Paul E. Hammerschlag

Facial reanimation with jump interpositional graft hypoglossal facial anastomosis and hypoglossal facial anastomosis: Evolution in management of facial paralysis†

When viable proximal facial nerve is inacessible, facial nerve paralysis has been classically managed with the hypoglossal facial anastomosis (HFA) for at least the past 70 years. While this procedure has proven its reliability, its problems with hemilingual atrophy (speech deglutition, drooling, mastication), hypertonia, synkinesis, and mimetic deficits indicate the need for a more perfect solution for facial paralysis. The jump interpositional graft hypoglossal facial anastomosis (JIGHFA) along with gold weight lid implantation and electromyographic (EMG) rehabilitation achieves substantial facial reanimation without hemilingual deficits. We present our results in 18 patients who underwent JIGHFA along with gold weight lid implantation and EMG rehabilitation for facial paralysis. These results were compared with those from published series of 30 patients treated with HFA with EMG rehabilitation evaluated with objective (House‐Brackmann) criteria. Anonymous retrospective information from questionnaires from 22 of 48 patients who were treated with the classic HFA was also presented. In properly selected patients, the JIGHFA technique is capable of achieving substantial facial reinnervation (House‐Brackmann grade III or better) in 83.3% of the patients without hemilingual sequelae which was seen in 45% of the HFA patients. In contrast to the HFA, this procedure can be used by patients with concomitant lower cranial nerve paralysis (except hypoglossal), and bilateral facial paralysis. Hypertonia, synkinesis, and lagophthalmus were less symptomatic in the JIGHFA patients. Mimetic expression was not improved in the JIGHFA population compared with the HFA group.

Acoustic Neuroma Surgery: An Eclectic Approach with Emphasis on Preservation of Hearing The New York University—Bellevue Experience

During the past 10 years, 157 patients have been operated on at the New York University-Bellevue Medical Center for acoustic neuromas and other cerebellopontine angle tumors. We describe our diagnostic protocol with joint neurosurgical evaluation leading to either translabyrinthine (otology only) or suboccipital-transmeatal (combined otology-neurosurgery) surgery. The decision is made on the basis of tumor size, level of hearing, age, and health of the patient. Using these criteria, 105 suboccipital and 59 translabyrinthine operations were performed with eight patients having had two-stage operations. In 12 of 29 patients, hearing was successfully preserved. Of 18 patients with good hearing and extracanalicular tumors less than 2 cm, hearing was preserved in 11. We describe the surgical technique used in this suboccipital-transmeatal operation and present illustrative cases in detail.

Acoustic neuroma presenting as sudden hearing loss with recovery.

In our series of patients operated on for acoustic neuromas at New York University Medical Center between 1974 and 1983, 13% (17 of 133) had sudden hearing loss. Of these, approximately 23% (four of 17) had recovered auditory function before acoustic neuroma extirpation. Three patients spontaneously recovered, while one improved with steroid therapy. Contrast computerized tomography demonstrated a widened internal auditory canal and evidence of cerebellopontine angle tumor, respectively, in 88% and 59% of patients with sudden hearing loss and acoustic neuroma. Clinical characteristics suggesting acoustic neuroma as the cause of sudden hearing loss with or without auditory recovery could not be identified in our series. Our data support the rationale that patients with unilateral sudden hearing loss, even with recovery, must be evaluated for a possible cerebellopontine lesion.

Otic Infection Due to Pneumocystis carinii in an Apparently Healthy Man with Antibody to the Human Immunodeficiency Virus

Excerpt Pneumocystis cariniirarely presents outside the lung; when it does, it occurs with lung involvement and severe disease. We report a case in whichP. cariniipresented as an otic polyp in an a...

A review of 308 cases of revision stapedectomy

Objective/Hypothesis: Identify causes of primary and revision stapedectomy failure in 308 patients, assess whether these are different based on source of initial surgery, and evaluate hearing results in revision stapedectomy to improve outcome. Study Design: Retrospective, nonrandomized chart review of patients undergoing revision stapedectomy in a referral otology practice in a large metropolitan region. Materials and Methods: Intraoperative findings, preoperative and postoperative revision stapedectomy air and bone conduction pure‐tone averages, speech discrimination scores, postoperative air‐bone gaps, complications, and repeated revisions were noted in 308 patients. Results: Leading causes of primary stapedectomy failure included dislocated prosthesis (24.4%), inadequate prosthesis length (14%), long process resorption (14%), and fibrous adhesions (13.6%). Revision stapedectomy air‐bone gaps were less than 10 dB in 80% and greater than 30 dB in 6.8% of cases. Increased sensorineural hearing loss occurred in 0.8% of revision stapedectomy cases. Five of seven cases of vertigo associated with primary stapedectomy resolved after revision surgery. Conclusion: Revision stapedectomy by experienced surgeons is highly effective in attaining successful air‐bone gap closure in 80% and improved closure in 84.8% of operative cases. Risk of vertigo and/or sensorineural hearing loss was not any higher in this patient population when compared with reports of primary stapedectomy.

Intraoperative Monitoring of Facial Nerve Function in Cerebellopontine Angle Surgery

Facial nerve paralysis associated with cerebellopontine angle surgery has been reported to range up to 26% in a recent series. Various methods of intraoperatively monitoring the facial nerve have been developed to reduce the incidence of facial paralysis. We report our experience with an intraoperative monitoring technique using intramuscular EMG electrodes to detect subclinical electrical responses that were amplified and made audible to the operating surgeon after gating stimulus artifacts. A 3.6% incidence of facial paralysis in 111 consecutive cases with this intraoperative monitoring method compared with 14.5% in 207 previously unmonitored cases indicates significant reduction of this complication in cerebellopontine angle surgery (p < 0.001). Along with this reduction in facial paralysis, an increase in the percentage of partial facial paresis was observed in the monitored group (p < 0.05). The percentage of those with intact facial function was similar in the monitored (82.0%) and unmonitored groups (78.3%).

Electromyographic rehabilitation of facial function and introduction of a facial paralysis grading scale for hypoglossal-facial nerve anastomosis†

For reinnervation of facial paralysis, the XII‐VII nerve anastomosis provides tone and mass contraction but rarely allows selective muscle control. The efficacy of EMG rehabilitation was evaluated in 30 patients who had no coordinated control of facial muscles. EMG signals from bilateral homologous facial muscle sites were converted into computer‐compatible waveform traces and displayed on a video monitor. This facilitated modification of neuromuscular responses using behavioral shaping techniques. A six‐point Facial Nerve Grading Scale was introduced for hypoglossal‐facial nerve anastomosis to assess the results of EMG rehabilitation. Rehabilitation lasted from 3 to 18 months. Ten patients (33%) achieved the highest possible grading (IT) with symmetry and synchrony of function and spontaneity of expression; 17 (57%) reached grade III, which allowed voluntary control of eye and mouth function; 3 (10%) showed minimal gains. It is suggested that neural plasticity allows therapeutic manipulation of central facilitory and inhibitory mechanisms, and possible unmasking of neural connections between the ipsilateral VII and XII nerve motor nuclei which leads to improved facial function.

Safety of high-dose corticosteroids for the treatment of autoimmune inner ear disease.

Objective: To report the adverse effects associated with prolonged high-dose prednisone for the treatment of autoimmune inner ear disease (AIED). Study Design: Prospective data collected as part of a multicenter, randomized, controlled trial for the treatment of corticosteroid-responsive AIED with methotrexate. Setting: Tertiary referral centers. Patients: One hundred sixteen patients with rapidly progressive, bilateral sensorineural hearing loss. Intervention: All patients completed a 1-month course of prednisone (60 mg/d). In Phase 2, 67 patients with improvement in hearing underwent a monitored 18-week prednisone taper, resulting in 22 weeks of prednisone therapy at an average dose of 30 mg per day. Thirty-three patients were randomized to receive methotrexate in Phase 2. Thirty-four patients received prednisone and placebo. Main Outcome Measure: Adverse events (AE) in patients treated with prednisone only. Results: Of 116 patients, 7 had to stop prednisone therapy during the 1-month challenge phase due to AE. Of 34 patients, 5 were unable to complete the full 22-week course of prednisone due to AE. The most common AE was hyperglycemia, which occurred in 17.6% of patients participating in Phase 2. Weight gain was also common, with a mean increase in body mass index of 1.6 kg/m2 (95% confidence interval, 0.77-2.3) during the 22-week steroid course. Patients entering Phase 2 were followed for a mean of 66 weeks. No fractures or osteonecrosis were reported. Conclusion: Although high-dose corticosteroids are associated with known serious side effects, prospective data in the literature are limited. The present study suggests that with appropriate patient selection, monitoring, and patient education, high-dose corticosteroids are a safe and effective treatment of AIED.

Pneumocystis Carinii in the Temporal Bone as a Primary Manifestation of the Acquired Immunodeficiency Syndrome

Extrapulmonary infection with Pneumocystis carinii is rare and is usually associated with severe systemic illness. We report, in two patients, the histologic, ultrastructural, and monoclonal cell surface antibody identification of P carinii in otic polyps. Both patients had serum antibody to human immunodeficiency virus. These P carinii infections in the temporal bone are unusual in their location and in the apparent absence of associated pulmonary infection. This otologic presentation was the primary manifestation of the acquired immunodeficiency syndrome.

Cholesteatoma vs. Cholesterol Granuloma of the Petrous Apex

Lesions involving the petrous apex are rarely encountered in clinical practice. This directly affects the ability of the otolaryngologist to diagnose and effectively treat these lesions. Greater physician awareness and increased technologic capability are leading to more effective management of pathologic conditions involving this area of the temporal bone.