Minimally invasive functional approach for cholesteatoma surgery.

OBJECTIVES/HYPOTHESIS: Report the efficacy of a functional minimally invasive approach for cholesteatoma surgery. STUDY DESIGN: Retrospective review of surgical cases performed between 1996 and 2008. METHODS: One hundred sixty-nine patient charts were reviewed in which ears with primary cholesteatomas that extended beyond the mesotympanum were operated on with a plan for canal wall up (CWU) mastoidectomy. The surgical approach consisted of progressive exposure from transcanal to postauricular tympanoplasty to CWU mastoidectomy, as needed, to identify and lyse the fibrous attachments that bind the capsule to the surrounding mucosa. Endoscopic guidance was employed as appropriate to minimize exposure needs. Any planned second-stage operations were attempted with a transcanal approach if appropriate and with endoscopic assistance. RESULTS: One hundred eighty-four ears of 169 patients were included. The median age was 32 years (range, 1-79 years). The mean follow-up was 3.2 years (range, 1-11 years). Eighty-three (45%) were planned for a second-look operation, and three (2%) required unplanned second operations. The overall recurrence rate was 24/184 (13%), and the unexpected residual rate was 5/184 (3%). The residual rate with endoscopy (5/119, 4%,) or without endoscopy (1/65, 2%), were not significantly different. Hearing results in 156 ears improved significantly, from a preoperative pure-tone average (PTA) of 41 dB to a postoperative PTA average of 29 dB (P < .0001). CONCLUSIONS: A functional minimally invasive approach to cholesteatoma surgery provided equivalent residual rates but higher recurrence rates compared to published canal wall down mastoidectomy. Endoscopic techniques were helpful in providing adequate views while minimizing exposure.

Unilateral cochlear nerve deficiency in children.

OBJECTIVE: Cochlear nerve deficiency (CND) is increasingly diagnosed in children with sensorineural hearing loss (SNHL). We sought to determine the prevalence of CND, its imaging characteristics, and correlations with audiologic phenotype in children with unilateral SNHL. DESIGN: Case series with chart review. SETTING: Tertiary pediatric hospital. SUBJECTS/METHODS: In 128 consecutive children with unilateral SNHL who underwent high-resolution magnetic resonance imaging, the diameters, area, and signal intensity of the cochlear nerve (CN) were measured and normalized to the ipsilateral facial nerve. Presence of CND was determined by comparison to normative data. Relationships among hearing loss severity, progression, and nerve size were investigated. RESULTS: Cochlear nerve deficiency was present in 26% of children with unilateral SNHL. Its prevalence was higher (48%) in severe to profound SNHL, especially when in infants (100%). Width of the bony cochlear nerve canal (BCNC) correlated strongly with relative CN diameter, density, and area (R = 0.5); furthermore, a narrow BCNC (<1.7 mm) strongly predicted CND. Severity of hearing loss modestly correlated with nerve size, although significant variability was observed. Progression never occurred unless there were other inner ear malformations, whereas in the non-CND group, it occurred in 22%. Ophthalmologic abnormalities were very common (67%) in CND children, particularly oculomotor disturbances. CONCLUSION: Cochlear nerve deficiency is a common cause of unilateral SNHL, particularly in congenital unilateral deafness. Width of the BCNC effectively predicts CND, a finding useful when only computed tomography imaging is available. In an ear with CND, hearing can be expected to remain stable over time. Diagnosis should prompt evaluation by an ophthalmologist.

Comparison of postoperative pain in pediatric patients undergoing coblation tonsillectomy versus cautery tonsillectomy.

OBJECTIVE: To compare postoperative pain scores between monopolar electrocautery and coblation subcapsular tonsillectomy. STUDY DESIGN: Prospective double-blind randomized study. SETTING: Tertiary care children's hospital. SUBJECTS AND METHODS: Between December 2004 and April 2008, 61 children, ages 4 to 20 years (mean age, 10 years; SD, 4 years), were randomized to have one tonsil removed by electrocautery and the other tonsil removed by coblation. Subjects used the FACES scale to rate pain on each side immediately postoperatively, 2 days postoperatively, and 2 weeks postoperatively. Postoperative hemorrhage was also tracked. RESULTS: Coblation tonsillectomy resulted in statistically less pain than electrocautery immediately after surgery, but this difference was not clinically significant. CONCLUSIONS: Pediatric pain is similar following monopolar electrocautery or coblation subcapsular tonsillectomy.

Comparison of activated caspase detection methods in the gentamicin-treated chick cochlea.

Aminoglycoside antibiotics induce caspase-dependent apoptotic death in cochlear hair cells. Apoptosis, a regulated form of cell death, can be induced by many stressors, which activate signaling pathways that result in the controlled dismantling of the affected cell. The caspase family of proteases is activated in the apoptotic signaling pathway and is responsible for cellular destruction. The initiator caspase-9 and the effector caspase-3 are both activated in chick cochlear hair cells following aminoglycoside exposure. We have analyzed caspase activation in the avian cochlea during gentamicin-induced hair cell death to compare two different methods of caspase detection: caspase antibodies and CaspaTag kits. Caspase antibodies bind to the cleaved activated form of caspase-9 or caspase-3 in specific locations in fixed tissue. CaspaTag is a fluorescent inhibitor that binds to a reactive cysteine residue on the large subunit of the caspase heterodimer in unfixed tissue. To induce cochlear hair cell loss, 1-2 week-old chickens received a single injection of gentamicin (300 mg/kg). Chicks were sacrificed 24, 30, 42, 48, 72, or 96 h after injection. Cochleae were dissected and labeled for activated caspase-9 or caspase-3 using either caspase-directed antibodies or CaspaTag kits. Ears were co-labeled with either phalloidin or myosin VI to visualize hair cells and to determine the progression of cochlear damage. The timing of caspase activation was similar for both assays; however, caspase-9 and caspase-3 antibodies labeled only those cells currently undergoing apoptotic cell death. Conversely, CaspaTag-labeled all the cells that have undergone apoptotic cell death and ejection from the sensory epithelium, in addition to those that are currently in the cell death process. This makes CaspaTag ideal for showing an overall pattern or level of cell death over a period of time, while caspase antibodies provide a snapshot of cell death at a specific time point.