Petrous apex cholesterol granuloma: pictorial review of radiological considerations in diagnosis and surgical histopathology.

BACKGROUND: Petrous apex cholesterol granulomas are expansile, cystic lesions containing cholesterol crystals surrounded by foreign body giant cells, fibrous tissue reaction and chronic inflammation. Appropriate treatment relies on an accurate radiological diagnosis and an understanding of the distinguishing radiological features of relevant entities in the differential diagnosis of this condition. METHODS: Firstly, this paper presents a pictorial review of the relevant radiological features of petrous apex cholesterol granuloma, and highlights unique features relevant to the differential diagnosis. Secondly, it reviews the histopathological and radiological findings associated with surgical drainage of these lesions. RESULTS: Radiological features relevant to the differential diagnosis of petrous apex cholesterol granuloma are reviewed, together with radiological and histopathological features relevant to surgical management. Following surgical management, histopathological and radiological evidence demonstrates that the patency of the surgical drainage pathway is maintained. CONCLUSION: Accurate diagnosis of petrous apex cholesterol granuloma is essential in order to instigate appropriate treatment. Placement of a stent in the drainage pathway may help to maintain patency and decrease the likelihood of symptomatic recurrence.

Diving after stapedectomy: clinical experience and recommendations.

OBJECTIVES: Much controversy exists concerning the risk of inner ear barotrauma after stapes surgery in scuba and sky divers. Uniform consensus has not been established regarding poststapedectomy barorestrictions. The purpose of this study was (1) to determine the prevalence of adverse auditory and/or vestibular sequelae in patients after stapedectomy related to scuba and sky diving, and (2) to offer recommendations on barometric exposure after stapes surgery. STUDY DESIGN: Survey questionnaires were mailed to 2222 patients who had undergone stapedectomies at a single tertiary otologic referral center between 1987 and 1998. Two hundred eight of the initial 917 respondents (22.7%) had snorkeled, scuba, or sky dived after stapes surgery, and 140 of these responded to a second questionnaire detailing dive protocols, otologic symptoms, and their relationship to the diving activities. Of the 140, 28 had scuba or sky dived. Their survey data were analyzed and their medical records were reviewed. RESULTS: Four of the 22 scuba divers (18.1%) experienced otologic symptoms at the time of diving. These included otalgia on descent (3/22; 13.6%), tinnitus (1/22; 4.5%), and transient vertigo on initial submersion (1/22; 4.5%). One patient had sudden sensorineural hearing loss and vertigo develop 3 months after scuba diving, which he related to noise exposure. He was subsequently found to have a perilymph fistula, which was successfully repaired. Of the 9 patients who sky dived, 2 patients (22.2%) reported otologic symptoms during the dive. No significant diving-related long-term effects indicative of labyrinthine injury were seen in any of the 28 patients. CONCLUSIONS: Stapedectomy does not appear to increase the risk of inner ear barotrauma in scuba and sky divers. These activities may be pursued with relative safety after stapes surgery, provided adequate eustachian tube function has been established.

Changes in Ménière's disease responses as a function of the menstrual cycle.

BACKGROUND: Ménière's disease is a complex, progressive disorder of the inner ear evidenced by characteristic responses including vertigo, hearing loss, and tinnitus. Though considered equally common across sexes, several recent studies describe women's increasing reports of symptom exacerbation during the perimenstruum. Empirical evidence proving this relationship is limited with no study exploring women's symptom reports using appropriate methodological procedures for menstrual cycle research. OBJECTIVES: To establish the relationship between menstrual cycle phases and Ménière's disease responses. Specific aims included comparison of Ménière's disease responses between menstruant women and men (control group) and examination of women's Ménière's disease responses and their relationship to their diverse menstrual symptom patterns. METHODS: Using a longitudinal, descriptive design, 12 men and 13 women were recruited via Internet and participated in daily data collection procedures over three study phases. RESULTS: Results showed that Ménière's disease responses were similar for men and women participants. Women with premenstrual magnification patterns did not vary with cycle phases. However, vertigo (P < .05) did decrease significantly postmenses for women with premenstrual syndrome patterns. CONCLUSIONS: Results from this study provide evidence that a unique relationship does exist between the menstrual cycle and Ménière's disease responses for some women. Knowledge gained from this study is beneficial in identifying the importance of appropriate clinical assessment methods of menstruant women with Ménière's disease. Recommendations include further research with larger samples and testing of different symptom management strategies for women of different perimenstrual symptom patterns.

Extrusion rates and hearing results in ossicular reconstruction.

OBJECTIVES: To examine hearing results, extrusion rates, and factors likely to affect outcome in patients who underwent ossicular chain reconstruction with Plasti-Pore and hydroxylapatite total ossicular replacement prostheses (TORPs) and partial ossicular replacement prosthesis (PORPs). STUDY DESIGN AND SETTING: Retrospective chart review was used. Subjects were 1210 consecutive tympanoplasties with or without mastoidectomy that involved ossicular reconstruction with TORPs (n = 560) or PORPs (n = 650) performed in a tertiary referral neurotologic private practice. Only 20% of the cases were primary surgeries, with the majority planned second stage or revision procedures. RESULTS: Average last postoperative air-bone gap (ABG) was 19.2 dB with closure of the ABG to within 20 dB in 62.9%. Hearing results were better for cases who had not had previous surgery, in those with a diagnosis other than chronic otitis media, when a cartilage graft was used, and for Plasti-Pore rather than hydroxylapatite. Extrusion was known to occur in 4%. CONCLUSION: After more than 25 years of use in our clinic, Plasti-Pore ossicular replacement prostheses continue to provide reliable hearing results with a low rate of extrusion.

Prognostic factors for hearing preservation in vestibular schwannoma surgery.

OBJECTIVE: To determine whether prognostic indicators for hearing preservation could be identified in patients with vestibular schwannoma undergoing middle fossa craniotomy resection. STUDY DESIGN: Prospective case review. SETTING: Private practice tertiary referral center. PATIENTS: 333 patients with serviceable hearing and vestibular schwannoma resected by middle fossa craniotomy from 1992 to 1998. MAIN OUTCOME MEASURES: Potential prognostic indicators, including tumor size and nerve of origin, preoperative pure-tone average, speech discrimination, distortion product otoacoustic emission testing, age, auditory brainstem response (ABR), and electronystagmography. RESULTS: Postoperative hearing near preoperative levels was attained in 167 patients (50%), with an American Academy of Otolaryngology-Head and Neck Surgery Class A hearing result in 33% and a Class B result in 26%. Comparison of potential prognostic indicators between groups with hearing preserved and the group with no measurable hearing revealed significant differences in preoperative hearing, ABR, and tumor origin data. Better preoperative hearing, shorter intraaural wave V latency, shorter absolute wave V latency, and superior vestibular nerve origin were associated with higher rates of hearing preservation. CONCLUSIONS: Preoperative hearing status, ABR, and intraoperative tumor origin data were shown to be of value as prognostic indicators.

Profound hearing loss associated with hydrocodone/acetaminophen abuse.

OBJECTIVES: To describe profound hearing loss associated with hydrocodone overuse and the successful rehabilitation of these patients with cochlear implantation. STUDY DESIGN: Retrospective review. SETTING: A tertiary otologic referral center. PATIENTS: Twelve patients with rapidly progressive hearing loss and a concurrent history of hydrocodone overuse. INTERVENTIONS: Comprehensive medical histories, physical findings, audiometric tests, and, in those patients undergoing cochlear implantation, postimplantation performance data were reviewed. MAIN OUTCOME MEASURES: Clinical characteristics of hydrocodone-related hearing loss and open set word and sentence performance in those patients undergoing cochlear implantation. RESULTS: Hydrocodone overuse was associated with rapidly progressive sensorineural hearing loss in 12 patients. In four patients the initial presentation was unilateral, and two of the patients experienced vestibular symptoms. None of the 12 patients experienced improved thresholds after high-dose prednisone. Seven of the eight patients undergoing cochlear implantation have demonstrated early success with their devices. CONCLUSIONS: Hydrocodone is frequently prescribed in combination with acetaminophen for the relief of pain and has a side effects profile similar to other medications in its class. Although not described previously, overuse or abuse can be associated with a rapidly progressive sensorineural hearing loss. These patients can be successfully rehabilitated with cochlear implantation.

Aspergillus mastoiditis in acquired immunodeficiency syndrome.

OBJECTIVE: This study aimed to analyze the clinical presentation, diagnosis, management, and results of treatment in a series of three patients with acquired immunodeficiency syndrome (AIDS) in whom Aspergillus mastoiditis developed. This study also aimed to compare these aspects of Aspergillus mastoiditis in patients with AIDS with three additional cases present in the current literature. A classification system for fungal infections of the ear and temporal bone is proposed. STUDY DESIGN: The study design was a retrospective case review. SETTING: The study was conducted at multiple tertiary referral centers. PATIENTS: Three individuals with diagnosed AIDS and mastoiditis resulting from culture-proven Aspergillus were studied. INTERVENTION: Patients were treated with both medical and surgical methods including local and systemic antimicrobial/antifungal agents and mastoidectomy. MAIN OUTCOME MEASURES: These measures included return of facial nerve function, control/resolution of disease, and survival. RESULTS: All three patients in this series initially presented with otalgia and otorrhea and intact facial nerve function. Facial nerve paresis developed in all patients between 5 and 12 weeks after initial symptoms. Paresis uniformly improved or resolved after mastoidectomy. Two patients treated with systemic antifungal therapy and prompt surgical debridement after development of facial palsy had full resolution of infection. One patient had full recovery of facial paresis and the other had partial recovery. The third patient was lost to follow-up after initial treatment with antimicrobials and surgery and died 3 months later without a clear etiology. CONCLUSIONS: Aspergillus mastoiditis is an unusual infection in patients with AIDS. Because of its rarity, fungal mastoiditis in immunocompromised individuals can result in a significant delay in diagnosis and treatment. The decision between conservative antimicrobial therapy and aggressive surgical treatment also can present a therapeutic challenge in the management of these life-threatening infections, especially in patients with existing immunodeficiency and illness. Early surgical debridement followed by antimicrobial therapy may be life preserving in this patient population.

Idiopathic Dandy's syndrome.

In 1941 Dandy described patients in whom he had performed bilateral vestibular nerve sections who reported "jumbling" objects in their visual fields when in motion and difficulty walking in the dark. We use the term Dandy's syndrome to describe patients with bilateral vestibular loss as the cause of the above symptoms. The caloric response in these patients is either markedly reduced or absent when the cause is in the peripheral vestibular system. This study explored whether differences exist between those patients in whom the cause is known and those patients with no known cause. We reviewed our experience with 105 patients in whom Dandy's syndrome was diagnosed between 1984 and 1994. Information on their presenting symptoms, findings on physical examination, audiometric status, electronystagmographic findings, laboratory test results, symptom outcome, and cause was collected. Patients with known causes (Meniere's disease, ototoxicity, tumors, vascular disease, trauma, heredity, autoimmune disease, infection) were compared as a group with those with no known cause. Of the 105 patients 34 (32%) had no obvious cause for their symptoms despite an extensive evaluation. This group was similar to those with a known cause except for having a greater preponderance of women (68% vs. 41%, p = 0.018) and an increased likelihood to have normal audiogram findings (53% vs. 19%, p = 0.0009). All other variables, including age, duration of and age at onset of symptoms, physical examination, and electronystagmographic findings did not differ significantly between the two groups. Only 28% of patients with known causes and 40% (p < 0.05) of those with idiopathic Dandy's syndrome had improvement of their symptoms, underscoring the problem with rehabilitation. The results of this study are compared with earlier reports from our and other institutions.

Relief of headache by cranioplasty after skull base surgery.

Headache after skull base surgery can cause profound morbidity in certain patients, resulting in significant impairment of their quality of life. Several methods to prevent postoperative headache have been described, including a modification of the skin/muscle incision replacing the craniotomy bone flap replacing the bone flap and filling in the residual defect with methyl methacrylate, using hydroxyapatite cement (HAC) to fill the craniectomy defect, and wiring hardened methyl methacrylate (MMA) into the defect. Ten patients with severe headache following craniectomy for a posterior fossa lesion underwent cranioplasty with MMA, which was placed exactly within the craniectomy defect and secured rigidly with miniplates and screws. The headache decreased in severity in all patients and resolved completely in 90%. Also, 78% of patients with dizziness improved. The procedure and its effect on headache and dizziness will be described.

Pediatric tympanoplasty. A 10-year experience.

OBJECTIVES: To determine if the age of the child is a factor in healing after tympanoplasty and to find other factors that affect the outcome in these patients. DESIGN: Case series by retrospective otological chart review. SETTING: A group private practice otology and neuro-otology referral center. PATIENTS AND OTHER PARTICIPANTS: A consecutive sample of all patients younger than 20 years who had tympanoplasty performed at the House Ear Clinic between January 1, 1983, and January 1, 1993. The 318 patients, who had had 381 ears operated on, were separated into four age groups: younger than 7 years, 7 to 8 years, 9 to 12 years, and 13 to 19 years. The 268 patients who had follow-up examinations for 6 months or longer after tympanoplasty are grouped in the same age categories for outcomes analysis. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Preoperative and postoperative audiometric data and otologic examination at the final follow-up examination. Results are reported for hearing, healing, and "success," which combines hearing and healing and is defined as an intact graft with a postoperative air-bone gap of less than 25 dB. RESULTS: The operation resulted in an intact graft in 92.5% of ears and a postoperative air-bone gap less than 25 dB in 84% of ears. Success was achieved in 81% of ears. No difference in outcome was observed among the four age groups. Success was negatively affected by mastoidectomy, previous tympanoplasty, and use of total ossicular replacement prosthesis ossiculoplasty; perhaps by the number of previous myringotomy and tubes; but not by age, status of the contralateral ear, middle ear discharge, or fellow as primary surgeon. CONCLUSION: Tympanoplasty can be safely and effectively performed in children.

Prostheses for stapes surgery.

A variety of different implants are available today for use by the otologic surgeon. All prostheses are well tolerated, and the risks of complication as a result of their implantation are comparable. The most commonly used prostheses are the wire-Teflon piston and the stainless steel bucket handle. Although the otologic surgeon has a wide variety of prostheses to choose from, most have a preference for one particular type. Results of hearing improvement following a successful stapedectomy is more a function of the surgeon's experience than of the type of prosthesis used. As James L. Sheehy, MD, so often says, "if a technique is working well for you, don't change for change's sake" (personal communication, 1994).

Acute postoperative hydrocephalus following translabyrinthine craniotomy for acoustic neuroma resection.

Acute mental status changes following craniotomy for acoustic tumors demand prompt evaluation and treatment to avoid serious morbidity and mortality. Two cases of acute obstructive hydrocephalus complicating the postoperative period following translabyrinthine craniotomy are presented. Diagnosis is made with noncontrast computed tomography scanning. Treatment is rendered at the bedside with placement of a ventriculostomy. Diagnosis and management implications for acoustic tumor patients are discussed.

Reclassification of aggressive adenomatous mastoid neoplasms as endolymphatic sac tumors.

The emerging concept that aggressive adenomatous tumors of the temporal bone arise from the endolymphatic sac and constitute a distinct clinicopathologic entity merits wider recognition. These tumors share a common clinical pattern and exhibit consistent imaging and histopathologic features. Endolymphatic sac tumors (ELSTs) have been mistaken for other neoplasms such as paragangliomas, adenomatous tumors of mixed histology, ceruminomas, and choroid plexus papillomas. A review of the literature shows similarities among case studies of these aggressive adenomatous lesions. An analysis of the data supports the endolymphatic sac as an origin for these tumors. This report also presents an additional case of a less differentiated variant of this rare but important clinicopathologic entity.

Endolymphatic sac tumors: radiologic appearance.

PURPOSE: To evaluate the radiologic appearance of endolymphatic sac tumors (ELSTs). MATERIALS AND METHODS: Four patients with ELST underwent computed tomography (CT), and two of the four also underwent magnetic resonance (MR) imaging. Their radiologic studies were reviewed for characteristic findings of ELST. RESULTS: Retrolabyrinthine bone destruction was centered at the external aperture of the vestibular aqueduct in all four patients. CT showed irregular bone margins and prominent intratumoral bone in all four patients. At MR imaging, one tumor was almost homogeneous and isointense to gray matter with T1 weighting, and the other was heterogeneous and contained hyper-, hypo-, and isointense foci with T1 and T2 weighting. CONCLUSION: These radiologic changes may help distinguish ELSTs from other tumors of the temporal bone and posterior fossa.

Stapedectomy technique.

This article reviews the evolution of the author's stapedectomy technique from total footplate removal with single loop wire prosthesis and Gelfoam seal to small fenestra stapedectomy with platinum ribbon piston prosthesis and blood seal. The author concludes that the microdrill is effective, safe, and cost effective for performing this procedure. Since using this technique, the author has had no cases of sensorineural hearing loss and few complaints of dizziness or vertigo.

Tympanosclerosis of the stapes: hearing results for various surgical treatments.

When tympanosclerosis involves the tympanic membrane or the lateral ossicles, treatment is usually straightforward and uncomplicated. When the stapes is involved, therapy is more controversial and may be more difficult. We report our results in 154 patients who underwent different surgical procedures for tympanosclerosis of the stapes. Followup was up to 10 years. Pure-tone average threshold was significantly improved (p < 0.05) in patients who underwent mobilization procedures or stapedectomy for definitive treatment. The air-bone gap was less than 20 dB at 6 months postoperative in 72% of patients and less than 30 dB in 90%. At 6 months, 2 years, and 5 years there were no statistically significant differences in hearing results between stapedectomy and mobilization patients, some of whom were followed for up to 10 years. No patient had a profound hearing loss after surgery. Surgical treatment for tympanosclerosis of the stapes is a safe procedure, with hearing results similar to those of surgery for other chronic ear diseases involving the ossicular chain.

Perilymphatic fistula: surgical experience in the United States.

One survey sent to 6953 individual otolaryngologic practices and 106 departments of otolaryngology at teaching hospitals in the United States, and a more limited survey of 75 patients operated on for perilymphatic fistula (PLF) at the House Ear Institute, addressed aspects of managing PLF: surgical incidence, reliability of diagnostic test, preoperative observations, and disability after surgery. Of surgeons sampled, 93% estimated incidence of PLF surgery to be less than or equal to 1 per 1000 otolaryngologic outpatient visits. The most reliable diagnostic indicators were history, symptomatology, and tympanometric and electronystagmographic fistula tests. About 72% of surgeons reported less than 4 weeks' average delay before surgery. Most surgeons and patients (greater than or equal to 70%) rated length of disability before return to work, exposure to noise, travel by airplane, swimming, and heavy lifting, at several weeks to several months. Diving was the most restricted activity. Results suggest that incidence of surgery and disability with PFL in the United States is very limited.

Perilymph fistulas: the House Ear Clinic experience.

The diagnosis, evaluation, and surgical treatment of perilymph fistulas has recently been the focus of a great deal of attention in otology. Authors have focused on perilymph fistulas as the cause of hearing loss and vertigo in many diverse situations. Additionally, surgical repair has been suggested when there is little objective support for intervention. To address some of the problems inherent in the diagnosis and treatment of perilymph fistulas, records of patients operated on at the House Ear Clinic during the past 12 years were reviewed retrospectively. Eighty-six patients were surgically explored for fistulas during this period. Thirty-five (40.7%) fistulas were found, and 51 ears were patched whether fistulas were found or not. Of the 80 patients who were seen for follow-up, 35 (43.8%) were subjectively better, and 45 (56.2%) were the same. Although the number of fistulas found and the number of patients improved were similar, the composition of the two groups was different. On the basis of audiometric results, improvement in hearing occurred in only 18.7% of the patients. None of the demographic factors or diagnostic tests were predictive of either the presence of a fistula or the therapeutic outcome. Further work is required to facilitate the preoperative diagnosis of fistulas and to design appropriate surgical intervention.