Pamela Roehm, MD, PhD, Professor, Director, Division of Otology and Neurotology, Department of Otolaryngology at Temple University School of Medicine, talks about a new keyhole brain surgery treatment for patients with TE.
Interview conducted by Ivanhoe Broadcast News in December 2017.
When people present certain symptoms in the ear, maybe like vertigo or pressure in the ear and fluid, how can someone decide whether or not is this serious, or is it something just basic? They just probably start off at an ENT I would assume, right?
Dr. Roehm: Not necessarily. Most people start off seeing their primary care doctor. Many of the have chronic otorrhea or drainage from their ears instead of having ear pressure or fullness,. Often, this would be after an outside otolaryngologist has put a tube into their ear for what they thought was a chronic serious otitis media or just a fusion of fluid behind the ear drum, but then ultimately it was found to be brain fluid, or cerebral spinal fluid. Then these people continue to return to their primary doctor often to that outside otolaryngologist and then they will often go through a series of different physicians trying to discern what the problem is due to and then eventually they will get referred to a sub-specialist; like myself, an Otologist and Neuro-Otologist.
And how do you know when you see these people, how do you suspect that it might be this hole?
Dr. Roehm: At first it is a problem that is diagnosed mainly from the history. Usually this problem will have gone on for an extended period of time and been unresponsive to antibiotics, so in that case, you start to suspect there is something more than just a run-of-the-mill ear infection going on.
When Agnes came in she had already been to the ENT and gotten her referral to you guys, what did you see in her that led you to believe she needed this surgery?
Dr. Roehm: She had a very similar history to the one we were just discussing. She had seen an outside otolaryngologist, she had a lot of other ear infections as well of that external ear canal, or the part that goes down to the eardrum; and so those kind of made the picture more obscure. But basically what we found was that she just did not respond very well to appropriate antibiotic therapy and treatment for the infection and then on her imaging studies, both CT and MRI, that was evidence of having a temporal encephalocele.
And do you know how, what causes that or why this happen in certain people?
Dr. Roehm: It can be caused by a variety of problems. In Mrs. McFadden’s case, it was due to having a number of ear infections over the years, but it can also happen after a traumatic injury, particularly one in which the temporal bones are fractured. It can also happen spontaneously, so we will see people who have developed these just as a consequence of having very thin bone in the area. The brain itself pulsates with every heartbeat and it start to break down that bone there; we see it more often in people who are overweight.
Because of the increase in the size of the brain along with everything else on your body or?
Dr. Roehm: It does not increase the size of the brain, but it can sometimes increase the pressure inside of the brain of the fluid itself.
So if the brain is pulsating, it is pushing against this bone, is this is what you are saying?
Dr. Roehm: Over and over again; 60 to 70 times a minute, on average.
So when you guys are in surgery how does that happen in the operating room?
Dr. Roehm: Over time we have developed a good way of partnering for this surgery and so after we do the initial incisions to open up the area then we make a small hole for the craniotomy and save all the bone and extra materials that we have to remove to do the surgery; and then later at the end of the surgery we will use those to repair whatever holes we find. Then Dr. Erkmen lifts the brain up from the underline bone or sometimes there is no bone at all underneath there, then I will be typically holding the camera. I will hold the camera as he repairs the holes that are in the covering of the brain, near the derma, but then typically he would hold the camera for me when I am repairing the bone between the brain and the ear, so it really is a partnership; it is a shared procedure.
And he said about an hour long in the OR and is that about a fair assessment or?
Dr. Roehm: That is about the time it takes for us to perform our part of surgery. These kinds of surgeries take a great deal of monitoring, both on the part of the anesthesiologist, as well as some nerve monitoring of the structures in the area including the hearing, as well as the face nerve. So all that has to be applied appropriately and then taking off and people have to wake up from anesthesia, so the whole procedure itself from start to finish if you count all that time, it takes at least 3 and a half to 4 hours.
And then they go home and they are pretty much fine, he said after a couple of days is that?
Dr. Roehm: After a few days they do, and they do extremely well.
Now you guys have published your findings.
Dr. Roehm: That is right.
So, that is out there, and I did ask him other doctors and other institutions are now employing this. Just from an emotional or pride stand point how does that make you feel because this is a tremendous discovery?
Dr. Roehm: Well of course, we are very happy. We are happy to be able to treat people in a way that is much less invasive now then what we had to do before we develop this procedure. Before we had to make a very large incision and shave half the head and then put in retractors that really push the brain down in order to repair these areas, because before we were using a microscope to visualize the area. With this approach we can make a much smaller incision, a much smaller craniotomy or hole through the bone around the brain and really get people in and out of the hospital quicker and in a safe fashion, so it is very gratifying to be able to do it. But honestly, I think the most rewarding good thing about it is when we have patients who have had similar repairs elsewhere or that we did before we developed this technique come back in and say this is so much easier this time..
Well, so they are going to have it done twice, then.
Dr. Roehm: Some people do. Typically it will be on the opposite side, so they will have the problem on one side and then they will go and develop the same issue on the other.
In the actual OR you are using a camera, are you looking at a screen while you are doing this or how does, what is that physically look like?
Dr. Roehm: There is a screen, a monitor, and so we are holding something that looks like a short glass wand, and putting it in and it is hooked up by cables to the monitor.
And how is Agnes done since you have performed the surgery?
Dr. Roehm: She has done really well, she has done extremely well, and she is a lovely woman so it has been very rewarding taking her of her as well..
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
If you would like more information, please contact:
Jennifer Lee
Pamela Roehm
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