Giuseppe Cuiuli

Vestibular evoked myogenic potentials and glycerol testing.

Objectives/Hypothesis: The objective was to evaluate dizziness as the first symptom of endolymphatic hydrops, which could provide valuable information on the initial stages of endolymphatic hydrops development.

Vestibular Evoked Myogenic Potentials and Distortion-Product Otoacoustic Emissions Combined with Glycerol Testing in Endolymphatic Hydrops: Their Value in Early Diagnosis

The present investigation was specifically designed to evaluate the ability of the glycerol test combined with pure tone audiometry, distortion-product otoacoustic emissions (DPOAEs), and vestibular evoked myogenic potentials (VEMPs) to diagnose endolymphatic hydrops early and to identify cases that may evolve toward Menieres disease. This investigation consisted of 29 consecutive patients with mild dizziness or vertigo who received no treatment. Each patient underwent glycerol testing measured with conventional pure tone audiometry and with both DPOAEs and VEMPs. It is interesting to note that in 7 and 8 of the 29 cases, the VEMPs and DPOAEs, respectively, showed an improvement after glycerol administration that had not been shown on traditional audiometry. A further element worthy of consideration emerges from an analysis of the VEMP results compared to the DPOAE results that divided the patients into 4 groups. The first group had a postglycerol improvement with both methods, which would seem to suggest hydrops in both the anterior and posterior parts of the labyrinth. In the second and third groups, there was an improvement only either with VEMPs or DPOAEs, and this finding seems to indicate that only one endolymphatic compartment might be involved. In the last group, all patients had a positive glycerol test with positive DPOAEs on one side and with positive VEMPs on the other. Although endolymphatic hydrops can only be proven after death, a combination of VEMPs and DPOAEs with the glycerol test may permit early diagnosis of endolymphatic hydrops. These results clearly imply that these methods should be permanently included in the diagnostic protocol of patients with vestibular and audiological symptoms.

Malleostapedotomy in tympanosclerosis patients.

OBJECTIVES To present our personal experience of a series of 10 patients suffering from tympanosclerosis with functional blocking of the stapes or footplate, who underwent malleostapedotomy surgery. The criteria for patient selection for this type of operation, and its results and complications, are discussed. METHODS Prospective study. RESULTS Incus and malleus dysfunction was observed in 70 per cent of cases, either alone or combined with fixation of the stapes. The post-operative hearing results were considered to be satisfactory (i.e. within 20 dB) in 80 per cent of cases. Only one patient had sensorineural hearing loss over 10 dB. CONCLUSIONS Malleostapedotomy has proved its practicability in the treatment of patients with fixed footplate or stapes complicated by ankylosis of the incudomalleolar joint. This procedure can be considered a further, valid technique within the otologists surgical armamentarium.

Partial labyrinthectomy in the treatment of labyrinthine fistula: how we do it

Dear Editor, A labyrinthine fistula due to cholesteatoma represents an alarming complication for the otologist. The surgeon has to balance the aims of removing cholesteatoma and not causing sensorineural hearing loss. Traditionally the choice has been either to conserve or remove the cholesteatoma matrix. Some surgeons have sought to minimise the risk of sensorineural hearing loss by avoiding working on the delicate structures of the membranous labyrinth. On the other hand, leaving residual cholesteatoma may increase the risk of the infective ⁄ inflammatory process spreading from the cholesteatoma matrix to the membranous labyrinth, a factor that may increase the risk of sensorineural hearing loss. Comparison between the two techniques is difficult because of the relative rarity of the condition and because no universally recognised system exists for staging fistulas. Donhoffer and Milewski have suggested a grading system as follows: 1 In type I, there is erosion of the bony labyrinth but an intact endosteum. 2 Type II and III are true fistulae with opening into the perilymphatic space. 3 In type IIa the perilymphatic space is opened but undisturbed. 4 In type IIb the perilymphatic space is disturbed either by ingrowth of cholesteatoma or by active suctioning by the surgeon before recognition of the fistula. 5 In type III there is concomitant involvement or destruction of the underlying membranous labyrinth. Following a careful analysis of the literature on the subject, Copeland and Buchman recommended conservative surgical treatment of the fistula, leaving the matrix in situ and using an open technique. A further treatment possibility that was proposed recently is the immediate removal of the matrix combined with removal of the affected semicircular canal, or ‘partial labyrinthectomy’. While this may seem radical, rationale exists in the principle of eliminating all of the infective and inflammatory processes that could in the future compromise hearing function. Van den Abeele and Offeciers and Kobayashi et al. proposed this alternative strategy that draws from the experiences of Parnes and McClure for the treatment of benign paroxysmal vertigo (occlusion of the posterior semicircular canal) and from those of numerous other authors for the treatment of skull-base lesions while preserving hearing function. This partial labyrinthectomy consists of removing the semicircular canal affected by the fistula together with the cholesteatoma matrix and sealing it immediately afterward. We describe our experience with a group of patients treated using this technique.

Vestibular Evoked Periocular Potentials in Meniere's Disease after Glycerol Testing

Objectives: The present investigation was specifically designed to evaluate the clinical application of vestibular evoked periocular potentials (VEPPs) in the diagnosis of endolymphatic hydrops. Methods: We compared the results of the traditional pure tone audiometry glycerol test with those of the vestibular evoked myogenic potential (VEMP) glycerol test and the VEPP glycerol test in 22 patients affected by unilateral endolymphatic hydrops. Results: Some patients had positive depletive tests with both VEMPs and VEPPs, and other patients had positive tests with either VEMPs or VEPPs. Conclusions: Our outcomes confirmed that vestibular evoked potentials represent a useful additional diagnostic tool in the diagnosis of endolymphatic hydrops. The role of VEPPs in this particular issue was not inferior to that of VEMPs. The outcomes also suggested that not only the saccule, but also the utriculus, may be involved in the genesis of VEPPs.

Intradural jugular paragangliomas: complications and sequelae.

OBJECTIVES To present the long-term results of a group of patients who underwent surgery for intradural jugular paragangliomas. We discuss the complications, sequelae, and evolution of recurrences and behavior of residual tumors. METHODS From 1989 to 2002, 11 patients with intradural jugular paragangliomas underwent surgery using different approaches. The paragangliomas were grouped according to the classification of Fisch. RESULTS Total removal of the paraganglioma was possible in eight patients, while a subtotal resection was achieved in the other three cases. The tumor remnant remained stable in two patients but continued to grow in one. Recurrence was observed in one patient. There were preoperative deficits in cranial nerves IX to XI in four patients and of XII in two patients. Deficits of cranial nerves IX to XI were acquired as a result of surgery in three cases and of XII in another. Six patients had a pure-tone average of 45 to 75 dB while the others had dead ears. Persistent dysphagia and dysphonia were managed in two patients by injection of the paralyzed cord with fat and subsequent medialization of the vocal cord by thyroplasty. Two patients had a cerebrospinal fluid leak. CONCLUSIONS Surgical results in patients with extensive jugular paragangliomas are consistent and offer an acceptable quality of life even in advanced cases.