REVISION EAR AND LATERAL SKULL BASE SURGERY

CONTENTS

Preface xiRichard J. Wiet and Robert A. Battista

Dedication xiiiRichard J. Wiet and Robert A. Battista

Revision Tympanoplasty Including Anterior Perforationsand Lateralization of Grafts 661J.V.D. Hough

Not long ago, the restoration of a perforated tympanic membraneby grafting over an air-containing tympanic cavity seemed impos-sible. Fortunately, successful results are so consistent and universaltoday that restoration of the tympanic membrane is expected, anda failure calls for careful evaluation as to ‘‘why.’’ If known princi-ples are observed, few complications need occur. Usually, compli-cations are the result of either the choice and placement of thegraft used in the repair, or the presence of unresolved upper re-spiratory pathology. When revision tympanoplasty is necessary,use of the underlay fascial graft technique, properly applied, usuallycan solve any difficult problems.

Revision Stapedectomy 677Robert A. Battista, Richard J. Wiet, and Jennifer Joy

Revision stapedectomy can be a technically demanding operation.The surgeon must be prepared for many pathologic conditionsbefore revision stapes surgery. Appropriate preoperative patientcounseling is a must. The best chance for hearing improvement isin those cases that have a delayed conductive hearing loss after pri-mary stapedectomy. This article serves as a guideline for discussingthe myriad possibilities that may be encountered during this typeof revision stapedectomy. Indications for revision stapedectomyand general surgical guidelines for management of specific patho-logic conditions are discussed. The material presented is based on

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literature review, the authors’ personal experience, and a review oftemporal bone studies relative to stapes surgery.

Revision Ossiculoplasty 699Ravi N. Samy and Myles L. Pensak

Although ossiculoplasty, also known as ossicular chain reconstruc-tion (OCR), was attempted initially in the early 1900s, it was not untilthe 1950s that it became commonplace and relatively well under-stood. Since then, there have been numerous technologic advancesand a gain in the understanding of ossiculoplasty. However, success-ful OCR with resulting long-term stability can be a daunting task.Typically, the most common condition requiring revision OCR ischronic suppurative otitis media (COM) with or without cholestea-toma. Primary and revision OCR are performed also for blunt andpenetrating trauma-induced conductive hearing loss, congenitaldefects (eg, atresia), and benign and malignant tumors. Typically, re-construction in ears with COM is more difficult than in ears withoutinfection. This article discusses the key factors involved in successfulrevision OCR.

Endolymphatic Sac Revision for Recurrent IntractableMeniere’s Disease 713Michael M. Paparella

Meniere’s disease can be observed uniquely in revisions of the con-servative surgical procedure for endolymphatic sac enhancement,which preserves the labyrinth, unlike destructive procedures. Ge-netic anatomic abnormalities in patients lead to malabsorption ofendolymph and symptoms of Meniere’s that are reversed by endo-lymphatic sac enhancement, but disabling symptoms eventuallymay recur in a few cases and require revisional surgery. We observedeveloping pathophysiologic conditions intraoperatively and havemodified our techniques to accommodate the redeveloped patho-genesis we observe and avoid complications found with earliertechniques. This conservative treatment allows patients (many ofwhom may develop bilateral Meniere’s) to retain capacity to acceptcochlear implants should they become advisable later.

Revision Mastoidectomy 723Joseph B. Nadol Jr.

The first three priorities in surgery for chronic otitis media are (1)the elimination of progressive disease to produce a safe and dryear, (2) modification of the anatomy of the tympanomastoid com-partment to prevent recurrent disease, and (3) reconstruction ofthe hearing mechanism. The indications for revision followingmastoidectomy for chronic otitis media thus involve failure toachieve any of these goals, including recurrent cholesteatoma, re-current suppuration, recurrent perforation, or recurrent or residualconductive hearing loss. The focus of this article is the management

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of recurrent cholesteatoma or suppuration; that is, failure toachieve either of the first two priorities.

Revision Surgery for Vertigo 741John F. Kveton

When confronted with vertigo after an otologic procedure, a sur-geon first must identify the functional status of the inner ear byperforming auditory and vestibular testing. Using this informa-tion in conjunction with knowledge of the primary disease pro-cess for which the initial procedure was performed, the surgeoncan make a rational selection of the procedure required to elimi-nate vertigo. This article outlines a systematic approach to the se-lection of the appropriate revision procedure and discusses thespecific advantages and disadvantages of these procedures usedto control vertigo.

Acoustic Neuroma (Vestibular Schwannoma) Revision 751Richard J. Wiet, Robert P. Kazan, Ivan Ciric,and Philip D. Littlefield

The authors present their experience of more than 25 years, now inexcess of 1200 patients, with cerebellopontine angle tumors. Thisarticle focuses on the management of planned subtotal resectionof acoustic tumors in five subjects, and unexpected ‘‘residual’’ dis-covered by MRI scanning in 10 cases, which represents, to the bestof the authors’ knowledge, a residual rate of 1% of operated pa-tients. The rate of residual tumor is as high as 19% in some seriesand, in part, depends on the surgical approach. For the purposeof this article, the authors did not include their cases of neurofibro-matosis, because these tumors behave differently than unilateralsporadic schwannomas.

Revision Glomus Tumor Surgery 763Mario Sanna, Giuseppe De Donato, Paolo Piazza,and Maurizio Falcioni

The infratemporal fossa approach type A is the best way to dealwith recurrent tympano-jugular paragangliomas because facialnerve rerouting is fundamental to reaching the area of the internalcarotid artery, where recurrence is likely to occur. Preservation oflower cranial nerve function is not feasible when there is tumor in-filtration of the medial wall of the jugular bulb; any attempt atnerve dissection increases the risk of leaving some tumor remnants.Correct management of the internal carotid artery, including pre-operative stent insertion or permanent preoperative balloon occlu-sion, is usually a fundamental step when dealing with these highlyvascularized lesions. Because of the tumor tendency to infiltratethe bony structures, aggressive drilling of the temporal bone is alsoadvised, especially at the level of the petrous apex. Patients affectedby uncontrolled recurrences still die of this disease.

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The Challenges of Revision Skull Base Surgery 783Anh Nguyen-Huynh, Nikolas H. Blevins,and Robert K. Jackler

Because the skull base is an anatomically complex structure, skullbase tumors can hide easily in the crevices that interconnect the in-tra- and extracranial spaces and intermingle with important neuro-vascular structures. Often, total surgical resection of these tumorsis not possible, and even with postoperative adjuvant radiotherapy,some recurrences after treatment are inevitable. Early detection ofrecurrent skull base tumors requires clinical vigilance and periodicimaging studies. The management of recurrent skull base tumorspresents many challenges beyond those associated with primaryprocedures. A multidisciplinary setting that includes modern mi-crosurgery and stereotactic radiation therapy provides patientswith optimal care.

Revision BAHA Surgery 801Robert A. Battista and Philip D. Littlefield

The osseointegrated auditory implant (BAHA) is a system used forhearing rehabilitation through direct bone conduction. AlthoughBAHA surgery is not difficult, the surgeon must observe meticu-lous technique to prevent complications. Indications for revisionBAHA surgery can be divided into (1) failure of fixture osseointe-gration; (2) bone overgrowth; or (3) skin reaction or skin loss. Thisarticle discusses the conditions that might predispose a patient torequire BAHA revision, and the steps, if any, that can be taken toprevent these complications. Specific surgical steps for revision ofeach of the three conditions are also addressed.

Revision Facial Nerve Surgery 815Arvind Kumar, John Ryzenman, and Arlene Barr

Transection of the facial nerve can result from blunt or penetratingtrauma to the face or temporal bone. It can also occur accidentallyduring surgery, or as a planned surgical procedure carried out inthe interest of eradicating disease. If transection is recognized at sur-gery, direct anastomosis or cable grafting is the procedure of choice.This article presents two cases with neither clinical nor electrical evi-dence of recovery. The authors review current understanding of thechanges that occur in the neuron, axon, and muscle after injury tothe nerve, and the underlying pathology that led to graft failurein these cases. They also evaluate surgical options and diagnostictest results that help in selecting appropriate surgical procedures.

Revision Cochlear Implantation 833J. Thomas Roland Jr., Tina C. Huang, and Noel L. Cohen

Reoperation on a patient with an indwelling cochlear implant isuncommon. When necessary, surgery is performed for explantation

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of an existing device with immediate or delayed reimplantation, orfor scalp flap revision and receiver-stimulator repositioning in thecase of infection or device migration. Rarely, revision surgery isperformed to reintroduce intracochlear electrodes that may havepartly or entirely extruded from the cochlea or were placed inap-propriately. Successful revision cochlear implant surgery requiresattention to certain surgical principles. Good outcomes, as mea-sured by speech perception tests, are common, but are not guaran-teed. This article outlines the indications for revision cochlearimplant surgery, the recommended surgical principles, and pub-lished outcomes from reimplantation.

Index 841

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