Charles W. Beatty

Benign Positional Vertigo: Incidence and Prognosis in a Population-Based Study in Olmsted County, Minnesota

A retrospective review of our population-based medical records linkage system for residents of Olmsted County, Minnesota, revealed 53 patients (34 women and 19 men; mean age, 51 years) with newly diagnosed benign positional vertigo in 1984. The age- and sex-adjusted incidence was 64 per 100,000 population per year (95% confidence interval, 46 to 81 per 100,000). The incidence of benign positional vertigo increased by 38% with each decade of life (95% confidence interval, 23 to 54%). One patient had an initial stroke during follow-up; thus, the relative risk for new stroke associated with benign positional vertigo was 1.62 (95% confidence interval, 0.04 to 8.98) in comparison with the expected occurrence based on incidence rates for an age- and sex-adjusted control population. The observed survival among the 53 Olmsted County residents with benign positional vertigo diagnosed in 1984 was not significantly different from that of an age- and sex-matched general population. Patients with benign positional vertigo seem to have a good prognosis.

Stereotactic radiosurgery using the gamma knife for acoustic neuromas

PURPOSE To assess the efficacy and toxicity of stereotactic radiosurgery using the gamma knife for acoustic neuromas. METHODS AND MATERIALS Between January 1990 and January 1993, 36 patients with acoustic neuromas were treated with stereotactic radiosurgery using the gamma knife. The median maximum tumor diameter was 21 mm (range: 6-32 mm). Tumor volumes encompassed within the prescribed isodose line varied from 266 to 8,667 mm3 (median: 3,135 mm3). Tumors < or = 20 mm in maximum diameter received a dose of 20 Gy to the margin, tumors between 21 and 30 mm received 18 Gy, and tumors > 30 mm received 16 Gy. The dose was prescribed to the 50% isodose line in 31 patients and to the 45%, 55%, 60%, 70%, and 80% isodose line in one patient each. The median number of isocenters per tumor was 5 (range: 1-12). RESULTS At a median follow-up of 16 months (range: 2.5-36 months), all patients were alive. Thirty-five patients had follow-up imaging studies. Nine tumors (26%) were smaller, and 26 tumors (74%) were unchanged. No tumor had progressed. The 1- and 2-year actuarial incidences of facial neuropathy were 52.2% and 66.5%, respectively. The 1- and 2-year actuarial incidences of trigeminal neuropathy were 33.7% and 58.9%, respectively. The 1- and 2-year actuarial incidence of facial or trigeminal neuropathy (or both) was 60.8% and 81.7%, respectively. Multivariate analysis revealed that the following were associated with the time of onset or worsening of facial weakness or trigeminal neuropathy: (a) patients < age 65 years, (b) dose to the tumor margin, (c) maximum tumor diameter > or = 21 mm, (d) use of the 18 mm collimator, and (e) use of > five isocenters. The 1- and 2-year actuarial rates of preservation of useful hearing (Gardner-Robertson class I or II) were 100% and 41.7% +/- 17.3, respectively. CONCLUSION Stereotactic radiosurgery using the gamma knife provides short-term control of acoustic neuromas when a dose of 16 to 20 Gy to the tumor margin is used. Preservation of useful hearing can be accomplished in a significant proportion of patients.

Conservative management of acoustic neuroma: an outcome study.

OBJECTIVE This study analyzed selection criteria, clinical outcome, and tumor growth rates in patients with acoustic neuromas in whom the initial management strategy was observation. METHODS A retrospective review of patients with conservatively managed unilateral acoustic neuromas was conducted. Minimum follow-up was 6 months. Patients with neurofibromatosis Type II were excluded. Differences in tumor growth rates were analyzed by use of the Wilcoxon rank sum test. RESULTS Sixty-eight patients (31 men and 37 women) with a mean age of 67.1 years were followed for an average of 3.4 years after diagnosis. The reasons for a trial of observation included advanced age (55%), patient preference (21%), minimal symptoms (9%), poor general medical condition (7%), asymptomatic tumor (4%), and tumor in the only hearing ear (4%). Fifty-eight patients (85%) were successfully managed with observation alone. Ten patients (15%) ultimately required treatment (nine received microsurgical treatment and one patient underwent radiosurgical intervention) at a mean time interval of 4.0 years after diagnosis. Forty-eight tumors (71%) showed no growth and 20 (29%) enlarged during the study period. The mean tumor growth rate at the 1-year follow-up was significantly higher in the group requiring treatment (3.0 mm) than in the group not requiring treatment (0.36 mm) (P < 0.0001). Thus, the tumor growth rate at the 1-year follow-up was a strong predictor of the eventual need for treatment. CONCLUSION Observation is a reasonable management strategy in carefully selected patients with acoustic neuromas. Diligent follow-up with serial magnetic resonance imaging is recommended, because some tumors will enlarge to the point at which active treatment is required.

The Canalith Repositioning Procedure for the Treatment of Benign Paroxysmal Positional Vertigo: A Randomized Controlled Trial

OBJECTIVE To compare the canalith repositioning procedure (CRP) with a sham maneuver for the treatment of benign paroxysmal positional vertigo. PATIENTS AND METHODS We recruited 50 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination (Dix-Hallpike maneuver). Patients were randomized to either the CRP (n = 24) or a sham maneuver (n = 26). Measured outcomes included resolution of vertigo and positional nystagmus at follow-up examination. RESULTS The mean duration of follow-up was 10 days for both groups. Resolution of symptoms was reported by 12 (50%) of the 24 patients in the CRP group and by 5 (19%) of the 26 patients in the sham group (P = .02). The results of the Dix-Hallpike maneuver were negative for positional nystagmus in 16 (67%) of 24 patients in the CRP group and in 10 (38%) of 26 patients in the sham group (P = .046). CONCLUSION The CRP is effective treatment of benign paroxysmal positional vertigo, and this procedure can be performed by general internists on outpatients with this disorder.

Improved Preservation of Facial Nerve Function With Use of Electrical Monitoring During Removal of Acoustic Neuromas

Continuous spontaneous electromyographic activity and responses to electrical stimulation of the facial nerve in the surgical field were monitored in 48 patients undergoing primary removal of an acoustic neuroma. The operative and postoperative results in these patients were compared with the results in 48 patients who were matched for age and size of tumor and who underwent the same surgical procedure without intraoperative monitoring. Eighty-three percent of the patients had preoperative evidence of facial neuropathy, which was more severe with larger tumors. Postoperative facial nerve function was most accurately predicted on the basis of the extent of facial neuropathy on preoperative electrophysiologic testing. Anatomic preservation of the facial nerve in patients with large tumors was substantially improved in the monitored patients (67%) in comparison with those without monitoring (33%). No difference was noted in facial nerve function in the two groups of patients immediately postoperatively. By 3 months, the degree of improvement in the monitored group exceeded that in those who were not monitored, particularly in patients with medium-sized and large tumors.

Implications of minimizing trauma during conventional cochlear implantation.

Objective: To describe the relationship between implantation-associated trauma and postoperative speech perception scores among adult and pediatric patients undergoing cochlear implantation using conventional length electrodes and minimally traumatic surgical techniques. Study Design: Retrospective chart review (2002-2010). Setting: Tertiary academic referral center. Patients: All subjects with significant preoperative low-frequency hearing (≤70 dB HL at 250 Hz) who underwent cochlear implantation with a newer generation implant electrode (Nucleus Contour Advance, Advanced Bionics HR90K [1J and Helix], and Med El Sonata standard H array) were reviewed. Intervention(s): Preimplant and postimplant audiometric thresholds and speech recognition scores were recorded using the electronic medical record. Main Outcome Measure(s): Postimplantation pure tone threshold shifts were used as a surrogate measure for extent of intracochlear injury and correlated with postoperative speech perception scores. Results: Between 2002 and 2010, 703 cochlear implant (CI) operations were performed. Data from 126 implants were included in the analysis. The mean preoperative low-frequency pure-tone average was 55.4 dB HL. Hearing preservation was observed in 55% of patients. Patients with hearing preservation were found to have significantly higher postoperative speech perception performance in the CI-only condition than those who lost all residual hearing. Conclusion: Conservation of acoustic hearing after conventional length cochlear implantation is unpredictable but remains a realistic goal. The combination of improved technology and refined surgical technique may allow for conservation of some residual hearing in more than 50% of patients. Germane to the conventional length CI recipient with substantial hearing loss, minimizing trauma allows for improved speech perception in the electric condition. These findings support the use of minimally traumatic techniques in all CI recipients, even those destined for electric-only stimulation.

Management of Cerebrospinal Fluid Leaks Involving the Temporal Bone: Report on 92 Patients†

Objective To investigate the success of different surgical and nonsurgical techniques in the management of cerebrospinal fluid otorrhea or otorhinorrhea.

Long-term follow-up of transtympanic gentamicin for Ménière's syndrome.

Objective Recent studies have shown that transtympanic gentamicin for Méniéres syndrome is effective. Current treatment protocols vary. One concept has been to perform a chemical ablation; the other has been to perform a chemical alteration. Ablation requires multiple injections and is effective in controlling the vertigo, but it is associated with a significant incidence of hearing loss. Chemical alteration uses a minimal dose to reduce vestibular function without affecting cochlear function. Study Design Prospective. Setting Tertiary medical center. Patients Patients had classic unilateral Méniéres syndrome that was unresponsive to medical therapy. Intervention A single injection of gentamicin is given, and the patient is seen 1 month after injection. If indicated, the patient receives another injection and is reevaluated 1 month later. Main Outcome Measures Control of vertigo and maintenance of hearing using the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) guidelines (1995). Results Fifty-six patients have documented follow-up for 2 years or more, and 21 have 4 years or more of follow-up. This article presents the 4-year results as outlined by the AAO-HNS guidelines. Vertigo classes A and B were seen in 82% of patients. The patients followed 2 to 4 years had 86% vertigo class A and B results. Those followed 4 years or more show 76% with a vertigo class A or B result. In this study there has been minimal cochlear loss. There was vestibular change clinically, which was documented by electronystagmography. Conclusions It appears that a single transtympanic gentamicin injection is effective in controlling the vertigo of Méniéres syndrome. Cochlear impact has been minimal. It is most useful for those patients who have failed medical management and are severely affected but not totally incapacitated by the disease.

Intratympanic steroid treatment: A review

Objective: To review published literature regarding the use of intratympanic steroids in the treatment of Ménière’s disease and sudden sensorineural hearing loss and to make recommendations regarding their use based on the literature review. Data Sources: Literature review from 1996 to 2003, PubMed, Medline Plus, and Web of Science. Study Selection: Retrospective case series and uncontrolled prospective cohort studies were the only types of studies available for review. Conclusion: On the basis of the available literature, a weak recommendation is made to use intratympanic steroid treatment of sudden hearing loss if oral steroid therapy fails or is con-traindicated. The available studies regarding intratympanic steroid treatment of Ménière’s disease and tinnitus are inadequate to answer the question of the efficacy of this treatment for these conditions. Higher quality studies are needed.

Evaluation of Posttonsillectomy Hemorrhage and Risk Factors

BACKGROUND: A 13-year retrospective study was undertaken to determine the incidence of posttonsillectomy hemorrhage, to evaluate potential risk factors, and to assess the efficacy and safety of ambulatory tonsillectomy. METHODS: From January 1985 to December 1997, 4662 patients underwent tonsillectomy at our institution. Ninety patients with posttonsillectomy bleeding were identified. For each patient with posttonsillectomy bleeding, 2 nonbleeding control subjects were selected and matched by age and sex to evaluate potential risk factors. RESULTS: Age was the only factor found to be statistically significant among the bleeding patients and the control group. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. In our experience, secondary hemorrhage was more common than primary hemorrhage, presenting most frequently on postoperative days 5 to 7. CONCLUSIONS: The incidence of posttonsillectomy bleeding in this review was 1.93%, and about half (47%) of the patients with posttonsillectomy hemorrhage returned to the operating room for hemorrhage control. The highest incidence (3.61%) of posttonsillectomy hemorrhage occurred in patients 21 to 30 years of age. Patients with posttonsillectomy hemorrhage, regardless of management, had a 12% incidence of subsequent hemorrhage. We found no difference in the incidence of posttonsillectomy bleeding between outpatient and inpatient procedures.