Endolymphatic Sac Decompression With Intra-Sac Dexamethasone Injection in Menière's Disease.

OBJECTIVE: Endolymphatic sac decompression surgery (ELSD) may be used to treat patients who have Menière's 's disease refractory to medical therapy. In this study, we investigated whether or not the injection of steroid into the endolymphatic sac at the time of ELSD provides additional benefit to patient outcomes. STUDY DESIGN: Randomized prospective single-blinded placebo-controlled study. SETTING: Tertiary center. PATIENTS: Patients with Menière's disease with poorly controlled vertigo despite medical therapy and serviceable hearing that were offered ELSD. INTERVENTION(S): Patients randomized into two groups, with control group (n = 17) undergone ELSD without steroid injection and experimental group undergone ELSD with steroid injection (n = 18) MAIN OUTCOME MEASURE(S):: Audiogram, dizziness handicap inventory, tinnitus handicap inventory, frequency of vertigo spells, functional level scale, and quality of life were obtained at multiple intervals from preoperatively to 24 months postoperatively. RESULTS: ELSD resulted in a statistically significant improvement in vertigo control whether or not steroid was injected into the endolymphatic sac at the time of surgery. However, no additional benefit was observed with the addition of intra-sac steroid injection. No statistical difference in pure-tone average, tinnitus handicap inventory, dizziness handicap inventory, or quality of life was observed between the steroid and nonsteroid surgical groups up to 24 months postoperatively. CONCLUSION: ELSD is an effective treatment for Menière's disease refractory to medical therapy; however, the addition of intra-sac steroid injection at the time of surgery does not seem to result in a further improvement in patient outcomes.

Comparison Study of Percutaneous Osseointegrated Bone Conduction Device Complications When Using the 9 mm Abutment Versus 6 mm Abutment at Initial Implantation.

OBJECTIVES: To assess differences in the incidence, type, and management of complications encountered with implantation of percutaneous osseointegrated bone conduction devices when using a 9 mm abutment versus 6 mm abutment at initial implantation. STUDY DESIGN: Retrospective cohort study. METHODS: One hundred thirty consecutive patients between January 2010 and December 2011 underwent single-stage percutaneous osseointegrated bone conduction device implantation using a 9 or 6 mm abutment. Clinical outcomes assessed for the two groups included the incidence, type, and management of postoperative complications. Abutment size, age, sex, indication for surgery, implant device type, duration of follow-up, and patient comorbidities were evaluated as potential factors affecting outcomes. RESULTS: Average duration of follow-up was 16 months (range 6-29 mo). Postoperative complications occurred in 38 (29.2%) patients. Twenty-four (18.4%) patients experienced minor complications requiring simple, local care; eight (6.1%) patients required in-office procedural intervention; and six (4.6%) patients required revision surgery in the operating room. Implant extrusion occurred in three (2.3%) patients. Eleven (8.5%) patients required placement of a longer abutment. Patients receiving the 6 mm abutment at initial surgery were significantly more likely to encounter a complication requiring in-office procedural intervention or revision surgery (p = 0.001). CONCLUSION: Minor complications after implantation of percutaneous osseointegrated bone conduction devices are common. The vast majority of these complications are due to localized skin reactions, most of which are readily addressed through local care. Patients receiving the 9 mm abutment during initial implantation are significantly less likely to require in-office procedural intervention or revision surgery postoperatively as compared with those receiving the shorter, 6 mm abutment.

Fully Endoscopic Retrosigmoid Vestibular Nerve Section for Refractory Meniere Disease.

OBJECTIVE: This study aims to report our results and technical details of fully endoscopic retrosigmoid vestibular nerve section. DESIGN: A prospective observational study was conducted. SETTING: A single academic, tertiary institution involving neurosurgery and neurotology. PARTICIPANTS: Previously diagnosed patients with Meniere disease, refractory to medical therapy, who underwent fully endoscopic vestibular nerve section. MAIN OUTCOME MEASURES: Postoperative improvement in vertiginous symptoms as well as hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons score and the Gardener and Robertson-Modified Hearing Classification. Facial nerve preservation based on the House-Brackman (HB) score. RESULTS: Symptoms improved or resolved in 38 of 41 (92.2%) patients with only 1 of 41 (2.4%) reporting worsening symptoms. All 41 patients (100%) had a postoperative HB score of 1/6, demonstrating full facial nerve preservation. Hearing was stable or improved in 34 of 41 (82.9%) patients. Three complications took place for a rate of 7.3%, one cerebrospinal fluid leak, and two wound infections. CONCLUSION: The fully endoscopic approach to vestibular nerve sections is a safe and effective technique for the treatment of medically refractory Meniere disease. This technique also utilizes smaller incisions, minimal cranial openings, and no cerebellar retraction with improved visualization of the cerebellopontine angle neurovascular structures.

Fully Endoscopic Resection of Cerebellopontine Angle Meningiomas.

OBJECTIVE: To describe our operative technique and results from patients who underwent fully endoscopic resection of cerebellopontine angle (CPA) meningiomas. DESIGN: Prospective observational study. SETTING: A single academic institution that includes both neurosurgery and neuro-otology. PARTICIPANTS: Eleven consecutive patients who underwent fully endoscopic resection of a CPA meningioma. MAIN OUTCOME MEASURES: Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons score as well as facial nerve preservation base on the House-Brackmann (HB) score. In addition, the extent of resection and complication rates was studied. RESULTS: All 11 patients underwent successful gross total resection, Simpson grade 2, of their meningioma, seen both intraoperatively and on postoperative imaging. Overall, 100% of patients maintained normal facial nerve function (HB 1/6). Audiometric testing revealed that 10 of 11 patients maintained either stable or improved hearing postoperatively based on Committee on Hearing and Equilibrium Guidelines for the Evaluation of Hearing Preservation in Acoustic Neuroma grade with the remaining patient retaining serviceable hearing. Tumor size ranged from 0.5 to 2.5 cm (mean: 1.54 cm). Mean operative time was 166 minutes (range: 122-207 minutes); estimated blood loss averaged 54.5 mL. Hospital length of stay ranged from 2 to 6 days (mean: 3.1 days), and a superficial wound infection was the only complication seen in one patient. CONCLUSION: Fully endoscopic techniques can be used in CPA meningioma resection with excellent clinical results as an alternative to the traditional open microscopic approach.

Acoustic Reflex Screening of Conductive Hearing Loss for Third Window Disorders.

OBJECTIVE: This study examines the effectiveness of acoustic reflexes in screening for third window disorders (eg, superior semicircular canal dehiscence) prior to middle ear exploration for conductive hearing loss. STUDY DESIGN: Case series with chart review. SETTING: Outpatient tertiary otology center. SUBJECTS AND METHODS: A review was performed of 212 ears with acoustic reflexes, performed as part of the evaluation of conductive hearing loss in patients without evidence of chronic otitis media. The etiology of hearing loss was determined from intraoperative findings and computed tomography imaging. The relationship between acoustic reflexes and conductive hearing loss etiology was assessed. RESULTS: Eighty-eight percent of ears (166 of 189) demonstrating absence of all acoustic reflexes had an ossicular etiology of conductive hearing loss. Fifty-two percent of ears (12 of 23) with at least 1 detectable acoustic reflex had a nonossicular etiology. The positive and negative predictive values for an ossicular etiology were 89% and 57% when acoustic reflexes were used alone for screening, 89% and 39% when third window symptoms were used alone, and 94% and 71% when reflexes and symptoms were used together, respectively. CONCLUSION: Acoustic reflex testing is an effective means of screening for third window disorders in patients with a conductive hearing loss. Questioning for third window symptoms should complement screening. The detection of even 1 acoustic reflex or third window symptom (regardless of reflex status) should prompt further workup prior to middle ear exploration.

Endoscopic Resection of Vestibular Schwannomas.

Objective To report our results and the technical details of fully endoscopic resection of vestibular schwannomas. Design Prospective observational study. Setting A single academic institution involving neurosurgery and neurotology. Participants Twelve consecutive patients who underwent fully endoscopic resection of a vestibular schwannoma. Main Outcome Measures Hearing preservation, based on the American Association of Otolaryngology-Head and Neck Surgeons (AAO-HNS) score as well as the Gardener and Robertson Modified Hearing Classification (GR). Facial nerve preservation based on the House-Brackmann (HB) score. Results All patients successfully underwent gross total resection. Facial nerve preservation rate was 92% with 11 of 12 patients retaining an HB score of 1/6 postoperatively. Hearing preservation rate was 67% with 8 of 12 patients maintaining a stable AAO-HNS grade and GR score at follow-up. Mean tumor size was 1.5 cm (range: 1-2 cm). No patients experienced postoperative cerebrospinal fluid leak, infection, or cranial nerve palsy for a complication rate of 0%. Mean operative time was 261.6 minutes with an estimated blood loss of 56.3 mL and average length of hospital stay of 3.6 days. Conclusion A purely endoscopic approach is a safe and effective option for hearing preservation surgery for vestibular schwannomas in appropriately selected patients.

Improved facial nerve outcomes using an evolving treatment method for large acoustic neuromas.

OBJECTIVE: To describe a successful paradigm for the treatment of large acoustic neuromas (vestibular schwannomas). STUDY DESIGN: Retrospective case review. SETTING: Tertiary referral center. PATIENTS: The charts of 2,875 acoustic neuroma patients at Michigan Ear Institute were reviewed to identify 153 patients who underwent surgical resection for large acoustic neuromas (>=3 cm) between 2000 and 2009. INTERVENTION(S): Staged surgical resection or single stage surgery with or without adjuvant stereotactic radiosurgery. MAIN OUTCOME MEASURE(S): Postoperative facial nerve outcomes are reported using the House-Brackmann (HB) facial nerve grading scale and compared with historical controls from a literature review. Rates of adverse outcomes are also reported. RESULTS: Seventy-five patients underwent staged surgical resection of their tumors, whereas 78 patients underwent either single stage surgery or surgery with subsequent stereotactic radiosurgery. Eighty-one percent of patients in the staged surgical resection group had a postoperative HB Grade I or II facial nerve function compared with 75% in the single stage surgical group. Overall, 78% of patients in the current study had HB Grade I or II after treatment compared with a mean of 53% in the literature for similar sized tumors. Our methods including the decision to use staged surgery when necessary, dissection of tumor with stimulating dissector-directed intraoperative monitoring, and use of adjuvant stereotactic radiosurgery are described. CONCLUSION: Using the described paradigm, large acoustic neuromas can be successfully treated with either staged or single-stage surgical resection with or without adjuvant radiosurgery to obtain more favorable facial nerve outcomes than historically reported controls while minimizing morbidity for the patient.

Endoscopic vascular decompression.

OBJECTIVE: This article describes the technique and reports the results of endoscopic vascular decompression (EVD) in patients with trigeminal neuralgia (TGN), hemifacial spasm (HFS), and cochleovestibular nerve compressive syndrome. STUDY DESIGN: Retrospective case review. SUBJECTS AND METHODS: This study evaluates the outcome and length of stay (LOS) of 20 patients who underwent EVD for vascular compressive disorders from 2005 to 2007. It also evaluates LOS in 41 patients who underwent traditional microvascular decompression (MVD) by the same surgeons from 1999 to 2004. RESULTS: Eighty-six percent (12 of 14) patients had resolution of their TGN, and 80% (4 of 5) had resolution of their HFS. There were no major complications. The EVD patients had an average LOS of 2.36 days as compared with 4.36 days for the MVD patient group (p < 0.001). CONCLUSION: Endoscopic vascular decompression for patients with vascular compressive syndromes such as TGN and HFS is a safe and equally effective procedure when compared with the traditional and widely successful MVD surgery, with the added benefit of less morbidity and shorter hospital stays.

Tumors and pseudotumors of the endolymphatic sac.

This article reports on the presentation, diagnosis, management, and treatment outcomes of lesions of the endolymphatic sac in patients treated at a tertiary neurotology referral center. It summarizes survival results in the largest series groups and presents a new diagnostic entity of pseudotumor of the endolymphatic sac. The study includes retrospective review of all patients diagnosed with lesions of the endolymphatic sac within our practice between 1994 and 2005 as well as review of the literature. The primary outcome measure was survival, and the secondary outcome measure was disease-free survival following definitive resection. Postoperative complications were assessed. Survival characteristics of the largest reported case series groups were reviewed. Five cases of endolymphatic sac lesions were identified. Of these, three were true endolymphatic sac tumors and two were inflammatory pseudotumors of the endolymphatic sac. All three of the endolymphatic sac tumors patients survived (100%), and two of the three had disease-free survival (67%). Two of three patients maintained persistent facial paresis postoperatively. Both patients with benign pseudotumors survived (100%). Our study concluded that endolymphatic sac tumors are rare neoplasms of the temporal bone that, although locally aggressive and invasive, have excellent prognosis for survival with complete resection. We report a new entity of pseudotumor of the endolymphatic sac that mimics true sac tumors in every respect on presentation but which is non-neoplastic in origin.

Quality-of-life assessment of Ménière's disease patients after surgical labyrinthectomy.

OBJECTIVE: To examine the impact of surgical labyrinthectomy on quality of life of Ménière's disease patients. STUDY DESIGN: Cross-sectional survey. SETTING: Otology subspecialty referral center. PATIENTS: All patients with Ménière's disease who underwent surgical labyrinthectomy between 1998 and 2004 were selected. Fifty-three patients satisfied inclusion criteria. Completed questionnaires were obtained from 44 patients. INTERVENTION(S): The Ménière's Disease Outcomes Questionnaire is a disease-specific quality-of-life questionnaire. It was used to assess the quality of life of patients before and after surgical labyrinthectomy. The questionnaire encompasses physical, mental, and social well-being domains of quality of life. MAIN OUTCOME MEASURE(S): Change in total quality-of-life score was used to assess the overall impact of surgical labyrinthectomy on subjective patient outcome. Individual quality-of-life domains were also assessed. RESULTS: Forty-three of 44 respondents (98%) had improvement in total score after surgery. The one patient who demonstrated deterioration developed latent contralateral disease. Average preoperative and postoperative scores were 34 +/- 14 and 67 +/- 15, respectively (p < 0.001). All questions showed significant improvement with surgery (p < 0.001) except questions pertaining to memory (no change) and hearing loss (nonsignificant decrease in score). CONCLUSION: This study comprises the first patient-directed assessment of quality-of-life outcomes in Ménière's disease patients after labyrinthectomy. Despite the disadvantage of hearing loss, patients consistently reported significant improvement in all quality-of-life domains and do not report a significant loss of quality of life in terms of their hearing loss. Surgical labyrinthectomy remains a highly effective treatment for Ménière's disease patients.

Ambulatory tympanomastoid surgery in children: factors affecting hospital admission.

OBJECTIVE: To identify clinical factors associated with postoperative nausea and vomiting (PONV) and failure to discharge from the hospital on the day of surgery in children undergoing tympanomastoid surgery. DESIGN: Records of 144 children undergoing 152 tympanomastoid surgical procedures from July 1, 2001, through June 30, 2002, were retrospectively reviewed and the data analyzed. SETTING: A tertiary care university-affiliated hospital. RESULTS: The mean +/- SD age of the cases was 11 +/- 3.7 years. Sixty-eight cases (45%) were middle ear procedures, while 84 cases (55%) were mastoid procedures. Forty-three cases (28%) were discharged home from the postanesthesia care unit (PACU), 55 cases (36%) were discharged on the day of surgery, and 142 cases (92%) were discharged home from the day surgery unit (DSU) within 23 hours after surgery. Patients who underwent mastoid procedures were more likely to require intravenous (IV) morphine sulfate in the PACU (75% vs 56%; P = .02) and were less likely to be discharged from PACU (15% vs 44%; P<.001) compared with patients who had middle ear procedures. In patients who underwent mastoid procedures, the presence of cholesteatoma (odds ratio, 1.9; 95% confidence interval, 1.0-3.7; P = .04) was associated with a higher likelihood of PONV. In both groups, the need for IV morphine sulfate to control pain on admission to DSU was associated with a higher occurrence of PONV. Factors that were significantly associated with failure to discharge from the hospital on the day of surgery were a pain score of 5 or greater, the presence of PONV, and the requirement of IV morphine sulfate on admission to DSU. CONCLUSIONS: Factors associated with higher risks of PONV and failure to discharge from the hospital on the day of surgery include the presence of cholesteatoma, a pain score of 5 or greater, and the requirement of IV morphine sulfate at the time admission to the DSU.

Evaluating quality of life after endolymphatic sac surgery: The Ménière's Disease Outcomes Questionnaire.

OBJECTIVE: To develop a disease-specific instrument to measure the quality of life in patients with Ménière's disease and to assess quality-of-life outcomes after endolymphatic sac decompression. STUDY DESIGN: Retrospective survey. PATIENTS: Patients with Ménière's disease who underwent endolymphatic sac decompression from June 1996 to June 2001, after failing a course of medical management. Two hundred fifteen potential subjects were identified; completed questionnaires were returned by 159 patients. MAIN OUTCOME MEASURES: The Ménière's Disease Outcomes Questionnaire was developed, and consists of questions in three domains that determine quality of life: physical, emotional, and social well-being. The Ménière's Disease Outcomes Questionnaire consisted of 18 multiple-choice questions that were paired for pre- and postoperative conditions, and one global quality-of-life question. The preoperative quality-of-life score (total score for preoperative items) was compared with the postoperative quality-of-life score. The main outcomes measure was the change in quality-of-life score. RESULTS: Overall, the mean change in quality-of-life score was +25.6 points (range, -34 to 83) (p < 0.001). The change in Ménière's Disease Outcomes Questionnaire quality-of-life score was highly correlated with the change in the global question score (p < 0.01). Quality of life was improved in 87% of respondents, unchanged in 3% of patients, and poorer in 9% of patients after endolymphatic sac decompression. CONCLUSIONS: The Ménière's Disease Outcomes Questionnaire is a new disease-specific quality-of-life tool that is a valid measure of quality of life in patients with Ménière's disease, and is responsive to measuring change in quality of life after treatment. Significant improvement in quality of life was reported by 87% of patients after endolymphatic sac decompression.

Round window gentamicin absorption: an in vivo human model.

OBJECTIVE/HYPOTHESIS: Using a novel human labyrinthine sampling model, in vivo gentamicin absorption through the round window can be measured. STUDY DESIGN: A prospective study. METHODS: Gentamicin was delivered either transtympanically (preoperative) or through a facial recess approach (intraoperative). The lateral semicircular canal and vestibule were opened, and by means of a microsyringe, labyrinthine fluid was aspirated. A sample of serum was also drawn. In all patients cerebrospinal fluid was also drawn. The samples were analyzed using a standard chemistry analyzer. RESULTS: Intratympanic gentamicin diffused through the round window membrane and achieved concentrations in the labyrinthine fluid ranging from 0 to 16 mg/L. Intratympanic gentamicin was absorbed into the systemic circulation in 4 of 11 patients with serum levels ranging from 0.3 to 0.4 mg/L. No gentamicin was detected in the cerebrospinal fluid. CONCLUSIONS: Intratympanic gentamicin diffuses rapidly through the round window membrane and achieves significant levels in the inner ear. Thus, this new model can be used to assess round window permeability to clinically relevant medications such as steroids and ototopical antibiotics.

Rapid elevation of gentamicin levels in the human labyrinth following intravenous administration.

HYPOTHESIS: Adequate quantities of labyrinthine fluid can be sampled from the human labyrinth to perform quantitative analysis of medications. A rapid elevation of intralabyrinthine gentamicin levels after intravenous administration can be measured. A model for the sampling of human inner ear fluid in this manner is described. BACKGROUND: The risk of aminoglycoside ototoxicity has been a long-standing concern. The kinetics of gentamicin diffusion into the inner ear have been extrapolated to humans from various animal models. The validity of extrapolation to humans is unknown. We have developed a new model to measure the uptake of gentamicin in vivo. METHODS: A single intravenous dose of gentamicin (80 mg) was given perioperatively to 13 patients undergoing translabyrinthine acoustic neuroma surgery. The lateral semicircular canal and vestibule were opened and a microsyringe was used to obtain a sample of labyrinthine fluid concomitant with a serum sample. The gentamicin concentration of the labyrinthine fluid and serum was analyzed using a standard chemistry analyzer. RESULTS: After parenteral administration of gentamicin, fluid was obtained from the inner ear of 13 acoustic neuroma patients. Inner ear concentrations were between 1.0 and 3.8 mg/L. Serum gentamicin levels ranged from 1.2 to 10.5 mg/L. CONCLUSIONS: This method allows the sampling of intralabyrinthine fluid in humans. Gentamicin was noted immediately in the labyrinth after intravenous administration. This model may be expanded to measure other compounds given either by intravenous or transtympanic routes.

Over-under tympanoplasty.

OBJECTIVE: Common techniques of tympanic membrane repair include underlay and overlay grafting. The over-under tympanoplasty, an innovative method for tympanic membrane repair, will be described as a reliable alternative that has advantages over traditional procedures. STUDY DESIGN: This study was a retrospective case review. SETTING: Tertiary referral center with hospital-setting surgery and outpatient ambulatory patient visits. PATIENTS: One hundred twenty patients who underwent over-under tympanoplasty were included in this study. Average follow-up was 1.8 years. INTERVENTION: Over-under tympanoplasty is performed by placing the graft over the malleus and under the annulus. This technique was used for patients undergoing ear surgery for chronic otitis media, perforations, cholesteatoma, and/or conductive hearing loss. All degrees of ear pathology were included. MAIN OUTCOME MEASURES: Main outcome measures were graft success (no perforation, atelectasis, or lateralization within 6 mo) and improvement of hearing. Patients were stratified by severity of disease (according to the Middle Ear Risk Index), cholesteatoma presence, and type of mastoidectomy. RESULTS: All 120 patients had successful grafts. Lateralization of the grafted drum did not occur. Seventeen patients had late atelectasis, and 12 patients had late perforations; nearly all of these were noted more than 1 year after surgery and were attributed to persistent eustachian tube dysfunction or infections. Average improvement in air-bone gap for all patients was 5.3 dB, whereas speech reception threshold improved by 5.9 dB. CONCLUSION: Over-under tympanoplasty has an excellent success rate while being technically easier than lateral tympanoplasty. Thus, it is a useful method for practitioners of all levels.