Ilka C. Naumann

Otosclerosis : Incidence of positive findings on high-resolution computed tomography and their correlation to audiological test data

Objectives: Computed tomographic (CT) scanning with slices of 1 mm or more has not been sufficient to demonstrate otosclerotic foci in most cases to date. Methods: We investigated the validity of CT scans with a 0.5-mm cubical scan technique, with and without planar reconstruction, and correlated these findings with audiological data. Forty-four temporal bone CT scans from 30 patients with conductive or mixed hearing loss were evaluated. Results: Otosclerotic foci were visualized in 74% of the cases. With reconstruction at the workstation, the sensitivity increased to 85%. Whereas in fenestral otosclerosis a correlation was found between the size of the focus and the air-bone gap, no correlation was seen between the size of the focus and bone conduction thresholds with cochlear involvement. Otosclerotic foci in patients treated with sodium fluoride were smaller than those in patients without treatment. This finding may indicate a beneficial effect of sodium fluoride on otosclerotic growth. Conclusions: High-resolution CT scans are a valid tool that can be used to confirm, localize, and determine the size of clinically suspected otosclerotic foci.

A new L-shaped titanium prosthesis for total reconstruction of the ossicular chain.

Objective: To describe the technique used for total ossiculoplasty with the Fisch titanium total prosthesis and evaluate the 1-year postoperative functional results in patients presenting with the stapes (or footplate) without the malleus handle. Study Design: Prospective trial with preoperative and postoperative comparison. Setting: Academic and private practice tertiary care center for otologic surgery. Patients: Forty-nine consecutive patients operated on from September 1996 to December 2000. Surgery: Staged ossicular reconstruction with a Fisch titanium total prosthesis placed between the footplate and the tympanic membrane without regard to the presence or absence of the stapes arch. Coupling of the prosthesis to the footplate was achieved by various techniques, including perforation, foot and spike on the footplate without perforation, and shaft alone (without foot) with tragal cartilage fixation (disc or small wedges). There was no interposition of cartilage between the prosthesis head and the tympanic membrane. Main Outcome Measures: Pre- and postoperative air and bone-conduction thresholds and air-bone gaps for pure-tone averages of three and four frequencies and for single frequencies. Results: Postoperative air-bone gap closures within 20 dB distributed equally (50%) between 0.5, 1, and 4 kHz and reached the highest rate (89%) at 2 kHz (p < 0.05). The postoperative air-bone gaps for pure-tone averages reached 0 to 20 dB in 57% and 0 to 30 dB in 87% of the cases. There were no dead ears and no partial or total extrusions of prostheses. The best functional results were achieved through perforation coupling of the spiked foot to the footplate in large oval windows and after fixation of the shaft (without foot) with tragal cartilage disc in narrow oval windows. Conclusion: The functional results of the L-shaped Fisch titanium total prosthesis implanted in ears with the stapes but no malleus handle are best at 2 kHz and better than those of comparable columellar titanium prostheses over the remaining tested frequencies.

Phylogeny of the stapes prosthesis.

Objective: To create the first ever stapes prosthesis phylogenetic tree for the evolution of the stapes prosthesis. Study Design: Retrospective literature review, personal interviews. Setting: University Medical Center. Patient: Not applicable. Intervention: Not applicable. Main Outcome Measures: Construction of a stapes prosthesis phylogenetic tree with branches capable of including all stapes prostheses. Results: One hundred five different stapes prostheses were reviewed, starting with the first-ever prosthesis used in the first stapedectomy and continuing up to the present time. The stapes prosthesis family tree contains 4 main branches that allow for categorization of all the commercial prostheses currently used. Many examples of atavistic prostheses, single surgeon use, and dead-end characteristics exist. Conclusion: An overview of the complicated phylogenetic tree for stapes prostheses gives great perspective to the history of stapedectomy and insights into many characteristics that are useful for designing new stapes prostheses.

Giant basal cell carcinoma of the forehead with extensive intracranial involvement.

Basal cell carcinoma (BCC) is the most common malignant skin lesion and is frequently curatively treated with local excision. Improper removal or neglect of BCC is a particular problem for head and neck surgeons. We describe a case of a recurrent BCC that aggressively grew from the forehead skin through the skull and into the frontal lobe. We also present a review of the literature. Despite its fairly benign growth pattern, BCC should never be underestimated, and care should be taken not only in the complete primary excision but also in cancer surveillance.

Magnetic properties of middle ear and stapes implants in a 9.4-T magnetic resonance field.

Hypothesis: A 9.4-T magnetic resonance (MR) field may cause motion displacement of the middle ear and stapes implants not previously observed with 1.5- and 3.0-T magnets. Background: Publications have described the safety limitations of some otologic implants in 4.7-T field and resulted in several companywide patient safety-related recalls. To date, no studies have been reported for otologic implants in a 9.4-T MR field nor have comparisons been made with 4.7-T field strengths. Methods: Twenty-three commonly used middle ear and stapes prostheses were selected and exposed to 9.4-T MR fields in vitro within petri dishes, and eight of the 23 implants were further studied ex corpus in human temporal bones (TBs) in a 9.4-T MR field. This study has been approved by the institutional review board. Results: Eight prostheses in petri dishes grossly displaced at 9.4 T, three of which had not previously moved in either the 1.5- or 3.0-T magnets. The eight TB preparations showed no avulsions or motion indicators after exposure at 9.4 T. Conclusion: Middle ear and stapes implants can move dramatically in petri dishes at 9.4-T MR field, more so than at 1.5 and 3.0 T. The absence of avulsions in the TB group strongly suggests that the surgical means used to fixate the middle ear implants to the middle ear structures successfully overcomes the magnetic moment produced at MR field strengths up to 9.4 T. The use of MR imaging is not contraindicated by this studys findings.

Cryptococcal meningitis with isolated otologic symptoms

Sensorineural hearing loss (SNHL) is a known complication of cryptococcal meningitis; however, it is unusual for a patient to present with isolated otologic symptoms. We review the case of a patient who is not immunocompromised and who presented with progressive gait instability and sudden onset of left-sided SNHL followed by progression to bilateral SNHL within a 3-week period. Cryptococcal meningitis was confirmed by lumbar puncture with positive cryptococcus antigen in the cerebrospinal fluid. The patient was treated with systemic antifungals, and the hearing loss persisted. The presented report outlines this patients unusual presentation and his treatment course and reviews the literature on the otologic manifestations of cryptococcal meningitis.

Patient, disease, and outcome characteristics of benign paroxysmal positional vertigo with and without Meniere’s disease

Abstract Background: Meniere’s disease (MD)-associated benign paroxysmal positional vertigo (BPPV) is complex and difficult to diagnose, and reports of its prevalence, pathologic features and outcomes are sparse and conflicting. Objective: Report disease characteristics and outcomes associated with the presence of MD in patients with BPPV. Materials/methods: A retrospective study of patients with BPPV between 2007 and 2017 at a single, high-volume institution. Results: Of 1581 patients with BPPV identified, 7.1% had MD and 71.9% of those patients had BPPV in the same ear(s) as MD. Patients with MD were more likely to have lateral semicircular canalithiasis (11.6% vs. 5.5%, p = .009) and multiple canalithiasis (7.1% vs. 2.5%, p = .005). MD was associated with an increased rate of resolution of BPPV (p = .008) but also increased time to resolution (p = .007). There was no association between MD and recurrence of BPPV. Conclusions: MD is associated with lateral canalithiasis. Contrary to prior reports, BPPV in MD can affect either ear and was not associated with poorer outcomes than idiopathic BPPV. Significance: The largest series to date investigating disease and outcome characteristics for BPPV in MD is presented. These data inform diagnosis and expectations in the management of these complex patients.

P083: Phylogenetic Tree of the Stapes Prosthesis

OBJECTIVES: Evaluate the clinical effect of the thyrohyoid procedure and introduce technical tips. METHODS: The subjects were 22 patients including 16 glottic insufficiency and 6 spasmodic dysphonia who had a previous botulinum injection history using other techniques. All patients underwent thyrohyoid vocal fold injection with either implant materials or botulinum toxin, using flexible videoendoscope under local anesthesia. Needles used were 1.5 inch and 2 inch in length with straight or bended curved shape. Stroboscopy, MPT, and GRBAS were performed to evaluate clinical results. Patients were asked on a 10-point rating scale to rate their tolerance of the procedure, voice satisfaction and comparison with other techniques. RESULTS: In glottal insufficiency, glottal gap area improved from 7.1 before the procedure to 3.2 after the procedure: MPT from 8 to 11 and GRBAS from 2.1 to 1.6. The difference of these values was found to be significant by a paired t-test. All patients successfully underwent the procedure. The mean patient tolerance score was 3.0. Bended 2-inch-length needle provided best access to a target location in the vocal fold compared to a straight or a shorter needle. All spasmodic dysphonia patients answered that the procedure produced “less discomfort” and clinical effect was “same” compared to previous injection technique. CONCLUSIONS: The thyrohyoid approach could be an excellent alternative procedure in vocal fold injection. The procedure can be easily performed and provides excellent access to any location of the vocal fold and also is readily tolerated by patients who would not be candidates for the other injection techniques.

P115: Movements of Ferro-Magnetic Prostheses in a 9.4 T MRI

a totally dehiscent internal carotid artery presented initially with signs of a pinna cellulitis. This settled with intravenous antibiotics and was replaced by signs and symptoms masquerading as OME. A junior member of the team decided a myringotomy and grommet insertion under general anaesthetic was needed. The patient was reviewed prior to admission by the consultant who arranged a high-resolution CT of the ear and temporal bone after otoscopic examination. RESULTS: Otoscopy revealed a highly vascular lesion pressing on the posterior-medial aspect of the tympanic membrane. No evidence of effusion was seen. CT showed a totally dehiscent internal carotid artery in the middle ear cleft, pressing on the tympanic membrane. Severe complications of a myringotomy were averted. CONCLUSIONS: An unusual pathology is described and illustrated with CT scans. Otoscopy prior to myringotomy should always be performed by clinicians with many years of practice at this difficult skill.