Surgical treatment for vertigo: patient survey of vertigo, imbalance, and time course for recovery.

OBJECTIVES: To assess surgical treatment of vertigo by patient ratings of postoperative vertigo, imbalance, and timing of symptom improvement. METHODS: A total of 3637 surgeries for vertigo were performed since 1974. Questionnaires sent to a random sample of patients operated since 1994 were completed by 28 endolymphatic sac shunt (ES), 54 vestibular nerve section (VNS), and 14 labyrinthectomy patients. RESULTS: All groups rated current vertigo characteristics and AAO-HNS disability as improved (all P

Chondrosarcoma of the skull base: long-term follow-up.

OBJECTIVE: Chondrosarcoma of the skull base is an uncommon neoplasm comprising 0.15% of all intracranial tumors and 6% of skull base neoplasms. The outcome of treatment is difficult to assess because the slow growth rate means that there is a long interval before detecting the recurrence. We describe the use of lateral skull base techniques for these lesions and examine the long-term outcomes. The pathological features, radiological findings, and radiotherapy options are also discussed. STUDY DESIGN: Retrospective case review with current follow-up where possible. SETTING: Tertiary referral neurotologic private practice. PATIENTS: Eight patients with histologically confirmed skull base chondrosarcoma operated on since 1979. At the time of the surgery, the five women and three men ranged in age from 31 to 63 years, with a mean of 42.9 years. The follow-up ranged from 9 months to 25 years and 5 months. INTERVENTIONS: All patients underwent surgical removal; the earliest patient underwent surgical removal via transcochlear and retrosigmoid approaches, and seven via an infratemporal fossa approach, with or without exenteration of the otic capsule. MAIN OUTCOME MEASURES: Number of patients with residual and recurrent tumors. RESULTS: In the patient who underwent surgery via the transcochlear approach, recurrence was noted within 3 months, and new exploration using the retrosigmoid approach was performed for the removal of the recurrent lesion. This patient showed no signs of recurrence for 25 years since last surgery. Of the seven patients who underwent surgery via the infratemporal fossa approach, one had residual tumor found at 1 year, but remained alive and well for 21 years after the surgery. The other six had gross total resection and showed no signs of recurrence at the last known follow-up. One patient died as a result of an unrelated cause 18 years after surgery for the chondrosarcoma. CONCLUSION: The gross total resection of these lesions is possible because of the evolution of lateral skull base techniques and can be routinely accomplished with the infratemporal fossa approach. The improved exposure afforded by this approach seems to have resulted in more complete extirpation of the tumor and a decrease in the recurrence rate.

The effect of organ of corti loss on ganglion cell survival in humans.

HYPOTHESIS: Severe spiral ganglion cell loss does not necessarily follow loss of hair cells or supporting cells in humans. BACKGROUND: Despite some publications to the contrary, statements that loss of hair cells and/or supporting cells of the organ of Corti results in a severe loss of spiral ganglion cells in humans still appear in the literature, especially in respect to cochlear implants. This assumption is apparently based on studies in animals or cell culture and not from studies of human temporal bones. METHODS: Morphological analysis of archival temporal bones with microscopic and statistical analysis of ganglion cell, hair cell, and supporting cell populations was performed in 33 ears with total hearing losses of varying causes and durations of deafness. None of the ears had remaining hair cells. Six ears had had cochlear implants. RESULTS: Ganglion cell counts ranging from 2,889 to 34,299 and the corresponding percentage of remaining ganglion cells based on age-normative data were not significantly related to the duration of hearing loss (r = -0.13 and 0.02, respectively, p > 0.05) or to remaining supporting cell populations (r's from 0.15 to 0.27, p > 0.05). More than half of ears (51.5%) had ganglion cell counts within two standard deviations of age-normative means. Mean ganglion cell counts and percentage of remaining ganglion cells of ears with surviving peripheral processes (dendrites) did not differ significantly from those of ears with no peripheral processes. CONCLUSION: The loss of hair and supporting cells in the organ of Corti in humans does not necessarily result in as significant a loss of spiral ganglion cells as has been reported animals. In fact, our results suggest that ganglion cell loss may be a primary concomitant loss due to the disease process.

Paget disease and sensorineural hearing loss associated with spiral ligament degeneration.

HYPOTHESIS: Previously unreported cystic degeneration of the spiral ligament in cases of Paget disease. BACKGROUND: About 70% of cases of Paget disease involve the skull, with hearing affected in approximately 50% of these. The hearing impairment may be sensorineural, mixed, or, rarely, only conductive. The etiology and pathogenesis of the hearing loss are not yet understood, and reports in the literature are inconsistent regarding the pathologic changes responsible for sensorineural hearing loss. Of six pairs of temporal bones from patients with Paget disease in the temporal bone collection of a research institution, two pairs have abnormalities not previously associated with sensorineural hearing loss or Paget disease. We report the histopathologic findings in these temporal bones. METHODS: The temporal bones were fixed in formalin, decalcified in ethylenediaminetetraacetic acid, embedded in celloidin, and sectioned in the horizontal plane at a thickness of 20 microm. Every 10th section was stained with hematoxylin-eosin and mounted on glass slides. The sections were examined by light microscopy. RESULTS: Cystic degeneration of the spiral ligament, primarily in the basal segment, was found in both cases. Endolymphatic hydrops and a small endolymphatic sac with calcification of the perisaccular tissue were found in one case. CONCLUSIONS: Cystic degeneration of the spiral ligament has not been previously reported and may be unique to Paget disease. This is consistent with recent literature showing a previously unsuspected role of the spiral ligament in sensorineural hearing loss.

Advances in congenital aural atresia surgery: effects on outcome.

OBJECTIVES: To compare modifications in the surgical technique of congenital aural atresia (use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks) by examining hearing results and complications before and after initiation of these changes. STUDY DESIGN AND SETTING: Retrospective chart review of patients who underwent congenital aural atresiaplasty between 1985 and 2002 in a tertiary referral neurotologic private practice. Complication rates and hearing results were compared before (n = 36) and after (n = 80) modifications in the surgical technique. RESULTS: Closure of the air-bone gap to 30 dB or less at short-term follow-up occurred in 63.1% of surgeries performed after modifications in the surgical technique and 44.5% of surgeries performed before these changes. The long-term postoperative air-bone gap was 30 dB or less in 50.0% of the surgeries performed after and 47.1% of the cases performed before the changes in surgical technique. Soft tissue stenosis and bony growth of the external auditory canal were seen in 3.8% of surgeries performed after and 13.9% of surgeries performed before the surgical technique changes. Ossicular chain refixation occurred in 3.8% of surgeries performed after and 25.0% of surgeries performed before such changes. There were no dead ears and no facial palsies. CONCLUSION: The use of argon laser, thinner split-thickness skin graft, Silastic sheets in the external auditory canal, and Merocel wicks, as a group, has helped to improve hearing results and decrease the incidence of complications in congenital aural atresia surgery. SIGNIFICANCE: Refinements in surgical techniques can lead to measurable improvements in outcome in atresiaplasty.

Congenital aural atresia surgery: long-term results.

OBJECTIVES: The study goal was to evaluate the stability of hearing results from short- to long-term follow-up in patients who underwent surgery for congenital aural atresia. We also reviewed complications such as external auditory canal stenosis, lateralization and perforation of the tympanic membrane, sensorineural hearing loss, and facial palsy. METHODS: We conducted a retrospective chart review of 116 patients who underwent congenital aural atresiaplasty between 1985 and 2002 at the House Ear Clinic. There were 116 atretic ears. Complication rates and short- and long-term (up to 13.6 years) hearing results were evaluated for primary and revision cases. RESULTS: Closure of the air-bone gap (ABG) to 30 dB or less at short-term follow-up occurred in 58.5% of primary surgeries and 56% of revisions. The long-term postoperative ABG was 30 dB or less in 50.8% of the primary cases and 39.1% of the revisions. Paired comparison analysis found no significant change in ABG from short- to long-term follow-up for either primary or revision cases. Soft tissue stenosis was seen in 8% of primary surgeries and 3.4% of revisions. Ossicular chain refixation was seen in 11.5% and 6.9% of primary and revision surgeries, respectively. There were no dead ears. CONCLUSION: Atresiaplasty surgery in individuals with congenital aural atresia can yield reliable, lasting hearing results with a low incidence of complications.

Tympanosclerosis: long-term hearing results after ossicular reconstruction.

OBJECTIVE: The study goal was to analyze long-term hearing results and factors likely to affect outcome after ossicular reconstruction in patients with tympanosclerosis, particularly tympanosclerotic stapes fixation. METHODS: We conducted a retrospective chart review of the past 10 years. The short- and long-term (up to 9(1/2) years) hearing results of first-stage and second-stage operations for middle ear tympanosclerosis in 203 consecutive patients, performed in a tertiary referral otologic private practice, are presented. There were 160 tympanoplasties and 43 tympanoplasties with mastoidectomy performed, with ossicular fixation secondary to tympanosclerosis in 135 cases. Of these 203, 42.9% were primary cases, with the majority being planned second-stage or revision procedures. RESULTS: The average preoperative air-bone gap (ABG) was 30.9 dB. The average short-term postoperative ABG was 17.4 dB with closure of the ABG within 20 dB in 64.6%. The success rate (ABG < or = 20 dB) for patients with ossicular fixation was 65.3%. Partial sensorineural hearing loss occurred in 1.0% of the patients, and none experienced profound sensorineural hearing loss (dead ears). There was no statistically significant change from short-term to long-term follow-up in either ABG or air PTA, with mean differences of only 0.3 and 2.0 dB, respectively. The mean time to the last follow-up was 1.6 years. CONCLUSION: Ossicular reconstruction in individuals with tympanosclerosis can yield satisfactory, lasting hearing results with a low incidence of complications and no dead ears.

Epistaxe severa: cirurgia micro endoscópica / Severe epistaxis: micro endoscopic surgery

A epistaxe é uma condiçäo freqüente na populaçäo em geral, sendo que a maioria é leve, com resoluçäo espontânea ou através de pequenos procedimentos. A epistaxe severa ocorre mais freqüentemente em adultos e pode ser resultante de trauma, tumores, doenças hereditárias, coagulopatias, malformaçöes vasculares e, principalmente, de causa desconhecida. As principais artérias envolvidas na epistaxe severa säo os ramos terminais da artéria maxilar e as artérias etmoidais anterior e posterior. No período de 1985-1998, 173 pacientes foram tratados cirurgicamente, utilizando-se a técnica micro-endoscópica transnasal e/ou por acesso externo, com alto índice de sucesso e baixo de morbidade