Paul Fagan

Rupture of the round window membrane

A perilymph leak into the middle ear through a ruptured round window membrane results in the symptoms of hearing loss, tinnitus and vertigo, either singly or in combination. The case histories of thirteen patients with such a fistula are described, these patients having in common a predisposing incident which had led to a rise of C.S.F. pressure. Symptomatology and the results of investigation are analysed and operative technique and results discussed. While it appears that vertigo uniformly responds very satisfactorily to operative treatment the improvement in hearing loss and tinnitus is more difficult to predict.

Conservative management of sporadic unilateral acoustic neuromas.

Our objective was to review retrospectively patients with a unilateral acoustic neuroma managed by observation. One hundred patients with tumours (<24 mm) were followed a median 25.5 months. Thirty-six acoustic neuromas grew with four growth patterns. No factors were associated with growth. Eighty percent of growing tumours grew in the first year. Eleven patients proceeded to surgery. Twenty-two patients were eligible for hearing preservation surgery; five of the 15 available for analysis subsequently lost eligibility. In conclusion, selected patients can be safely observed with serial imaging and follow up. Size increase in the first year may predict future growth. Delaying surgery until required by symptoms or tumour growth does not result in more morbidity for the patient. Some may lose the opportunity for hearing preservation surgery but operating on all would result in more sustaining a loss of hearing in the first few years after diagnosis.

Endolymphatic sac tumors: a review of the St. Vincent's hospital experience.

Objective: To describe the clinical, radiologic and histopathologic features of endolymphatic sac tumors using the St Vincent’s Hospital experience with these tumors to highlight important aspects of tumor diagnosis and treatment. Possible explanations are given for the apparent increasing incidence of these tumors. Study Design: Retrospective review of the senior author’s (P.A.F.) database of skull base lesions. Setting: Tertiary referral teaching hospital. Patients: All patients with a proven diagnosis of endolymphatic sac tumor treated at St Vincent’s Hospital, Sydney. Outcome Measures: Survival in months, after surgery. Results: Seven cases of endolymphatic sac tumors. All were treated surgically. Mean follow-up of 70.2 months (range, 6–144 mo). Conclusion: Endolymphatic sac tumors are becoming increasingly recognized because of awareness of their existence as a separate entity from middle ear tumors. This has been achieved by improved imaging and histopathologic techniques. Surgery is the mainstay of treatment.

The management of multiple paraganglioma of the head and neck

During the years 1984 to 1991, of 32 patients who had one large glomus or carotid body tumour, six were found to have other paragangliomas. Excluded from the above total of 32 are patients whose only lesion was a solitary glomus tympanicum. No two patients had identical problems and no pattern emerged on which patient management in any particular case could be based. The major problems associated with the tumours themselves and their treatment is the risk to hearing and the lower cranial nerves. Individual cases and their treatment are discussed.

Cochlear implants to treat deafness caused by vestibular schwannomas.

Objective Rehabilitation of hearing is complicated in patients with profound bilateral hearing loss in the presence of sporadic vestibular schwannoma (VS) or neurofibromatosis 2 (NF2), especially if the tumor does not need to be removed. We present the outcome of patients who have had a cochlear implant in the tumor affected ear without removal of the primary tumor. Design This is a retrospective multicentre study investigating outcomes of cochlear implantation in profoundly deaf patients with vestibular schwannoma in the implanted ear. Materials and Methods Out of 11 implanted patients, 5 required no treatment for their tumor, whereas 6 had previously undergone radiotherapy. Nine patients experienced NF2, and 2 had unilateral VS in the only hearing ear. Postoperative hearing was assessed with open and closed set speech discrimination, including City University of New York (CUNY) in noise and Bamford, Kowal and Bench (BKB) sentence scores. Results Patients with untreated lesions experienced marked improvement in their BKB and CUNY scores in the implanted ear and were daily cochlear implant users. The improvement was less consistent in the patients who had radiotherapy where only 1 patient attained open set speech discrimination. Conclusion Patients with unilateral VS (sporadic or those affected with NF2) whose tumor status was stable, benefited from cochlear implantation in their tumor-affected ear. Patients who had radiotherapy also benefited from CI, but their outcomes were variable.

Canalplasty: review of 100 cases

Canalplasty is the surgical procedure whereby the external auditory meatus is widened. The indications include exostoses, stenosing external otitis and widening for surgical access. One hundred consecutive ears operated on by one surgeon are reported. The surgical technique is described in detail, paying particular attention to bone removal from the anterior canal wall. In this paper the majority of cases were occasioned by soft tissue rather than bony stenosis. The re-stenosis rate was four per cent and in each case this was associated with the use of a middle temporal artery flap. Partial, transient, delayed facial palsy occurred in two per cent, probably relating to thermal injury transmitted from the burr. A full, spontaneous recovery of facial function occurred in each case. This is a safe and effective technique for canal widening.

Actinomycosis oto-mastoiditis.

Actinomycosis of the temporal bone is uncommon. There have only been 24 cases previously reported in the English literature. The responsible organism is Actinomyces israelii, an anaerobic filamentous Gram positive bacterium. While the cervico-facial region is the most common site of the disease, involvement of the temporal bone is rare. The diagnosis can sometimes be made clinically by identification of sulphur granules in a glue-like substrate but in all cases involving the temporal bone, the diagnosis has been made at histopathology. Effective therapy consists of surgery followed by the long-term administration of penicillin.

Middle temporal artery flap in mastoid surgery.

Objective: The objective of this study was to describe the anatomy of the middle temporal artery (MTA) flap and its application in mastoid surgery. Study Design: A description of the anatomy and surgical technique. Conclusion: The middle temporal flap is extremely useful in lining mastoid cavities, especially those in which poor healing is anticipated. It is available in most cases and is easily harvested and inset. It is particularly useful in revision cases, if present.

A radiologic study of the tympanic bone: anatomy and surgery.

Objective The aim of this study was to obtain data on the anatomic structure of the tympanic bone using parasagittal reformatted images created from high-resolution axial computed tomographic scans. In particular, the thickness of the bone in the region of the temporomandibular joint and the floor of the external auditory canal was assessed. The findings are discussed with particular emphasis on the relevance to surgery in this area. Background Surgical management of the tympanic bone forms the basis of canalplasty, which is an essential step in the management of disorders of the external auditory canal. Adequate canalplasty is also crucial in the provision of access for tympanoplasty and to ensure optimal cavity geometry in canal wall down mastoidectomy. Tympanic bone removal is a major step in approaches to the lateral skull base and infratemporal fossa. The tympanic bone is also important because it has critical neurovascular relations in this region of the skull base. Methods Computed tomography of the tympanic bone (parasagittal reformatted images) in 54 consecutive adults. Results The mean thickness of the anterosuperior, anteroinferior, and inferior aspects of the tympanic bone are 2.6, 2.8, and 8 mm, respectively. Conclusion Canalplasty is safely performed in the regions outlined. The technique of canalplasty described in this article is essential for good exposure in external ear, middle ear, mastoid, and skull base surgery

Vestibular schwannoma in an only hearing ear

A vestibular schwannoma in an only hearing ear is a difficult management problem. A case is presented of a patient who had a Nucleus-22 channel device implanted into a nonfunctioning ear and auditory rehabilitation prior to resection of a large vestibular schwannoma in the contralateral ear.