Bromocriptine in the treatment of premenstrual tension syndrome.

Twenty-four women with regular cycles who reported moderate to severe premenstrual tension participated in a double-blind study to test the effectiveness of CB154 on the control of their symptoms. Symptoms were scored daily and were further evaluated objectively twice monthly by physical examination. Control cycle follicular/luteal delta weights were not different statistically from a 0 change (P > .10), despite long-standing symptoms of bloating, swelling, and reported weight gain. CB154 treatment resulted in statistically significant improvement in daily ratings of breast tenderness (P < .005), bloating (P < .02), and depression (P < .05). Significant placebo effects observed for several other symptoms emphasize the psychologic component of this condition as well as the need for caution in the interpretation of any uncontrolled trials for therapies thought effective in the treatment of this disorder.

The ultrastructure of the endolymphatic sac in man.

The present investigation describes the ultrastructure of the human endolymphatic sac in surgical biopsy specimens from 14 patients with acoustic neuroma and Ménière's disease. The intent of the study is to illustrate the normal appearing human endolymphatic sac by transmission electronmicroscopy (TEM) and to detail histopathologic alterations which occur in patients with acoustic neuroma and Ménière's disease. Normal endolymphatic sac histology is elucidated and provides a basis for discussing pathologic changes seen in disease states. The endolymphatic sac undergoes similar histopathologic changes in patients with acoustic neuroma and Ménière's disease. Epithelial degeneration, thickening of the basilar lamina and perisaccular fibrosis appear in both disease processes. The presence of similar pathologic changes in the endolymphatic sac patients with acoustic neuroma and Ménière's disease suggests that the sac degeneration is the result of the disease process and not necessarily its cause.

Multichannel cochlear implant. Preliminary results in man.

Cochlear implantations of multichannel electrode arrays have been recently undertaken at the University of California, San Francisco in several totally deaf investigational subjects. One patient was extensively tested with a psychoacoustical battery and is the subject of this communication. Speech testing with CID sentences and open sets of spondee words revealed that this totally deaf subject could achieve approximately 40 to 50% discrimination level with his implant device alone in the absence of visual cues. This represents the first time that speech discrimination has been definitely shown in a cochlear implant subject, and this result has important implications for the future of cochlear implantations.

Multichannel cochlear implants. Current status and future developments.

The University of California, San Francisco has been active in the development of the multichannel cochlear implants for rehabilitation of total sensory deafness for the past 8 years. Patients implanted with experimental prototypes of the devices now in use have demonstrated that speech discrimination of 40% to 50% is possible for common everyday words and sentence material. These devices provide the same stimulation to each of the 8 bipolar pairs in the cochlea. They have an internal disconnect device which allows for replacement and upgrading of implanted receiver-drivers without disturbing the scala tympani electrodes. Application of these devices in a larger deaf population is currently underway. The present report discusses the current status of implants and the future developments we fell are necessary to achieve improved speech discrimination.

The surgical management of recalcitrant malignant external otitis.

Aggressive medical management and surgical debridement is curative in most cases of malignant external otitis. Recently, four patients with this condition were treated at the University of California, San Francisco, who did not respond to conventional therapy. In each case, appropriate intravenous antibiotics, diabetic management, and extensive excision of involved tissue failed to eradicate the infection. Progression of the disease was evidenced by any one of the following: 1. Persistence of granulation tissue in the external auditory canal, 2. Development of cranial neuropathies during treatment, 3. Other signs or symptoms of active infection for more than two weeks after institution of therapy. Any one of these criteria was considered an indication for more radical surgical intervention. In three patients, the operative procedure consisted of a subtotal temporal bone resection to gain access to the primary focus of infection and provide adequate drainage. The common finding in each case was an abscess cavity in the soft tissues at the base of the skull. A description of the clinical course and surgical management of malignant external otitis forms the basis of this communication.

Mondini's dysplasia with recurrent meningitis.

This report describes the diagnosis and surgical management of two patients with similar inner ear malformations resulting in recurrent otitic meningitis. Each patient had a meningocele presenting through the oval window associated with Mondini's anomaly. Details of radiographic diagnosis and surgical management strategies will be discussed and long-term follow-up presented.

Preliminary results with the Clarion cochlear implant.

A new cochlear implant has become available. This device, called the Clarion Multichannel Cochlear Implant, is the result of collaborative efforts between the University of California, San Francisco (UCSF), the Research Triangle Institute (RTI), Research Triangle Park, North Carolina, and the device manufacturer and sponsor, MiniMed Technologies of Sylmar, California. The Clarion represents a new generation of multi-programmable cochlear implant systems. Options in waveform, the stimulation mode, and the temporal distribution of the signal permit the device to be optimally customized for each individual patient. The speech coding scheme offering the greatest opportunity for speech recognition can be selected. The first Clarion recipient has recently been implanted at UCSF, initiating the Clarion's investigational clinical trials. A description of the device and preliminary patient results are presented.

Role of the mastoid in tympanic membrane reconstruction.

Otologists have long debated the importance of the mastoid in determining the success or failure of tympanic membrane reconstruction. The pneumatic spaces within the mastoid represent an "air reservoir" which can be drawn upon during periods of eustachian tube dysfunction and buffer the middle ear against the development of detrimental negative pressures. Mastoid inflammatory disease, if untreated, may result in recurrent suppuration and graft failure. Small mastoid volume, aside from its well known association with chronic infectious middle ear disease, has been shown to effect adversely graft survival following myringoplasty. In 48 patients undergoing myringoplasty with simple mastoidectomy, neither small mastoid size nor inflammatory mastoid disease significantly decreased the rate of graft healing. This suggests that simple mastoidectomy is an effective means of repneumatizing the mastoid and eradicating mastoid sources of infection. The successful surgical creation of a pneumatized mastoid cavity in communication with the middle ear was confirmed by postoperative computerized tomographic (CT) scans. In failed cases, CT scanning predictably identified residual mastoid disease. Simple mastoidectomy is considered to be a safe and useful adjunct to myringoplasty in selected cases of chronic otitis media with perforation.

Stapedectomy in residency training.

The number of new patients with otosclerosis seen by the average otolaryngologist has declined over the past several years. As a result, a controversy has arisen regarding the ability to train residents adequately in the technique of stapedectomy. In this regard, we have analyzed 44 consecutive stapedectomies performed by senior residents, under direct faculty supervision, at the University of California, San Francisco. All procedures were total stapedectomies, performed under local anesthesia, utilizing either wire-vein or wire-perichondrium technique. Four of the ears required footplate or promontory drilling. Closure to within 10 dB of the preoperative bone conduction, averaged over the speech frequencies of 500, 1000, and 2000 Hz, was achieved in 75% of ears, and closure to within 20 dB in 93% of ears. In no patient was hearing made worse. While there were no permanent complications, self-limited problems occurred in 9% of the procedures. Despite a declining caseload of otosclerotic ears in residency programs, it is possible to train residents safely in stapes surgery, given a program of consistent technique and close faculty supervision.

Dermoid of the petrous apex.

Radiolucent lesions of the petrous apex of the temporal bone are unusual, with an incidence of less than 1%. The differential diagnosis includes giant apical air cells, acquired cholesteatomas, congenital cholesteatomas or epidermoids, true dermoids and teratomas, and benign and malignant neoplasms. The authors present an extremely rare case of a true dermoid of the petrous apex which eroded into the clivus of the occipital bone, and discuss the differential diagnosis, symptomatology, and diagnostic work-up. Complete resection is the preferred management if it can be done easily and and safety; however, since the lesions are usually unresectable and manifest few symptoms, a conservative surgical approach for diagnosis and decompression is urged. The authors discuss in detail a surgical approach which allows for preservation of function and hearing, as well as diagnosis and immediate decompression. Further surgical decompressions, when needed, can be easily, quickly, and safely achieved through the same surgical approach. A review of the medical literature has revealed no previously reported case of a true dermoid involving the petrous apex.

Cerebellar infarction--a presentation of vertigo.

The differential diagnosis of acute vertigo includes cerebellar infarction. In the past a mortality rate of 50% - 80% was reported with cerebellar infarction. This is no doubt related to an inability to accurately diagnose small lesions which carry a better prognosis. The advent of computerized tomography (CT) now permits accurate diagnosis of small cerebellar infarctions. Seven patients admitted with acute onset of vertigo which mimicked a peripheral labyrinthine disorder are presented. In all patients a cerebellar etiology was demonstrated by CT. One patient had been subjected to therapeutic labyrinthectomy; three of seven patients had associated unilateral hearing loss suggesting partial brain stem involvemtation. Computerized tomography should be included in the routine work-up of acute vertigo with any associated neurologic findings to aid in proper diagnosis and effect appropriate treatment.

The ultrastructure of the endolymphatic sac in Ménière's disease.

Meniere's disease is a well recognized clinical entity, yet the etiology and pathophysiology of the disease is not fully understood. Impaired endolymphatic sac function resulting in faulty reabsorption of endolymph has been implicated in the production of the disease. The histopathological findings from biopsied sac specimens and observed by transmission (TEM) and scanning (SEM) electronmicroscopy in two patients with early Meniere's disease are presented and discussed. Extensive subepithelial fibrosis with loss of vascularity and obliteration of portions of the lumen of the endolymphatic sac by an ingrowth of collagen is noted in both specimens. The implications of these findings are discussed and the need for more TEM and SEM studies of inner ear disorders is stressed.

Computed tomography in suppurative ear disease: a correlation of surgical and radiographic findings.

Forty-two patients with chronic otitis media underwent preoperative CT scanning followed by surgical exploration of the middle ear and mastoid. The CT finding of abnormal soft tissue density associated with bone erosion was highly correlated with the surgical finding of cholesteatoma. By contrast, the total absence of abnormal soft tissue on CT essentially excluded cholesteatoma. However, 50% of all patients had abnormal soft tissue on CT scan not accompanied by bone erosion. In this largest group of patients it was not possible to diagnose or exclude cholesteatoma on the basis of CT findings alone. Also, CT occasionally gave the erroneous impression of lateral semicircular canal fistulization, tegmen tympani erosion, and facial nerve involvement due to volume averaging of these structures with adjacent soft tissues. CT scan has a role in the evaluation of selected patients with chronic otitis media, but must be interpreted cautiously in view of its limitations and numerous pitfalls.

Effects of endolymphatic duct occlusion on the structure and function of the endolymphatic sac in the adult guinea pig.

The endolymphatic sac (ELS) has been shown to respond rapidly to sudden disruptions in fluid balance such as labyrinthectomy or systemic administration of hyperosmolar agents. The present study was designed to determine the ELS response to slower changes in fluid dynamics by occluding the endolymphatic duct (ELD), thereby interrupting the longitudinal flow of endolymph to the ELS. Morphologic studies and autoradiographic techniques were used to evaluate the effects of ELD obstruction on the structure and function of the ELS after 48 hours. There were no significant changes in cellular morphology and a slight decrease in the incorporation of radiolabeled glucose when compared with normal ELS cells. We conclude that it is rapid change in fluid balance that triggers the ELS response, which is not seen with disruption of longitudinal flow.

The UCSF/Storz multichannel cochlear implant: patient results.

Using the four channel cochlear implant system with a vocoder-based processor developed at UCSF over an extensive period of research, clinical trials of the UCSF/Storz device were initiated in February 1985, under the sponsorship of Storz Instrument Company. To date, 13 patients have been implanted with this device, nine of whom have been fitted with their external processor and transmitter and have received at least their initial postoperative evaluation. Patient results have been extremely promising, with eight of the nine patients obtaining some open-set auditory only speech understanding. Most patients have demonstrated improvement over time and all patients have attained an enhancement in lipreading ability with the use of the UCSF/Storz device.

Insulin receptors on the endolymphatic sac: an autoradiographic study.

Light microscopic autoradiographs were prepared of isolated guinea pig endolymphatic sac (ES) tissue incubated with iodine (I)-125-labeled insulin (insulin I 125). These demonstrated specific binding of the insulin I 125 to receptors in the ES. Receptor-mediated endocytosis of the insulin-receptor complex is postulated to occur, and the relevance of insulin receptors in the ES is discussed, with particular emphasis on the previously observed synthesis of hyaluronan from glucose by the ES.

Hyaluronan synthesis in the adult guinea pig endolymphatic sac.

The endolymphatic sac is believed to play a major role in membranous labyrinth homeostasis by controlling the volume of endolymph, removing debris, and participating in the immune response of the inner ear. The endolymphatic sac is postulated to absorb endolymph and to synthesize and secrete high-molecular-weight and osmotically active glycosaminoglycans (GAGs). The present study examines the ability of in vitro adult guinea pig endolymphatic sac cells to synthesize complex proteins and polysaccharides. The intent is to characterize the nature of these compounds by studying carbon-14 (14C) glucose incorporation in tissue cultured endolymphatic sac specimens using autoradiographic and specific enzymatic digestion techniques. Our results suggest that sac cells can synthesize GAGs and proteins in vitro in proportionately larger amounts than surrounding connective tissue and dura. The principal GAG synthesized by the endolymphatic sac appears to be hyaluronan.

Contemporary presentation and management of a spectrum of mastoid abscesses.

BACKGROUND: The incidence of complications resulting from suppurative otitis media has significantly decreased since the introduction of antibiotics. At the start of the 20th century 50% of all cases of otitis media developed a coalescent mastoiditis. By 1959, the incidence had fallen to 0.4%. Recent studies suggest a current incidence of only 0.24%. Additionally, during the time of Friedrich Bezold (1824-1908), 20% of patients with mastoiditis developed subperiosteal abscess. Interestingly, this has incidence increased; today nearly 50% of patients diagnosed with coalescent mastoiditis have subperiosteal abscess. OBJECTIVE: To review the contemporary presentation, diagnosis, and management of a spectrum of mastoid abscesses. DESIGN: Retrospective case series. SETTING: Hospitals associated with the Department of Otolaryngology/Head and Neck Surgery at the University of California, San Francisco. PATIENTS: Three patients with mastoid abscesses are reported. One patient displayed "classic" Bezold's abscess, with pus escaping the mastoid near the incisura digastrica and tracking along the digastric and sternocleidomastoid muscles into the neck. The second and third patients exhibited temporoparietal swelling secondary to mastoid abscess eroding the root of the zygomatic process, a complication noted by Bezold in 1908 as occurring "in only very rare cases." RESULTS AND CONCLUSIONS: Since only one third of patients show pathologic tympanic membrane changes, and since complaints of otalgia, fever, and tenderness are inconstant, subperiosteal mastoid abscess is frequently a delayed diagnosis. The clinical presentation, pathogenesis, and routes of abscess spread are presented with photographic and radiographic illustration. Medical and surgical management is reviewed, and methods for accurate diagnosis are emphasized.

Cochlear patency problems in cochlear implantation.

Sensory deafness may be associated with partial or total obliteration of the cochlear scalae. Before undertaking cochlear implant surgery, a preoperative assessment of cochlear patency with high-resolution computed tomography (CT) is indicated. To determine the accuracy of pre-implant CT, a review of the radiographic and surgical findings in 36 implanted ears was performed. An abnormal CT scan was found to be a reliable predictor of compromised cochlear patency at operation. These findings help the surgeon to select the side most favorable for implantation and to anticipate problems that may be encountered during device insertion. A normal pre-implant CT scan, however, does not exclude the possibility of compromised cochlear patency. A 46% false negative rate was encountered, presumably because subtle degrees of osseous or fibrous obliteration of the cochlea are beyond the resolution by current generation CT scanners. In our opinion, the radiographic finding of cochlear ossification is not a contraindication to an attempt at cochlear implantation. The only assured way of determining the extent of cochlear patency is by performing an "exploratory cochleostomy" with fenestration of the basal cochlear turn. Drilling anteriorly through an ossified basal scala tympani will often expose an adequate lumen and permit insertion of even a long multichannel electrode into a partially ossified cochlea. Nevertheless, it is essential that the implant team be prepared with devices appropriate for whatever existing or surgically created lumen may be available.

Surgical considerations and hearing results with the UCSF/Storz cochlear implant.

Sixteen patients have been implanted with the UCSF/Storz multichannel implant, 11 of whom have been fitted with their external speech processors and transmitters and administered postoperative audiological evaluations. Both the surgical procedures used and the hearing results for these patients are presented. The potential medical/surgical complications of implant surgery and the future direction of research and development within the UCSF/Storz implant program are discussed.