Do Postoperative Antibiotics Improve Skin Reactivity Following Percutaneous Auditory Osseointegrated Implant Placement?

OBJECTIVE: To determine if the routine use of postoperative antibiotics following percutaneous auditory osseointegrated implant placement reduces skin reactivity. STUDY DESIGN: Retrospective matched case-controlled series. SETTINGS: Tertiary academic medical center. SUBJECT AND METHODS: A total of 44 patients who underwent percutaneous auditory osseointegrated implant placement were divided into those who received 5 days of postoperative antibiotics (AB) and those who received no antibiotics (NAB). All surgery was performed using the same surgical technique (Minimally Invasive Ponto Surgery). Variables recorded included patient demographics, Holgers skin reaction score, complications, and need for further intervention. RESULTS: A total of 23 patients received prophylactic postoperative antibiotics (AB) while 21 patients did not (NAB). At the first postoperative visit (AB 12.7 d versus NAB 12.3 d, p = 0.9) there were no differences in average Holgers score (AB 0.3 ±â€Š0.7 versus NAB 0.2 ±â€Š0.5, p = 0.27). The odds ratio for skin reactivity at the first visit was 0.11 (95% CI 0.01-2.32). There were also no statistical differences in Holgers score (AB 0.05 ±â€Š0.2 versus NAB 0.1 ±â€Š0.3, p = 0.25) at most recent followup visit (AB mean 97.5 d versus NAB 102.8 d, p = 0.84). The odds ratio for skin reactivity at the most recent visit was 0.16 (95% CI 0.01-3.64). CONCLUSIONS: The use of postoperative antibiotics does not appear to confer significant difference in skin reactivity in patients receiving percutaneous osseointegrated auditory implants. Such findings support the theory that skin reactivity, when it does occur, may not be an infectious-mediated process.

Standardization of the Punch Technique for the Implantation of Bone Anchored Auditory Devices: Evaluation of the MIPS Surgical Set.

OBJECTIVE: To describe and assess intraoperative and postoperative outcomes in the insertion of osseointegrated auditory implants with a newly designed surgical instrumentation set through a punch type technique. STUDY DESIGN: Retrospective case series. METHODS: Patients who underwent bone anchored auditory implant surgery using the Minimally Invasive Ponto Surgery (Oticon Medical, Somerset, NJ) surgical set through a punch technique at nine neurotology tertiary referral based practices were identified. Demographic data, skin thickness at implant site, implant used, duration of surgery, adverse intraoperative events, and postoperative outcomes were recorded. RESULTS: Seventy-five patients comprised the study cohort (32 males, 43 females). Most patients (57. 3%) were aged 51 to 75 years while 30.7% of the cohort comprised those aged 18 to 50 years and 12% were over 75 years. All but two patients received 4 mm fixtured implants and 68% received the Oticon Medical BioHelix implant. Two patients received 3 mm fixture implants and 32% received the Oticon Medical Wide Ponto implant. Mean surgical time was 12.2 minutes (6-45 min, standard deviation of 6.88 min). In three instances, surgery was converted to a linear incision to control brisk bleeding. Skin condition was Holgers 0 to 1 in 91.8%, while 5.5% had Holgers 2, and 2.7% had Holgers 3 at the first postoperative visit. At second postoperative visit, 94.3% had Holgers 0 to 1, 4.3% had Holgers 2, and 1.4% had Holgers 3. All instances of adverse skin reactions were treated with topical or systemic antibiotics and/or local debridement. There were no instances of implant loss. One patient had his implant traumatically displaced to a 45-degree angle necessitating implant replacement at a second site. CONCLUSION: Punch technique placement of osseointegrated auditory implants using the Minimally Invasive Ponto Surgery surgical set represents a safe technique that further simplifies a progressively minimally invasive surgery.

Hydroxyapatite cement resurfacing the dehiscent jugular bulb: Novel treatment for pulsatile tinnitus.

OBJECTIVES/HYPOTHESIS: The objectives were to discuss the presentation and symptomatology of patients with jugular bulb abnormalities, summarize the literature describing jugular bulb abnormalities, compare methods of treating symptomatic dehiscent jugular bulb, describe a novel surgical technique and pitfalls to repair dehiscent bulbs with hydroxyapatite cement, and present a case series to demonstrate outcomes with this technique STUDY DESIGN: Case series presentation, PubMed literature review, and description of operative technique. METHODS: A series of patients presenting with pulsatile tinnitus due to dehiscent jugular bulbs who underwent operative repair with hydroxyapatite cement resurfacing is described. Literature review was conducted via a PubMed database search. Abstracts and references were reviewed to identify relevant sources. Surgical technique of repair and outcomes are reported. RESULTS: Three patients who presented with unilateral, bothersome, pulsatile tinnitus with history and imaging consistent with a diagnosis of high riding, dehiscent jugular bulbs underwent jugular bulb resurfacing with hydroxyapatite cement. Two patients associated the onset of their symptoms with trauma. All patients reported complete resolution of their tinnitus at an average follow-up of 15 months. No hearing, vestibular, or intracranial complications were encountered. CONCLUSIONS: Compressive, obliterative, and endovascular interventions have been attempted to treat pulsatile tinnitus due to high-riding dehiscent jugular bulbs. Reconstruction of the middle ear floor with autologous tissue grafts has also been described. These techniques have been associated with variable results and with the risk of increased intracranial pressure. Hydroxyapatite cement resurfacing may be considered as an alternative for the treatment of this pathology. LEVEL OF EVIDENCE: 4. Laryngoscope, 128:1186-1190, 2018.

Evolution in surgical management of superior canal dehiscence syndrome.

PURPOSE OF REVIEW: This manuscript will review the progression of surgical techniques currently being used to repair a defect in the superior semicircular canal in symptomatic patients. Originally described via the middle cranial fossa route, larger series of patients have been demonstrated through less invasive approaches. These new innovative approaches will be discussed. RECENT FINDINGS: Recently, the surgical indications for the repair of superior canal dehiscence have been broadened. As a result, several surgical techniques have been demonstrated to limit inherent risks to patients while still adequately treating the symptoms known to be associated with superior canal dehiscence. Transmastoid plugging, transmastoid resurfacing, endoscopic resurfacing and endaural approaches will be described and recent results discussed. SUMMARY: Although the optimal surgical approach for superior canal dehiscence has yet to be determined, clearly a progression in techniques has been demonstrated. Surgical management of superior canal dehiscence syndrome began requiring a craniotomy but has now progressed to transmastoid and even endaural approaches.

Quality-of-life assessment of Ménière's disease patients after surgical labyrinthectomy.

OBJECTIVE: To examine the impact of surgical labyrinthectomy on quality of life of Ménière's disease patients. STUDY DESIGN: Cross-sectional survey. SETTING: Otology subspecialty referral center. PATIENTS: All patients with Ménière's disease who underwent surgical labyrinthectomy between 1998 and 2004 were selected. Fifty-three patients satisfied inclusion criteria. Completed questionnaires were obtained from 44 patients. INTERVENTION(S): The Ménière's Disease Outcomes Questionnaire is a disease-specific quality-of-life questionnaire. It was used to assess the quality of life of patients before and after surgical labyrinthectomy. The questionnaire encompasses physical, mental, and social well-being domains of quality of life. MAIN OUTCOME MEASURE(S): Change in total quality-of-life score was used to assess the overall impact of surgical labyrinthectomy on subjective patient outcome. Individual quality-of-life domains were also assessed. RESULTS: Forty-three of 44 respondents (98%) had improvement in total score after surgery. The one patient who demonstrated deterioration developed latent contralateral disease. Average preoperative and postoperative scores were 34 +/- 14 and 67 +/- 15, respectively (p < 0.001). All questions showed significant improvement with surgery (p < 0.001) except questions pertaining to memory (no change) and hearing loss (nonsignificant decrease in score). CONCLUSION: This study comprises the first patient-directed assessment of quality-of-life outcomes in Ménière's disease patients after labyrinthectomy. Despite the disadvantage of hearing loss, patients consistently reported significant improvement in all quality-of-life domains and do not report a significant loss of quality of life in terms of their hearing loss. Surgical labyrinthectomy remains a highly effective treatment for Ménière's disease patients.

Tumors and pseudotumors of the endolymphatic sac.

This article reports on the presentation, diagnosis, management, and treatment outcomes of lesions of the endolymphatic sac in patients treated at a tertiary neurotology referral center. It summarizes survival results in the largest series groups and presents a new diagnostic entity of pseudotumor of the endolymphatic sac. The study includes retrospective review of all patients diagnosed with lesions of the endolymphatic sac within our practice between 1994 and 2005 as well as review of the literature. The primary outcome measure was survival, and the secondary outcome measure was disease-free survival following definitive resection. Postoperative complications were assessed. Survival characteristics of the largest reported case series groups were reviewed. Five cases of endolymphatic sac lesions were identified. Of these, three were true endolymphatic sac tumors and two were inflammatory pseudotumors of the endolymphatic sac. All three of the endolymphatic sac tumors patients survived (100%), and two of the three had disease-free survival (67%). Two of three patients maintained persistent facial paresis postoperatively. Both patients with benign pseudotumors survived (100%). Our study concluded that endolymphatic sac tumors are rare neoplasms of the temporal bone that, although locally aggressive and invasive, have excellent prognosis for survival with complete resection. We report a new entity of pseudotumor of the endolymphatic sac that mimics true sac tumors in every respect on presentation but which is non-neoplastic in origin.

Lipomatous hemangiopericytoma of the skull base and parapharyngeal space.

OBJECTIVE: To discuss the diagnosis and clinical management of lipomatous hemangiopericytoma. STUDY DESIGN: Case report. SETTING: Tertiary referral center. PATIENT: A 36-year-old woman was encountered with symptoms of facial numbness, blurred vision, headache, and lightheadedness of 6 weeks' duration. Magnetic resonance imaging revealed a 5.0-cm mass in the right parapharyngeal space and skull base extending inferiorly to the level of the carotid bifurcation. The mass was consistent radiographically with a glomus jugulare tumor, and surgical extirpation was performed. INTERVENTION: The patient underwent a transtemporal approach to the right posterior fossa and jugular foramen including mastoidectomy and isolation and preservation of Cranial Nerves VII, X, XI, and XII. Microscopic analysis of the mass revealed a highly cellular spindled mesenchymal tumor with a pericytoma pattern. Almost half of the mass displayed a mature lipomatous component. These findings were consistent with a lipomatous hemangiopericytoma. RESULTS: The authors describe the first case of lipomatous hemangiopericytoma involving the skull base. This rare variant of the more common hemangiopericytoma has been described previously in the retroperitoneal and lower extremities. Although one case of lipomatous hemangiopericytoma has been described in the occipital region, this is the first report of this entity involving the parapharyngeal space, skull base, and jugular foramen. CONCLUSION: The authors demonstrate that lipomatous hemangiopericytoma can occur in the parapharyngeal space and skull base. Once thought to be an aggressive variant, this tumor has an extremely low propensity for distant or local recurrence. Adjuvant therapies such as radiation and chemotherapeutic agents are reserved for recurrent or metastatic lesions.

Success of posterior semicircular canal occlusion and application of the dizziness handicap inventory.

OBJECTIVES: To determine the long-term efficacy and patient satisfaction of posterior semicircular canal occlusion (PSCO) as a treatment for intractable benign paroxysmal positional vertigo (BPPV). STUDY DESIGN AND SETTING: Retrospective analysis of patients with BPPV who underwent PSCO was conducted in a tertiary referral center. Demographic data, clinical records, and audiometric data were reviewed. Dix-Hallpike maneuver, dizziness handicap inventory (DHI), and a specific PSCO questionnaire (PCOQ) were used to measure outcome. RESULTS: Twenty-eight patients underwent PSCO. The mean follow-up time was 40 months. All patients had normalization of the Hallpike test. DHI scores of 20 patients were recorded. The mean preoperative score was 70 compared with postoperative mean of 13 (P < 0.001). Mild hearing loss was found in 1 patient. CONCLUSIONS AND SIGNIFICANCE: PSCO is highly successful. The DHI scores postoperatively show significant improvement. The PCOQ revealed an overall 85% patient satisfaction rate. PSCO is a safe and effective intervention for intractable BPPV with a high patient satisfaction rate. EBM RATING: C-4.

The jaundiced gunn rat model of auditory neuropathy/dyssynchrony.

OBJECTIVE: High levels of bilirubin are neurotoxic and may result in deafness or auditory neuropathy/auditory dyssynchrony (AN/AD). The jaundiced (jj) Gunn rat animal model of kernicterus has electrophysiologic and neuroanatomic abnormalities of brainstem auditory nuclei with normal cochlear microphonic recordings. We examined morphologic changes in the cochlea, spiral ganglion, and auditory nerve and relate these findings to current understanding of AN/AD. METHODS: At 15 days of age, jj and nonjaundiced (Nj) littermates were injected with sulfadimethoxine (sulfa) and killed 3 days later by transcardial perfusion. Sections were cut through decalcified temporal bones, cochlear nerves, and auditory brainstem and processed for light and electron microscopy and immunohistochemical localization of calbindin-D and parvalbumin. RESULTS: Spiral ganglion neurons were severely degenerated with a paucity of myelinated axons in jj animals. Electron microscopy of the intramodilar auditory nerve revealed a lack of large caliber axons in jj-sulfa versus Nj-sulfa controls. Large diameter degenerating axons were characterized by an electron-dense atrophied axis cylinder resembling an axonopathy. CONCLUSIONS: Our findings of abnormal spiral ganglion cells and selective loss of large, myelinated auditory nerve fibers with no abnormalities in cochlear hair cells, support the sulfa-treated jj Gunn rat as a model for bilirubin induced AN/AD. The paucity of large caliber neurons undermines temporal coding of auditory information and neural synchrony and demonstrates that in addition to brainstem auditory nuclei, spiral ganglion neurons are selectively vulnerable to bilirubin toxicity.

Demyelination of vestibular nerve axons in unilateral Ménière's disease.

We conducted a study to determine whether vestibular nerves in patients with unilateral Ménière's disease whose symptoms are refractory to medical management exhibit neuropathologic changes. We also endeavored to determine whether retrocochlear abnormalities are primary or secondary factors in the disease process. To these ends, we obtained vestibular nerve segments from five patients during retrosigmoid (posterior fossa) neurectomy, immediately fixed them, and processed them for light and electron microscopy. We found that all five segments exhibited moderate to severe demyelination with axonal sparing. Moreover, we noted that reactive astrocytes produced an extensive proliferation of fibrous processes and that the microglia assumed a phagocytic role. We conclude that the possible etiologies of demyelination include viral and/or immune-mediated factors similar to those seen in other demyelinating diseases, such as multiple sclerosis and Guillain-Barré syndrome. Our findings suggest that some forms of Ménière's disease that are refractory to traditional medical management might be the result of retrocochlear pathology that affects the neuroglial portion of the vestibular nerve.

Localization of biotinidase in the brain: implications for its role in hearing loss in biotinidase deficiency.

Biotinidase deficiency is an autosomal recessively inherited disorder characterized by neurological and cutaneous features, including sensorineural hearing loss. Although many of the features of the disorder are reversible following treatment with biotin, the hearing loss appears to be irreversible. To better characterize the nature of the hearing loss in this disorder, location of the expression and presence of biotinidase within the brain was examined using Northern blot analysis, in vitro hybridization of a cDNA panel, and immunohistochemical staining. Results indicate low, but detectable expression of biotinidase throughout the brain, but increased concentrations of biotinidase within the dorsal cochlear nucleus, ventral cochlear nucleus, and superior olivary complex of the brainstem, as well as, in the hair cells and spiral ganglion of the cochlea. These findings suggest that biotinidase and possibly biotin plays an important role in hearing.

Immunohistochemical localization of calcium-binding proteins in the brainstem vestibular nuclei of the jaundiced Gunn rat.

Vestibular gaze and postural abnormalities are major sequelae of neonatal hyperbilirubinemia. The sites and cellular effects of bilirubin toxicity in the brainstem vestibular pathway are not easily detected. Since altered intracellular calcium homeostasis may play a role in neuronal cell death, we hypothesized that altered expression of calcium-binding proteins may occur in brainstem vestibular nuclei of the classic animal model of bilirubin neurotoxicity. The expression of the calcium-binding proteins calbindin-D28k and parvalbumin in the brainstem vestibular pathways and cerebellum of homozygous recessive jaundiced (jj) Gunn rats was examined by light microscopy and immunohistochemistry at 18 days postnatally and compared to the findings obtained from age-matched non-jaundiced heterozygous (Nj) littermate controls. Jaundiced animals exhibited decreased parvalbumin immunoreactivity specifically in synaptic inputs to superior, medial, and inferior vestibular nuclei, and to oculomotor and trochlear nuclei, whereas the neurons retained their normal immunoreactivity. Jaundiced animals also demonstrated a decrease in calbindin expression in the lateral vestibular nuclei and a paucity of calbindin-immunoreactive synaptic endings on the somata of Deiters' neurons. The involved regions are related to the control of the vestibulo-ocular and vestibulospinal reflexes. Decreased expression of calcium-binding proteins in brainstem vestibular neurons may relate to the vestibulo-ocular and vestibulospinal dysfunction seen with clinical kernicterus, and may provide a sensitive new way to assess bilirubin toxicity in the vestibular system.

Changes in calcium-binding protein expression in the auditory brainstem nuclei of the jaundiced Gunn rat.

Sensorineural hearing loss and auditory dysfunction are major sequelae of neonatal hyperbilirubinemia. The sites and cellular effects of bilirubin toxicity in the auditory brainstem pathway are not easily detected. Since altered intracellular calcium homeostasis may play a role in neuronal cell death, we hypothesized that the expression of calcium-binding proteins may be altered in the classic animal model of bilirubin neurotoxicity. The expression of the calcium-binding proteins, calbindin-D28k and parvalbumin, in the brainstem auditory pathway of homozygous recessive jaundiced (jj) Gunn rats was examined by light and electron microscopic immunohistochemistry at 18 days postnatally and compared to the findings obtained from age-matched non-jaundiced heterozygous (Nj) littermate control rats. Immunoreactive staining for both calbindin and parvalbumin was reduced in the cochlear nuclei and the superior olivary complex in jj rats. The extent of the reduction in immunoreactivity was related to the severity of the clinical symptoms. By contrast, immunoreactive staining in other brainstem areas (e.g., dorsal and ventral nuclei of the lateral lemniscus, inferior colliculus), thalamic (medial geniculate body) auditory areas, and neighboring non-auditory structures was similar in jaundiced and control rats. Calbindin-immunoreactive staining in the superior paraolivary and medial superior olivary nuclei in Nj rats was associated with myelinated axons, whereas parvalbumin-immunoreactive staining was localized postsynaptically in neuronal somata and dendrites. Immunoreactive staining for the calcium-binding proteins calbindin and parvalbumin in lower brainstem auditory nuclei shows abnormalities in areas susceptible to the effects of hyperbilirubinemia and provides a sensitive new way to assess bilirubin toxicity in the auditory system.