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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The superior canal dehiscence syndrome &#40;SCDS&#41; was initially reported by Minor et al&#46; in 1998&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It consists in a bony gap in the arcuate eminence&#44; which is the bone that covers the superior semicircular canal<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> producing then a connection between it and the middle fossa&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">Physiologically&#44; the cochlear apparatus presents two windows&#44; oval and round&#44; which interact between the liquid medium of the inner ear and the air medium of the middle ear&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> This previously detailed defect would give rise to a &#8220;third window&#8221; that causes a series of symptoms&#46; Result from the diversion of the normal labyrinthine circulation towards this new low-pressure route&#44; while the Valsalva maneuver can produce a reversal of this flow&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">Hearing loss&#44; autophony or vertigo induced by sounds &#40;Tullio&#8217;s phenomenon&#41;&#59; are among the most frequent clinical manifestations among others&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> The milder cases can be treated conservatively&#44; but other severe ones will require surgical treatment&#59; which traditionally consisted of a subtemporal approach to the middle fossa through a temporal craniotomy and sealing of the bone defect&#46; In recent years&#44; the performance of this technique endoscope-assisted has helped to improve the visualization of the dehiscence&#44; especially in those cases located in the medial part of the arcuate eminence&#44; where it is difficult to access in microsurgical approaches&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">We present a case series of SCDS operated on in our center jointly with the Otolaryngology team using an endoscope-assisted microscopic approach&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical cases</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Patient selection</span><p id="par0025" class="elsevierStylePara elsevierViewall">These are 3 patient&#44; all of them women with an average age of 57&#46;3 years with no relevant clinical background who underwent surgery between 2019 and 2022 at the Reina Sof&#237;a University Hospital in C&#243;rdoba&#46; All cases had the defect on the left side&#46; The main and first symptom was vertigo induced by sounds followed by and hearing loss&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">The patients consent to procedure and publication of their images were previously obtained&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Preoperative study</span><p id="par0035" class="elsevierStylePara elsevierViewall">Neuroimaging studies &#40;cranial and ear CT&#44; cranial MRI&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41; and evaluation by Otorhinolaryngology were carried out in all patients to complete the study of the clinical picture and rule out other more frequent pathologies that could cause the symptoms&#46; Surgery was planned with neuronavigation&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Surgical technique</span><p id="par0040" class="elsevierStylePara elsevierViewall">The patients were positioned in the supine position&#44; with the head fixed on the Mayfield craniostat&#44; turned towards the contralateral side and with slight lateralization&#44; orienting the cranial vertex towards the floor to keep the temporal scale &#40;working area&#41; parallel to it&#46; After performing the neuronavigation recording and following minimally shaving the patient&#39;s hair&#44; a supra&#47;retroauricular incision was made in an italic &#8220;S&#8221; shape with an extension 1&#8239;cm posterior and superior to the helix of the ear curving anteriorly along the floor of the middle fossa and over the temporal muscle to end at the hairline&#46; Likewise&#44; the incision took minimum distance of 1&#8239;cm from the pinna&#44; to avoid causing discomfort in patients who wear glasses&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The skin and subcutaneous cellular tissue were dissected until the temporal fascia is located with a cold scalpel&#44; avoiding the use of monopolar coagulation to avoid generating alopecia areas&#46; Bipolar coagulation is used when required to control minor bleeding&#46; Subsequently&#44; a temporalis fascia graft is removed in such a way as to allow its primary closure&#44; and the temporalis muscle is dissected anteriorly and inferiorly&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">A 3&#8239;x&#8239;2&#8239;cm craniotomy is made approximately centered on the line of the external auditory canal and with the microscope aid&#44; a careful dissection of the dura of the tegmen mastoideum and tegmen tympani and of the temporal fossa from posterior to anterior is performed until the arcuate eminence is visualized&#46; It is of special interest not to perform direct suction on this structure to avoid causing additional neurological damage&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">In our series of cases&#44; direct visualization with the microscope was not achieved &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#44; so then&#44; it was necessary to introduce the endoscope&#44; initially with the 0&#186; optics and later continue with the 30&#186; or 45&#186; optics&#46; This is due to the fact that the dehiscence was located in the medial region of the eminence and is &#8220;hidden&#8221; by it&#44; making it very difficult to visualize it with microscopy techniques<a class="elsevierStyleCrossRefs" href="#bib0025"><span class="elsevierStyleSup">5&#44;6</span></a> &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#46; In one of the patients there was no clear bone defect&#44; instead of that a thin bluish line was visible on the arcuate eminence&#59; already described previously by Cheng et al&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0060" class="elsevierStylePara elsevierViewall">There are different methods for sealing the bone defect&#46; In our series&#44; we mainly used the temporalis muscle fascia graft previously obtained together with bone wax and bone chips obtained during the craniotomy&#44; all sealed with fibrin glue&#46; After repositioning the bone flap with titanium plates&#44; a continuous suture of the temporal muscle is performed with 0 vicryl&#44; the subcutaneous tissue is approximated with an interrupted 2&#47;0 vicryl suture and for skin closure a 2&#47;0 prolene braided uninterrupted suture&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Results</span><p id="par0065" class="elsevierStylePara elsevierViewall">We achieved clinical improvement in all patients that underwent this technique&#44; with no intra&#47;postoperative complications&#44; no increased length of hospital stay&#44; or symptomatic recurrence&#46; It should be noted that symptomatic relief was lesser in one of the patients because the defect was bilateral&#59; and is waiting contralateral intervention&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discussion</span><p id="par0070" class="elsevierStylePara elsevierViewall">The superior canal dehiscence syndrome is a recently diagnosed pathology that has historically been treated by approaching the middle fossa through a temporal craniotomy&#59; although it is true that other techniques have been described&#44; such as the transmastoid approach used by Gioacchini et al&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In recent years&#44; endoscope-assisted surgery has undergone important advances both in the devices used and in the development of new surgical techniques&#46; In our department&#44; the classic middle fossa craniotomy has been chosen to address this pathology because we support that it is the one that offers the best surgical field for optimal repairing of the defect&#46; Most commonly&#44; this dehiscence locates in the arcuate eminence&#44; and good visualization of the arcuate eminence is possible under microscopic vision&#46; However&#44; there is a not insignificant number of cases &#40;28&#46;9&#37;&#41; in which the defect is located in the medial part of the arcuate eminence and cannot be objectified with microscopy techniques&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0080" class="elsevierStylePara elsevierViewall">By using the endoscope&#44; alternating 0&#186;&#44; 30&#186; and&#47;or 45&#186; optics&#44; and a four-handed approach&#44; optimal sealing is possible in these cases&#44; without increasing the number of complications or surgical time&#44; it could even be carried out fully assisted surgery with endoscopy from it is beginning&#46;</p><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Limitations</span><p id="par0085" class="elsevierStylePara elsevierViewall">The main limitation of the work is the low incidence of this pathology in our environment and the realization of a good diagnosis in the presence of characteristic symptoms&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conclusion</span><p id="par0090" class="elsevierStylePara elsevierViewall">It is necessary to take into account the diagnosis of SCDS in patients with vertigo or related symptoms&#44; since it is a surgically treatable entity&#46; Endoscope-assisted surgery&#44; performed by a multidisciplinary trained team&#44; is simple and safe and allows for the best visualization of medial defects&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">SCDS is a pathology that&#44; although its discovery dates back barely 20 years&#44; its pathophysiology has already been widely studied&#59; as well as several surgical techniques have been developed for its treatment&#46; Among them&#44; endoscope-assisted surgery stands out&#44; which allows a better sealing&#44; especially in medial defects of the arcuate eminence&#59; where microsurgery techniques cannot reach and whose complications do not exceed those of classical surgery&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Funding</span><p id="par0100" class="elsevierStylePara elsevierViewall">We have not received funding of any kind&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Conflicts of interest</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors have no personal&#44; financial&#44; or institutional interest in any of the drugs&#44; materials&#44; or devices described in this article&#46;</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Authors&#8217; contributions</span><p id="par0110" class="elsevierStylePara elsevierViewall">All authors have participated in the study&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Ethics approval</span><p id="par0115" class="elsevierStylePara elsevierViewall">Not applicable&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Consent to participate</span><p id="par0120" class="elsevierStylePara elsevierViewall">The patients consent to procedure was previously obtained&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Consent for publication</span><p id="par0125" class="elsevierStylePara elsevierViewall">The patients consent publication of their images was previously obtained&#46;</p></span><span id="sec0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0100">Disclosures</span><p id="par0130" class="elsevierStylePara elsevierViewall">The authors have no personal&#44; financial&#44; or institutional interest in any of the drugs&#44; materials&#44; or devices described in this article&#46;</p></span></span>"
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Journal Information
Vol. 35. Issue 4.
Pages 221-224 (July - August 2024)
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Vol. 35. Issue 4.
Pages 221-224 (July - August 2024)
Case Report
Unveiling the importance of the endoscope in the sealing of the superior canal dehiscence syndrome, how we do it
Importancia del endoscopio en el sellado de la dehiscencia del canal semicircular superior
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Carlos Doval-Rosaa,
Corresponding author
cadoro30@gmail.com

Corresponding author.
, Francisco Javier Dorado-Capotea, Alvaro Toledano-Delgadoa, Jose Miguel Sequí-Sabaterb, Román Carlos-Zamorac, Juan Solivera-Velaa
a Reina Sofía University Hospital, Córdoba, Spain
b Rheumatology Department, La Ribera University Hospital, Alzira, Valencia, Spain
c Otorhinolaryngology department, Reina Sofía University Hospital, Córdoba, Spain
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Abstract

The superior canal dehiscence syndrome is a pathology that affects the arcuate eminence creating a “third window” between the inner ear and the middle fossa. This condition can lead to symptoms such as hearing loss, autophony, or sound-induced vertigo. Traditionally, surgical treatment has been performed by microscope-assisted temporal craniotomy, but when the dehiscence is in the medial part of the arcuate eminence the bone defect may not be seen.

We present case series treated at our institution diagnosed of superior canal dehiscence syndrome involving the medial slope of the arcuate eminence. During surgery, the bone defect could not be visible with traditional microscopic techniques. Nonetheless, by introducing the endoscope with the 0º and 30º optics, the dehiscence could be clearly observed and treated correctly.

Our results show a clinical improvement without side effects or complications in the patients undergoing this technique. Endoscope-assisted surgery is a safe procedure and provides a better visualization of medial defects.

Keywords:
Arcuate eminence
Endoscope-assisted surgery
Medial defect
Superior canal dehiscence
Resumen

La dehiscencia del canal semicircular superior es una patología que afecta a la eminencia arcuata creando una "tercera ventana" entre el oído interno y la fosa media. Este defecto puede provocar síntomas como pérdida de audición, autofonía o vértigo inducido por el sonido. Tradicionalmente, el tratamiento quirúrgico se ha realizado mediante craneotomía temporal asistida por microscopio, pero cuando la dehiscencia se encuentra en la parte medial de la eminencia arcuata el defecto óseo puede no verse.

Presentamos una serie de casos intervenidos en nuestro centro diagnosticados de dehiscencia del canal semicircular superior que afecta a la pendiente medial de la eminencia arqueada. Durante la cirugía, el defecto óseo no pudo ser visible con las técnicas microscópicas tradicionales. Sin embargo, al introducir el endoscopio con óptica de 0º y 30º se pudo observar claramente la dehiscencia y tratarla correctamente.

Nuestros resultados muestran una mejoría clínica sin complicaciones en los pacientes sometidos a esta técnica. La cirugía asistida por endoscopio es un procedimiento seguro y proporciona una mejor visualización de los defectos mediales.

Palabras clave:
Eminencia arcuate
Cirugía asistida por endoscopio
Defecto medial
Dehiscencia del canal semicircular superior

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