David Foyt

Dural closure with laser tissue welding

This study investigates the use of tissue-soldering techniques to substitute or reinforce traditional suture closure of dural incisions. Fresh human cadaveric dura was incised and subsequently closed by use of three techniques: (1) conventional interrupted suture with 4-0 silk (n = 25), (2) laser solder reinforced suture closure (n = 25), and (3) laser solder closure alone (n = 25). Anastomosis tensile strength and hydrostatic leak pressures were measured. Dural repair was also performed in 15 live Lewis rats. Dural closure was accomplished with 9-0 Prolene sutures (n = 5), laser-reinforced suture closure (n = 5), and laser solder closure alone (n = 5). Histologic examination of the closure immediately after soldering and 2 weeks later was performed. Suture closure alone had the lowest leak pressure, 9.4 +/- 1.7 mm Hg, and an intermediate break point, 13.3 +/- 2.1 Kgf/cm2. Measurements with laser solder alone revealed a mean leak pressure of 26.2 +/- 3.7 mm Hg and a break point of 4.6 +/- 1.4 Kgf/cm2. Solder-reinforced suture closure leak pressure measured 64.0 +/- 6.7 mm Hg and 21.4 +/- 2.4 Kgf/cm2. There was a statistically significant increase in leak pressure and tensile strength in the closures performed with laser weld reinforcement of traditional suture technique (p = 0.0001). Dural closure with laser tissue welding alone provided an immediate leak-free closure, but with poor tensile strength. Histologic examination of welded dura and underlying brain tissue showed no evidence of thermal injury in four of five animals studied. Laser welding may significantly decrease the incidence of cerebrospinal fluid leak after dural closure. In addition, laser tissue welding also makes dural closure possible where space constraints make traditional suture closure difficult.

Minimal access surgery for the Symphonix/Med-El Vibrant Soundbridge middle ear hearing implant.

Objective: To develop a minimal access approach for implantation of the Vibrant Soundbridge middle ear hearing implant. This approach ideally uses the smallest skin incision possible, minimal or no hair shave, and the least possible amount of tissue and bone manipulation. This will facilitate the acceptability of the procedure to the general community and reduce the flap-related complication rate. The procedure is similar to the minimal access approach described for cochlear implantation. Study Design: Eight patients with various degrees of sensorineural hearing loss and one with a mixed hearing loss who met implant criteria for the Vibrant Soundbridge middle ear hearing implant received the device over a 42-month period. The first two patients underwent the traditional implant procedure with postauricular hair shave, postauricular S-shaped incision, and implant receiver suture fixation to the temporal bone. The following seven consecutive patients received a progressively smaller C-shaped postauricular skin incision, no hair shave, retrograde skull drilling for the implant seat, and no implant suture fixation until the technique closely approximated the minimal access cochlear implant procedure. Postoperative performance of the Soundbridge/Vibrant Med-El was evaluated through audiology testing and subjective patient reports. Setting: Private neurotology clinic and tertiary care teaching hospital. Results: The technique was feasible in all patients. Follow-up for the minimal access group ranged from 3 years to 5 months. There were no complications related to the approach, and all patients were satisfied users of the implant. The lack of hair shave and small incision size was greatly appreciated and warmly endorsed by the patients. Conclusion: The Vibrant Soundbridge/Vibrant Med-El can be safely implanted using the minimal access method that has been popularized for cochlear implant surgery. A large incision, extensive hair shave, risk of flap necrosis, and possibility of unsightly scar may deter patients from pursuing the potential benefits of implanted hearing technology. The technique may make the device more accessible to individuals who have concerns regarding cosmetics and potential flap complications.

Selective cochlear neurectomy for debilitating tinnitus

Eighth nerve sections have been performed to control debilitating tinnitus, with various success rates (45% to 76%). Patients with a unilateral profound sensorineural hearing loss and disabling tinnitus perceived in that ear are candidates for such surgery. The concept of a selective cochlear neurectomy with preservation of the vestibular nerve is introduced with two case presentations. The indications for surgery, surgical technique, and results are described. Advantages of preserving the vestibular nerve fibers include the lack of postoperative vertigo and disequilibrium and thus a shorter length of hospital stay, and the conservation of a symmetric vestibular input, obviating the lengthy compensation process that might otherwise be needed, particularly in the elderly. A selective cochlear neurectomy for the control of debilitating tinnitus has proven to be successful in controlling tinnitus in the two patients presented, with the added advantage of preservation of their vestibular function. Further controlled studies are necessary to confirm the advantages and effectiveness of this technique.

Epidural Hematoma After Tympanomastoidectomy and Bone-Anchored Hearing Aid (BAHA) Placement: Case Report

BACKGROUND AND IMPORTANCE:Epidural hematoma (EDH) has never been reported as a complication after placement of a bone-anchored hearing aid (BAHA). To our knowledge, this is the first case report of an EDH after placement of a BAHA. CLINICAL PRESENTATION:We report the case of a 15-year-old girl with an EDH after placement of a BAHA. Initially, she presented with a history of right ear conductive hearing loss and had a tympanomastoidectomy and placement of a BAHA at an outpatient surgical facility. Postoperatively, the patient was transferred to the postoperative care unit in stable neurological condition but was subsequently noted to be lethargic with dilated, nonreactive pupils and extensor posturing. A computed tomography scan revealed a large right temporal EDH with midline shift. She was then taken to the operating room emergently for craniotomy and evacuation of the EDH. After evacuation, she was admitted to the pediatric intensive care unit and slowly emerged from her coma with supportive care. She was discharged to inpatient rehabilitation and has made a good recovery. CONCLUSION:This report emphasizes the need for a high index of suspicion of this rare, but life-threatening complication of an EDH after the placement of a BAHA.

Fibromuscular dysplasia of the internal carotid artery causing pulsatile tinnitus.

A 40-year-old woman presented to a neurotology subspecialty clinic with a 1-month history of unilateral pulsatile tinnitus in the right ear. She denied history of hearing loss, noise exposure, or thyroid problems. On physical examination, the tympanic membranes were found to be normal with no middle ear masses identified. Carotid, auricular, or temporal bruits were not appreciated. Compression of the jugular vein did not stop the tinnitus. Findings of a complete head and neck examination were negative. An audiogram was normal with type A tympanograms. Laboratory workup, including complete blood count, chemistry panel, and thyroid function tests, were normal. Computed tomography of the temporal bone, magnetic resonance imaging, and magnetic resonance angiography of the neck and temporal bone (Fig 1), and carotid Doppler study were negative. The patient was seen 4 weeks after her initial presentation. Her tinnitus had become worse. The tinnitus was now clearly audible by the examiner and could not be silenced with jugular compression. Because of the worsening of her symptoms and new physical findings, a formal arteriogram of the carotid system was done (Fig 2). The arteriogram revealed fibromuscular dysplasia of both internal carotid arteries. Vascular surgery and interventional radiology subspecialists were consulted. Brain SPECT scan and duplex sonogram of the kidneys were recommended and results were found to be negative. The option of intravascular dilation and stenting of the internal carotid artery was offered to the patient. Risks of the procedure were discussed in light of her symptoms. She has to this date declined.

Utility of intraoperative computed tomography for cochlear implantation in patients with difficult anatomy

Objective and importance: To describe cases that illustrate the utility of intraoperative computed tomography (CT) in cochlear implantation of patients with difficult temporal bone anatomy. Clinical presentation: A 2-year-old male with congenital X-linked stapes gusher syndrome and a 2-year-old female with enlarged vestibular aqueduct underwent successful cochlear implantation with the help of intraoperative CT. In the latter case, the initial intraoperative C-arm fluoroscopy suggested malposition of the electrode, however, was not able to provide details for adjustments. In both cases, intraoperative CT changed the insertion technique of the operating surgeon and allowed for improved electrode positioning. A 47-year-old female with polyostotic fibrous dysplasia and a 55-year-old male with post-meningitis near-total cochlear obliteration underwent successful cochlear implantation with confirmation of electrode position with intraoperative CT. In the former case, the image-guided navigation system was also implemented. Finally, a 72-year-old female underwent cochlear implantation during which intraoperative C-arm fluoroscopy suggested intra-cochlear insertion. However, postoperative CT showed the electrode extending into the internal auditory canal (IAC), illustrating the limitations of C-arm fluoroscopy. Intervention: Intraoperative CT imaging and image-guided navigation system. Conclusion: When faced with challenging temporal bone anatomy, intraoperative CT can provide critical details of the patient’s microanatomy that allows for improved localization of the electrode and adjustments in operative techniques for successful cochlear implantation.

09:02: Validity of the Hum Test in Predicting Hearing Loss

performed at the presenters’ institution between January 2005 and June 2006. Patients were included if they were 18 years of age or older and had their BAHA for at least two months. It is a postal-based study using the Single Sided Deafness Questionnaire. RESULTS: Of the 80 patients, 36 patients completed the questionnaire. Responses indicate that 64% of patients (n 23) use their BAHA seven days a week and 92% (n 33) wear it at least five to six days per week. Only three patients do not currently use their BAHA. Overall, 86.2% (n 31) indicate some improvement in QoL whereas only five patients (13.8%) did not have any change in QoL with the BAHA. The mean level of satisfaction based on a 10-point scale (1 unsatisfied) is 7.30 /2.74; 77% of patients (n 28) would recommend BAHA implantation to another patient. CONCLUSIONS: This is the largest series to date assessing QoL outcomes in patients with SSD after undergoing BAHA implantation. The conclusion is that the BAHA provides an overall positive impact in QoL among this patient population. Therefore, BAHA implantation should be recommend to patients suffering from SSD.

P087: A Simple Bilateral Cochlear Implant Head Band Retainer

hearing loss. Both were evaluated through lumbar puncture with cerebrospinal fluid cytology and MRI of posterior fossa. RESULTS: Two patients presented with rapidly progressive, bilateral sensorineural hearing loss. One patient also had a complete unilateral facial paralysis. MRI of the brain demonstrated enhancing lesions in each internal auditory canal. Lumbar puncture with cerebrospinal fluid (CSF) cytology was performed for both patients. CSF cytology was positive for malignant cells in the patient with facial paralysis with subsequent diagnosis made of adenocarcinoma of the colon. The patient died within two weeks of diagnosis. The other patient had a history of ductal cell carcinoma of the breast, which was believed to be metastatic to the internal auditory canals. There have been less than 30 cases reported of bilateral sensorineural hearing loss due to meningeal carcinomatosis. The majority of these 30 cases were due to adenocarcinoma. CONCLUSIONS: The differential diagnosis of patients with progressive, bilateral sensorineural hearing loss should include metastatic disease. Facial paralysis in this situation is a poor prognostic sign. CSF cytologic analysis may help to determine if lesions found on MRI are due to malignant disease.

P105: Staged vs. Simultaneous Bilateral Cochlear Implant Outcomes

Staphylococcus aureus (59.1%). CONCLUSIONS: Immediate relief of the otological symptoms can be provided by laser myringotomy alone. But the persistent perforation and OME recurrence rate were still high. The team tried to add intratympanic steroid injection in these patients. In this study, 78.3% persistent perforation ears could remain in dry ears. The team’s method might provide a way to achieve a stable condition for the NPC patients with OME after radiation. However, the best treatment for those patients should be identified by a further prospective randomized study.

Simultaneous use of soundbridge implantable hearing device and conventional hearing aid

Abstract Objectives: The Vibrant Symphonix Soundbridge (VSB) middle ear hearing implant has proven to be an effective alternate treatment modality for patients with mild to moderate sensorineural hearing loss. The purpose of this study was to evaluate the audiologic performance of patients wearing the Soundbridge and a conventional hearing aid simultaneously in the same ear. This study was prompted by several Soundbridge patient reports that they obtained improved hearing with simultaneous use. Methods: Two patients who were audiologically marginal Soundbridge implant candidates reported marginal performance with their implants after surgery. These patients reported significant improvement with simultaneous use of a canal hearing aid and the Soundbridge. A full audiologic battery and subjective questionnaire was performed on these patients. Results: Both patients reported a significant subjective improvement in performance using both devices. Word discrimination score was significantly improved when both devices were worn. Conclusion: This is the first report of simultaneous use of an implantable hearing device and conventional hearing aid. This technique may be offered to patients who may be marginal candidates for either device separately and may be a benefit as an alternative to cochlear implantation.