper buttress (fossa incudes) and then incus is removed. Then decompression starts by the mastoid segment then the tympanic segment from 2nd genu to geniculate ganglion beneath the malleus. Decompression is
extended to the labyrinthine segment according to the extension of the fracture (supra-labyrinthine approach). After complete decompression (Fig. 1a), the incus is articulated in its normal position. The prepared cement is applied by a needle to malleus head (Fig. 1b), then incus is repositioned, and then cement is applied drop by drop to fix it first to malleus head (Fig. 1c), then to stapes (Fig. 1d). During this, facial nerve is covered with pieces of gelfoam that are removed after cement hardens. All patients were followed up for 12 months and the degree of facial improvement was detected. Post-operative audiometry was performed three to six months after surgery. Statistical study was carried out (SPSS, ver. 20), and a paired t-test was used to compare the pre- and postoperative hearing results. P < 0.05 was accepted as statistically significant.
(a)
(b)
(c)
(d)
Fig. 1. (a) Decompressed facial nerve after removal of incus, malleus (dashed black arrow) and stapes head (black arrow). (b) A drop of bone cement is put on articular fossa for incus on the malleus head (black arrow head). (c) Incus reposition and fixation to the malleus by bone cement. (d) Incus fixation to stapes head by bone cement. © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
Results
Among the 17 patients, there were 14 males (82.4%) and three females (17.6%) with mean age 21.35 (9–37 years). The commonest cause was traffic accident in 13 patients (76.5%), blunt trauma in three patients (17.6) and fall from height in one patient (5.9%). All patients had immediate complete facial paralysis, with nine in left side (52.9%) and eight in right side (47.1%). Surgery timing after injury ranged from 3 to 11 weeks. All patients had HRCT performed. Fifteen patients (88.3%) showed longitudinal fractures and two patients (11.8%) showed mixed longitudinal and transverse fractures. All fractures were otic capsule sparing (Figs 2b and 3). At time of surgery, tympanic membrane was intact in all patients; middle ear was free in six patients, showed hemotympanum in three patients, granulation tissue and fibrosis in eight patients, and tegmen defect in two patients. Ossicular chain was intact in 11 patients, incudomalleal dislocation in five patients, and one patient showed complete displaced incus to aditus ad antrum (Fig. 2). The nerve integrity was not interrupted in any patient. The injury involved 2nd genu and tympanic nerve segment in nine patients (53%), tympanic segment in two patients (11.8%) and vertical segment in two patients (11.8%), in which decompression was performed from the tympanic segment to the digastric ridge. The site of injury involved 1st genu and labyrinthine segment in four patients (23.4%) in which total
(a)
97
decompression was performed via supra-labyrinthine approach beneath the malleus. There were 14 patients with conductive HL (group A) and three patients with normal hearing (group B). There were no patients with mild-to-moderate sensorineural or mixed HL. The mean pre- and post-operative AC for all patients was 30.88 dB 10.99 and 17.72 dB 6.61, in group A was
Fig. 3. Axial CT showing the fracture line (black arrow) with incudomalleal dislocation (astrix).
(b)
Fig. 2. (a) Axial CT showing the fracture line (black arrow), dislocated incus to the aditus ad antrum (star) with posteriorly displaced malleus (asterisk). (b) The dislocated incus to the aditus ad antrum (I), black arrows mark the fracture line, and LSCC (L). © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
P ˂ 0.001 P ˂ 0.001 P = 0.423 4.22 (6.31) 4.19 (6.99) 4.33 (1.15) 20.29 (10.18) 23.66 (7.65) 4.58 (0.72) P = 0.160 P = 0.193 P = 0.230 13.5 (6.79) 14.28 (7.28) 9.83 2.88) 10.58 (2.9) 10.98 (3.06) 8.75 P ˂ 0.001 P ˂ 0.001 P = 0.184 30.88 (10.99) 34.64 (7.89) 13.33 (0.72) All patients = 17 Group A = 14 Group B = 3
17.72 (6.61) 18.48 (7.07) 14.17 (1.44)
Post-ABG dB Pre-ABG dB Sig. Post-BC dB Pre-BC dB Sig. Post-AC dB
Objectives of otologic surgery are to eliminate ear pathology and, whenever possible, preserve or improve hearing.6 In transmastoid facial decompression, incudostapedial disarticulation can lead to an ABG up to 60 dB. Thus, after complete decompression, ossiculoplasty should be performed to restore hearing.3 Incus interposition remains the most widely used ossiculoplasty technique.7 It is performed by reshaping incus to fit between malleus and stapes, which are normally not in line with each other making ossiculoplasty unstable and mechanically inefficient, particularly if incus is angulated more than 45° from the axis of stapes.8 Besides, this angulation may be increased when interposition is performed through posterior tympanotomy, so anatomical reposition of incus would be more suitable. Literature showed many studies that focused on the surgical technique and outcome of facial improvement after transmastoid decompression,1 but no studies that described
Pre-AC dB
Discussion
Group
34.64 dB 7.89 and 18.48 dB 7.07 and in group B was 13.33 dB 0.72 and 14.17 dB 1.44, respectively. There was significant improvement in the mean post-operative AC in all patients and in group A (P ˂ 0.001 and P ˂ 0.001, respectively), while there was no significant change in group B (P = 0.184). The mean pre- and post-operative ABG for all patients was 20.29 dB 10.18 and 4.22 dB 6.31, in group A was 23.66 dB 7.65 and 4.19 dB 6.99 and in group B was 4.58 dB 0.72 and 4.33 dB 1.15, respectively. In all patients and in group A, there was significant improvement in the mean post-operative ABG (P ˂ 0.001 and P ˂ 0.001, respectively), while in group B, there was no significant change (P = 0.423). In all patients, the post-operative ABG was reduced below 10 dB in 13 patients (76.47%), from 10 to 20 dB in four patients (23.53%). The mean pre- and post-operative BC for all patients was 10.58 dB 2.9 and 13.5 dB 6.79. The mean pre- and postoperative BC in group A was 10.98 dB 3.06 and 14.28 dB 7.28. The mean pre- and post-operative BC in group B was 8.75 dB and 9.83 dB 2.88, respectively. There was no significant difference in post-operative BC in all patients or in both groups A and B (P = 0.160, P = 0.193 and P = 0.230, respectively). Table 1 shows the hearing results. High-frequency HL at 6 kHz was noticed in all patients. After surgery, five patients have recovered to House– Brackmann grade 1 (29.4%), eight patients to grade 2 (47.1%), three patients to grade 3 (17.6%) and one patient to grade 4 (5.9%). There were no complications reported in any patient in relation to bone cement application as ear discharge, granulations or polyps.
Sig.
Correspondence
Table 1. Hearing results, pre-operative air conduction (pre-AC), post-operative air conduction (post-AC), pre-operative bone conduction (pre-BC), post-operative bone conduction (post-BC), pre-operative air–bone gap (pre-ABG), post-operative air–bone gap (post-ABG) and significance (Sig.)
98
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
the way or discussed hearing results after incus reposition, which we believe that it is an important concern to all patients after successful decompression. There are different types of cements. The use of glass ionomer cements in otologic surgery seems promising. It is commonly used for bridging the incudostapedial joint and is considered as cheap and physiological ossiculoplasty with comparable hearing results to incus interposition.9 During cement ossiculoplasty, middle ear mucosa, facial nerve and stapes footplate should be covered with pieces of sponge to protect these structures from potential neurotoxic effects.6 In this study, no complications were encountered in relation to cement application. In this study, hearing improvement was achieved and the post-operative ABG was within 20 dB in all patients. There was significant improvement in the mean post-operative AC and ABG in all patients and in group A, while in group B, there was no significant change. There was no significant change in post-operative BC in all patients. However, there was a high-frequency HL in all patients. One possible explanation is concussive injury to the basal cochlea by transmission of vibration of drilling near the incus.10 This can be prevented by incudostapedial separation before drilling by initial transcanal approach. In conclusion, after transmastoid facial nerve decompression, the anatomical reposition of incus using bone cement is easy, cheap and safe technique with excellent hearing results. Keypoints
• • • •
In transmastoid facial decompression, incudostapedial disarticulation can lead to an ABG up to 60 dB; thus, ossiculoplasty should be performed to restore hearing. The use of glass ionomer cements in otologic surgery seems promising with comparable hearing results to incus interposition. During cement ossiculoplasty, middle ear mucosa, facial nerve and stapes footplate should be covered with pieces of sponge. Many studies focused on the surgical technique and outcome of facial improvement after transmastoid
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
•
99
decompression, but no studies described the way or discussed hearing results after incus reposition. Anatomical reposition of incus using bone cement is easy, cheap and safe technique with excellent hearing results.
Conflict of interest
The authors report no conflict of interests. The authors alone are responsible for the content and writing of the paper. References 1 Yetiser S. (2012) Total facial nerve decompression for severe traumatic facial nerve paralysis: a review of 10 cases. Int. J. Otolaryngol. 2012, 607359 2 Dahiya R., Keller J.D., Litofsky N.S. et al. (1999) Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J. Trauma 47, 1079–1083 3 Elsheikh M.N., Elsherief H. & Elsherief S. (2006) Physiologic reestablishment of ossicular continuity during excision of retraction pockets: use of hydroxyapatite bone cement for rebridging the incus. Arch. Otolaryngol. Head Neck Surg. 132, 196–199 4 House J.W. & Brackmann D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg. 93, 146–147 5 Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss (1995) American academy of otolaryngology-head and neck surgery. Arch. Otolaryngol. Head Neck Surg. 13, 186–187 6 Bayazit Y.A., Ozer E., Kanlikama M. et al. (2005) Bone cement ossiculoplasty: incus to stapes versus malleus to stapes cement bridge. Otol. Neurotol. 26, 364–367 7 O’reilly R.C., Cass S.P., Hirsch B.E. et al. (2005) Ossiculoplasty using incus interposition: hearing results and analysis of the middle ear risk index. Otol. Neurotol. 26, 853–858 8 Vincent R., Oates J., Sperling N.M. et al. (2004) Malleus relocation in ossicular reconstruction: managing the anteriorly positioned malleus: results in a series of 268 cases. Otol. Neurotol. 25, 223–230 9 Wegner I., Van Den Berg J.W., Smit A.L. et al. (2015) Systematic review of the use of bone cement in ossicular chain reconstruction and revision stapes surgery. Laryngoscope 125, 227–233 10 Palombo A.A., Shibukawa A.F., Barros F. et al. (2012) Hearing loss in peripheral facial palsy after decompression surgery. Braz. J. Otorhinolaryngol. 78, 21–26
1 Canadian Institute for Health Information (CIHI). (2012) What factors have determined hospital expenditure trends in Canada? Hospital Cost Drivers Technical Report. 2 Pfuntner A, Wier LM & Steiner C. (2013) Costs for hospital stays in the United States, 2011. URL http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb168-Hospital-Costs-United-States-2011.jsp [accessed on 26 April 2014] 3 Schneider G.T., Christensen N. & Doerr T.D. (2009) Early tracheotomy in elderly patients results in less ventilator-associated pneumonia. Otolaryngol. Head Neck Surg. 140, 250–255
4 Organization WH. (2014) Definition of an older or elderly person. URL http://www.who.int/healthinfo/survey/ageingdefnolder/en/ [accessed on 19 April 2014] 5 Rockwood K. (1990) Delays in the discharge of elderly patients. J. Clin. Epidemiol. 43, 971–975 6 Hwabejire J.O., Kaafarani H.M., Imam A.M. et al. (2013) Excessively long hospital stays after trauma are not related to the severity of illness: let’s aim to the right target!. JAMA Surg. 148, 956–961 7 Baskin J.Z., Panagopoulos G., Parks C. et al. (2004) Clinical outcomes for the elderly patient receiving a tracheotomy. Head Neck 26, 71–75
Anatomical reposition of incus after transmastoid facial nerve decompression using bone cement: preliminary results in 17 patients Ghonim, M.R., Shabana, Y.K., Ashraf, B. & Salem, M.A. Department of ORL (Otology & Neurotology Unit), Mansoura Faculty of Medicine, Mansoura University, Mansoura, Egypt Accepted for publication 24 May 2015
Dear Editor, Management of traumatic facial nerve disorders is challenging. The type, onset and localisation of the injury, and complete or partial paralysis are the main determinants of the prognosis.1 Temporal bone fractures are classified according to the axis of petrous apex into longitudinal fractures (80%) and transverse fractures (20%). More recently, another classification: otic capsule sparing (OCS) or disrupting (OCD) fractures, showed better clinical correlation.2 Surgical repair of facial nerve includes the following: decompression – decompression with end-to-end anastomosis or with nerve grafting. Transmastoid facial decompression approach can be utilised when trauma is localised to tympanic or mastoid segments. Important landmarks for this approach include the lateral semicircular canal (LSCC) and fossa incudis. The incus should be removed to decompress the tympanic segment, and this can lead to an air–bone gap (ABG) up to 60 dB.3 The aim of this study was to evaluate the efficacy of anatomical reposition of incus after transmastoid facial decompression using bone cement and evaluation of hearing.
Correspondence: B. Ashraf, Department of ORL (Otology & Neurotology Unit), Mansoura Faculty of Medicine, Mansoura University, El-Gomhoria St., Mansoura 35516, Egypt. Tel.: 0020502267011-0020502267012; Fax: 0020502267016-0020502360138; e-mail: [email protected] © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Patient and methods Ethical considerations
This study was performed fulfilling the requirements of ethical committee of ORL Department, Faculty of Medicine, Mansoura University. This is a prospective clinical study carried out at NeuroOtology Unit, Otolaryngology Department, Mansoura University, Egypt. This study was conducted on 17 patients with traumatic facial paralysis operated by transmastoid decompression approach from December 2011 to January 2014. Inclusion criteria
1 Traumatic complete facial nerve paralysis 2 Evidence of OCS fracture by HRCT Exclusion criteria
1 Sever or profound hearing loss (HL) (dead ear) The degree of facial paralysis was recorded according to House–Brackmann scale before and after the procedure.4 HRCT temporal bone and pure tone audiometry were performed for all patients; air conduction (AC), bone conduction (BC) and ABG were recorded at 0.5, 1, 2 and 4 kHz. Hearing results were reported in conformity with the American Academy of Otolaryngology Head and Neck Surgery Guidelines.5 Successful hearing was defined as a
CORRESPONDENCE: OUR EXPERIENCE
References
95
96
Correspondence
post-operative ABG within 20 dB. Patients are divided into two groups according to their hearing: group A, conductive or mixed HL, and group B, normal hearing or mild-tomoderate sensorineural HL. Surgical technique
All patients were operated with senior surgeon (Ghonim MR) using a post-auricular approach. After standard mastoidectomy, identification of the mastoid segment of facial nerve starts from digastric ridge; then, a posterior tympanotomy is made, then extended superiorly by removing its upper buttress (fossa incudes) and then incus is removed. Then decompression starts by the mastoid segment then the tympanic segment from 2nd genu to geniculate ganglion beneath the malleus. Decompression is
extended to the labyrinthine segment according to the extension of the fracture (supra-labyrinthine approach). After complete decompression (Fig. 1a), the incus is articulated in its normal position. The prepared cement is applied by a needle to malleus head (Fig. 1b), then incus is repositioned, and then cement is applied drop by drop to fix it first to malleus head (Fig. 1c), then to stapes (Fig. 1d). During this, facial nerve is covered with pieces of gelfoam that are removed after cement hardens. All patients were followed up for 12 months and the degree of facial improvement was detected. Post-operative audiometry was performed three to six months after surgery. Statistical study was carried out (SPSS, ver. 20), and a paired t-test was used to compare the pre- and postoperative hearing results. P < 0.05 was accepted as statistically significant.
(a)
(b)
(c)
(d)
Fig. 1. (a) Decompressed facial nerve after removal of incus, malleus (dashed black arrow) and stapes head (black arrow). (b) A drop of bone cement is put on articular fossa for incus on the malleus head (black arrow head). (c) Incus reposition and fixation to the malleus by bone cement. (d) Incus fixation to stapes head by bone cement. © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
Results
Among the 17 patients, there were 14 males (82.4%) and three females (17.6%) with mean age 21.35 (9–37 years). The commonest cause was traffic accident in 13 patients (76.5%), blunt trauma in three patients (17.6) and fall from height in one patient (5.9%). All patients had immediate complete facial paralysis, with nine in left side (52.9%) and eight in right side (47.1%). Surgery timing after injury ranged from 3 to 11 weeks. All patients had HRCT performed. Fifteen patients (88.3%) showed longitudinal fractures and two patients (11.8%) showed mixed longitudinal and transverse fractures. All fractures were otic capsule sparing (Figs 2b and 3). At time of surgery, tympanic membrane was intact in all patients; middle ear was free in six patients, showed hemotympanum in three patients, granulation tissue and fibrosis in eight patients, and tegmen defect in two patients. Ossicular chain was intact in 11 patients, incudomalleal dislocation in five patients, and one patient showed complete displaced incus to aditus ad antrum (Fig. 2). The nerve integrity was not interrupted in any patient. The injury involved 2nd genu and tympanic nerve segment in nine patients (53%), tympanic segment in two patients (11.8%) and vertical segment in two patients (11.8%), in which decompression was performed from the tympanic segment to the digastric ridge. The site of injury involved 1st genu and labyrinthine segment in four patients (23.4%) in which total
(a)
97
decompression was performed via supra-labyrinthine approach beneath the malleus. There were 14 patients with conductive HL (group A) and three patients with normal hearing (group B). There were no patients with mild-to-moderate sensorineural or mixed HL. The mean pre- and post-operative AC for all patients was 30.88 dB 10.99 and 17.72 dB 6.61, in group A was
Fig. 3. Axial CT showing the fracture line (black arrow) with incudomalleal dislocation (astrix).
(b)
Fig. 2. (a) Axial CT showing the fracture line (black arrow), dislocated incus to the aditus ad antrum (star) with posteriorly displaced malleus (asterisk). (b) The dislocated incus to the aditus ad antrum (I), black arrows mark the fracture line, and LSCC (L). © 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
P ˂ 0.001 P ˂ 0.001 P = 0.423 4.22 (6.31) 4.19 (6.99) 4.33 (1.15) 20.29 (10.18) 23.66 (7.65) 4.58 (0.72) P = 0.160 P = 0.193 P = 0.230 13.5 (6.79) 14.28 (7.28) 9.83 2.88) 10.58 (2.9) 10.98 (3.06) 8.75 P ˂ 0.001 P ˂ 0.001 P = 0.184 30.88 (10.99) 34.64 (7.89) 13.33 (0.72) All patients = 17 Group A = 14 Group B = 3
17.72 (6.61) 18.48 (7.07) 14.17 (1.44)
Post-ABG dB Pre-ABG dB Sig. Post-BC dB Pre-BC dB Sig. Post-AC dB
Objectives of otologic surgery are to eliminate ear pathology and, whenever possible, preserve or improve hearing.6 In transmastoid facial decompression, incudostapedial disarticulation can lead to an ABG up to 60 dB. Thus, after complete decompression, ossiculoplasty should be performed to restore hearing.3 Incus interposition remains the most widely used ossiculoplasty technique.7 It is performed by reshaping incus to fit between malleus and stapes, which are normally not in line with each other making ossiculoplasty unstable and mechanically inefficient, particularly if incus is angulated more than 45° from the axis of stapes.8 Besides, this angulation may be increased when interposition is performed through posterior tympanotomy, so anatomical reposition of incus would be more suitable. Literature showed many studies that focused on the surgical technique and outcome of facial improvement after transmastoid decompression,1 but no studies that described
Pre-AC dB
Discussion
Group
34.64 dB 7.89 and 18.48 dB 7.07 and in group B was 13.33 dB 0.72 and 14.17 dB 1.44, respectively. There was significant improvement in the mean post-operative AC in all patients and in group A (P ˂ 0.001 and P ˂ 0.001, respectively), while there was no significant change in group B (P = 0.184). The mean pre- and post-operative ABG for all patients was 20.29 dB 10.18 and 4.22 dB 6.31, in group A was 23.66 dB 7.65 and 4.19 dB 6.99 and in group B was 4.58 dB 0.72 and 4.33 dB 1.15, respectively. In all patients and in group A, there was significant improvement in the mean post-operative ABG (P ˂ 0.001 and P ˂ 0.001, respectively), while in group B, there was no significant change (P = 0.423). In all patients, the post-operative ABG was reduced below 10 dB in 13 patients (76.47%), from 10 to 20 dB in four patients (23.53%). The mean pre- and post-operative BC for all patients was 10.58 dB 2.9 and 13.5 dB 6.79. The mean pre- and postoperative BC in group A was 10.98 dB 3.06 and 14.28 dB 7.28. The mean pre- and post-operative BC in group B was 8.75 dB and 9.83 dB 2.88, respectively. There was no significant difference in post-operative BC in all patients or in both groups A and B (P = 0.160, P = 0.193 and P = 0.230, respectively). Table 1 shows the hearing results. High-frequency HL at 6 kHz was noticed in all patients. After surgery, five patients have recovered to House– Brackmann grade 1 (29.4%), eight patients to grade 2 (47.1%), three patients to grade 3 (17.6%) and one patient to grade 4 (5.9%). There were no complications reported in any patient in relation to bone cement application as ear discharge, granulations or polyps.
Sig.
Correspondence
Table 1. Hearing results, pre-operative air conduction (pre-AC), post-operative air conduction (post-AC), pre-operative bone conduction (pre-BC), post-operative bone conduction (post-BC), pre-operative air–bone gap (pre-ABG), post-operative air–bone gap (post-ABG) and significance (Sig.)
98
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
Correspondence
the way or discussed hearing results after incus reposition, which we believe that it is an important concern to all patients after successful decompression. There are different types of cements. The use of glass ionomer cements in otologic surgery seems promising. It is commonly used for bridging the incudostapedial joint and is considered as cheap and physiological ossiculoplasty with comparable hearing results to incus interposition.9 During cement ossiculoplasty, middle ear mucosa, facial nerve and stapes footplate should be covered with pieces of sponge to protect these structures from potential neurotoxic effects.6 In this study, no complications were encountered in relation to cement application. In this study, hearing improvement was achieved and the post-operative ABG was within 20 dB in all patients. There was significant improvement in the mean post-operative AC and ABG in all patients and in group A, while in group B, there was no significant change. There was no significant change in post-operative BC in all patients. However, there was a high-frequency HL in all patients. One possible explanation is concussive injury to the basal cochlea by transmission of vibration of drilling near the incus.10 This can be prevented by incudostapedial separation before drilling by initial transcanal approach. In conclusion, after transmastoid facial nerve decompression, the anatomical reposition of incus using bone cement is easy, cheap and safe technique with excellent hearing results. Keypoints
• • • •
In transmastoid facial decompression, incudostapedial disarticulation can lead to an ABG up to 60 dB; thus, ossiculoplasty should be performed to restore hearing. The use of glass ionomer cements in otologic surgery seems promising with comparable hearing results to incus interposition. During cement ossiculoplasty, middle ear mucosa, facial nerve and stapes footplate should be covered with pieces of sponge. Many studies focused on the surgical technique and outcome of facial improvement after transmastoid
© 2015 John Wiley & Sons Ltd Clinical Otolaryngology 41, 76–99
•
99
decompression, but no studies described the way or discussed hearing results after incus reposition. Anatomical reposition of incus using bone cement is easy, cheap and safe technique with excellent hearing results.
Conflict of interest
The authors report no conflict of interests. The authors alone are responsible for the content and writing of the paper. References 1 Yetiser S. (2012) Total facial nerve decompression for severe traumatic facial nerve paralysis: a review of 10 cases. Int. J. Otolaryngol. 2012, 607359 2 Dahiya R., Keller J.D., Litofsky N.S. et al. (1999) Temporal bone fractures: otic capsule sparing versus otic capsule violating clinical and radiographic considerations. J. Trauma 47, 1079–1083 3 Elsheikh M.N., Elsherief H. & Elsherief S. (2006) Physiologic reestablishment of ossicular continuity during excision of retraction pockets: use of hydroxyapatite bone cement for rebridging the incus. Arch. Otolaryngol. Head Neck Surg. 132, 196–199 4 House J.W. & Brackmann D.E. (1985) Facial nerve grading system. Otolaryngol. Head Neck Surg. 93, 146–147 5 Committee on Hearing and Equilibrium guidelines for the evaluation of results of treatment of conductive hearing loss (1995) American academy of otolaryngology-head and neck surgery. Arch. Otolaryngol. Head Neck Surg. 13, 186–187 6 Bayazit Y.A., Ozer E., Kanlikama M. et al. (2005) Bone cement ossiculoplasty: incus to stapes versus malleus to stapes cement bridge. Otol. Neurotol. 26, 364–367 7 O’reilly R.C., Cass S.P., Hirsch B.E. et al. (2005) Ossiculoplasty using incus interposition: hearing results and analysis of the middle ear risk index. Otol. Neurotol. 26, 853–858 8 Vincent R., Oates J., Sperling N.M. et al. (2004) Malleus relocation in ossicular reconstruction: managing the anteriorly positioned malleus: results in a series of 268 cases. Otol. Neurotol. 25, 223–230 9 Wegner I., Van Den Berg J.W., Smit A.L. et al. (2015) Systematic review of the use of bone cement in ossicular chain reconstruction and revision stapes surgery. Laryngoscope 125, 227–233 10 Palombo A.A., Shibukawa A.F., Barros F. et al. (2012) Hearing loss in peripheral facial palsy after decompression surgery. Braz. J. Otorhinolaryngol. 78, 21–26
