Lance E. Jackson

Anterior Canal Benign Paroxysmal Positional Vertigo: An Underappreciated Entity

Objective: Evaluate the frequency and characteristics of benign paroxysmal positional vertigo (BPPV) arising from involvement of the anterior semicircular canal (AC) as compared with the posterior canal (PC) and horizontal canal (HC). Study Design: Prospective review of patients with BPPV. Setting: Tertiary referral center. Patients: A total of 260 patients who were evaluated for vertigo were identified as experiencing BPPV. Interventions: Standard vestibular assessment including the use of electrooculography (EOG) or video-oculography (VOG) was completed on all patients. Based on EOG/VOG findings, the BPPV origin was attributed to AC, PC, or HC involvement secondary to canalithiasis versus cupulolithiasis. Treatment was performed with canalith repositioning maneuvers (CRMs) appropriate for type of canal involvement. Results: For the 260 patients, the positionally induced nystagmus patterns suggested the canal of origin to be AC in 21.2%, PC in 66.9%, and HC in 11.9%. Cupulolithiasis was observed in 27.3% of the AC, 6.3% of the PC, and 41.9% of the HC patients. Head trauma was confirmed in the history preceding the onset of vertigo in 36.4% of the AC, versus 9.2% of the PC and 9.7% of the HC patients (p < 0.001). The number of CRMs completed to treat the BPPV did not differ between canals involved (1.32 for AC, 1.49 for PC, and 1.34 for HC). Conclusion: The direction of subtle vertical-beating nystagmus underlying the torsional component is critical in differentiating AC versus PC origin; EOG/VOG aids in accurate assessment of the vertical component for the diagnosis of canal involvement. AC involvement may be more prevalent than previously appreciated, particularly if the examiner does not appreciate the vertical component of the nystagmus or the diagnosis is made without the assistance of EOG/VOG. Head trauma history is significantly more frequent in AC versus other forms of BPPV, and patients with a history of head trauma should be examined closely for AC involvement. CRM is as successful for treatment of AC BPPV as for other types of BPPV.

Chemical perfusion of the inner ear

In general, chemical perfusion therapy of inner ear disease is safe, inexpensive, and easy to perform. High inner ear medication concentrations can be achieved while minimizing systemic side effects. Most delivery methods are minimally invasive and can be performed in the office. The treatment is usually well accepted by patients. Vertigo control rates for Menieres disease have been excellent--rivaling other prominent surgical treatments--allowing intratympanic therapy to become the most prominent first-line treatment for Menieres disease. Side effects of ototoxicity occurring in approximately 30% of patients remain as one of the primary hurdles to overcome. Most patients who experience hearing loss, however, do not complain of the loss and are simply happy to be free of their vertigo attacks. The use of oral steroids to rescue and preserve hearing during gentamicin perfusion remain promising, and complete recovery and even hearing improvement have been observed [30]. Steroid perfusion of the inner ear also is variably effective for the treatment of SSHL, and is particularly indicated when oral steroids fail or are contraindicated due to other health reasons. Many inner ear perfusion methods and philosophies of treatment exist. Each technique has its associated advantages and disadvantages, and the individual surgeon must decide which technique to use in concordance with the patients disease and expectations. In the future, new medications likely will be developed to treat certain types of inner ear disease, including SSHL, tinnitus, and various forms of vertigo. These medications can be administered by direct chemical perfusion of the inner ear.

Vestibular nerve section

In the nearly 90 years since Frazier first performed an eighth nerve section through the posterior fossa for the treatment of Ménièress disease, the surgical management of Ménières disease has come full circle. With refinements in surgical technique and advancements in instrumentation, optics, illumination, and neuromonitoring, a procedure that was once resoundingly condemned by the otologic community is now regarded as the procedure of choice in patients with serviceable hearing. The vestibular nerve section has experienced a renaissance. The posterior fossa vestibular nerve section has undergone an evolution, and the combined retrolabyrinthine-retrosigmoid vestibular nerve section represents the highest form. It is a significant improvement over its predecessors and our procedure of choice in properly selected patients.

Acoustic neuroma surgery: Absent auditory brainstem response does not contraindicate attempted hearing preservation†

Objective: Absence of auditory brainstem response (ABR) waveforms has been associated with a poor likelihood of hearing preservation following resection of acoustic neuromas. Our experience is reviewed for patients with absent preoperative ABR regarding hearing preservation, hearing improvement, and return of ABR. Study Design: Retrospective review of 22 cases of acoustic neuroma resection. Nine patients with absent preoperative ABR were identified. All underwent tumor resection utilizing intraoperative cochlear nerve action potential (CNAP) monitoring. Postoperative hearing results and ABR waveforms were examined. Methods: Charts were reviewed and tabulated for age, sex, tumor side, tumor size, preoperative and postoperative audiometric and ABR results, intraoperative monitoring results by ABR and CNAP, and surgical complications. Results: Hearing preservation was achieved in seven of nine patients (78%) with absent preoperative ABR, as well as six of seven patients (86%) with tumors less than or equal to 20 mm in greatest dimension. Although intraoperative ABR monitoring was not possible in any of these patients, CNAP monitoring was successful in all. Return of ABR waveforms was observed in four of the six patients (67%) tested from 3 to 22 months postoperatively. Four of the seven patients (57%) enjoyed improvement in hearing class as defined by the guidelines of the American Academy of Otolaryngology—Head and Neck Surgery. Conclusions: Absent ABR waveforms have not been a negative prognostic sign regarding hearing preservation. CNAP monitoring is possible in these patients and likely helps to minimize iatrogenic cochlear nerve trauma. Patients with no ABR waveforms have hope of hearing preservation and even improvement following acoustic neuroma resection performed utilizing CNAP monitoring and hearing preservation surgical techniques. Key Words: Acoustic neuroma, auditory brainstem response, cochlear nerve action potential, hearing preservation.

Gentamicin perfusion vestibular response and hearing loss.

Objective To compare hearing results as a function of vestibular ablation in the treatment of Ménières Disease, using gentamicin perfusion. Study Design A retrospective review of patients with Ménières Disease treated by gentamicin perfusion of the inner ear via the MicroWick device. Setting A tertiary otologic referral center. Patients and Interventions The charts of patients treated with gentamicin perfusion via the MicroWick between the years 1998 and 2000 were reviewed. The results for patients with functional hearing in the affected ear were analyzed and were compared with the results in patients without functional hearing. Main Outcome Measures Audiologic and vestibular test results as well as subjective symptoms. Results There were 45 patients who met the inclusion criteria. The averages for speech discrimination score and pure tone average before treatment were 92% and 38 dB, and after treatment were 82% and 47 dB. Patients were divided into two groups: Group 1 (20 patients), less than 75% ice air caloric reduced vestibular response (RVR); Group 2 (25 patients), those who reached greater than 75% ice air caloric RVR. There were 8 patients (17.6%) with persistent vertigo; 7 were from Group 1, and 1 was from Group 2, which was statistically significant (p = 0.007)wwww. The pure tone average dropped an average of 3 dB for Group 1 and 15 dB for Group 2. The difference in hearing loss between the two groups was statistically significant (p = 0.01). Conclusion This study suggests that there is a correlation between the degree of vestibular ablation, the control of vertigo, and the risk of hearing loss. Patients with functional hearing seem to have a similar success rate for vertigo control, compared with patients who already had lost functional hearing before treatment. Future investigation may determine if less than 100% RVR, but greater than 75% RVR, is an alternative end point with adequate vertigo control and reduced risk of hearing loss.

Pleomorphic Adenoma of the Lateral Nasal Wall

Few cases of intranasal pleomorphic adenoma have been reported in the English literature. Of those observed in the nose, the vast majority of tumors originate from the septum and <10% originate from the lateral nasal wall. 1 We present the case of a man with a unilateral nasal mass arising from the lateral nasal wall confirmed to be a pleomorphic adenoma on pathologic examination.

Pediatric Laser-Assisted Tympanostomy

Objective To evaluate effectiveness of laser‐assisted tympanostomy in treatment of pediatric patients with chronic otitis media with effusion.

Laser stapedotomy minus prosthesis (laser STAMP): absence of refixation.

Objective To determine what percentage of patients with otosclerosis could successfully undergo a laser stapedotomy minus prosthesis over a 5-year period, and to determine the percentage of patients in whom refixation develops during follow-up. Study Design Retrospective case review of 136 patients (137 ears) who underwent primary surgery for otosclerosis. Setting An otology/neurotology tertiary referral center. Patients Patients were chosen if they had clinical evidence of otosclerosis without a history of otologic surgery. Interventions A standard stapes approach was used for all patients. For the laser stapedotomy minus prosthesis, a hand-held laser probe was used to vaporize the anterior crus of the stapes and perform a linear stapedotomy across the anterior one third of the footplate. If otosclerosis was confined to the fissula ante fenestram, the stapes became completely mobile. The stapedotomy opening was sealed with an adipose tissue graft from the ear lobe. Main Outcome Measures Pure-tone audiometry with appropriate masking and auditory discrimination testing was performed before surgery, 6 weeks after surgery, and every year thereafter. Results Of the 137 cases, favorable anatomy and minimal otosclerosis allowed 46 (33.6%) of these patients to undergo laser stapedotomy minus prosthesis. Fifty-seven patients (41.6%) could not undergo the procedure because of extensive otosclerosis. The remaining 34 patients (24.8%) did not receive laser stapedotomy minus prosthesis because of other anatomic or technical difficulties. Of the 34 patients in the laser stapedotomy minus prosthesis group with more than 4 months follow-up, the average air-bone gap was closed from a mean of 22 dB (SD 10 dB) to 6 dB (SD 4 dB) 6 weeks postoperatively. Follow-up periods ranged from 5 months to 53 months (mean 767 days, SD 437 days). The long-term air-bone gap improved slightly to an average of 5 dB (SD 6 dB) in comparison with the sixth postoperative week value. Conclusion Laser stapedotomy minus prosthesis is a minimally invasive procedure, which over the follow-up period has a very low incidence of refixation, as evidenced by a lack of progressive conductive hearing loss. The success of this procedure depends on the correct selection of cases. This procedure has been successfully performed on 33.6% of patients undergoing primary stapes surgery. Laser stapedotomy minus prosthesis seems to be a viable alternative to conventional stapedotomy that yields good results without evidence of refixation over an extended time.