Intratympanic dexamethasone versus high dosage of betahistine in the treatment of intractable unilateral Meniere disease.

PURPOSE: The objective of our randomized, double-blind study was to compare the effectiveness of intratympanic (IT) dexamethasone versus high-dosage of betahistine in the treatment of patients with intractable unilateral Meniere disease (MD). MATERIALS AND METHODS: Sixty six patients with definite unilateral MD were randomly divided in two groups: Group A received a combination of IT dexamethasone (DX) and identical-appearing placebo pills while Group B received a combination of high-dosage betahistine and IT saline. Intratympanic injections were repeated for three times with an interlude of 3days. High-dosage of betahistine entailed 144mg/day. Mean outcome measures consisted of vertigo control, pure tone average (PTA), speech discrimination score, Functional Level Score, Dizziness Handicap Inventory and Tinnitus Handicap Inventory. RESULTS: Fifty nine patients completed the study and were available at 12months for analysis. In Group A complete vertigo control (class A) was attained in 14 patients (46.6%) and substantial control (class B) in 7 patients (20%). In Group B, 12 patients (41%) achieved complete vertigo control (class A), 5 patients (17%) substantial control (class B). There is no statistical difference in vertigo control between the two treatment groups. In Group A hearing was unchanged in 14 patients and improved in 4 patients, while in Group B hearing was unchanged in 16 patients and improved in 2 patients. CONCLUSIONS: Our preliminary results demonstrate that high-dosage of betahistine achieved similar outcomes as IT dexamethasone in the control of vertigo and hearing preservation.

Endolymphatic sac surgery versus tenotomy of the stapedius and tensor tympani muscles in the management of patients with unilateral definite Meniere's disease.

This study aims to compare the outcomes of patients with Meniere's disease submitted to either endolymphatic mastoid shunt (ES) or tenotomy of the stapedius and tensor tympani muscles (TSTM). This is a retrospective chart review of patients treated with ES or TSTM between 2000 and 2010 and followed up for at least 12 months. The main outcomes were represented by: (1) vertigo class, hearing stage and functional level according to the American Academy of Otolaryngology-Head and Neck Surgery criteria; (2) adjustment of dizziness handicap inventory (DHI) and (3) complete and substantial vertigo control using the Kaplan-Meier survival method. Sixty-three patients met the inclusion criteria: 34 underwent ES and 29 TSTM. The baseline demographic characteristics, the hearing stage, the functional level, the DHI and hearing levels were not different between the two groups. No significant difference in vertigo class was demonstrated: 66 % of TSTM patients attained class A compared to 44 % in the ES group (p = 0.14). Kaplan-Meier survival curves specific to class A showed significant differences, favoring TSTM (log-rank test, p = 0.022). TSTM patients demonstrated significantly improved functional level (p = 0.0004) and improved DHI scores (p = 0.001). Eight ES patients (25 %) demanded a second surgical attempt compared to none in the TSTM. Aural fullness was significantly improved in TSTM group (p = 0.01), while the difference in tinnitus improvement was non-significant. Hearing preservation was significantly better in TSTM group (p = 0.001). TSTM is a safe surgical procedure, with significant vertigo control rates, and important hearing preservation rates. More patients and longer follow-up are needed to support our preliminary findings.

Endoscopic surgery for recurrent undifferentiated nasopharyngeal carcinoma.

One of the biggest challenges for otolaryngologists is represented by the locally recurrent undifferentiated nasopharyngeal carcinoma (uNPC). Despite improvements in its treatment options, such as modern radiotherapy, chemotherapy, or external surgical approaches, the risk for severe complications, functional disabilities, and even death remains considerable. Over the years, advances in endoscopic surgery have led to a new alternative in the salvage surgery for recurrent uNPC: the nasopharyngeal endoscopic resection (NER). We retrospectively reviewed clinical records of 8 patients (6 men and 2 women), who underwent NER for recurrent T1 (rT1) locally recurrent uNPC between 2008 and 2011. Together with resections for subsequent recurrences, a total of 9 NERs were performed by a single surgeon with curative intent. Negative margins were obtained for the whole group of patients. After a mean follow-up period of 27 months (range, 16-54 mo), all the patients had no evidence of the disease. We had only 1 recurrence after 7 months. Two-year overall survival and disease-free survival rates were 100% and 88.9%, respectively. Only 1 patient presented with a complication, osteitis. Nasopharyngeal endoscopic resection can be considered a valid and promising treatment option for rT1 locally recurrent uNPC, showing encouraging short-term outcomes and complication rate. Long-term follow-up is needed to state the efficacy of NER, together with a larger number of patients.

Predictors of hearing preservation in the management of labyrinthine fistulas positioned on the semicircular canals.

OBJECTIVES: We sought to identify factors that would predict hearing preservation in the treatment of semicircular canal labyrinthine fistulas. METHODS: Between 1990 and 2010, 97 patients with semicircular canal fistulas were operated on and enrolled in this retrospective study. In 62 patients the matrix was removed and the fistula was sealed, whereas in 35 patients the canal was drilled, the matrix was detached, and the canal was occluded. Perioperative corticosteroids were administered in 51 patients. The main outcome measures were the bone conduction thresholds evaluated at 1 year after the operation. Factors considered for possible association with hearing preservation included age, gender, site and size of the fistula, primary versus revision surgery, surgeon, perioperative corticosteroid treatment, and surgical management of the fistula. RESULTS: The bone conduction hearing level was improved in 16 patients, remained unchanged in 73 patients, and had worsened in 11 patients. On the univariate analysis, good hearing was predicted by grade II fistula, canal plugging, and corticosteroid treatment. However, none of these factors attained significance in the logistic regression model. CONCLUSIONS: In surgery of semicircular canal fistulas, good hearing outcomes are to be expected if perioperative corticosteroids are administered, matrix removal and fistula sealing is performed in grade II fistulas, and canal occlusion is performed in grade III and IV fistulas.

Failures in stapedotomy for otosclerosis.

OBJECTIVE: To review the results of 78 revision stapedotomies, determining the causes of failure and the predictors of surgical success. STUDY DESIGN: Case series with chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: Seventy-eight operations were performed in a tertiary referral center on 72 patients between 1995 and 2005. Indication for surgery was recurrent or persistent conductive hearing loss. RESULTS: The most common causes of failure were prosthesis displacement, incus necrosis, and oval window fibrosis. Postoperative air-bone gap was closed to within 10 dB in 54 percent of cases, and mean postoperative air-bone gap was 13.6 dB. Overclosure occurred in five percent of cases, sensorineural hearing loss in six percent of cases, and we had one postoperative dead ear. Success rates were higher in cases presenting prosthesis or ossicular malfunction than in cases with oval window problems. Hearing results did not differ if the prosthesis was crimped to either the malleus or the remnant of the long incudal process. Outcomes were similar for local or general anesthesia, and the nitinol piston did not significantly improve the hearing results. CONCLUSION: Revision stapedotomy is less successful than primary procedure. Lessening the surgical trauma provides the most favorable results.

Nucleolus vs Nucleus Count for Identifying Spiral Ganglion in Human Temporal Bone.

OBJECTIVES: Spiral ganglion (SG) counting is used in experimental studies conducted on age-, noise-, and drug-induced sensorineural hearing loss, as well as in the assessment of cochlear implant performances. Different methods of counting have been reported, but no definite standardization of such procedure has been published. The aim of our study is to identify the best method to count human spiral ganglions (SGs). MATERIALS AND METHODS: By identification of nuclei or nucleoli as described by Schucknect, seven researchers with different experience levels counted SGs in 123 human temporal bones (TBs). Data on time of post-mortem bone removal post-mortem, methods of specimen's fixation, decalcification, and coloration were collected to test their possible influence on human tissue. Percentage, two-tailed t-test, Spearman's test, and one-way ANOVA were used to analyze the data. RESULTS: Nucleoli were identified in 61% of cases, whereas nuclei were recognized in 100% of cases (p<0.005). Nucleoli presence in all four segments in the same temporal bone (TB) was observed in 69 cases (92%), whereas nuclei were identified in all four segments in 103 cases (83.7%) (p<0.001). The junior investigators requested a double check by the seniors in 25 (20.3%) cases for identifying and counting nucleoli, whereas the senior researchers showed no doubts in their identification and count. The only parameter positively affecting nucleoli identification in tissue preparation was bone removal for <12 h with respect to longer post-mortem time (p<0.001). CONCLUSION: We suggest counting nuclei, rather than nucleoli, for spiral ganglion computation because of easier recognition of nuclei, especially in case of investigator's limited experience.

Posterior and attic wall osteoplasty: hearing results and recurrence rates in cholesteatoma.

OBJECTIVE: To assess the efficacy of a surgical technique, the temporary attic and posterior canal wall osteoplasty, in preventing cholesteatoma recurrence. DESIGN/PARTICIPANTS: The records of 94 patients submitted to tympanoplasty for cholesteatoma in the ear, nose, and throat department of a main city hospital between 1989 and 1997 were retrospectively reviewed. INTERVENTIONS: Intact canal wall procedure with attic and posterior canal wall temporary removal was performed in 47 cases. A canal wall down operation was performed in the 47 remaining cases. The follow-up ranged from 22 to 84 months. METHODS AND MAIN OUTCOME MEASURES: The patients from one group could be exactly matched for the main prognostic factors (type of cholesteatoma, ossicular status, and preoperative auditory status) with the patients from the other group. Auditory results were defined according to the Committee on Hearing and Equilibrium Guidelines. A 1-way analysis of variance was used to determine group differences. A probability value of p < 0.05 was the level of significance selected. RESULTS: All of the patients in the 2 groups were cholesteatoma free at the last follow-up, and significantly better hearing results were observed in the osteoplasty group. CONCLUSIONS: The osteoplasty with temporary removal of the posterior and attic canal wall is a useful adjunct to tympanoplasty in cholesteatoma cases as far as the hearing results and recurrence rates are concerned. This method combines the functional advantages of canal wall up operations with the safety yielded by canal wall down procedures.

A scanning electron microscopic study of crimping of stapedial prostheses.

OBJECTIVE: The aim of this study was to evaluate, through the Scanning Electron Microscopy, the loop closure of four types of stapedial prostheses and to compare the different systems of crimping to the long process of the incus. MATERIALS AND METHODS: Four types of stapedial prostheses (one platinum-teflon, two different titanium and one nitinol-teflon pistons) were inserted in 40 specially prepared temporal bones simulating the in vivo stapedotomy procedure. Two pistons were crimped by single manual manoeuvre with a McGee microforceps; the remainders were self-retained and thermal-crimped, respectively. All the specimens were evaluated through the Operative Microscopy and the Scanning Electron Microscopy. RESULTS: Through the Operative Microscopy, all prostheses apparently achieved a correct adhesion to the long process of the incus; on the contrary the Scanning Electron Microscopy study demonstrated some limits of the manual crimping and the different coupling with the ossicular chain of each type of stapedial prosthesis. CONCLUSION: A complete adhesion of the prosthetic loop cannot be obtained because of the irregular profile of the incus at the site of attachment of the stapedial prosthesis. Consequently, on the basis of the morphological analysis with Scanning Electron Microscopy, in the surgical practice, the preference could be given to the stapedial prostheses that achieve greater contact such as the self-retaining and thermal crimping pistons compared to the standard sized prostheses considered.

The heat-activated stapes prosthesis 'SMart' Piston: technique and preliminary results.

Since 2003 we are using in our stapedotomies the Nitinol 'Smart' Piston. This prosthesis has a Teflon 'vestibular' end and a wire shaft made by Nitinol, with a heat activated self-crimping loop. Nitinol is an alloy of Nickel + Titanium, belonging to the class of the so-called smart materials, i.e. materials with shape-memory and superelastic properties. Nitinol is lightweight and highly biocompatible thanks to the thin layer of Titanium oxide covering the Nickel surface. The special advantage of this piston is that the loop grips by itself very uniformly and quite tightly around the incudal process or the malleus handle when a minimal heating (about 60 degrees C) is applied using a disposable heater ('Thermal Tip'). This piston was successfully used in our Department between 2003 and 2004 in a first group of 42 cases of stapedotomy and in 7 cases of malleostapedotomy. The shape and the uniformity of the loop grip was controlled by examining fresh temporal bone specimens by S.E.M. (x21 / 166) and in all specimens the loop was uniformly surrounding the ossicle, without 'dead' spaces. It is our feeling that this prosthesis is very useful in stapes surgery for at least two reasons: 1. because it improves the quality of the interface 'piston loop/long process of incus'; 2. because the duration of the procedure is reduced.

Connexin 26 preverbal hearing impairment: mutation prevalence and heterozygosity in a selected population.

The objective of this investigation was to determine the prevalence of Cx26 mutations in familial and sporadic cases of non-syndromic preverbal hearing impairment (HI). Molecular analysis of the Connexin 26 (Cx26/GJB2) gene was performed in 271 non-consanguineous individuals from the north of Italy, enrolled in the study because of the presence of non-syndromic preverbal sensorineural HI. One hundred and forty-six subjects (group 1) were referred from different ENT, paediatric and clinical genetic services, while 125 individuals (group 2) underwent Cx26 analysis based on precise anamnestic and clinical criteria for non-syndromic HI and low risk of acquired deficit. All of the cases were also classified as familial or sporadic due to the presence or absence of other documented childhood HI in the family. Of the total 271 individuals, 36.9% were positive for Cx26 mutations: 37 belonged to group 1 and 63 to group 2, which delineates a statistically significant difference between the two groups. The difference is mainly attributable to sporadically occurring cases. No significant differences between group 1 and group 2 were found regarding the prevalence of the common 35delG variant and the number of unidentified putative Cx26 alleles, although these latter were shown to be higher in sporadically occurring cases of the unselected group 1. The difference observed in Cx26 prevalence can be explained by the clinical selection of group 2, which ensures minimum risk of including cases of acquired HI. In particular, in cases of sporadically occurring HI, the use of a defined protocol increases the chances of a positive molecular result, improving genetic counselling and the possibility of establishing better genotype-phenotype correlation. Our data raise questions about the possible interpretation of Cx26 heterozygosity in a selected population of hearing-impaired individuals.