G. Mark Pyle

Effects of vestibular and balance rehabilitation on sensory organization and dizziness handicap.

This retrospective study was undertaken to assess balance recovery and dizziness handicap in 32 patients after a vestibular and balance rehabilitation program. Outcomes were compared between 12 patients with peripheral vestibular disorders and 20 patients with central or mixed balance disorders. The patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and after their therapy program. The vestibular SOT, composite SOT, and functional DHI scores obtained before and after exercise were significantly improved in both the peripheral and central groups. The visual SOT mean scores obtained before and after therapy were significantly different only for the group with central or mixed vestibular disorders. Changes in SOT scores were not directly correlated with changes in DHI scores. Outcome measures of vestibular rehabilitation protocols confirmed objective and subjective improvement of balance and dizziness handicap in patients with peripheral and central vestibular disorders.

Outcomes in vestibular ablative procedures.

Objective To assess dizziness handicap and postural recovery in 17 patients undergoing a vestibular ablative procedure. Study Design Outcomes were compared between nine patients who underwent selective vestibular neurectomy and eight patients who underwent a transmastoid labyrinthectomy. Setting Patients underwent ablative procedures at a tertiary care facility. Methods Patients were tested with posturography (sensory organization test [SOT]) and the Dizziness Handicap Inventory (DHI) before and 4 to 5 weeks after their procedure. Results The mean change scores for each of the DHI subscales and the total DHI score showed significant improvement for the labyrinthectomy group. For the neurectomy group, only the emotional DHI subscale change score showed significant improvement. No difference was noted between preprocedure and postprocedure SOT scores for either group. The results indicated that the largest proportion of significant correlations existed between DHI and the somatosensory and vestibular subtests of platform posturography. In regression analyses, a model with age (p = 0.04) and vestibular score (p = 0.001) fitted the data well and explained 52.9% of the variance. Persons who were less than 69 years old were three times more likely to report persistent episodes of dizziness after the ablative procedure, and those who had neurectomies were 2.3 times more likely to report episodes of dizziness than those who underwent transmastoid labyrinthectomy. Conclusion Dizziness handicap after an ablative procedure is influenced by the type of procedure (labyrinthectomy versus neurectomy), age, and preoperative vestibular score on the SOT. Preoperative vestibular SOT score is highly associated with the emotional, physical, and functional domains of perceived handicap and quality of life after the surgery.

Embryological Development and Large Vestibular Aqueduct Syndrome

Objectives/Hypothesis Large vestibular aqueduct syndrome (LVAS) is a significant cause of hearing loss in early childhood. Many theories on the origins and causes of LVAS have been proposed, including arrest or maldevelopment of the vestibular labyrinth in embryonic life. Prior studies have described postnatal and adult vestibular aqueduct anatomy, but none has analyzed aqueduct growth throughout embryonic life. This study was undertaken to characterize the growth of the developing vestibular aqueduct to gain a better understanding of the possible origins of LVAS.

Endolymphatic sac decompression as a treatment for Meniere's disease.

Objectives/Hypothesis: Endolymphatic sac decompression is a surgical treatment option for patients with medically intractable Menieres disease. However, effectiveness is debated because published data show great variability. Outcome‐based research studies are useful in incorporating the patients perspective on the success of treatment. To further assess effectiveness of endolymphatic sac decompression, we performed a prospective study to examine both symptom‐specific and general health outcomes.

Elevation of internal auditory canal pressure by vestibular schwannomas

Objective The exact mechanism of hearing loss, the most common presenting symptom in patients with vestibular schwannomas, remains unclear. To test whether increased pressure in the internal auditory canal from tumor growth is responsible for this clinical finding, the intracanalicular pressure in patients harboring these tumors was measured. Study Design Prospective study. Setting Tertiary referral hospital. Patients Fifteen consecutive patients undergoing a retrosigmoid approach for resection of vestibular schwannomas were included in the study. Intervention The intracanalicular pressure in every patient was measured by introducing a pressure microsensor into the internal auditory canal. The pressure readings, which were performed before tumor resection, were then correlated with tumor size and respective preoperative hearing status. Results Placement of the pressure monitor into the internal auditory canal revealed a biphasic waveform in every patient. Whereas the mean intracanalicular pressure was 20 mm Hg, there was significant variability among patients (range, 1–45 mm Hg). The intracanalicular pressure directly correlated with the amount of tumor in the internal auditory canal (r > 0.63, p < 0.012) but not with the total tumor size (r ≤ 0.40, p > 0.075). Furthermore, eight patients with class A preoperative hearing (American Academy of Otolaryngology–Head and Neck Surgery classification) had lower intracanalicular pressures than did five patients with class B hearing (16 ± 5 vs. 28 ± 4). Although this observation suggested an inverse correlation between the intracanalicular pressure and hearing function, the difference between the two groups was not statistically significant (p = 0.14). Conclusion Pressure on the cochlear nerve as a result of tumor growth in the internal auditory canal may be responsible for hearing loss in patients with vestibular schwannomas. Modification of surgical techniques to address the elevated intracanalicular pressure may be beneficial in improving hearing preservation in these patients.

OSSICULAR SCULPTING FOR CONDUCTIVE HEARING LOSS

Abstract Although declining in popularity, autograft bone and cartilage provide the surgeon with a predictable and well-established option for ossicular reconstruction. This article reviews the indications, advantages, techniques, and complications of sculpted autograft ossiculoplasty. Reconstructive procedures using bone and cartilage grafts are illustrated.

Transmastoid approach to the superior semicircular canal: An anatomical study

OBJECTIVE We examined the anatomic features of the top of the superior semicircular canal (SSC) to help guide the surgeon considering resurfacing or plugging of an associated dehiscence, thorough the transmastoid (TM) approach. METHODS 19 selected cadaveric temporal bones, which had no supralabyrinthine tract, were dissected, and distances between the SSC and various structures within the temporal bone were measured with a, fine caliper. RESULTS The average distances from the sino-dural angle, horizontal canal top, and subacurate artery, to the top of the SSC were 31.1, 7.8, and 3.9 mm, within a small range. 7 (36.8%) out of 19 bones with a, low hanging tegmen needed a wide exposure and elevation of the dura to access the SSC top. CONCLUSION Knowledge of the anatomical details associated with the SSC from this study may help to, access the SCC dehiscence safely for resurfacing surgery via a TM approach.

Resection of middle petroclival meningioma via combined anterior transpetrosal and retrosigmoid approaches at two separate stages: 3D operative video

Surgical access to the petroclival region poses a challenge to neurosurgeons. A wide range of approaches has been demonstrated in the past. In this video, the authors present a 69-year-old male patient who presented with 3-month history of worsening left-sided numbness. The tumor was totally removed in 2 sessions via anterior transpetrosal and retrosigmoid approaches, respectively. The authors demonstrate 2 separate skull base approaches to resect a petroclival meningioma and discuss pitfalls and problems of management for challenging meningiomas. The authors suggest that surgical approaches to petroclival meningiomas should be selected based on an individual case. A skull base team should be versatile in performing all these approaches. The video can be found here: https://youtu.be/BCVrn3TeNvE .

Treatment of vagal injuries in resection of large glomus tumors

Abstract Postoperative dysfunction of the vagus nerve following the resection of glomus jugulare and glomus vagale tumors often results in significant morbidity. Preoperative mapping of tumor extent, approach selection, superselective angiographic embolization, intraoperative monitoring, and dissection technique are factors that may contribute to preservation of the vagus nerve. Should vagal injury occur, a number of options to restore glottic closure are available. Nerve reanastomosis, cable grafting, and nerve transfer are reinnervation techniques available to the surgeon. Vocal fold medialization is also effectively achieved through the use of arytenoid adduction, medialization thyroplasty, and vocal fold augmentation.