Giant cell tumors of the jugular foramen.

PURPOSE: To review the diagnosis and treatment of giant cell tumors of the jugular foramen. MATERIALS AND METHODS: A typical case is reported. Symptoms, signs, and diagnostic studies are reviewed. Photomicrographs and angiographic studies showing the differences between these and glomus jugulare tumors are provided. A coherent approach to their management is presented. RESULTS: These hypervascular, traditionally radioresistant tumors may cause pulsatile tinnitus, conductive hearing loss, and lower cranial nerve paresis. Angiographic studies showed a hypervascular lesion supplied by numerous small branches of the external carotid artery, making embolization difficult. Complete resection was achieved by an infratemporal fossa approach with preoperative embolization. CONCLUSION: Giant cell tumors of the temporal bone may mimic glomus jugulare tumors with respect to anatomic location, cranial nerve deficits, and vascularity.

Use of glycopyrrolate in the treatment of Meniere's disease.

OBJECTIVES/HYPOTHESIS: The objective of this study was to determine whether glycopyrrolate is useful as a vestibular suppressant in patients with Meniere's disease. The tested hypotheses were that glycopyrrolate would decrease the perception of dizziness measured by the Dizziness Handicap Inventory in patients with Meniere's disease and that placebo would cause no such decrease. STUDY DESIGN: Randomized, prospective. METHODS: Thirty-seven subjects with a diagnosis of Meniere's disease were administered either 2 mg of glycopyrrolate or placebo twice daily as needed for vertigo. All were also administered the regimen of 1500 mg sodium/day diet and diuretic. The following indices were examined: Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, Beck Depression Inventory, hearing examination, and electronystagmography. After 4 to 6 weeks of the drug regimen, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, and Beck Depression Scale were reexamined. Paired t tests were performed to verify the significance of improvement before and after treatment. RESULTS: Subjects who received glycopyrrolate had statistically significant reduction in Dizziness Handicap Inventory, Beck Depression Score, and Modified Somatic Perception Score. In the placebo group, no improvement in any index was found. CONCLUSIONS: The hypothesis that glycopyrrolate is a useful vestibular suppressant in patients with Meniere's disease was statistically verified.

Management of nonacoustic cranial nerve neuromata.

OBJECTIVE: This study aimed to review the authors' experience with diagnosis and management of nonacoustic neuroma of the cerebellopontine angle and skull base. In addition, management strategies for each type of tumor are suggested. STUDY DESIGN: A retrospective review of the charts of patients at the authors' institutions who underwent surgery for neuroma of the fifth through twelfth cranial nerves, between the years 1980-1996, was undertaken. Presenting symptoms, diagnostic techniques, and treatment are discussed for each type of lesion. PATIENTS: Four individuals with trigeminal neuroma, 1 individual with abducens neuroma, 40 individuals with facial neuroma, 3 individuals with glossopharyngeal neuroma, 21 individuals with vagal neuroma, 1 individual with accessory neuroma, and 4 individuals with hypoglossal neuroma participated. INTERVENTIONS: Surgical resection versus observation was examined. MAIN OUTCOME MEASURES: Freedom from recurrence or complication was measured. RESULTS: Surgical resection achieved in all patients, aside from the patient with abducens neuroma who is being observed, was measured. CONCLUSIONS: The preoperative diagnosis of nonacoustic lower cranial nerve neuroma is fairly common at the authors' institutions. Each type of neuroma requires its own tailored surgical approach once a decision has been made to resect the tumor.

Electrocochleography in retrosigmoid vestibular nerve section for intractable vertigo caused by Menière's disease.

Interest in electrocochleography has increased in recent years because of the discovery of an elevated summating potential to action potential amplitude ratio (SP/AP ratio) in patients with endolymphatic hydrops caused by Menière's disease or perilymph fistula. It was the purpose of this investigation to determine whether the intraoperative SP/AP ratio will decrease after vestibular nerve section in patients with intractable Meniere's disease. Fourteen patients with medically intractable classic Menière's disease underwent retrosigmoid vestibular nerve section. Intraoperative transtympanic electrocochleography was performed with alternating click stimuli presented at 95 dB HL. In all patients the SP/AP ratio was recorded before the skin incision ("baseline" condition) and after the dura was closed ("closing" condition). Statistical analysis was applied to the recorded data. In 11 (79%) patients, the SP/AP ratio was found to be elevated above 0.30 in the baseline state. In 13 (93%) patients, the SP/AP ratio decreased more than 25% after the nerve was sectioned. These results were highly statistically significant (p < 0.001). We conclude that the SP/AP ratio does decrease in patients with Menière's disease after undergoing retrosigmoid vestibular nerve section and offer a possible explanation.

Meningiomas intrinsic to the geniculate ganglion.

OBJECTIVE: To present the clinical, surgical and histopathological manifestations of meningioma intrinsic to the geniculate ganglion. STUDY DESIGN: Retrospective study of outcome. SETTING: Three private tertiary and one university (otology/neurotology) referral centers. PATIENTS: Six patients with cranial nerve VII paresis underwent magnetic resonance imaging and/or high-resolution computed tomography for subsequently histologically proven intrinsic meningioma of the geniculate ganglion. An additional six cases were identified in the literature. Most patients were female and ranged in age from 5 to 40 years. INTERVENTION: Total tumor removal via middle fossa and mastoid exposures followed by cable graft VII-VII neuroanastomosis. MAIN OUTCOME MEASURE: Meningioma can occur intrinsic to the geniculate ganglion and produces gradual VIIth nerve paresis as its first symptom. Other sites of predilection may occur extrinsically within the temporal bone or along intracranial venous sinuses at sites of arachnoid villi. RESULTS: Hearing was maintained in each patient, and postoperative House-Brackmann grade III-V facial nerve function was achieved. CONCLUSIONS: Intrinsic meningiomas of the geniculate ganglion rarely occur. However, this entity should be included in the differential diagnosis of a slowly progressive VIIth nerve paresis, especially in young females. Surgical removal and cable graft VII-VII neuroanastomosis is the treatment of choice. Long-term follow-up should be maintained because of the potential for von Recklinghausen's disease.

Brain herniation into the middle ear and mastoid: concepts in diagnosis and surgical management.

OBJECTIVE: To review the occurrence characteristics of and clinical repair experience with brain herniation in to the middle ear and mastoid from 1970-1995. STUDY DESIGN: Retrospective chart/case review. SETTING: Private Otology/Neurotology referral practice. PATIENTS: Thirty-five patients with temporal bone brain herniation diagnosed and treated from 1970-1995. INTERVENTION: Diagnosis confirmed by CT and/or MRI. Treatment was surgical. MAIN OUTCOME MEASURES: Success of surgical repair of the problem in a large experience with follow-up of up to 180 months (mean, 48.7 months). RESULTS: Diagnosis is most effectively made by both (computed tomography (CT) and magnetic resonance imaging (MRI). In this series diagnosis was accurate in 89% with MRI. Primary repair was successful in all but three patients, two of whom required a second repair. One was unreconstructable. CONCLUSIONS: Temporal bone encephaloceles occur after ear surgery and in chronic otitis media. Prompt and effective surgical repair is successful and integral to complication avoidance.

Management of acoustic neuroma in the elderly population.

OBJECTIVE: Ongoing controversy regarding the optimal treatment of acoustic neuromas in the elderly population has prompted us to examine the our experience in order to arrive at a treatment algorithm. STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: The records of 48 elderly patients ranging from age 70 to 90 years with acoustic tumors were reviewed. INTERVENTIONS: In 34 cases, tumor size was followed through serial imaging for a mean 28.5 months (range 5-108 months). Eight of these patients subsequently required surgery for significant tumor growth. An additional 12 patients were managed surgically from the time of diagnosis. MAIN OUTCOME MEASURE: The natural history of acoustic neuromas in the elderly population. RESULTS: The mean tumor growth rate for the watched group was 0.29 cm/y. Fifteen patients demonstrated no growth whereas accelerated growth was noted in eight cases. Ten patients with tumors confined to the internal auditory canal demonstrated an average growth rate of only 0.06 cm/y over a mean interval of 38 months. For the surgically treated group, the mean tumor size at the time of resection was 2.8 cm. Resection was described as complete in 17 cases and near-total in three cases. Perioperative complication rates and facial nerve results were comparable to our figures for all age groups. There was one perioperative death. CONCLUSIONS: Elderly patients with small acoustic neuromas should be offered a trial of observation. When significant tumor growth, size, or neurologic deterioration are demonstrated, early surgical intervention is required to avoid complications associated with the removal of larger tumors.

Stapedectomy in profound cochlear loss.

Stapedectomy can be used in certain patients with profound sensorineural hearing loss and stapes fixation to improve hearing to a level at which a hearing aid may be effective. This study reviews the outcomes of 11 patients with profound cochlear loss secondary to otosclerosis who underwent stapes surgery performed by the senior author (M.E.G.) over a 25-year period. Postoperative hearing aid usage was effective in 9 of 11 patients. Preoperatively, these patients derived no benefits from hearing aids. Stapedectomy may be of immense value in patients with the proper history and profound cochlear loss.

Hearing conservation in surgery for glomus jugulare tumors.

The most common ground on which surgery for glomus jugulare (GJ) tumors is criticized is the perceived risk of functional incapacity that attends possible cranial nerve (CN) loss. It is aggregate lower CN loss that is most often highlighted as particularly disabling to the quality of postsurgical survival. The documented success of both conservation surgery and operative rehabilitation of phonopharyngeal surgical deficits has, however, neutralized much of this criticism. The issue of hearing conservation (HC) in neurotologic skull base surgery, on the other hand, has not been well documented toward this end. The presence of a GJ neoplasm need not reflexly nor technically forfeit preexisting hearing. HC is, admittedly, a subordinate priority to total tumor removal, successful distal control of the internal carotid artery, and even facial nerve integrity. Yet, in appropriately selected patients, existing operative technology permits hearing preservation, a noteworthy addition to the high-grade functional outcome we have come to reasonably expect of conservation surgery. Hearing salvage further serves to define the concept of neurotologic skull base surgery. Hearing preservation in 122 GJ tumor patients is reviewed. Intuitively, as for acoustic tumor, HC appears tumor size related. Selection criteria for conservation surgery and its operative technique are detailed. Outcome is appropriately scored. The radiation therapy literature on this subject will be assiduously scrutinized for comparison.

Twenty-five years of experience with stapedectomy.

The purpose of this report is to review the outcomes of patients undergoing stapes surgery by the senior author during the past 25 years, and to compare these results with those obtained in other series. A retrospective analysis of 902 patients who underwent stapes surgery by the senior author from 1970 to 1994 was performed. Twenty-two patients underwent stapedotomy; the remainder underwent stapedectomy. Pure-tone averages for air and bone conduction, air-bone gap closure, technique, complications, and patient satisfaction were compared with results obtained in other stapedectomy and stapedotomy series.

The role of radiation therapy in the treatment of head and neck cutaneous melanoma.

INTRODUCTION: This study was undertaken to elucidate the efficacy of external beam irradiation in the treatment of head and neck malignant melanoma, in comparison with the efficacy of surgical excision and the efficacy of surgical excision combined with external beam irradiation. MATERIALS AND METHODS: A retrospective chart review of all patients seen at the Department of Radiation Oncology at the University of California at Los Angeles Medical Center with the diagnosis of head and neck melanoma from 1973 to 1992 was conducted. Using chi 2 analysis, survival rates were examined for patients treated with excision alone, irradiation alone, and both excision and irradiation. RESULTS: Patients were treated with primary excision (96%), salvage excision for recurrent or residual disease (47%), primary irradiation (9%), post-surgical-planned irradiation (22%), adjuvant chemotherapy (45%), and adjuvant immunotherapy (36%). The overall survival rate for the entire group was 29%. For patients with recurrent or regional disease, survival rates were 37% for those treated with excision in combination with irradiation, 20% for those treated with irradiation alone, and 19% for those treated with excision. Whereas the differences among groups were not statistically significant, the biologic implication is that external beam irradiation is effective in controlling regional disease, since the tumors treated with irradiation alone or excision in combination with irradiation were larger and more aggressive than those treated with excision alone. CONCLUSION: External beam irradiation is of benefit in treating patients with melanoma who are ineligible for salvage surgery or as an adjunctive modality in situations where the risk of recurrence is high.

The galvanically-induced vestibulo-ocular reflex in the cat.

Rotatory vestibular input is processed by receptor organs and relayed along the vestibular nerves to a central processor, whence the vestibulo-ocular reflex (VOR) is generated. Electrical stimuli applied to the labyrinth can bypass receptors and stimulate the nerve directly, thereby generating horizontal eye movements (EVOR). It was our purpose to mathematically relate the EVOR to the VOR in an effort to generate a parameter by which the experimental effects of ototoxins on the inner ear can be evaluated. A feline preparation was created in which the VOR and EVOR were measured in response to various sinusoidal stimuli. A detailed comparison between VOR and EVOR with respect to gain and phase was performed. From analysis of the data, the differential sensitivity to rotatory amplitude with respect to electrical amplitude was proposed as this parameter.

Is human galvanically induced triceps surae electromyogram a vestibulospinal reflex response?

Interest in understanding the human vestibulospinal reflex has increased enormously over the past three decades, because this reflex is the primary effector of maintenance of posture and balance. On a posture platform, forces exerted by the triceps surae (TS) and tibialis anterior muscles are measured to calculate center of mass sway. We wished to determine whether the TS response is a direct component of the vestibulospinal reflex. Ten healthy human beings were stimulated with sinusoidal galvanic currents delivered over their mastoid processes. Sway response on a posture platform and TS electromyogram (EMG) were recorded for the following conditions: (1) standing unrestrained; (2) standing completely restrained above the leg; and (3) sitting unrestrained. Results were similar for all subjects. Computer-aided analysis for case 1 reveals that TS EMG and horizontal body sway responses are generated at the same frequency as the stimulating current, with a phase lag of 90 degrees. For case 2, body sway response and any component of the TS EMG over the unstimulated condition were absent in all subjects. For case 3, body sway persisted, but no TS EMG above the unstimulated condition was recorded. As the TS EMG disappears when the standing subject is restrained from swaying or in the unrestrained seated subject, we conclude that the TS EMG response is compensatory to motion of more superior portions of the musculoskeletal system; it is not part of the vestibulospinal reflex.

Cholesteatoma of the maxillary sinus.

Cholesteatoma of the maxillary sinus, also known as keratoma, primary epidermoid tumor, epidermoid cyst, and keratocyst, is a rare entity, with a clinical presentation and radiologic findings that are difficult to distinguish from those of malignancy. We report a case of cholesteatoma of the maxillary antrum that occurred in a 12-year-old boy without any history of predisposing factors. Multiple theories of pathogenesis have been proposed throughout history; currently there are two accepted ones. We discuss these theories and present, along with the differential diagnosis, a review of the literature and the characteristic radiologic and pathologic findings. While it is a rare entity, the diagnosis of cholesteatoma should be considered for any slowly expanding lesion of the maxillary antrum.

Differential diagnosis of virus-like particles in the human inner ear.

The entire endolymphatic duct and sac as well as the vestibular epithelia were obtained from four patients with Meniere's disease during translabyrinthine (TL) eighth nerve section and from 12 patients undergoing TL resection of acoustic schwannomas. After these specimens were processed for routine transmission electron microscopy (TEM), they were studied for morphologic evidence of viral infection. Although no virus particles were identified, numerous regularly occurring cell components and artifacts were found to morphologically mimic viruses. An atlas of these structures is presented.

Laryngeal edema induced by neck dissection and catheter thrombosis.

PURPOSE: There are many possible causes of airway edema in a patient being treated for squamous cell carcinoma of the head and neck. The differential diagnosis includes radiation changes, anaphylaxis, and venous or lymphatic obstruction secondary to mechanical compromise resulting from infection, recurrent tumor, or anatomic distortion. METHODS: A 60-year-old man underwent partial glossectomy and right radical neck dissection for squamous cell carcinoma of the tongue. He subsequently required insertion of a Hickman catheter for administration of chemotherapy to treat recurrent disease. Edema of the left neck, shoulder, and arm was noted to accompany the onset of laryngeal obstruction secondary to supraglottic edema. RESULTS: Catheter-induced thrombosis of the left brachycephalic vein obstructed the only residual jugular vein and was responsible for the sudden airway obstruction. CONCLUSION: Acute laryngeal edema may be caused by obstruction of venous outflow. Invasive catheters should be placed with caution in patients who have undergone surgical sacrifice of the contralateral internal jugular vein.