Effects of surgical lesions on choline acetyltransferase activity in the cat cochlea

Although it is well established that the choline acetyltransferase (ChAT, the enzyme for acetylcholine synthesis) in the mammalian cochlea is associated with its olivocochlear innervation, the distribution of this innervation in the cochlea varies somewhat among mammalian species. The quantitative distribution of ChAT activity in the cochlea has been reported for guinea pigs and rats. The present study reports the distribution of ChAT activity within the organ of Corti among the three turns of the cat cochlea and the effects of removing olivocochlear innervation either by a lateral cut aimed to totally transect the left olivocochlear bundle or a more medial cut additionally damaging the superior olivary complex on the same side. Similarly to results for guinea pig and rat, the distribution of ChAT activity in the cat outer hair cell region showed a decrease from base to apex, but, unlike in the guinea pig and rat, the cat inner hair cell region did not. As in the rat, little ChAT activity was measured in the outer supporting cell region. As previously reported for whole cat cochlea and for rat cochlear regions, transection of the olivocochlear bundle resulted in almost total loss of ChAT activity in the hair cell regions of the cat cochlea. Lesions of the superior olivary complex resulted in loss of ChAT activity in the inner hair cell region of all cochlear turns only on the lesion side but bilateral losses in the outer hair cell region of all turns. The results are consistent with previous evidence that virtually all cholinergic synapses in the mammalian cochlea are associated with its olivocochlear innervation, that the olivocochlear innervation to the inner hair cell region is predominantly ipsilateral, and that the olivocochlear innervation to the outer hair cells is bilateral.

[Anatomical study of auditory brainstem implantation through retrosigmoid approach]

OBJECTIVE

To provide anatomic data for auditory brainstem implantation (ABI) through the retrosigmoid approach.

METHODS

Simulated operations were performed on 30 web adult head specimens and the structure around the foramen of luschka was observed. Both microscope and endoscope were employed.

RESULTS

(1)The bony window, the most adjacent but not overlapping with sigmoid sinus, was a circle with a radius of 20 mm. Its center was located behind midpoint of the line from parietal notch to mastoid apex with a distance of (26.42 +/- 1.29) mm. The distance between bony window and transverse sinus, mastoid apex, foramen of luschka, jugular foramen, posterior edge of internal auditory meatus and root entry zone of the IX cranial nerve were (22.45 +/- 1.41) mm, (35.51 +/- 1.65) mm, (43.86 +/- 2.20) mm, (16.56 +/- 1.64) mm, (15.01 +/- 0.63) mm and (46.27 +/- 1.70) mm respectively; (2) The foramen of luschka can be spotted by using microscope or endoscope, especially 30 degrees angled endoscope. By this way, we could obtain a more distinct visual field without over-retraction of cerebellum and achieve the goal of minimally invasive surgery. The distance between the foramen of luschka and internal acoustic porus was (15.01 +/- 0.53) mm; (3) The foramen of luschka lies in the triangle formed by flocculus and root entry zone of glossopharyngeal nerve and rostral margin of biventer lobule. Choroids plexus acts as a direct landmark. the length of lateral recess was (17.53 +/- 1.03) mm. The distance between acoustic tubercle and the foramen of luschka and the root of cochlea never was (16.52 +/- 1.67) mm and (13.77 +/- 1.66) mm respectively.

CONCLUSION

Adjustment of the angle of skull bone window and clarification of cerebellopontine angle are the keys to positioning the foramen of luschka. The usage of 30 degrees angled endoscope can identify the angle are the keys to positioning the foramen of luschka. The usage of 30 degrees angled endoscope can identify the foramen of luschka more accurately and expose the operation area more clearly.

A Model for Auditory Brain Stem Implants: Bilateral Surgical Deafferentation of the Cochlear Nuclei in the Macaque Monkey

BACKGROUND

Patients with extensive bilateral lesions of the auditory nerve have a profound and irreversible sensorineural hearing loss (SNHL), which can only be overcome with individually-fitted auditory brain stem implants that directly stimulate the cochlear nuclei. Despite the enormous potential of this increasingly applied treatment, the auditory performance of many implanted patients is limited, and the variability between cases hinders a complete understanding of the role played by the multiple parameters related to the efficacy of the implant.

OBJECTIVES

To mimic the condition of patients who have bilateral lesions of the auditory nerve, we developed an experimental model of bilateral deafferentation of the cochlear nuclei by surgical transection of the cochlear nerves of adult primates.

MATERIALS AND METHODS

We performed bilateral transection of the cochlear nerves of six adult, healthy, male captive-bred macaques (Macaca fascicularis). Before surgery, brain stem auditory evoked potentials were recorded. The histological material obtained from these animals was compared with similarly processed sections from seven macaques with intact cochlear nerves. The surgical technique, similar to that used in human neuro-otology, combined a labyrinthectomy and a neurectomy of the cochlear nerves, and caused deafness. We analyzed immunocytochemically the expression in cochlear nerve fibers of neurofilaments (SMI-32), and cytosolic calcium binding proteins calretinin, parvalbumin and calbindin, and also applied a histochemical reaction for acetylcholinesterase.

RESULTS

None of the primates had any major complications due to the surgical procedure. The lesions produced massive anterograde degeneration of the cochlear nerves, evidenced by marked gliosis and by loss of both type I fibers (which in this species are immunoreactive for calretinin, parvalbumin and neurofilaments) and type II fibers (which are acetylcholinesterase positive). The model of surgical transection described herein causes extensive damage to the cochlear nerves while leaving the cochlea intact, thus mimicking the condition of patients with profound SNHL due to bilateral cochlear nerve degeneration.

CONCLUSIONS

The phylogenetic proximity of primates to humans, and the paramount advantage of close anatomical and physiological similarities, allowed us to use the same surgical technique applied to human patients, and to perform a thorough evaluation of the consequences of neurectomy. Thus, bilateral surgical deafferentation of the macaque cochlear nuclei may constitute an advantageous model for study of auditory brain stem implants.

Remodeling of synaptic structure in sensory cortical areas in vivo

Although plastic changes are known to occur in developing and adult cortex, it remains unclear whether these changes require remodeling of cortical circuitry whereby synapses are formed and eliminated or whether they rely on changes in the strength of existing synapses. To determine the structural stability of dendritic spines and axon terminals in vivo, we chose two approaches. First, we performed time-lapse two-photon imaging of dendritic spine motility of layer 5 pyramidal neurons in juvenile [postnatal day 28 (P28)] mice in visual, auditory, and somatosensory cortices. We found that there were differences in basal rates of dendritic spine motility of the same neuron type in different cortices, with visual cortex exhibiting the least structural dynamics. Rewiring visual input into the auditory cortex at birth, however, failed to alter dendritic spine motility, suggesting that structural plasticity rates might be intrinsic to the cortical region. Second, we investigated the persistence of both the presynaptic (axon terminals) and postsynaptic (dendritic spine) structures in young adult mice (P40-P61), using chronic in vivo two-photon imaging in different sensory areas. Both terminals and spines were relatively stable, with >80% persisting over a 3 week period in all sensory regions. Axon terminals were more stable than dendritic spines. These data suggest that changes in network function during adult learning and memory might occur through changes in the strength and efficacy of existing synapses as well as some remodeling of connectivity through the loss and gain of synapses.

Engraftment of embryonic stem cell-derived neurons into the cochlear modiolus

This study aimed to evaluate the potential of embryonic stem cell-derived neural progenitors for use as transplants for the replacement of the auditory primary neurons, spiral ganglion neurons. Mouse embryonic stem cell-derived neural progenitors were implanted into the base of the cochlear modiolus of normal or deafened guinea pigs, which contains spiral ganglion neurons and cochlear nerve fibers. Histological analysis demonstrated the survival and neural differentiation of transplants in the cochlear modiolus and active neurite outgrowth of transplants toward host peripheral or central auditory systems. Functional assessments indicated the potential of transplanted embryonic stem cell-derived neural progenitors to elicit the functional recovery of damaged cochleae. These findings support the hypothesis that transplantation of embryonic stem cell-derived neural progenitors can contribute to the functional restoration of spiral ganglion neurons.

Rehabilitation of hearing and communication functions in patients with NF2

Most patients with neurofibromatosis type 2 (NF2) lose hearing either spontaneously or after removal of their neurofibromas. The patient may benefit from conventional hearing aids if, due to modern microsurgery and intraoperative monitoring the integrity of the cochlea and the 8th nerve is preserved. With lost auditory function but preserved electrical stimulibility of the 8th nerve a cochlear implant may be appropriate. But if the patients have no remaining 8th nerve to stimulate, there is no benefit from cochlear implants. Until some years ago, vibrotactile aids, lip-reading, and sign language have been the only communication modes available to these patients. With auditory brain stem implants it is now possible to bypass both the cochlea and the 8th nerve and to stimulate the cochlear nucleus directly. Stimulation of the devices produces useful auditory sensations in almost all patients. Testing of perceptual performance indicated significant benefit from the device for communication purposes, including sound-only sentence recognition scores and the ability to converse on the telephone. Also lip-reading is significantly improved with brain stem implants. The successful work of an auditory brainstem program center depends very much on the close interdisciplinary collaboration between the Departments of Neurosurgery and ENT-surgery. In the future new developments like speech processing strategies and new designed electrodes accessing the complex tonotopic organization of the cochlear nucleus may further improve rehabilitation in these patients who would have been deaf some years ago.

Enhanced plasticity of retinothalamic projections in an ephrin-A2/A5 double mutant

Ascending sensory information reaches primary sensory cortical areas via thalamic relay neurons that are organized into modality-specific compartments or nuclei. Although the sensory relay nuclei of the thalamus show consistent modality-specific segregation of afferents, we now show in a wild-type mouse strain that the visual pathway can be surgically "rewired" so as to induce permanent retinal innervation of auditory thalamic cell groups. Applying the same rewiring paradigm to a transgenic mouse lacking the EphA receptor family ligands ephrin-A2 and ephrin-A5 results in more extensive rewiring than in the wild-type strain. We also show for the first time that ephrin-A2 and ephrin-A5 define a distinct border between visual and auditory thalamus. In the absence of this ephrin-A2/A5 border and after rewiring surgery, retinal afferents are better able to invade and innervate the deafferented auditory thalamus. These data suggest that signals that induce retinal axons to innervate the denervated auditory thalamus may compete with barriers, such as the ephrins, that serve to contain them within the normal target. The present findings thus show that the targeting of retinothalamic projections can be surgically manipulated in the mouse and that such plasticity can be controlled by proteins known to regulate topographic mapping.

Regeneration and recovery of the hearing function of the central auditory pathway by transplants of embryonic brain tissue in adult rats

The present study is the first report of successful regeneration and recovery of hearing function of the central auditory pathway after transection in the adult rat. The ventral cochlear tract in the brain stem to pons was transected on one side in adult rats. Tissue from embryos (E14 to E16) was used to cover the lesion site. In 30% of the rats examined, the axons regrew beyond the transected site and regenerated into the denervated side and terminated at the normal targets. The hearing function of rats was elucidated by recording the auditory brain stem response (ABR). Rats with successful regeneration showed nearly normal ABR. In rats receiving simple transection without covering embryonic tissue, there was no regeneration and hearing function did not recover. Thus, the present findings contradict the widely held view that the adult mammalian central auditory system cannot be restored following damage.

The retrosigmoid approach for auditory brainstem implantation

OBJECTIVE

To describe our experience with the retrosigmoid-transmeatal (RS-TM) approach in auditory brainstem implantation (ABI) as well as the anatomosurgical guidelines for this route.

STUDY DESIGN

Retrospective case review.

SETTING

Ear, Nose, and Throat Department of the University of Verona.

PATIENTS

Five patients with neurofibromatosis type 2 (NF2) were operated on for vestibular schwannoma removal with ABI implantation from April 1997 to June 1999. The patients were four men and one woman, whose ages ranged from 22 to 37 years. The tumor sizes ranged from 12 to 30 mm. The records of a total of 179 patients operated on for vestibular schwannoma (VS) removal via the RS-TM approach from January 1990 to June 1999 were also evaluated. Their ages ranged from 18 to 88 years (average 54 years). The tumor sizes ranged from 4 to 50 mm. Five patients had a solitary VS in the only hearing ear.

INTERVENTION

The classic RS-TM approach was used in all patients. After tumor excision, for ABI implantation, the landmarks (seventh, eighth, and ninth cranial nerves, choroid plexus) for the foramen of Luschka were carefully identified. The choroid plexus was then partially removed, and the tela choroidea was divided and bent back. The floor of the lateral recess of the fourth ventricle and the convolution of the dorsal cochlear nucleus became visible. The electrode array was then inserted into the lateral recess and correctly positioned with the aid of electrically evoked auditory brainstem responses (EABRs).

MAIN OUTCOME MEASURES

Intraoperative EABR and postoperative speech perception evaluation.

RESULTS

Auditory sensations were induced in all patients with various numbers of electrodes. Different pitch sensations could be identified with different electrode stimulation.

CONCLUSIONS

In the authors' experience, the RS-TM approach is the route of choice for patients who are candidates for ABI when there is a chance of hearing preservation during surgery. If auditory function is lost during surgery, anatomical preservation of the cochlear nerve may allow hearing restoration with a cochlear implant. Direct intraoperative recording of cochlear nerve action potentials (CNAPs) and round window electrical stimulation are mandatory for these purposes. In addition, decompression of the intrameatal portion of the vestibular schwannoma and planned partial tumor resection with hearing preservation are also possible with the RS-TM approach.

Surgically created neural pathways mediate visual pattern discrimination

Combined lesions of retinal targets and ascending auditory pathways can induce, in developing animals, permanent retinal projections to auditory thalamic nuclei and to visual thalamic nuclei that normally receive little direct retinal input. Neurons in the auditory cortex of such animals have visual response properties that resemble those of neurons in the primary visual cortex of normal animals. Therefore, we investigated the behavioral function of the surgically induced retino-thalamo-cortical pathways. We showed that both surgically induced pathways can mediate visually guided behaviors whose normal substrate, the pathway from the retina to the primary visual cortex via the primary thalamic visual nucleus, is missing.

Long-term changes in middle latency response and evidence of retrograde degeneration in the medial geniculate body after auditory cortical ablation in cats

Short- and long-term changes in the middle latency response (MLR) after bilateral ablation of the auditory cortices were studied in awake cats. The amplitude of the negative peak with a latency of about 15 ms (NA) decreased to 60% of the original value 1 week after ablation (short-term change). In the long term, i.e. 11-30 months, NA either decreased further (decreased group) or remained unchanged (non-decreased group). A histological study with light microscopy revealed degeneration of neurons in the ventral nucleus of the medial geniculate body (MGv) in the decreased group, whereas the neurons in this region were preserved in the non-decreased group. This study suggests that long-term changes in NA reflect retrograde degeneration in the MGv after auditory cortical ablation.

Evaluation of surgical approaches to endoscopic auditory brainstem implantation

OBJECTIVES

This study investigates the use of endoscopy for the placement of an auditory brainstem implant by translabyrinthine, retrosigmoid (suboccipital), and middle cranial fossa approaches.

STUDY DESIGN

Cadaver dissection and endoscope-assisted placement of the auditory brainstem implant.

METHODS

Translabyrinthine, retrosigmoid, and middle cranial fossa dissections were performed bilaterally in five cadaveric heads. An auditory brainstem implant was placed within the lateral recess of the fourth ventricle under endoscopic visualization. The implantation was performed with all approaches and documented by digital image capture followed by production of dye-sublimation photographic prints.

RESULTS

The lateral recess was visualized with the endoscope in all three approaches to the brainstem. The 30 degrees endoscope provided the best visualization by translabyrinthine and retrosigmoid dissection and was essential for the middle cranial fossa approach. Refinement of implant position was readily achieved, as even the deepest portion of the recess could be seen with all three approaches.

CONCLUSIONS

This study finds that endoscopy provides superior visualization of the lateral recess of the fourth ventricle than the operating microscope with all approaches. The retrosigmoid approach is recommended, as it provides the best view of the implantation site and the easiest angle for placement of the prosthesis. The use of the endoscope may allow for a smaller craniotomy than with conventional microscopic techniques, depending on tumor size. The translabyrinthine approach provides a good view of the lateral recess but had no advantage over other approaches. The middle cranial fossa approach is only possible with angled endoscopes; however, it is technically the most difficult and places the facial nerve at greatest risk.

Effect of olivocochlear bundle section on evoked otoacoustic emissions recorded using maximum length sequences

Presenting clicks according to maximum length sequences (MLS) enables transient evoked otoacoustic emissions (TEOAE) to be recorded at very high stimulation rates. As the click rate is increased from 40 clicks/s up to a maximum rate of 5000 clicks/s there is a reduction in TEOAE amplitude that reaches an approximate asymptote at 1500 clicks/s. One hypothesis put forward to explain this MLS 'rate effect' is that ipsilateral efferent activity is involved. To test this hypothesis TEOAEs were recorded from both ears of five patients who had undergone a unilateral vestibular nerve section--a surgical procedure which also entails sectioning the olivocochlear bundle. TEOAEs were recorded conventionally at 40 clicks/s and using MLS stimulation at 5000 clicks/s. Increasing the rate from 40 to 5000 clicks/s was found to reduce the amplitude of the TEOAEs by equivalent amounts in ears ipsilateral and contralateral to a vestibular nerve section as well as in the ears of normal-hearing adults. Since an ear ipsilateral to a vestibular nerve section should have no efferent innervation the hypothesis that efferent activity is the major mechanism involved in the MLS rate effect is rejected. Instead, the possibility that intracochlear processes are the underlying mechanism will now be investigated.

On the role of the olivocochlear bundle in hearing: 16 case studies

Earlier we presented data (Scharf et al. (1994) Hear. Res. 75, 11-26) from a young patient (S.B.) who had undergone a vestibular neurotomy, during which the olivocochlear bundle (OCB) was severed. Those data are complemented by measurements on 15 other patients-some like S.B. with normal audiometric thresholds, none with a loss greater than 35 dB at experimental frequencies. Comparisons of performance for the same ear before and after surgery or between the operated and healthy ears do not provide evidence that the lack of OCB input impairs the following psychoacoustical functions: (1) detection of tonal signals, (2) intensity discrimination, (3) frequency selectivity, (4) loudness adaptation, (5) frequency discrimination within a tonal series, (6) in-head lateralization. Data on single-tone frequency discrimination are equivocal. These mostly negative results apply to listening both in the quiet and, where relevant, in noise. The only clear change in hearing after a vestibular neurotomy is that most patients detect signals at unexpected frequencies better than before. This change suggests an impaired ability to focus attention in the frequency domain. Although limited in scope, our finding that human hearing without OCB input is essentially normal agrees with much of the relevant literature on animal behavior and with the patients' self-reports.

Tinnitus and hearing loss in pineal region tumours

The authors report an underestimated symptom and sign arising in pineal region tumours: tinnitus and hearing loss. It has been observed in 13 out of 72 pineal region tumours (18%). Three illustrative cases are reported in this paper. The inferior colliculi, the structure more dense in fibres than any other auditory brain stem site and at which majority of the acoustic pathways relay, is closely adjacent to the pineal body. Displacement of this structure may be responsible for acoustic symptoms together with common visual symptoms.

Effects of olivocochlear bundle section on otoacoustic emissions in humans: efferent effects in comparison with control subjects

The effects of contralateral acoustic stimulation on evoked otoacoustic emissions (OAE) were examined in three subject groups in order that the impact of efferent olivocochlear bundle section (as a consequence of vestibular neurectomy) could be compared with normal findings, and with a control surgical population. Results demonstrated that the inhibitory effect of contralateral noise on OAE amplitude was absent from the cochlea with severed efferent fibers. These findings appear to be independent of acoustic reflex activity, as suppression was absent despite normal reflexes. Inter-aural suppression of emissions recorded from the patients' intact cochleae act as a control and show a clear reduction in amplitude during contralateral stimulation in a frequency specific pattern consistent with normal findings. Patients who had undergone a similar surgical approach for vascular decompression of the VIIIth nerve without vestibular nerve section, were studied in order to assess the impact of retrolabyrinthine surgery on inter-aural suppression. Inhibition of OAE amplitude was maintained in all control cases in both the operated and intact sides, and was consistent with suppression observed in normal subjects, suggesting that the surgical procedures had not disturbed inter-aural suppression of otoacoustic emissions. It is concluded that the olivocochlear efferent system, when activated by low level contralateral acoustic stimulation, has an inhibitory role in controlling the cellular mechanisms responsible for the generation of otoacoustic emissions in humans. OAE techniques in conjunction with contralateral acoustic stimulation may thus prove to be of value in providing a rapid and non-invasive clinical test of efferent function and offer a means of investigating the functional significance of the efferent auditory system in humans.

Ocular tilt reaction resulting from vestibuloacoustic nerve surgery

The ocular tilt reaction (OTR) is a triad of head-eye synkinesis composed of head tilt, conjugate ocular torsion in the direction of head tilt, and skew deviation. The OTR represents a normal compensatory response to lateral head tilts and is produced by activation of the utricle of the lowermost ear. A pathological OTR results when otolith activity is unopposed as the result of injury to the opposite utricle or its nerve. Vertical diplopia may be the only symptom of OTR in patients who have undergone surgery involving the vestibuloacoustic nerve. We report a series of patients with OTR after surgery for acoustic neuroma or Meniere's disease. In each patient, the manifesting symptom was vertical diplopia. Bedside neuro-ophthalmological testing readily excluded a brain stem cause for the double vision. We conclude that OTR after vestibuloacoustic surgery is a benign condition with spontaneous resolution of symptoms within several months.

Analysis of the frequency following response in the cat

The generators of the frequency following response (FFR) were characterized for three frequency ranges by studying changes in FFR response after lesioning the nuclei within the central brainstem auditory pathway. Responses to low frequency (200-500 Hz) stimulation demonstrated changes in the complexity of the FFR waveform in both time and frequency domains following lesions in the brainstem auditory pathway. The results indicate that the complexity of the low frequency FFR is due to activity from multiple sites within the auditory pathway. The intermediate frequency (700-1500 Hz) responses showed unpredictable amplitude changes following similar lesions and no conclusion could be drawn about the generators of the FFR in this frequency range. The responses to high frequency (3-8 Hz) stimulation showed no reduction in amplitude following serial lesioning. These results, combined with other experimental evidence presented, indicate that the high frequency FFR response originates from the cochlear microphonic. Different electrode configurations were used to evaluate the low frequency FFR. In contrast to multiple generator sources recorded with the standard vertex-mastoid electrode configuration, we were able to record a response contributed primarily by the inferior colliculi with a less peripherally sensitive electrode configuration (vertex-linked-pinnae) at low intensity stimulation. The fact that auditory brainstem nuclei contribute to the FFR in varying amounts depending on the electrode configuration may explain some of the conflicting characterizations of this response in the literature. Despite this difficulty, the FFR neural generators were identified and characterized in the low frequency range using our most sensitive electrode configuration (vertex-mastoid) and in the high frequency range where the single generator is the cochlear microphonic.

Experimental grafting of the auditory nerve

The auditory nerve of five cats was sectioned unilaterally. Its proximal stump was immediately sutured to the proximal stump of the simultaneously severed facial nerve to study afferent sensory nerve regeneration. After time intervals of nine to 18 months, the nerve anastomosis was tested by electrical stimulation of the anastomosis and by recording evoked cortical responses at the auditory cortex. Electrophysiologic evidence of both fiber regeneration within the sectioned auditory nerve and of the reestablishment of a functional synapse at the cochlear nucleus was obtained. Further support of the concept of a possible auditory nerve grafting was added by the histologic examination of the nerve anastomosis and of the cochlear nuclei, which showed signs of the outspreading of axons from the facial nerve through the auditory nerve and through the barrier of the brain stem into the areas of the cochlear nuclei.

[Surgical treatment of acquired stenosis of the external auditory meatus (author's transl)]

Acquired stenosis caused by augmentation of the soft tissues usually are arrayed circulary and less diffusely; the posterior and superior wall seems to be favoured. Circular stenosis are to excise and to cover by a free skin flap. So the circular scars are changed into longitudinale and prevent a circular recurrent. Also after removal of a diffuse stenosis finally longitudinal stripes of skin are implanted with analogous effect. The transplantation of a new and healthy skin may work additionally against a shrinking-tendency of the local skin. The removal of bone is only needed exceptionally. We did not see any indication for a mastoidectomy and removal of the posterior bony wall; our last case should even demonstrate a contraindication.

[Meatoplasty with allogenic preserved cartilage. Histomorphological model in animal experiments (author's transl)]

The reconstruction of the posterior wall of the external acoustic meatus destroyed by surgery or a cholesteatoma is necessary for the complete restoration of function. For this purpose, allogen cartilage preserved in thiomersalate has been transplanted on the anterior wall of the air-containing mastoid bone in 160 clinical cases. The histomorphological reaction of the recipient to unilaterally uncovered transplant material has previously been unknown. In 10 guinea pigs, 15 fenestrated bullae (hypotympanum equivalents) were closed with cartilage transplants fixed in place with tissue adhesive. After a period varying between 7 1/2 and 11 months, the walls of the bullae with the transplant were then examined histomorphologically. Despite the variations in the period in situ, the avital cartilage transplant, which remained largely constant in volume and shape, was always to be found. It was tolerated without reaction and was "enveloped"--also on the primarily uncovered surface--by a capsule of bone and connective tissue. In no case was rejection observed. Marked foreign-body reaction was, however, found in the vicinity of the tissue adhesive, which was absorbed only slowly. The clinically well-known tissue-compatible and complication free behaviour of the allogenic cartilage transplant preserved in thiomersalate, is thus explained by the histomorphological findings. In contrast, the fact that marked foreign-body reaction was demonstrable even after almost one year, suggests that tissue adhesive should not be used.

Suboccipital microsurgical removal of acoustic neurinomas of all sizes

This report discusses a combined neurosurgical-otologic team approach to the management of 16 consecutive suspected VIII nerve neurinomas, all operated via the suboccipital route. A suboccipital craniectomy is done with the patient in the prone position. Dissection for all size tumors began with exposure of the internal auditory canal to the transverse crest with dissection of the neurinoma from the VII and VIII cranial nerves beginning in the lateral most posterior portion of the internal auditory canal. There was one death and one cerebrospinal fluid (CSF) leak. Total tumor removal was accomplished in 14 of 15 acoustic neurinoma patients. Facial nerve function was preserved in 12 of 15 patients and preoperative hearing maintained in 5 of 15 patients.

Surgery for acoustic neurinoma

This presentation is concerned with the one-stage translabyrinthine operation of small acoustic neurinomas and a combined translabyrinthine suboccipital staged operation for removal of large acoustic neurinomas. The technique for the translabyrinthine approach to the cerebellopontine angle is described in detail and demonstrated by photographs of the dissection as it progresses. The technique includes both a one-staged translabyrinthine operation for removal of small acoustic neurinomas and preparation of the involved field when the second stage suboccipital operation is necessary. The first 75 consecutive cases are reviewed. Total removal of tumor was accomplished in 43 of these patients by the translabyrinthine route with incidence of 12% permanent facial nerve paralysis. Twenty-seven patients required a second stage suboccipital operation. Total removal was accomplished in 16 of these patients. Only three of the 11 patients with subtotal removal of tumor have required additional surgery. There was an incidence of permanent facial nerve paralysis in eight of these patients. Five of 75 patients underwent a translabyrinthine operation with subtotal removal of tumor. A second stage suboccipital operation was not performed in these patients because of advanced age or refusal. One of these five patients has a permanent facial paralysis and none have required further surgery to date. There was an incidence of 18% permanent facial paralysis among the entire 75 cases. The author prefers the hypoglossal facial nerve anastomosis procedure for rehabilitation for those patients with facial nerve paralysis. There has been no operative mortality in this entire series and 94% of the patients have been able to resume their previous level of work and activity. There was only one transient episode of cerebrospinal fluid otorhinorrhea among the 75 patients.

The translabyrinthine removal of acoustic and other cerebellopontine angle tumors

This paper reviews the history of acoustic tumor surgery and sets forth the technique of translabyrinthine surgery. Thirty-five patients with 36 tumors are presented and the results explained in detail. A plea is made for standardization of reporting results and some of the controversy concerning surgical technique is discussed briefly.