Malcolm D. Graham

Total en bloc resection of the temporal bone and carotid artery for malignant tumors of the ear and temporal bone

A technique for single stage total en bloc resection of the temporal bone and infratemporal carotid artery with immediate reconstruction has been described. This formidable procedure requires the collaborative efforts of neurotologic skull base surgeons, neurosurgeons, and head and neck surgeons.

Intraoperative facial nerve monitoring: A comparison of stimulating electrodes

Preservation of the facial nerve during acoustic neuroma resection may be enhanced by the use of intraoperative electrical stimulation. Although stimulation of the extratemporal facial nerve is an effective and established procedure, anatomic differences of the intradural facial nerve and its microenvironment demand more exacting stimulus protocols. The absence of epineurium may make the intradural nerve more susceptible to mechanical or electrical trauma while intermittent pooling of cerebrospinal fluid (CSF) at the cerebellopontine angle may shunt current away from nerve.

Normal auditory brainstem response in patients with acoustic neuroma

Auditory brainstem response testing has been a major breakthrough in audiologic screening for acoustic neuroma because of its high degree of sensitivity. Although it is not uncommon for other cerebellopontine angle masses to present with normal ABR findings, reports of eighth nerve tumors with false‐negative auditory brainstem response tests are quite rare. A series of 120 acoustic neuromas resected at the University of Michigan was reviewed and revealed two such patients. These two patients presented with asymmetric sensorineural hearing loss and unilateral tinnitus and were found to have completely normal auditory brainstem response. The diagnosis of acoustic neuroma would have been delayed if a comprehensive evaluation had not been pursued.

The giant cholesterol cyst of the petrous apex: A distinct clinical entity†

The giant cholesterol cyst (GCC) of the petrous apex may now be considered a distinct clinical entity and should be considered in the differential diagnosis of lesions of the midcranial skull base.

Transmastoid labyrinthectomy: Reliable surgical management of vertigo

Transmastoid labyrinthectomy has continued to be an important part of the surgical armamentarium for patients with vertigo and nonserviceable hearing loss. Continuing experience substantiates our earlier impression that the vestibular system usually accommodates rapidly to complete unilateral surgical ablation, regardless of age or degree of residual vestibular activity in the ear (as measured by preoperative bithermal caloric testing). Although the symptom of vertigo is reliably treated by transmastoid labyrinthectomy, a patient questionnaire has demonstrated a significant incidence of mild to moderate persisting postoperative dysequilibrium. Although this dysequilibrium is usually not debilitating, this questionnaire has demonstrated its existence more precisely than a retrospective review of the patients clinical records. This study reviews 110 patients who underwent labyrinthectomy between 1978 and 1985. We remain impressed at the efficacy of the transmastoid labyrinthectomy in relieving the symptom of vertigo.

Titration streptomycin therapy for bilateral Meniere's disease: a preliminary report.

Intramuscular dosages of streptomycin sulfate were titrated in eight patients with bilateral Menieres disease in an attempt to alleviate disabling vertigo and hearing loss. It appears possible to eliminate the vertiginous episodes, preserve or improve hearing, and avoid ataxia and oscillopsia in most of these individuals. At present we consider this treatment regimen our first choice of therapy in people with bilateral active Menieres disease or in patients whose only hearing ear is actively fluctuating and in whom associated disabling vertigo is present. Great caution and supervision should be exercised in the use of streptomycin titration therapy in the individual with bilateral Menieres disease, as further experience is required to determine the efficacy of this form of management.

Chemical and physical labyrinthectomy for Meniere's disease

The use of intratympanic gentamicin is currently a popular and easily performed office procedure for the conservative treatment of the Menieres disease patient who has failed medical therapy or who is not a candidate for surgical therapy. The procedure provides excellent control for the symptom of vertigo. Despite this success, there remains a significant risk of hearing loss irrespective of administered dose. In the future, antioxidant [42,43] or salicylate therapy may prevent aminoglycoside toxicity [44]. These prophylaxis methods have shown promise in the laboratory. Current methods do not allow for accurate drug delivery to the inner ear. Middle ear mucosal status, round window thickness or adhesion, patency of eustachian tube, and the effect of endolymphatic hydrops on ototoxicity are factors simply out of the control of the operators hands. Judging by the number of recent articles, intratympanic gentamicin instillation will continue to be an area of interest for the otologist. Users should be encouraged to be consistent and conservative in gentamicin dosing. It is clear that vestibular ablation is not necessary for adequate control of vestibular symptoms and that larger doses may increase the risk of hearing loss. American Academy of Otolaryngology-Head and Neck Surgery guidelines [45] should be used and adhered to for reporting on the treatment of Menieres disease, so that the literature may be more comparable. In the same light, a prospective standardized trial would be helpful in determining ultimate efficacy and risk to the patient. Transmastoid labyrinthectomy remains the surgical standard for extirpating the offending labyrinth when hearing preservation is not an issue. In appropriate patients, the procedure is a safe and effective method for relieving patients of vertiginous attacks. Most patients tolerate the procedure very well and are able to compensate fairly well over the course of several weeks to months.

Post‐traumatic cholesteatoma of the external auditory canal

Post‐traumatic cholesteatoma of the external auditory canal is a rare condition which is not mentioned in any of the American or British otological reference works. Three cases are described, and the pathogenesis, management, and medico‐legal implications discussed.

Morphological Evidence of Vestibular Pathology in Long-Term Experimental Diabetes Mellitus: I. Microvascular Changes

The influence of long-term experimental diabetes on the microvasculature of the saccule and utricle was investigated using quantitative light and electron microscopic techniques. Basal lamina thickening or reduplication, typically seen in diabetic microangiopathy, were not observed. However, morphometric analysis did reveal a statistically significant increase in capillary diameters along with an increased vascularization of both the saccule and utricle. Both of these microvascular abnormalities may have been caused by the hemodynamic alterations known to occur in diabetes. These alterations include decreased deformability of red blood cells and increased blood viscosity. Either of these factors can lead to a greater stress on the capillary wall and possibly to a reduced oxygen delivery to the tissues.

The investigation and management of petrous apex ersion

Disease of the apex of the petrous temporal bone, while rarely encountered, can present a unique challenge to the otologist. Lesions tend to be advanced at presentation, as massive bony erosion can remain asymptomatic. When symptoms occur, they reflect involvement of the neurovascular contents of the temporal bone. The earliest clinical features, such as headache, facial numbness and middle-ear effusion, do not immediately suggest the site or gravity of the underlying pathology. Anterior extension of disease may produce ophthalmoplegia and diplopia whilst posterior spread involves the lower cranial nerves, within the internal auditory canal, jugular foramen and hypoglossal canal. Evaluation of apical disease relies on radiological evidence of bony erosion and should include polytomography, CT scanning and angiography. The clinical features and radiological findings in a series of patients with various apical lesions are presented. The surgical approaches reviewed aim to reconcile the need for adequate access to this remote site, with the desire to preserve residual facial nerve and cochlear function and to protect the brain-stem.