John W. House

Facial Nerve Grading System

Normal Normal facial function in all areas Mild dysfunction Gross: slight weakness noticeable on close inspection; may have very slight synkinesis At rest: normal symmetry and tone Motion Forehead: moderate to good function Eye: complete closure with minimum effort Mouth: slight asymmetry III Moderate dysfunction Gross: obvious but not disfiguring difference between two sides; noticeable but not severe synkinesis. contracture. and/or hemifacial spasm At rest: normal symmetry and tone Motion Forehead: slight to moderate movement Eye: complete closure with effort Mouth: slightly weak with maximum effort rv Moderately severe dysfunction Gross: obvious weakness and/or disfiguring asymmetry At rest: normal symmetry and tone Motion Forehead: none Eye: incomplete closure Mouth: asymmetric with maximum effort V Severe dysfunction Gross: only barely perceptible motion At rest: asymmetry Motion Forehead: none Eye: incomplete closure Mouth: slight movement VI Total paralysis No movement From the Otologic Medical Group. Supported by funds from the House Ear Institute, affiliated with the University of Southern California School of Medicine. Submitted for publication Dec. 7, 1984; accepted Jan. 29, 1985. Reprint requests: John W. House, MD, The Otologic Medical Group, 2122 W. Third St., Los Angeles, CA 90057. At the Annual Meeting of the Table 1. Facial nerve grading system American Academy of Otolaryngology-Head and Neck Surgery, the Facial Nerve Disorders Committee adopted a universal standard for grading facial nerve recovery. This standard is based on articles by US. •2 It is intended for use when a patients facial nerve recovery is being assessed. The system involves a six-point scale with I being normal and VI total, flaccid paralysis (Table 1). Those who have their own method of assessing facial nerve recovery are encouraged to convert their results to this six-point scale, which will be required when results are reported in Otolaryngology-Head and Neck Surgery. To assist in placing patients in the proper group, an easy method of measuring facial movement has been developed by one of us (D.E.B.). This system involves

The tinnitus functional index: development of a new clinical measure for chronic, intrusive tinnitus.

Objectives: Chronic subjective tinnitus is a prevalent condition that causes significant distress to millions of Americans. Effective tinnitus treatments are urgently needed, but evaluating them is hampered by the lack of standardized measures that are validated for both intake assessment and evaluation of treatment outcomes. This work was designed to develop a new self-report questionnaire, the Tinnitus Functional Index (TFI), that would have documented validity both for scaling the severity and negative impact of tinnitus for use in intake assessment and for measuring treatment-related changes in tinnitus (responsiveness) and that would provide comprehensive coverage of multiple tinnitus severity domains. Design: To use preexisting knowledge concerning tinnitus-related problems, an Item Selection Panel (17 expert judges) surveyed the content (175 items) of nine widely used tinnitus questionnaires. From those items, the Panel identified 13 separate domains of tinnitus distress and selected 70 items most likely to be responsive to treatment effects. Eliminating redundant items while retaining good content validity and adding new items to achieve the recommended minimum of 3 to 4 items per domain yielded 43 items, which were then used for constructing TFI Prototype 1. Prototype 1 was tested at five clinics. The 326 participants included consecutive patients receiving tinnitus treatment who provided informed consent—constituting a convenience sample. Construct validity of Prototype 1 as an outcome measure was evaluated by measuring responsiveness of the overall scale and its individual items at 3 and 6 mo follow-up with 65 and 42 participants, respectively. Using a predetermined list of criteria, the 30 best-functioning items were selected for constructing TFI Prototype 2. Prototype 2 was tested at four clinics with 347 participants, including 155 and 86 who provided 3 and 6 mo follow-up data, respectively. Analyses were the same as for Prototype 1. Results were used to select the 25 best-functioning items for the final TFI. Results: Both prototypes and the final TFI displayed strong measurement properties, with few missing data, high validity for scaling of tinnitus severity, and good reliability. All TFI versions exhibited the same eight factors characterizing tinnitus severity and negative impact. Responsiveness, evaluated by computing effect sizes for responses at follow-up, was satisfactory in all TFI versions. In the final TFI, Cronbach’s alpha was 0.97 and test–retest reliability 0.78. Convergent validity (r = 0.86 with Tinnitus Handicap Inventory [THI]; r = 0.75 with Visual Analog Scale [VAS]) and discriminant validity (r = 0.56 with Beck Depression Inventory-Primary Care [BDI-PC]) were good. The final TFI was successful at detecting improvement from the initial clinic visit to 3 mo with moderate to large effect sizes and from initial to 6 mo with large effect sizes. Effect sizes for the TFI were generally larger than those obtained for the VAS and THI. After careful evaluation, a 13-point reduction was considered a preliminary criterion for meaningful reduction in TFI outcome scores. Conclusions: The TFI should be useful in both clinical and research settings because of its responsiveness to treatment-related change, validity for scaling the overall severity of tinnitus, and comprehensive coverage of multiple domains of tinnitus severity.

Bone-anchored hearing aids: incidence and management of postoperative complications.

Objectives: To determine the incidence of complications associated with implantation of the bone-anchored hearing aid (BAHA) and the management of these complications. Study Design: Retrospective case review. Setting: Tertiary referral center. Patients: One hundred forty-nine consecutive patients between October 25, 2001, and June 29, 2005, underwent implantation of a BAHA. The majority of patients had unilateral profound sensorineural hearing loss after removal of an acoustic neuroma or skull base tumor (59.1%) with the next most common etiology of deafness secondary to sudden sensorineural hearing loss (16.1%). Intervention(s): Implantation of a BAHA. Main Outcome Measure(s): Incidence of complications occurring after implantation of a BAHA. Results: There were no intraoperative or perioperative complications. Significant postoperative complications requiring intervention occurred in 19 (12.8%) patients. Skin overgrowing the abutment occurred in 11 (7.4%) patients, and 10 of these patients required revision in the operating room. Skin overgrowth was a late complication, occurring an average of 12 months after the initial procedure. Implant extrusion occurred in 5 (3.4%) patients, with 3 requiring revision surgery. Two patients elected not to have the device reimplanted. Two patients had local wound infections requiring oral antibiotics. Conclusion: Significant complications are uncommon after implantation of a BAHA; however, these complications may require local wound care, antibiotics, or revision surgery.

Stapedectomy Versus Stapedotomy: Comparison of Results With Long-Term Follow-up

Objective/Hypothesis To compare the effectiveness and long‐term stability of hearing results between stapedectomy and small fenestra stapedotomy in patients with conductive hearing loss due to otosclerosis.

Acute mastoiditis in children: a review of 54 cases.

Fifty‐four children with acute mastoiditis were managed at the Los Angeles County‐University of Southern California Medical Center from 1972 through 1982. Our criteria for the diagnosis of acute mastoiditis are acute or subacute otitis media, postauricular swelling and erythema, protrusion of the auricle, and clouding of mastoid air cells on radiographs. Thirty‐one (57%) recovered with conservative therapy consisting of early myringotomy and intravenous antibiotic, usually ampicillin. Twenty‐three patients were managed surgically. The indication for surgery in each case was the clinical diagnosis of subperiosteal abscess; mastoid radiographs played no part in the decision to operate. Two of the 23 patients managed surgically had only incision and drainage of abscess; simple mastoidectomy was performed on 20 and radical mastoidectomy on one. Etiologic bacteria were cultured in 21 instances. S. pyogenes was cultured in 9, S. pneumoniae was cultured in 6, H. nfluenzae in 1, enterococci in 1, anaerobes in 2, and M. tuberculosis in 2.

Meniere's disease: prevalence of contralateral ear involvement.

Objective: Determine the prevalence and time interval for conversion from unilateral to bilateral involvement in Menieres disease and cochlear hydrops. Study Design and Setting: Retrospective chart review in a tertiary otologic referral center. Patients: 232 patients diagnosed with Menieres Disease (n = 186) or cochlear hydrops (n = 46) between 1959 and 2001, who visited the clinic over a five-year period between 1997-2001 and have at least 2 audiograms more than 12 months apart. Main Outcome Measures: Prevalence of cochlear hydrops relative to Menieres Disease, rate of progression from unilateral to bilateral involvement; interval between unilateral onset of symptoms and bilateral involvement; and rate of progression from cochlear hydrops to Menieres disease. Results: Initial diagnosis was Menieres disease in 71% and cochlear hydrops in 29% of all 950 hydropic patients presenting between 1997 and 2001. In the study sample, Menieres disease was bilateral at presentation in 11%; an additional 12% (14% of unilaterals) became bilateral during the follow-up period. At presentation, 6.5% of cochlear hydrops patients were bilateral, with another 26% becoming bilateral. Conversion from cochlear hydrops to Menieres disease occurred in 33% and some of these are included among the bilateral. The average time interval for conversion from unilateral to bilateral Menieres was 7.6 years (SD = 7.0 years). Conclusion: Most otologists are aware of the potential for contralateral ear involvement and conversion from cochlear hydrops to Menieres disease after diagnosis. These changes are significant, require long-term follow-up for detection, and may necessitate further treatment. Patients should be counseled regarding this potential when interventions are considered, especially with respect to ablative treatments.

Reclassification of aggressive adenomatous mastoid neoplasms as endolymphatic sac tumors

The emerging concept that aggressive adenomatous tumors of the temporal bone arise from the endolymphatic sac and constitute a distinct clinico‐pathologic entity merits wider recognition. These tumors share a common clinical pattern and exhibit consistent imaging and histopathologic features. Endolymphatic sac tumors (ELSTs) have been mistaken for other neoplasms such as paragangliomas, adenomatous tumors of mixed histology, ceruminomas, and choroid plexus papillomas. A review of the literature shows similarities among case studies of these aggressive adenomatous lesions. An analysis of the data supports the endolymphatic sac as an origin for these tumors. This report also presents an additional case of a less differentiated variant of this rare but important clinicopathologic entity.

Extrusion rates and hearing results in ossicular reconstruction.

OBJECTIVES: To examine hearing results, extrusion rates, and factors likely to affect outcome in patients who underwent ossicular chain reconstruction with Plasti-Pore and hydroxylapatite total ossicular replacement prostheses (TORPs) and partial ossicular replacement prosthesis (PORPs). STUDY DESIGN AND SETTING: Retrospective chart review was used. Subjects were 1210 consecutive tympanoplasties with or without mastoidectomy that involved ossicular reconstruction with TORPs (n = 560) or PORPs (n = 650) performed in a tertiary referral neurotologic private practice. Only 20% of the cases were primary surgeries, with the majority planned second stage or revision procedures. RESULTS: Average last postoperative air-bone gap (ABG) was 19.2 dB with closure of the ABG to within 20 dB in 62.9%. Hearing results were better for cases who had not had previous surgery, in those with a diagnosis other than chronic otitis media, when a cartilage graft was used, and for Plasti-Pore rather than hydroxylapatite. Extrusion was known to occur in 4%. CONCLUSION: After more than 25 years of use in our clinic, Plasti-Pore ossicular replacement pros-theses continue to provide reliable hearing results with a low rate of extrusion.

Single vertical incision for Baha implant surgery: preliminary results.

Objectives: A single vertical skin incision with subcutaneous tissue removal is a cosmetic alternative for Baha implant placement. We aimed to determine the preliminary complication rate using a 4-cm vertical skin incision. Study Design: Retrospective review. Subjects and Methods: Vertical incision Baha implant placements from January 2006 to August 2007 were reviewed. Complications including skin irritation, skin overgrowth, and implant extrusion were tallied. A total of 71 patients underwent surgery, with a mean follow-up time of 7 months. Results: There were five minor complications (three cases of skin irritation, one wound infection requiring oral antibiotics, one postoperative hematoma) and seven major complications (one case of irritation requiring abutment removal, six cases of skin overgrowth or infection requiring flap revision), for a total complication rate of 16.9 percent. Conclusions: A single vertical incision for Baha implant placement has a complication rate similar to that of traditional dermatome use in this preliminary study. Patients with thick scalps or risk factors for hypertrophic scarring may require longer abutments.

Is there Consensus in Perilymph Fistula Management

A perilymph fistula is an abnormal communication between the inner ear fluids and the middle ear space. This article identifies areas of agreement in perilymph fistula management based upon 167 questionnaire responses from active surgeons of the American Otological Society and the American Neurotological Society. The average respondent performed 4.6 fistula explorations among 197 otologic surgeries (some of these were myringotomies) per year. The following statements represent areas of general agreement. The single most important feature of the history is previous trauma or barotrauma. At present no test can replace clinical judgment; however, despite sound judgment and sophisticated testing, it is very difficult to document the presence or absence of a fistula preoperatively. Most often the diagnosis is based on the total clinical picture: history, physical examination, and laboratory testing.