Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma Filiz G¨ul¨ustan, Hale Aslan, Murat Songu, Mehmet Sinan Bas¸o˘glu, H¨useyin Katılmıs¸ PII: DOI: Reference:

S0196-0709(14)00096-9 doi: 10.1016/j.amjoto.2014.04.002 YAJOT 1377

To appear in:

American Journal of Otolaryngology–Head and Neck Medicine and Surgery

Received date: Accepted date:

21 January 2014 22 April 2014

Please cite this article as: G¨ ul¨ ustan Filiz, Aslan Hale, Songu Murat, Ba¸so˘ glu Mehmet Sinan, Katılmı¸s H¨ useyin, Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma, American Journal of Otolaryngology–Head and Neck Medicine and Surgery (2014), doi: 10.1016/j.amjoto.2014.04.002

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ACCEPTED MANUSCRIPT Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma

İzmir Training and Research Hospital, İZMİR-TURKEY

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2-Hale Aslan, specialist

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Department of Otorhinolaryngology and Head and Neck Surgery

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1-Filiz Gülüstan, specialist

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Department of Otorhinolaryngology and Head and Neck Surgery İzmir Katip Çelebi Universty Atatürk Research and Training Hospital, İZMİR-TURKEY 3- Murat Songu, specialist

Department of Otorhinolaryngology and Head and Neck Surgery

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İzmir Katip Çelebi Universty Atatürk Research and Training Hospital, İZMİR-TURKEY 4- Mehmet Sinan Başoğlu, specialist

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Department of Otorhinolaryngology and Head and Neck Surgery

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İzmir Katip Çelebi Universty Atatürk Research and Training Hospital, İZMİR-TURKEY 5- Hüseyin Katılmış, Prof.

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Department of Otorhinolaryngology and Head and Neck Surgery İzmir Katip Çelebi Universty Atatürk Research and Training Hospital, İZMİR-TURKEY Corresponding Author: Op. Dr. Hale ASLAN Kasırga sok No:22/1 Özyıldırım Sitesi B blok K:8 D:18 Balçova/İzmir Telephone number +90 232 2444444 / 2580Fax number: +90 232 2431530 E-mail: [email protected]

ACCEPTED MANUSCRIPT Relationships between facial canal dehiscence and other intraoperative findings in

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chronic otitis media with cholesteatoma

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ABSTRACT

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Objective: We investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for cholesteatoma.

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Methods: We examined retrospectively 334 patients who had been operated on for cholesteatoma in Izmir Katip Celebi University, Ataturk Research and Training Hospital, ENT Clinic, between April 1997 and April 2010. The patients were examined for facial canal dehiscence according to age, gender, side of the ear , surgery type, first or revision surgery,

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localization of the facial canal dehiscence, spread of the cholesteatoma, with the presence of

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lateral semi-circular canal (LSCC) fistula and any defect in the ossicle chain, and destruction in the posterior wall of the external auditory canal(EAC).

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Results: Of the patients, 23.6% had facial canal dehiscence and detected most commonly in the right ear 28,9% and tympanic segment, 83.5% . Facial canal dehiscence was found to be

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24.2-fold more common in patients with LSCC fistula and 4.1-fold more common in patients with destruction in the posterior wall of the (EAC). In patients located cholesteatoma in tympanic cavity + antrum and the tympanic cavity + all mastoid cells and with incus and stapes defect, increased incidence of dehiscence. Age, first or revision operation and canal wall down tympanoplasty (CWDT) or canal wall up tympanoplasty(CWUT) did not affect the incidence of dehiscence. Conclusions: That the likelihood of facial canal dehiscence occurrence is increased in patients with LSSC fistulas, destruction in the posterior wall of the EAC, or a stapes defect is important information for surgeons. Key words: Facial canal dehiscence, lateral semicircular canal fistula, ossicules defect,

ACCEPTED MANUSCRIPT external auditory canal, cholesteatoma with chronic otitis media INTRODUCTION

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Cholesteatoma is the accumulation of stratified squamous epithelium showing keratinization

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in the middle ear or in other pneumatized areas of temporal bone. Most cases with facial paralysis due to chronic otitis media have cholesteatoma in the middle ear (1). Damage that

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may occur to the facial nerve is the biggest fear of the otologic surgeon. The likelihood of facial nerve damage during the operation can be minimized by better understanding ear

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anatomy and increased surgical experience.

In histological studies of the temporal bones of normal humans, the prevalence of facial canal dehiscence has been reported to be 25–57% (2). Although progress in otologic surgery is

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encouraging, the incidence of iatrogenic facial nerve damage due to cholesteatoma-related

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bone erosion and anatomical variations in the facial nerve was 0.6–3.6%; the corresponding

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rates were 4-10% in patients who underwent revision operations (3).

Although facial canal dehiscence is generally detected in the tympanic segment and at the

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level of fenestra ovalis, it may also be observed at the level of geniculate ganglion and in the mastoid segment. In the presence of dehiscence, the facial nerve may be damaged during the dissection of the cholesteatoma from the middle ear cavity, epitympanum, and mastoid cavity (2). In this study, we sought to report results that will facilitate determination of the incidence of facial canal dehiscence and the localization of the dehiscence and avoidance of damage to the facial nerve in patients operated on for cholesteatoma.

MATERIALS AND METHODS We examined retrospectively 334 patients with cholesteatoma who had been operated on for chronic otitis media in Izmir Katip Celebi University, Atatürk Research and Training

ACCEPTED MANUSCRIPT Hospital, Ear, Nose, and Throat Clinic between April 1997 and April 2010. To avoid repetition of the same data in ears that had been operated on more than once, the data for one

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ear were included in the study. Of the patients, seven had undergone bilateral operations. 134

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of all the patients of the computed tomography(CT) in the temporal bone investigated in terms of facial canal dehiscence.

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Based on the patient files, age, gender, the side of the operated ear, and type of surgery and findings were determined. The data were examined in terms of the presence or absence of

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facial canal dehiscence, the localization and incidence of cholesteatoma, lateral semi-circular canal (LSCC) fistula, condition of the ossicle chain, the presence or absence of destruction in the posterior wall of the external auditory canal, and the presence of pre- and post-operative facial paralysis. Subjects were classified according to whether they underwent a first or a

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revision operation. The procedures applied during the operation were classified as canal wall

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down tympanoplasty (CWDT) and canal wall up tympanoplasty (CWUT). The ages of the patients were classified as below or above 18 years.

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In the patients with facial canal dehiscence, the localization of the dehiscence was classified as being in the tympanic segment, in the mastoid segment, or in the tympanic +

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mastoid segments, based on the operation reports. The localization of the cholesteatoma was classified as attic + antrum, attic + meso-hypotympanum (tympanic cavity), tympanic cavity + antrum, or tympanic cavity + all mastoid cells. Patients in whom defects of the ossicle chain were identified were classified as having an incus defect, incus + malleus defect, defect of incus + stapes suprastructure, or defects in all ossicles. Statistical analyses were performed using the SPSS software (ver. 15 for Windows). Chi-squared and Fisher’s exact tests were used to detect significant differences between frequencies. The t-test was used to detect significant differences between mean values. To determine the likelihood of simultaneous observation of two parameters, the odds ratio was calculated. P values < 0.05 were considered to indicate statistical significance.

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RESULTS

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Of the total of 334 subjects enrolled in the study, 192 (57.5%) were male and 142 (42.5%) were female. Their mean age was 33.1 (range, 6-69) years.

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In 79 of the 334 subjects (23.6%), facial canal dehiscence was detected perioperatively. Of these 79 subjects, 66 had dehiscence in the tympanic segment (83.5%), 9 had dehiscence in the mastoid segment (11.4%), and 4 in the tympanic + mastoid segments (5.1%). The difference between the localization of the dehiscence was statistically significant (chi squared

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test, P < 0.001).

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Of the 334 subjects, 61 were aged below 18 years and 273 were aged above 18 years at the time of the operation. The incidence of facial canal dehiscence was 21.3% (n = 13) in

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subjects aged below 18 years, 24.2% (n = 66) in subjects aged 18 years and above, and 23.6% in all subjects. Thus, the age groups showed no statistically significant difference in terms of

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facial canal dehiscence (chi-squared test, P = 0.634). Of the 334 subjects enrolled, 173 had operations on their right ear and 161 on their left ear. While facial canal dehiscence was observed in 50 of 173 operations performed on the right ear (28.9%), it was detected in 29 of 161 operations performed on the left ear (18%; this difference was statistically significant: chi-squared test, P = 0.019). In our study, 329 subjects were operated on using a canal-wall-down technique and 14 using a canal-wall-up technique. The difference between the canal-wall-down (23.5%, n = 75) and canal-wall-up (28.5%, n = 4) techniques in terms of the incidence of facial canal dehiscence was not statistically significant (Fisher’s exact test, P = 0.748).

ACCEPTED MANUSCRIPT While 311 subjects (93%) were operated on for the first time, 23 (7%) underwent revision procedures. First operations in the subjects who had revision operations had been

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performed at other institutions. While 72 of the subjects who were operated on for the first

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time (23.2%) had facial canal dehiscence, seven of those who underwent revision operations (30.4%) showed facial canal dehiscence. This difference was not statistically significant (chi-

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squared test, P = 0.428).

The cholesteatoma was located in the attic in 32(%9,5) subjects, in the attic + antrum in

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113(%33,8) subjects, in the attic + meso-hypotympanum (tympanic cavity) in 55(16,4) subjects, in the tympanic cavity + antrum in 105(%31,4) subjects, and in the tympanic cavity + all mastoid cells in 29(%8,6) subjects. In subjects in whom the cholesteatoma was located in the tympanic cavity + antrum and the tympanic cavity + all mastoid cells, the incidence of

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facial canal dehiscence was high. However, the difference between cholesteatoma localization

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in terms of the incidence of dehiscence was not statistically significant (chi-squared test, P < 0.001).

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In our study, lateral semi-circular canal fistula was detected in 26 patients (7.8%), 22 of whom showed facial canal dehiscence (84.6%). The incidence of LSCC fistula was 7.8%

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among the 334 subjects, 27.8% among those with facial canal dehiscence, and only 1.6% among those in whom facial canal dehiscence was not detected. The correlation between LSCC fistula and facial canal dehiscence was statistically significant (chi-squared test, P < 0.001). For the concomitance of LSCC fistula and facial canal dehiscence, the odds ratio was 24.2; that is, the incidence of facial nerve dehiscence in subjects with LSCC fistula was 24.2fold more common (Table 1). Among the 26 subjects found to have LSCC fistulas, 12 had the cholesteatoma localized in the tympanic cavity + all mastoid cells and 11 in the tympanic cavity + antrum. In subjects in whom the cholesteatoma was localized only in the attic, no LSCC fistulas were identified. Cholesteatoma was localized in the attic + antrum in two subjects and in the attic +

ACCEPTED MANUSCRIPT meso-hypotympanum (tympanic cavity) in one subject. Of our subjects, 310 (93%) had a defect in the ossicle chain, and of 24 subjects with an intact ossicle chain, 6 had

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cholesteatoma localized in the attic + antrum, 15 in the attic + antrum, and 3 in the attic +

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meso-hypotympanum (tympanic cavity). In subjects in whom cholesteatoma was limited to the attic or attic + antrum, cholesteatoma was more common and was found to be intact, with

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statistical significance, compared to other subjects (Fisher’s exact test, P < 0.001)(Table 2) While only 1 of 24 subjects (4.2%) with an intact ossicle chain had facial canal dehiscence, 78

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of 310 subjects with ossicle chain defects (25.2%) showed facial canal dehiscence. Of 78 subjects who showed facial canal dehiscence in the presence of an ossicle chain defect, 8 had isolated incus defects, 8 had incus + malleus defects, 33 had incus + stapes suprastructure defects, and 29 had erosion in all ossicles. In the subjects in whom the stapes was affected, the

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incidence of facial canal dehiscence was high. There was a statistically significant difference

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between the incidences of facial canal dehiscence according to ossicle chain defect localization (chi-squared test, P < 0.001) ( Table 2).

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Among subjects with a defect in the ossicle chain, 26 had the cholesteatoma in the attic, 98 in the attic + antrum, 52 in the attic + meso-hypotympanum (tympanic cavity), 105 in

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the tympanic cavity + antrum, and 29 in the tympanic cavity + all mastoid cells. The malleus, incus, and stapes were destroyed in 37, 86, and 21% of cases, respectively, in subjects with cholesteatoma located in the attic + antrum; in 25.2, 89, and 43% of cases, respectively, in subjects with cholesteatoma located in the tympanic cavity, without expansion to the antrum and mastoid cells; and in 52.2, 100, and 82.8% of cases, respectively, in the subjects with cholesteatoma that filled all the tympanic cavity and had expanded to the antrum and mastoid cells. In all subjects, the malleus, incus, and stapes were destroyed in 40, 93, and 51.7% of cases, respectively . In all 26 subjects with a fistula in the lateral semi-circular canal, a concomitant defect in the ossicle chain was also detected. The defect was in the incus in one subject (3.8%), incus

ACCEPTED MANUSCRIPT and malleus in 3 (11.5%), and incus and stapes suprastructure in 7 (26.9%). In 15 subjects, all ossicles were eroded (57.7%). Compared with subjects with a defect in the ossicle chain with

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incidences of LSCC fistulas (chi-squared test, P < 0.001).

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no LSCC fistula, those in whom all ossicles were eroded showed significantly higher

In our study, destruction in the posterior wall of the external auditory canal (EAC) was

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identified in 60 subjects during the operation. In 29 subjects, facial canal dehiscence accompanied the destruction in the posterior wall of the external auditory canal(EAC). The

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concomitance of facial canal dehiscence and destruction in the posterior wall of EAC was statistically significant (chi-squared test, P < 0.001). The odds ratio + 95% confidence interval was found to be 4.1 for the likelihood of the concomitance of destruction in the posterior wall of EAC and facial canal dehiscence; that is, the incidence of facial nerve dehiscence in

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subjects with a defect in the posterior wall of EAC was 4.1-fold higher. Of the 60 subjects

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with destruction in the posterior wall of EAC, 14 also had fistulas in the LSCC. Compared with subjects with no destruction in the posterior wall of EAC, those with destruction in EAC

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DISCUSSION

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showed a higher incidence of LSCC fistula (chi-squared test, P < 0.001).(Table 3)

Dehiscence may be acquired, due to bone resorption in the inflammatory and infectious processes, or may be congenital, due to deficient ossification of the osseous canal surrounding the facial nerve. Dehiscence in the Fallopian canal was first described by Politzer in 1894 (4). Politzer stated that dehiscence of varying extent may be seen in the facial nerve in the tympanic cavity. Many subsequent studies reported varied facial canal dehiscence results in normal and diseased ears (5). Facial canal dehiscence may be determined in preoperative computerized tomography of temporal bone but some of the study are presenting of

correlation of preoperative

radiological images with intra-operative clinical findings of facial canal dehiscence were

ACCEPTED MANUSCRIPT weak and insignificant(6,7) In our study was founded poor sensitivity of CT. This condition

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may be depending on inadequate reports of CT by external medical center.

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In 1971, in an anatomical study performed on 535 normal temporal bones, the incidence of Fallopian canal dehiscence was 55%. It was reported that 91% of the dehiscence was

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located in the tympanic segment and 9% in the mastoid segment (8). In a histological study by Moreano et al. reported that 1000 normal temporal bones, at least one macrodehiscence in the

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facial canal was identified in 56% of subjects. They investigated 644 temporal bones for microdehiscence and reported that the incidence of facial canal dehiscence, along with microdehiscences, was 69% and that dehiscence was located in the fenestra ovalis in the tympanic segment in 74% of the subjects (2). In other studies of normal temporal bones, the

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incidence of facial nerve dehiscence was 20–74% (9).

In 1977, Sheehy et al. reported that of 1024 subjects on whom they had operated for

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cholesteatoma, 335 had available facial canal data; the incidence of facial canal dehiscence

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was 17% (10).

Selesnick ve Lynn-Macrae reported an incidence of facial canal dehiscence of 33% in

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67 subjects with cholesteatoma (11). In a study of 202 subjects by Bayazit et al., the incidence of facial canal dehiscence was 18.4% (12). In a study by Ozbek et al., with 265 subjects, the incidence of facial canal dehiscence during chronic otitis surgery was 37.2% (13). Moody and Lambert reported an incidence of facial canal dehiscence of 18.8% in 416 subjects with cholesteatoma (14). In our series of 334 subjects, the incidence of facial canal dehiscence was 23.6%. This incidence is consistent with those in the literature. In patients who have been operated on for cholesteatoma, facial canal dehiscence has been reported to be found most commonly in the tympanic segment. In the tympanic segment, cholesteatoma is closely associated with the facial canal, and the bone surrounding the facial nerve is thinner in this location than in other areas of the facial nerve . Due to the close relationship between the cholesteatoma and facial nerve in the tympanic area and the growth

ACCEPTED MANUSCRIPT pattern of the cholesteatoma, the facial nerve is vulnerable to the mechanical trauma of the dissection during the cholesteatoma operations. At the same time, the cholesteatoma tends to

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be diffused in this area; the tympanic segment is also the most common site of mechanical

facial canal dehiscence was detected most commonly.

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dissection (11). Similarly, in our study, the tympanic segment (83.5%) was the area in which

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In the study by Moody and Lambert of 416 subjects with cholesteatoma, only one was found to have dehiscence in the mastoid segment, whereas 296 subjects had undergone

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mastoidectomies (14). In our study, while all subjects underwent mastoidectomies, 9 had dehiscence only in the mastoid segment and 4 had dehiscence in both the mastoid and tympanic segments.

In the study by Ozbek et al., the incidence of dehiscence was found to be higher in

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men (13). In the study by Moreano et al., on 1000 temporal bones, the prevalence of facial

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canal dehiscence was found to be similar between males and females (2). In our study, the incidence of facial nerve dehiscence was found to be similar between male (25%) and female

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(21%) patients; moreover, the difference in dehiscence incidence between genders was not statistically significant.

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In the study by Moody and Lambert, the incidence of facial nerve dehiscence was 25% in patients aged over 18 years and 8.8% in younger patients (14). Ozbek et al. reported an incidence of dehiscence of 10.2% in a pediatric group and 24.8% in an adult group (13). In both studies, the difference was reported to be significant. In our study, the incidence of dehiscence was 21.3% in patients aged below 18 years and 24.2% in older patients; the difference was not significant. In our study, 173 subjects had the operation in the right ear and 161 in the left ear. The incidences of facial nerve dehiscence were 28.9% and 18%, respectively; this difference was significant. Few reports identify the side in which the incidence of dehiscence is higher.

ACCEPTED MANUSCRIPT Selesnick ve Lynn-Macrae reported an incidence of dehiscence of 44% in patients who underwent mastoidectomies and 25% in those who did not (11). In our study, although

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all subjects underwent mastoidectomies, no significant difference in the incidence of facial

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canal dehiscence was found between the patients who underwent the canal-wall-down technique and those who underwent the canal-wall-up technique. In the same study, no

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significant difference in the incidence or localization of the facial nerve dehiscence was found between patients who underwent first and revision operations. Similarly, in our study, no

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significant difference in dehiscence was found between patients who underwent first versus revision operations.

Ozbek et al. detected LSCC fistula in 21.1% of the patients in whom they detected facial canal dehiscence, and reported that the incidence of facial canal dehiscence in the

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presence of LSCC fistula was 22.5-fold higher (13). In our study, 27.8% of subjects with

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facial nerve dehiscence had LSCC fistulas. That is, 84.6% of the subjects with LSCC fistulas also had facial nerve dehiscence (24.2-fold increase). As imaging of the facial canal is much

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more difficult than imaging of the LSCC using preoperative CT, this finding is important for otologic surgery. Although there is no report of a correlation between facial canal dehiscence

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and destruction of the posterior wall of the EAC, in our study, 36.7% of subjects with facial nerve dehiscence also had destruction in the posterior wall of the EAC. Of the patients with destruction in the posterior wall of EAC, 48.3% were found to have dehiscence. Accordingly, the incidence of dehiscence in the presence of the destruction of the posterior wall of EAC was 4.1-fold higher. Bone erosion is an important pathological finding in otitis media, which leads to hearing loss due to an impaired sound transmission mechanism. Although the presence of cholesteatoma is not necessary for the destruction of the ossicle, bone destruction is known to be more common in patients with cholesteatoma (15). In the study by Mayerhoff et al. on 800 postmortem temporal bones, chronic otitis media was detected in 333 temporal bones; the

ACCEPTED MANUSCRIPT incidence of ossicle destruction was 82.1%. In the same study, the incidence of ossicle destruction was 69.5% in patients without cholesteatoma and 100% in those with

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cholesteatoma (16). In our study, we also found defects in the ossicle chain, at an incidence of

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93%.

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In the study by Tos on 1100 subjects, ossicles of 426 subjects with cholesteatoma were examined; the rates of destruction were 25, 74, and 21% in the malleus, incus, and stapes,

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respectively, when the cholesteatoma was localized in the attic + antrum, and 48, 87, and 45% in the malleus, incus and stapes, respectively, when the cholesteatoma was localized in the tympanic cavity (17). In our study, the rates of destruction were 37, 86, and 21% in the malleus, incus and stapes, respectively, when the cholesteatoma was localized in the attic +

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antrum, and 25.2, 89, and 43% in the malleus, incus and stapes, respectively, when the cholesteatoma was localized in the tympanic cavity. Thus, our results are consistent with

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literature reports.

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Of the patients with facial nerve dehiscence, 98.7% showed a defect in the ossicle chain. The stapes was affected in 79.4% of these subjects. In subjects with an affected stapes,

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the incidence of facial canal dehiscence was found to be significantly higher. This may be result of concomitant exposure of the facial nerve and stapes to the destructive effects of the cholesteatoma, due to their close relationship.

Facial nerve paralysis both negatively affects the psychology of patients and puts the physician in a difficult position in the presence of the patient. Direct invasion of the facial nerve by inflammatory diseases, erosion of the Fallopian canal, and the presence of destructive cholesteatoma increase the incidence of intraoperative iatrogenic facial nerve damage (18). The frequency of iatrogenic facial nerve damage is 0.6–3.6% for all otologic surgery procedures and 4–10% for revision surgery procedures (3). In our study of 334 subjects, no permanent iatrogenic facial paralysis was observed.

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CONCLUSIONS

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In this study, during cholesteatoma surgery, the incidence of facial canal dehiscence was

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23.6% and it was localized most commonly in the tympanic segment. The incus was the ossicle destroyed most commonly. The incidence of facial canal dehiscence was significantly

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higher in patients with LSCC fistulas, the presence of EAC in the posterior wall and stapes destruction. Identification of such findings before the operation may be considered a warning

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of the presence of facial canal dehiscence because of the facial canal dehiscence was not

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adequate determination in computerized tomography of temporal bone .

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REFERENCES

1-Yetiser S, Tosun F, Kazkayası M. Facial nevre paralysis due to chronic otitis media. Otol

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Neurotol 2002;23:580-8.

2-Moreano EH, Pararella MM, Zelterman D, et al. Prevalence of facial canal dehiscence and

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of persistent stapedial artery in the human ears: a report of 1000 temporal bones. Laryngoscope 1994;104:309-320. 3-Wiet RJ. İatrogenic facial paralysis. Otolaryngol Clin North Am 1982;15:773-80. 4-Politzer A. Diseases of the Ear and Adjacent Organs. For Students and Practitioners. London: Bailliere Tindell and Cox, 1894. 5-DiMartino E, Sellhaus B, Haensel J, et al. Fallopian canal dehiscences: a survey of clinical and anatomical findings. Eur Arch Otorhinolaryngol 2005;262:120-6.

ACCEPTED MANUSCRIPT 6-Gerami H, Naghavi E, Wahabi-Moghadam M, Forghanparast K, Akbar MH. Comparison of preoperative computerized tomography scan imaging of temporal bone with the intra-

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operative findings in patients undergoing mastoidectomy. Saudi Med J. 2009;30:104-8

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7-Kucur C, Simşek E, Kuduban O, Celebi I, Gürsel AO. The clinical value of temporal bone tomography in chronic otitis media. Kulak Burun Bogaz Ihtis Derg. 2013 Jan-Feb;23(1):21-5.

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doi: 10.5606/kbbihtisas.2013.30164.

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8-Baxter A. Dehiscence of the fallopian canal: an anatomical study. J Laryngol Otol. 1971 Jun;85(6):587-94.

9-Takahashi H, Sando I. Facial canal deiscence: histologic study and computer recanstruction.

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Ann Otol Rhinol Laryngol 1992;101:925-30.

10-Sheehy JL, Brackmann DE, Graham MD. Cholesteatoma surgery, residual and recurrent

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disease: a review of 1024 cases. Ann Otol 1977;86:451-62.

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11-Selesnick SH, Lynn-Macrae AG. The incidence of facial nevre dehiscence at surgery for

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cholesteatoma. Otol Neurotol. 2001;22:129-132 12-Bayazit YA, Ozer E, Kanlikama M. Gross dehiscence of the bone covering the facial nevre in the light of otological surgery. J Laryngol Otol. 2002;116:800-803 13-Ozbek C,Tuna E, Ciftci O, et al. Incidence of fallopian canal dehiscence at surgery for chronic otitis media. Eur Arch Otorhinolaryngol 2009;266:357-362 14-Moody MW, Lambert PR. Incidenceof dehiscence of thefacial nerve in 416 cases of cholesteatoma. Otol Neurotol 2007;28:400-404. 15-Wright CG,Mayerhoff WL. Pathology of otitis media. Ann Otol Laryngol. 1994;103:2426.

ACCEPTED MANUSCRIPT 16-Mayerhoff WL, Giebbink GS.Paparella MM. Pathology of chronic otitis media. Ann Otol Rhinol Laryngol 1978;87:749-59.

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17-Tos M. Pathology of the ossicular chain in various chronic middle ear disease. The Journal

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of Laryngology and Otology 1879;93:769-80.

18-Wang HM, Lin JC, Lee KW, et al. Analysis of mastoid findings at surgery to treat middle

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ear cholesteatoma. Arch Otolaryngol Head Neck Surg. 2006;132:1307-10

Table Legends

Table 1: Relationship between lateral semisircular canal (LSSC) fistula and facial nerve dehissance

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Table 2: Disturbation of ossicular chain defect according to facial canal dehissance

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external ear canal(EAC)

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Table 3: Relationship between facial canal dehissence and destruction of the posterior wall of

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ACCEPTED MANUSCRIPT Table 1. Relationship between LSSC fistula and facial nerve dehissance

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( LSSC: Lateral semisircular canal)

FACİAL CANAL

LSSC FISTULA

TOTAL

absence

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DEHİSSANCE presence

251

57

308

presence

4

22

26

255

79

334

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absence

Relationships between facial canal dehiscence and other intraoperative findings in chronic otitis media with cholesteatoma.

We investigated the relationship between facial canal dehiscence and intraoperative middle ear and mastoid findings in patients operated on for choles...
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