Surgery for Pituitary Tumor Apoplexy Is Associated with Rapid Headache and Cranial Nerve Improvement.

Pituitary tumor apoplexy (PTA) classically comprises sudden-onset headache, loss of vision, ophthalmoparesis, and decreased consciousness. It typically results from hemorrhage and/or infarction within a pituitary adenoma. Presentation is heterologous, and optimal management is debated. The time course of recovery of cranial nerve deficits (CNDs) and headaches is not well established. In this study, a retrospective series of consecutive patients with PTA managed at a single academic institution over a 22-year period is presented. Headaches at the time of surgery were more severe in the early and subacute surgical cohort and improved significantly within 72 h postoperatively (p < 0.01). At one year, 90% of CNDs affecting cranial nerves (CNs) 3, 4, and 6 had recovered, with no differences between early (<4 d), subacute (4−14 d), and delayed (>14 d) time-to-surgery cohorts. Remarkably, half recovered within three days. In total, 56% of CN2 deficits recovered, with the early surgery cohort including more severe deficits and recovering at a lower rate (p = 0.01). No correlation of time-to-surgery and rapidity of recovery of CNDs was observed (p = 0.65, 0.72). Surgery for PTA is associated with rapid recovery of CNDs in the early, subacute, and delayed time frames, and with rapid headache improvement in the early and subacute time frames in 50% or more of patients.

The Impact of Age on Noise Sensitivity in Cochlear Implant Recipients.

OBJECTIVE: To evaluate the impact of different open set sentence recognition tests in quiet, +10 dB signal to noise ratio (SNR), and +5 dB SNR in adult cochlear implant (CI) recipients above and below 65 years of age. STUDY DESIGN AND SETTING: Multi-institution, prospective, non-randomized, single-subject repeated measures design. PATIENTS: Ninety six adults more than or equal to 18 years old with postlingual bilateral sensorineural hearing loss. INTERVENTIONS: Participants received a CI532 in one ear. Speech perception measures were evaluated before and 6-months after activation. MAIN OUTCOME MEASURES: Subjects completed consonant-nucleus-constant (CNC) words in quiet and AzBio sentences in noise using +10 and +5 dB SNR, and Montreal Cognitive Assessment (MOCA). RESULTS: Ninety six adult patients were enrolled (n = 70 older [≥65 yr], n = 26 younger [<65 yr]). There was no difference in CNC scores (CI alone 58.4% versus 67.5%, p = 0.0857; best aided 66.7% versus 76.1%, p = 0.3357). Older adults performed worse on AzBio +10 dB SNR compared with younger patients (CI alone 37.4% versus 56.9%, p = 0.0006; best aided 51.4% versus 68.2%; p = 0.01), and in AzBio +5 dB SNR (CI alone 7.7% versus 11.2%, p = 0.0002; best aided 15.3% versus 22.3%, p = 0.0005). The magnitude of change in AzBio +10 dB SNR was significantly less in older adults in CI alone (15.3% versus 22.3%; p = 0.0493) but not best aided (21.5% versus 31.3%; p = 0.105). The magnitude of change was drastically worse in AzBio +5 dB SNR for older adults (CI alone 6.7% versus 22.1%, p = 0.0014; best aided 9.5% versus 21.5%; p = 0.0142). There was no significant difference in MOCA between the two age groups. CONCLUSIONS: While both older and younger patients have similar outcomes with respect to CNC word scores in quiet, the addition of noise disproportionally impacts older patients. Caution should be exercised testing the elderly in noise; testing in noise may disproportionally impact performance expectations and should be more carefully considered when used for candidacy criteria and counseling. Future studies need to further investigate the disproportionate effect of noise on candidacy testing and its impact on how elderly patients are qualified.

Long-term Hearing Preservation and Speech Perception Performance Outcomes With the Slim Modiolar Electrode.

OBJECTIVE: Describe audiologic outcomes in hearing preservation (HP) cochlear implant candidates using a slim modiolar electrode (SME). STUDY DESIGN: Retrospective. SETTING: Tertiary referral center. PATIENTS: Two hundred three adult cochlear implant patients with preoperative low-frequency pure-tone average (LFPTA) ≤ 80 dB HL that received the SME. INTERVENTION: Implantation with a SME electrode. MAIN OUTCOME MEASURES: Primary outcome was postoperative HP, defined as LFPTA ≤80 dB HL. HP status was analyzed at "early" (activation or 3 mo) and "long-term" (6 or 12 mo) time frames using the patient's worst audiogram. Speech perception tests were compared between HP and non-HP cohorts. RESULTS: Of the 203 HP candidates, the tip fold-over rate was 7.4%. The mean shifts in LFPTA at the "early" and "long-term" time points were 25.9 ±â€Š16.2 dB HL and 29.6 ±â€Š16.9 dB HL, respectively. Of 117 patients with preoperative LFPTA ≤60 dB HL, the early and long-term mean LFPTA shifts were 19.5 ±â€Š12.3 dB HL and 32.6 ±â€Š17.2 dB HL, respectively; early and long-term HP rates were 61.1% and 50.8%, respectively. For patients with preoperative LFPTA ≤80 dB HL, early and long-term HP rates were 45.5% and 43.7%, respectively. No significant difference was observed in postoperative speech perception performance (CNC, AzBio, HINT) at 3, 6, or 12 months between HP versus non-HP groups. CONCLUSIONS: HP is feasible using the SME. While electroacoustic stimulation was not studied in this cohort, HP provided no clear advantage in speech perception abilities in this group of patients. The current reporting standard of what constitutes HP candidacy (preoperative LFPTA ≤80 dB HL) should be reconsidered.

Handheld Briefcase Optical Coherence Tomography with Real-Time Machine Learning Classifier for Middle Ear Infections.

A middle ear infection is a prevalent inflammatory disease most common in the pediatric population, and its financial burden remains substantial. Current diagnostic methods are highly subjective, relying on visual cues gathered by an otoscope. To address this shortcoming, optical coherence tomography (OCT) has been integrated into a handheld imaging probe. This system can non-invasively and quantitatively assess middle ear effusions and identify the presence of bacterial biofilms in the middle ear cavity during ear infections. Furthermore, the complete OCT system is housed in a standard briefcase to maximize its portability as a diagnostic device. Nonetheless, interpreting OCT images of the middle ear more often requires expertise in OCT as well as middle ear infections, making it difficult for an untrained user to operate the system as an accurate stand-alone diagnostic tool in clinical settings. Here, we present a briefcase OCT system implemented with a real-time machine learning platform for middle ear infections. A random forest-based classifier can categorize images based on the presence of middle ear effusions and biofilms. This study demonstrates that our briefcase OCT system coupled with machine learning can provide user-invariant classification results of middle ear conditions, which may greatly improve the utility of this technology for the diagnosis and management of middle ear infections.

Cochlear Implant Outcomes Following Vestibular Schwannoma Resection: Systematic Review.

OBJECTIVE: Hearing loss remains a significant morbidity for patients with vestibular schwannomas (VS). A growing number of reports suggest audibility with cochlear implantation following VS resection; however, there is little consensus on preferred timing and cochlear implant (CI) performance. DATA SOURCES: A systematic literature search of the Ovid Medline, Embase, Scopus, and clinicaltrails.gov databases was performed on 9/7/2018. PRISMA reporting guidelines were followed. STUDY SELECTION: Included studies reported CI outcomes in an ear that underwent a VS resection. Untreated VSs, radiated VSs, and CIs in the contralateral ear were excluded. DATA EXTRACTION: Primary outcomes were daily CI use and attainment of open-set speech. Baseline tumor and patient characteristics were recorded. Subjects were divided into two groups: simultaneous CI placement with VS resection (Group 1) versus delayed CI placement after VS resection (Group 2). DATA SYNTHESIS: Twenty-nine articles with 93 patients met inclusion criteria. Most studies were poor quality due to their small, retrospective design. Group 1 had 46 patients, of whom 80.4% used their CI on a daily basis and 50.0% achieved open-set speech. Group 2 had 47 patients, of whom 87.2% used their CI on a daily basis and 59.6% achieved open-set speech. Group 2 had more NF2 patients and larger tumors. CI timing did not significantly impact outcomes. CONCLUSIONS: Audibility with CI after VS resection is feasible. Timing of CI placement (simultaneous versus delayed) did not significantly affect performance. Overall, 83.9% used their CI on a daily basis and 54.8% achieved open-set speech.

Hearing and Quality-of-Life Outcomes After Cochlear Implantation in Adult Hearing Aid Users 65 Years or Older: A Secondary Analysis of a Nonrandomized Clinical Trial.

Importance: Hearing loss, especially moderate to severe forms, has the potential to negatively affect an individual's physical, social, emotional, and cognitive well-being. Moreover, having ineffective binaural hearing increases difficulty understanding speech in noise and leads to a greater degree of social isolation and loneliness and a reduced quality of life (QoL). Objective: To explore the audiometric and holistic effects of cochlear implantation in a group of adults 65 years or older compared with an optimized bilateral hearing aid condition. Design, Setting, and Participants: This ad hoc secondary analysis of a prospective, single-subject, repeated-measures nonrandomized clinical trial included 13 cochlear implantation centers across the United States. Participants 65 years or older with postlingual bilateral moderate-to-profound sensorineural hearing loss with aided Consonant-Vowel Nucleus-Consonant (CNC) word scores in quiet of 40% or less in the ear to undergo implantation and 50% or less in the contralateral ear were included in the analysis. Baseline QoL testing was performed after 1 month of optimized bilateral hearing aid use. Participants were enrolled from February 20, 2017, to May 3, 2018, and follow-up was completed December 21, 2018. Data were analyzed from March 25, 2019, to March 31, 2020. Interventions: Unilateral implantation with a slim, modiolar cochlear implant device. Hearing aid use in the contralateral ear was required through the 6-month primary end-point interval. Main Outcomes and Measures: The primary objective was to evaluate speech perception before and 6 months after activation of a new cochlear implant. Secondary objectives were QoL metrics in the everyday listening condition before and 6 months after implantation. Results: Seventy participants (51 men [73%]) with a median age of 74 (range, 65-91) years were included in the analysis. No major adverse events occurred. Mixed-model analysis with estimated marginal means and 95% CIs compared preimplantation baseline performance with 6-month postimplantation performance. A clinically important improvement in CNC words was shown in the bimodal condition, with a mean difference of 37.2% (95% CI, 32.0%-42.4%), and in the unilateral (cochlear implant only) condition, with a mean difference of 44.1% (95% CI, 39.0%-49.2%). A clinically important improvement in noise (AzBio sentences signal-to-noise ratio of +10 dB) was also shown, with a mean difference of 21.6% (95% CI, 15.7%-27.5%) in the bimodal condition and 24.5% (95% CI, 18.3%-30.7%) in the unilateral condition. The Health Utilities Index Mark 3 multiple-attribute score improved by 0.186 (95% CI, 0.136-0.234); the Speech, Spatial, and Qualities of Hearing Scale total score improved by 2.58 (95% CI, 2.18-2.99); and a novel Device Use Questionnaire reported 94% of participants were satisfied with overall hearing in the everyday listening condition. Conclusions and Relevance: This subgroup analysis of patients 65 years or older enrolled in a within-subject clinical trial of cochlear implantation demonstrated clinically meaningful audiometric and QoL benefit with an acceptable risk profile. These findings suggest that cochlear implantation in older adults may facilitate the concept of healthy aging. Trial Registration: ClinicalTrials.gov Identifier: NCT03007472.

Assessment of Speech Understanding After Cochlear Implantation in Adult Hearing Aid Users: A Nonrandomized Controlled Trial.

Importance: Cochlear implants were approved for use in adults in the 1980s, but use remains low owing to a lack of awareness regarding cochlear implantation candidacy criteria and expected outcomes. There have been limited, small series examining the safety and effectiveness of cochlear implantation in adult hearing aid (HA) users with and without mild cognitive impairment (MCI). Objective: To investigate the safety and effectiveness of a single-ear cochlear implant in a group of optimized adult HA users with and without MCI across a variety of domains. Design, Setting, and Participants: In this nonrandomized controlled trial, a multicenter, prospective, repeated-measures investigation was conducted at 13 US institutions. The setting was academic and community-based cochlear implant programs. Eligible participants were 100 adults (aged >18 years) with postlinguistic onset of bilateral moderate sloping to profound or worse sensorineural hearing loss (≤20 years' duration). Fluent English speakers underwent an optimized bilateral HA trial for at least 30 days. Individuals with aided Consonant-Vowel Nucleus-Consonant (CNC) word score in quiet of 40% or less correct in the ear to be implanted and 50% or less correct in the contralateral ear were offered cochlear implants. The first participant was enrolled on February 20, 2017, and the last participant was enrolled on May 3, 2018. The final follow-up was on December 21, 2018. Interventions: Participants received the same cochlear implant system and contralateral HA. Main Outcomes and Measures: The primary outcome measure was speech understanding in quiet (CNC word score) using both the cochlear implant and opposite ear HA. Secondary outcome measures included the following: adverse events; speech understanding in noise (AzBio signal-to-noise ratio of +10 db [+10 SNR]) Health Utilities Index Mark 3 (HUI3); Speech, Spatial, and Qualities of Hearing Questionnaire 49 (SSQ49); and Montreal Cognitive Assessment (MoCA). Results: The median age at cochlear implantation of the 96 patients included in the trial was 71 years (range, 23-91 years), and 62 patients (65%) were male. Three serious adverse events requiring revision surgery occurred, and all resolved without sequelae. By 6 months after activation, the absolute marginal mean change in CNC word score and AzBio +10 SNR was 40.5% (95% CI, 35.9%-45.0%) and 24.1% (95% CI, 18.9%-29.4%), respectively. Ninety-one percent (87 of 96) of participants had a clinically important improvement (>15%) in the CNC word score in the implant ear. Mild cognitive impairment (MoCA total score ≤25) was observed in 48 of 81 study participants (59%) at baseline. Speech perception marginal mean improvements were similar between individuals with and without baseline MCI, with values of 40.9% (95% CI, 35.2%-46.6%) and 39.6% (95% CI, 31.8%-47.4%), respectively, for CNC word score and 27.5% (95% CI, 21.0%-33.9%) and 17.8% (95% CI, 9.0%-26.6%), respectively, for AzBio +10 SNR. Statistically significant and clinically important improvements in the HUI3 and SSQ49 were evident at 6 months. Conclusions and Relevance: The findings of this nonrandomized controlled trial seem to indicate that cochlear implants are safe and effective in restoring speech understanding in both quiet and noise and improve quality of life in individuals with and without MCI. Trial Registration: ClinicalTrials.gov Identifier: NCT03007472.

Axis-specific analysis and predictors of endocrine recovery and deficits for non-functioning pituitary adenomas undergoing endoscopic transsphenoidal surgery.

PURPOSE: Endoscopic transsphenoidal surgery (ETSS) is a well-established treatment for patients with nonfunctioning pituitary adenomas (NFPAs). Data on the rates of pituitary dysfunction and recovery in a large cohort of NFPA patients undergoing ETSS and the predictors of endocrine function before and after ETSS are scarce. This study is purposed to analyze the comprehensive changes in hormonal function and identify factors that predict recovery or worsening of hormonal axes following ETSS for NFPA. METHODS: A retrospective review of 601 consecutive patients who underwent ETSS between 2010 and 2018 at one institution was performed. Recovery or development of new hypopituitarism was analyzed in 209 NFPA patients who underwent ETSS. RESULTS: Patients with preoperative endocrine deficits (59.8%) in one or more pituitary axes had larger tumor volumes (P = 0.001) than those without preoperative deficits. Recovery of preoperative pituitary deficit occurred in all four axes, with overall mean recovery of 29.7%. The cortisol axis showed the highest recovery whereas the thyroid axis showed the lowest, with 1-year cumulative recovery rates of 44.3% and 6.1%, respectively. Postoperative hypopituitarism occurred overall in 17.2%, most frequently in the thyroid axis (24.3%, 27/111) and least frequently in the cortisol axis (9.7%, 16/165). Axis-specific predictors of post-operative recovery and deficiency were identified. CONCLUSIONS: Dynamic alterations in pituitary hormones were observed in a proportion of patients following ETSS in NFPA patients. Postoperative endocrine vulnerability, recovery, and factors that predicted recovery or loss of endocrine function depended on the hormonal system, necessitating an axis-specific surveillance strategy postoperatively.

Immediate and 1-Year Outcomes with a Slim Modiolar Cochlear Implant Electrode Array.

OBJECTIVE: To explore the immediate and 1-year outcomes of patients who underwent implantation with the slim modiolar electrode (SME). STUDY DESIGN: Consecutive case series with chart review. SETTING: Tertiary referral academic center. SUBJECT AND METHODS: Between May 2016 and August 2018, a total of 326 cochlear implantations (CIs) were performed. Intraoperative x-rays were performed in all cases to identify tip rollovers. Scalar location was identified for 76 CIs that had postoperative computed tomography reconstructions. Speech outcomes were measured at 3, 6, and 12 months with consonant-nucleus-consonant word and AzBio sentences in quiet and noise (+10-dB signal-to-noise ratio). Preservation of hearing was defined as maintaining a low-frequency pure tone average ≤80 dB at 250 and 500 Hz. RESULTS: Among 326 CIs, 23 (7%) had tip rollovers. Postoperative reconstructions revealed 5 of 76 (6.6%) scalar translocations. A subset of 177 cases met criteria for evaluation of speech perception scores. The marginal mean differences between presurgery and 12 months for speech tests were as follows: consonant-nucleus-consonant, 43.7 (95% CI, 39.8-47.6); AzBio in quiet, 49.7 (95% CI, 44.9-54.4); and AzBio in noise, 29.9 (95% CI, 25.2-34.7). Sixty-one patients were identified with preservable hearing (low-frequency pure tone average ≤80 dB), and 12 of 61 (20%) preserved hearing at 1 year. CONCLUSION: CI with SME provides reliable scala tympani insertion in a consistent perimodiolar position. An initially increased tip rollover rate improved with case volume and sheath design improvement. For long-term outcomes, speech performance was comparable to that of other cochlear implants. While hearing preservation for the SME may be better than prior perimodiolar electrodes, consistent outcomes are unlikely.

Development of a Mixed Reality Platform for Lateral Skull Base Anatomy.

OBJECTIVES: A mixed reality (MR) headset that enables three-dimensional (3D) visualization of interactive holograms anchored to specific points in physical space was developed for use with lateral skull base anatomy. The objectives of this study are to: 1) develop an augmented reality platform using the headset for visualization of temporal bone structures, and 2) measure the accuracy of the platform as an image guidance system. METHODS: A combination of semiautomatic and manual segmentation was used to generate 3D reconstructions of soft tissue and bony anatomy of cadaver heads and temporal bones from 2D computed tomography images. A Mixed-Reality platform was developed using C# programming to generate interactive 3D holograms that could be displayed in the HoloLens headset. Accuracy of visual surface registration was determined by target registration error between seven predefined points on a 3D holographic skull and 3D printed model. RESULTS: Interactive 3D holograms of soft tissue, bony anatomy, and internal ear structures of cadaveric models were generated and visualized in the MR headset. Software user interface was developed to allow for user control of the virtual images through gaze, voice, and gesture commands. Visual surface point matching registration was used to align and anchor holograms to physical objects. The average target registration error of our system was 5.76 mm ±â€Š0.54. CONCLUSION: In this article, we demonstrate that an MR headset can be applied to display interactive 3D anatomic structures of the temporal bone that can be overlaid on physical models. This technology has the potential to be used as an image guidance tool during anatomic dissection and lateral skull base surgery.

Early Outcomes With a Slim, Modiolar Cochlear Implant Electrode Array.

OBJECTIVE: To describe outcomes from cochlear implantation with a new, slim modiolar electrode array. STUDY DESIGN: Retrospective cohort study. SETTING: Tertiary referral centers. PATIENTS: Adult cochlear implant candidates. INTERVENTIONS: Cochlear implantation with CI532 (Cochlear Corp). MAIN OUTCOME MEASURES: Pre- and postoperative speech perception scores, operative details, and postoperative computed tomography (CT) reconstructions of array location. RESULTS: One hundred seventeen patients are implanted to date. There were eight tip rollovers identified with intraoperative x-ray and resolved with reinsertion. An additional rollover was identified on postoperative CT. CT reconstructions in 17 of 23 patients showed complete scala tympani placement with a wrap factor of 58% (range 53-64%) and a mean insertion angle of 406 degrees (range 360-452 degrees). Three implants demonstrated array translocation with electrodes in the scala vestibuli. Consonant-nucleus-consonant word scores improved from 10% preoperatively to 48% at 3 months postoperatively. Pure-tone thresholds were preserved postoperatively in 37 to 52% of patients across frequencies from 250 to 4000 Hz. Functional pure-tone thresholds (≤80 dB) were recorded in 9 to 25% of patients. CONCLUSION: CI532 array insertion results in consistent scala tympani location and provides expected audiologic performance. Initial hearing preservation results are not consistent with current electro-acoustic arrays.

Skew Deviation and Partial Ocular Tilt Reaction Due to Intratympanic Gentamicin Injection, with Review of the Literature.

Skew deviation is a rare side effect of intratympanic gentamicin injection for intractable Meniere's disease. When the skew deviation is accompanied by pathologic head tilt and ocular torsion, the result is an ocular tilt reaction (OTR). The authors report the case of a 56-year-old man with refractory Meniere's disease who developed binocular vertical diplopia following intratympanic gentamicin injection and was found to have skew deviation and a partial ocular tilt reaction. The authors also review the reported cases of skew deviation following intratympanic gentamicin and confirm this phenomenon, which has only rarely been reported in the literature.

Primary melanoma of the petrous temporal bone.

Melanoma is a malignant tumor of melanocytes that is predominantly found in the skin. In rare cases, it arises from mucosal melanocytes. We describe a case of a solitary melanoma of the petrous apex of the temporal bone in a 67-year-old woman who presented with sudden hearing loss, aural fullness, and headaches, all on the right side. Magnetic resonance imaging identified a mass located at the right petrous apex; the lesion was hyperintense on T1-weighted imaging and isointense on T2 weighting, and it enhanced brightly with gadolinium contrast. The patient underwent removal of the lesion via a transcochlear approach with facial nerve translocation. Intra- and postoperative pathology identified a poorly differentiated malignancy consistent with a melanoma. Further investigations found no evidence of metastasis. Given a concern for residual disease, the patient was treated with radiation to the primary site. To the best of our knowledge, only 1 other case of primary melanoma of the petrous apex has been described in the literature.

The use of extemporaneously compounded 1% tetracaine to improve adherence with clotrimazole 1% topical solution in the treatment of ear infection: a case report.

For most medically amenable conditions, adherence to drug therapy is a necessary condition for a successful outcome. Drug side effects, especially pain, can interfere with the desired outcome. We report a case of non-adherence due to severe pain associated with the topical use of clotrimazole 1% solution in the ear. Instillation of tetracaine 1% solution prior to the administration of the clotrimazole blocked the pain sensation allowing the patient to successfully complete the antifungal therapy.

Complications in pediatric cochlear implants.

OBJECTIVE: The purpose of this study is to retrospectively review the complications of pediatric patients undergoing cochlear implantation at a tertiary referral center. METHOD: Institutional review board permission was obtained. A retrospective analysis of all pediatric patients (younger than 18 years) who underwent primary cochlear implantation was performed from January 2001 to December 2005. The patients were reviewed for demographic information, type of hearing loss, cochlear implant device, and complications including implant failure, meningitis, hematoma, implant extrusion, cerebrospinal fluid leak, facial palsy, and wound infection. RESULTS: One hundred sixty-five patient records were reviewed. Twenty-nine patients were lost to follow-up or were revision cases; therefore, 136 records were analyzed. Of the patients, 53.5% were male. The most common etiology of hearing loss was nonsyndromic, nongenetic, congenital sensorineural hearing loss (60.6%). Other less common etiology of hearing loss included TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus, herpes simplex virus) (8.3%), connexin mutation (5.8%), and enlarged vestibular aqueduct (6.5%). All patients had a follow-up of 3 years. There were no intraoperative complications. The most common complications were flap infections (2.6%) and immediate postoperative hematomas (1.9%). Flap problems mostly occurred within 2 weeks of implantation. Within the study period, there was only one device failure (0.7%). CONCLUSIONS: Cochlear implantation in children continues to be reliable and safe in experienced hands, with a low percentage of severe complications. The patients should have a lifetime follow-up.

Technique selection for orbital decompression: combined endoscopic and transconjunctival versus combined endoscopic and transantral approach.

Surgical orbital decompression is indicated for patients with compressive optic neuropathy, exposure keratopathy, an uncontrolled elevation of intraocular pressure, globe subluxation, and disfiguring proptosis secondary to Graves ophthalmopathy. Controversy exists, however, regarding the selection of surgical technique to achieve orbital decompression. We compared the results of our combined transnasal endoscopic and transconjunctival approach with those of our combined transnasal endoscopic and transantral approach to orbital decompression. We conducted a retrospective chart review of patients who had undergone medial- and inferior-wall orbital decompression from January 1994 through January 2004. During that time, 189 combined medial- and inferior-wall orbital decompressions were performed on 124 patients; 51 combined endoscopic and transantral decompressions were performed on 28 patients, and 138 combined endoscopic and transconjunctival decompressions were performed on 96 patients. Patient demographics and the degree of preoperative proptosis were statistically equal in the 2 groups. The incidence of optic neuropathy in the transantral group was significantly higher than the incidence in the entire group (p = 0.03), and the incidence of exposure keratopathy was significantly lower in the transantral group than in the entire group (p = 0.03). Postoperatively, the reduction in proptosis in the 2 groups was statistically equivalent, but the transconjunctival group had a significantly lower incidence of both infraorbital hypesthesia (p< 0.0001) and early rhinosinusitis (p = 0.008). Three cases of globe ptosis and 2 of infraorbital neuralgia occurred. No cases of visual loss, worsened optic neuropathy, diplopia in patients without preexisting diplopia, cerebrospinal fluid leak, significant epistaxis, or periorbital hematoma were noted. We conclude that combined endoscopic and transconjunctival orbital decompression offers equivalent efficacy with less postoperative infraorbital hypesthesia and early rhinosinusitis than does combined endoscopic and transantral orbital decompression.

Lithotripsy for refractory pediatric sialolithiasis.

Symptomatic salivary stones in the middle or proximal parotid duct have traditionally been treated by gland excision, which is associated with a 3% to 27% risk to the facial nerve in the pediatric population. Minimally invasive approaches to the management of salivary duct calculi have been introduced over the last several years. Fluoroscopically guided basket retrieval, lithotripsy, and intraoral stone removal under general anesthesia have found favor with many surgeons. Our patient had extracorporeal lithotripsy to his parotid gland with complete disintegration of the stone. He has had no evidence of stone recurrence or further bouts of parotitis. Extracorporeal shock wave lithotripsy with or without duct dilation is an efficient technique for the therapy of sialolithiasis in selected patients, especially patients who are at higher risk from a surgical standpoint.