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Open access

Endoscopic closure of the Eustachian tube orifice for refractory lateral skull base cerebrospinal fluid leak using autologous fat graft: illustrative case

Gautam U. Mehta, Nida Fatima, Gregory P. Lekovic, and William H. Slattery

BACKGROUND

Rhinorrhea due to lateral skull base cerebrospinal fluid (CSF) leaks can be a challenge to manage. Multiple strategies exist for treating CSF leaks in this region including direct repair, posterior Eustachian tube packing, and CSF diversion. Endonasal closure of the Eustachian tube has been reported using cerclage and mucosal flaps.

OBSERVATIONS

We present the first reported case of endoscopic autologous fat packing of the Eustachian tube orifice to repair a CSF leak. In this case a 42-year-old woman who underwent middle fossa meningioma resection 20 years ago presented with refractory CSF rhinorrhea despite blind sac closure of the ear canal. This persisted after CSF diversion and only resolved after endoscopic endonasal Eustachian tube closure described herein.

LESSONS

This technique is simple to perform with minimal risk of morbidity. Eustachian tube orifice fat packing may be particularly useful for patients with refractory CSF rhinorrhea with low CSF pressure.

Restricted access

Hearing preservation surgery for neurofibromatosis Type 2–related vestibular schwannoma in pediatric patients

William H. Slattery III, Laurel M. Fisher, William Hitselberger, Rick A. Friedman, and Derald E. Brackmann

Object

The authors reviewed the proportion of pediatric patients with neurofibromatosis Type 2 (NF2) in whom hearing was preserved after middle fossa resection of vestibular schwannoma (VS).

Methods

In this retrospective chart review the authors examined the cases of 35 children with NF2 who had undergone middle fossa resection (47 surgeries) between 1992 and 2004 in a neurotological tertiary care center. Surgical outcome was assessed using pure-tone average (PTA) thresholds obtained before and immediately after resection. Speech discrimination scores (SDSs) and pre- and postfacial nerve grades were also recorded. In 55% of surgeries, hearing of less than or equal to 70 dB PTA was maintained postoperatively. The American Academy of Otolaryngology–Head and Neck Surgery Class A hearing (PTA ≤ 30 dB and SDS ≥70%) was preserved in 47.7%. Facial nerve function was good (House–Brackmann Grades I or II) in 81% of the patients. Twelve patients had bilateral middle fossa resections; in nine (75%) of these patients hearing was maintained postoperatively in both ears.

Conclusions

More than half of the children with NF2 in the authors' cohort experienced hearing preservation after middle fossa resection was performed for VS. The authors recommend this approach for preserving hearing in children with NF2.

Open access

Malignant progression of cerebellopontine angle solitary fibrous tumors following radiation: illustrative case

Anna K. La Dine, Nida Fatima, Zachary R. Barnard, William H. Slattery, and Gregory P. Lekovic

BACKGROUND

Intracranial solitary fibrous tumors (ISFTs) are rare mesenchymal tumors originating in the meninges and constitute a heterogeneous group of clinical and biological behavior. Benign histotypes, such as hemangiopericytomas are now considered as a cellular phenotypic variant of this heterogenous group of rare spindle-cell tumors. IFSTs are poorly recognized and remain a diagnostic challenge due to rarity and resemblance to other brain tumors. Previously, IFSTs were thought to pursue a slow, indolent, and nonaggressive course, however, a growing body of literature based on longer follow-up demonstrates an unpredictable clinical course and an uncertain diagnosis.

OBSERVATIONS

A rare case report of malignant transformation of IFST following radiation therapy is reported. In this case a 60-year-old female who underwent gross total resection of the cerebellopontine angle tumor with histopathology consistent with solitary fibrous tumor followed by salvage stereotactic radiosurgery, presented with another recurrence after 2 years of surgery. The authors performed complete removal of the tumor with pathology now consistent with malignant solitary fibrous tumor. A recent follow-up magnetic resonance imaging did not show any recurrence or residual tumor, and the patient reports a generalized well-being.

LESSONS

This report will help to understand the natural history and unusual clinical behavior of these intracranial tumors.

Free access

Endoscope-assisted middle fossa craniotomy for resection of inferior vestibular nerve schwannoma extending lateral to transverse crest

Adam N. Master, Daniel S. Roberts, Eric P. Wilkinson, William H. Slattery, and Gregory P. Lekovic

OBJECTIVE

The authors describe their results using an endoscope as an adjunct to microsurgical resection of inferior vestibular schwannomas (VSs) with extension into the fundus of the internal auditory canal below the transverse crest.

METHODS

All patients who had undergone middle fossa craniotomy for VSs performed by the senior author between September 2014 and August 2016 were prospectively enrolled in accordance with IRB policies, and the charts of patients undergoing surgery for inferior vestibular nerve tumors, as determined either on preoperative imaging or as intraoperative findings, were retrospectively reviewed. Age prior to surgery, side of surgery, tumor size, preoperative and postoperative pure-tone average, and speech discrimination scores were recorded. The presence of early and late facial paralysis, nerve of tumor origin, and extent of resection were also recorded.

RESULTS

Six patients (all women; age range 40–65 years, mean age 57 years) met these criteria during the study period. Five of the 6 patients underwent gross-total resection; 1 patient underwent a near-total resection because of a small amount of tumor that adhered to the facial nerve. Gross-total resection was facilitated using the operative endoscope in 2 patients (33%) who were found to have additional tumor visible only through the endoscope. All patients had a House-Brackmann facial nerve grade of II or better in the immediate postoperative period. Serviceable hearing (American Academy of Otolaryngology–Head and Neck Surgery class A or B) was preserved in 3 of the 6 patients.

CONCLUSIONS

Endoscope-assisted middle fossa craniotomy for resection of inferior vestibular nerve schwannomas with extension beyond the transverse crest is safe, and hearing preservation is feasible.

Restricted access

Translabyrinthine microsurgical resection of small vestibular schwannomas

Marc S. Schwartz, Gregory P. Lekovic, Mia E. Miller, William H. Slattery, and Eric P. Wilkinson

OBJECTIVE

Translabyrinthine resection is one of a number of treatment options available to patients with vestibular schwannomas. Though this procedure is hearing destructive, the authors have noted excellent clinical outcomes for patients with small tumors. The authors review their experience at a tertiary acoustic neuroma referral center in using the translabyrinthine approach to resect small vestibular schwannomas. All operations were performed by a surgical team consisting of a single neurosurgeon and 1 of 7 neurotologists.

METHODS

Data from a prospectively maintained clinical database were extracted and reviewed. Consecutive patients with a preoperative diagnosis of vestibular schwannoma that had less than 1 cm of extension into the cerebellopontine angle, operated on between 2008 and 2013, were included. Patents with neurofibromatosis Type 2, previous treatment, or preexisting facial weakness were excluded. In total, 107 patients were identified, 74.7% of whom had poor hearing preoperatively.

RESULTS

Pathologically, 6.5% of patients were found to have a tumor other than vestibular schwannoma. Excluding two malignancies, the tumor control rates were 98.7%, as defined by absence of radiographic disease, and 99.0%, as defined by no need for additional treatment. Facial nerve outcome was normal (House-Brackmann Grade I) in 97.2% of patients and good (House-Brackmann Grade I–II) in 99.1%. Complications were cerebrospinal fluid leak (4.7%) and sigmoid sinus thrombosis (0.9%), none of which led to long-term sequelae.

CONCLUSIONS

Translabyrinthine resection of small vestibular schwannomas provides excellent results in terms of complication avoidance, tumor control, and facial nerve outcomes. This is a hearing-destructive operation that is advocated for selected patients.