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Semicircular Canal Fistulas and Hearing Loss Single Surgeon's Experience

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Semicircular Canal Fistulas and Hearing Loss Single Surgeon's Experience International Journal of ISSN 2692-5877 Clinical Studies & Medical Case Reports DOI: 10.46998/IJCMCR.2020.05.000136 Case Report Semicircular Canal Fistulas and Hearing Loss Single Surgeon’s Experience Stefano D * Department of Surgery, Otorhinolaryngology Unit, A. Murri” Hospital, ASUR Marche, Area Vasta n. 4, Fermo, Italy *Corresponding author: Stefano Dallari, Department of Surgery, Head Otorhinolaryngology Unit, Ospedale “A. Mur- ri”, Fermo, 63900, Italy. Tel/Fax: +3907346252975; E-mail: [email protected] Received: September 14, 2020 Published: November 03, 2020 Abstract Fistulas of the lateral semicircular canal may occur mainly in cholesteatoma cases, both as consequence of the disease and an excessive or inadvertent drilling of the bone. The risk of significant hearing loss had been stressed, especially in the past. More recent experiences have shown that a careful approach allows to save the pre-operative hearing in the majority of the cases, even when the cholesteatoma matrix is removed from the fistula and the canal is plugged. The author presents his experience in 22 cases collected since year 1989. Keywords: Labyrinthine Fistula; Hearing Loss; Cholesteatoma Introduction results will be hereby reported. Fistulas of the semicircular canals may be primitive or follow an erosive process of the endochondral bone of the labyrinth. Materials and Methods A type of primitive/malformation fistula involves the superior From 1989 up to December 2019 the Author performed 111 canal and may show up as Minor's Syndrome [1]. Also, the tympanoplasties (TPLs) for cholesteatoma (65 males and 46 posterior semicircular canal may be involved, in rare cases as- females), 39 TPLs for other diseases (28 males and 11 females) sociated with a high-riding jugular bulb and fibrous dysplasia and 8 “radical” operations (4 males and 4 females). In 22 cases [2]. Secondary fistulas generally follow a middle ear infection, (15 males and 7 females), a fistula of the lateral semicircular most of the cases a cholesteatoma [3]. canal was detected (18 cases) or provoked (4 iatrogenic cases). An iatrogenic origin should also be taken into account, as a In Table I all these 22 cases are described. Several items have consequence of an excessive drilling during a middle ear sur- been taken into account: sex, age at operation, ear pathology, gical procedure [4]. Because of its anatomical location, the year of surgery, pre-operative imaging availability, state of the lateral semicircular canal is normally involved. As reported in facial nerve (covered, exposed, pre-operative presence of pal- the literature, a fistula of the semicircular canal brings a vari- sy), state of the semicircular canal, in accordance with the clas- able, often high risk of hearing loss until anacusis, due to the sification of Dornhoffer and Milewski [10], simplified (simple damage to the membranous labyrinth [5]. The crucial point is bone erosion with presence of a “blue line”, type I; bony fistula the injury to the endosteum of the canal, while its blue lining with endosteum exposed and closed, type II or open, type III), is considered safe. When dealing with fistulas due to a bony type of operation performed, pre-operative hearing (air con- erosion caused by a cholesteatoma, removal of the matrix may duction between 500 and 4000 Hz), post-operative hearing (air lead to open the endosteum. This is why, especially in the past, conduction between 500 and 4000 Hz) and post-operative bone for fistulas of more than 2 mm, leaving a piece of matrix in conduction (0.5,1,2,4 kHz) as compared with the pre-operative place, over the fistula, used to be advised [6]. It had also been one. demonstrated that, at a second look operation, most of the time this piece of matrix disappears into normal mucosa. Results Conversely, in the more recent literature there have been sever- The results will be hereby globally analyzed. Furthermore, six al suggestions for a careful but complete removal of the matrix, cases will be reported and documented, to illustrate the various with immediate coverage of the fistula with autologous tissue, scenarios. The series consists of 22 patients, 15 males (mean even until the obliteration of the canal itself [7,8,9]. age 52 years) and 7 females (mean age 46 years). The Author’s attitude has always been a careful removal of the Over the whole number of cases, the incidence of fistula is pathology and, in regards to the matrix, the decision of com- 14 % (22/158). All the cases but one had a middle ear choles- pletely removing it or leaving a piece over the fistula was based teatoma. The sole non-cholesteatoma case was an iatrogenic upon the size of the fistula but also the easiness of detaching one. Thus, the percentage among the cholesteatoma cases is the matrix from the endosteum. When the detachment seemed 21/111 (19 %). In 11/22 patients a pre-operative CT had been to be too difficult, a piece of matrix and/or inflammatory mu- performed. In all cases but one (case n. 3 of the year 1991), cosa was left over the fistula itself. The Author’s series was where a complete fistula was present, with endosteum exposed, revised mainly in the light of the audiologic outcome and the the exam was positive for fistula. For the three cases with bony Copyright © All rights are reserved by Stefano D * 1 ijclinmedcasereports.com Volume 5- Issue 4 Table 1: Case series. Pre-oper- Post-oper- Type of Post- Age Ear Year Lateral ative hear- ative hear- Post-operative Imag- Facial operation op Patient Sex at pathol- of semic. ing (AC ing (AC bone conduction ing nerve Type of ver- oper. ogy surg. canal 0.5,1,2,4 0.5,1,2,4 (0.5,1,2,4 kHz) repair tigo kHz) kHz) conduc- cholest endosteum open TPL 1 CT + tive HL M 42 right 1989 open exposed, fascia + no --- --- V.B. fistula 55,55,50,60 ear open fibrin glue dB matrix conduc- conduc- closed TPL 2 cholest CT + removed tive HL tive HL M 44 1990 closed I stage --- as pre-op (8m p-o) R.G. left ear fistula endosteum 20,30,40,60 60,60,60,55 blood clot closed dB dB endosteum mixed HL mixed HL 3 cholest CT - open TPL as pre-op (2m p-o); F 58 1991 closed exposed, 65,70,75,90 no 70,85,80,80 N.G. left ear fistula fascia 40-60 dB in y 2000 closed dB dB Tomo- conduc- cholest open TPL 4 graph matrix left tive HL M 69 right 1992 open matrix in no --- --- B.A. ? fis- in situ 65,70,45,45 ear situ tula dB matrix conduc- conduc- removed; open TPL 5 cholest tive HL tive HL F 30 1992 --- closed endosteum bone+ no as pre-op (2m p-o) M.P. left ear 40,40,25,30 30,30,35,35 exposed, fascia dB dB closed cholest endosteum 6 open TPL F 64 right 1994 --- open exposed, --- --- --- --- V.MP. fascia ear closed closed TPL endosteum conductive conductive 7 cholest I stage F 31 1995 --- closed exposed, HL 40-40- no HL 55-60- as pre-op (3m p-o) F.A. left ear silastic+ closed 45-40 dB 60-55 dB fascia closed TPL cholest 8 bone ero- I stage --- F 45 right 1996 --- closed --- --- --- M.P. sion silastic+ ear fascia cholest rev closed 9 right bone ero- TPL M 69 1996 --- open --- --- --- --- M.A. ear re- sion open TPL current fascia cholest rev closed endosteum left ear TPL 10 P.O. M 78 1999 --- open exposed, --- --- --- --- recur- open TPL closed rent fascia open TPL conduc- conduc- cholest endosteum absorbable 11 tive HL tive HL M 42 right 2002 --- open exposed, gelatin+ --- as pre-op (2m p-o) BZ.EA. 60,60,50,60 50,35,35,35 ear open bone+ dB dB fascia conduc- endosteum mixed HL 12 cholest open TPL tive HL worsened at F 48 2002 --- closed exposed, yes 65,80,85,120 N.G. left ear fascia 60,65,40,40 35,45,60,-- dB closed (a) dB dB closed TPL cholest 13 F.A. matrix left I stage M 27 right 2002 --- closed --- --- --- --- (b) in situ silastic+ ear fascia conduc- conduc- cholest open TPL bone ero- tive HL tive HL 14 Z.T. M 38 right 2004 --- open bone+ --- as pre-op (2m p-o) sion (c) 55,45,35,55 65,45,70,75 ear fascia dB dB 2 ijclinmedcasereports.com Volume 5- Issue 4 open TPL endosteum absorbable mixed HL 15 cholest CT + M 69 2005 open exposed, gelatin+ 60,70,65,80 no --- as pre-op (48h p-o) R.M. left ear fistula open bone+ dB fascia open TPL cholest CT - bone ero- mixed HL 16 T.L. M 76 2007 open bone+ --- --- --- left ear fistula sion 80--- dB fascia cholest open TPL mixed HL mixed HL CT + matrix left 17 G.G. M 62 left 2008 open matrix in 70-95-80- --- 100-110-80-- as pre-op (3m p-o) fistula in situ ear situ 95 dB - dB endosteum cholest + matrix open TPL mixed HL mixed HL CT + 18 L.C. M 62 right 2008 open cleaning + fascia+ 35,40,60,70 no 30,50,50,65 as pre-op (7m p-o) fistula ear immediate bone dB dB obliter conduc- conduc- cholest endosteum open TPL CT - tive HL tive HL 19 F.D. F 47 right 2012 open exposed, + obliter no as pre-op (8y p-o) fistula 60,50,40,60 65,50,40,50 ear closed (d) fascia dB dB conduc- conduc- cholest endosteum CT + open TPL tive HL tive HL 20 S.G.
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