A nonprescription cerumenolytic.

Cerumen impaction and removal is a very common otologic problem. The perfect cerumenolytic agent has yet to be developed. After years of trying multiple different cerumenolytics without satisfaction, a stool softener, docusate sodium, has become our agent of choice. A commonly used stool softener, it is widely available without prescription. It is a highly effective cerumenolytic, but remains relatively unknown in this capacity.

Enflurane-induced grand mal seizures during otic microsurgery.

Abnormal electroencephalographic seizure-like activity and myoclonic movements have been recognized during enflurane anesthesia. This is most commonly seen in the presence of respiratory alkalosis and high concentrations of enflurane. Immediate and delayed postoperative generalized tonic-clonic convulsions have also been reported after enflurane anesthesia. Experimental studies have shown that auditory stimuli could facilitate seizure activity during deep enflurane anesthesia. Here we report a case of intraoperative generalized tonic-clonic convulsion during low concentrations of enflurane without evidence of hyperventilation and the presence of auditory stimulation.

Otorhinological brain abscess therapy--past and present.

In the past several years a concensus approach has been reached in diagnosis and therapy of brain abscess. The ease and accuracy of evaluation of intracranial lesions afforded by third generation computerized tomography scanners has lead to reliable, quick, non-surgical diagnoses and monitoring which is relatively non-invasive. The use of multiple agent, increased spectrum, antimicrobials has resulted in acceptable reduced morbidity and mortality. This has decreased the need for therapeutic surgical intervention. The non-surgical approach was preceded by several other modes of management which were acceptable in their time. During the past 21 years, 17 patients have been under the care of one or more of the above authors. A review of these cases is presented with instructive and informative histories. A knowledge of past therapeutic modalities and their attendant complications compared with present medical therapy assures an acceptance of the latter as the method of choice. A search of the general literature shows wide acceptance in other fields; however, no reference could be found in the recent otolaryngological literature to support a non-surgical approach.

Temporal bone histopathology of necrotizing external otitis. A case report.

Histopathological examination of the temporal bone of an individual with necrotizing external otitis revealed severe inflammation with necrosis in the subcutaneous granulation tissue in the external auditory canal. Erosion of the bony walls of the canal had created a defect in the anterior wall, through which infection spread to the preauricular region. The lateral part of the middle ear cavity was also filled with granulation tissue and purulent exudate. A dehiscence of the horizontal portion of the facial canal had apparently allowed spread of an inflammatory round cell infiltrate along the facial nerve up to the fundus of the internal auditory canal. The only evidence of inner ear pathology was the presence of eosinophilic fluid material in the perilymphatic spaces of the labyrinth. A review of other reports of cases of necrotizing external otitis seems to show that this is the only instance of this disease in which infection spread from the external canal through the tympanic membrane to the middle ear and thence to the internal auditory canal.

Sensorineural hearing loss in the unoperated-on otosclerotic ear.

Severe sensorineural hearing loss occurs in less than 1% of stapedectomized ears. This low percentage remains as an irreducible minimum even among the most experienced and competent surgeons. The etiology has been hypothesized; however, the actual cause remains unknown. The rare occurrence of sensorineural hearing loss of undetermined etiology in the unoperated-on side was reported first in 1967 by Armstrong who presented a series of three patients. No other references have been found since this initial report. Recently three unilateral stapedectomized patients who developed sudden severe sensorineural hearing loss in the unoperated-on ear were studied during the years 1971 through 1979. The hearing loss occurred within 1 week, 6 weeks, and 12 years postoperatively. Although the number is small, a study of this group, in addition to Armstrong's, leads to several interesting considerations: 1. Is the incidence of sudden sensorineural type hearing loss greater, the same as, or less than that which develops in the non-otosclerotic general population? 2. Is there a possibility that the sudden sensorineural hearing loss of undetermined origin would occur at the time of surgery? Would this then be considered as a predisposing if not the actual etiology? The present series of six cases is so small that a conclusion is not possible and inference is only conjecture. It is hoped, however, that this may stimulate past, present, and future search for this unusual occurrence. This may help determine whether or not there is a causal or merely a coincidental relationship.

Cost-benefit ratio in our search for cerebellopontine angle tumors.

There is agreement that the morbidity and mortality of CPA tumors are directly proportional to the size of the tumor. The diagnostic difficulty, however, is indirectly proportional to the size: the large tumors are diagnosed with little difficulty, the smaller ones with considerable challenge. In the search for these tumors, it is apparent that the incidence of all sizes is low. To arrive at the diagnosis, efforts must be pursued in any patient with unilateral sensorineural hearing loss, unilateral tinnitus, or vertigo. In the past 12 years, 19,000 new patients were seen in the office of the Pittsburgh Otological Association. In this new patient population, 120 tumors were proven by surgery. Six others (bilateral tumors) were diagnosed but not operated on, and four others were diagnosed but were operated on elsewhere for a total of 130 patients. An estimate of the cost of diagnosing these tumors is presented. Consideration is given to the cost-benefit ratio of diagnosing those diseases which must be considered also in the differential diagnosis when the above symptoms are present. These are: congenital changes, trauma, metabolic neuropathies, Meniere's disease, noise-induced hearing loss, lues, sudden hearing loss, and unilateral symptoms of undetermined etiology.

A comparison of fenestration of the horizontal canal and stapedectomy in the opposite ear.

The Lempert one stage horizontal semicircular canal fenestration was the surgical procedure of choice for otosclerosis from 1939 to 1954. Subsequently, mobilization and stapedectomy replaced fenestration. In the offices of Drs. Day, Jordan, and Caparosa, the horizontal semicircular canal fenestration was performed from 1940 to 1955; the mobilization, two years; and, thereafter, the stapedectomy. A significant number of patients have had fenestration on one side and stapedectomy on the opposite ear. Fifty patients seen consecutively were reviewed. Reliable office audiological testing has been available only in the more recent years; and, therefore, audiological statistical comparison has limited reliability. It is felt, however, that a review of these patients and the study of their surviving hearing results is a worthwhile inferential comparison.

"How I do it"--otology and neurology. A specific issue and its solution. The diagnosis of a posterior fossa tumor.

In summary, the patient with a unilateral sensorineural type hearing loss, unilateral tinnitus, or dysequilibrium may have a tumor in the posterior fossa. This is diagnosed by the history, ear nose, throat and otoneurological examination, the audiological studies, electronystagmography, radiological tests using the Compere unit, the CT Scan, and when indicated the posterior fossa myelogram. The list of causes for these symptoms other than tumefaction is large and there are a significant number of cases that remain "cause undetermined." The latter requires diligent follow-up and even consultation elsewhere.

Stapedectomy--fistula repair.

Perilymphatic fistulae have been proposed to occur most frequently on the short side of the graft in stapedectomized patients. The usual recommendation in fistula cases has been replacement of the entire prosthesis by a piston and tissue graft complex. In this case the stapedectomy had been performed, using a polyethylene Shea strut, 15 years previously. The air-bone gap had been closed during this entire period. A fistula was suspected after sudden hearing loss developed after barotrauma. At the time of exploratory tympanotomy, a fistula was noted on the long side of the oval window graft. It was elected to leave the polyethylene tube prosthesis in place because of its solid fixation, both laterally and medially. The fistula was closed by subcutaneous tissue graft.

Office otology follow-up.

The validation of otological care in the previous quarter century has been based, by and large, on short-term follow-up information. The rapid variation in procedures introduced during this period indicates that there may be need for further consideration. Analyses based on relatively short duration have led the "acceptance" of a variety of diagnostic and treatment methods which have proven disappointing in some cases. To help avoid this invalid "acceptance," a review of patients with significant follow-up may result in a more critical evaluation of future procedural changes. This presentation will be in four parts: 1. History of the office structure. 2. Discussion of five long-term patients that illustrates and supports certain otological concepts. 3. A review of surgical care for chronic suppurative otitis media in 1968. 4. A review of patients treated for serous otitis media with myringotomy and tubal insertion in 1968.