Clinical experience with a surgical approach to hydrops.

This work was based upon the need to look at the role of surgical intervention in cases of presumed hydrops encountered in usual medical practice. A retrospective cohort study of 292 consecutive cases diagnosed as Meniere's disease was used to identify subjects severely enough affected to elect surgical relief. Two nested case-control design studies were subsequently conducted: one to compare surgical failures (4 cases) with successes (15 controls); and the other to compare the surgical group (19 cases) with a uniform random sample of all presenting Meniere's disease cases (10 controls). These data suggest the following testable hypotheses: (1) the younger the age of onset, the higher the probability that surgical intervention will be required to control episodic vertigo; (2) the younger the age of onset, the higher the probability of the failure of nondestructive surgery; and (3) patients destined for surgical intervention are likely to require at least twice as much office-based medical care as the general group of presenting Meniere's patients. A biological question arising from these data is, Does age influence the putative homeostatic pathophysiology implicated in hydrops?

Lateral temporal bone resections.

Eighteen consecutive patients underwent a lateral temporal bone resection for the treatment of tumors originating in the auricle, the external auditory canal, the periauricular skin, or the parotid and were retrospectively analyzed. The different lateral temporal bone resections performed have been categorized into four types. The type I resection consists of the removal of the tympanic bone and the external auditory canal lateral to the tympanic membrane. The type II resection consists of the removal of the entire tympanic bone, the tympanic membrane, the incus, and the malleus, preserving the facial nerve and the inner ear. Type III resections remove, in addition to the those structures removed in type II resections, the distal facial nerve and fallopian canal, the mastoid tip, the styloid process, and the stylomastoid foramen. The type IV resection consists of the removal of only the mastoid tip and the inferior portion of the tympanic bone. When the techniques of lateral temporal bone resection are used appropriately, adequate surgical treatment of patients with selected advanced and recurrent malignant tumors of the external ear, the periauricular skin, and the parotid is possible with low morbidity and a high probability of local regional control.

Detection and localization of heat shock protein 70 in the normal guinea pig cochlea.

Normal guinea pig cochlear sections were treated with an antibody against heat shock protein (HSP70). HSP70-like immunoreactivity was observed in Claudius' cells and in the interdental cells of the spiral limbus. In the organ of Corti, immunoreactivity was confined to pillar cells, as well as Hensen's and Deiters' cells.

Gross and microscopic anatomy of the eighth cranial nerve in relationship to the solitary schwannoma.

Surgical advances over the past two decades, allowing the discovery of smaller solitary schwannomas of the VIIIth cranial nerve and their extirpation with preservation of the VIIth cranial nerve, have lead to attempts to resect the tumor without completely resecting its nerve of origin. This paper reports the macroscopic and microscopic observations of 22 solitary schwannomas of the VIIIth cranial nerve as they relate to the nerve of origin. Nine tumors were removed, en bloc with the VIIIth nerve, transversely subserially sectioned and studied by light microscopy. Four of the en bloc cases and 13 additional cases were studied by biopsying the VIIIth nerve branches, lateral, and the VIIIth nerve trunk medial to the tumor. The results suggest that the VIIIth nerve is involved throughout the extent of the tumor and, in some cases, beyond the tumor limits with intraneural invasion by tumor cells. There is an immediate dispersion of VIIIth nerve fibers to extremely small aggregates dispersed peripherally about the tumor surface. These fiber aggregates are not surgically dissectable from the tumor because of the difficulty in identifying the fibers and because of tumor infiltration of normal appearing nerves. The pure tone threshold average of 500-2,000 Hz. tends to correlate more closely with the number of cochlear fibers present, lateral to the tumor, than do other auditory tests. The percent of unilateral vestibular weakness does not correlate with the number of fibers present in the superior vestibular nerve. In summary, these histologic data suggest that complete tumor resection from VIIIth nerve fibers may be beyond our present technological capabilities. They further suggest severe limits to accurate identification of candidates for this conservation surgery.

Diagnosis and treatment of iatrogenic cerebrospinal fluid leak and brain herniation during or following mastoidectomy.

Iatrogenic brain herniation, with meninges (meningoencephalocele) or without meninges (encephalocele), following mastoidectomy is rare. However, the seriousness of the complication and the potential for its prevention necessitate periodic review and emphasis. In this study, 6 patients with small iatrogenic dural injury during mastoidectomy, 1 patient with postoperative large encephalocele, and 2 patients with three spontaneous meningoencephaloceles are reviewed. These cases, and the literature, support the following: 1. A dural injury is necessary for herniation. 2. If the arachnoid remains intact, a meningoencephalocele results with the potential for cerebrospinal fluid leak into the middle ear and recurrent meningitis. 3. If the arachnoid is not intact, an encephalocele results which presents predominantly as a mass without a cerebrospinal fluid leak. 4. The dura and arachnoid may be torn during mastoidectomy, resulting in an immediate cerebrospinal fluid leak that can go easily unrecognized. Taking time to carefully inspect any area of dural exposure obviates this oversight. 5. A satisfactory technique of tegmen and dural-arachnoid repair in these ten cases is described.

Growth of the lateral surface of the temporal bone in children.

The adaptation of implantable auditory prostheses for use in children has raised questions concerning both what effect growth may have on the implant and what effect the implant may have on growth. The purpose of this study is to describe temporal bone lateral surface dimensions in children of different ages to draw inferences about growth rates. Using a surface projected grid and point calipers, 158 intact temporal bones from 103 individuals of known ages between birth and 20 years were measured at six points from a fixed reference. These specimens were located in the skeletal collections of the Smithsonian Institute's Museum of Natural History, the Medical Museum of Walter Reed Hospital at the Armed Forces Institute of Pathology, and the Cleveland Museum of Natural History. Linear regression analysis helped clarify a bimodal pattern of growth in which marked increases in dimension occur from birth to 4 years of age and much less change is seen from age 4 to 20 years. These data suggest that implantation in children under 4 years of age is subject to maximal growth effects.

Validation of objective measures for facial paralysis.

A shift from subjective scales to objective measures of facial paralysis requires physical models against which to validate and calibrate the new objective techniques. The purpose of this report was to demonstrate such a model and to test the capacity of an objective computer system to accurately measure physical change. The physical model consisted of an advancing edge of a spreading gelatin film. The model was measured in submillimeter increments. Concurrent measurements were made using the computed system. Ten trials were conducted. The objective system proved to be exquisitely sensitive (0.03 mm) and highly correlated with the physical criterion model (Pearson's product moment correlation coefficient [r]=0.9849). Sensitive and calibrated objective methods of analysis of facial motion are crucial to the design of clinical trials, clinical studies of nerve regeneration, and comparisons of reanimation techniques.

Patterns of facial nerve synkinesis.

Facial nerve synkinesis is an extremely distressing sequela of facial paralysis, and its prevention and treatment are less than adequate. Improved therapeutic interventions await better understanding of its pathogenesis. In this study, 11 patients with synkinesis and 11 normal control subjects were quantitatively assessed using a new computer-assisted, motion-sensitive system. Two additional, informative cases presenting at the completion of the study are also briefly reported. The observed synkinetic patterns appear predictable and nonrandom. In addition, these observations tend to raise doubts that the aberrant fiber regeneration hypothesis is the sole explanation of synkinesis. They further implicate facial nuclear hyperexcitability as an explanation in at least some cases of synkinesis. Understanding these patterns enhances clinical detection and evaluation and may lead to a better knowledge of the fundamental pathophysiology of synkinesis and its prevention.

Unrelated sensorineural hearing loss in patients with otosclerosis. A report of three cases.

Although it is generally accepted that 20% or more of patients with clinically manifest otosclerosis have a concomitant sensorineural hearing loss, it is still debated whether otosclerosis is the cause of the neural loss. Three cases are presented of other causes of sensorineural loss in otosclerotic patients who underwent stapes surgery. One of these cases, the Mondini malformation, is discussed in detail.

Building the powerful 10-minute office visit: Part II. Beginning a critical literature review.

OBJECTIVE: This is the second part in a series of sequential Tutorials in Clinical Research. The objective of this tutorial is to introduce methods of searching the vast stores of information now available, to review some of the computer resources available, to reintroduce the concept of an a priori design for the search, and to reveal the need for assessment of the clinical importance and validity of each pertinent article found. STUDY DESIGN: Tutorial. METHODS: An open working group has been formed with the specific aim of surveying and translating the large volume of complex information on research design and statistics into easily understood, useable, and non-threatening tutorials for the busy practitioner. The hypotheses under which this work is conducted are highly intelligent, but extremely busy, surgeons are interested in evidence-based medicine and will increase personal participation in critical reading of the literature, pending an expanded familiarity with clinical research design and statistics. RESULTS: Available resources for literature searching, methods of quick personal overviews, and quick question-specific reviews are discussed. Additionally, the methods, with examples, of beginning a critical literature review are presented. CONCLUSIONS: Rapid, personal, critical literature review requires succinct formulation of the question, efficient search for the best available evidence, and critical appraisal of the pertinent individual articles to determine if sufficient evidence exists to support a clinical contention.

Computer-assisted clinimetric tool for the study of facial expression: a pilot validity study.

Clinimetrics is the measurement of clinical phenomena; more specifically, it is mensuration, the act of acquiring and labeling basic raw data that is used to describe or measure symptoms, signs, and other distinctly clinical phenomena. Over the last 5 years, a new computer method for measuring facial expression has been developed. Refinement and validation of this technique are necessary before clinical applications are appropriate. Four hundred fifty data points from two human observers and the computed method were compared with one another by using indices of location, dispersion, and association within the framework of the logical construct of validity. These results suggest that the computed method is valid. This new method may be nearly ready for clinical applications as a primary or adjunctive clinimetric tool.

Microscopic characteristics of the acoustic tumor in relationship of its nerve of origin.

The microscopic characteristics of a 0.9 cm vestibular schwannoma en bloc resected with its nerve of origin which occurred in a 54-year-old white woman presenting with a two-year history of a unilateral progressive sensori-neural hearing loss is described. The tumor originated in the inferior vestibular portion of the vestibular division of the VIIIth cranial nerve just medial to the internal auditory canal meatus at approximately the level of the glial-non-glial junction. The tumor demonstrated two distinctly different, yet simultaneous, modes of involvement with its nerve of origin: 1. inseparable cellular continuity; and 2. peripheral compression of the remainder of the nerve within the tumor capsule. Despite only slight microscopic continuity of the nerve histologically, electronystagmography showed no unilateral weakness on bithermal caloric testing, and pure tone and speech audiometry was only moderately depressed.

Homograft replacement of the tympanic membrane.

This paper presents the authors' experiences with one method of reconstruction of the tympanic membrane when it is totally absent or when there is a fixed, retracted, defective, or absent malleus. Ten patients undergoing surgery for chronic suppurative otitis media between April, 1971, and January, 1973, had homograft tympanic membranes and/or ossicles used to reconstruct the defect in the tympanic membrane or ossicular mechanism. The patients had certain clinical and surgical characteristics in common: 1. all had either an absent tympanic membrane or almost total perforation of it; 2. all were operated upon in the absence of acute infection or active drainage; cholesteatoma, if present, was totally removed; 3. all had patent eustachian tubes; 4. all had intact middle ear mucosa at the time of utilization of the homograft; 5. all patients were operated upon by the same surgeon; 6. all of the homografts were obtained within 24 hours and were used within one month after the death of the donor; 7. all of the homografts used had been preserved in 70 percent ethyl alcohol; 8. all of the homograft materials came from donors who were under 40 years of age at the time of death and who died of accidental causes. (None of the donors was known to have any pre-existing disease); 9. all homografts, after being placed in proper position in the recipient, were covered with ear canal skin; 10. all patients received homografts that were from the corresponding ear of the donor. (In other words, right ear homografts were used in the patient's right ear, etc.); 11. whenever the tympanic ring was greater than the size of the homograft, the patient's temporalis fascia was used in conjunction with the homograft tympanic membrane to bridge the defect; 12. all patients had the middle ear packed with gelfoam prior to inserting the homograft (compressed gelfoam was used also for the outer packing); 13. none of the patients had tissue-typing procedures carried out in an effort to match the donor and the recipient, nor was any attempt made to match the sex of the donor and the recipient; and 14. all patients received antibiotics postoperatively; however, none received immunosuppressive therapy postoperatively. In 3 of 10 patients receiving homografts, the malleus was normal, and only the tympanic membrane was reconstructed. In seven others there was a fixed, retracted, defective or absent malleus in addition to the tympanic membrane defect.(ABSTRACT TRUNCATED AT 400 WORDS)

Diagnosis and treatment of spontaneous cerebrospinal fluid otorrhea.

Two consecutively operated-on adult cases with spontaneous cerebrospinal fluid otorrhea were reviewed. Three meningoencephaloceles through tegmental defects were found. Each cele was peduculated through a small dural dehiscence partially obstructed by herniated brain. The otic capsule was normal in both cases. Bipolar cautery was used to reduce the size of the meningoencephalocele and to allow this tissue to assist in the closure of the defect. Conchal cartilage was placed through the tegmental defect to act as a self maintaining intracranial repair of the bony dehiscence. These cases and the literature suggest that fistulization of dura is more frequently the cause of spontaneous cerebrospinal fluid otorrhea in adults than is a defect in the otic capsule. Thus, direct surgical inspection of these areas is required.

Tutorials in clinical research: part III. Selecting a research approach to best answer a clinical question.

OBJECTIVE: This is the third in a series of sequential "Tutorials in Clinical Research." The objectives of this specific report are to enable the reader to rapidly dissect a clinical question or article to efficiently determine what critical mass of information is required to answer the question and what study design is likely to produce the answer. STUDY DESIGN: Tutorial. METHODS: The authors met weekly for 3 months exploring clinical problems and systematically recording the logic and procedural pathways from multiple clinical questions to the selection of proper research approaches. The basic elements required to understand the processes of selection were catalogued and field tested, and a report was produced to define and explain these elements. RESULTS: Fundamental to a research approach is the assembly of subjects and the allocation of exposures. An algorithm leading to the selection of an approach is presented. The report is organized into three parts. The tables serve as a rapid reference section. The initial two-part narrative explains the process of approach selection. The examples section illustrates the application of the selection algorithm. CONCLUSIONS: Selecting the proper research approach has six steps: the question, logic and ethics,identification of variables, data display considerations, original data source considerations, and selection of prototypical approaches for assembly of subjects. Field tests of this approach consistently demonstrated its utility.

Quantitative assessment of the variation within grades of facial paralysis.

A completely objective, unambiguous outcome measure of facial function is now available. A new automated computer-assisted clinimetric system combines the crucial detection capabilities of the human observer and the unique capacity of the computer to quantify the image light reflectance difference observed during facial expression. The new system was applied to 27 patients with a variety of diseases affecting the facial nerve. All subjects could be individually and objectively ranked, and disease-specific profiles could be constructed. These tasks are not possible with the House-Brackmann scale, because of the wide variation within grades and the ambiguity between grades. With the automated objective, unambiguous outcome measure, it may be possible to define individual case progression, recovery, and outcome over the course of disease.

Classification of spontaneous cerebrospinal fluid middle ear effusion: review of forty-nine cases.

This article presents a classification system of spontaneous cerebrospinal fluid middle ear effusion to facilitate early diagnosis and lesion localization for surgical correction. Thirty-eight articles containing case histories of 45 patients with spontaneous cerebrospinal fluid middle ear effusion reported in the English literature from 1913 to 1983 were reviewed. Four additional personal cases, representing the largest single series, are described in detail. Classification of these cases into the following three types has been possible: (type I, abnormal connections through the otic capsule; type II, abnormal connections adjacent to the otic capsule; and type III, abnormal connections distant from the otic capsule. The diagnostic and therapeutic implications of each type are unique. Age, auditory and vestibular test results, and computerized or hypocycloidal tomography differentiate the three.

Is it possible to totally resect an acoustic tumor and conserve hearing?

Over the last 19 years there has been increasing interest in the conservation of hearing while acoustic tumors are being resected. As enthusiasm has increased for the conservation surgery, so has controversy. The key to the controversy is a dissociation between gross anatomic and histologic observations. The purpose of this paper is to summarize our laboratory experiments and clinical observations in three areas: (1) Our experiments and observations suggest that it is probably not possible to totally resect an acoustic tumor medial to Scarpa's ganglion and conserve hearing. (2) It has not been possible to predict from preoperative auditory and vestibular function tests the number of fibers present within the cochlear and vestibular nerves lateral to the tumor, nor the number of fibers in small aggregates that may pass the tumor periphery. (3) If microscopic amounts of tumor are left behind, is that significant? It is too early to answer this question.

Literature review articles as a research form.

The purpose of this article has been to outline the JOURNAL format, to present some methodologic suggestions for this new section, and, hopefully, to excite and challenge authors to this form of research. Fundamental to a quality overview are A PRIORI EXPLICIT CRITERIA for each component of the review process. Details of what this means have been presented. The length of the review will depend on the objectives; however, approximately 20 double-spaced manuscript pages (about eight published pages) should be considered close to maximal for a readable review. References may be too extensive for full publication; one way to manage this is to choose about 50 or less key references for publication and suggest to the readers that a full bibliography is available, upon request, from the corresponding author. We hope this new section will be exciting and will be of benefit.

Induction of heat shock protein in interdental cells by hyperthermia.

The effect of hyperthermia on induction of the 72 kilodalton (kDa) heat shock protein (HSP72) was examined in interdental cells of the guinea pig cochlea. After being immersed in a water bath of either normal body temperature (37 degrees C, control condition) or 43 degrees C (hyperthermic condition), animals were killed either 0, 1, 2, 6, or 18 hours later. Cochlear sections were incubated with a monoclonal antibody raised against HSP72 and relative staining densities were quantified with a light microscopic image analysis system. Optical densities of the interdental cell region of animals receiving hyperthermia treatment were significantly greater than those of animals in the control group. Further analysis revealed that levels of HSP72 immunoreactivity began increasing by 1 hour after hyperthermia and continued to increase thereafter, to reach maximal levels at 6 hours. The maximal levels were maintained for the rest of the experiment--18 hours. The results indicate that hyperthermia leads to an increase in the synthesis of HSP72 in guinea pig interdental cells.