Incidence and nature of primary granulomatous inflammation in surgically removed material.

A large number of cases (303) of primary granulomatous inflammation, present in surgically removed specimens from a broad range of locations, were reviewed and examined in detail. The granulomas were characterized as to morphology, location, and etiology. Epithelioid granulomas without necrosis were most frequently due to sarcoidosis and mycobacterial infection, while epithelioid granulomas with necrosis were most commonly due to mycobacterial infection, fungal infection, rheumatoid arthritis and sarcoidosis. Mature granulomas, most of which did not contain necrosis, were generally due to foreign bodies. The responsible etiologic agents were generally identified in granulomas due to fungi, bacteria, or foreign bodies (92%). However, mycobacteria were infrequently identified in granulomas, even when the lesions were examined by the auramine-O technique (31%). Overall, the majority of the granulomas (76%), were due to five causes: sarcoidosis, mycobacterial infection, particulate inclusions, fungal infection, and rheumatoid arthritis. The frequency of a given etiology, however, varied widely depending on the location of the lesion. By classifying granulomas morphologically and knowing their location, useful predictive information concerning the etiology of a given granuloma, beyond that obtained by histochemical stains, could be derived.

Natural history of acoustic neuromas.

OBJECTIVES/HYPOTHESIS: 1) Develop a computerized technique to accurately compare acoustic neuroma size on routine computed tomography and magnetic resonance imaging (MRI) scans; 2) use this technique to determine the growth pattern in a large series of patients with acoustic neuroma who were conservatively managed; 3) describe the natural history of patients with acoustic neuromas who did not receive surgical intervention and those who underwent subtotal resection; 4) correlate the size and growth rate of acoustic neuromas to clinical presentation and auditory and vestibular testing; and 5) recommend guidelines for the management of patients with acoustic neuromas. STUDY DESIGN: A retrospective study from 1974 to 1999 of patients with unilateral acoustic neuromas who had conservative treatment by serial imaging studies (80 patients) or subtotal resection (49 patients). METHODS: All patient charts were evaluated for presenting symptoms, reasons for the type of management given, and clinical outcome. Charts were also reviewed with respect to serial audiological assessment, electronystagmography, and brainstem auditory evoked response. Imaging studies were analyzed using a computer technique so that serial studies could be compared to determine growth rates. RESULTS: Rigorous computer analysis of tumor size and growth rate was statistically the same as the radiologist's description of the tumor size and growth rate. Of 70 patients who were older than 65 years of age old at the time their tumor was discovered, 4 (5.7%) required intervention and 18 (26%) were dead of unrelated causes. These patients had a mean follow-up of 4.8 years (range, 0.01-17.2 y). Overall, growth rate for nonsurgical patients was 0.91 mm per year. Nonsurgical tumors did not grow or regressed in 42%. Overall postoperative growth rate for surgical subtotal resection patients was 0.35 mm per year. Surgical tumors did not grow or regressed after subtotal resection of acoustic neuroma in 68.5% of patients. Three patients (6.1%) required revision surgery because of tumor growth or the development of symptoms. Neither auditory nor vestibular testing was a reliable measure for determining tumor growth. CONCLUSION: Measurement of the maximal tumor diameter on MRI scans is a reliable method for following acoustic neuroma growth. There is no need to perform a rigorous analysis of tumor size to determine whether the tumor is growing significantly. The vast majority of patients older than 65 years with acoustic neuromas do not require intervention. The indications for intervention should be based on a combination of rapid tumor growth with the development of symptoms.

Prediction of facial nerve function following acoustic neuroma resection using intraoperative facial nerve stimulation.

Methods of monitoring the facial nerve during posterior fossa surgery continue to evolve. In an effort to predict acute and final facial nerve function following acoustic neuroma resection, the lowest current applied to the facial nerve at the brainstem necessary to elicit facial muscle response was measured using strain gauge and electromyographic facial nerve monitors. A retrospective analysis of 121 patients who had undergone acoustic neuroma surgery was performed. Sixty-five patients had intraoperative facial nerve monitoring and 44 had sufficient data for inclusion in this study. The acute and final facial nerve functions, according to the House-Brackmann classification, were assessed with regard to intraoperative stimulation-current thresholds. Nineteen of 20 patients who required 0.10 mA or less to elicit a facial muscle response had a House-Brackmann grade I facial nerve outcome. The upper limit of the 95% confidence interval of stimulation threshold for patients with a final grade I facial nerve function is 0.17 mA. All of the patients in this study, with stimulation thresholds ranging up to 0.84 mA, had a final grade III or better result. A poor outcome in our series, a final grade III facial nerve function, is best predicted by a poor acute result, specifically an acute grade VIA facial nerve function. We suggest that it is possible to predict the facial nerve function based on intraoperative threshold testing.

Pediatric laser-assisted tympanostomy.

OBJECTIVE: To evaluate effectiveness of laser-assisted tympanostomy in treatment of pediatric patients with chronic otitis media with effusion. STUDY DESIGN: Retrospective review of 23 pediatric patients who received office laser-assisted tympanostomy. METHODS: A CO2 laser attached to an operating microscope with a microscope laser adaptor device or the handheld Oto-LAM (Needham, MA) was used to perform all of the tympanostomies. The average diameter of tympanostomy was 2 mm; on average, 13.6 W was applied for 0.13 seconds. RESULTS: Laser-assisted tympanostomy was performed on 37 pediatric ears (patient age range, 2-16 y) for the diagnosis of chronic otitis media with effusion. Average follow-up time was 4.7 weeks. At the time of the follow-up examination, 46% of the ears had no evidence of fluid and required no further intervention. Forty-nine percent of the ears required placement of pressure equalization tubes. The average SRT improved from 30.8 dB preoperatively to 21.03 dB postoperatively. CONCLUSIONS: Laser-assisted tympanostomy appears to be an effective treatment for chronic otitis media with effusion in pediatric patients.

Effect of melatonin on tinnitus.

OBJECTIVE: Evaluate melatonin as a treatment for subjective tinnitus. STUDY DESIGN: Randomized, prospective, double-blind, placebo-controlled crossover trial. Patients were given 3.0 mg melatonin, which was taken nightly for 30 days followed or preceded by a placebo nightly for 30 days, with a 7-day washout period between medications. SETTING: Outpatient, private, neurotology practice. PATIENTS: Thirty patients with subjective tinnitus. MAIN OUTCOME MEASURES: Tinnitus matching, Tinnitus Handicap Inventory (THI), patient questionnaire and interview. RESULTS: The average pretreatment THI score was 33.91 as compared with 26.43 after the placebo and 26.09 after melatonin. The difference in the THI scores between melatonin and placebo treatment were not statistically significant. The average pretreatment THI score for patients who reported overall improvement with melatonin was statistically higher (P = 0.02) than the average pretreatment THI score for patients who reported no improvement with melatonin. Among subjects reporting difficulty sleeping attributable to their tinnitus, 46.7% reported an overall improvement after melatonin compared with 20.0% for placebo (P = 0.04). There was also a statistically significant difference in improvement with melatonin for those patients with bilateral tinnitus compared with those with unilateral tinnitus (P = 0.02). CONCLUSION: Melatonin has been shown to be useful in the treatment of subjective tinnitus. Patients with high THI scores and/or difficulty sleeping are most likely to benefit from treatment with melatonin. In light of its minimal side effects, melatonin should be a part of the physician's armamentarium in the treatment of tinnitus.

Preservation of the stapedius tendon in laser stapes surgery.

OBJECTIVES/HYPOTHESIS: The stapedius tendon is routinely transected during stapes surgery. The objective of this study was to evaluate the technique of stapedial tendon preservation during stapes surgery and to compare results of these cases with cases where the stapedial tendon was not preserved. STUDY DESIGN: Retrospective study. METHODS: Four groups of patients were evaluated. Two groups had undergone stapes surgery with preservation of the stapedial tendon. One of these groups underwent a laser stapedotomy minus prosthesis (laser STAMP) procedure, while the other group had a prosthesis inserted. The other two groups had undergone laser stapedotomy with one of two different prostheses being used. Audiometric data were obtained and reviewed both preoperatively and at approximately 6 weeks postoperatively. RESULTS: All groups had overall successful results demonstrating that stapedial tendon preservation is technically possible and does not compromise outcomes. CONCLUSIONS: Based on the results, it is recommended that the stapedius tendon be preserved whenever possible during laser stapes surgery. Reasons justifying its preservation are discussed.

Laser-assisted tympanostomy.

Laser-assisted tympanostomy (LAT) was performed in 70 ears to ventilate the middle ear space without using a pressure-equalizing tube. Using a CO2 laser attached to an operating microscope with a Microslad (microscope laser adaptor device), tympanostomies of 1.0 to 3.0 mm (average, 1.6 mm) in diameter were created and remained patent for an average of 3.14 weeks. Patency time was directly related to the size of the opening. Nearly all (97.9%) of the tympanostomies healed with no noticeable scarring and no persistent perforations. Seventy-eight percent of patients at the Florida Ear & Sinus Center (FESC, Sarasota, Fla.) and 84% of patients at the Head & Neck Surgery Group (New York) showed no evidence of recurrent effusion after a minimum follow-up of 3 months. LAT appears to be a safe, cost-effective procedure which can easily be performed in an office setting when bloodless opening in the tympanic membrane is needed for either treatment or diagnosis using endoscopes.

Diagnosis and management of spontaneous cerebrospinal fluid-middle ear effusion and otorrhea.

OBJECTIVES/HYPOTHESIS: Spontaneous leak of cerebrospinal fluid (CSF) into the middle ear can occur in adults without a history of temporal bone trauma or fracture, meningitis, or any obvious cause. Therefore, clues may be lacking that would alert the otolaryngologist that fluid medial to an intact eardrum, or fluid emanating from an eardrum perforation, is likely to be CSF fluid. A review of relevant medical literature reveals that herniation of the arachnoid membrane through a tegmen defect may be congenital, or CSF leak may occur when dynamic factors (i.e., brain pulsations or increases in intracranial pressure) produce a rent in the arachnoid membrane. Because tegmen defects may be multiple rather than single, identifying only one defect may not be sufficient for achieving definitive repair. Data on nine cases of spontaneous CSF leak to the ear in adult patients from four medical centers are presented and analyzed to provide collective information about a disorder that can be difficult to diagnose and manage. STUDY DESIGN: Retrospective review of nine cases of spontaneous CSF middle ear effusion/otorrhea. RESULTS: The majority of patients presented with symptoms of aural fullness and middle ear effusion. Many developed suspicious clear otorrhea only after insertion of a tympanostomy tube. Two patients had multiple defects in the tegmen and dura, and five patients had meningoencephaloceles confirmed intraoperatively. Five patients underwent combined middle cranial fossa/transmastoid repair. Materials used in repair included temporalis fascia, free muscle graft, Oxycel cotton, calvarial bone, pericranium, bone wax, and fibrin glue. CONCLUSIONS: CSF middle ear effusion/otorrhea can develop in adults without a prior history of meningitis or head trauma or any apparent proximate cause. Although presenting symptoms can be subtle, early suspicion and confirmatory imaging aid in establishing the diagnosis. Because surgical repair by way of a mastoid approach alone can be inadequate if there are multiple tegmen defects, a middle fossa approach alone, or in combination with a transmastoid approach, should be considered in most cases.

Age-related changes in the internal branch of the rat superior laryngeal nerve.

This investigation was initiated to provide data on the ultrastructural basis for neurologic age-related changes in laryngeal sensory function. In the present study, an animal model (female Wistar rats: age range: young [Y], 3 to 5 months; old [O], 25 months; and very old [VO], 29 to 30 months) was used to examine systematically changes in the internal branch of the superior laryngeal nerve with age using electron microscopic morphometric techniques. Total fiber counts, fiber populations (size categories), and mean fiber size for myelinated and unmyelinated fibers did not change with age. Qualitative changes were consistent with segmental demyelination and axonal degeneration in the older animals. There was also a significant age-related increase in the volume fraction of adaxonal Schwann cell cytoplasm (Y, 0.019; O, 0.041; and VO, 0.042). Ultrastructural correlates of intracellular support and axonal transport showed a significant decrease in the numerical density of neurofilaments (Y, 0.126/micron2; O, 0.073/micron2; and VO, 0.078/micron2) in the older animals, but no change in the numerical density of microtubules. Energy metabolism correlates in the form of mitochondrial volume fraction did not change with age. There was a significant increase in the volume fraction of the intrafascicular extracellular space (Y, 0.224; O, 0.271; and VO, 0.301), indicating a late, age-related change in the extracellular environment. These changes could lead to decreased conduction velocity or complete fiber dysfunction. A number of these changes resembled those of aged human peripheral nerves already examined.

Use of endoscopes for chronic ear surgery in children.

OBJECTIVE: To determine whether an endoscopic second-look examination of the mastoid and middle ear could replace an open second-look mastoidectomy. DESIGN: Patients were examined endoscopically. The findings were compared with a standard open mastoidectomy procedure during the same operation. The mastoid can be inspected through a small postauricular incision and the middle ear can be inspected through a myringotomy incision or tympanomeatal flap. PATIENTS: Ten patients aged 6 to 16 years. RESULTS: Endoscopic findings correlated exactly with open mastoidectomy findings in all cases. CONCLUSION: In light of this study an open second-look mastoidectomy may be avoided if minimal or no recurrent cholesteatoma is found during the endoscopic exploration. The use of the ridged endoscope has added another dimension to the standard microsurgical techniques used in pediatric otology. The indications, techniques, and findings of otoendoscopy in the management of chronic otitis media in children will be presented.

Age-related changes in Schwann cells of the internal branch of the rat superior laryngeal nerve.

While previous studies have examined the role of neurons in age-related changes of laryngeal sensory nerve function, investigators have not focused on the significant role of Schwann cells in the aging process. This investigation used an electron microscopic morphometric technique to systematically study Schwann cells of the internal branch of the superior laryngeal nerve of three Wistar rat age groups: young = 3 to 5 months; old = 25 months; very old = 29 to 31 months. In Schwann cells of myelinated axons, a substantial and significant reduction (p = 0.0127) in mitochondrial volume fraction was found between the young and old groups, and also between the young and very old groups (young = 0.0034, old = 0.00175, very old = 0.0019). The volume fraction of compact myelin also showed a trend (p = 0.0683) toward decreasing with age. The volume fractions of cytoplasm, nuclei, and lipofuscin granules showed no significant age-related changes (lipofuscin in myelinating Schwann cells: young = 0.0025, old = 0.0020, very old = 0.0051; lipofuscin in non-myelinating Schwann cells: young = 0.012, old = 0.0061, very old = 0.0051). Our observations on mitochondria lead to two possible conclusions regarding energy availability in aged Schwann cells. One possibility is that aged cells have a decreased energy requirement, which is reflected in the decreased mitochondrial densities in old and very old specimens. The other possibility is the reduced mitochondrial volume fractions are independent of cellular energy requirements and are indicative of some aging or pathologic process.(ABSTRACT TRUNCATED AT 250 WORDS)

Hearing results after posterior fossa vestibular neurectomy.

The effect of posterior fossa vestibular neurectomy on postoperative hearing levels of 172 patients was studied at 1 week, 1 month, 1 year, and 18 to 24 months. According to the 1985 American Academy of Otolaryngology-Head and Neck Surgery guidelines for reporting treatment outcome, 66% of patients had improved or unchanged hearing at 18 to 24 months. One-week postoperative hearing was poorer than at 1 month or later follow-up. Permanent profound hearing loss occurred in 4.7% of patients. In patients who had worse than 80 dB pure-tone average and 20% speech discrimination score hearing loss before surgery, 68% improved above this hearing level, and 16% improved to better than 50 dB pure-tone average and 50% speech discrimination after surgery. This suggests that it may be worthwhile to preserve the cochlear nerve in certain patients who may otherwise be candidates for labyrinthectomy. These hearing results are comparable with other treatment modalities including endolymphatic sac surgery.

A comparison of growth rates of acoustic neuromas: nonsurgical patients vs. subtotal resection.

A conservative approach to the management of acoustic neuromas in elderly patients has been used since 1971. Elderly patients without symptoms of brain stem compression are initially treated by observation and yearly radiographic imaging. A translabyrinthine radical-subtotal resection is performed if brain stem compression is present or if tumor is growing rapidly. Twenty-three patients, ages 65 to 86 years, had initial nonsurgical management of their tumors. Growth rates could be determined for 16 patients. Thirteen patients not requiring surgery had an average tumor growth rate of 0.6 mm/yr. Three patients with an average growth rate of 6.8 mm/yr eventually required surgery. No patient whose tumor was < 15 mm at initial evaluation has experienced brain stem symptoms or demonstrated rapid tumor growth. Twenty-four patients ages 65 to 86 years underwent planned subtotal tumor excision. Eighteen patients followed postoperatively for more than 1 year demonstrated an average rate of regrowth of tumor of 0.7 mm/yr.

Middle ear air injection after chronic ear surgery.

In the early period after chronic ear surgery, the reasons for conductive hearing loss may be difficult to determine. Patients who cannot autoinflate the middle ear after 3 weeks, or who have a negative Rinne test result with the 512 Hz tuning fork, are treated with a transtympanic injection of 0.5 cc of air with a 27-gauge needle and tuberculin syringe. This represents 20% of patients who had chronic ear surgery. Results show that hearing may be immediately improved, the sensation of pressure in the ear may be reduced, and fluid may be cleared from the middle ear. Other benefits may include the release of adhesions. The surgeon is better able to assess the thickness of the graft, and the status of the ossicular chain reconstruction can be determined. There have been no complications of middle ear infection or failure of the micropuncture site to heal. In our practice, middle ear air injection is a routine procedure in patients with inadequate eustachian tube function after chronic ear surgery. This report describes the results of 100 patients over 14 years who received middle ear air injections after chronic ear surgery compared with a control group of 100 patients who did not meet the criteria for requiring air injection. Hearing was immediately improved in 74% of patients as determined by Rinne testing. Audiograms were performed in 25 of these patients, documenting a mean improvement in pure-tone average of 16 dB. The long-term hearing results in patients undergoing air injection, who by definition had evidence of poor eustachian tube function, are similar to the results in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

An algorithm for the management of acoustic neuromas regarding age, hearing, tumor size, and symptoms.

An algorithm has evolved for the management of patients with acoustic neuroma. Decisions as to surgery vs. observation, surgical approach, and whether hearing preservation should be attempted depend on age, patient symptoms, size of the tumor, residual hearing, and degree of facial nerve involvement at the time of surgery. Conservative management is used for patients over 65 years of age. This consists of observation or subtotal resection through a translabyrinthine approach, depending on the absence or presence of brainstem signs or symptoms. In patients under 65 years of age, hearing preservation is attempted through the retrosigmoid approach in tumors 1.5 cm or less if pure-tone average is less than 30 dB and the discrimination score is greater than 70%. The translabyrinthine approach is our preferred approach for tumors of any size when hearing is not serviceable. A near-total excision is performed when the facial nerve cannot be separated from the tumor. The rationale for this algorithm in the management of 130 cases of acoustic neuroma over the past 17 years is presented.

Direct round window membrane application of gentamicin in the treatment of Meniere's disease.

OBJECTIVE: To evaluate the effectiveness of the round window membrane (RWM) Gelfoam gentamicin technique in patients with Meniere's disease who were unresponsive to medical management or in whom surgical therapy failed. STUDY DESIGN: Protocol 1, single intratympanic gentamicin infusion; protocol 2 (the best method), 2 infusions, 5 days apart with reevaluation at 1 month; and protocol 3, multiple infusions 1 to 4 weeks apart. PATIENTS: In total, 32 patients (19 male, 13 female) were enrolled in the study. The mean age was 65 years (range 34 to 94 years). Seven of these patients were surgical salvage cases. INTERVENTIONS: Laser-assisted otoendoscopy with a 1.7-mm otoendoscope (Smith-Nephew Richards, Memphis, TN) was performed first. If the RWM was obscured by mucosa or adhesions, these were cleared before placing a 2 x 3 mm piece of dry Gelfoam against the RWM. Buffered gentamicin (26.7 mg/mL) was then injected into the middle ear (0.2 to 0.3 mL). RESULTS: Overall, vertigo was controlled in 75% of the patients after the completion of the treatment, with subtotal vestibular ablation in two thirds of patients. Hearing was preserved in 90% of the patients (within 15 dB pure-tone average or 15% speech discrimination score), tinnitus improved in 48%, and aural pressure improved in 62.5%.

Endoscopic otologic surgery.

In this article, various otologic and neurotologic procedures, including middle ear exploration, chronic ear disease surgery, second-look mastoidectomy, acoustic neuroma surgery, and vestibular neurectomy, are reviewed for the usefulness of minimally invasive endoscopic techniques.

Vestibular surgery for Ménière's disease in the elderly: a review of techniques and indications.

There are several safe and effective surgical options for the treatment of vertigo associated with Ménière's disease in the elderly patient. The choice of procedure depends on the patient's hearing status and overall health. Since 1987, combined retrolabyrinthine-retrosigmoid posterior fossa vestibular neurectomy was performed on 29 older patients who were in good physiologic health and whose hearing was better than 80 dB pure-tone average and 20% speech discrimination. Patients whose hearing is worse are offered transmastoid labyrinthectomy or transmeatal cochleovestibular neurectomy, barring contraindications. When extensive surgery is medically contraindicated and hearing is not a significant concern, cochleosacculotomy is preferred; this procedure has been performed with minimal morbidity on patients as old as 85. Finally, over the past several years, patients have been treated with transtympanic placement of gentamicin. Early results with this office-based local procedure demonstrate a high care rate, but also a high incidence of sensorineural hearing loss.

Laryngeal involvement in neurofibromatosis.

Neurofibromas of the larynx are an uncommon component of neurofibromatosis, but should be considered in the differential diagnosis of patients with a submucosal supraglottic mass. Complete surgical excision is the treatment of choice; however, incomplete excision may be preferable to aggressive debilitating surgery. Plexiform neurofibroma differs from non-plexiform neurofibroma in that it is poorly circumscribed and highly infiltrative. Tracheostomy may be necessary. Sarcomatous degeneration is reported and carries a poor prognosis.

Intratympanic steroid treatment of inner ear disease and tinnitus (preliminary report).

Intratympanic instillation of Depo-Medrol (80 mg/cc), dexamethasone ophthalmic solution (1 mg/cc), or dexamethasone intravenous (4 mg/cc) solution produces improvement of cochlear function in certain patients with Meniere's disease, autoimmune inner ear disease and sudden sensorineural deafness. Tinnitus improved in 47%, most often in patients with Meniere's disease (9 of 15; 60%). The SRT improvement of greater than 10 dB or SD greater than 15% was documented in 41% (average improvement in SRT: 15 dB; SD: 24%). Patients with tinnitus and bilateral sensorineural hearing loss (i.e., presbycusis) did not benefit from the treatment. Prior to treatment with intratympanic medication, laser assisted tympanostomy with middle ear exploration, using otoendoscopy to determine the status of the round window niche and remove mucosal folds, helps in making the round window membrane accessible to local application of drops. Placing Gelfoam into the round window niche under direct vision, and using a Venturi Bobbin tube in the tympanic membrane, appears to be a satisfactory method for delivering medication to the inner ear fluids. The medication can be injected by the physician through the tube into the middle ear, or the patient can perform self-treatment at home, placing medication in the external auditory canal. A double-blind, cross-over study in patients with Meniere's disease is now in progress with Institutional Review Board (IRB) approval, which will be reported at a later date. This preliminary study has shown that intratympanic steroids may affect the symptoms of hearing loss and tinnitus in patients with various inner ear problems. Patients with Meniere's disease appear to respond in the highest percentage of cases. Hopefully, additional research will suggest the appropriate drugs which can be used to treat inner ear disease. Direct application of the drug to the round window membrane may increase the concentration in the inner ear fluids, thus avoiding the systemic effects.