Evaluation of Subjective Tinnitus Severity and Distortion Product Otoacoustic Emissions and Extended High-Frequency Audiometry

OBJECTIVE

Tinnitus is a multifactorial phenomenon with quality-of-life detriments for those affected by it. We aim to establish a relationship between subjective tinnitus severity with objective audiometric data in the extended high frequency (EHF) from 9 to 16 khz and with distortion product otoacoustic emissions (DPOAE). We hypothesize that severe subjective tinnitus as measured by the Tinnitus Handicap Inventory (THI) does not correlate with increased hearing thresholds in the EHF range.

STUDY DESIGN

Prospective.

SETTING

Single Tertiary Care Center.

METHODS

Patients identified with tinnitus and normal hearing thresholds within standard frequency range (250-8000 Hz) were consented for participation. Those with underlying otologic disease, trauma, radiotherapy, or ototoxic drug use were excluded. The THI questionnaire was given to eligible patients and audiometric test results were collected. THI scores were categorized by severity groups. An n = 20 to 30 was determined to have an effect size of 0.7 with a significance level of P = .05.

RESULTS

THI and audiometric data were collected for 38 patients and categorized into mild (n = 18, 47.4%), moderate (n = 8, 21.1%), slight (n = 7, 18.4%), and severe (n = 5, 13.2%) tinnitus severity groups. Mean THI score was 32.3 ± 19.6 with a statistically significant difference in scores by assigned THI severity group (P < .01). There were no significant differences or linear relationship among hearing thresholds in EHF range or DPOAE stratified by subjective tinnitus group (P = .49, r2 = 0.10) CONCLUSION: Subjective tinnitus severity is not predictive of audiometric outcomes. This finding can be used as a counseling tool to help tinnitus patients manage symptoms, expectations, and overall treatment outcomes.

Cognitive and language outcomes for pediatric hearing loss with otologic surgery

OBJECTIVES

To test the hypothesis that surgical otologic intervention for any type of pediatric hearing loss decreases the odds for incident adverse cognitive and linguistic developmental outcomes.

STUDY DESIGN

Retrospective cohort database study.

METHODS

Electronic medical record data from the TriNetX Research Network were queried for children with congenital, sensorineural, conductive, and mixed hearing loss (HL) between ages 0 and 5 years. Patients were further stratified by presence (HL + surgery) or absence (HL-surgery) of surgical intervention at any point following diagnosis, including cochlear implantation, tympanoplasty with or without mastoidectomy, and tympanostomy. Primary outcomes were defined as odds for new adverse cognitive or linguistic outcomes at any point given HL treatment status [odds ratio with 95% confidence interval, (OR; 95%CI, p-value)]. Cohorts were balanced using propensity-score matching (PSM) based on US census-defined demographics and clinically relevant congenital conditions.

RESULTS

Of 457,636 total patients included in the study, 118,576 underwent surgery (HL + surgery cohort) and 339,060 did not (HL-surgery). In matched cohorts, surgical otologic intervention significantly decreased the odds of developing cognitive disorders including scholastic, motor, psychological developmental disorders, and pervasive developmental delays (p < 0.01).

CONCLUSIONS

Surgical interventions for treatment of pediatric HL including cochlear implantation, tympanoplasty with or without mastoidectomy, and tympanostomy should be considered as they may prevent delays in development.

Association of Smoke and Nicotine Product Consumption With Sensorineural Hearing Loss: A Population-Level Analysis

OBJECTIVE

To test the hypothesis that use of cigarettes or other products with either cigarette-like smoke profile or high nicotine content by young populations increases the odds of developing sensorineural hearing loss (SNHL).

STUDY DESIGN

Retrospective cohort study.

SETTING

TriNetX US Collaborative Network (2003-2022).

PATIENTS

Approximately 3.6 million patients at least 18 years old.

INTERVENTION

None.

MAIN OUTCOME MEASURES

The primary outcome of interest was diagnosis of SNHL, defined using medical billing codes ( International Classification of Diseases, Tenth Revision , Current Procedural Terminology , etc.). Cohort inclusion criteria included electronic health record entry after 2003, age 18 to 54 or 55+ years at index, and status of cigarette, noncigarette nicotine, or cannabis use. Covariates were controlled via 1:1 propensity score matching for SNHL-related conditions, including diabetes mellitus and ischemic diseases. Odds for developing SNHL were calculated against control subjects aged 18 to 54 years who have no record of nicotine/cannabis use.

RESULTS

Odds for developing SNHL are higher for people 18 to 54 years old who use any nicotine product (odds ratio [95% confidence interval], 5.91 [5.71-6.13]), cigarettes only (4.00 [3.69-4.33]), chewing tobacco only (9.04 [7.09-11.63]), or cannabis only (3.99 [3.60-4.44]) compared with control. People 55+ years old who use no products also showed increased odds for SNHL (4.73 [4.63-4.85]).

CONCLUSIONS

Both nicotine and smoke exposure seem to be strongly associated with increased odds for developing SNHL, with chewing tobacco having the strongest association.

A Comparison of Outcomes Using Combined Intra- and Extradural versus Extradural-Only Repair of Tegmen Defects

Objective  Tegmen tympani or tegmen mastoideum defects involve dehiscence of the temporal bone that can be a source of cerebrospinal fluid (CSF) otorrhea. Herein, we compare a combined intra-/extradural repair strategy with an extradural-only repair as it pertains to surgical and clinical outcomes. Design  A retrospective review from our institution was performed of patients with tegmen defects requiring surgical intervention. Participants  Patients with tegmen defects who underwent surgery (combined transmastoid and middle fossa craniotomy) for repair of tegmen defects between 2010 and 2020 were inclined in this study. Results  A total of 60 patients with 40 intra-/extradural (mean follow-up time: 1,060 ± 1,103 days) and 20 extradural-only (mean follow-up time: 519 ± 369 days) repairs were identified. No major differences in demographic factors or presenting symptoms were identified between the two cohorts. There was no difference in hospital length of stay between the two patient cohorts (mean: 4.15 vs. 4.35 days, p  = 0.8). In the extradural-only repair technique, synthetic bone cement was more frequently used (100 vs. 7.5%, p  < 0.01), whereas in the combined intra-/extradural repair, synthetic dural substitute was used more often (80 vs. 35%, p  < 0.01), with similar successful surgical outcomes achieved. Despite disparities in the techniques and materials used for repair, there were no differences in complication rates (wound infection, seizures, and ossicular fixation), 30-day readmission rates, or persistent CSF leak between the two treatment cohorts. Conclusion  The results of this study suggest no difference in clinical outcomes between combined intra-/extradural versus extradural-only repair of tegmen defects. A simplified extradural-only repair strategy can be effective, and may reduce the morbidity of intradural reconstruction (seizures, stroke, and intraparenchymal hemorrhage).

Rate of tympanic membrane perforation after intratympanic steroid injection

PURPOSE

To determine the rate of persistent tympanic membrane perforation after intratympanic steroid injection. To determine which comorbid conditions and risk factors are associated with prolonged time to perforation closure following intratympanic steroid injection.

MATERIALS AND METHODS

Clinical data were gathered for patients who had undergone intratympanic steroid injection to treat sudden sensorineural hearing loss or Ménière's disease. Primary outcomes analysis included rate of persistent tympanic membrane perforation, defined as perforation at least 90days following last injection, and time to perforation healing. Age, sex, number of injections, smoking status, diabetes mellitus, previous head and neck irradiation, and concurrent oral steroids, were analyzed as potential predictors of persistent perforation.

RESULTS

One hundred ninety two patients were included in this study. Three patients (1.6%) had persistent tympanic membrane perforations. All three patients received multiple injections. One patient underwent tympanoplasty for repair of persistent perforation. The median time to perforation healing was 18days. There was no statistically significant variable associated with time to perforation healing. However, patients with prior history of head and neck radiation averaged 36.5days for perforation healing compared to 17.5days with no prior history of radiation and this approached statistical significance (p=0.078).

CONCLUSIONS

The rate of persistent tympanic membrane perforation following intratympanic steroid injection is low. Patients with a history of radiation to the head and neck may be at increased risk for prolonged time for closure of perforation.

Chiari Type I Malformations in Patients with Dizziness

Objectives:

(1) Investigate the association between magnetic resonance imaging (MRI) findings of Chiari Type I malformation and symptoms of dizziness in patients presenting to a neurotology clinic. (2) Recommend indications for intervention for Chiari Type I malformation in patients presenting with dizziness.

Methods:

A retrospective chart review was conducted for 16 patients presenting to our neurotology clinic between 2002 and 2009 found to have Chiari Type I malformation on MRI. All patients presented with symptoms of disequilibrium and/or vertigo. Charts were reviewed for demographics, symptoms, surgical procedures, videonystagmography, and degree of malformation based radiographic measurements.

Results:

The prevalence of Chiari Type I malformation in patients presenting to the neurotology clinic with dizziness is 16 out of 6427 (0.2%). During this time period, 16 patients were found to have radiographically confirmed Chiari Type I malformations. The mean herniation was 6.3 mm with a range of 5 to 13mm. Videonystagmography testing was done on 12 out of 16 patients and 7 out of 12 were abnormal with a mean RVR of 38%. Two of 16 patients (12.5%) underwent posterior fossa decompression. Surgical patients tended to have more severe symptoms.

Conclusions:

A small subset of patients who present to neurotology clinics with vertigo and/or disequilibrium will have radiographic findings of Chiari Type I malformation without the traditional symptoms of headaches and neurologic disturbances. The dilemma for clinicians is to determine if the radiographic findings are contributing to the patients symptoms or are an incidental finding. Intervention should only be considered if the herniation is greater than 10 mm, a cervical syrinx is present, or patients have the classic Chiari-type symptoms.

Surgical management of temporal meningoencephaloceles, cerebrospinal fluid leaks, and intracranial hypertension: treatment paradigm and outcomes

OBJECT

Thinning of the tegmen tympani and mastoideum components of the temporal bone may predispose to the development of meningoencephaloceles and spontaneous CSF leaks. Surgical repair of these bony defects and associated meningoencephaloceles aids in the prevention of progression and meningitis. Intracranial hypertension may be a contributing factor to this disorder and must be fully evaluated and treated when present. The purpose of this study was to establish a treatment paradigm for tegmen defects and elucidate causative factors.

METHODS

The authors conducted a retrospective review of 23 patients undergoing a combined mastoidectomy and middle cranial fossa craniotomy for the treatment of a tegmen defect.

RESULTS

The average body mass index (BMI) among all patients was 33.2 ± 7.2 kg/m(2). Sixty-five percent of the patients (15 of 23) were obese (BMI > 30 kg/m(2)). Preoperative intracranial pressures (ICPs) averaged 21.8 ± 6.0 cm H(2)O, with 10 patients (43%) demonstrating an ICP > 20 cm H(2)O. Twenty-two patients (96%) had associated encephaloceles. Five patients underwent postoperative ventriculoperitoneal shunting. Twenty-two CSF leaks (96%) were successfully repaired at the first attempt (average follow-up 10.4 months).

CONCLUSIONS

Among all etiologies for CSF leaks, those occurring spontaneously have the highest rate of recurrence. The surgical treatment of temporal bone defects, as well as the recognition and treatment of accompanying intracranial hypertension, provides the greatest success rate in preventing recurrence. After tegmen dehiscence repair, ventriculoperitoneal shunting should be considered for patients with any combination of the following high-risk factors for recurrence: spontaneous CSF leak not caused by another predisposing condition (that is, trauma, chronic infections, or prior surgery), high-volume leaks, CSF opening pressure > 20 cm H(2)O, BMI > 30 kg/m(2), preoperative imaging demonstrating additional cranial base cortical defects (that is, contralateral tegmen or anterior cranial base) and/or an empty sella turcica, and any history of an event that leads to inflammation of the arachnoid granulations and impairment of CSF absorption (that is, meningitis, intracranial hemorrhage, significant closed head injury, and so forth).

Atypical presentation of geniculate ganglion venous malformation in a child: conductive hearing loss without facial weakness

We describe an unusual presentation of geniculate ganglion venous malformation, a rare facial nerve lesion, emphasizing the importance of the differential diagnosis, imaging characteristics, and controversies in management. A child presented with moderate right-sided conductive hearing loss and a House-Brackmann grade I facial nerve function bilaterally. Computed tomography and magnetic resonance imaging showed a mass demonstrating features consistent with a geniculate ganglion venous malformation. To our knowledge, this is the first pediatric case of geniculate ganglion venous malformation presenting solely with conductive hearing loss. Proper management requires differentiating this condition from other geniculate and temporal bone lesions.

Bilateral skull base osteomyelitis in an immunocompetent patient

A 75-year-old immunocompetent man presented to our office with right otalgia. After a comprehensive workup, he was found to have right temporal bone osteomyelitis and was treated with intravenous antibiotics. He then began to experience left-sided otalgia and was diagnosed with and treated for left temporal bone osteomyelitis. Subsequently, he began to exhibit myelopathic symptoms, and imaging revealed a C2 inflammatory process. The patient underwent endoscopic transoral odontoidectomy with resection of a large C1 to C2 pannus and recovered with no neurologic deficit. Skull base osteomyelitis is an uncommon condition that usually occurs in immunocompromised patients. Prompt diagnosis and appropriate treatment are of utmost importance in managing this condition.

Current results of the surgical management of acoustic neuroma

A retrospective analysis of 162 consecutive cases in 160 patients who underwent microsurgical resection of vestibular schwannomas between October 1995 and June 2001 was undertaken to compare the results with those of other treatment modalities. Patient hospital records, operative video pictures, neuroimaging studies, audiograms, and follow-up data were reviewed. The mean follow-up period was 24 months.There were 34 small (<1.5 cm), 92 medium (1.5-3 cm), and 36 (>3 cm) large tumors. Six were recurrent tumors. Gross total resection was accomplished in all 34 small tumors and 92 medium tumors but only in 50% of the large tumors. Among the 126 small and medium tumors, the facial nerve was saved anatomically in 124 patients. On long-term follow up, facial function was preserved in 94.4% of all patients. Anatomically, the cochlear nerve was preserved in 55.9% of the small and 20.7% of the medium tumors. Function was preserved (Gardner-Robertson class 1 and 2) in 25% of the small and in 19.4% of the medium tumors. Cerebrospinal leakage was present in 10.5%, meningitis in 9.9%, wound infection in 3.7%, and hematoma or contusion in 2.5%. Only one patient died (mortality rate 0.6%). Our data reflect that surgical removal should be the standard management for acoustic tumors, particularly for large and medium tumors, and can be accomplished with acceptable complication rates.

The jugular dural fold-a helpful skull base landmark to the cranial nerves

During a retrosigmoid (or combined retrolabyrinthine-retrosigmoid) approach to the posterior fossa for vestibular neurectomy or removal of small acoustic neuromas, a white dural fold is a consistent landmark to cranial nerves VII through XII. This fold of dura appears as a white linear structure extending from the foramen magnum across the sigmoid sinus, attaching to the posterior aspect of the temporal bone, anterior to the vestibular aqueduct. The name "jugular dural fold" is suggested for this landmark. The jugular dural fold overlies the junction of the sigmoid sinus and the jugular foramen. As measured in formalin-fixed cadaver heads, the overall length of the jugular dural fold is 20.8 mm (+/- 2.9 mm). The cochleovestibular nerve lies 9.9 mm (+/- 1.5 mm) anterior to the superior aspect of the jugular dural fold, the glossopharyngeal nerve lies 9.5 mm (+/- 1.6 mm) anterior to the midpoint of the jugular dural fold, and the operculum of the vestibular aqueduct lies 6.6 mm (+/- 0.7 mm) posterior to the jugular dural fold. Intraoperative measurements in patients undergoing combined retrolabyrinthine-retrosigmoid vestibular neurectomy show an overall length of the jugular dural fold of 16.3 mm (+/- 1.9 mm). The cochleovestibular nerve lies 8.6 mm (+/- 1.3 mm) anterior to the superior aspect of the jugular dural fold, the glossopharyngeal nerve lies 8.6 mm (+/- 1.3 mm) anterior to the midpoint of the jugular dural fold, and the operculum lies 7.5 mm (+/- 0.8 mm) posterior to the jugular dural fold. The jugular dural fold can be used as a reliable landmark for rapidly locating cranial nerves in the posterior fossa.

Retropharyngeal Pseudomeningocele Presenting as Dysphagia After Atlantooccipital Dislocation

EDUCATIONAL OBJECTIVE

At the conclusion of this paper, the readers should be able to recognize a retropharyngeal pseudomeningocele as a potential complication of atlanto occipital dislocation.

OBJECTIVES

To demonstrate how a retropharyngeal pseudomeningocele may present as dysphagia in a patient who is recovering from atlanto occipital dislocation as well as to discuss the treatment options in this situation.

STUDY DESIGN

Case report and literature review.

METHODS

Analysis of a case through medical record and literature review.

RESULTS

A retropharyngeal pseudomeningocele is a very rare complication of atlanto occipital dislocation. It may develop weeks after the initial injury and can present with respiratory or swallowing difficulties. Decompression via a ventriculoperitoneal or lumboperitoneal shunt facilitates resolution of the cerebral spinal fluid collection.

CONCLUSIONS

A retropharyngeal pseudomeningocele should be considered in all patients status post-atlanto occipital dislocation who are experiencing respiratory distress or dysphagia.

Penetrating Middle Ear Trauma: A Report of 2 Cases

Penetrating middle ear injury can result in hearing loss, vertigo, and facial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disruption; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a perforation in the posterosuperior quadrant of the tympanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other. Both children underwent middle ear exploration and reduction of a subluxed stapes. We discuss the diagnosis, causes, and management of penetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeons should act promptly and be versatile in choosing methods of repairing ossicular chain injuries.

Penetrating middle ear trauma: a report of 2 cases

Penetrating middle ear injury can result in hearing loss, vertigo, and facial nerve injury. We describe the cases of 2 children with penetrating trauma to the right ear that resulted in ossicular chain disruption; one injury was caused by cotton-tipped swabs and the other by a wooden matchstick. Symptoms in both children included hearing loss and otalgia; in addition, one child experienced ataxia and the other vertigo. Physical examination in both cases revealed a perforation in the posterosuperior quadrant of the tympanic membrane and visible ossicles. Audiometry identified a moderate conductive hearing loss in one child and a mild sensorineural hearing loss in the other. Both children underwent middle ear exploration and reduction of a subluxed stapes. We discuss the diagnosis, causes, and management of penetrating middle ear trauma. To reduce the morbidity associated with these traumas, otologic surgeons should act promptly and be versatile in choosing methods of repairing ossicular chain injuries.

Intralabyrinthine schwannomas

OBJECTIVE

To describe the patient presentation, radiographic findings, and treatment results in a series of eight patients with a diagnosis of intralabyrinthine schwannoma, and to review the presentation of other cases of intralabyrinthine schwannoma in the English otolaryngologic literature.

METHODS

Retrospective review of patient records, operative reports, and radiologic studies, and review of the literature.

RESULTS

Eight patients with a variety of otologic symptoms including progressive hearing loss, episodic vertigo, and tinnitus were found to have a schwannoma involving the vestibule or cochlea. Surgery was performed to remove the tumors from four patients with nonserviceable hearing. The patients experienced significant improvement in their vertigo and tinnitus after surgery. Observation and serial magnetic resonance imaging were adequate treatment of the four patients with serviceable hearing. In the literature review, 447 cases of intralabyrinthine schwannoma were identified, and the presentations were similar to those in the cases described here.

CONCLUSION

Intralabyrinthine schwannomas are rare tumors that arise from the distal portion of either the vestibular nerve or the cochlear nerve. Consequently, the cochlea, the semicircular canals, the vestibule, or a combination of these structures may become involved with these lesions. Transmastoid labyrinthectomy or a transotic approach can be used to remove intralabyrinthine tumors from patients with nonserviceable hearing and severe vertigo or tinnitus. In addition, these surgical approaches should be used if the tumor grows to involve the internal auditory canal. Observation is an appropriate option for patients who have serviceable hearing.

Temporal bone hemangiomas involving the facial nerve

OBJECTIVE

Hemangiomas of the facial nerve are rare tumors that can mimic more common temporal bone tumors such as vestibular schwannomas and facial nerve schwannomas. This article reviews the diagnostic challenges in the surgical treatment of facial nerve hemangiomas.

STUDY DESIGN

Two case reports and literature review.

RESULTS

Early diagnosis and surgical excision of facial nerve hemangiomas can sometimes allow tumor removal with facial nerve preservation. In patients in whom the facial nerve needs to be resected to remove the hemangioma, primary anastomosis or cable nerve grafting can yield House-Brackmann Grade III/VI postoperative facial nerve function.

CONCLUSION

Complete surgical excision of facial nerve hemangiomas with primary facial nerve repair (when necessary) is the treatment of choice for these lesions.

Hepatocellular cancer metastatic to the zygoma: primary resection and immediate reconstruction

Hepatocellular carcinoma is common worldwide but relatively rare in the United States, where only 13,000 new cases are diagnosed each year. Metastasis to osseous structures in the head and neck are extremely rare; when they do occur, most appear as oral cavity masses secondary to mandibular and maxillary involvement. We report the case of an isolated zygomatic metastasis in a patient who had been previously treated for hepatocellular carcinoma with orthotopic liver transplantation. The patient underwent a complete excision of the mass followed by immediate reconstruction of the zygomaxillary buttress and the orbital rim and floor. To our knowledge, only one other case similar to ours has been previously reported; in that instance, the metastatic tumor was not resectable.

Pneumolabyrinth: A Late Complication of Stapes Surgery

As temporal bone imaging techniques continue to improve, it is likely that we will see an increase in the detection of pneumolabyrinth. Several mechanisms have been proposed to explain how air enters the labyrinth. A small number of authors has reported an association between pneumolabyrinth and temporal bone fractures, perilymphatic fistulae, and displaced stapes prostheses. In this article, we describe a new case of pneumolabyrinth that was seen as a late complication of stapes surgery, and we summarize what is known about this rare condition.

Pneumolabyrinth: a late complication of stapes surgery

As temporal bone imaging techniques continue to improve, it is likely that we will see an increase in the detection of pneumolabyrinth. Several mechanisms have been proposed to explain how air enters the labyrinth. A small number of authors has reported an association between pneumolabyrinth and temporal bone fractures, perilymphatic fistulae, and displaced stapes prostheses. In this article, we describe a new case of pneumolabyrinth that was seen as a late complication of stapes surgery, and we summarize what is known about this rare condition.

Xanthoma of the temporal bone: a unique case of this rare condition

Xanthoma of the temporal bone is extremely rare; we describe only the fourteenth reported case. Our case is further remarkable because it is the first report of such an occurrence in a patient with familial type III hyperlipoproteinemia. Moreover, while otalgia, infection, hearing loss, and tinnitus were the most common initial symptoms in the previous 13 cases, our patient reported only diplopia, vertigo, and unstable gait. The patient underwent a simple mastoidectomy and debulking, and his diplopia, vertigo, and unstable gait resolved.

Endoscopic repair of cerebrospinal fluid rhinorrhea

Endoscopic repair of cerebrospinal fluid rhinorrhea is a promising alternative to traditional repair techniques. This article reports our experience with 21 cases (10 spontaneous, 8 iatrogenic, and 3 traumatic). Various diagnostic radiographic modalities were used, including computer-aided techniques. Most repairs were accomplished with a free fascial graft positioned in the epidural space. Postoperative lumbar drainage was used in 15 cases. Initial repair was successful in 18 cases (85.7%). In all 3 failures, the surgeon had difficulty with proper graft placement. Additionally, 2 of these cases were confounded by early inadvertent removal of the lumbar drain. All patients in whom the procedure failed underwent a second successful endoscopic repair. There were no major complications. In our experience endoscopic repair of cerebrospinal fluid rhinorrhea is a safe and effective approach that can be improved with computer-aided localization devices. Proper graft placement is critical, and lumbar drainage is an important adjunct in selected cases.

Intraoperative facial nerve monitoring: a comparison between electromyography and mechanical-pressure monitoring techniques

OBJECTIVES

To examine the hypothesis that for intraoperative facial nerve monitoring, an EMG monitor is more sensitive than a mechanical-pressure monitor. To compare the threshold sensitivity of the two facial nerve monitoring methods-mechanical-pressure versus EMG--by using them simultaneously during surgery. To assess and compare their true- and false-positive responses in otologic and neurotologic procedures.

SETTING

A tertiary referral private otology/neurotology practice.

STUDY DESIGN

Prospective case-controlled study.

PATIENTS AND METHODS

The facial nerve of 46 consecutive patients undergoing various otologic and neurotologic procedures was stimulated intraoperatively using a pulsed constant-current. Facial responses were monitored using the Silverstein WR-S8 Monitor/Stimulator and the Brackmann EMG System simultaneously. The threshold (i.e., minimal) current level required to elicit a response from each monitor was recorded. Monitor responses to facial nerve manipulation (including false-positive responses) were assessed by continuous recording of all responses, using the Wiegand Monitoring System, and noting the causative event for each response.

RESULTS

The EMG monitor responded to lower current threshold (p < 0.001) in every surgical procedure and for every nerve segment studied. However, the average threshold difference was <0.05 mAmps and in clinical practice, when using above threshold stimulation, becomes negligible. In posterior fossa surgery, the EMG monitor showed higher sensitivity by responding earlier to various manipulations of the bare facial nerve. The EMG had more false-positive responses than the mechanical-pressure monitor.

CONCLUSIONS

In otologic surgery, if monitoring is required, the mechanical-pressure monitor is used. In neurotologic surgery, both monitors are used simultaneously.

A reevaluation of the 512-Hz Rinne tuning fork test as a patient selection criterion for laser stapedotomy

OBJECTIVE

This study aimed to challenge the classical hypothesis that a negative preoperative 512-Hz Rinne tuning fork test (bone conduction greater than air conduction) is a necessary condition to allow consistent objective and subjective hearing improvement with surgery for otosclerosis.

STUDY DESIGN

The study design was retrospective (chart review and questionnaire).

SETTING

The study was conducted at a Florida Ear and Sinus Center at Sarasota, Florida, a tertiary otology-neurotology referral center.

PATIENTS

Patients who underwent primary laser stapedotomy with equivocal (air=bone) preoperative 512-Hz Rinne test results participated.

INTERVENTION

KTP laser stapedotomy was performed.

MAIN OUTCOME MEASURES

Audiologic measurements of air-bone gap closure and patient assessment of hearing improvement and satisfaction were conducted.

RESULTS

The air-bone gap was closed to within 10 dB in all cases. There were no complications. Eighteen patients were questioned about their results. Hearing improvement was subjectively described as "excellent" or "good" by 17 (94%), and 16 (89%) thought the surgery was "absolutely" worthwhile.

CONCLUSIONS

The preoperative 512-Hz Rinne test results need not be negative to achieve significant air-bone gap closure and subjective appreciation of improved hearing.

Lightning injury of the tympanic membrane

Lightning injury to the ear is known, but specific reports are lacking. Four patients with tympanic membrane perforations who were managed surgically are reported. Their presentations, evaluations, intraoperative findings, and outcomes are discussed as they relate to the proposed pathogenic mechanisms. The authors' standard wide exposure tympanoplasty approach with two layer tympanic membrane repair is described. The added steps in performing this procedure may be necessary to ensure a good result in this unique group of patients.

Prediction of facial nerve function following acoustic neuroma resection using intraoperative facial nerve stimulation

Methods of monitoring the facial nerve during posterior fossa surgery continue to evolve. In an effort to predict acute and final facial nerve function following acoustic neuroma resection, the lowest current applied to the facial nerve at the brainstem necessary to elicit facial muscle response was measured using strain gauge and electromyographic facial nerve monitors. A retrospective analysis of 121 patients who had undergone acoustic neuroma surgery was performed. Sixty-five patients had intraoperative facial nerve monitoring and 44 had sufficient data for inclusion in this study. The acute and final facial nerve functions, according to the House-Brackmann classification, were assessed with regard to intraoperative stimulation-current thresholds. Nineteen of 20 patients who required 0.10 mA or less to elicit a facial muscle response had a House-Brackmann grade I facial nerve outcome. The upper limit of the 95% confidence interval of stimulation threshold for patients with a final grade I facial nerve function is 0.17 mA. All of the patients in this study, with stimulation thresholds ranging up to 0.84 mA, had a final grade III or better result. A poor outcome in our series, a final grade III facial nerve function, is best predicted by a poor acute result, specifically an acute grade VIA facial nerve function. We suggest that it is possible to predict the facial nerve function based on intraoperative threshold testing.

Vestibular nerve section

In the nearly 90 years since Frazier first performed an eighth nerve section through the posterior fossa for the treatment of Ménières's disease, the surgical management of Ménière's disease has come full circle. With refinements in surgical technique and advancements in instrumentation, optics, illumination, and neuromonitoring, a procedure that was once resoundingly condemned by the otologic community is now regarded as the procedure of choice in patients with serviceable hearing. The vestibular nerve section has experienced a renaissance. The posterior fossa vestibular nerve section has undergone an evolution, and the combined retrolabyrinthine-retrosigmoid vestibular nerve section represents the highest form. It is a significant improvement over its predecessors and our procedure of choice in properly selected patients.

Endoscopy in otology and neurotology

Since the early 1980s rigid endoscopes have been used by otorhinolaryngologists in the United States primarily for sinus surgery. Recently rigid endoscopes have been used as an adjunct to standard otologic and neurotologic procedures. Diagnostic inspection of the middle ear can be performed through a myringotomy incision to rule out perilymphatic fistula, for identification of cholesteatoma, or for evaluation of the status of the ossicular chain. During chronic ear surgery endoscopes can be used to locate hidden cholesteatoma in difficult to visualize areas such as the eustachian tube, attic, sinus tympani, and beneath an intact posterior canal wall. In acoustic neuroma surgery in which hearing preservation is an objective endoscopes are used to inspect the lateral aspect of the internal auditory canal (IAC) for residual tumor. During vestibular neurectomy endoscopes are used to view the IAC and to help identify the cochleovestibular cleavage plane. The applications, techniques, and limitations of rigid endoscopy in otology and neurotology are discussed.

Laryngeal Involvement in Neurofibromatosis

Neurofibromas of the larynx are an uncommon component of neurofibromatosis, but should be considered in the differential diagnosis of patients with a submucosal supraglottic mass. Complete surgical excision is the treatment of choice; however, incomplete excision may be preferable to aggressive debilitatingsurgery. Plexiform neurofibromadiffers from non-plexiform neurofibroma in that it is poorly circumscribed and highly infiltrative. Tracheostomymaybe necessary. Sarcomatous degeneration is reportedandcarries a poor prognosis.

Laryngeal involvement in neurofibromatosis

Neurofibromas of the larynx are an uncommon component of neurofibromatosis, but should be considered in the differential diagnosis of patients with a submucosal supraglottic mass. Complete surgical excision is the treatment of choice; however, incomplete excision may be preferable to aggressive debilitating surgery. Plexiform neurofibroma differs from non-plexiform neurofibroma in that it is poorly circumscribed and highly infiltrative. Tracheostomy may be necessary. Sarcomatous degeneration is reported and carries a poor prognosis.

A comparison of growth rates of acoustic neuromas: nonsurgical patients vs. subtotal resection

A conservative approach to the management of acoustic neuromas in elderly patients has been used since 1971. Elderly patients without symptoms of brain stem compression are initially treated by observation and yearly radiographic imaging. A translabyrinthine radical-subtotal resection is performed if brain stem compression is present or if tumor is growing rapidly. Twenty-three patients, ages 65 to 86 years, had initial nonsurgical management of their tumors. Growth rates could be determined for 16 patients. Thirteen patients not requiring surgery had an average tumor growth rate of 0.6 mm/yr. Three patients with an average growth rate of 6.8 mm/yr eventually required surgery. No patient whose tumor was < 15 mm at initial evaluation has experienced brain stem symptoms or demonstrated rapid tumor growth. Twenty-four patients ages 65 to 86 years underwent planned subtotal tumor excision. Eighteen patients followed postoperatively for more than 1 year demonstrated an average rate of regrowth of tumor of 0.7 mm/yr.

Middle ear air injection after chronic ear surgery

In the early period after chronic ear surgery, the reasons for conductive hearing loss may be difficult to determine. Patients who cannot autoinflate the middle ear after 3 weeks, or who have a negative Rinne test result with the 512 Hz tuning fork, are treated with a transtympanic injection of 0.5 cc of air with a 27-gauge needle and tuberculin syringe. This represents 20% of patients who had chronic ear surgery. Results show that hearing may be immediately improved, the sensation of pressure in the ear may be reduced, and fluid may be cleared from the middle ear. Other benefits may include the release of adhesions. The surgeon is better able to assess the thickness of the graft, and the status of the ossicular chain reconstruction can be determined. There have been no complications of middle ear infection or failure of the micropuncture site to heal. In our practice, middle ear air injection is a routine procedure in patients with inadequate eustachian tube function after chronic ear surgery. This report describes the results of 100 patients over 14 years who received middle ear air injections after chronic ear surgery compared with a control group of 100 patients who did not meet the criteria for requiring air injection. Hearing was immediately improved in 74% of patients as determined by Rinne testing. Audiograms were performed in 25 of these patients, documenting a mean improvement in pure-tone average of 16 dB. The long-term hearing results in patients undergoing air injection, who by definition had evidence of poor eustachian tube function, are similar to the results in the control group.(ABSTRACT TRUNCATED AT 250 WORDS)