European Archives of Oto Rhino Laryngology

Author’s reply to letter at the editor: primary hyperparathyroid surgery under local anaesthesia: benefits of hypnosis

01-03-2020 – S Morinière


Abstract The hypnosis gives more comfort to the patient and can be used in patients at risk of a general anaesthesia.

Letter to editor: Primary hyperparathyroid surgery under local anesthesia: benefits of hypnosis

01-03-2020 – S Mayilvaganan,RB Panchangam


Response to the letter to the editor: "Score risk scale as a prognostic factor after sudden sensorineural hearing loss"

01-03-2020 – A Sousa Menezes,D Ribeiro,A Lima,D Miranda,J Guimarães,L Dias


Abstract We appreciate the opportunity to comment the observations on our paper entitled "Score risk scale as a prognostic factor after sudden sensorineural hearing loss", by Capuano et al. This letter highlights several important points, including the role of hyperbaric oxygen therapy and the possible association between patent foramen ovale and sudden sensorineural hearing loss (SSHL). Further research is needed to strengthen the association between cardiovascular risk and SSHL. We thank the authors for their insights into our paper and for adding their experience and observations on the potential role of cardiovascular risk in the etiology of SSHL.

Acknowledgement to referees 2019

01-03-2020 –

Journal Article

SCORE risk scale as a prognostic factor after sudden sensorineural hearing loss

01-03-2020 – M Cavaliere,P De Luca,A Scarpa,M Ralli,P Bottiglieri,E Cassandro,M Iemma


Abstract Menezes et al. recently published an interesting study on cardiovascular prognostic factors for sudden sensorineural hearing loss (SSNHL), analyzing therapeutic strategies with intravenous and intratympanic corticosteroids and evaluating the application of the Systematic Coronary Risk Evaluation risk scale to classify risk in patients with SSNHL. In addition to intravenous and intratympanic corticosteroids, we would like to stress the role of hyperbaric oxygen therapy (HBOT). The new guidelines on SSNHL and the most recent scientific evidence emphasize the therapeutic role of HBOT. In a previous study, we recommended the use of HBOT in addition to intravenous steroid for patients with idiopathic SSNHL. For the best outcomes, we also recommended starting treatment within 14 days from the onset of SSNHL. In the same article, we discussed potential risk factors for SSNHL. Among cardiovascular risk factors, we suggest the possible association between patent foramen ovale (PFO) and SSNHL. The higher prevalence of PFO in our patients (50%) compared to controls suggests that SSNHL may be attributable to a paradoxical embolism, such as a venous embolism as a result of PFO.

Efficacy of prophylactic central neck dissection in hemithyroidectomy for papillary thyroid carcinoma

01-03-2020 – SH Jin,IS Kim,YB Ji,CM Song,MS Chung,K Tae

Journal Article

Abstract Purpose To evaluate the efficacy of prophylactic central neck dissection (p
CND) in hemithyroidectomy for clinically node-negative papillary thyroid carcinoma (PTC). Methods We retrospectively analyzed 299 patients who underwent thyroid lobectomy with or without p
CND for unilateral PTC. Of the 299 patients, 245 (81.9%) underwent unilateral p
CND along with lobectomy, and 54 (18.1%) patients underwent lobectomy without p
CND. Propensity score matching was performed for five covariates to reduce selection bias. Results In the baseline cohort of 299 patients, mean age, extrathyroidal extension, T classification and stage were higher in the cases undergoing p
CND than in those not undergoing p
CND. After propensity score matching, the significant differences between the two groups seen in the baseline cohort disappeared. Recurrence rates and recurrence-free survival curves did not differ between the 2 matched groups each of 54 patients. Conclusion The value of p
CND in hemithyroidectomy for PTC is limited.

Feasibility of 3D printed salivary duct models for sialendoscopic skills training: preliminary report

01-03-2020 – P Canzi,P Capaccio,S Marconi,G Conte,L Preda,I Avato,F Aprile,M Gaffuri,A Occhini,L Pignataro,F Auricchio,M Benazzo

Journal Article

Abstract Purposes To explore the feasibility of 3D printed salivary duct models for the sialendoscopic skills training. Methods Healthy volunteers and patients affected by obstructive salivary gland disorders were submitted to 3 Tesla MR sialography. The MR data underwent an image segmentation process to produce the 3D printed salivary duct prototypes. Sialendoscopies were carried out by three groups of investigators with different levels of endoscopic experience. Realism, usefulness of the training process and potential advantages of the 3D printed models in the preoperative surgical planning were evaluated by means of a specific survey. Results Four cases were included in our study: one healthy parotid, one submandibular gland, one case of lithiasis and one of stenosis involving the parotid gland. In all cases, the three groups of investigators successfully explored the salivary ducts up to the tertiary branches, detected the cause of obstruction and correctly treated it. Seven untoward events occurred during the operative sialendoscopies. Overall, the questionnaire score was about 79.3%, reflecting a positive impression regarding the models on behalf of all the investigators. Conclusions 3D printed salivary duct models resulted feasible for the sialendoscopic skills training. The opportunity to reproduce the patient-specific anatomy may add further information useful in the preoperative decision making. These positive results should be verified by further researches and experiences.

A tiny retraction of the pars flaccida may conceal an attic cholesteatoma

01-03-2020 – GW Kim,HK Jung,JM Sung,JS Kim,CW Kim

Journal Article

Abstract Objective The purpose of this study was to evaluate the possibility of attic cholesteatomas concealed within a tiny retraction of the pars flaccida (classification of Tos and Poulsen type I or II attic retraction) in patients with an intact pars tensa of the tympanic membrane. Methods The clinical records of patients with a tiny retraction of the pars flaccida and an intact pars tensa of the tympanic membrane who presented to the ear clinic of a tertiary care medical center for the first time between March 2012 and February 2015 were retrospectively reviewed. All patients who had an abnormal pars flaccida of the tympanic membrane were recommended to undergo temporal bone computed tomography (CT) scans. In cases of a soft tissue density lesion within Prussak’s space, an exploratory operation was recommended. Results Among 1320 adult patients, 146 patients (n = 168 ears) who had a tiny attic retraction with a normal pars tensa in unilateral or bilateral ears underwent temporal bone CT scans, and 18 ears had a soft tissue density lesion within Prussak’s space. Among the ears with a tiny retraction of the pars flaccida and a normal pars tensa, an attic cholesteatoma was suspected in 10.7% (n = 18 ears) of cases based on the CT scans. After exploratory operations, 2% of patients who underwent CT scans (3 out of 146 patients) and 23% of patients who had a soft tissue density lesion within Prussak’s space on CT scans (3 out of 13 operations) had an attic cholesteatoma. Conclusion All attic retractions which are even in cases of Tos type I or II should be examined closely using endoscopy, microscopy, and, if necessary, temporal bone CT scan.

Clinical difference between benign and malignant tumors of the hard palate

01-03-2020 – HY Kim,EK Jung,DH Lee,TM Yoon,JK Lee,SC Lim

Journal Article

Abstract Objective To determine the clinical characteristics and treatment results of benign and malignant tumors of the hard palate in our hospital. Patients and methods A total of 25 patients who underwent surgical treatment for hard palate tumors between 2008 and 2018 were included in this study. Their demographic characteristics, smoking status, alcohol consumption, symptoms, duration of symptoms, size and localization of hard palate tumor, status of mucosal surface, radiologic examinations, surgery, reconstruction method, histopathologic results, treatment outcomes, oral intake start time, adjuvant treatment, postoperative complications, and recurrence were reviewed. Results Of the 25 patients with hard palate tumors, 15 (60.0%) had benign tumors and 10 (40.0%) had malignant tumors. Both benign and malignant tumors of the hard palate occurred more frequently in females than in the males. The most common symptom of hard palate tumor was palate mass. The most common benign tumor was pleomorphic adenoma (n = 13). The most common malignant tumors were squamous cell carcinoma and carcinoma ex pleomorphic adenoma (n = 3 for each). All patients were operated via transoral approach without external incision. We did not experience any recurrence in this study. The oral intake start time was late in malignant hard palate tumors (p < 0.05). Conclusion The comparison of clinical features of benign and malignant hard palate tumors showed a statistical significance only for oral intake start time. Transoral surgical removal with clear margin is a safe and effective procedure for benign and malignant hard palate tumors.

Effect of voice therapy with or without transcutaneous electrical stimulation on recovery of injured macroscopically intact recurrent laryngeal nerve after thyroid surgery

01-03-2020 – M Formánek,R Walderová,Š Baníková,I Chmelová,D Formánková,K Zeleník,P Komínek

Journal Article

Abstract Purpose Electrical stimulation-supported therapy is an often used modality. However, it still belongs to experimental methods in the human larynx. Data are lacking with which to evaluate the real effect in recurrent laryngeal nerve injury. The aim of this study was to investigate whether transcutaneous electrical stimulation added to voice therapy has a beneficial effect compared to voice therapy alone on vocal fold movement recovery in the case of an injured macroscopically intact recurrent laryngeal nerve. Methods Adults with unilateral vocal fold paralysis after thyroidectomy, in which the recurrent laryngeal nerve was left macroscopically intact, were included in this case–control study performed in tertiary referral hospital between September 2006 and June 2018. Among 175 eligible participants, 158 were included. Compliance with 6 months follow-up was 94.3%. Interventions: medicament therapy and voice therapy (group 1) vs. medicament therapy and voice therapy and transcutaneous electrical stimulation (group 2). Main outcome: vocal fold movement. Results A total of 149 patients were included in the analysis (group 1, 89 patients; group 2, 60 patients). The groups were homogenous. In groups 1 and 2, 64% and 60% of vocal folds, respectively, were improved after 6 months (P = 0.617). No difference was found between patients who improved and patients who did not improve. Conclusions Adding transcutaneous electrical stimulation to voice therapy provided no beneficial effect on the recovery of vocal fold movement. Therefore, its indications should be re-evaluated; it is questionable whether stimulation should be routinely recommended.

Prognostic factors and risk factors for development and recurrence of sinonasal papillomas: potential role of different HPV subtypes

01-03-2020 – A Pähler Vor der Holte,I Fangk,S Glombitza,L Wilkens,HJ Welkoborsky

Journal Article

Abstract Purpose and methods A retrospective study was conducted to identify and assess potential clinical and molecularbiological risk factors for development and recurrence of sinonasal papillomas (i.e. inverted (IP), fungiform (FP), and oncocytic papillomas (OCP)). Investigated risk factors included age, gender, tumor size and localization, tobacco smoking, regular alcohol consumption, essential hypertension, anticoagulant medication, allergies, surgical approach, and HPV infection. Risk factors were evaluated by regression analysis. Results Apart from age and incomplete tumor resection, the recurrence of Schneiderian papillomas is independent of conventional risk factors. Patients in this study displayed higher HPV infections rates in IP (38.8%) and in FP (100%) than in healthy mucosa, which is reported 0–5.8% in Germany and central Europe. The proportion of HPV-positive IP decreased with advanced tumor stages: 100% HPV positivity of T1 IP (2/2), 40.9% of T2 IP (9/22), and 35.7% of T3 IP (20/56). Most commonly detected HPV types were HPV 6, 11, and 16; however, patients in this study also displayed HPV types that have rarely or not at all been described in sinonasal papillomas before, such as HPV 58, 42, 83, and 91. Recurrent sinonasal papillomas displayed higher rates of HPV infections than non-recurrent tumors. Conclusions Young age at initial diagnosis and incomplete tumor resection are risk factors for recurrence of sinonasal papillomas. Our data suggest that HPV infection supports development and/or perpetuation of sinonasal papillomas. Additionally, sinonasal papillomas seem to display a unique subset of HPV genotypes, including genotypes that have not often been described before.

Video head impulse test and caloric test in definite Ménière’s disease

01-03-2020 – S Limviriyakul,C Luangsawang,K Suvansit,S Prakairungthong,K Thongyai,S Atipas

Journal Article

Abstract Purpose The objective of the study was to compare the results of caloric reflex tests and video head impulse tests (v
HITs) of lateral semicircular canals (SCCs). Methods Patients aged over 18 years diagnosed with definite Ménière’s disease (MD) according to the AAO–HNS 1995 criteria were recruited. Audiological tests, caloric tests and v
HITs were conducted on all participants. A caloric weakness (canal paresis) of > 25% was considered significant. A VOR gain of < 0.8 in lateral or 0.7 in vertical SCCs was defined as significant. Patients were classified into active (having symptoms during the preceding 3 months) and inactive groups (free of symptoms for over 3 months). Results 51 patients (13 males and 38 females) participated. Caloric weakness was found in 39 patients (76.5%), while abnormal VOR gain was found in 24 (47.1%). The active group had 40 patients, and the inactive group had 11. There was statistical significance (p, 0.002) for disease duration but not for the caloric weakness and v
HIT results of the two groups. Moreover, caloric weakness with an abnormal v
HIT was not statistically significant, and there was no correlation between the two tests (r, 0.207) in lateral SCCs. The most common abnormal VOR gain in patients with caloric weakness was found in anterior SCCs. Conclusions The caloric test can detect abnormalities of the vestibular function better than v
HIT in all stages of MD. However, the v
HIT showed more specificity for the detection of abnormal SCC function. The v
HIT test can be used as a screening tool and the caloric test should be considered if a v
HIT result is normal.

Primary hyperparathyroid surgery under local anaesthesia: benefits of hypnosis

01-03-2020 – AS Touzé,E Fournier,M Laffon,S Morinière

Journal Article

Abstract Purpose Minimally invasive parathyroid surgery and hypnosis are both increasing in prevalence. The objective of this study was to evaluate the efficacy of hypnoanalgesia compared with sedation during primary hyperparathyroid surgery under local anaesthesia. Methods All patients who underwent primary hyperparathyroid surgery under local anaesthesia in our department between January 2013 and April 2018 were included retrospectively in two groups: patients operated under hypnoanalgesia (HYP group), and patients operated under sedation (LA group). The evaluation criteria were postoperative pain and analgesic consumption, amount of perioperative anti-emetics required, and length of hospital stay. Results Thirty-six patients were included, 19 in the HYP group and 17 in the LA group. Postoperative pain levels and analgesic consumption rates were lower in the HYP group (numeric scale = 0.5/10 vs. 2.7/10, p = 0.0001; 11% vs. 47%, p = 4.9 × 10−8). Intraoperative anti-emetics delivery was lower in the HYP group (5% vs. 35%, p = 2.9 × 10−7). The ambulatory care rate was higher in the HYP group (74% vs. 59%, p = 0.03). Conclusion Local anaesthesia with hypnoanalgesia, compared with sedation during minimally invasive parathyroid surgery, improved early postoperative outcomes, making outpatient management more efficient.

Deep neck space infections: an upward trend and changing characteristics

01-03-2020 – J Velhonoja,M Lääveri,T Soukka,H Irjala,I Kinnunen

Journal Article

Abstract Purpose This study reviews our experience with deep neck space infections (DNIs) requiring surgical intervention, including cervical necrotizing fasciitis. The aim of the study was to identify predisposing and aggravating factors of the disease and recognize the possible factors that can lead to life-threatening complications and slow down the healing process. Methods We compare the results to previous data from 1985 to 2005 to find possible alterations and changing trends. The characteristics of four lethal cases are described. This retrospective analysis includes patient data from 2004 to 2015 in tertiary referral hospital and in total, 277 patients were found. Results Surgical drainage through a neck opening ± intraoral incision was made in 215 (77.6%) patients, an intraoral incision was only made in 62 patients (22.4%). ICU care was needed in 66 (23.8%) cases. Odontogenic etiology (44.8%) was the most common origin. The most common comorbidity was a psychiatric disorder and/or dementia and occurred in 55 (19.9%) patients. Patients with underlying illnesses were more likely to be admitted to the ICU (p = 0.020), required a longer ICU stay (p = 0.004) and repeated surgery (p = 0.009). Gas formation seemed to be predictive of a more severe course of infection. Early extraction of the odontogenic foci was related to a lower length of stay (LOS) (p = 0.039). Conclusion The annual numbers have risen from 14 to 24 cases per year when compared to previous data. DNIs remain a cause of lethal complications; the mortality was 1.4% and overall complications occurred in 61 (22.0%) patients.

Endoscopic transnasal transmaxillary approach to the upper parapharyngeal space and the skull base

01-03-2020 – Q Liu,H Wang,W Zhao,X Song,X Sun,H Yu,D Wang,JC Fernandez-Miranda,CH Snyderman

Journal Article

Abstract Purpose Treatment of tumors arising in the upper parapharyngeal space (PPS) or the floor of the middle cranial fossa is challenging. This study aims to present anatomical landmarks for a combined endoscopic transnasal and anterior transmaxillary approach to the upper PPS and the floor of the middle cranial fossa and to further evaluate their clinical application. Methods Dissection of the upper PPS using a combined endoscopic endonasal transpterygoid and anterior transmaxillary approach was performed in six cadaveric heads. Surgical landmarks associated with the approach were defined. The defined approach was applied in patients with tumors involving the upper PPS. Results The medial pterygoid muscle, tensor veli palatini muscle and levator veli palatini muscle were key landmarks of the approach into the upper PPS. The lateral pterygoid plate, foramen ovale and mandibular nerve were important anatomical landmarks for exposing the parapharyngeal segment of the internal carotid artery through a combined endoscopic transnasal and anterior transmaxillary approach. The combined approach provided a better view of the upper PPS and middle skull base, allowing for effective bimanual techniques and bleeding control. Application of the anterior transmaxillary approach also provided a better view of the inferior limits of the upper PPS and facilitated control of the internal carotid artery. Conclusions Improving the knowledge of the endoscopic anatomy of the upper PPS allowed us to achieve an optimal approach to tumors arising in the upper PPS. The combined endoscopic transnasal and anterior transmaxillary approach is a minimally invasive alternative approach to the upper PPS.

Prognostic value of the posterior cricoarytenoid muscle atrophy in computerized tomography scans for unilateral vocal fold paralysis recovery

01-03-2020 – DY Lee,D Kogay,S Song,YJ Shim,BH Kim,YJ Jin,SD Kim,Y Kim,EJ Chung,TK Kwon

Journal Article

Abstract Objectives To evaluate the prognostic value of the posterior cricoarytenoid (PCA) muscle atrophy observed on neck computed tomography (CT) in patients with unilateral vocal fold paralysis. Methods CT images of 87 subjects with unilateral vocal fold paralysis (UVFP) were evaluated to analyze the PCA muscle atrophy and to measure the severity of the PCA muscle atrophy in semi-quantitative manner. The grading of the PCA muscle atrophy was compared with the recruitment pattern of laryngeal electromyography (LEMG) and restoration of vocal fold movement. Results The PCA muscle was identifiable on CT in 73 subjects. Using the PCA muscle atrophy as an indicator of UVFP, we correctly predicted the paralysis in 69 (94.5%). Grade of the PCA muscle atrophy is significantly correlated with recruitment pattern of LEMG. If the positive result is defined as the PCA muscle showed moderate to severe degree of atrophy, we could predict the persistent UVFP in 88% of patients. Conclusions PCA muscle atrophy identified on CT scan in patients with UVFP, is associated with low rates of return of mobility in the affected vocal fold.

Fine needle aspiration cytology for parotid neoplasms: risk of malignancy through inconclusive results and lower grade tumors

01-03-2020 – A Galli,M Tulli,L Giordano,M Biafora,D Di Santo,S Bondi,LO Piccioni,M Bussi

Journal Article

Abstract Purpose Fine needle aspiration cytology (FNAC) is a commonly performed procedure for parotid masses, although its accuracy in detecting malignancies widely varies through different series. We evaluated our single-center cohort of parotidectomies to highlight possible limitations of preoperative FNAC. Methods Seven hundred and eighteen consecutive patients submitted to parotid surgery at San Raffaele Scientific Institute (Milan) were retrospectively evaluated (2002–2018). Five hundred and fifty four FNAC were analyzed. FNAC accuracy was assessed with and without inclusion of “inconclusive” results. The peculiar role of lower grade primary parotid cancers was investigated. Results FNAC reports were “diagnostic” in 502 cases (90.4%) and “inconclusive” in 52 (9.6%). Histopathology revealed 488 benign lesions (88.1%) and 66 malignancies (11.9%). FNAC sensitivity, specificity, PPV, NPV and accuracy in detecting malignancies were 59%, 99%, 89%, 95%, and 95%, respectively. Sensitivity fell to 48%, when “inconclusive” FNAC was computed. Within 66 parotid cancers, FNAC could discriminate malignancy in 32 cases (48.5%), provide proper grading in 21 (31.8%), and precise histopathological diagnosis in 15 (22.7%). Malignancy was more likely in patients with “inconclusive” FNAC than in those with “diagnostic” cytologies (23.1% vs 10.8%, p = 0.003). Low-intermediate-grade primary parotid cancers were associated to a higher rate of FNAC failure in comparison with high-grade ones (86.4% vs 19.0%; p < 0.001). Conclusion FNAC is an important tool for preoperative assessment of parotid masses, though its sensitivity in detecting malignancy remains poor. “Inconclusive” FNAC results could further jeopardize FNAC accuracy and should elicit resorting to additional tests, especially when a lower grade parotid cancer is suspected.

Clinicopathologic characteristics of paranasal sinus fungus ball: retrospective, multicenter study in Korea

01-03-2020 – DW Kim,YM Kim,JY Min,JW Kim,JK Kim,JH Mo,JM Shin,KS Cho,SG Kwak,SH Shin

Journal Article

Abstract Purpose Fungus ball (FB) is the most common type of fungal rhinosinusitis and the prevalence of FB has increased over the past 10 years. The aim of this study was to compare the clinical characteristics of Korean adult patients with FB and chronic rhinosinusitis (CRS) without FB. Methods We retrospectively analyzed data on 1362 patients (147 FB and 1215 CRS) who underwent endoscopic sinus surgery at nine Korean medical centers in 2005, 2010, and 2016. We evaluated the prevalence of FB and compared the clinical characteristics of FB and CRS. Medical records, computed tomography (CT) findings, atopic status, concomitant diseases, tissue, and blood eosinophil count were assessed. Results The prevalence of FB was significantly higher in 2016 (15.9%) than in the other years (7.8% in 2005 and 7.5% in 2010). The FB patients were more likely to be female, older, have unilateral disease and less likely to have allergy compared to the CRS patients. The most common main complaint related to CRS and FB was nasal obstruction. CT determined that unilateral disease and maxillary sinus dominancy were common in patients with FB. The incidence of concomitant diseases was much higher in FB, with lower tissue and blood eosinophilia. Conclusion FB is commonly encountered in older women with the increased prevalence. FB had a different clinical presentation, radiological findings, and prognosis than CRS. Further studies are needed to understand the pathophysiologic mechanisms underlying the development of FB.

Immunohistochemical expression of TFIIH and XPF in oral tongue squamous cell carcinoma

01-03-2020 – MC Sá,TS Conceição,E de Moura Santos,EF de Morais,HC Galvão,R de Almeida Freitas

Journal Article

Abstract Purpose The query for biomarkers that indicate tumor aggressiveness and the host’s response to treatment is still one of the leading aims of cancer research. To investigate a possible role for DNA nucleotide repair proteins in oral cancer behavior, this study evaluated the immunoexpression of the proteins TFIIH and XPF and its association with clinical, histological, and survival parameters in oral tongue squamous-cell carcinoma (OTSCC). Methods TFIIH and XPF immunoexpressions were evaluated in 82 cases of oral tongue squamous-cell carcinoma. Tumor budding and depth of invasion were assessed for histopathological grading (BD model). Results Tumor cells exhibited high expression of TFIIH and XPF, which was associated to nodal status; both proteins were not associated with other clinical parameters, histopathological grading or survival. Tumor size, nodal status, tumor staging, and depth of invasion > 4 mm were significantly associated to disease-specific survival. Conclusions We have demonstrated that the overexpression of TFIIH correlates positively with node metastasis, while XPF correlates negatively with node metastasis; therefore, the expression of XPF and TFIIH had a potential value for predicting the progression of OTSCC patients.

Distinct features of malignant carotid body tumors and surgical techniques for challengeable lesions: a case series of 11 patients

01-03-2020 – G Gu,Y Wang,B Liu,Y Chen,J Shao,F Li,X Wu,L Cui,X Lu,C Liu,H Guan,Z Gao,G Feng,Y Zheng

Journal Article

Abstract Purpose Malignant carotid body tumor (CBT) is a rare disorder with poor prognosis. In this article, we presented the clinical features and surgical management of malignant CBTs at our department, aiming to improve the outcome for treating such lesions. Methods A retrospective analysis (2005–2018) of CBT excisions at our institution was performed. About 195 patients with CBTs were identified, among which 11 patients with eleven malignant CBTs were identified and carefully reviewed. Data obtained included demographics, radiological details, intra-operative details, post-operative morbidity, and long-term outcomes. Results Compared with benign CBTs, malignant CBTs have more advanced Shamblin classification (p < 0.001) and larger tumor size (4.5 ± 2.1 cm vs. 6.7 ± 2.6 cm, p = 0.003). Among the 11 malignant cases, 9 patients underwent surgical resection and 8 cases (8/9, 89%) underwent internal carotid artery (ICA) reconstruction. Intra-operative findings showed that malignant CBTs revealed more severe arterial and nerve adhesions. With the use of specific techniques including pre-reconstruction technique and carotid shunt, all surgeries were successful and no deaths or major complications including stroke or hemiplegia occurred perioperatively and during the follow-up. During the follow-up period (41.6 ± 44.5 months), two patients developed distant metastasis at 7 and 11 years post-operatively. The 5-year and 10-year distant metastasis-free survival rates were 72.7% and 36.4%, respectively. Conclusions With more advanced Shamblin classification and larger tumor size, malignant CBTs remain challengeable for surgery due to severe intra-operative hemorrhage, need of vascular reconstruction and cervical nerve injury. Specific surgical techniques including pre-reconstruction technique and carotid shunt are safe and effective to improve the outcome.