Persistent stapedial artery: CT findings.

CT of a patient with conductive hearing loss showed a small vascular structure leaving the carotid canal and passing through the stapes to join the facial nerve canal. The small bony channel paralleled the anterior tympanic segment of the facial nerve, continuing beyond the geniculate ganglion into the middle cranial fossa. Otoendoscopic photography documented the presence of a persistent stapedial artery.

Diagnosis and management of paragangliomas of the skull base.

In appropriately selected patients, glomus tumors of the head and neck are best treated surgically. Unresectability is not a factor in therapeutic planning for local disease control. Existing techniques and exposures for tumor removal can be reliably applied to these paragangliomas, with acceptable morbidity and mortality. A team approach to this problem is mandatory.

Laser-assisted endoscopic stapedectomy: a prospective study.

OBJECTIVE: To improve the techniques required to perform a stapedotomy without prosthesis (stapedioplasty). STUDY DESIGN: New infrared lasers were evaluated for potential use in otological surgery in guinea pigs. A prospective human trial of 34 primary stapes operations using the Argon ion laser was performed, with 11 stapedioplasties and 23 conventional stapedotomies as controls. METHODS: Laser-tissue interactions were evaluated for temporal bone and live guinea pig tissues, measuring crater histology and labyrinthine temperature elevations. Patients undergoing stapedioplasty had Argon ion laser cuts with endoscopic assistance made in the anterior crus and footplate to mobilize the posterior segment of the stapes while the anterior portion remained fixed. RESULTS: Diode laser (808-nm) vaporization craters and temperature elevations in the vestibule were suitable for clinical use. Overall, stapedioplasty patients' hearing was improved with air-bone gap closure to a mean of 8.3 dB (SD +/- 9.8 dB). CONCLUSIONS: Patients with anterior footplate otosclerosis are candidates for stapedioplasty preserving the annular ring and stapes tendon and eliminating prosthesis complications. High-resolution small endoscopes, coupled with Argon ion or diode lasers promise to improve stapes visualization, enhancing the ability to perform minimally invasive surgery on the stapes footplate.

Endoscope-assisted second-stage tympanomastoidectomy.

Intact canal wall mastoidectomy techniques for cholesteatoma are often followed by a planned second look for residual disease and possible ossicular reconstruction. Endoscopic techniques may reduce morbidity but introduce new concerns. Twenty-five consecutive second-look procedures were performed from July 1994 to July 1996 utilizing endoscopes in 19 cases and avoiding or terminating their use in the others because of known difficult anatomy, inadequate exposure, or excessive bleeding. Thirteen cases were prospectively explored first through a planned exclusively endoscopic approach and then opened for a conventional second look in comparison. In one of the 13 cases, endoscopy was abandoned. There were no cases in which endoscopy yielded a false-negative result. Endoscopes underestimated the size of recurrence in one case. Our experience, indications, and precautions for endoscope-assisted second-stage tympanomastoidectomy are presented.

Cartilage tympanoplasty for management of retraction pockets and cholesteatomas.

Retraction pockets of the tympanic membrane, often associated with dysfunction of the eustachian tube, can be destructive, leading to loss of hearing, ossicular erosion, and development of cholesteatomas. This retrospective study reviews results from 35 patients (38 ears) operated on from January 1988 to June 1991 whose composite cartilage-perichondrial grafts harvested from the tragus were used to reconstruct the tympanic membrane. Early grafts reinforcing the posterosuperior quadrant of the pars tensa showed some failures, with recurrent retraction in the attic. In later grafts, additional placing of cartilage under the pars flaccida prevented failures in the attic. Our indications, initial technique and refinements to the present form, and hearing results are discussed.

Facial reanimation by XI-VII anastomosis without shoulder paralysis.

Transposition of the spinal accessory (XI) and facial (VII) nerves has been used successfully in reanimation of facial paralysis, but because of the severity of symptoms associated with denervation of the trapezius muscle, this technique has largely been abandoned. Hypoglossal-facial (XII-VII) nerve anastomosis has now become a more favored procedure; however, the resultant hemiglossal atrophy carries some morbidity. Transposition of the sternocleidomastoid (SCM) branch of the accessory nerve as a way to avoid shoulder paralysis was reported more than 20 years ago with initially excellent results, yet few follow-up studies have been done. Twenty-one fresh cadaver dissections of the accessory nerve-SCM branch and facial nerve were performed to determine if adequate numbers of fascicle groups and sufficient proximal nerve length are available for an adequate end-to-end anastomosis without nerve interposition grafting. This paper presents our anatomic and histologic findings to support the use of proximal SCM nerve anastomosis to distal facial nerve in facial reanimation. When feasible, the use of this technique to correct facial paralysis is encouraged rather than hypoglossal-to-facial nerve anastomotic repair.

Proliferative myositis of the masseter muscle.

The authors present a case of a 33-year-old white man with a 4-month history of a rapidly enlarging, tender, painful, circumscribed facial mass located in the masseter muscle. CT scan and fine needle aspiration cytology, coupled with clinical assessment, suggested the diagnosis of proliferative myositis. Curative intraoral excisional biopsy was done, thereby avoiding a parotidectomy incision and approach to the lesion. The pathology showed proliferative myositis. A review of the literature revealed 36 cases which indicated that proliferative myositis is a relatively rare etiology of a head and neck mass. Careful clinical, radiologic, and pathologic evaluations were required to make this unusual diagnosis and avoid any unnecessary facial mutilation in its treatment.

Long-term results after lateral cranial base surgery.

The surgical management of patients with slow-growing benign temporal bone neoplasms has been criticized because of its significant morbidity and mortality compared with results after radiation therapy, but long-term control by irradiation remains unproved. Long-term surgical results have not been studied previously. One hundred twenty-nine skull base operations were performed in 126 patients at the Otology Group, Nashville, Tenn., from January 1970 through May 1987. Fifty-eight patients responded to questionnaires focusing on recovery from loss of cranial nerves. All patients regained some degree of facial function (class V or better), no alimentary tubes or tracheotomies were in use, and no patients had debilitating aspiration. Long-term compensation from the cranial nerve deficits of lateral skull base surgery can be expected in most patients and should not be used as an argument for irradiation in patients with a long life expectancy at time of diagnosis.

Management of large dural defects in skull base surgery: an update.

The use of a ventriculoatrial shunt for long-term CSF diversion for reconstruction after resection of large skull base tumors with intradural extension has been discontinued. The concern about placing a permanent foreign body in a wound open for 12 to 18 hours is our primary reason for changing the technique. Our present approach uses a rectus abdominis microvascular free flap over the fascial closure of the dural defect. Although our experience with this technique is limited, the advantages over the technique used previously warrant its continued use.

Transtympanic endoscopy of the middle ear.

Modern optical technology has made available fiberoptic and rigid endoscopes with diameters of 2 mm and less with acceptable resolution. Endoscopes of small caliber were introduced through a strategically placed myringotomy or an existing perforation to perform exploration of the middle ear as an in-the-office procedure. This technique is now routinely used as an adjunct in the diagnostic evaluation of patients with suspected middle ear conditions. Exploratory surgery of the middle ear may be avoided or definitive procedures may be planned better based on endoscopic findings.

Endoscope-assisted vestibular neurectomy.

OBJECTIVE/HYPOTHESIS: In some instances endoscopes offer better visualization than the microscope and frequently allow less invasive surgery. This study was undertaken to determine whether endoscopy is safe and effective during neurectomy of the vestibular nerve. METHOD: Ten patients with intractable unilateral Meniere's disease underwent a retrosigmoid craniotomy for neurectomy of the vestibular nerve. Endoscopy with a Hopkins telescope was used during each procedure to study posterior fossa anatomic relationships and to assist the neurectomy. Preoperative and postoperative audiometric evaluation was performed in all patients undergoing vestibular neurectomy. Nine of these patients had preoperative electronystagmography, and four patients completed postoperative electronystagmography. The 1995 American Academy of Otolaryngology-Head and Neck Surgery's Committee on Hearing and Equilibrium guidelines for the diagnosis and evaluation of therapy in Meniere's disease were used. RESULTS: Complete neurectomy was achieved in all 10 patients. Endoscopy allowed improved identification of the nervus intermedius and the facial, cochlear, and vestibular nerves and adjacent neurovascular relationships without the need for significant retraction of the cerebellum or brainstem. In addition, endoscopic identification of the cleavage plane between the cochlear and vestibular nerves medial to or within the internal auditory canal (n = 3) was not made with the 0-degree endoscope; however, identification was made with the 30- or 70-degree endoscope in all cases. In all patients with Meniere's disease, elimination of the recurrent episodes of vertigo (n = 10) or otolithic crisis of Tumarkin (n = 1) was achieved. CONCLUSIONS: Posterior fossa endoscopy can be performed safely. Endoscope-assisted neurectomy of the vestibular nerve may offer some advantages over standard microsurgery including increased visualization, more complete neurectomy, minimal cerebellar retraction, and a lowered risk of cerebrospinal fluid leakage.

Cochlear implantation after transmastoid labyrinthectomy.

Hearing rehabilitation with an intracochlear prosthesis is well documented in patients who have an intact otic capsule prior to implantation. However, the suitability for implantation of patients who have undergone extensive procedures involving the otic capsule such as labyrinthectomy has not been directly addressed. This report documents a case of a patient deafened by a transmastoid labyrinthectomy who subsequently received a cochlear implant. Postimplantation performance of this patient was compared with the performance of three other postlingual implant recipients. The results suggest that labyrinthectomy is not a contraindication to auditory rehabilitation by a cochlear implant. The implications of implantation in a surgically manipulated otic capsule are discussed.

Erbium laser in middle ear surgery: in vitro and in vivo animal study.

Cadaveric human temporal bones, cadaveric rabbits, and live rats were used to demonstrate the utility and safety of the erbium:yttrium-scandium-gallium-garnet (Er:YSGG) laser for otologic applications. The shallow penetration in water of this wave-length and its ability to ablate bony tissue with minimal collateral thermal effects spare underlying and adjacent structures and make it appealing for stapedotomy. The authors were able to satisfactorily perform small fenestra stapedotomy, atticotomy facial nerve decompression, and mastoidectomy. Temperature measurements from the round window area during Er:YSGG stapedotomy recorded an elevation of less than 2 degrees C, which is well within acceptable limits. An acoustic shock produced at the impact site is the major disadvantage and requires further in vivo investigation of the transient and sustained deleterious effects away from the application site. This work supports further investigation into potential applications of the Er:YSGG laser in otology.

Adjunctive use of endoscopy during acoustic neuroma surgery.

OBJECTIVE/HYPOTHESIS: In specific clinical situations, endoscopes offer better visualization than the microscope during acoustic neuroma (vestibular schwannoma) surgery and can therefore decrease the incidence of the postoperative complications of cerebrospinal fluid (CSF) leakage and recurrence of tumor. This study was undertaken to determine if the use of adjunctive endoscopy provides complementary information to the operating surgeon during surgery for acoustic neuromas. METHOD: Seventy-eight patients with acoustic neuromas underwent tumor excision by two neurotologists (PAW., D.S.P.), together with their respective neurosurgical partners, via a retrosigmoid (suboccipital) approach (n = 68), translabyrinthine approach (n = 7), or middle cranial fossa approach (n = 3). Endoscopy with a rigid glass lens endoscope was used during tumor removal to examine posterior fossa neurovascular structures, and after tumor excision to inspect the internal auditory canal (IAC), inner ear, and middle ear, depending on the approach used. One of the authors (D.S.P.) has not used adjunctive endoscopy during resections via the translabyrinthine and middle cranial fossa approaches, and therefore, these cases were excluded from the data collection and analysis. RESULTS: Complete tumor excision was achieved in 73 patients. Endoscopy allowed improved identification of tumor and adjacent neurovascular relationships in all cases. In addition, residual tumor at the fundus of the IAC (n = 11) and exposed air cells (n = 24) not seen with the microscope during retrosigmoid approaches were identified endoscopically. In one of the translabyrinthine cases, the endoscope allowed identification of open air cells not visualized with the microscope. None of the 78 patients developed CSF rhinorrhea. Incorporating the endoscope did not significantly increase operative time. CONCLUSIONS: Endoscopy can be performed safely during surgery to remove acoustic neuromas. The adjunctive use of endoscopy may offer some advantages including improved visualization, more complete tumor removal, and a lowered risk of CSF leakage.

Surgical management of cholesteatoma in an only hearing ear.

The patient with a cholesteatoma in an only hearing ear presents a management dilemma: how best to treat the patient to minimize the chances of developing a severe hearing loss in that ear. Twelve patients managed surgically for cholesteatoma in their only hearing ear are reviewed. The location and extent of the cholesteatoma, the type of operation performed, and postoperative hearing results are presented. Eleven of the 12 patients maintained their bone-conducted speech reception threshold to within 5 dB of the preoperative level during follow-up periods of 2 months to 4 years. Recommendations are made regarding preoperative evaluation, perioperative use of antibiotics and steroids, operative planning, ossicular reconstruction, and postoperative care. Special attention is given to the evaluation and management of the ear that has a fistula eroding into the cochlea and semicircular canals, both when suspected from preoperative imaging studies and when discovered intraoperatively.

Analysis of the dysfunctional eustachian tube by video endoscopy.

OBJECTIVE: Human eustachian tubes with known pathologic conditions of the ear were inspected endoscopically, and video recordings were made for slow-motion analysis of the pathophysiologic changes. SETTING: Ambulatory office in a tertiary referral center. SUBJECTS: Forty-four adults with 64 ears having pathologic conditions. INTERVENTIONS: Transnasal endoscopic examination of the nasopharyngeal opening of the eustachian tube during rest, swallowing, and yawning to study the dilatory movements of the eustachian tube. MAIN OUTCOME MEASURES: Slow-motion video analysis of the dilatory movements of the eustachian tube. RESULTS: Sixty-four ears and eustachian tubes with pathologic changes were studied. Tubal function was graded on (1) the extent of lateral excursion and progression of dilatory wave as estimates of tensor veli palatini and dilator tube muscle function, reduced function being observed in 43 tubes; (2) the degree of mucosal disease, which was significant in 48 tubes; (3) obstructive mucosal changes, which were present in 15 tubes; (4) ease and frequency of tubal dilation with maneuvers-26 tubes opened moderately, 21 opened minimally, and 11 were unable to open; and (5) patulous tubes-all 6 clinically patulous tubes showed concavities in the superior third of the tube, which is convex in normal subjects. All tubes with active pathologic conditions of the ear (otitis media with effusion, tympanic membrane retraction, draining ear, cholesteatoma) had significant abnormalities. A correlation could not be made between the severity of middle ear disease and the severity of observed eustachian tube dysfunction. CONCLUSIONS: Slow-motion endoscopic video analysis is a potentially useful technique in classifying types of pathologic changes in the eustachian tube. Additional studies of dysfunctional tubes are needed to predict outcomes in operative ear cases and to design intratubal therapy for chronically dysfunctional tubes.

Etanercept therapy for immune-mediated cochleovestibular disorders: preliminary results in a pilot study.

OBJECTIVE: Immune-mediated cochleovestibular disorders (IMCVDs) continue to present a management challenge to the otolaryngologist. Antirheumatic agents, commonly used for IMCVDs, are associated with variable efficacy and sometimes with serious side effects. The authors describe the preliminary result of their experience in patients with IMCVDs who have been treated with etanercept, a tumor necrosis factor alpha receptor blocker, recently approved by the United States Food and Drug Administration for the treatment of rheumatoid arthritis. STUDY DESIGN: Retrospective case series. SETTING: Tertiary care hospital. PATIENTS: Twelve patients suspected of having IMCVD who did not respond to conventional therapies or experienced side effects of the conventional therapies. INTERVENTION: Etanercept 25 mg by subcutaneous injection twice per week. MAIN OUTCOME MEASURES: The main outcome measurement was assessment of hearing change by air conduction pure tone audiograms and/or word discrimination. When present, vertigo, tinnitus, and aural fullness were assessed as well. RESULTS: Follow-up of more than 5 months was available for all patients (range, 5-12 months). Eleven (92%) of 12 patients had improvement or stabilization of hearing and tinnitus, seven (88%) of eight patients who had vertigo and eight (89%) of nine patients who had aural fullness had resolution or significant improvement of their symptoms. The benefit persisted until the last visit (5-12 months after etanercept was begun). The condition of one patient improved dramatically at first but deteriorated after 5 months. The patient's hearing was rescued and stabilized with the addition of leflunomide to etanercept. Similarly, three other patients required a second antirheumatic agent to stabilize their hearing. There were no significant side effects from the etanercept therapy. CONCLUSIONS: Our limited data suggest that etanercept therapy is safe and may be efficacious in carefully selected patients with IMCVDs, at least on a short-term basis. These preliminary efficacy and safety results appear encouraging enough to warrant further follow-up and studies for better determination of the potential clinical utility of etanercept for IMCVDs.

Long-term hearing results following middle fossa vestibular nerve section.

Hearing stabilization following middle fossa vestibular nerve section (MFVNS) has been observed to occur in a large percentage of patients (71% to 86%) after short-term followup. This study looks at the long-term audiological followup (5 to 15 years) of 46 patients who underwent a MFVNS for intractable Meniere's disease. Although the percentage of patients with stabilized hearing was relatively high within the first 2 years postoperatively (61%), it dropped to 41% after a longer followup of 5 to 15 years. When this patient population is divided into two groups based on their preoperative PTA, those patients in whom hearing had bottomed out to greater than or equal to 50 dB PTA preoperatively lost only 5 dB PTA over the course of the follow-up period. The patients with better preoperative hearing (less than 50 dB PTA) lost 30 dB PTA over the same follow-up period. As this pattern is similar to what has been observed in nonsurgically treated Meniere's patients, we conclude that the MFVNS has no beneficial effect on the hearing loss associated with Meniere's disease.

Experimental CO2 laser myringotomy.

OBJECTIVE: The purpose of this study was to compare closure rates of CO2 laser myringotomies with those produced conventionally with a knife. STUDY DESIGN AND SETTING: We investigated closure rates in 3 experimental groups of chinchillas: (1) semicircular myringotomy in both ears either produced with a knife or CO2 laser; (2) CO2 laser myringotomy, round in one ear and kidney shaped in the other; (3) CO2 laser myringotomy, incisional in one ear and kidney shaped in the other. RESULTS: Patency of knife myringotomies was shorter (P < 0.01) than of similar laser myringotomies, means 10.0 and 21.8 days, respectively. The patency of kidney-shaped laser myringotomies was longer (P < 0.05) than of round ones. Incisional laser myringotomies remained open longer (P < 0.01) than round ones. CONCLUSION: Use of CO2 laser as well as certain geometries delay the closure of myringotomies. By allowing perforations of different shapes and sizes, CO2 laser myringotomy may become an alternative in the treatment of otitis media.

A paraneoplastic syndrome associated with glomus tumors of the skull base? Early observations.

Independent secretion of vasoactive substances by glomus tumors of the skull base is widely recognized. Surgical removal of these tumors often results in an unexplained prolonged postoperative ileus, even in cases in which the vagus nerve is preserved. There is evidence that these tumors may secrete neuropeptides, such as cholecystokinin, in addition to catecholamines. A retrospective analysis of cases of glomus tumors of the skull base operated on at The Otology Group was carried out to correlate preoperative neuropeptide levels, vagus nerve status at surgery, and duration of postoperative ileus. High circulating levels of cholecystokinin associated with these tumors may be responsible for the unexplained phenomenon of prolonged postoperative ileus. The relevance of neuropeptides to the postoperative management of these patients is discussed. Preventive measures that may avert the potentially lethal complications of aspiration and negative nitrogen balance are described.