Frederick M. Byl

The true nature of Bell's palsy: analysis of 1,000 consecutive patients.

In a series of 1502 patients seen in our Facial Paralysis Research Clinic 1048 were diagnosed as having Bells palsy. Review of clinical, epidemiologic, and laboratory data, plus review of the literature, has led to the conclusion that Bells palsy is an acute benign cranial polyneuritis probably caused by reactivation of the herpes‐simplex virus, and the dysfunction of the motor cranial nerves (V, VII, X) may represent inflammation and demyelinization rather than ischemic compression. Spinal fluid analysis suggests that the disease is a phenomenon of the central nervous system with secondary peripheral neural manifestations. With our presently available information, treatment of a viral disease with an anti‐inflammatory agent is rational. Prednisone treatment started within the first week of the disease can restore better function to the paralyzed face than is achieved without such therapy, and facial nerve decompression has been unnecessary.

Bell's Palsy Treatment with Acyclovir and Prednisone Compared with Prednisone Alone: A Double-Blind, Randomized, Controlled Trial

In a double-blind study, we compared the final outcome of 99 Bells palsy patients treated with either acyclovir-prednisone (53 patients) or placebo-prednisone (46 patients). For patients receiving acyclovir, the dosage was 2,000 mg (400 mg 5 times daily) for 10 days. Electrical tests included electroneurography and the maximal stimulation test. Univariate comparisons of outcome and electrical tests between the two groups were made with χ2 analysis, Fishers exact test, and t-tests. The outcome in acyclovir-prednisone-treated patients was superior to that in placebo-prednisone-treated patients. Treatment with acyclovir-prednisone was statistically more effective in returning volitional muscle motion (recovery profile of 10; p = .02) and in preventing partial nerve degeneration (p = .05) than placebo-prednisone treatment. The t-tests indicated that the recovery profile and index means were significantly better for the acyclovir-treated group (recovery profile t = 1.99, p = .051; recovery index t = 2.10, p = .040). We conclude that acyclovir-prednisone is superior to prednisone alone in treating Bells palsy patients and suggest that herpes simplex is the probable cause of Bells palsy.

Computer-Generated Three-Dimensional Reconstruction of the Cochlea

Computer-generated three-dimensional reconstructions of the nerve fibers from the organ of Corti to the spiral ganglion were used to determine the optimum maximal length of the cochlear implant electrode. The spiral ganglion within the modiolus is much shorter than the organ of Corti. The spiral ganglion has turns and reaches no higher than the middle of the second turn of the organ of Corti, which has turns. The spiral ganglion is concentric and basal with respect to the organ of Corti. The spiral ganglion dendrites within the osseous spiral lamina of the basal turn project radially, nearly perpendicular to the central axis of the modiolus. Upon entering the modiolus, they turn basally at an angle of approximately 120 degrees. The projection of dendrites within the osseous spiral lamina became increasingly oblique as the ganglion extended apically. The organization of the cochlear nerve results from the spiraling of the ganglion. These findings are in agreement with previous reports. Implications of these findings and their possible relevance to the optimum length of the cochlear implant electrode are discussed with reference to cochlear damage resulting from longer electrodes.

Stapes Surgery in a Residency Training Program

Objectives: Determine parameters for successful stapedectomy and whether this procedure can be performed safely by residents in a teaching hospital. Study Design: Retrospective analysis of techniques and results for 71 stapedectomy procedures. Materials and Methods: Charts were reviewed for technique, audiological test results, complications, operative time, and anesthetic used. Results: Overall, closure of the air‐bone gap at 10 dB was achieved in 87% of patients. Use of general anesthesia and a laser‐assisted, small‐fenestra technique allowed residents to complete more operations. No severe sensorineural hearing loss was noted. Conclusions: Residents can safely and successfully perform stapes surgery using a laser‐assisted, small‐fenestra technique.

Herpes Simplex Polyganglionitis

Evidence suggests that many cranial nerve syndromes, such as migraine headache, acute vestibular neuronitis, globus hystericus, carotidynia, acute facial paralysis (Bells palsy), and Menieres disease, are caused by the neurotropic herpes simplex virus (HSV). Because transitory cranial nerve dysfunction during acute HSV infection can be asymptomatic but often occurs in conjunction with mucocutaneous vesicles, we tested five subjects with herpes labialis for cranial nerve dysfunction. Four of the subjects had hypesthesia of the trigeminal nerve (which recurred in two); four, hypesthesia of the glossopharyngeal nerve; and two, hypesthesia of the second cervical nerve. Three of the subjects had positional or spontaneous nystagmus (which recurred in one); one of the subjects had a unilateral, decreased caloric response of 50%. Unilateral weakness of the cricothyroid muscle or the palate occurred in three of the subjects (and recurred in one). Volitional electromyograms were normal in all the subjects, but two of the subjects had increased facial nerve latency (which recurred in one). Similar findings of an acute, transitory nature should suggest to the clinician a viral polyganglionitis caused by HSV infection.

Endoscopic Zenker's Diverticulotomy (Dohlman Procedure): Forty Cases Reviewed

Pharyngoesophageal diverticula, first described in 1769, occur in an area of natural weakness between the inferior pharyngeal constrictor muscles of the pharynx and the cricopharyngeus muscle. The cause of these acquired diverticula is controversial, although most likely it is related to cricopharyngeus muscle dysfunction. Treatment is directed toward correcting the underlying sphincter dysfunction and managing the diverticulum. Endoscopic diverticulotomy requires division of the cricopharyngeus and the common wall between the esophagus and diverticulum, a technique popularized by Dohlman. We reviewed the results of 40 endoscopic diverticulotomy patients, ranging in age from 46 to 88 years, many of whom had significant existing comorbidities. The mean size of the diverticula was 4.1 cm, mean surgery time was 41 minutes, and mean hospital stay was 4.5 days. Thirty-seven of 40 patients, including 3 whose previous external procedure was not successful, returned to a regular diet, reported no regurgitation and were satisfied with the procedure. Complications in order of occurrence were pneumomediastinum (4 patients), urinary tract infection (2), upper respiratory tract infection (2), and lip laceration (1). Our results compare favorably with those of external approaches. The technique should be considered safe, expedient, and effective, particularly in patients with existing comorbidities.

Endoscopic Diverticulotomy for the Treatment of Zenker's Diverticulum

First described by Mosher in 1916, endoscopic treatment of Zenkers diverticulum has since been reported infrequently in the surgical literature and continues to engender controversy. Between 1978 and 1989, we treated 11 unselected patients surgically for pharyngoesophageal diverticula. Endoscopic diverticulotomy was used in 11 patients and an external approach was used in the others. The endoscopically treated patients had no serious complications, resumed oral intake early, and were discharged from the hospital earlier. Our review of the surgical literature confirmed our experience with the efficacy and safety of the procedure. We therefore recommend endoscopic diverticulotomy as being equal to external approaches with regard to effectiveness; and it affords the patient a shortened hospital stay and more rapid return to the premorbid State.

Audiometric comparison of Lassa fever hearing loss and idiopathic sudden hearing loss: evidence for viral cause.

A recently published prospective study on acute sensorineural deafness in Lassa fever among a West African population showed the audiometric pattern of a known virally induced hearing loss. Using the audiometric data from the patients with Lassa fever in that study, we analyzed and classified the initial hearing loss and final recovery into three groups by pure-tone average values and then did the same for 222 patients with idiopathic sudden hearing loss (SHL) in our study. Statistical analyses of the severity of initial hearing loss and the hearing recovery pattern indicate that the clinical course of our 222 patients with idiopathic SHL showed no statistically significant differences from the clinical course of the patients with Lassa fever. We found a marked difference in age, however, and a clinically significant difference in the incidence of bilateral hearing loss. In reviewing the literature on sudden sensorineural hearing loss, we found no apparent relation between severity of viral illness and initial hearing loss or subsequent recovery. Cummins et al. suggest that virally induced hearing loss in Lassa fever is linked to the hosts immune response and not to the viremia. We thus propose a virally induced immune response mechanism for idiopathic sensorineural SHL. Further prospective studies are needed for verification.

Manual Dexterity Aptitude Testing: A Soap Study

Objective: To determine whether or not manual dexterity aptitude testing in the form of soap carving during otolaryngology residency interviews at Kaiser Permanente Oakland Medical Center predicts surgical skill at the time of graduation from otolaryngology residency programs. Methods: Over the past 25 years, applicants to the residency program at Kaiser Permanente Oakland were required to carve soap. This study was conducted to determine how applicants with the best and worst soaps compared at the time of graduation with respect to various metrics including visiospatial ability and manual dexterity. Results: The best and worst soaps from 1990 to 2006 were determined. Sixty-two individuals qualified for the study and matriculated into otolaryngology residency programs. Surveys were sent to their residency programs to evaluate those individuals on a 5-point Likert scale in various categories. There was no difference between individuals with the “best soaps” and those with the “worst soaps” in all categories: cognitive knowledge, visiospatial ability, manual dexterity, decision making, and overall score (P > .1 for all categories). There was a 95% response rate with 35 of 37 residency programs responding, and 59 of 62 surveys returned. Conclusion: Although further studies need to be conducted to determine the role of manual dexterity and visiospatial aptitude testing in the otolaryngology application process, individuals who have the “best soaps” did not score higher than those with the “worst soaps” in several metrics.

Management of Sudden Sensorineural Hearing Loss

Educational objectives: To better understand the etiology and natural history of sudden sensorineural hearing loss and to develop a practical, cost-effective management plan consistent with sound medical judgment.