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Iatrogenic inner ear dehiscence associated with lateral skull base surgery: a systematic analysis of drilling injuries and their causal factors

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Abstract

Purpose

Drilling injuries of the inner ear are an underreported complication of lateral skull base (LSB) surgery. Inner ear breaches can cause hearing loss, vestibular dysfunction, and third window phenomenon. This study aims to elucidate primary factors causing iatrogenic inner ear dehiscences (IED) in 9 patients who presented to a tertiary care center with postoperative symptoms of IED following LSB surgery for vestibular schwannoma, endolymphatic sac tumor, Meniere’s disease, paraganglioma jugulare, and vagal schwannoma.

Methods

Utilizing 3D Slicer image processing software, geometric and volumetric analysis was applied to both preoperative and postoperative imaging to identify causal factors iatrogenic inner ear breaches. Segmentation analyses, craniotomy analyses, and drilling trajectory analyses were performed. Cases of retrosigmoid approaches for vestibular schwannoma resection were compared to matched controls.

Results

Excessive lateral drilling and breach of a single inner ear structure occurred in 3 cases undergoing transjugular (n=2) and transmastoid (n=1) approaches. Inadequate drilling trajectory breaching ≥1 inner ear structure occurred in 6 cases undergoing retrosigmoid (n=4), transmastoid (n=1), and middle cranial fossa approaches (n=1). In retrosigmoid approaches the 2-cm visualization window and craniotomy limits did not provide drilling angles to the entire tumor without causing IED in comparison to matched controls.

Conclusions

Inappropriate drill depth, errant lateral drilling, inadequate drill trajectory, or a combination of these led to iatrogenic IED. Image-based segmentation, individualized 3D anatomical model generation, and geometric and volumetric analyses can optimize operative plans and possibly reduce inner ear breaches from lateral skull base surgery.

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Abbreviations

3D:

Three dimensional

CT:

Computed tomography

CPA:

Cerebellopontine angle

ELS:

Endolymphatic sac

HIPAA:

Health Insurance Portability and Accountability Act

IAC:

Internal auditory canal

IED:

Iatrogenic inner ear dehiscence

LSB:

Lateral skull base

LSCC:

Lateral semicircular canal

MRI:

Magnetic resonance imaging

PSCC:

Posterior semicircular canal

SSCC:

Superior semicircular canal

SS:

Sigmoid sinus

TRE:

Target registration error

VS:

Vestibular schwannoma

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Funding

This work was supported in part by the National Institute of Biomedical Imaging and Bioengineering of the National Institutes of Health through Grant Numbers R01EB025964 and P41EB015898 (JJ). This work was also supported in part by the National Institutes of Health Institutional National Research Award, T32 #5T32DC000040 (NB).

Author information

Authors and Affiliations

Authors

Contributions

All authors contributed to the study conception and design. Material preparation, data collection, and analysis were performed by NBS. The first draft of the manuscript was written NBS, and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Carleton Eduardo Corrales.

Ethics declarations

Ethics approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards. The study was approved by the Brigham and Women’s Hospital Institutional Review Board (No. 2017P002162).

Competing interests

Unrelated to this publication, Jagadeesan Jayender owns equity in Navigation Sciences, Inc. He is a co-inventor of a navigation device to assist surgeons in tumor excision that is licensed to Navigation Sciences. Dr. Jagadeesan’s interests were reviewed and are managed by BWH and Partners HealthCare in accordance with their conflict of interest policies.

Additional information

Comments

The concept of anatomic variability and tailoring surgical approach based upon what is the situation in the individual patient merits emphasis.(1) Our group in 1994 demonstrated this concept for the retrosigmoid approach by utilizing CT measurements and determination of certain available angles of approach. Our method has stood the test of time. The major difference in applying this concept today lies with our increasing sophistication in imaging and the computing power to manipulate those images. The method demonstrated in this paper for determining the ability to obtain exposure of the fundus via transmeatal bone removal through the retrosigmoid approach represents a useful update. I think it worth stressing the importance of meticulous and thoughtful preoperative planning to optimize outcomes.

John Day

Arkansas, USA

1. Day JD, Kellogg JX, Fukushima T, Giannotta SL (1994) Microsurgical anatomy of the inner surface of the petrous bone: neuroradiological and morphometric analysis as an adjunct to the retrosigmoid transmeatal approach. Neurosurgery 34:1003-1008

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Supplementary information

Series of axial images from postoperative CT scrolling from superior to inferior in 3D slicer software. Inner ear structures were segmented from preoperative CT and registered to postoperative CT (TRE=0.649mm) and tumor (light green) was segmented from preoperative MRI and registered to postoperative CT (TRE=0.862mm). The drilling path can be seen as a straight line to the internal auditory canal, and the absence of the bony otic capsule exposes a dehiscent superior semicircular canal (yellow), posterior semicircular canal (pink), and vestibule (blue). Additional structures shown include the lateral semicircular canal (brown) and cochlea (dark green). (MP4 8363 kb)

3D model of the postoperative scene from the surgeon’s perspective. Peering through the restrosigmoid craniotomy, one can see the vestibular schwannoma (green) and the drilling path to the internal auditory canal. Visualization of the posterior semicircular canal (pink) and superior semicircular canal (yellow) is made possible due to the absence of overlying bony otic capsule, which occurred as a result of drilling in order to reach the internal auditory canal. The malleus (magenta) and the incus (blue) can be visualized through the external auditory canal. Inner ear and middle ear structures were segmented from preoperative CT and registered to postoperative CT (TRE=0.649mm) and tumor was segmented from preoperative MRI and registered to postoperative CT (TRE=0.862mm). (MP4 5221 kb)

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Ben-Shlomo, N., Jayender, J., Guenette, J.P. et al. Iatrogenic inner ear dehiscence associated with lateral skull base surgery: a systematic analysis of drilling injuries and their causal factors. Acta Neurochir 165, 2969–2977 (2023). https://doi.org/10.1007/s00701-023-05695-3

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