Syphilis causing hearing loss.

An HIV-positive man with hepatitis B co-infection, naïve to highly active antiretroviral therapy, with a CD4 of 594 copies/mL and HIV-1 viral load of 140,070 copies, presented with right-sided facial weakness and hearing loss. He had been treated for secondary syphilis three months earlier when his rapid plasma reagin (RPR) result was 1:16, this had fallen to neat. At presentation, his RPR had risen to 1:16 again. A magnetic resonance imaging scan showed enhancement of the internal auditory canal and right cochlea. His cerebrospinal fluid examination was normal. He was treated with acyclovir and prednisolone before the syphilis serology was known. He was then treated for syphilis with doxycycline. He made an excellent recovery.

Repair of facial nerve after removal of cerebellopontine angle tumors: a comparative study.

The results of repair of 18 facial nerves were examined by means of a modified House-Brackmann grading system. Six were repaired by end-to-end anastomosis and 12 by nerve graft. The reliability of the simplified House-Brackmann grading system was also assessed, using the kappa statistic to analyze the agreement between pairs of observers who examined the function of 40 nerves in 37 patients. Facial nerves studied had been either preserved, repaired or grafted, or divided and treated by faciohypoglossal nerve anastomosis. One nerve was not treated. The grading system proved to be somewhat unreliable, with complete agreement between observers in only 25% of cases. Facial nerve repair produced a fair return of function in just under two-thirds of the cases. The ability of an examiner ignorant of the patient's history to assess from the end result how the nerve had been managed was also estimated. Observers showed little ability to decide correctly on the previous treatment of the nerve when the patient showed moderate dysfunction postoperatively. The implications of these findings for grading systems and for management of the facial nerve in acoustic nerve tumor surgery are discussed.

Autophony and the patulous eustachian tube.

Autophony and the patulous Eustachian tube is a real but rare clinical entity often misdiagnosed because the symptoms so mimic those of middle ear effusion. The diagnosis is made by the history of fullness or blockage and hearing ones own voice and breath sounds in the ear. The drum is usually atrophic and moves with respiration but this may not be visible. The usual past history is of weight loss. The diagnostic test is to observe a regular increase or decrease in middle ear pressure when increasing or decreasing the ambient pressure while measuring the impedance in a pressure chamber. The usual variations in pressure with opening and closing of the tube are not seen because the tube remains open all the time. Few patients need operative intervention and explanation is all that is usually required. When surgical treatment is necessary the application of 20% silver nitrate to the lumen of the tube on a wire covered by cotton has given results with few complications. Injection of Teflon paste anterior to the mouth of the Eustachian tube has been stopped by the manufacturer of the paste because of serious complications caused by the Teflon paste being accidentally injected into the internal carotid artery. Why some patients with a patulous tube and movement of the drug with respiration have no symptoms and other patients with very bothersome symptoms have so few objective signs and no movement of the drum, that can be observed with respiration, remains a mystery that needs further study.

Significance of tomography in Meniere's disease: visualization and morphology of the vestibular aqueduct.

The revival of endolymphatic sac surgery has led to many investigations in Meniere's disease, including lateral tomography of the vestibular aqueduct. Contrary to recent literature, we found no difference in the presence and morphology of the vestibular aqueduct when assessed radiologically in a group of Meniere's patients and a control group. Our assessment of this information in regard to etiology and treatment of Meniere's disease is presented.

Significance of tomography in Meniere's disease: periaqueductal pneumatization.

The revival of endolymphatic sac surgery has led to many investigations in Meniere's disease, including lateral tomography of the periaqueductal pneumatization. We radiologically assessed a series of Meniere's patients and a control group, and found hypocellularity to be more common in Meniere's disease as the literature has stated. However, we found this finding bilaterally in patients with unilateral disease. Our assessment of this information in regard to the etiology and treatment of Meniere's disease is presented.

Autoimmunity and inner ear disorders: an immune-complex mediated sensorineural hearing loss.

An immune-complex mediated form of autoimmune disease is described with the inner ear as one of its target organs. Around 40 dB bilateral sensorineural hearing loss improved on short-term corticosteroid therapy to normal levels. This case report is presented against the background of a general survey on autoimmunity and inner ear diseases. Cellular and humoral immune reactions may be etiologic moments in an audiovestibular dysfunction of autoimmune character.

Clinical experience with the Vibrant Soundbridge implant device.

OBJECTIVE: To evaluate the full degree and range of benefits provided by the Vibrant Soundbridge (VSB; Symphonix Devices, Inc., San Jose, CA, U.S.A.) and analyze pre-and postoperative results of audiologic tests. STUDY DESIGN: Single-subject study with each subject serving as his or her own control. SETTING: Multicenter clinical study conducted at 10 centers in Europe. PATIENTS: 47 patients who met the selection criteria for participation in the study. INTERVENTIONS: Implantation of the VSB direct-drive middle ear hearing device. MAIN OUTCOME MEASURES: Average change in unaided thresholds with the patient wearing headphones at each frequency pre-and postsurgery was measured. A mean threshold change less than 5 dB across all frequencies was considered clinically nonsignificant. RESULTS: 47 patients had successful surgery for implantation and fitting with the VSB device. CONCLUSION: The VSB is a new middle ear implant device that can be used safely in the treatment of patients with moderate to severe sensorineural hearing loss.

Clinical usefulness of electrocochleography in Meniere's disease: an analysis of dehydrating agents.

Both electrocochleography and glycerol dehydration have an important diagnostic and prognostic role in the management of patients with endolymphatic hydrops, whether idiopathic as in Meniere's disease or secondary to certain diseases of the otic capsule. Abnormal electrocochleographic responses in a "normal" ear can be used to predict when Meniere's disease will become bilateral. There is a significant correlation between the effects of glycerol and of endolymphatic sac surgery on the pars inferior, at least over the span of several years. The subject hearing gains, the objective improvements in electrocochleographic responses, and the objective evidence of diminished inner ear impedance, all following proven glycerol dehydration, indicate that even in fairly advanced Meniere's disease, but especially in the earlier stages, reversibility is possible. This is a tantalizing therapeutic challenge.

Multicenter audiometric results with the Vibrant Soundbridge, a semi-implantable hearing device for sensorineural hearing impairment.

The Vibrant Soundbridge, a semi-implantable hearing device for subjects with moderate to severe sensorineural hearing impairment was introduced commercially. First audiologic results are presented on 63 patients from 10 European implant centers. Hearing loss was at 0.5, 1, 2, and 4 kHz varying between 43 and 81 dB HL. The patients used the analogue audio processor, type 302. Measured sound-field gain was compared with NAL-R target values. For most patients an acceptable agreement was found. There was a subgroup of patients, however, with relatively low gain. The results suggest that this was related to the suboptimal positioning and fixation of the transducer to the incus.

Electrophoretic separation and identification of perilymph proteins in cases of acoustic neuroma.

Previous studies of perilymph proteins have emphasised the difficulty of obtaining samples free of blood or serum proteins. The present investigation has established a method of polyacrylamide gel electrophoresis, which enables contaminated specimens to be readily identified and therefore discarded. Analysis of uncontaminated samples has confirmed the presence of an elevated perilymph protein in cases of acoustic neurinomata. Perilymph proteins have been separated and identified and although no characteristic pattern of proteins associated with acoustic neurinomata has emerged, further work should be undertaken to establish the site of origin of perilymph proteins and the pattern of abnormalities to be expected in pathological processes.

Regional postgraduate training in otolaryngology: a study programme.

For the last three years the South East Thames Regional Training Committee (SETRTC) in Otolaryngology has held a series of training days for the Senior House Officers and Higher Surgical Trainees (HSTs) working in the region. These have proved popular and reportedly useful for the trainees. Although such a programme requires a widespread commitment from both trainers and trainees there are benefits in terms of both education and morale. We discuss these issues and make practical suggestions from our experience.

Emergency treatment of tracheal tear during pharyngolaryngectomy.

Longitudinal tracheal tear (of the trachealis muscle), an unusual but acknowledged complication of pharyngolaryngectomy, was encountered during a total pharyngo-oesophagolaryngectomy with gastric replacement. Due to serious ventilatory difficulties a rapid repair was required to obtain an airtight seal to allow continued mechanical ventilation. A reinforced polytetrafluoroethylene (PTFE) vascular graft was used as an intratracheal stent to seal the air leak. This technique proved effective and the tracheal defect had healed by the time the stent was removed 10 days later.

Measurement of drill-generated noise levels during ear surgery.

The results of intraoperative monitoring of the electrocochleogram in patients undergoing surgery for poorly controlled Menières Disease are presented with particular reference to the masking effect of drill-generated noise. The results obtained using a direct, in vivo, electrophysiological method of assessment of drill-generated noise levels are compared with previous postmortem and intraoperative studies and the implications with respect to the likelihood of drill-generated noise induced acoustic trauma are discussed.

Long-term middle-ear effects of middle-ear/eustachian tube packing after translabyrinthine surgery.

The purpose of this study was to evaluate the long-term effect on middle ear and eustachian tube function following the packing of the middle-ear space to prevent cerebrospinal fluid rhinorrhoea at the termination of translabyrinthine vestibular schwannoma removal. This was an observational study of a sample of 14 patients examined between two and five years post-operatively. Photo-otoscopy and tympanometry were performed bilaterally to evaluate appearance and function. All operated middle ears were air-containing although eight out of 14 showed scarring as evidence of operative intervention. There were no drum retractions. Ten out of 14 middle-ear compliance peaks were lower in the operated ear with four flat traces. Two out of 14 were the same and two out of 14 showed high compliance. The middle-ear pressure was always within the normal range when determinable. This technique appears to have no detrimental effects on the middle ear and does not permanently obliterate the eustachian tube. The reduced compliance in the majority of cases is probably a result of scarring and fibrosis. When drum hypermobility is seen this is accounted for by incus removal.

Cinefluorography in the diagnosis of pharyngeal palsies.

(1) The aetiology of dysphagia may be difficult to diagnose when it presents without clinical signs or an associated clinical syndrome. (2) Pharyngeal palsies present in acute and chronic forms. (3) Cinefluorographic techniques are helpful in making an objective diagnosis of pharyngeal palsy. (4) Advice may be given to the patient on head and neck positions during swallowing that is based on the findings of the cinefluorographic examination, in order to alleviate symptoms. (5) Good fluoroscopy, preferably with video-tape recording facilities may be perfectly adequate provided that the diagnosis is considered at that time.

Otogenic intracranial hypertension. Otitic hydrocephalus.

Otogenic intracranial hypertension is a rare complication of suppurative otitis media. Two patients with the typical features of the disease are presented. An historical review of the literature on the subject and a discussion of the differential diagnosis have been carried out. In the light of recent neuro-otological advances the management has been reappraised.

Fine needle aspiration cytology of a head and neck swelling in a child: a non-invasive approach to diagnosis.

A 12-year-old boy presented with a three-month history of a painful parotid swelling. Fine needle aspiration cytology indicated a pleomorphic adenoma--an uncommon lesion in a child. This diagnostic technique plays a useful role in the investigation of head and neck swellings.

Does post-operative nasal packing cause nocturnal oxygen desaturation?

Previous studies have shown an increased frequency and duration of apnoeic episodes during sleep when the nose is occluded. The aim of this study was to ascertain whether oxygen desaturation occurs with nasal occlusion by post-operative packing. Continuous digital pulse oximetry was carried out before and after submucous resection of the nasal septum in 17 otherwise healthy patients. Post-operative nasal packing produced a statistically significant change in oxygen saturation during sleep. The change was, however, of such small magnitude that it is unlikely to be clinically significant.

Air travel induced meningitis following vestibular schwannoma (acoustic neuroma) surgery.

Two cases are presented in which patients flying home shortly after translabyrinthine removal of a vestibular schwannoma (acoustic neuroma) developed acute bacterial meningitis on landing. This complication has not been described before. The incidence and management of CSF leaks after vestibular schwannoma surgery is also discussed.

Out-patient myringoplasty.

A simple technique for closing small-to-medium sized perforations of the tympanic membrane in the Out-Patient Department has been described. Homograft temporalis fascia was used as a graft material. In a series of eighteen patients a closure rate of 78.2 per cent was obtained. The advantages of the method have been discussed.