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Why did we encounter gusher in a stapes surgery case? Was it enlarged medial aperture of the cochlear aqueduct?

  • Anatomic Variations
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Abstract

Background and purpose

Preoperative prediction of cerebrospinal fluid (CSF) gusher is important for stapes surgery. According to the current opinion settled among otologists and radiologists, the issues of whether enlarged cochlear aqueduct might be a cause of CSF gusher in stapes surgery and which segment of the aqueduct should be taken into account to diagnose enlarged cochlear aqueduct in computerized tomography (CT) are controversial. The case we encountered led us to hypothesize that enlarged cochlear aqueduct might cause CSF gusher in stapes surgery and that shape and diameter of medial aperture of the cochlear aqueduct are important in this prediction.

Methods and results

Enlarged medial aperture of the cochlear aqueduct with a shape differed from that of the other side was retrospectively diagnosed in thin-slice CT in a patient who had been undergone middle ear and stapes surgery for conductive hearing loss. This finding went unnoticed in preoperative CT. In the small fenestra stapedotomy operation, CSF gusher occurred through opening in the ill-defined, fixed and thickened stapes footplate. A piece of temporalis fascia and reshaped incus were appropriately placed which stopped the gusher. Re-evaluation of preoperatively taken CT showed that anterior–posterior and superior–inferior diameters of the medial aperture were 11.7 mm and 2.87 mm in CSF gusher side versus 2.95 mm and 1.88 mm on the other side, respectively. Its shape in gusher side differed from that of the other side.

Conclusion

This report is the first to show video-documented CSF gusher in a patient with enlarged medial aperture of the cochlear aqueduct. It appears to be plausible to propose that these findings have to change the otologists’ and radiologists’ perspective to the cochlear aqueduct. It can be deduced that difference in shapes of the medial aperture in both sides might be an indicator of potential CSF gusher.

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Funding

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Authors and Affiliations

  1. Department of Otorhinolaryngology, Head and Neck Surgery, Gulhane Medical School, University of Health Sciences, 06018, Etlik, Ankara, Turkey

    Bulent Satar, Hakan Genc & Salih Cengiz Meral

Authors
  1. Bulent Satar
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  2. Hakan Genc
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  3. Salih Cengiz Meral
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Contributions

BS contributed to hypothesis and manuscript writing/editing. HG helped in project development, video editing and manuscript writing. SCM collected the data.

Corresponding author

Correspondence to Bulent Satar.

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The scientific material used in the manuscript was de-identified. The authors have the undersigned document stating that medical material and other relevant documents could be used for scientific purpose.

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Electronic supplementary material

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Supplementary file1 Video Small fenestra stapedotomy in the right ear. The footage begins with palpation of ill-defined and thickened stapes footplate with a sickle knife. Then, it continues with using a microdrill on stapes footplate area. Gusher starts at 14th second of the video file. Immediately after, stapedotomy opening was plugged with a piece of temporalis fascia which stopped the gusher. Reshaped long arm of the incus was positioned between the stapedotomy opening and the malleus neck (MPG 21847 kb)

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Satar, B., Genc, H. & Meral, S.C. Why did we encounter gusher in a stapes surgery case? Was it enlarged medial aperture of the cochlear aqueduct?. Surg Radiol Anat 43, 225–229 (2021). https://doi.org/10.1007/s00276-020-02602-8

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  • DOI: https://doi.org/10.1007/s00276-020-02602-8

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