Douglas A. Chen

Individualizing Hearing Preservation in Acoustic Neuroma Surgery

Surgical series of hearing preservation in acoustic neuroma usually emphasize a teams results with one particular technique. This report reviews acoustic neuroma outcomes of individualizing the surgical approach to patient and tumor characteristics. This study reviews 60 consecutive hearing preservation acoustic neuroma surgeries in a total series of 330 acoustic neuromas. Tumor sizes ranged from 0.3 to 4 cm in patients ranging from 23 to 74 years of age. Middle fossa surgery was performed in 57%, retrosigmoid in 43%. Overall, measurable hearing was preserved in 77%, and useful hearing in 67%. Among middle fossa cases, 85% had measurable and 74% had useful hearing. Among retrosigmoid surgeries, 65% had measurable hearing and 58% had useful hearing. Overall, long‐term facial nerve function was excellent (grade I or II) in 90% and poor (grade V or VI) in 2%. There was one case of bacterial meningitis(2%), and cerebrospinal fluid leaks requiring surgery occurred in four patients (7%). The hearing preservation and other outcome parameters in this series compare favorably with other reports. We believe that individualizing the surgical approach to the patients tumor characteristics and clinical features contributed to the high rate of hearing preservation.

Endolymphatic mastoid shunt versus endolymphatic sac decompression for Ménière's disease:

Objective This study compares the efficacy of endolymphatic mastoid shunt (EMS) versus endolymphatic sac decompression (ESD) without sac incision for the treatment of Ménières disease. Study Design and Setting The AAO-HNS Guidelines for the Diagnosis and Evaluation of Therapy in Ménières disease were used to retrospectively identify suitable candidates for the study. All patients who failed medical management and underwent either endolymphatic-mastoid shunt (EMS) (n = 88) or endolymphatic sac decompression (ESD) (n = 108) were selected for review using the AAO-HNS guidelines. The study was carried out at a tertiary care neurotology private practice. Results EMS and ESD were equally effective in reducing the incidence and severity of vertigo attacks with significant improvement in 67 percent and 66 percent of patients, respectively. Conclusion Both EMS and ESD are effective, nondestructive alternatives for patients who have failed medical management of Ménières disease with similar long-term hearing outcomes. Significance This is the only study within the same institution using AAO-HNS guidelines comparing EMS versus ESD.

The Learning Curve for Acoustic Tumor Surgery

Although operative experience is considered to be critically important in the surgical management of acoustic tumors, little objective evidence substantiates this claim. The present study was undertaken to determine whether a learning curve exists for acoustic tumor surgery.

Hydroxyapatite cement cranioplasty in translabyrinthine acoustic neuroma surgery.

OBJECTIVES: Hydroxyapatite cement cranioplasty (HAC) after translabyrinthine resection of acoustic neuroma is a promising new technique for wound reconstruction. This study reviews the efficacy of HAC for the prevention of cerebrospinal fluid (CSF) leakage and the long-term wound outcomes of HAC versus abdominal fat graft (AFG) reconstruction. METHODS: This retrospective study of 108 consecutive acoustic neuromas operated on by Pittsburgh Ear Associates uses chart review, telephone interview, and mail questionnaire data. Fifty-four patients received AFG dural repair, and 54 patients received HAC. RESULTS: Seven AFG patients (12.5%) had CSF leaks versus 2 (3.7%) of the overall group of 54 HAC patients. However, none (0%) of the 47 HAC patients had CSF leakage with current HAC techniques. HAC also produced significantly less postauricular wound depression and superior cosmetic results in comparison with AFG. Although HAC patients experienced less postoperative discomfort, wound complications requiring medical or surgical intervention were extremely uncommon in both groups. Conclusion: HAC offers significant CSF leakage control and long-term cosmetic and comfort advantages over AFG alone. We recommend HAC as the standard closure technique for translabyrinthine acoustic neuroma surgery.

Intratympanic steroids: do they acutely improve hearing in cases of cochlear hydrops?

Objective: To study the acute effects on hearing of intratympanic dexamethasone in patients with cochlear hydrops. Study Design: Retrospective review. Methods: Patients who met established criteria for the diagnosis of Ménières disease or had a history of fluctuating hearing loss and met hearing loss criteria for Ménières disease, indicating cochlear hydrops, underwent a series of one to three intratympanic injections of dexamethasone in the affected ear. Follow‐up audiograms were obtained 1 week after each injection and, in many patients, several months after injection. Results: Fifty patients met inclusion criteria and were studied. Using the American Academy of Otolaryngology‐Head and Neck Surgery reporting guidelines, hearing improved acutely in 20 of the 50 patients (40%), was worse in 2 (4%), and did not change in 28 (56%). For those who improved, the average decrease in threshold was 14.2 dB. Whether the patient had typical Ménières disease or cochlear hydrops did not affect the response to therapy. There were no significant complications from the injections. Conclusions: Intratympanic administration of dexamethasone may acutely affect sensorineural hearing loss associated with endolymphatic hydrops. A prospective, controlled study is required.

Vestibular Nerve Section Versus Intratympanic Gentamicin for Meniere's Disease

Objectives/Hypothesis: Vestibular nerve section and transtympanic gentamicin administration are procedures with proven efficacy in the treatment of vertigo associated with Menieres disease refractory to medical management. Hearing loss is a known complication of each of these procedures; however, there has not been a report of hearing results of both treatments from a single institution.

Cochlear histopathology in the labyeinthectomized ear: Implications for cochleae implantation†

Limited damage to the cochlea and preservation of hearing after labyrinthectomy have been the subject of many case reports. One might hypothesize that, even when hearing is lost, there may be less damage to the cochlea than anticipated, and some neural elements that can be electrically stimulated may be preserved. Four labyrinthectomized temporal bones on file at the House Ear Institute were evaluated histopathologically. All had some remaining spiral ganglion cell population, the neural element that we think is stimulated by the intracochlear electrode. We also examined the population of hair cells and dendrites and the presence and extent of cochlear ossification, factors that may influence the performance of a cochlear implant. This is the first study of its type. Results indicate that cochlear implantation in the labyrinthectomized ear may be feasible.

Association of benign intracranial hypertension and spontaneous encephalocele with cerebrospinal fluid leak.

Objective To determine the incidence of intracranial hypertension in patients with spontaneous encephalocele with cerebrospinal fluid (CSF) leak. Study Design Retrospective case review. Setting Tertiary care neurotology practice. Patients Patients presenting between 2008 and 2011 with spontaneous encephalocele and CSF leak in the temporal bone. Intervention(s) Lumbar puncture with opening pressure measurement after encephalocele repair. Main Outcome Measures Patient age, sex, postoperative course, body mass index, and postoperative intracranial pressure. Results Of the 26 patients identified with spontaneous encephalocele with CSF leak, 9 patients had postoperative lumbar puncture data. Of those 9, 89% were female subjects, and 11% were male, with a mean age of 57 and a mean BMI of 41 kg/m2 (morbidly obese). The mean opening pressure was 24.5 cm H2O. Approximately 33% had normal intracranial pressure (mean, 15 cm H2O; range, 10–17 cm H2O); 67% had elevated intracranial pressure (mean, 29 cm H2O; range, 23.5–40 cm H2O). The incidence of BIH in the general population is 0.001%. Of the 6 with intracranial hypertension, 3 (50%) were placed on acetazolamide for fundoscopic findings, postoperative headache, and/or visual changes. Mean time to LP after repair of encephalocele was 13 months (range, 4 days to 75 months). Conclusion This study shows that benign intracranial hypertension is prevalent in a significant number of patients presenting with spontaneous encephalocele with CSF otorrhea at a rate much higher than is found in the general population. This finding has direct clinical implications and suggests that all patients with spontaneous encephalocele/CSF leak warrant evaluation for benign intracranial hypertension.

Rotational Chair (ROTO) Instead of Electronystagmography (ENG) as the Primary Vestibular Test

OBJECTIVES: To compare the sensitivity of rotational chair (ROTO) versus electronystagmography (ENG) in peripheral vestibular pathology. METHODS: Retrospective chart review. RESULTS: One thousand consecutive patients undergoing evaluation for dizziness and imbalance at a tertiary care referral balance center were reviewed. ROTO was the primary vestibular study used in all patients with ENG used as a confirmatory test at the discretion of the treating physician. A subgroup of 478 patients underwent both ROTO and ENG. Among the patients diagnosed with peripheral vestibulopathy, sensitivity for peripheral vestibulopathy was 71% for ROTO and 31% for ENG. However, specificity was 54% for ROTO and 86% for ENG. CONCLUSIONS: We conclude that in this retrospective cohort with the authors’ clinical diagnoses, ROTO is a more sensitive diagnostic study of peripheral vestibular pathology. The higher sensitivity of ROTO and the higher specificity of ENG may support the use of ROTO as the primary vestibular study and ENG as a supplemental vestibular study. Prospective analysis with distinct diagnostic criteria and defined inclusion criteria are necessary before these results can be widely extrapolated.

Bone cement reconstruction of the ossicular chain : A preliminary report

Objective: To determine the feasibility and efficacy of using a bone cement, Oto‐Cem, to reconstruct the ossicular chain.