[Vestibular schwannoma: active treatment or follow-up?]. / Vestibulaarischwannooma: aktiivinen hoito vai seuranta?

Vestibular schwannoma is a rare benign tumor of a cranial nerve. The symptom picture is usually a varying one, centering on otogenic symptoms, such as hearing loss, tinnitus and dizziness. The diagnosis is often made only after the patient has already had symptoms for a longer time. The number of tumors found yearly in Finland is estimated to be approximately 50 to 100. Even very small tumors are detected by contrast-enhanced magnetic resonance imaging. Since a significant proportion of the tumors remain unchanged in size over a follow-up observation period of several years, follow-up instead of surgical treatment is considered adequate for some of the patients.

Obliteration of radical cavities with autogenous cortical bone; long-term results.

BACKGROUND: To evaluate the long-term surgical outcome(s) in patients who have undergone canal-wall-down operation with mastoid and epitympanic obliteration using autologous cortical bone chips, bone pate and meatally-based musculoperiosteal flap technique. METHOD: Retrospective evaluation of seventy patients operated during 1986-1991 due to a cholesteatoma. An otomicroscopy was performed to evaluate the postoperative outer ear canal configuration with a modified Likert scale (1 - 4). The outer ear canal physical volume was assessed by tympanometry. The hearing outcome and a patient-filled questionnaire were also analyzed. RESULTS: The posterior wall results were 1.8 (+/- 0.9 SD) and the attic region 1.8 (+/- 0.9 SD) (ns., p > 0.05). These values show either no cavity formation or minor formation of a cavity, with a good functional result. The mean volume of the operated ear canal was 1.7 (+/- 0.5 SD) ml. The volume of the contralateral ear canal was 1.2 (+/- 0.3 SD) ml (*** p < 0.0001). A comparison of the current mean ABG to the preoperative mean ABG and to the ABG at one-year postoperatively, 5-years postoperatively or 10-years postoperatively showed no statistical significance (p > 0.05). CONCLUSION: ABG does not significantly change in the long-term. The configuration of the cavity tends to change, however, the obliteration material is stable in the long-term and clinically significant cavitation rarely occurs.

Simultaneous bilateral stapes surgery.

CONCLUSIONS: The patients recovered from the surgery as after unilateral surgery. The success rate for hearing improvement was good both subjectively and objectively, and this was also displayed in the quality of life. According to our study, simultaneous bilateral stapes surgery can be performed safely in selected patients with bilateral conductive hearing loss. OBJECTIVES: Otosclerosis is bilateral in the majority of patients. In this study we evaluated the outcome of simultaneous bilateral stapes surgery. SUBJECTS AND METHODS: Eighteen patients suffering from bilateral otosclerosis or osteogenesis imperfecta were prospectively included. After operation, hearing and vestibular function were followed by audiometry and visual feedback posturography (VFP). Patients estimated their hearing gain, the intensity of vestibular symptoms and quality of life score with a questionnaire during the follow-up period of 1 year. RESULTS: The mean improvement in pure-tone average (PTA) air conduction (PTA-AC) was 18 dB (range 1-41 dB). The mean air-bone gap (AB-GAP) diminished from 22 dB (range 10-41 dB) to 7 dB on both sides (range 0-18 dB). The mean preoperative score of 2.3 for hearing improved significantly to 4.1 (p<0.001). Vestibular symptoms were mild and temporary. The VFP was not permanently impaired in any of the patients. The quality of life score improved significantly from 3.4 to 1.3 postoperatively (p<0.001).

Aeration of Prussak's space is independent of the supradiaphragmatic epitympanic compartments.

HYPOTHESIS: This study's aim was to find out how well various microdissection approaches reveal the basic anatomy of the epitympanum, especially the pathways of aeration to Prussak's space, without the help of serial sections, which many find difficult to interpret. BACKGROUND: The basic studies where made during the latter half of the 19th and the first half of the 20th century. Conflicting concepts have later been published, and doubtful information has been included even in textbooks. METHODS: We have studied 145 temporal bones via microdissection to record the state of the soft tissue structures of the epitympanum, particularly upon Prussak's space with its boundaries. A normal surgical otomicroscope was used in the evaluation, and the findings were recorded via black and white and/or color photography; for recent cases, a digital video camera was used. RESULTS: The epitympanic diaphragm separates the large upper floor compartments from the small, laterally placed lower floor unit. The latter consists of Prussak's space and the posterior pouch, at times also of the lower lateral attic. The tympanic isthmus connects the upper unit to the medial tympanum. Defects in the diaphragm create additional airways to the upper unit, in 29% via the tensor fold and in 19% via the lateral incudomalleal fold. In only 7% was there a small opening in the roof of Prussak's space connecting it to the upper unit. Effective aeration of Prussak's space was independent of the upper floor compartments. CONCLUSION: Microdissection is a reliable and sufficient method for teaching epitympanic anatomy. All important structures can be identified and defects in the epitympanic diaphragm verified. Data obtained via serial sections are invaluable in research but not essential in the training of ear surgeons. The two-floor structure of the epitympanum with an independent aeration of the two units should be the starting point for all anatomy teaching.

Simultaneous bilateral stapes surgery--a pilot study.

CONCLUSIONS: The short-term postoperative results of bilateral stapes surgery were satisfactory. Hearing results between the two ears were comparable and there was no increased complication risk for the second ear. The results are encouraging, although a larger series and longer follow-up time are needed to confirm them. OBJECTIVE: The purpose of our study was to evaluate the preliminary outcome of simultaneous bilateral stapes operation. PATIENTS AND METHODS: Eight patients suffering from bilateral otosclerosis and one from osteogenesis imperfecta were prospectively included in the pilot study. Both ears were operated under general anesthesia by the same surgeon. Inclusion criteria were mean conductive hearing loss of 15 dB or more at frequencies 0.5-4.0 kHz and negative Rinne fork test (256 Hz) on both sides. Patients with mean thresholds for sensorineural hearing over 40 dB or other otoneurological diseases or medications were excluded. Pure tone audiogram was performed 3 months after the operation. RESULTS: The air-bone gap diminished from 28 (range 19-41) to 10 (range 4-23) dB in the first ear and from 24 (range 16-40) to 8 (range 3-19) dB in the second. Four patients experienced mild, temporary dizziness during rapid head movements, but that resolved fully. No patient suffered significant sensorineural hearing loss.

Meconium contaminated amniotic fluid and infant otitis media. Is it a risk factor in children surviving aspiration and initial distress of respiration?

OBJECTIVE: Histological studies show that amniotic fluid cellular content (AFCC) causes in the middle ear a foreign body reaction, the extent and severity of which depends upon the massiveness of contamination. We studied how factors related to birth and environment affect proneness to acute otitis media (AOM) in infants born through meconium contaminated amniotic fluid. METHODS: From the birth records of infants born from 1996 to 2000 a list was made of those born through meconium contaminated amniotic fluid with pulmonary aspiration and tracheal suctioning, followed by treatment in a neonatal intensive care unit. Thirty-seven such children formed the study group, 43 children matching the study cases but born through clear fluids formed the control group. Birth and environmental factors together with the frequency and number of episodes of AOM were analyzed in all, based on a verified questionnaire. In addition, 27 children in the study group and 21 in the control group received a specialist ENT examination, hearing tests and tympanometry. RESULTS: The events at delivery were highly significantly different between the two groups, manifested by the lower Apgar points in the study group (p<0.001) while other birth and environmental factors appeared equalized. The first episode of AOM in the study group came earlier than in the control group and their frequency was significantly higher during the 1st and 2nd year of life and during the entire observation period (p<0.001). Tympanostomy was performed more often in the study group. Tympanometry showed more cases of reduced static admittance and negative pressure than in the control group and hearing was poorer. CONCLUSIONS: Cases with compromised delivery through meconium contaminated fluids, resulting in pulmonary aspiration and in need of intensive care treatment, form a risk group, which should be closely followed. Early nasopharyngeal suctioning of AFCC may reduce its entry into the middle ear. A prolonged episode of AOM suggests mucosal involvement of several middle ear compartments, shown by histological studies to occur in all cases of massive contamination. Placement of a ventilation tube after the first prolonged AOM allows regression of the granulation tissue in the air spaces together with the secretory elements in the mucosa.

Indium-111-bleomycin complex in squamous cell cancer xenograft tumors of nude mice.

INTRODUCTION: Labeling of bleomycin with Auger-emitter Indium-111 increases cytotoxicity in squamous cell cancer (SCC) cell lines, as we have reported earlier. In this study, we investigated whether (111)In- BLMC is toxic and effective in vivo among SCC-xenografted mice. The influence of (111)InBLMC on the squamous cell carcinoma cell cycle stimulated interest. MATERIALS AND METHODS: In an animal experiment, 10 SCC-xenografted mice were used, two for demonstrating targeting in gamma-camera images, eight for intraperitoneally receiving NaCl, BLM, or (111)InBLMC as therapy. After a 2-week follow-up, the tumors were analyzed for proliferation (mitoses, Ki-67). DNA flow cytometric analysis was carried out from tumor samples and three UT-SCC cell lines. RESULTS: Tumors were observed on gamma-camera images in xenografted mice after a (111)InBLMC injection. The UT-SCC-19A-xenografted mouse had a T/non-T uptake of 7.54 at 4 hours after the injection. At the end of the therapeutic trial, the mice were alive. In spite of a small number of animals, our findings indicate that BLM and (111)InBLMC seem to be more effective than NaCl in reducing tumor size. The proliferative activity was strong in BLM and in (111)InBLMC groups, indicating regrowth of the tumors. In DNA analysis, the percentages of cells in the G2/M-phases increased after exposure to BLM and particularly to (111)InBLMC in all three cell lines. CONCLUSIONS: The effect of BLM is preserved after the adding of Auger-emitter In-111. Tumor-seeking (111)InBLMC can be administered safely at tumor-decreasing concentrations in xenograft head and neck cancers. To demonstrate the antitumor effect of (111)InBLMC, the experiments should be extended to include a larger number of mice. BLM, and especially (111)InBLMC, seems to induce alteration in the cell cycle by producing a G2/M block. The verification of the result requires repeated in vitro experiments.

Fate of the mesenchyme in the process of pneumatization.

HYPOTHESIS: This study's aim was to find histologic data that would indicate the mode of disappearance of the embryonal mesenchyme. BACKGROUND: The basic studies made during the first half of the 20th century concluded that mesenchyme disappears by regression and resorption. Recently, it was suggested that mesenchyme disappears by receding, spreading, and thinning to match the enlarging bony spaces. METHODS: We studied 11 serially sectioned temporal bones from newborns to adults and describe detailed findings in a 9-day-old newborn and in a 1.5-year-old infant. The temporal bones were sectioned to 20 mum and stained by hematoxylin and eosin. RESULTS: Histologic evidence of regression was found in the form of degenerating mesenchymal cells and fibers, in areas free of cells, and with empty spaces of varying size between the fibers. Vacuoles differing much in size appeared, and phagocytic cells were frequent. A rich capillary network allowed resorption of hemopoietic cells dispersed from the marrow spaces into the mesenchyme. From the lower lateral attic, from Prussak's space, and from the mastoid air cells, mesenchyme can disappear only by regression-there is no space where it could recede. CONCLUSION: Pneumatization of the middle ear spaces occurs by regression and resorption with an individual speed under genetic guidance. The osteoclastic activity of the periosteum, intertwined with the nearest mesenchyme, is decisive in the mastoid air cell formation. Dispersion and reabsorption of hemopoietic cells is a normal phenomenon in this process. Underpressure in the middle ear spaces, caused either by a meconium-related foreign body otitis media in infancy or by chronic otitis media in childhood, are factors that may lead to a partial or full arrest of pneumatization.

Long-term hearing results after stapes surgery: a 20-year follow-up.

OBJECTIVE: The aim of this study was to evaluate the results of stapes surgery after 20 years of follow-up and to compare the results between large fenestra versus small fenestra stapedotomy. STUDY DESIGN: Retrospective clinical study. SETTING: Tertiary referral center (university hospital). PATIENTS: One hundred forty-two patients with otosclerosis treated by surgery. INTERVENTION: Eighty patients had a total stapedectomy with House-wire prosthesis and 62 patients a stapedotomy with Teflon-piston prosthesis. MAIN OUTCOME MEASURES: Preoperative, postoperative, and long-term hearing thresholds were compared. Patients filled in a questionnaire about the impact of surgery on the quality of life and postoperative symptoms. RESULTS: The long-term pure tone average improvement did not differ significantly between the techniques compared with the preoperative values. The air-bone gap tended to enlarge as a function of time. The change in the pure tone average was 0.9 dB per year for both techniques. In the questionnaire, some patients reported vertigo, tinnitus, loud noise intolerance, and taste disturbances. Loud noise intolerance seemed to persist in the long term. Surgery had no effect on preoperative tinnitus. CONCLUSIONS: There were no statistically significant differences between the techniques regarding hearing results. Over the long term, both techniques are safe and effective in restoring hearing and improving quality of life.