Hamid R. Djalilian

Stereotactic radiosurgery for recurrent malignant gliomas.

PURPOSE To evaluate the role of stereotactic radiosurgery in the management of recurrent malignant gliomas. PATIENTS AND METHODS We treated 35 patients with large (median treatment volume, 28 cm3) recurrent tumors that had failed to respond to conventional treatment. Twenty-six patients (74%) had glioblastomas multiforme (GBM) and nine (26%) had anaplastic astrocytomas (AA). RESULTS The mean time from diagnosis to radiosurgery was 10 months (range, 1 to 36), from radiosurgery to death, 8.0 months (range, 1 to 23). Twenty-one GBM (81%) and six AA (67%) patients have died. The actuarial survival time for all patients was 21 months from diagnosis and 8 months from radiosurgery. Twenty-two of 26 patients (85%) died of local or marginal failure, three (12%) of noncontiguous failure, and one (4%) of CSF dissemination. Age (P = .0405) was associated with improved survival on multivariate analysis, and age (P = .0110) and Karnofsky performance status (KPS) (P = .0285) on univariate analysis. Histology, treatment volume, and treatment dose were not significant variables by univariate analysis. Seven patients required surgical resection for increasing mass effect a mean of 4.0 months after radiosurgery, for an actuarial reoperation rate of 31%. Surgery did not significantly influence survival. At surgery, four patients had recurrent tumor, two had radiation necrosis, and one had both tumor and necrosis. The actuarial necrosis rate was 14% and the pathologic findings could have been predicted by the integrated logistic formula for developing symptomatic brain injury. CONCLUSION Stereotactic radiosurgery appears to prolong survival for recurrent malignant gliomas and has a lower reoperative rate for symptomatic necrosis than does brachytherapy. Patterns of failure are similar for both of these techniques.

Etiology, pathophysiology of symptoms, and pathogenesis of Meniere's disease

Endolymphatic hydrops is the pathologic feature associated with Menieres disease. The development of endolymphatic hydrops appears to arise from multifactorial inheritance with alteration of endolymphatic homeostasis. Various factors associated with the phenomenon of hydrops include functional or anatomic obstruction of endolymphatic flow, malabsorption of endolymph, genetic anomalies, vasodilation, allergy, viral infection, and autoimmunity.

Facial Nerve Grading System 2.0

Objective: To present an updated version of the original Facial Nerve Grading Scale (FNGS), commonly referred to as the House-Brackmann scale. Study Design: Controlled trial of grading systems using a series of 21 videos of individuals with varying degrees of facial paralysis. Results: The intraobserver and interobserver agreement was high among the original and revised scales. Nominal improvement is seen in percentage of exact agreement of grade and reduction of instances of examiners differing by more then one grade when using FNGS 2.0. FNGS 2.0 also offers improved agreement in differentiating between grades 3 and 4. Conclusion: FNGS 2.0 incorporates regional scoring of facial movement, providing additional information while maintaining agreement comparable to the original scale. Ambiguities regarding use of the grading scale are addressed.

Cochlear implantation in the elderly: results and quality-of-life assessment.

To assess the efficacy, quality of life, and complication rate of cochlear implantation in patients over 60 years of age, we performed a retrospective chart review of 31 cochlear implant patients more than 60 years old at the time of surgery (mean, 70 years; range, 62 to 86 years). All patients had improvement in their audiological test results after operation. Twenty-eight patients (93%) are regular implant users at a median follow-up of 12 months. Major complications occurred in 2 patients (6%). We conclude that cochlear implantation in the elderly population has excellent results, with a complication rate similar to that in patients less than 60 years old, and yields an improved quality of life.

Radiographic incidence of multicentric malignant gliomas.

BACKGROUND Multicentric malignant gliomas are interesting yet uncommon clinical entities with an unknown rate of occurrence. METHODS We reviewed the computed tomography (CT) and magnetic resonance (MR) images of 100 consecutive patients with malignant gliomas to determine the incidence of multicentricity in malignant glial neoplasms. RESULTS Five patients had multiple lesions on their initial radiographic study (synchronous lesions) and in four patients multiplicity developed after initial diagnosis (metachronous lesions). MR imaging demonstrated one lesion not seen on CT. CONCLUSIONS Because synchronous or metachronous multicentricity was found in 9% of patients with malignant gliomas, treatment delivery should not be based on radiographic imaging without attempting to obtain an accurate diagnosis of the ongoing intracranial process.

Imaging the Human Tympanic Membrane Using Optical Coherence Tomography In Vivo

Objective: Optical coherence tomography (OCT) is a diagnostic imaging modality that combines low coherence light with interferometry to produce high-resolution cross-sectional images of living tissues. Using this technology, we have imaged in vivo the human tympanic membrane (TM) in the office clinic setting and characterized TM microstructure in normal and pathologic conditions. Study Design: Prospective clinical trial. Materials and Methods: The normal and diseased TMs in 10 adult subjects were examined. Each subject underwent direct microscopic examination before OCT imaging to provide visual coregistration of associated subsites including the anulus fibrosus, pars tensa, pars flaccida, and umbo. The probe from the imaging system (1,310-nm central wavelength, 15-&mgr;m coherence length, Niris; Imalux, Cleveland, OH, USA) was introduced into the ear canal to obtain lateral cross-sectional images. Results: Systematic imaging of the TM was performed with characterization of the epithelial and collagenous layers. The overall TM thickness was clearly demonstrated and quantified. Conclusion: The ability to noninvasively study middle ear microstructures in vivo is essential in the treatment of diseases of the ear. OCT may provide the otologist/neurotologist with the ability to 1) image pathology such as cholesteatoma, dimeric TMs, and chronic otitis media; 2) gauge the response to pharmacological therapy; and 3) monitor postsurgical changes after tympanoplasty and other procedures. OCT may provide a means to optimize the diagnosis and management of patients with middle ear disease.

Automated audiometry using apple iOS-based application technology.

Objective The aim of this study is to determine the feasibility of an Apple iOS-based automated hearing testing application and to compare its accuracy with conventional audiometry. Study Design Prospective diagnostic study. Setting Academic medical center. Subjects and Methods An iOS-based software application was developed to perform automated pure-tone hearing testing on the iPhone, iPod touch, and iPad. To assess for device variations and compatibility, preliminary work was performed to compare the standardized sound output (dB) of various Apple device and headset combinations. Forty-two subjects underwent automated iOS-based hearing testing in a sound booth, automated iOS-based hearing testing in a quiet room, and conventional manual audiometry. Results The maximum difference in sound intensity between various Apple device and headset combinations was 4 dB. On average, 96% (95% confidence interval [CI], 91%-100%) of the threshold values obtained using the automated test in a sound booth were within 10 dB of the corresponding threshold values obtained using conventional audiometry. When the automated test was performed in a quiet room, 94% (95% CI, 87%-100%) of the threshold values were within 10 dB of the threshold values obtained using conventional audiometry. Under standardized testing conditions, 90% of the subjects preferred iOS-based audiometry as opposed to conventional audiometry. Conclusion Apple iOS-based devices provide a platform for automated air conduction audiometry without requiring extra equipment and yield hearing test results that approach those of conventional audiometry.

Optical Coherence Tomography of the Cochlea in the Porcine Model

Objectives/Hypothesis: To demonstrate the feasibility of optical coherence tomography in microstructural imaging of the porcine cochlea.

Treatment of culture-negative skull base osteomyelitis.

Objective: To evaluate the efficacy of a therapeutic regimen in the treatment of patients with culture-negative skull base osteomyelitis. Study Design: Retrospective case review. Setting: Tertiary referral hospital. Patients: Eight patients with diabetes mellitus presented with otalgia and were found to have positive technetium and gallium scans of the temporal bone. These patients, however, all had negative cultures of their external auditory canals. All patients had been treated with ototopic drops and two patients had undergone a 2-week course of oral quinolones. Interventions: All patients were treated with a 6-week course of intravenous ceftazidime or aztreonam for penicillin-allergic patients, oral ciprofloxacin at a higher dose than normal, and topical aminoglycoside steroid drops. Main Outcome Measures: Resolution of the temporal bone gallium scan abnormality, recurrence rate, and time to discharge from the hospital. Results: The patients were discharged from the hospital within 4 days from admission. All patients showed resolution of the temporal bone abnormality on the gallium scan at the 6-week time point. The median follow-up period was 6 months, and none of the patients had a recurrence of the infection. Conclusion: The above-described treatment regimen will result in a high cure rate and a short hospitalization period.

The prevalence and characteristics of tinnitus in the youth population of the United States

To evaluate the prevalence, characteristics, and associated risk factors of tinnitus in U.S. adolescents.