Comparative study of otologic surgery in outpatient and hospital settings.

The results of nine years' experience with 1,750 otologic surgical procedures are reviewed; 1,110 of these procedures were performed in an outpatient surgical setting and 640 procedures were performed in a general hospital. The results and complications are compared between these two settings. This study includes tympanoplasty, stapedectomy, mastoidectomy, labyrinthectomy, and other otologic procedures. The study is not concerned with minor procedures such as myringotomy. A detailed analysis of results for each type of procedure compares hearing results, graft take rates, and the occurrence of complications in both outpatient and inpatient settings. No significant differences are seen between the results or complications of outpatient and inpatient procedures, thus supporting the use of outpatient surgical settings for most standard otologic procedures.

Cholesteatoma in children.

The surgical management of cholesteatoma in children remains a controversial subject. Many authors hold that the disease itself is more aggressive than that seen in adults. Furthermore, there appears to be a consensus that intact canal wall procedures, if used at all, should be reserved for adults only. The purpose of this paper is to study a group of children and adults who underwent the surgical removal of their cholesteatoma by intact canal wall tympanoplasty at the Otology Group between March 1, 1971 and March 1, 1977. A comparison of the results and complications in the two groups is presented in detail.

Herpes zoster oticus: treatment with intravenous acyclovir.

Herpes zoster oticus generally has a poor prognosis, leaving many patients with permanent facial nerve dysfunction. This preliminary report describes results in seven patients treated for zoster; all were given intravenous acyclovir. Patients were infused with 10 mg/kg every 8 hours over a 7-day hospitalization period. Five of the seven patients showed some return of facial function at the time of discharge. At follow-up, 4 patients had achieved a House grade I result, 1 patient a grade II, and 2 patients a grade III. Reasons for the differences in final results are discussed, along with a recommended regimen for treatment.

Panel discussion: glomus jugulare tumors of the temporal bone. The surgical management of glomus tumors.

The authors describe the diagnosis and surgical management of 70 glomus tumors seen at the Otology Group in an 8 yr. period. The need for bilateral arteriograms to detect associated tumors (carotid body and intervagale) is stressed. A new surgical technique, the modified intratemporal fossa approach, is described for the removal of large glomus jugulare tumors involving the carotid artery. Complications and results are discussed in detail.

Rehabilitation of the face following traumatic injury to the facial nerve.

Etiology, diagnosis, and surgical management of facial paralysis due to traumatic injury of the VIIth cranial nerve are discussed. Sixty patients are reviewed who underwent some type of surgical procedure for the repair of the facial nerve. These cases are categorized according to etiology, which includes temporal bone fractures, iatrogenic injuries, and penetrating wounds of the head and neck. The results of a poll of eight leading otologists on their approaches to several aspects of the surgical management of these injuries are presented in the Discussion section. The diagnostic and prognostic studies associated with facial paralysis, as well as the more common surgical procedures available for repair of the facial nerve, are briefly reviewed.

Surgical management of brain tissue herniation into the middle ear and mastoid.

In the well pneumatized temporal bone, the temporal lobe of the brain is separated from the middle ear and mastoid process by a thin layer of bone known as the tegmen. Congenital defects, infection, and trauma can alter this structure in such a way that cerebral tissue herniates into the ear. This unusual condition may precipitate numerous otologic problems such as hearing loss, trapped squamous epithelium, and the potential for meningitis or encephalitis. The purpose of this paper is to define the problem as well as discuss the diagnosis and surgical management. The authors feel this should be a team effort, in many cases employing the assistance of a neurosurgeon, as the repair must often be intradural. Case histories and an extensive review of the literature are to be included.

Vascular anomalies of the middle ear.

The patient presenting with a red mass behind the eardrum and a pulsating tinnitus may well have a vascular tumor. One must be ever mindful, however, that the mass may represent a congential vascular anomaly. The most common one seen is the uncovered jugular bulb in which the vessel extends superiorly into the middle ear to or above the incudostapedial joint. More rare is the uncovered and posteriorly displaced carotid artery. The purpose of this paper is to review the literature on the subject of vascular anomalies of the middle ear and temporal bone and to discuss the diagnosis and management of these lesions. Illustrative case reports with color photographs are presented as well.

Brain stem evoked response audiometry in a clinical practice.

Brain stem evoked response audiometry (BERA) is an effective method of evaluating the auditory pathway from the peripheral endorgan through the brain stem. The authors have found this test to be a valuable adjunct to the neurotologic evaluation and have applied the study to over 500 patients (639 ears) in a 22 month time span. BERA has an excellent success rate (98%) in determining the presence of cerebellopontine angle lesions and is helpful in establishing whether a hearing loss is of cochlear or retrocochlear type. The authors have found BERA of use in the diagnosis of multiple sclerosis as well as other neurologic diseases affecting the brain stem. It is a valid method of dealing with suspected malingerers and those who cannot respond to standard audiometric techniques. BERA has been helpful in determining the threshold of hearing in these patients. The authors conclude that BERA is a clinical study of practical significance and that more otolaryngologists should consider adding it to their diagnostic protocol.

Clinical significance of type 5 patterns in platform posturography.

Several abnormal patterns have been identified on the sensory portion of the computerized dynamic posturography test. The vestibular deficit pattern, also known as the "5-6" pattern, is frequently seen in patients with either uncompensated unilateral vestibular lesions, severe bilateral peripheral vestibular loss, or dysfunction involving the vestibular pathways in the brain stem and/or cerebellum. In both sensory conditions 5 and 6, the patient's balance/equilibrium is determined primarily by the vestibular system. A subgroup of the vestibular deficit pattern has been identified, in which only sensory condition 5 is abnormal. This article presents findings in several cases identified with the 5 pattern. Implications for diagnosis and for monitoring the recovery phase after treatment are discussed.

Endolymphatic mastoid shunt surgery using the Denver inner ear shunt.

This study, merging data from two different clinics, was undertaken to evaluate the efficacy of endolymphatic mastoid shunt surgery using the Denver Inner Ear Shunt operation for Meniere's disease. This surgery was performed by the senior authors (C.G.J., J.R.E.D., and M.E.G.) between May 1984 and October 1986, after we attended the Colorado Otologic Research Center (CORC) instructional course. Sixty-six and thirty-four cases, respectively, were performed. Follow-up questionnaires were sent to this total of 100 patients. Fifty-six patients returned completed questionnaires, which formed the basis of this report. A retrospective chart study was also carried out. The results of surgery and questionnaires are reported as statistical data, and, where applicable, the 1985 AAO-HNS criteria for reporting vertigo and hearing results in the treatment of Meniere's disease are used. Preliminary analysis of these data is reported because of its profound effect upon our treatment protocol for patients with Meniere's disease. Results on use of the Denver valve do not appear to be significantly different than the results of other shunt surgery not using the valve.

Complications of acoustic tumor surgery.

In removing acoustic tumors, the primary goal is total removal, with preservation of life and the least possible permanent neurological sequelae. In all but the smallest of cerebellopontine angle lesions, total tumor removal necessitates sacrifice of the eighth cranial nerve. In large lesions, total tumor removal may necessitate sacrifice of the seventh cranial nerve as well. The optimal approaches for accomplishing these goals with minimal complications are the translabyrinthine and combined translabyrinthine-suboccipital approaches. The middle fossa approach is appropriate only for intracanalicular lesions. In the series of 383 tumor cases discussed, total tumor removal was accomplished in 379 (99 per cent) of the cases. Overall, the facial nerve was preserved in 80 per cent of the patients. There were no fatalities. The most frequent complication was postoperative cerebrospinal fluid leakage. Surgery of the posterior fossa continues to be hazardous, with significant morbidity rates. Complications do occur, and those performing these procedures must be prepared to manage them. The occurrence of complications can be greatly reduced through a thorough preoperative evaluation as well as through meticulous microsurgical attention to detail. It is important for all surgeons working in the cerebellopontine angle to reassess their technique periodically in order to improve results. In our experience, self-re-evaluation has reduced postoperative complications, particularly in regard to cerebrospinal fluid leaks. Early diagnosis of acoustic neuromas would permit surgery for smaller lesions, thereby decreasing complications. However, it is well recognized that we will continue to see a high percentage of large tumors and must be prepared to handle these difficult lesions and their complications.

Approach to diagnosis of skull base lesions.

The ability to operate safely on the skull base and yet preserve cranial nerves and leave the patient with minimum neurologic deficit is a fairly new development. The field is expanding rapidly, and lesions that were once deemed unresectable can now be resected. With this in mind, one must maintain an extremely high index of suspicion for lesions in this area. Early diagnosis of skull base lesions is enhanced by a careful neuro-otologic history and physical examination on all patients with complaints of pain, headache, or cranial nerve dysfunction, either motor or sensory. Based on a thorough examination, a tentative lesion localization is made and appropriate special sensory, laboratory, and radiographic tests are used to confirm the abnormality. In addition, it is our responsibility to maintain a knowledge of the state of the art as to treatment possibilities for skull base lesions.

Menière's disease--1983-1989.

A MEDLINE review of Menière's disease for the years 1983 through June, 1989 identified over 300 articles published in the English language. These articles have been reviewed, and those which represent significantly new or different findings from a previously published review article are summarized. Specific studies have been selected to highlight new areas of interest as well as new areas of controversy. Major trends in the period from 1983 through 1989 include a new AAO-HNS criteria for reporting results in Menière's disease, expanding interest in the relationship between immune disorders and Menière's disease, and new long-term studies of endolymphatic shunt procedures, with many reporting that these procedures provide only short-term relief and no long-term preservation of hearing.

A comparison of facial nerve monitoring systems in cerebellopontine angle surgery.

The use of peripheral nerve monitoring during skull base surgery is becoming a more common procedure. One widely used method (Jako) detects surface muscle contraction, which can be transduced into an audible signal. A 200 microsecond square wave current can be delivered periodically, in order to identify the nerve and verify its integrity. Another monitoring method has been developed, which provides a continuous audible needle electromyographic (EMG) feedback signal from computer averaging of a monopolar low impedance constant voltage stimulus. This study compares facial nerve preservation and postoperative facial nerve function results of three groups of cerebellopontine angle surgical cases: 38 cases performed with no monitoring; 29 cases done with Jako motion detection monitoring; and 41 performed with evoked needle EMG audible feedback monitoring. Postoperative facial nerve function is evaluated using the House-Brackmann grading system. Each of the three study groups are matched for a time at which postoperative evaluation was made. Analysis of results reveals that in addition to the expected increase in facial nerve preservation rates when monitoring is in use, the near real-time feedback provided by audible evoked EMG results in a significant reduction in permanent postoperative facial nerve dysfunction. Using evoked monitoring, a greater proportion of the cases had a final outcome of class I or II results, compared to those cases performed using Jako motion detection monitoring.

Evaluation of the dizzy patient.

The differential diagnosis of dizziness is difficult, yet challenging. There continues to be a need for improvement in assessment and evaluative procedures for patients with symptoms of dizziness. The otologist must exclude a wide variety of potential disorders which could be sources of the symptoms. The key to a well-made differential diagnosis is a very carefully taken, thorough, medical history, and the integration of that history with the physical examination, the audiometry, and the vestibular evaluation.

Otologic surgery in the outpatient versus the hospital setting.

The results of 11 years experience with 1,577 otologic surgical procedures performed in The Ear & Nose-Throat Clinic, P.A. in Little Rock, Arkansas, a freestanding outpatient surgical setting, are analyzed and compared to 703 hospitalized inpatient cases performed during the same time period. This study includes tympanoplasty, stapedectomy, mastoidectomy, labyrinthectomy and other otologic procedures. Analysis of results in these cases compares hearing results, graft take rates and the occurrence of complications in both the outpatient and inpatient settings. No significant differences are seen between the results or complications in these settings, thus supporting the use of outpatient surgical settings for most standard otologic procedures.