Use of nimodipine in the medical treatment of Menière's disease: clinical experience

PURPOSE

Nimodipine is a highly lipophilic, centrally acting calcium channel blocker. It is similar in action to flunarizine, which has been studied for use in the medical treatment of Menière's disease.

METHODS

Nimodipine was offered to patients with Menière's disease for whom first-line medical management failed (dietary restrictions and diuretics or vestibular suppressants).

RESULTS

Our preliminary clinical experience using nimodipine in 12 patients with Menière's disease from December 1992 until March 1995 resulted in successful control of vertigo and hearing improvement or stabilization in seven (58%) of 12 patients. When hearing stabilization was not considered, eight (67%) patients had vertigo satisfactorily controlled (AAOO class A, B, or C). The four (33%) patients whose vertigo symptoms persisted despite treatment with nimodipine (AAOO class D) were surgically treated with successful vertigo control. Nimodipine was discontinued in one class D patient because of gastrointestinal intolerance.

CONCLUSIONS

Nimodipine provides an alternative successful means for medical management of Menière's disease.

Clinical applications of three-dimensional magnetic resonance image analysis

A methodology for measuring the kinematic parameters of joints in vivo has been refined using the technique of computerized three-dimensional reconstruction from magnetic resonance images. A research protocol has been developed to establish a classification of normal and pathologic foot function that will have broad clinical application. Development of algorithms for a computer-directed program that can predict resultant kinematics and joint morphometry for a given osteotomy or osseous remodeling procedure will assist the surgeon in preoperative surgical planning.

New method of studying joint kinematics from three-dimensional reconstructions of MRI data

A new method of measuring the kinematic parameters of joints has been developed. This article describes the procedure, using tarsal joints as examples. The method uses the technique of computerized three-dimensional reconstruction from magnetic resonance images, taken at regular intervals throughout a foot's range of motion. From these reconstructions, various kinematic information, such as orientation of instantaneous axes, amounts of rotation, amounts and direction of translation, and bony contact areas, is derived. The method is noninvasive and can be applied to individual subjects or patients.

Oculostapedial synkinesis

A 51-year-old woman with persistent oculostapedial synkinesis after successful microvascular surgical decompression of the facial nerve in the cerebellopontine angle is presented. Auditory symptoms are common in patients with hemifacial spasm manifested by a low-pitch rumbling noise, ear fullness or stuffiness, subjective reduction of hearing acuity, and as described in this case, ear tightness and "drumming." Ephaptic neural transmission is the proposed cause of hemifacial spasm. The exacerbation of auditory symptoms with voluntary blinking and eye closure can be explained by ephaptic transmission and/or aberrant regeneration. Should the aggravating and annoying symptoms of stapedial muscle dysfunction persist in the face of successful treatment of hemifacial spasm, transmeatal division of the stapedial tendon provides immediate relief.

Oculostapedial Synkinesis

A 51-year-old woman with persistent oculostapedial synkinesis after successful microvascular surgical decompression of the facial nerve in the cerebellopontine angle is presented. Auditory symptoms are common in patients with hemifacial spasm manifested by a low-pitch rumbling noise, ear fullness or stuffiness, subjective reduction of hearing acuity, and as described in this case, ear tightness and "drumming." Ephaptic neural transmission is the proposed cause of hemifacial spasm. The exacerbation of auditory symptoms with voluntary blinking and eye closure can be explained by ephaptic transmission and/or aberrant regeneration. Should the aggravating and annoying symptoms of stapedial muscle dysfunction persist in the face of successful treatment of hemifacial spasm, transmeatal division of the stapedial tendon provides immediate relief.

Imaging of ossicular prostheses

The prostheses available for reconstruction of the ossicular chain have expanded to include a variety of synthetic materials. Hydroxyapatite contains the inorganic constituents found in human living bone and is currently being incorporated into many new prostheses. This study demonstrates the computed tomography and magnetic resonance image characteristics of eight middle ear prostheses, a block of dense hydroxyapatite, and a human incus. Imaging of ossicular prostheses is more informative with computed tomography.

Panic in otolaryngology patients presenting with dizziness or hearing loss

This study compared 50 patients presenting to an otolaryngology clinic with a complaint of dizziness and 50 patients presenting with hearing loss on questionnaire measures of panic, phobic avoidance, generalized anxiety, and depression. Clinical and laboratory evaluations of vestibular and audiological complaints were also completed. Twenty percent of the group with dizziness and none of the group with hearing loss reported symptoms that met DSM-III-R criteria for panic disorder. Patients with dizziness and peripheral vestibulopathy had more symptoms of phobic avoidance, generalized anxiety, and depression than patients with confirmed hearing loss.

Excision of petroclival tumors by a total petrosectomy approach

The surgical removal of intradural petroclival tumors of any size is demanding because of the restricted surgical exposure and relation of the tumor with the brain stem, cranial nerves, and vertebrobasilar artery and branches. When petroclival tumors are large or giant sized and involve multiple areas of the clivus, adequate surgical exposure is difficult to achieve, yet is critical for safe tumor removal. In 17 patients with extensive petroclival tumors, total removal of the petrous bone was performed to gain a wide and shallow surgical exposure. This report details the intraoperative and postoperative complications, cranial nerve status, pre- and postoperative disability scores, and extent of tumor resection in these 17 patients. Deterioration of facial nerve function was the most common new cranial nerve injury following surgery. Three patients suffered major neurologic complications; six other patients suffered significant but temporary neurologic complications. Gross total tumor resection was accomplished in 9 of 17 patients, and most patients (15/17) maintained or improved their disability status. Tumor residual was related to cavernous sinus involvement, vascular encasement, or brainstem pial invasion. Total petrosectomy is an intensive and complex approach with inherent morbidity and thus should be reserved for extensive petroclival tumors that cannot be removed using less complicated approaches.

Combined approaches for resection of extensive glomus jugulare tumors. A review of 12 cases

Complete resection with conservation of cranial nerves is the primary goal of contemporary surgery for glomus jugulare tumors. This publication reports the value of combined surgical approaches in achieving this goal in 12 patients with extensive tumors. Eleven of these tumors were classified as Fisch Class C and/or D, while eight were categorized as Jackson-Glasscock Grade III or IV. Intracranial (intradural) extension was present in 10 patients; four patients had tumor extension into the clivus and two into the cavernous sinus. The petrous internal carotid artery (ICA) was involved in eight and the vertebral artery (VA) in one. Subtemporal-infratemporal, retrosigmoid, and/or extreme lateral transcondylar approaches were added to the usual transtemporal-infratemporal approach. This improved the exposure, provided early control of the petrous ICA, and facilitated tumor removal from the clivus, cavernous sinus, posterior fossa, and foramen magnum, allowing a single-stage resection in eight patients. Ten patients had a complete microscopic resection with no mortality. The facial nerve was preserved in nine cases, with tumor involvement requiring nerve resection followed by grafting in the remaining three. Mobilization of the facial nerve was avoided in five cases; of these, three had intact function and two had House-Brackmann Grade III function on follow-up review. Only one patient had a mild persistent swallowing difficulty. The ICA was preserved in 10 patients and resected in two, while the VA required reconstruction in one case. There were no instances of stroke, and blood transfusions were required in five patients who had tumors with nonembolizable ICA or VA feeders. While complete resection provides the best possibility for cure, the important role of adjuvant radiation therapy in cases with residual tumor is discussed. The importance of degrees of brain-stem compression and vascular encasement is emphasized in classifying the more extensive tumors.

Hydroxyapatite cement: a new method for achieving watertight closure in transtemporal surgery

Transtemporal approaches to the petrous apex and CP angle are standard procedures in the armamentarium of the neurotologist. In the majority of these cases, it is not possible to achieve a watertight suture closure of the dura following the procedure. Subsequently, cerebrospinal fluid leakage and potential meningitis are among the most troublesome complications for both patient and surgeon. Recent use of calcium phosphate cement (hydroxyapatite [HA]) has proved efficacious in animal studies and is now being used to close cranial defects in several medical centers, as part of an FDA-IDE study in human subjects. The use of this material is described in 11 neurotologic procedures. It is believed that hydroxyapatite cement (HAC) will become a standard tool in the management of cranial base and temporal bone defects following surgery.

Evolution and advances of the lateral surgical approaches to cranial base neoplasms

The evolution and advances of the lateral surgical approaches used for neoplasms of the cranial base involving the middle and posterior cranial fossa are reviewed. The lateral approaches available for access to the cranial base are diverse and are often used in combination. Approaches for tumors that are completely extradural, usually involving the temporal bone or infratemporal fossa, include the infratemporal fossa approach described by Fisch and the preauricular subtemporal-infratemporal fossa approach. Lateral approaches used to provide exposure of intradural tumors involving the clivus and traversing the middle and posterior cranial fossa are based on the following approaches: the frontotemporal orbitozygomatic, subtemporal/middle fossa, transpetrosal, lateral suboccipital, and transcondylar approaches. The great strides that have been made in the safe and effective surgical treatment of cranial base neoplasms are due, in part, to the availability of multiple surgical approaches and the ability to tailor the planned operative procedure to the precise location and extent of the cranial base tumor.

Sources of error in use of beta-2 transferrin analysis for diagnosing perilymphatic and cerebral spinal fluid leaks

Beta-2 transferrin is a protein found in cerebral spinal fluid and inner ear perilymph, but not in blood, nasal, or ear secretions. The clinical use of this test has been previously demonstrated, but sources of test error have not been addressed. The purpose of this study was to evaluate sources of error related to this test in order to improve its clinical use. We reviewed the specimens submitted for beta-2 analysis over the first 12 months of test availability at our institution to identify potential factors leading to test error. Sources of error were categorized into the following groups: sample collection, delivery, and extraction factors; assay factors; physician-related factors; and patient-related factors. The test for beta-2 transferrin is a valuable diagnostic tool for the management of difficult clinical problems, provided the physician is aware of potential factors that can lead to test error and clinical mismanagement.

Translabyrinthine approach to skull base tumors with hearing preservation

The improvement in surgical techniques and the experience gained in treatment of skull base tumors have stimulated more aggressive management of larger lesions. Patients presenting with limited preoperative deficits have challenged the surgeon to design the surgical approach so as to minimize postoperative morbidity and preserve function. Tumors of the middle fossa and clivus with extension into the posterior fossa are usually approached by a combined subtemporal, transtentorial, transpetrous approach. In patients with preoperative hearing, the surgical exposure is often limited by the labyrinthine portion of the otic capsule. The technique of partial labyrinthectomy, removing the posterior and/or superior semicircular canals, maximizes exposure with preservation of hearing. This report details our experience with the partial labyrinthectomy approach for 14 patients with large skull base lesions. All patients had hearing preserved despite sacrifice of one or two of the semicircular canals. Bone pure-tone averages and speech discrimination scores were maintained near their preoperative levels. The indications, benefits, techniques, and hearing results of this approach are reviewed.

Beta-2 transferrin assay in clinical management of cerebral spinal fluid and perilymphatic fluid leaks

Beta-2 transferrin is a protein found in cerebral spinal fluid (CSF) and inner ear perilymph, but not in blood, nasal or ear secretions. The purpose of this paper is to evaluate the clinical usefulness of the current assay for beta-2 transferrin for detecting CSF and perilymphatic leaks. We reviewed the hospital records of the first 88 patients having specimens submitted for beta-2 transferrin analysis at our institution. Both CSF and perilymph leaks were identified. However, confirmation of the absence or presence of beta-2 transferrin was directly used in the clinical management of only 55% of the patients. This was largely secondary to the time delay in test processing and initial lack of physician confidence with the test. However, our review of the clinical outcomes relating to the use of the beta-2 transferrin analysis suggests high sensitivity and specificity for the test. Analysis of beta-2 transferrin appears to be a valuable test for detecting CSF leakage and a promising test for confirming perilymphatic leaks. However, to achieve greater clinical usefulness a rapid clinical assay needs to be developed and further information gained regarding the sensitivity and specificity of the beta-2 transferrin assay for detecting CSF and perilymphatic fluid leakage.

Facial nerve near the external auditory meatus in man: computer reconstruction study--preliminary report

The anatomy of the facial nerve relative to its intratemporal and extratemporal courses varies over time with developmental changes. Otologic and parotid surgery in infants and children demands detailed knowledge of the precise anatomy of the facial nerve with respect to the tympanic ring and external auditory canal. The authors analyzed this area using our three-dimensional (3-D) computer-aided reconstruction and measurement method studying the spatial relations of the facial nerve to the tympanic ring and stylomastoid foramen. Temporal bones from five normal individuals aged 36 gestational weeks, 3 months, 8 months, 4 years, and 17 years were retrieved from the temporal bone collection stored at the Elizabeth McCullough Knowles Otopathology Laboratory in Pittsburgh. Three-dimensional reconstruction of the facial nerve comparing the developmental anatomy across the various age groups provides the surgeon with the technical information necessary to address problems in this area.

Hypercoagulability in otologic patients

INTRODUCTION

Three patients with otologic disorders developed complications related to hypercoagulability. This report was prepared to increase the awareness among otolaryngologists of the diagnosis and management of hypercoagulable states, and to encourage expert consultation when indicated.

MATERIALS AND METHODS

One patient with dural venous sinus thrombosis complicating an otitis media, one patient with a large glomus jugulare tumor, and one patient with a sudden sensorineural hearing loss were treated by the otolaryngology service. Suspicious thromboembolic events were evaluated by the hematology service, and appropriate anticoagulative therapy was recommended.

RESULTS

One patient with an inherited hypercoagulopathy and two patients with acquired hypercoagulopathies were treated for otologic problems. Two of the patients were stabilized and discharged on life-long anticoagulation therapy. The third patient, in spite of intensive medical and surgical support, eventually succumbed to complications to which an acquired hypercoagulable state made a significant contribution. Expert consultants made the hematologic diagnoses and treatment recommendations.

CONCLUSION

Otolaryngologists should be aware that hypercoagulable states may now be more accurately diagnosed and characterized, and that thorough investigation of thromboembolic events may affect treatment decisions.

Facial nerve function following cerebellopontine angle surgery: prognostic value of electroneurography

Preoperative counseling of patients, regarding facial nerve function following cerebellopontine angle (CPA) surgery, has remained a difficult task. Facial nerve electroneurography (ENoG) or evoked electromyography can detect subclinical neural degeneration. This test was used in 44 patients undergoing CPA surgery, and facial nerve function was followed postoperatively. A normal preoperative ENoG study appeared to predict an 81 percent and 84 percent chance of good (House grade I-II) early and late postoperative facial function, respectively. An abnormal test is not as reliable. The relation of preoperative ENoG results with tumor size and tumor adherence to the facial nerve is investigated. Electroneurography appears to be a useful preoperative test when counseling patients regarding facial function following CPA surgery.

Facial nerve function following cerebellopontine angle surgery: prognostic value of intraoperative thresholds

Intraoperative stimulation of the facial nerve during surgery of the cerebellopontine angle greatly aids the surgeon in identification of the nerve. The preservation of the ability to stimulate the facial nerve, at the brain stem following tumor removal, has been shown to correlate with good postoperative facial outcome. Thresholds of facial nerve stimulation recorded in our series, using constant voltage stimulation, showed statistically significant relevance to facial nerve outcome. When the difference between thresholds before and after tumor removal was 0.2 V or less or when the threshold after tumor removal was less than or equal to 0.2 V, a good postoperative facial outcome could be expected. This paper discusses the relevance of stimulation threshold prior to tumor removal to the size of tumor.

Simultaneous presentation of malignant external otitis and temporal bone cancer

Malignant external otitis and squamous cell carcinoma of the external auditory meatus are both characteristically seen in the older population. While some of the signs and symptoms of these two diseases are similar (otalgia, otorrhea, bone destruction on computed tomographic scan), they have rarely been reported in the same patient. We present an unusual case of temporal bone cancer and malignant external otitis presenting concurrently in an elderly, nondiabetic host. Precipitating factors and diagnostic criteria are discussed. This case illustrates the importance of an adequate biopsy specimen in all patients presenting with presumed "classic" malignant external otitis. Consideration must also be given for the existence of malignant external otitis in the presence of carcinoma. Finally, evolution of malignant external otitis in this patient following aural irrigation supports previous suggestions that this disease may be induced iatrogenically.

Treatment of idiopathic sudden sensorineural hearing loss

A retrospective review was done, examining the charts of 41 patients admitted to The Eye and Ear Hospital of Pittsburgh with a diagnosis of sudden hearing loss (SHL). Treatment consisted of (1) systemic steroids; (2) daily intravenous histamine infusion; and (3) carbogen (95% oxygen and 5% CO2) inhalation. Parameters examined included age, sex, duration of symptoms prior to admission, days hospitalized, side of lesion, vestibular symptoms, tinnitus, blood work, radiography, vestibular function (ENG), and serial audiograms. Fifty-four percent showed improvement in hearing, defined as at least a 10-dB increase at any frequency following therapy. There was no correlation of preexisting signs, symptoms, or findings with hearing recovery. Since the natural history of this process demonstrates spontaneous improvement in approximately two thirds of patients without treatment, we conclude that for the group of patients that we treated, our therapeutic regimen was ineffectual.

Preservation of vestibular nerves in surgery of the cerebellopontine angle: effect on hearing and balance function

INTRODUCTION

Small tumors of the cerebellopontine angle (CPA) can frequently be removed with preservation of the auditory and the vestibular portion of the eighth cranial nerve. This study was undertaken to estimate the effect of vestibular nerve preservation on both balance and hearing following surgery.

MATERIALS AND METHODS

A retrospective study of all cases of CPA lesions between 1987 and 1991 was undertaken. This identified 11 patients in whom either the superior and/or inferior vestibular nerves were preserved. This included eight acoustic neuromas and three meningiomas. The retrosigmoid approach and total tumor extirpation was undertaken in all cases. Patients undertook a vestibular questionnaire, audiometric testing, and evaluation of vestibulo-ocular responses preoperatively and postoperatively. Additionally, static and dynamic platform posturography was performed postoperatively in 9 of 11 patients.

RESULTS

Follow-up ranged from 6 to 44 months. Of the eight patients with acoustic neuroma, four had a preoperative balance disorder that resolved postoperatively. One patient died of unrelated causes. Of the remaining seven patients with caloric testings, one maintained normal caloric responses. A persistent postoperative phase shift was noted in 4 of the 7 cases with rotatory testing. Three patients were treated for a meningioma. All had a preoperative balance disorder that resolved postoperatively. Two patients showed vestibular response indicative of residual but compromised function on the involved side. The third patient showed absent responses indicating an anatomically intact nerve that does not necessarily predict functional activity. Preservation of the vestibular nerve was associated with preservation of preoperative hearing in five of the patients. This included four of the eight acoustic patients and one of the three meningioma patients.

CONCLUSIONS

Preservation of the vestibular nerve did not result in a chronic balance disorder in this patient population. This study does not allow the authors to conclude if vestibular nerve preservation improves overall hearing after CPA surgery; however, these data suggest that preservation of the inferior vestibular nerve may result in less damage to the cochlear nerve in some patients. Accordingly, preservation of the vestibular nerve in CPA meningioma surgery can be recommended.

Beta 2 transferrin application in otology

The diagnosis and management of perilymphatic fistula has received considerable attention in recent years. Despite the use of sophisticated technology, the diagnosis of perilymphatic fistula continues to rest primarily upon clinical suspicion and the exclusion of other disorders. In addition, the confirmation of a perilymphatic fistula during surgical exploration is usually based upon the subjective observation of fluid pooling in niches of the middle ear. A sensitive and objective laboratory test for identifying perilymph in the middle ear would be a useful adjunct for the diagnosis and management of perilymphatic fistula. The objective of this paper is to demonstrate the potential utility of beta 2 (beta 2) transferrin assay in the diagnosis of perilymphatic fistula. To accomplish this objective, we confirmed that beta 2 transferrin is present in living human perilymph and is absent in the normal or inflamed middle ear. In addition, the utility of beta 2 transferrin assay in the diagnosis of cerebrospinal fluid otorrhea is presented.

Magnetic resonance imaging of the large vestibular aqueduct

The large vestibular aqueduct syndrome describes an abnormally large endolymphatic duct and sac with associated sensorineural hearing loss. This entity was originally reported in 1978 and has since been identified as a finding in children with progressive hearing loss. The original description of the large vestibular aqueduct employed hypocycloidal polytomography of temporal bone. Subsequent reports studied patients identified with this syndrome using computed tomographic scans. We report magnetic resonance imaging of two patients diagnosed with the large vestibular aqueduct syndrome. The magnetic resonance imaging and computed tomographic scans are compared and the significant findings on magnetic resonance imaging are reviewed. This should assist the otolaryngologist and radiologist with establishing the appropriate diagnosis.

Single-stage management of cholesteatoma

Surgical management of chronic otitis media with cholesteatoma can be performed in a single-stage procedure, with revision surgery necessary because of recurrent disease or electively with unsatisfactory hearing results. We retrospectively reviewed 164 cases with cholesteatoma surgically managed from 1980 through 1986. In total there were 11 tympanoplasties, 36 canal wall-up mastoidectomies, 81 canal wall down modified radical mastoidectomies, and 36 radical mastoidectomies. The recidivistic rate for cholesteatoma in patients available for 5-year followup was 11% for tympanoplasties, 19% for canal wall-up mastoidectomies, 5% for canal wall-down modified radical mastoidectomies, and 0% for radical mastoidectomies. Hearing results were best in patients who required tympanoplasty alone, followed by those who underwent canal wall-down procedures. Single-stage management of cholesteatoma with modified radical mastoidectomy (canal wall-down) required fewer revisions for recidivistic cholesteatoma and achieved better hearing results than canal wall-up procedures. We conclude, therefore, that staging is not necessary. Improved hearing may likely be achieved with a second procedure, but this is at the patient's discretion.

Hyperbaric oxygen therapy: effect on middle ear and eustachian tube function

Hyperbaric oxygen therapy (HBO) involves intermittent inhalation of 100% oxygen under a pressure greater than 1 atm. It is an important mode of adjuvant therapy for disease processes such as decompression sickness, osteomyelitis, carbon monoxide poisoning, and poorly healing wounds. Patients undergoing this therapy often complain of ear pain and/or fullness which can be transient or long standing. This prospective study objectively measured the changes in eustachian tube function before and after HBO treatment in 33 adult patients by the 9-step inflation-deflation test described by Bluestone. The results show 15 of the 33 patients (45%) had evidence of eustachian tube dysfunction after treatment was initiated. Of these, 15 (100%) developed the sensation of fullness, 13 (87%) developed serous otitis media, and 7 (47%) required tympanostomy tubes. The overall incidence of middle ear problems was 27 patients (82%) experiencing a sensation of fullness, 17 (52%) developing serous otitis media, and 8 (24%) requiring tympanostomy tubes. The middle ear complications reported in this study are much higher than those in previous reports in the literature. Twelve of 33 patients presented with a subjective history of eustachian tube dysfunction, and all 12 (100%) developed fullness in their ears and serous otitis media during the course of the treatment. The findings reveal that patients manifesting eustachian tube dysfunction after their first HBO treatment were at significantly greater risk toward developing symptoms of fullness and serous otitis media, often requiring tympanostomy tube placement. In addition, a history of eustachian tube dysfunction accurately predicted the development of fullness and serous otitis media.

High signal from the otic labyrinth on unenhanced magnetic resonance imaging

High signal from the otic labyrinth was observed on precontrast MR scan of two patients who presented with sudden hearing loss and vertigo. The authors suggest the possibility that the high signal was caused by hemorrhage but that clinical significance and therapeutic implications of this finding need further study.

Bell's palsy. A diagnosis of exclusion

In cases of acute unilateral facial weakness, a careful and systematic evaluation is necessary to identify the cause. Idiopathic facial paralysis (Bell's palsy) is a diagnosis of exclusion. It is also the most common cause of unilateral facial weakness seen by primary care physicians. The most important aspect of initial treatment is eye protection. Administration of systemic oral corticosteroids may lessen severity and duration of symptoms.

Structural biomechanics of the foot bones

The structure of the tarsal and metatarsal bones reflects the functional demands placed on them. Their shape and the arrangement of compact and trabecular bone within them help them resist the normal forces of everyday life. When the limits of their strength are exceeded, failure can occur.

Dehiscent temporomandibular joint

The appearance of an acute effusion in a well-pneumatized temporal bone directs attention to the nasopharynx and skull base. Two patients are described in whom dehiscence of the temporomandibular joint allowed herniation of the contents of the joint posteromedically, where they obstructed the middle ear entrance of the eustachian tube, the protympanum. This is, to the authors' knowledge, a previously unreported cause of an acute middle ear and mastoid effusion.

Metastatic atrial myxoma to the temporal bone: case report

A 25-year-old male underwent right mastoid surgery for removal of a soft tissue mass. At age 29 a left cardiac atrial myxoma was excised. At age 34 an expanding right supra-auricular mass with extension into the middle and posterior fossa necessitated total temporal bone resection. Pathology proved to be myxoma. Retrospective review of tissue obtained from the initial mastoid procedure was also myxoma. The temporal bone lesion was considered to be persistent and metastatic atrial myxoma. A review of atrial myxomas and this most unusual metastatic presentation is discussed.

Instillation of vancomycin into a cerebrospinal fluid reservoir to clear infection: pharmacokinetic considerations

Vancomycin instilled in an Ommaya reservoir was used to treat a reservoir-associated infection. Vancomycin concentrations in cerebrospinal fluid (CSF) were measured, and derivation of pharmacokinetic parameters allowed tailoring of dosing. First-order kinetics were observed. The calculated half-life of 3.52 h was less than reported by others, and the apparent volume of distribution (60 ml) was less than anticipated. The elimination constant was 0.197 h-1. Empiric dosing based on schedules suggested in the literature would have led to high peak and low mean concentrations of intrareservoir vancomycin. Patients with reservoir-associated infections have a variety of pathophysiologic conditions that can result in alteration of normal CSF dynamics. Pharmacokinetic analysis is useful to individualize dosing and to optimize therapy with intrareservoir vancomycin.

Staging proposal for external auditory meatus carcinoma based on preoperative clinical examination and computed tomography findings

An accepted staging system for squamous cell carcinoma of the external auditory meatus is currently lacking and would permit accurate comparison of treatment strategies and results for patients with this unusual neoplasm. In order to develop such a staging system we reviewed the prognostic variables and the accuracy of radiographic diagnosis in 39 patients undergoing temporal bone resection for squamous carcinoma of the external auditory meatus. Predictors of poor survival were extensive tumor involvement, facial nerve paralysis, middle ear involvement, and cervical or periparotid lymphadenopathy. In a comparison of 12 specific anatomic sites, computed tomography was found to be an accurate indicator of histopathologically proven tumor invasion. On the basis of this clinical radiographic-histopathologic analysis, we propose a TNM staging system for external auditory meatus carcinoma utilizing preoperative computed tomography and physical examination. This system fulfills the requirements of the American Joint Committee on Cancer that a staging system should provide a sound basis for therapeutic planning for cancer patients by describing the survival and resultant treatment of different patient groups in comparable form.

Osteogenesis imperfecta tarda: appearance of the temporal bones at CT

The computed tomographic findings in the temporal bone of two patients with osteogenesis imperfecta tarda are described. One of the patients had bilateral facial nerve paresis, and both patients presented with hearing loss.

Squamous cell carcinoma of the external auditory meatus (canal)

A retrospective study of 35 patients with squamous cell carcinoma of the external auditory meatus treated at the Eye and Ear Hospital of the University of Pittsburgh was performed. The standard treatment was a temporal bone resection that corresponded to the extent of the lesion, followed by postoperative radiation therapy. The tumor extensions, symptoms, treatments, survival rates, and prognostic variables were reviewed. Overall, 12 of 35 patients survived. Lesions limited to the external auditory meatus with no erosion had excellent prognoses. Survival in intermediate lesions with bony erosion or middle ear involvement was related to the status of surgical margins after partial or subtotal temporal bone resections. Extensive lesions that involved the surrounding soft tissue or dura had poor prognoses. The survival value of total temporal bone resection remains unproved.

Three-dimensional reconstruction of the foot from computed tomography scans

Recently developed computer programs create a new type of image from the sections created in computed tomography. These images look like actual photographs of internal structures. The authors describe the process of three-dimensional reconstruction in nonmathematical terms, and provide examples of its use in imaging the bones of the foot. They demonstrate the technique's ability to resolve small details, and its usefulness in displaying articular surfaces.

Posterior nasal packing. Are intravenous antibiotics really necessary?

The use of antimicrobial prophylaxis in the presence of posterior nasal packing for the treatment of posterior epistaxis remains controversial. Twenty patients were prospectively randomized into this placebo-controlled, double-masked pilot study to receive either placebo or cefazolin sodium. Antibiotic-impregnated posterior gauze packing was employed in all patients. No infectious complications were noted in either group. The packings from the patients in the placebo group were foul smelling and heavily colonized with gram-negative bacteria while the packings from the antibiotic group were odor-free and lightly colonized with gram-positive organisms. This preliminary study suggests the usefulness of antimicrobial prophylaxis for preventing complications from posterior nasal packing, although a larger sample size will be needed to decrease the type II (beta) error.

Cardiac myxoma metastatic to the temporal bone

Two metastases from an atrial myxoma occurred in the right common carotid artery distribution of a 34-year-old man. One metastasis caused the phenomenon of intracranial pseudoaneurysm in a distal branch of the middle cerebral artery. The other resulted in the unusual radiographic appearance of a tremendous, "bubbly" expansion of the temporal bone.

Nasopharyngeal teratoma involving the temporal bone

Teratoma is the most common nasopharyngeal tumor in neonates. The tumor is usually limited to the oropharynx and is manifest by stridor and respiratory distress. Complete excision affects a cure. An unusual case of nasopharyngeal teratoma extending into the temporal bone, causing facial paralysis and conductive hearing loss, in addition to stridor, is presented. Stridor was relieved by transoral partial excision shortly after birth. Complete removal of the tumor by way of a subtemporal and infratemporal fossa approach was performed at 14 months of age. The defect was filled with a rectus abdominis muscle graft with microvascular anastomoses. The facial nerve was reconstructed secondarily with a sural nerve graft. The patient has no recurrence tumor and has good facial function at 30 months. This case demonstrates the first known case of facial paralysis due to nasopharyngeal teratoma. The surgical approach for tumor removal: lateral infratemporal fossa dissection, and the method of reconstruction: free rectus abdominis muscle flap with microvascular anastomoses, had so far not been described in a patient this young.

The origins and function of the interosseous muscles of the foot

The dorsal and plantar interosseous muscles of the foot arise, not only from the metatarsal bones, but also from ligamentous tissue proximal to the tarsometatarsal joints. The interossei also take origin from the fascia of adjacent muscles, and the first dorsal interosseous muscle usually arises in part from a slip of the peroneus longus tendon. A means may thus exist to ensure that the interossei contract in a coordinated manner. Their positions and time of contraction during the gait cycle imply a possible role as stabilisers of the forefoot, rendering the tarsometatarsal joints rigid when weight is carried on the ball of the foot.

New-onset atrial fibrillation: is there need for emergent hospitalization?

Patients with new-onset atrial fibrillation are often hospitalized emergently. To determine whether this is necessary, the authors retrospectively reviewed the care of 97 consecutive patients with this illness. No reason for the atrial fibrillation in 43 patients could be identified. Hypertension, coronary artery disease, and valvular heart disease were the most commonly associated conditions; myocardial infarction occurred in one patient. In 82% of patients, atrial fibrillation reverted to normal sinus rhythm during hospitalization. Three patients needed emergent hospitalization irrespective of the presence of atrial fibrillation. In the remainder, admission was based solely on the diagnosis of new-onset atrial fibrillation. Ninety-eight per cent had an uncomplicated hospital course. It is concluded that hospitalization is not necessary for all patients with new-onset atrial fibrillation. Those in whom reversion to normal sinus rhythm occurs rapidly during digoxin therapy can be discharged. Where no major medical illness is evident patients can be admitted to a bed outside the intensive care unit until reversion to normal sinus rhythm or rate control is achieved.

Adult supraglottitis

Hospital records from 1974 through 1983 contained the cases of 20 patients over 18 years old admitted with supraglottitis (epiglottitis). Most patients presented with pharyngitis and odynophagia, and were diagnosed by laryngoscopy and neck radiographs. Four patients required tracheostomies, and one was nasotracheally intubated because of impending airway obstruction. Visualization of the hypopharynx was often necessary for diagnosis and in accordance with previously reported cases, did not precipitate airway obstruction. Adults without respiratory distress can be treated in the intensive care unit with inhaled mist, antibiotics, and corticosteroids, and such patients usually recover in a few days. Tracheostomy is being supplanted by nasotracheal intubation as the preferred means of securing an endangered airway.

Paraganglioma of vagal origin

Vagal paragangliomas are anatomically specific tumors of neuroectodermal origin. The history, embryology, and anatomic classification of these tumors will be reviewed and our present experience with six patients with vagal paragangliomas summarized. All patients had vocal cord dysfunction; various other findings depended upon the extent of the tumor. We found that massive tumors extending rostral to the jugular fossa may be difficult or impossible to distinguish from jugulotympanic paragangliomas.