Vestibular evoked myogenic and periocular potentials after vestibular schwannoma surgery.

OBJECTIVES: We analyzed the behavior of preoperative and postoperative vestibular evoked myogenic potentials (VEMPs) and vestibular evoked periocular potentials (VEPPs) in 3 patients who had vestibular schwannoma and underwent modified translabyrinthine surgery. METHODS: We compared VEMPs and VEPPs, measured with both air-conducted (AC) and bone-conducted (BC) stimulations. Vestibular evoked potentials were measured both in the immediate postoperative period and some months later. RESULTS: At the immediate postoperative examination, VEPPs were preserved in all 3 patients with both AC and BC stimulations. The VEMPs showed stable or improved parameters in 2 of our patients and were absent in the third patient. At the follow-up examination, VEMPs did not show any significant change with respect to the previous evaluation. In contrast, VEPPs were absent in 2 of our patients with AC stimulation and in 1 patient with BC stimulation. CONCLUSIONS: Our results seem to indicate a greater stability and reproducibility of VEMPs compared with VEPPs. In 1 patient, who had a schwannoma of the inferior vestibular nerve, the preservation of VEPPs and the absence of VEMPs in the immediate postoperative period confirm that the saccule represents the origin of VEMPs. Furthermore, these results suggest that not only the saccule, but also the utriculus, could be implicated in the origin of VEPPs.

Vestibular evoked periocular potentials in Meniere's disease after glycerol testing.

OBJECTIVES: The present investigation was specifically designed to evaluate the clinical application of vestibular evoked periocular potentials (VEPPs) in the diagnosis of endolymphatic hydrops. METHODS: We compared the results of the traditional pure tone audiometry glycerol test with those of the vestibular evoked myogenic potential (VEMP) glycerol test and the VEPP glycerol test in 22 patients affected by unilateral endolymphatic hydrops. RESULTS: Some patients had positive depletive tests with both VEMPs and VEPPs, and other patients had positive tests with either VEMPs or VEPPs. CONCLUSIONS: Our outcomes confirmed that vestibular evoked potentials represent a useful additional diagnostic tool in the diagnosis of endolymphatic hydrops. The role of VEPPs in this particular issue was not inferior to that of VEMPs. The outcomes also suggested that not only the saccule, but also the utriculus, may be involved in the genesis of VEPPs.

Intradural jugular paragangliomas: complications and sequelae.

OBJECTIVES: To present the long-term results of a group of patients who underwent surgery for intradural jugular paragangliomas. We discuss the complications, sequelae, and evolution of recurrences and behavior of residual tumors. METHODS: From 1989 to 2002, 11 patients with intradural jugular paragangliomas underwent surgery using different approaches. The paragangliomas were grouped according to the classification of Fisch. RESULTS: Total removal of the paraganglioma was possible in eight patients, while a subtotal resection was achieved in the other three cases. The tumor remnant remained stable in two patients but continued to grow in one. Recurrence was observed in one patient. There were preoperative deficits in cranial nerves IX to XI in four patients and of XII in two patients. Deficits of cranial nerves IX to XI were acquired as a result of surgery in three cases and of XII in another. Six patients had a pure-tone average of 45 to 75 dB while the others had dead ears. Persistent dysphagia and dysphonia were managed in two patients by injection of the paralyzed cord with fat and subsequent medialization of the vocal cord by thyroplasty. Two patients had a cerebrospinal fluid leak. CONCLUSIONS: Surgical results in patients with extensive jugular paragangliomas are consistent and offer an acceptable quality of life even in advanced cases.

Stapedotomy and post-operative benign paroxysmal positional vertigo.

In our experience some patients subjected to stapedotomy presented vestibular symptoms characterized by brief episodes of vertigo that only lasted 10 to 20 seconds, accompanied by rapid paroxysmal nystagmus similar to that found in benign paroxysmal positional vertigo (BPPV). For this study, 141 otosclerotic patients were enroled and underwent stapedotomy following the Fisch and Dillier's technique. Twelve out (8.5%) of all the patients under study complained of post-operative vertigo and the physical examination of the positional nystagmus confirmed the presence of paroxymal positional vertigo. The percentage seems particularly high and does not agree with the data reported in literature. The onset of the vestibular symptoms appeared between the 5th and 21st day after surgery. To our knowledge, this is the first prospective study existing in literature on the incidence of BPPV after surgery of the stapes. It must also be stressed that the patient should be informed beforehand during the consultation phase of the possibility of post-stapedotomy BPPV together with the other causes of post-operative vertigo.

Modified translabyrinthine approach and hearing preservation.

OBJECTIVES/HYPOTHESIS: In 1991, the translabyrinthine approach was modified by sealing the vestibule with bone wax, which allowed preservation of the hearing function in one patient. The present study aimed specifically at evaluating the effectiveness of the modified translabyrinthine approach in preserving hearing function in a group of patients with vestibular schwannoma that involved the internal auditory canal. STUDY DESIGN: Prospective study. METHODS: The series consisted of 12 patients with vestibular schwannoma (average age, 49.7 y). The schwannoma was smaller than 2 cm in all patients who had surgery. The patients accepted for the study were required to have preserved hearing function. RESULTS: None of the patients has shown signs of persistence or tumoral relapse on postoperative magnetic resonance imaging. Immediately after surgery, the entire group had excellent facial functionality. Six patients had maintained their hearing function (four in Class 1 and two in Class 2 according to the Gardner-Robertson scale) at the last follow-up after surgery. A patient during follow-up noted fluctuating hearing contemporarily with a tinnitus in the ear that had maintained its hearing, which was attributable to an endolymphatic hydrops. Three of the six patients with preserved hearing complained of persistent tinnitus. None of the patients had any of the complications or consequences of cerebellopontine surgery. CONCLUSION: In our patients, Class 1 or 2 hearing was preserved in 50% of the patients, with no persistence or tumoral relapse. The follow-up has obviously been short, but the first results are encouraging and deserve to be studied further in a more comprehensive survey.

Detection of postoperative relapsing/residual cholesteatomas with diffusion-weighted echo-planar magnetic resonance imaging.

PURPOSE: To assess the capability of echo-planar diffusion-weighted magnetic resonance imaging (MRI) (EPI-DWI) in diagnosing relapsing/residual cholesteatomas after canal wall-up mastoidectomy. MATERIALS AND METHODS: In a blinded study design, we investigated with MRI, including standard spin-echo sequences, 18 patients evaluated with clinical examination and computed tomography (CT) suspected for relapsing/residual cholesteatoma 7 to 19 months after a canal wall-up mastoidectomy. Images were evaluated by two radiologists blinded to patients' identities, CT findings, and clinical data set, who decided in a consensus agreement whether there was a pathologic signal increase in the petrous bone in a single-shot EPI-DWI sequence. All the patients underwent a second tympanoplasty or revision surgery of the mastoidectomy cavity within 15 days after magnetic resonance investigation.Sensitivity, specificity, and predictive values were evaluated separately for standard sequences and EPI-DWI. RESULTS: In EPI-DWI, five of six patients with cholesteatoma showed a bright signal, whereas those patients with a noncholesteatomatous tissue showed no anomalies. The only misdiagnosed cholesteatoma was a pearl 2 mm in diameter. Sensitivity, specificity, and positive predictive values, and negative predictive values of EPI-DWI in diagnosing relapsing/residual cholesteatomas were 86, 100, 100, and 92%, respectively. CONCLUSION: EPI-DWI may be a useful tool in differentiating between cholesteatomatous and noncholesteatomatous tissues after closed cavity mastoidectomy. Further investigations are, however, required to establish the practical utility of EPI-DWI on larger series as a screening modality in the follow-up after closed cavity mastoidectomies.

Surgical management of the labyrinthine fistula complicating chronic otitis media with or without cholesteatoma.

OBJECTIVES: To present our most recent experience on the diagnosis and treatment of the labyrinthine fistula. The relative data are compared with those of our past experiences adopting the same modality of presenting the results. METHODS: The clinical and surgical records of 334 patients affected with chronic otitis media with or without cholesteatoma were analyzed to evaluate the frequency, site, and size of the labyrinthine fistulae. In this study, a more aggressive strategy was adopted that comprised immediate total removal of the cholesteatoma matrix and the surrounding inflammatory tissues even when they involved the membranous labyrinth. RESULTS: Sixteen labyrinthine fistulae were found, only one of which was in a patient with chronic otitis media without cholesteatoma. Only one patient suffered from postoperative hearing deterioration of the bone conduction above 10 dB. The fistulae were smaller in size than in the previous survey, although the total incidence was slightly higher. CONCLUSIONS: Imaging techniques have demonstrated a favourable clinical impact on the diagnosis regarding the size and involvement of one or more anatomic structures of the otic capsule, not on the frequency percentage of fistulae. Total removal of the cholesteatoma matrix in one step, also combined with partial labyrinthectomy, yields satisfactory hearing results. To obtain successful outcomes, it is essential to respect certain fundamental precautions.

Cavernous hemangioma of the tympanic membrane and external ear canal.

OBJECTIVES: The aims of this study are to document the occurrence of a cavernous hemangioma of the tympanic membrane (TM) and external auditory canal (EAC) that invaded the middle ear spaces and to review the relevant literature. METHODS: The clinical presentation, imaging studies, operative report, and histologic findings of this new case of cavernous hemangioma are reviewed. RESULTS: A cavernous hemangioma of the TM and EAC involving the middle ear spaces was surgically excised without complications. The pulsatile tinnitus, which affected our patient at the same ear where the lesion was situated, disappeared after surgery. Our case represents the first documented cavernous hemangioma of the TM and EAC that invaded the middle ear spaces and the eighth case of cavernous hemangioma of the EAC/TM. Computed tomography is the method of choice in evaluating this lesion. CONCLUSIONS: Hemangiomas of the EAC and/or TM are extremely rare entities amenable to surgical excision. With magnetic resonance imaging, there is difficulty in defining the exact location of the tumor and degree of soft tissue involvement.

Osteopathia striata-cranial sclerosis: otorhinolaryngologic clinical presentation and radiologic findings.

BACKGROUND: Osteopathia striata with cranial sclerosis (OS-CS) is a rare bone dysplasia that presents with variable symptoms mainly due to the associated CS. METHODS: The otorhinolaryngologic clinical presentation and temporal bone computed tomography (CT) findings of a new case of OS-CS are presented. Differential diagnosis is also discussed. RESULTS: Our study confirms the typical appearance of the temporal bone reported in previous CT studies and the utility of CT for evaluating the various etiologies of conductive-mixed hearing loss present in OS-CS. Radiographs of the femur and pelvis revealed the typical striations of OS-CS and allowed us to diagnose this rare form of generalized skeletal dysplasia involving the skull base. CONCLUSIONS: To our knowledge, this is the third reported case of OS-CS in which temporal bone CT evaluation corroborated the smallness of the middle ear cavities, abnormal ossicular fixation, and bone sclerosis of the mastoid cells. Other radiographic studies regarding the whole skeleton may, in combination, be very helpful in the differential diagnosis between the different forms of generalized skeletal diseases with bone sclerosis involving the skull base.