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    © All Rights Reserved
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    8 views11 pages

    Menieres Thyroid

    Uploaded by

    Sangam Adhikari

    Copyright:

    © All Rights Reserved
    Download as PDF or read online from Scribd
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    of 11
    e only area in mn the reanalysis» the OM oso at ean are oP a verent. ean be suially return 10. imastoidectony nausea (P <0: performed in an outpatient ork within a week,— ‘alone. Although the be a hearing: paring, procedure with * Fhearing loss may be as high as shall risk of facial nerve damage ended to nal morbidity, the Fisk inv addition, there is # S vith the procedure cries have dramatic success with endolym- ror studies have shown it to be + yo patients after endolymphatic sac ‘95% reported an improvement 76 patients who had undergone sled that more than half of the d to have vertigo.“ Othe rudies have shown ts who refused surgery; but only 40% of those .dolymphatie shunt surgery obtained com- ars follow-up. The effect, if rrcurgery on vertigo control is likely ess than intratym- eee vestibular nerve section, oF labyrinthectomy."* ¥ over this procedure it continues to be Some reported cangerys whereas ot of no benefit. A survey’ o sion revealed that © Another study of 6) surgery t phatic sac decompres in vert endolymphatic patients continues that 57% of patient who actually had en ‘ontrol of vertigo after 2 ye ple penic gentamic Despite the controvers) commonly performed for vertigo.“ Vestibular Neurectomy Several approaches to the vestibular nerve The earliest approach was the retrosigmoid, with the first large series by Walter Dandy in the 1930s.!® The suboccipital approach i essentially identical but historical concerns regarding this epproach developed due to poor results during the early years of surgery for vestibular schwannomas. The terms retrosigmoi and suboccipital are now used interchangeably. The middle fossa approach to the internal auditor superior vestibulat ‘herve was developed by William House in the early 1960s,” and segs later modified to include inferiovestibulanerve sector” A retrolabyrinthine approach-to sectioning of the vestibular nerve was introduced in 1980, but concernis exist regarding this approach due to the poor exposure achieved relative to other techniques.” A transmeatal cochleovestibular neurectomy has also been described,” but has largely been abandoned due to the superior exposure and more consistent results afforded by other approaches. The middle fossa and retrosigmoid approaches remain the most commonly performed today. thereto Bete wil 90% of patients maintainigé pecnconerat in immediately postoperatively” iach eos prea vertigo control rates than ence technically chalerging lures, but is also a more invasive an¢ ig procedure, Vestibular nerve section bas been argued t es to have a lower ris ii i 3 tohar sk of hearing loss when compa va entamicin injection ho tisk re os with gentamicin seem; ; a icin seems to be greatest with high-dose prowooo™ Lower-dose oe gentamicin seem: i i imi] Bo, ii ear ing loss simniap thn 2 catty a long-term risk of he have been described. 7D os FiGui id arial as viewed from the retrosigmold approach. The upper. GORE 3-3 ponies of HERE wal aditory cal each The ups pone ghd oaniaton wine temporal bore shown Bsa eration one owe ef The Pee ee deta the seventh and eighth caval nerves inher cours irom the baln stem. Cross FEE eta Shonnon the lower igh. The facial nave (fred, the cochlear nerve (Vl <) is ue, the n) : Section begins witha standard suboéciptal criniotamy basing the sige roid sinus as the anterior limit ‘The posterior fossa dua is opened, and the cerebellum is'retracted to expose the cerebellopontine angle and petrous ridge. The cistern isdecam- pressed with-an incision that allows the cérebellum to fall medi- ally obviating retraction. The vestibular, cochlear, and facial, nerves are dented and hen hespeior and inferior estib- suITTTETWeS con besectioned (Figure 34-5). Afterward the dura is reapproximated, and the bone flap is replaced and covered as the wound is closed. The middle fossa approach for vestibular nerve section is similar to that for vestibular schwannoma resection and has the advantage of requirin (Figure 34-6). A vertical incision is made above the auricle and the temporalis muscle is freed from squamous pol ‘empozal bone) A small craniotomy is made in the squamous portionvof the temporal bone. The middle fossa dura is elevated a son peel ca 20. (PPD dort TpiCre not, Vatu dealt. Cte Lym Vo pa le Fe PRO ban retractor is ust maintain tem- oral lobe elevation. The supérior semicircular canal (arcuate eminence) and geniculate ganglion are identified on the floor of the ile fossa as landmarks for the internal auditory canal. ‘The internal auditory canal is unroofed using a diamond bur, and the dissection is carried out to the lateral extent of the canal to identify “Bill's bar,” which divides the facial nerve (anterior) ‘fiom the superior vestibular nerve (posterior). The dura of the ster tibular nerve is identified, As the superior vestibular nerve is retracted, the inferior vestibular nerve can be identified, taking care to avoid the internal auditory artery and cochlear nerve. Often it is difficult to definitively separate the inferior vestibu- ar nerve from the cochlear nerve, which can lead to remaining vestibular symptoms after surgery or hearing loss. Upon nerve sectioning, theinternal auditory canal canbe covered wih is Pei as cia, the bone flap replaced, and the incision closed. The risk of 572 SURGERY OF THE EAR + Retrosigmoid approach to vestibular nerve 54-8 + Retrosigmoid appr ro a tibular nerves. A, The sion ofthe superior and inferior vstbu 5, The superior vestibular nerve is separated from has been sectioned. section. The cerebell eri (0888 Is €XPOS the more anterior facial jinerve, C, The super |FIGURE 9¢-6 » Surgeon's view from the head of __the table during the middle fossa approach toa vestibular nerve section. A right-sided procedure is shown with anterior toward the left. View of the middle fossa after the bone flap has been emoved and the temporal lobe has been elevated. 8, A diamond bur is used to thin the bone over the internal auaitory canal between the arcuate eminence and geniculate ganglion. C, The internal __2ultory canal is opened revealing the facial nerve (anterior) and the superior vestibular nerve {Posteror) which are separated by Bills bar {aterally. The superior-vestibular nerve is carefully Separated from the facial nerve in preparation for Sectioning. “anacanal labyrinthectomy: facial paresis is higher using a middle fossa approach than with ‘the procedure start with a standard mastoidectomy in whit i Shandon tis thehorizon valridge are identified Figure 34~8) = Dri \¢ horizontal canal between the labyrinth vechniauein scenes. jing supesiato the hori tech the labyrint m jentification of the supetior canal, The SIE He oot destructive procedure in the ~ and the tegmen allows identihcars ithe supeti a a SMTSERD ptt eal seni poster hepa Sa etian {deal candidates for labyrinthectomy are those Ths a Jined and followed medially to the ‘sho have no hearing and have filed mace conservative ts5t- veatiule while removing the neuroepitheliam under direct Tooie cach as gentamicin iniection, Despite its morbidity, the sion. NEU srocere has a higher rte of vet Sonal than vestibular Complete loss of hearing is an expected outcome of laby- PSGroctomy aid has been reported 10 improve quality of life rinthectomy. However, it may be possible to preserve hearing by PSSST Tena Thee are two approaches Transcapaland packing the semicircular canals with bone wax" and using a transmastoid, although the transma Soh-affards diamond bur to remove the canal while preserving the vesti- much better exposure and js more popula, ule. Although this approach has been demonstrated to have The transcanal approach (Figure 34-7) involves exposing a high rate of hearing preservation in cases involving tumor the mite thous tympanomeatal Nap” The incu and removal" less destructive procedures are indicated for Stapeeareemaved to expe teal window. A ook then paints with etgo wherehearing remains serviccable inserted into the vestibule to remove the neuroepithelium. A variation on thisbasic technique involves deilling out the prom- ser cocgnnet tic oval and round window Tha ipkation | CEN Yoana eNaes Gf the transcanal approach isthe poor access yields to the pos- LON AE VERGO lean ae alto il nares crt Bengn oxy postions wetig (BPP) the most com- {lation may not be achieved, The limited exposure also makes mon cause of dizziness, ing for about 40% of pate the procedure more technically difficult than the transmastoid aE eo a LEY i oan complaints of vertigo ts generally accepted that BPPV is ; ‘ caused by cupulolithiasis or canallithiasis. Typically, symptoms ‘The transmastoid approach to labyrinihgcomy is more comprise brit (lasting less than 1 sin) epizodes of vertign thst commonly performed and has the advantage of allowing direct occur after turning the head, especially when the head is fac visualization of the vestibular end organs as they are removed. ing upward, such as rolling over in bed. Canal repositioning ills. pproach begins with a standard postauriculariincision.”:~ > three semicircular canals.and.the facial nerve. The facial. rt of the procedure. C, The three semicircular canals are mpullae and neuroepithelium of the three semicircular saccule and the utricle). of BPPV has focused on cases involving the posterior canal that have been refractory to multiple canalith repositioning PABRERVETS. t ayafeurectomy was prepssed by-Gacekas a treatme” for tefrattOry BPPV.> During the three decades following i description, the procedure has esas used at least 342 times? yarscane will cause a brief es the ¢, whic z rocedure carr ca eth eewet J nyctagmn Cat iny atocctusion was introduced aor 4 This technique blocks the cand sonsive to angular accelera- | jmnen eo that it becomes unrespon fin the literature. a 97 cases have been reported in | _ tien. A total of 97 ca vas associated with brief, postopera Although the procedure was associ Ae ured.” The operation tive vertigo, 94 of the 97 patients ah the bony posterior canal begins wilh 9 et Oe te alec 4 t the point furthest from camp st inferior to 2 y Screg deamalbe: aed co dull (athe membranous aa A plug is created with bone chips or fascia and aca inserted to completely fill the canal and compress the mem. branous duct. oe Despite BPPV being a very common cause of dizziness, sur- gical therapy for this disease is decidedly uncommon, because most cases are successfully treated with repositioning maneu- vers. In patients who present with severe, intractable BPPV, other causes of dizziness should be considered and ruled out prior to considering surgical therapy. Posterior fossa outlet obstruction, such as that associated with the Chiari malformation or with posterior fossa cysts, should always be considered in the differ- ential diagnosis of refractory positional vertigo. These entities can be evaluated with appropriate imaging and interpretatior of the associated nystagmus. The nystagmus of posterior foss: come eatmustion does not parallel the plane of any specifi ar canal, as does the nystagmus of BPPV. h 7 endolyry —7 U e RGED VESTIBULAR mre OUCT . Fhlarged vestibular aqueduct &: tome ned —70clu finding on Zomputed tomercs rome is the most commo with a progressi omography (CT) scan that 4 Progressive hearing loss. oftes : head trauma Alth 8 8s, often in brings these paca ne eT 1058 is us mevaits a Patients to the attention of a los: aa Perience vertigo. The. ‘gOlogists, th also can be tri - Pacterion

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