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array:21 [ "pii" => "S0001651924000487" "issn" => "00016519" "doi" => "10.1016/j.otorri.2024.03.001" "estado" => "S300" "fechaPublicacion" => "2024-11-01" "aid" => "1236" "copyrightAnyo" => "2024" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Acta Otorrinolaringol Esp. 2024;75:341-6" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "itemSiguiente" => array:18 [ "pii" => "S0001651924000529" "issn" => "00016519" "doi" => "10.1016/j.otorri.2024.03.002" "estado" => "S300" "fechaPublicacion" => "2024-11-01" "aid" => "1240" "copyright" => "Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello" "documento" => "article" "crossmark" => 1 "subdocumento" => "fla" "cita" => "Acta Otorrinolaringol Esp. 2024;75:347-53" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Artículo original</span>" "titulo" => "Situación actual de la tutoría en la formación especializada en otorrinolaringología en España. ¿Dónde estamos? ¿Hacia dónde queremos ir?" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "347" "paginaFinal" => "353" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The current situation of tutoring in specialised training in otorhinolaryngology-head and neck surgery in Spain. Where are we? Where do we want to go?" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figura 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 2081 "Ancho" => 3333 "Tamanyo" => 599050 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Análisis DAFO aplicado a la Formación Sanitaria Especializada de Otorrinolaringología.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Pedro Díaz de Cerio Canduela, Francesc Xavier Avilés Jurado, Julia de Juan Beltrán, Carlos Magri Ruiz, Alfonso Santamaría Gadea, Fernando López" "autores" => array:6 [ 0 => array:2 [ "nombre" => "Pedro" "apellidos" => "Díaz de Cerio Canduela" ] 1 => array:2 [ "nombre" => "Francesc Xavier" "apellidos" => "Avilés Jurado" ] 2 => array:2 [ "nombre" => "Julia" "apellidos" => "de Juan Beltrán" ] 3 => array:2 [ "nombre" => "Carlos" "apellidos" => "Magri Ruiz" ] 4 => array:2 [ "nombre" => "Alfonso" "apellidos" => "Santamaría Gadea" ] 5 => array:2 [ "nombre" => "Fernando" "apellidos" => "López" ] ] ] ] ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0001651924000529?idApp=UINPBA00004N" "url" => "/00016519/0000007500000006/v1_202411050541/S0001651924000529/v1_202411050541/es/main.assets" ] "en" => array:19 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Original article</span>" "titulo" => "Retrolabyrinthine approach to the lateral skull base: The value of preoperative temporal bone CT analysis" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "341" "paginaFinal" => "346" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Fabrizio Salvinelli, Francesca Bonifacio, Carlo A. Mallio, Andrea Pescosolido, Giulia Chiappino, Fabio Greco, Maurizio Iacoangeli" "autores" => array:7 [ 0 => array:3 [ "nombre" => "Fabrizio" "apellidos" => "Salvinelli" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 1 => array:4 [ "nombre" => "Francesca" "apellidos" => "Bonifacio" "email" => array:1 [ 0 => "f.bonifacio@unicampus.it" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 2 => array:3 [ "nombre" => "Carlo A." "apellidos" => "Mallio" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Andrea" "apellidos" => "Pescosolido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "Giulia" "apellidos" => "Chiappino" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 5 => array:3 [ "nombre" => "Fabio" "apellidos" => "Greco" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 6 => array:3 [ "nombre" => "Maurizio" "apellidos" => "Iacoangeli" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] ] "afiliaciones" => array:5 [ 0 => array:3 [ "entidad" => "Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 21 - 00128, Rome, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Multidisciplinary Group for Skull base surgery, Università Campus Bio-Medico di Roma, Rome, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Research Unit of Radiology, Department of Medicine and Surgery, Università Campus Bio-Medico di Roma, Roma, Italy" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Department of Neurosurgery, Le Marche Polytechnic University Hospital, Ancona Italy" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Istituto di Ricovero e Cura a Carattere Scientifico-Istituto Nazionale di Ricovero e Cura per Anziani (IRCCS-INRCA), 60127 Ancona, Italy" "etiqueta" => "e" "identificador" => "aff0025" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Abordaje retrolaberíntico a la base lateral del cráneo: el valor del análisis preoperatorio de la TC del hueso temporal" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 815 "Ancho" => 1341 "Tamanyo" => 67745 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Angle with the apex at the level of the posterior lower lip of the porus, created by the intersection of the line drawn along the tangent of the PSC and a line drawn at the beginning of the presigmoid dura and lower lip of the porus (Dura presig-IAC-PSC).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The retro-labyrinthine approach to the cerebellar pontine angle (CPA) requires detailed knowledge of labyrinthine block anatomy to avoid iatrogenic injury of the VII cranial nerve (CN) and accidental drilling of the posterior semicircular canal (PSC). This access is challenging due to the limited angle of view for the surgeon.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The presigmoid pathway can be used either for CPA lesion removal, such as acoustic schwannoma,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> dermoid cysts, petro-clival meningioma, or to treat vascular-nerve conflict, and perform vestibular neurectomy in patients with Ménière disease. This is a minimally invasive approach not suitable for the removal of large schwannomas but for small tumors of the APC. The most common approach for accessing the CPA is the retrosigmoid route.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Indeed, a poor angle of view can lead to incomplete removal of CPA tumors and poor suturing of dura, possibly resulting in increased risk of CSF fistula.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In the retrolabyrinthine approach, preoperative planning of retrolabyrinthine pathway is of paramount importance. This is mainly based on a detailed study of Trautmann’s triangle (TT) on temporal bone CT scan.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Trautmann’s triangle is composed by the petrous sinus superiorly, the posterior semicircular canal anteriorly, and the sigmoid sinus (SS) posteriorly.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> These landmarks, define a window into the posterior cranial fossa.</p><p id="par0025" class="elsevierStylePara elsevierViewall">The aim of this paper is to investigate the relationship between anatomical measurements taken on preoperative temporal bone CT and degree of surgical difficulty or risk of complications. Other articles describe the surgical anatomy of this region, including analyses of a much larger number of cases. This is the first article where the analysis of the cases was based on surgical comparison method.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Methods</span><p id="par0030" class="elsevierStylePara elsevierViewall">Several anatomical measurements were obtained on preoperative CT of patients with Ménière’s disease, treated with vestibular neurectomy using the presigmoid retrolabyrinthine approach (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0035" class="elsevierStylePara elsevierViewall">A cohort of consecutive patients who treated with vestibular neurectomy from November 2020 to September 2022 was enrolled in the study (M = 10, F = 8; left side = 9; right side = 9). All patients were diagnosed with Meniere’s disease according to the Barany society criteria and underwent medical therapy for more than six months without benefit.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Patients underwent previous endolymphatic sac surgery, therefore, enlarged mastoidectomy was performed before the enrollment in the present study.</p><p id="par0045" class="elsevierStylePara elsevierViewall">The authors hypothesized that anatomical measurements of temporal bone CT could guide the surgeon in retrolabyrinthine presigmoid access and predict surgical difficulty. On this respect, a surgical difficulty scale was calculated considering operating times, hospital stay, minor and major complications. Measurements are not affected by the previous mastoidectomy.</p><p id="par0050" class="elsevierStylePara elsevierViewall">Among the considered CT-scan parameters, the distance between the jugular bulb and the superior petrosal sinus and the distance between PSC and the sigmoid sinus were multiplied to obtain Trautmann’s area. Moreover, the petro-clival angle, with apex at the level of the internal auditory canal (IAC), was calculated.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> The authors computed another angle with the apex at the level of the posterior lower lip of the porus, created by the intersection of the line drawn along the sigmoid sinus and the tangent of the PSC (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The authors included also two additional parameters: the distance between the posterior lower lip of the porus and the beginning of the presigmoid dura (<a class="elsevierStyleCrossRef" href="#fig0015">Fig. 3</a>) and the angle created by these measures and the tangent to the lower boundary of PSC (<a class="elsevierStyleCrossRef" href="#fig0020">Fig. 4</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">Potential relationships were explored between anatomical measures and length of the procedure and between anatomical measures and the length of hospital stay, using multiple linear regression with stepwise method. Moreover, other possible effects were explored between anatomical measures, length of the procedure and length of hospital stay by the means of Receiving Operative Curve (ROC).</p><p id="par0060" class="elsevierStylePara elsevierViewall">Statistical analysis was conducted with a statistical significance threshold set at p < 0,05, by means of MedCalc® Statistical Software version 20 (MedCalc Software Ltd, Ostend, Belgium; <a href="https://www.medcalc.org">https://www.medcalc.org</a>; 2021).</p><p id="par0065" class="elsevierStylePara elsevierViewall">The authors assert that this work comply with the ethical standards. The Campus Bio-medico University of Rome Ethics Committee approved this study, opinion 82.22(OSS).</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Surgical technique</span><p id="par0070" class="elsevierStylePara elsevierViewall">The exposure of the mastoid cortex in these patients showed the signs of previous ELSS. Hence the following landmarks are exposed: mastoid antrum, superior petrosal sinus, sigmoid sinus, sino-dural angle, dura mater of the middle and posterior cranial fossa. The meningeal incision is carried out superior to the endolymphatic sac and as close as possible to the posterior margin of the posterior semicircular canal, with access to the pontocerebellar angle (CPA). Deliquoration and the opening of the arachnoid is then performed. The use of 0°, 30°, 45° endoscopes allowed a wide visualization of the CPA, without having to displace the cerebellum which usually reduces the underlying vision. Once the landmarks (VIII, VII, V and VI cranial nerves) are recognized, as well as the vascular structures, the authors shifted to the microscope. The opening of CSF cisterns allowed the retraction of the cerebellum, with a larger visual space, and the Vestibular nerve section is then performed. At this point, the endoscope allowed a correct visualization of the VII cranial nerve, which is hidden behind the VIII cranial nerve. The meninx cannot be watertight sutured with this technique, so the space is filled and closed with the addition of abdominal fat tissue. The supramastoid planes are sutured.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Results</span><p id="par0075" class="elsevierStylePara elsevierViewall">The median and the interquartile range of variables explored are reported in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0080" class="elsevierStylePara elsevierViewall">No potential correlation was found between the PSC - sigmoid sinus distance, JB- superior petrosal sinus distance, TT area, petro-clival angle, PSC-dura presigmoid distance, SS-IAC-PSC angle and the length of the procedure while there was a potential correlation between the dura presig-IAC-PSC angle and the length of the procedure (Intercept: 24,56; IQ:15,64 - 33,48; F-ratio 5,7644; R = 0,44; R2 = 0,19 P < 0,0001) (<a class="elsevierStyleCrossRef" href="#fig0025">Fig. 5</a>). No potential correlation was found between the PSC-SS distance, JB-superior petrosal sinus distance, TT area, petro-clival angle, SS-IAC-PSC angle, IAC-dura presigmoid distance and the dura presig-IAC-PSC angle and the length of hospital stay. Moreover, a potential correlation was observed between the risk to develop a complication and dura presigmoid-IAC-PSC angle (AUC = 0,889, P < 0,001, Associated criterion ≤14, Sensitivity = 100, Specificity = 72,22), Sigmoid sinus- PSC distance (AUC = 0,759, P = 0,018, Associated criterion ≤11, Sensitivity = 100, Specificity = 66,67) and the length of the procedure (AUC = 0,963, P < 0,001, Associated criterion >7, Sensitivity = 100,Specificity = 94,44) (<a class="elsevierStyleCrossRef" href="#fig0030">Fig. 6</a>).</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia><elsevierMultimedia ident="fig0030"></elsevierMultimedia></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Discussion</span><p id="par0085" class="elsevierStylePara elsevierViewall">Each surgical approach to the CPA has advantages and disadvantages. Among advantages, the retro-sigmoid access to the posterior cranial fossa enables wider angle of view and allows for dura closure with sutures, reducing the risk of postoperative CSF fistula.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> The same surgical approach has the disadvantage an angle of view usually far from the lesions which is located at the level of the internal auditory canal, therefore, cerebellum retraction can be mandatory, with possible consequent tissue lesion.<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> The approach to the middle cranial fossa holds the advantage to facilitate resections of small endo-canal lesions while pursuing hearing conservation. The disadvantages are that the technique requires temporal lobe compression to access the internal auditory canal, possible facial nerve injury during exposure to the IAC dura, and worse approach to lesion with extra canal extension.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7,8</span></a> The technique is uncommonly attempted, since other less invasive approaches are usually preferred. The retrolabyrinthine presigmoid route has the significant advantage to expose the lateral skull base space with minimal, if any, cerebellar retraction. The disadvantage is that it requires more surgical time and detailed knowledge of the labyrinth block anatomy to avoid damage to the VII cranial nerve and accidental drilling of the PSC with consequent hearing loss.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,9</span></a> The working space is narrower with respect to retrosigmoid route because is limited upward by the labyrinthine block, at the bottom by the sigmoid sinus, and in-depth by the jugular bulb, thus, endoscope usage is usually needed to increases vision. The translabyrinthine pathway has the advantage of allowing the direct vision of the CPA without cerebellar manipulation with the possibility of reaching the lateral portion of the pons and the upper part of the medulla. The disadvantage is that the broad and direct vision impact patients hearing.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">The difficulty of the proposed intervention does not depend on the diagnosis of Meniere's Disease but rather on the anatomical variability among different individuals. CT scanning in patients with Meniere’s Disease is used to exclude other causes of vertigo (third window syndrome) and in our study, also for the planning of vestibular neurectomy surgery.</p><p id="par0095" class="elsevierStylePara elsevierViewall">In endolymphatic sac surgery, the previously performed extended mastoidectomy alters the anatomy of the temporal bone: reducing the height of the sigmoid sinus and pneumatizing the mastoid. However, the parameters used in the study do not undergo variations caused by the previous intervention. According to the literature, there seem to be CT variations in patients with Meniere’s disease compared to the control group, but it is noteworthy that there are no variations compared to the healthy ear. Among the anatomical variations studied in CT, a high jugular bulb is described, but it does not seem to play any role in endolymphatic hydrops at a functional level.</p><p id="par0100" class="elsevierStylePara elsevierViewall">A lower rate of vestibular aqueduct identification has also been studied in CT scans of patients with MD. However, their role in the pathophysiology of MD remains purely speculative. Longitudinal studies are needed to observe whether patients with the aforementioned anatomical alterations develop MD more frequently.</p><p id="par0105" class="elsevierStylePara elsevierViewall">Preoperative temporal bone CT scan study can help the surgeon to achieve a safe CPA surgery with retrolabyrinthine approach. In a study performed on 177 CTs, the TT area calculation was assessed by multiplying the PSC-SS and JB-PR distance. The variability of ​​Trautmann’s triangle area was reported between 71 and 426 mm2, against an area of ​​45–210 mm<span class="elsevierStyleSup">2</span> on ten cadavers.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> The same authors included an additional parameter: the calculation of the Petrus slope, which on CT study of 177 patients resulted to be between 106 and 178 degrees.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> The study confirms the variability of the retrolabyrinthine space. A smaller TT area and a sharp petrous slope angle imply a narrowed presigmoid space.</p><p id="par0110" class="elsevierStylePara elsevierViewall">Another important anatomical landmark to consider in the surgical approach is the position of the sigmoid sinus. According to cadaver studies, the SS displaced laterally or medially to a line drawn along the long axis of the PSC. A laterally displaced sigmoid sinus makes the retrolabyrinthine access more complex, and the TT is more hidden and medial. An SS placed further forward reduces the TT. A medially displaced sigmoid sinus is associated with a larger triangle.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> According to this series, a sigmoid sinus placed medially (i.e. deep) is associated to greater surgical difficulty.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> The real limitation to consider is the distance between the inferior margin of the sigmoid sinus and the posterior semi-circular canal, which is difficult to assess on CT scan. Indeed, small length makes the dura less available to be incised. Furthermore, a minor sigmoid sinus manipulation reduces the risk of venous thrombosis.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a></p><p id="par0115" class="elsevierStylePara elsevierViewall">The authors investigated two additional angles in the CT scan: the presigmoid dura-IAC-PSC angle and the PSC-IAC-SS angle. Obtuse angles allow for better labyrinth block isolation and easier exposure of the dura mater in its extremities. In this study, the authors obtained CT-based quantitative measurements on patients who had already undergone endolymphatic sac surgery -ELSS-, so it was not possible to calculate the distance between the posterior semicircular canal and the temporal bone cortex or the mastoid aeration. A more pneumatized mastoid makes it easier to locate temporal bone landmarks. Furthermore, a greater mastoid aeration has been associated to a proportional reduction of the TT area.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">In this series, the measurements of retrolabyrinthine space up to the incision of the vestibular nerve were considered. When an IAC opening is necessary, preoperative measurements on temporal bone CT are of great importance. On this respect, Vachata et al. defined a high jugular bulb, as a bulb that reaches or exceeds the IAC floor. This characteristic covered 16.5% of the temporal bones studied, with an average length between IAC and the closest point to the jugular bulb apex of 7.5 ± 2.3 on 200 CT scans.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> In another study conducted on 208 CT,<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> the jugular bulb was higher than the IAC in 5.28% of cases. In a further study on CT with volumetric reconstructions of the retrolabyrinthine space in 104 patients, Hao et al. considered the mean anteroposterior diameter of 5.8 mm (midpoint perpendicular of the PSC to the petrous pyramid), the average diameter from upward to bottom of 10.25 mm (distance from the vestibular aqueduct to the middle cranial fossa), and a depth distance of 10.3 mm (PSC to IAC). With these three measurements, it was possible to achieve a guide for surgeons for safe bone removal in the three planes.<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">To perform this type of surgical intervention, the following are necessary: a microscope for access, an endoscope for the section of the nerve that allows 360° visualization through the narrow space between the CSP and the sigmoid sinus. Without endoscopy, this operation would be very treacherous and risky.</p><p id="par0130" class="elsevierStylePara elsevierViewall">From a surgical point of view, the combination of microscopic and endoscopic visions helps the surgeon if the TT area is narrow. In microscopic view, the two-handed work facilitates bone drilling and compression of the sigmoid sinus. Angled endoscopic optics facilitate viewing within the CPA after the dura opening.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> A high jugular bulb is a limitation that can be overcome by exposure of jugular bulb together with bone wax and “SURGICEL®” sponge application, to move the JB downward. The “SURGICEL®” swells and limits the space, but it has a haemostatic effect and permits to dislocate the jugular bulb and gain space. Bone wax favours the instruments sliding on a smoother and more compressible surface.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Indeed, the ideal surgical access depends on the following characteristics: JB lower than the IAC and lateral positioning of the sigmoid sinus. Consequently, a greater TT area and a wider petro-clival angle make the surgeon’s job easier. On the other hand, a small surface of the presigmoid dura is a challenge for the surgeon.</p><p id="par0140" class="elsevierStylePara elsevierViewall">In the present study, a potential correlation between the IAC-dura presig-PSC angle and the length of the procedure was found. The low R2 value shows a weak relationship between these two values, probably due to the small sample size.</p><p id="par0145" class="elsevierStylePara elsevierViewall">Lastly, we reported a strong correlation between the risk to develop a complication and IAC-presig-PSC angle, SS-PSC distance, and the length of the procedure, with the respective cut-offs. This result could be of great importance to predict the likelihood of helping the surgeons to face the procedure.</p><p id="par0150" class="elsevierStylePara elsevierViewall">The support of preoperative CT allows the surgeon to be more careful in the most surgical critical area, thus reducing surgical complication. However in case of difficult angles the use of the presigmoid retrolabyrinthine access in our series was not precluded. The aid of the optics allows the procedure to be performed even when the CT highlights difficult anatomy, without affecting the surgical technique adopted.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusion</span><p id="par0155" class="elsevierStylePara elsevierViewall">A narrow presigmoid retro-labyrinth space can be a challenge for surgeons. Preoperative analysis of temporal bone CT may have an impact in predicting surgical difficulty. Detailed knowledge of the temporal bone anatomical landmarks and familiarity with the endoscopic optics usage are essential for the surgeons to reach the CPA safely. Be prepared, do not despair.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflicts of interest and source of funding</span><p id="par0160" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interests or external fundings.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres2292797" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1905433" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres2292796" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1905434" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Surgical technique" ] ] ] 6 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 9 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest and source of funding" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-07-28" "fechaAceptado" => "2024-03-05" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1905433" "palabras" => array:4 [ 0 => "Skull base surgery" 1 => "Cerebellopontine angle" 2 => "Presigmoid approach" 3 => "Semicircular canals" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1905434" "palabras" => array:4 [ 0 => "Cirugía de la base del cráneo" 1 => "Ángulo cerebelopontino" 2 => "Enfoque presigmoideo" 3 => "Canales semicirculares" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Purpose</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">The most used neurosurgical approach to reach cerebellar-pontine angle is the retrosigmoid route. This article describes the presigmoid approach which requires excellent knowledge of the labyrinthine block together with quantitative analysis of temporal bone CT.</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Methods</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">CT-based quantitative measurements were obtained in patients undergoing vestibular neurectomy with a presigmoid approach. Eighteen patients were enrolled, and five measures were taken: Trautmann’s area, the petro-clival angle, presigmoid dura length and its angle. The relationship between these measurements and hospitalization days, operating times, and complications was explored.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">The posterior semicircilar canal (PSC)-sigmoid sinus (SS) distance, presigmoid dura- internal auditory canal (IAC)-PSC angle, and duration of surgery are predictors of complications. Specifically, a PSC-sigmoid sinus distance <11 mm, a dura presig-IAC-PSC angle <14 are associated with the highest risk of complications.</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusion</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Preoperative temporal bone CT scan can guide the surgeon through the narrowest areas of the surgical approach. Trautmann’s triangle area and petro-clival angle reduction are challenging and can be faced with combined microscopic-endoscopic technique, and with optics angulation-rotation. The retrolabyrinthine approach can enable hearing preservation and minimal cerebellar retraction.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Purpose" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusion" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Propósito</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">El abordaje neuroquirúrgico más utilizado para llegar al ángulo cerebelopontino es la vía retrosigmoidea. Este artículo describe el abordaje presigmoideo, que requiere un excelente conocimiento del bloque laberíntico junto con un análisis cuantitativo de la TC del hueso temporal.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Métodos</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Se realizaron mediciones cuantitativas basadas en TC en pacientes sometidos a neurectomía vestibular con un enfoque presigmoideo. Se inscribieron dieciocho pacientes y se tomaron cinco medidas: el área de Trautmann, el ángulo petro-clival, la longitud de la duramadre presigmoidea y su ángulo. Se exploró la relación entre estas mediciones y los días de hospitalización, los tiempos de operación y las complicaciones.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">La distancia entre el canal semicircular posterior (CSP) y el seno sigmoides (SS), el ángulo entre la duramadre presigmoidea, el canal auditivo interno (CAI) y el CSP, y la duración de la cirugía son predictores de complicaciones. Específicamente, una distancia CSP-seno sigmoides <11 mm, un ángulo duramadre presig-CAI-CSP <14 están asociados con el mayor riesgo de complicaciones.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusión</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La tomografía computarizada preoperatoria del hueso temporal puede guiar al cirujano a través de las áreas más estrechas del abordaje quirúrgico. El área del triángulo de Trautmann y la reducción del ángulo petro-clival son desafiantes y pueden abordarse con una técnica combinada microscópica-endoscópica y con angulación-rotación óptica. El abordaje retrolaberíntico puede permitir la preservación de la audición y una retracción mínima del cerebelo.</p></span>" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Propósito" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusión" ] ] ] ] "multimedia" => array:7 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 946 "Ancho" => 1675 "Tamanyo" => 216173 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0005" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Endoscopic image of initial view during presigmoid-retrolabyrinthine access.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1182 "Ancho" => 1508 "Tamanyo" => 116914 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0010" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Angle with the apex at the level of the posterior lower lip of the porus, created by the intersection of the line drawn along the tangent of the PSC and a line drawn along the sigmoid sinus (SS-IAC-PSC).*PSC (posterior semicircular canal);SS (Sigmoid sinus).</p>" ] ] 2 => array:8 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 898 "Ancho" => 1341 "Tamanyo" => 66640 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0015" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Distance between the posterior lower lip of the porus and the beginning of the presigmoid dura (Dura presig-IAC).</p>" ] ] 3 => array:8 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 815 "Ancho" => 1341 "Tamanyo" => 67745 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0020" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Angle with the apex at the level of the posterior lower lip of the porus, created by the intersection of the line drawn along the tangent of the PSC and a line drawn at the beginning of the presigmoid dura and lower lip of the porus (Dura presig-IAC-PSC).</p>" ] ] 4 => array:8 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1281 "Ancho" => 1675 "Tamanyo" => 170644 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0025" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Linear regression comparison between the length of the procedure and dura presig-IAC-PSC angle.</p>" ] ] 5 => array:8 [ "identificador" => "fig0030" "etiqueta" => "Figure 6" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr6.jpeg" "Alto" => 1080 "Ancho" => 3175 "Tamanyo" => 287124 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0030" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Roc curves correlating sigmoid-PSC distance, length of the procedure and dura presig-IAC-PSC angle with the complication risk.</p>" ] ] 6 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0035" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">Median with interquartile range \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">PSC - sigmoid sinus distance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13(10–14) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">JB- superior petrosal sinus distance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">17(15–17) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">TT area \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">224(160–238) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Petro-clival angle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">165(156–171) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sigmoid sinus-IAC- PSC angle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8(4–12) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">IAC-dura presigmoid distance \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">28(25–30) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Dura presig-IAC-PSC angle \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">16(11–18) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Length of stay at the hospital (days) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6(5,31–7) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Length of the procedure (hours) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7(6–8) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3715788.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">List of patients variables use for correlation measurement.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:16 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Microsurgical endoscopy-assisted presigmoid retrolabyrinthine approach as a minimally invasive surgical option for the treatment of medium to large vestibular schwannomas" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Iacoangeli" 1 => "F. Salvinelli" 2 => "A. Di Rienzo" 3 => "M. Gladi" 4 => "L. Alvaro" 5 => "F. Greco" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00701-012-1591-y" "Revista" => array:7 [ "tituloSerie" => "Acta Neurochir (Wien)" "fecha" => "2013" "volumen" => "155" "numero" => "4" "paginaInicial" => "663" "paginaFinal" => "670" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23361635" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "An analysis of the retrolabyrinthine vs. the retrosigmoid vestibular nerve section" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M.E. Glasscock" 1 => "B.A. Thedinger" 2 => "R.A. Cueva" 3 => "C.G. Jackson" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Otolaryngol Neck Surg" "fecha" => "1991" "volumen" => "104" "numero" => "1" "paginaInicial" => "88" "paginaFinal" => "95" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Trautmann’s triangle anatomy with application to posterior transpetrosal and other related skull base procedures" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "R.S. Tubbs" 1 => "C. Griessenauer" 2 => "M. Loukas" 3 => "S.F. Ansari" 4 => "M.H. Fritsch" 5 => "A.A. 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