John T. McElveen

Intratympanic Steroid Injections for Intractable Ménière's Disease†

Objective To examine whether intratympanic injection of dexamethasone is effective in controlling vertigo in patients with Ménières disease who have persistent vertigo despite standard medical treatment, including a low‐salt/no‐caffeine diet and diuretics.

Cochlear Implantation in the Congenitally Malformed Ear

A child with a congenital hearing loss and auricular malformations was evaluated for cochlear implantation. Preoperative radiologic studies demonstrated a common cavity cochlear malformation and a contralateral narrow internal auditory canal. Intraoperative findings included an aberrantly coursing facial nerve, preventing routine placement of the electrode array. The surgical approach was consequently modified and the cochlea was accessed through a malformed semicircular canal. Cochlear implantation can be performed safely and effectively in children with congenitally malformed ears.

Preliminary ossiculoplasty results using the Kurz titanium prostheses

Objective Limitations in biocompatibility and hearing improvement with ossicular chain reconstruction prostheses are addressed with new, lightweight titanium prostheses designed to maximize visualization of the capitulum and footplate regions. The effectiveness of these new prostheses is being tested in a prospective multicenter study. Study Design Prospective case series. Setting Multicenter (8 sites), primarily tertiary private practice or academic otologic clinics. Patients A convenience sample of 31 patients undergoing ossiculoplasty, with 16 partial ossicular chain reconstructions using the Bell prosthesis and 15 total reconstructions using the Aerial prosthesis. Intervention Ossiculoplasty using new Kurz titanium prostheses. Cartilage was interposed between the tympanic membrane and the prosthesis. Main Outcome Measures Air-bone gap for pure tone average and 3,000 and 4,000 Hz, assessed preoperatively and 3 months, 6 months, and 12 months postoperatively; percent of patients obtaining an air-bone gap of ≤20 dB; high-frequency average (1,000, 2,000, and 4,000 Hz) to evaluate sensorineural hearing loss; and extrusion rate. Results A postoperative air-bone gap of ≤20 dB was obtained in 81% of Bell prosthesis patients and 67% of Aerial prosthesis patients at 3 months. The results were stable to improved for later time intervals. High-frequency gaps were similar to the pure tone average gap. To date, there have been no instances of extrusion, and all the surgeons found the prostheses easy to use and thought that the design characteristics facilitated accurate placement. Conclusions Initial evaluation of the Kurz titanium prostheses produced low extrusion rates (none to date) with excellent hearing results, including good high-frequency conduction. Good visualization and accurate placement were easy to achieve. Further studies are needed to confirm long-term efficacy.

Cochlear implantation in common cavity malformations using a transmastoid labyrinthotomy approach

The transmastoid facial recess approach has become the standard technique for cochlear implantation. Although this approach has been used for implantation in patients with common cavity deformities, it is not without increased risk to the facial nerve. Using a direct approach to the common cavity that circumvents the facial recess, we have successfully implanted four patients with common cavity deformities. An aberrant facial nerve in one patient would have precluded placement of the electrode array using standard cochlear implant techniques. As demonstrated in these four patients, the direct approach to the common cavity is an effective approach for placement of the electrode array, minimizes risk to the facial nerve, and may decrease the likelihood of postoperative cerebrospinal fluid leaks. Intraoperative video footage demonstrates the feasibility and facility of this approach in patients with common cavity deformities.

Critical assessment of operative approaches for hearing preservation in small acoustic neuroma surgery: retrosigmoid vs middle fossa approach.

BACKGROUNDFor hearing preservation in acoustic neuroma (AN) surgery, the middle fossa (MF) or retrosigmoid (RS) approach can be used. Recent literature advocates the use of the MF approach, especially for small ANs. OBJECTIVETo present our critical analysis of operative results comparing these 2 approaches. METHODSWe reviewed 504 consecutive AN resections performed between November 1998 and September 2007 and identified 43 MF and 82 RS approaches for tumors smaller than 1.5 cm during hearing preservation surgery. Individual cases were examined postoperatively with respect to hearing ability, facial nerve activity, operative time, blood loss, and symptoms resulting from retraction of the cerebellar or temporal lobes. RESULTSGood hearing function (American Academy of Otolaryngology-Head and Neck Surgery class B or better) was preserved in 76.7% of patients undergoing surgery via the MF approach and in 73.2% of the RS group (P = .9024). Temporary facial nerve weakness was more frequent in the MF group (P = .0249). However, late (8–12 months) follow-up examinations showed good recovery in both groups. The mean operative time was 7.45 hours for the MF group and 5.2 hours for the RS group (P = .0318). The mean blood loss was 280.5 mL for the MF group and 80.8 mL for the RS group (P < .0001). Temporary symptoms of temporal lobe edema (drowsiness or speech disturbance) were noted in 6 MF cases. No cerebellar dysfunction was noted in the RS group. CONCLUSIONSAlthough hearing and facial nerve function assessed at approximately 1 year was similar with these 2 approaches, the RS approach provided several advantages over the MF approach for ANs smaller than 1.5 cm.

A review of facial nerve outcome in 100 consecutive cases of acoustic tumor surgery.

Objective To determine the facial nerve outcomes at a tertiary neurotological referral center specializing in acoustic neuroma and skull base surgery.

Remote programming of cochlear implants: a telecommunications model.

Objective: Evaluate the effectiveness of remote programming for cochlear implants. Study Design: Retrospective review of the cochlear implant performance for patients who had undergone mapping and programming of their cochlear implant via remote connection through the Internet. Methods: Postoperative Hearing in Noise Test and Consonant/Nucleus/Consonant word scores for 7 patients who had undergone remote mapping and programming of their cochlear implant were compared with the mean scores of 7 patients who had been programmed by the same audiologist over a 12-month period. Times required for remote and direct programming were also compared. The quality of the Internet connection was assessed using standardized measures. Remote programming was performed via a virtual private network with a separate software program used for video and audio linkage. Results: All 7 patients were programmed successfully via remote connectivity. No untoward patient experiences were encountered. No statistically significant differences could be found in comparing postoperative Hearing in Noise Test and Consonant/Nucleus/Consonant word scores for patients who had undergone remote programming versus a similar group of patients who had their cochlear implant programmed directly. Remote programming did not require a significantly longer programming time for the audiologist with these 7 patients. Conclusion: Remote programming of a cochlear implant can be performed safely without any deterioration in the quality of the programming. This ability to remotely program cochlear implant patients gives the potential to extend cochlear implantation to underserved areas in the United States and elsewhere.

Contemporary Surgical Management of Vestibular Schwannomas: Analysis of Complications and Lessons Learned Over the Past Decade

BACKGROUND: Despite advanced microsurgical techniques, more refined instrumentation, and expert team management, there is still a significant incidence of complications in vestibular schwannoma surgery. OBJECTIVE: To analyze complications from the microsurgical treatment of vestibular schwannoma by an expert surgical team and to propose strategies for minimizing such complications. METHODS: Surgical outcomes and complications were evaluated in a consecutive series of 410 unilateral vestibular schwannomas treated from 2000 to 2009. Clinical status and complications were assessed postoperatively (within 7 days) and at the time of follow-up (range, 1-116 months; mean, 32.7 months). RESULTS: Follow-up data were available for 357 of the 410 patients (87.1%). Microsurgical tumor resection was performed through a retrosigmoid approach in 70.7% of cases. Thirty-three patients (8%) had intrameatal tumors and 204 (49.8%) had tumors that were <20 mm. Gross total resection was performed in 306 patients (74.6%). Hearing preservation surgery was attempted in 170 patients with tumors <20 mm, and good hearing was preserved in 74.1%. The main neurological complication was facial palsy (House-Brackmann grade III-VI), observed in 14% of patients (56 cases) postoperatively; however, 59% of them improved during the follow-up period. Other neurological complications were disequilibrium in 6.3%, facial numbness in 2.2%, and lower cranial nerve deficit in 0.5%. Nonneurological complications included cerebrospinal fluid leaks in 7.6%, wound infection in 2.2%, and meningitis in 1.7%. CONCLUSION: Many of these complications are avoidable through further refinement of operative technique, and strategies for avoiding complications are proposed. ABBREVIATIONS: ABR, auditory brainstem response AICA, anterior inferior cerebellar artery CN, cranial nerve CPA, cerebellopontine angle FN, facial nerve GTR, gloss total resection H-B, House-Brackmann HPS, hearing preservation surgery NTR, near-total resection SRT, stereotactic radiation therapy STR, subtotal resection VAFE, vascular, adherent, fibrous, and engulfing VS, vestibular schwannoma

Bone cement reconstruction of the ossicular chain : A preliminary report

Objective: To determine the feasibility and efficacy of using a bone cement, Oto‐Cem, to reconstruct the ossicular chain.

Effect of Mastoid Cavity Modification on Middle Ear Sound Transmission

The modified radical mastoidectomy and intact canal wall mastoidectomy are the two most popular procedures used today for the treatment of chronic middle ear and mastoid disease. Their effects on the anatomy of the middle ear and mastoid cavity are quite different and it might also be expected that they would modify middle ear sound transmission in different ways. This paper describes experiments with human temporal bones and a middle ear computer analog model that attempt to define acoustic differences produced by cavity modifications in these two procedures. The temporal bone studies showed that blocking the aditus (as in modified radical mastoidectomy) produced improved sound transmission in the 1,500- to 4,000-Hz range and decreased transmission below 1,000 Hz when compared to the enlarged aditus and enlarged mastoid condition (as in intact canal wall mastoidectomy). The computer model showed better transmission at all frequencies with the intact canal wall mastoidectomy simulation.