Triple fluorochrome labeling of cochlear bone growth.

A new technique is described which measures the extent and time course of intracochlear bone formation after cochlear implantation in an experimental animal model. A series of fluorescent histochemical markers is used to delineate the amount of intracochlear bone deposition during specified time periods.

Application of an implantable bone conduction hearing device to patients with unilateral sensorineural hearing loss.

This investigation, comprised of five studies, was undertaken to determine if individuals with newly acquired profound unilateral hearing losses would benefit from an implantable bone-conduction hearing device. The bone conductor was implanted on the side of the deaf ear at the time of translabyrinthine acoustic tumor resection. Two areas greatly affected by unilateral hearing loss, speech recognition in noise and sound localization, were examined. No improvement in aided performance could be documented in either area.

Hearing preservation in vestibular neurectomy.

The goal of vestibular neurectomy is to control disabling vertigo while preserving hearing in patients with nonhydropic intractable peripheral vertigo or in patients with Meniere's disease in which an endolymphatic sac procedure has failed. Labyrinthectomy continues to be used to treat patients with intractable vertigo and serviceable hearing. We feel that a labyrinthectomy is contraindicated when any useful hearing remains. Vestibular neurectomy affords the surgeon a means to eliminate the abnormal vestibular input without sacrificing hearing. Two approaches have been used to section the vestibular nerves: the middle fossa approach since 1961 and the retrolabyrinthine approach more recently. Both approaches are effective in relieving vertigo while preserving hearing. This paper presents a statistical analysis of these two approaches. Although differences did exist, both were found to be highly successful in alleviating incapacitating vertigo and preserving hearing in a large percentage of patients.

A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery.

OBJECTIVE: To determine the facial nerve outcomes at a tertiary neurotological referral center specializing in acoustic neuroma and skull base surgery. STUDY DESIGN: Retrospective review of 100 consecutive patients in whom acoustic neuromas were removed using all of the standard surgical approaches. METHODS: Functional facial nerve outcomes were independently assessed using the House-Brackmann facial nerve grading system. RESULTS: The tumors were categorized as small, medium, large, and giant. If one excludes the three patients with preoperative facial palsies, 100% of the small tumors, 98.6% of the medium tumors, 100% of the large tumors, and 71% of the giant tumors had facial nerve function grade I-II/VI after surgery. CONCLUSION: Facial nerve results from alternative nonsurgical treatments must be compared with facial nerve outcomes from experienced surgical centers. Based on the facial nerve outcomes from our 100 consecutive patients, microsurgical resection remains the preferred treatment modality for acoustic tumors.

Retrolabyrinthine vestibular neurectomy: a reevaluation.

Selective vestibular neurectomy is considered an effective means of relieving intractable vertigo while preserving hearing. In order to determine the effectiveness of the retrolabyrinthine approach to selective vestibular neurectomy, we evaluated 161 patients who underwent vestibular neurectomy between April 1981 and September 1985. Questionnaire responses indicated that 97% of the Meniere's disease patients and 68% of the non-Meniere's disease patients experienced a substantial improvement or resolution of their vertiginous symptoms. Hearing was maintained within 10 dB of the preoperative level in the majority of the patients. Neurological complications were limited to 2 cases of meningitis which resolved with medical therapy, 7 cases of cerebral spinal fluid leaks, and 3 cases of complete sensorineural hearing loss. Based on this review, we concluded that retrolabyrinthine vestibular neurectomy continues to be a safe and effective approach to relieve ear-related vertigo.

Intratympanic steroid injections for intractable Ménière's disease.

OBJECTIVE: To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménière's disease who have persistent vertigo despite standard medical treatment, including a low-salt/no-caffeine diet and diuretics. STUDY DESIGN: A prospective study. METHODS: From August 1999 to November 2000, 21 patients with intractable Ménière's disease underwent intratympanic injections of 4 mg/mL dexamethasone over a period of 4 weeks as an office procedure. American Academy of Otolaryngology-Head and Neck Surgery guidelines for the definition and reporting of results in Ménière's disease were used. RESULTS: Complete relief of vertigo was maintained in 11 of the 21 patients (52%) at 3 months and in 9 of 21 patients (43%) at 6 months. Repeat injections in 5 patients who had initial control of vertigo, but later failed, yielded control in 3 (60%) patients. The complication rate was low: one patient had a 35-decibel pure tone average decrease in hearing during treatment and one patient had a persistent tympanic membrane perforation. CONCLUSIONS: Intratympanic injections of dexamethasone are a reasonable initial surgical treatment for persistent vertigo in Ménière's disease. The principal benefits are avoidance of systemic administration of steroids, lower cost than endolymphatic sac surgery, and ease of administration as an office procedure. The disadvantages are the need for repeated office visits for injections and the decreasing effectiveness over time.

Lipomas of the internal auditory canal.

Intracranial lipomas are rare tumors which may occur in the cerebellopontine angle (CPA) or internal auditory canal (IAC). Although seemingly innocuous in other parts of the body, lipomas within the CPA and IAC often involve the surrounding cranial nerves, making attempts at hearing conservation largely unsuccessful. In an attempt to differentiate the IAC lipoma from the more commonly found acoustic schwannoma, the preoperative imaging studies (magnetic resonance and computerized tomography) on five previously unreported cases of IAC lipomas were evaluated. Based on these studies, features were determined that may allow the surgeon to diagnose IAC lipomas preoperatively. These features will be discussed, as well as the surgical and pathological findings.

Cochlear implantation in common cavity malformations using a transmastoid labyrinthotomy approach.

The transmastoid facial recess approach has become the standard technique for cochlear implantation. Although this approach has been used for implantation in patients with common cavity deformities, it is not without increased risk to the facial nerve. Using a direct approach to the common cavity that circumvents the facial recess, we have successfully implanted four patients with common cavity deformities. An aberrant facial nerve in one patient would have precluded placement of the electrode array using standard cochlear implant techniques. As demonstrated in these four patients, the direct approach to the common cavity is an effective approach for placement of the electrode array, minimizes risk to the facial nerve, and may decrease the likelihood of postoperative cerebrospinal fluid leaks. Intraoperative video footage demonstrates the feasibility and facility of this approach in patients with common cavity deformities.

Bone cement reconstruction of the ossicular chain: a preliminary report.

OBJECTIVE: To determine the feasibility and efficacy of using a bone cement, Oto-Cem, to reconstruct the ossicular chain. STUDY DESIGN: Prospective clinical trial on nine consecutively chosen adult patients with ossicular chain defects. PATIENTS AND SETTING: Nine patients with ossicular chain defects involving the long process of the incus were treated at the Carolina Ear and Hearing Clinic. The ossicular chain was reconstructed using bone cement by itself or in conjunction with a stapes prosthesis. MAIN OUTCOME MEASURES: Preoperative audiograms were compared with audiograms 3, 6, and 12 months after reconstruction. RESULTS: There was a mean pure-tone average (PTA) improvement of 15 dB in patients undergoing incus to stapes suprastructure reconstruction with the bone cement. The incus to mobile footplate reconstruction (using a stapes prosthesis attached to the newly reconstructed incus) resulted in a 34-dB PTA postoperative improvement. Two of the three patients with incus to oval window repairs experienced a 10-dB improvement in PTA. One of the three patients experienced a loss in speech discrimination and a 2-dB loss in PTA. CONCLUSIONS: Despite the limited number of patients, this preliminary study demonstrates the effectiveness of Oto-Cem in reconstructing a foreshortened incus. There was a substantial hearing improvement in all but one patient in the incus to stapes or the incus to footplate categories.

Inverting papilloma of the sphenoid sinus.

Although inverting papillomas originating from the paranasal sinuses have been reported, inverting papillomas emanating from the sphenoid sinus are exceedingly rare. The following is a case report and one year follow-up of a 57-year-old white man who underwent a radical sphenoidostomy for recurrent inverting papilloma of the sphenoid sinus. The patient, to date, is free of disease.

The patulous eustachian tube: management options.

The patulous eustachian tube is a benign, yet annoying condition that may be over-looked or misdiagnosed. It is frequently associated with peritubal atrophy, and usually responds to conservative measures such as weight gain or mucus-producing agents. In patients not responding to these measures, a variety of surgical options are available. We have been using a technique that avoids elevating a tympanomeatal flap, is reversible, and is effective. This technique, as well as other surgical options, are reviewed. The advantages and disadvantages inherent in them are discussed.

Management of vertigo in patients with syphilis: is endolymphatic shunt surgery appropriate?

Endolymphatic shunt surgery has been suggested as a means to relieve vertigo caused by syphilis in patients unresponsive to conventional medical therapy. We reviewed results of endolymphatic shunt surgery on vertigo and hearing in six patients with syphilis. We found no relief of vertigo in four patients who qualified for this measure and no improvement in hearing. Histologic review of temporal bones from three patients with syphilitic hydrops revealed syphilitic involvement of the endolymphatic duct system. This may explain why endolymphatic shunt surgery may not be beneficial.

Digital camera documentation system for facial nerve outcome assessment.

OBJECTIVE: To describe the use of a digital camera to document facial nerve function after skull base surgery. SETTING: Patients undergoing skull base surgery at a tertiary care otologic and neurotologic clinic were used in the study. INTERVENTIONS: None. RESULTS: A digital camera system provided still images and a video strip lasting less than a minute to document facial nerve motion. CONCLUSIONS: An inexpensive digital camera system can be used to capture still and moving images of facial nerve function on a floppy disk. The images can then be transferred to compact disks for storage of many patient files. Such a system allows documentation for research, exchange of data between offices, and patient education, and it can be used for medical-legal purposes among other uses.

Cochlear implantation in the congenitally malformed ear.

A child with a congenital hearing loss and auricular malformations was evaluated for cochlear implantation. Preoperative radiologic studies demonstrated a common cavity cochlear malformation and a contralateral narrow internal auditory canal. Intraoperative findings included an aberrantly coursing facial nerve, preventing routine placement of the electrode array. The surgical approach was consequently modified and the cochlea was accessed through a malformed semicircular canal. Cochlear implantation can be performed safely and effectively in children with congenitally malformed ears.

Surgical accessibility of the cochlear nuclear complex in man: surgical landmarks.

Patients deafened by bilateral acoustic tumors or by transections of both cochlear nerves are excluded as candidates for cochlear implantation. These patients require more proximal stimulation of the auditory pathway. One potential area for such stimulation is the cochlear nuclear complex (CNC) in the lateral recess of the fourth ventricle. If animal studies establish the safety and efficacy of such stimulation, electrical stimulation of the human cochlear nuclear complex may become an accepted treatment modality for this select group of patients. Such implantation requires that the surgeon accurately locate the cochlear nuclear complex without destruction of vital surrounding neural and vascular structures. With ten fresh human brains, oriented for a translabyrinthine approach, we determined key anatomical landmarks to the exposed surface of the CNC on both sides of each brain. Using a combination of anatomical landmarks--including the flocculus, eighth nerve root, choroid plexus, and taenia--we located the cochlear nuclear complex (without disruption of surrounding neural or vascular structures) and marked it with colloidal carbon. Access to the CNC was obtained in all 20 specimens, and histologic sections confirmed the carbon marker in the CNC in 19 of 20 specimens.

Hearing preservation using the modified translabyrinthine approach.

Removal of an acoustic neuroma using the translabyrinthine approach has previously been considered "incompatible" with hearing preservation. By modifying the approach and preventing the loss of endolymph, we have successfully removed two intracanalicular acoustic neuromas that originated from the inferior vestibular nerves, and preserved serviceable hearing in the ears operated on. This report represents the preliminary findings using this particular technique in the management of intracanalicular acoustic neuromas.

Aberrant internal carotid artery: classic findings on computed tomography.

An aberrant internal carotid artery passing through the middle ear is rare and may be misdiagnosed. Surgical intervention can lead to massive bleeding, possible hemiparesis, or both, as demonstrated by the following cases. The purpose of this article is to alert the otolaryngologist and the radiologist to the condition and to subtle computed tomographic features of an aberrant internal carotid artery. Recognition of these features should spare both surgeon and patient the consequences of ill-advised surgery.

Retrolabyrinthine vestibular nerve section: a viable alternative to the middle fossa approach.

Vestibular nerve section, whether by the middle fossa or retrolabyrinthine approach, is effective in relieving intractable vertigo while preserving hearing. However, the potential morbidity and technical difficulty of the middle fossa approach have limited its usefulness. In an attempt to determine if the two approaches produce comparable results, we evaluated 52 patients who underwent retrolabyrinthine vestibular neurectomy between April 1981 and March 1983 at the Otologic Medical Group. We compared their audiometric data and questionnaire responses with published data on patients who had a middle fossa vestibular neurectomy. Although differences between the two procedures do exist, the retrolabyrinthine method, with its 93% success rate in improving or resolving vertigo and its zero incidence of total sensorineural hearing loss, offers the surgeon a strong alternative to the middle fossa approach.

Ossiculoplasty with polymaleinate ionomeric prosthesis.

With the continued concern over the possible transmission of viral infections through homologous middle ear implants, there is increasing pressure to develop a truly biocompatible alloplastic middle ear prosthesis. The polymaleinate ionomer, which has been used in dentistry as a filling and luting material for more than 15 years, has recently been used to construct total and partial ossicular replacement prostheses. In an attempt to evaluate these new implants, a multicenter prospective clinical trial was initiated. To date, 92 patients have undergone implantation. The follow-up interval ranged from 3 months to 22 months. Although it is premature to discuss the long-term results, the preliminary surgical experience and audiometric data with these implants are reviewed. From a surgical perspective, the ionomeric prostheses were easily contoured with a diamond burr and were not prone to shattering. Preliminary follow-up audiometric data were available on 80 patients (59 partial ossicular replacement prostheses and 21 total ossicular replacement prostheses). Of the 59 partial ossicular replacement prostheses the air-bone gaps (average of 500 Hz, 1 kHz, 2 kHz and 3 kHz) were as follows: 0 dB to 10 dB, 15 (25%) of 59; 11 dB to 20 dB, 20 (34%) of 59; 21 dB to 30 dB, 11 (19%) of 59; and greater than 30 dB, 13 (22%) of 59. Of the 21 total ossicular replacement prostheses the air-bone gaps were as follows: 0 dB to 10 dB, 6 (29%) of 21; 11 dB to 20 dB, 6 (29%) of 21; 21 dB to 30 dB, 5 (24%) of 21; and greater than 30 dB, 4 (19%) of 21.

Lyophilized partial ossicular replacement allografts.

This report deals with the use of partial ossicular replacement allografts (PORAs) in the stable ear, ie, a middle ear free of any residual or recurrent disease process such as fluid, cholesteatoma, or infection. PORAs have been used by Shinn and Smith at the Ear Medical Clinic of Santa Clara Valley between July 1978 and December 1981: they are used to span the distance between the malleus and the head of the stapes or tympanic membrane. Lyophilized ethylene oxide sterilized PORAs have been available through the Northern California Transplant Bank. San Francisco, since July 1978. Twenty-four of 32 PORAs (75%) used in stable ears closed the air-bone gap within 10 dB. Of the eight ears that did not have satisfactory functional hearing, it was evident within one year and there was no further deterioration noted up to four years. These was no evidence of PORA extrusion or erosion.