Surgical management of perilymphatic fistulas: a Portland experience.

A comprehensive review of our series of surgical perilymphatic fistula (PLF) repairs, as well as a review of published results from other otologists, suggested an unacceptably high rate of postoperative PLF recurrence. Some recurrences were related to specific events (i.e., coughing, strenuous activity, Valsalva-type maneuvers). However many cases had no apparent cause. Rather, the patients' symptoms recurred spontaneously, and at reoperation the graft was seen to have not "taken," suggesting graft failure rather than "patient failure." After a critical evaluation of current PLF surgical procedures and state-of-the-art concepts of wound healing, we developed a new surgical technique for PLF closure. Combining the use of laser graft-site preparation, an autologous fibrin glue "buttress," and a program of postoperative activity restriction, the new procedure allowed us to achieve statistically significant improvements in graft retention and surgical outcome, with recurrences dropping from 27 percent to 8 percent. In addition, complete resolution or significant symptomatic improvement occurred in 89 percent of patients with vertigo and/or dizziness and in 84 percent with disequilibrium. We conclude that this new surgical technique is an important addition to the otologic surgeon's arsenal for PLF management.

Surgical management of perilymph fistulas. A new technique.

A wide range of recurrence rates (21% to 47%) for perilymph fistula repairs have been reported in the otology literature. An improved surgical technique developed at the Portland (Ore) Good Samaritan Hospital and Medical Center Neurotology Department was used to repair perilymph fistulas in 58 patients from October 1986 to October 1988. Our recurrence rate was reduced from 27% in a 1982-1985 study to 8% in our study. At 1 year postoperatively, improvements in disequillibrium, dizziness, and vertigo were comparable with results of older surgical techniques. Functional outcomes were also good: 83% of patients returned to normal activities of daily living, and 71% also returned to school or resumed gainful employment outside the home.

The dynamic posturographic pressure test for the presumptive diagnosis of perilymph fistulas.

A diagnosis of perilymph fistulas (PLFs) can be made only by identification of repeated accumulation of crystal-clear fluid from an otic capsule defect or labyrinthine window at tympanotomy. It would be highly desirable to base a decision to operate for the diagnosis and management of PLFs on a database that includes quantitative test data, which confirms, with a high probability, a clinical suspicion of PLF. This article reviews progress in the development of a test of the vestibular response to external auditory canal pressure changes as recorded by dynamic posturography. Based on results to date, it appears that a fistula test with dynamic posturography is more sensitive than those based on VOR responses. This may be due to the ability of dynamic posturography to isolate vestibular from both visual and somatosensory influences on motor responses during external canal pressure changes.

The perilymph fistula syndrome defined in mild head trauma.

Neurological and neuro-otological studies were carried out on 102 adults with mild cranio-cervical trauma productive of positional vertigo and perilymph fistula as confirmed by laboratory tests, and by the finding of perilymph fistula at tympanotomy in the surgically managed group. In this patient group, all other neurological and neuro-otological diagnoses were excluded, e.g. epilepsy, cerebral palsy, multiple sclerosis, retardation; and for the neuro-otological group those with a history of ototoxicity, labyrinthitis, Meniere's disease, chronic ear infections, or developmental or familial disorders. Emphasis in this study was on mild trauma: fewer than half of the sample had been rendered unconscious in the injury of record, and a third of the cases were of whiplash type, with no loss of consciousness (LOC) and no remembered headstrike. These concomitant lesions comprise the perilymph fistula syndrome (PLFS) with a unique profile of neurological, perceptual, and cognitive deficits resembling a post-concussion injury. A complete description of the clinical picture is given, including psychological, cognitive and diagnostic tests, and the outcome of bedrest vs. surgical management. PLFS can arise from minor trauma, fistula are frequently bilateral (71/102), a mild sensorineural hearing loss is of variable occurrence (53%), secondary hydrops is not uncommon, and women appear more vulnerable than men for developing the syndrome. As based upon combined laboratory techniques and clinical symptomology, fistula were correctly predicted in 61 of 65 laser-operated ears. The positional vertigo component of PLFS was in all cases managed according to a special physical therapy program utilizing exercises for vestibular symptom habituation. Even when diagnosed late, a good-to-excellent outcome was achieved in 70% of treated patients.

Prehistoric trephination of the frontal sinus.

Two examples of prehistoric trephination of the frontal sinus are presented. Both specimens were collected in Peru during the second decade of this century and are currently preserved at the Museum of Man in San Diego. One of the skulls represents trephining by incision and the other by scraping. Both show signs of healing indicating that the operated individuals survived the procedure. No definite clues as to the indications for surgery were found in one of the specimens. Trauma involving the frontal sinus appears to have been the reason for trephination in the other.

Congenital basal cell adenoma of the submandibular gland.

Basal cell adenoma is a specific type of monomorphic tumor of the salivary glands that closely resembles basal cell lesions of the skin. Twenty-six of these tumors have been reported in the American literature, the majority occurring in patients 60 years or older. The most common sites of occurrence have been the minor salivary glands (especially in the upper lip) and the parotid. We report an exceptional case of basal cell adenoma in the submandibular gland of a neonate. Review of reported congenital epithelial tumors of the salivary glands indicates that at least two similar neoplasms have been described previously.

Role of periosteum on the fate of pedicle osteocutaneous grafts.

Recent studies on the fate of pedicle osteocutaneous grafts have shown that they remain viable and may be actively involved in the mechanics of bone repair. This communication reports on a series of experiments aimed to clarify the role of periosteum in the survival of pedicle-assisted bone grafts. Osteocutaneous grafts were developed in dogs in such a manner as to isolate the implant from normal recipient bone. Free bone grafts were used as controls and a group of pedicle periosteal grafts were studied as potential sources of bone formation. Specimens were evaluated at regular intervals over a 40-week period. The pedicle bone grafts maintained their viability and developed vigorous osteoneogenesis. The process was progressive and eventually resulted in partial substitution of the original graft by new bone of periosteal origin. The free bone grafts were resorbed and no bone formation was obtained in pedicle periosteum specimens. The study provides clear evidence that under experimental conditions no bone contact is needed to maintain the viability of pedicle osteocutaneous grafts. It also shows that the periosteum has the leading role in the restructuring process of these grafts.

Nasopharyngeal rhabdomyosarcoma. A clinical perspective.

Embryonal rhabdomyosarcoma of the nasopharynx is an uncommon tumor occurring almost exclusively in children. The clinical characteristics of 56 previously reported cases are analyzed and four patients recently treated at the UCLA Center for the Health Sciences are described. Special attention has been given to the prognosis of these tumors as it relates to current methods of treatment.

The value of sialography in the diagnosis of parotid tumors. A clinicopathological correlation.

The importance of sialography in the diagnostic evaluation of the condition of a patient with a parotid mass remains uncertain; some proponents advise use of sialography routinely, while others believe it to be worthless. To help resolve these conflicting opinions, a retrospective study of 40 patients was carried out that compared sialographical interpretations with respective surgical-histological findings. The results of this study show that generally reliable information, which may serve to influence therapeutic decisions concerning these patients, can be gleaned from sialography.

Laryngocele--an updated review.

This communication reviews the clinical and pathological features of 121 cases of laryngocele reported in the English literature and the authors experience with 10 cases. A case of an infected laryngocele presenting with airway obstruction and one of an external laryngocele associated with laryngeal cancer are described in detail. An instance of bilateral congenitally long saccules is also presented, and the role of this anomaly in the pathogenesis of laryngoceles is discussed.

Simultaneous glottic and supraglottic laryngeal webs: report of a case.

In a rare case of simultaneous glottic and supraglottic webbing a tantalum keel, as described by McNaught, and a silcone elastomer keel, as described by Montgomery, were placed simultaneously via laryngofissure. Use of different materials appeared to have no bearing on the final, successful outcome.

Eversion of the laryngeal ventricle.

Eversion of the laryngeal ventricle is a rare lesion that presents with cough and/or voice changes. Laryngoscopy reveals a polypoid mass arising from the ventricle. Microscopically a polyp covered with ventricular mucosa and containing normal laryngeal mucous glands is seen. Chronic inflammation is usually present. Treatment in symptomatic cases consists of surgical removal endoscopically or by laryngofissure. The management of one patient is reported with a discussion of the cause, symptoms, and treatment of this condition.