Raleigh Jones

Natural History vs. Surgery for Meniere's Disease

Menieres disease has an episodic course, and certain patients undergo spontaneous remission of their vertigo. A retrospective study of patients treated from 1974 to 1983 was undertaken to evaluate the long-term outcome of patients with Menieres disease for whom surgery was recommended, comparing those who had a surgical procedure with a similar group of patients who declined surgery. The surgical procedures performed were endolymphatic subarachnoid shunt (ELS), retrolabyrinthine vestibular neurectomy (RVN), middle fossa vestibular neurectomy (MFVN), and transmeatal cochleovestibular neurectomy (CVN). We used a questionnaire, made up according to the 1985 American Academy of Otolaryngology (AAO) criteria, for reporting results for Menieres disease treatment, and compared patients who were offered surgery but declined (N = 50) with those who underwent surgery (N = 83). The data were analyzed statistically. Initial evaluation, which included air and bone conduction audiometry, speech discrimination, electronystagmography (ENG), frequency of vertigo attacks per month, and disability, showed both groups to be comparable at the outset. Of the nonoperated group 57% had complete control of vertigo at 2 years; 71% had complete control after an average of 8.3 years. After an ELS, 40% of patients had complete control of vertigo after 2 years; 70% had complete control after an average of 8.7 years. After a neurectomy (RVN or CVN), 93% had complete control of vertigo (average followup, 4.4 years). These results indicate statistically that the ELS procedure does not alter the long-term natural course of vertigo control in Menieres disease, whereas both the RVN and CVN significantly improve the patients chance of being permanently free of vertigo attacks.

Small fenestra stapedotomies with and without ktp laser: A comparison†

The results of 33 small fenestra stapedotomies performed using conventional techniques were compared with the results of 33 stapedotomies performed using the argon or KTP laser. The ossicular chain was reconstructed using a Teflon® wire piston of 0.6 mm diameter, and follow‐up was at least 1 year. Over‐closure of the air‐bone gap or closure to within 10 dB was accomplished in 91% of the laser‐treated group versus 72% of the conventionally treated group (p<0.10). The hearing results were statistically better in the laser group (p<0.05). Transient delayed vestibular symptoms, lasting from 1 to 3 weeks, were present in 39% of the laser‐treated group and in 12% of the patients treated by conventional techniques (p<0.05).

Expected neurologic outcomes for surgical treatment of cervical neurilemomas

Objective: Neurilemomas are classically described as fusiform tumors that eccentrically displace the undisturbed neural fascicles. The authors seek to clarify the relationship of cervical neurilemomas to their nerve of origin and assess the functional outcome of surgical extirpation. Study Design: A retrospective review of clinical, intraoperative, and histopathologic data of six patients with cervical extracranial neurilemomas. Methods: Additional histochemical staining of the pathologic specimens was performed to evaluate the tumor for neurites. A comprehensive literature review of cervical neurilemoma cases and meta‐analysis of clinical outcomes in these cases were performed. Results: In the series of five consecutive cervical neurilemomas, only one was an eccentric mass pushing the undisturbed nerve aside. In the five other cases, excision of the neurilemoma required complete nerve excision. Neural elements traveling through the central portions of the tumor were clearly demonstrated histologically. Collective analysis of the literature on cervical neurilemomas revealed that although some cases allow nerve preservation, preservation of function is frequently poor. Conclusions: This experience and that reported in the literature suggest that it is frequently impossible to preserve the function of the nerve of origin with surgical treatment of cervical neurilemomas.

Routine identification of the facial nerve using electrical stimulation during otological and neurotological surgery

We routinely identify the facial nerve to avoid facial nerve injury during most otologic surgery. Since 1985, we have used a facial nerve stimulator/monitor as an added safety feature in 383 consecutive otologic and neurotologic cases. In our last 30 middle‐ear, 8 retrolabyrinthine vestibular neurectomy, and 14 acoustic neuroma cases we used the monopolar stimulator probe‐tip to determine threshold currents needed to produce facial twitch. Stimulation thresholds varied according to the amount of soft tissue or bone overlying the facial nerve. The stimulator was useful for predicting dehiscences in the bony facial canal during middle‐ear and mastoid surgery. The exposed facial nerve usually stimulated at a level less than 0.1 mA (mean 0.05 mA), and the horizontal facial nerve covered by bone stimulated at 0.25 mA or greater (mean 0.6 mA). The stimulator was also used to predict the amount of bone overlying the vertical facial nerve at the annulus. An approximate relationship of 1.0 mA of threshold current to 1.0 mm of bony covering was found. After acoustic neuroma surgery, the stimulation threshold of the facial nerve at the brain stem helped predict postoperative facial function. Cases with current thresholds of 0.3 mA or less resulted in normal facial function. During ear surgery, routine identification of the facial nerve with the aid of a facial nerve stimulator will help avoid facial nerve injury.

Low dose fractionated radiation potentiates the effects of taxotere in nude mice xenografts of squamous cell carcinoma of head and neck

This study evaluated the combined effect of Low Dose Fractionated Radiation (LDFRT) and Taxotere (TXT) therapy on the growth of SCCHN (squamous cell carcinoma of head and neck; SQ-20B, a p53 mutant SCCHN cell line) tumors in a nude mouse model to exploit the increased hyper radiation sensitivity (HRS) phenomenon present in G2M cell cycle phase when induced by low doses of radiation that was demonstrated in in-vitro settings. Seventy-eight animals were randomized into one control group and 5 treatment groups (treatments were administered weekly for six weeks). Tumor regression was observed in all the groups, however, tumor regression was not significant in 2 Gy or TXT or 2 Gy plus TXT treated groups when compared to control group. The tumor regression was significant in both the LDFRT group (p

An evolution of approach in vestibular neurectomy.

Since introducing the retrolabyrinthine vestibular neurectomy in 1978, we have performed 78 procedures with good results. In 1985 we introduced the retrosigmoid-IAC vestibular neurectomy, which allows a more complete transection of the vestibular nerves within the internal auditory canal (IAC). Vertigo control has been excellent; however, in 75% of patients, postoperative headaches have been a significant problem. In 1987, the best aspects of the two procedures were incorporated and the combined retrolab-retrosigmoid vestibular neurectomy was developed. The procedure is similar to the RVN in that all bone covering the lateral venous sinus is removed. It differs from the RVN in that a limited mastoidectomy is performed and the dura is opened just behind the LVS. The LVS is retracted forward, exposing the cerebellopontine angle. This allows the surgeon the option to section the vestibular nerve in either the CP angle or the IAC, depending upon the presence or absence of a cochieovestibular cleavage plane in the CP angle. The results have been good and the incidence of headache has been reduced to 10%. The technique, results, and complications are reported here.

Severe hospitalized croup: Treatment trends and prognosis†‡

We have reviewed 43 cases of severe croup admitted from 1977 to 1981 at North Carolina Memorial Hospital. All patients were treated with mist, 23 (54%) of 43 were treated with racemic epinephrine, but only 7 (16%) of 43 were treated with steroids. None of the 5 patients who required intubation received steroids. Nine (36%) of 25 patients available for at least 6 months of follow‐up had subsequent clinical diagnoses of asthma.

Connexin26 (GJB2) deficiency reduces active cochlear amplification leading to late-onset hearing loss

Connexin26 (Cx26, GJB2) mutations account for >50% of nonsyndromic hearing loss. The deafness is not always congenital. A large group of these patients (∼30%) demonstrate a late-onset hearing loss, starting in childhood. They have normal hearing early in life and are therefore good candidates for applying protective and therapeutic interventions. However, the underlying deafness mechanism is unclear. In this study, we used a time-controlled, inducible gene knockout technique to knockout Cx26 expression in the cochlea after birth. We found that deletion of Cx26 after postnatal day 5 (P5) in mice could lead to late-onset hearing loss. Similar to clinical observations, the mice demonstrated progressive, mild to moderate hearing loss. The hearing loss initiated at high frequencies and then extended to the middle- and low-frequency range. The cochlea showed normal development and had no apparent hair cell loss. However, distortion product otoacoustic emission (DPOAE) was reduced. The reduction was also progressive and large at high-frequencies. Consistent with DPOAE reduction, we found that outer hair cell electromotility-associated nonlinear capacitance was shifted to the right and the slope of voltage dependence was reduced. The endocochlear potential was reduced in Cx26 conditional knockout (cKO) mice but the reduction was not associated with progressive hearing loss. These data suggest that Cx26 deficiency may impair active cochlear amplification leading to late-onset hearing loss. Our study also helps develop newer protective and therapeutic interventions to this common nonsyndromic hearing loss.

Protection against aminoglycoside otic drop–induced ototoxicity by a spin trap: I. Acute effects ☆ ☆☆ ★ ★★

Topical administration of aminoglycoside antibiotic drops containing neomycin and polymyxin B disrupts cochlear structure and function in rodents, possibly as a result of reactive oxygen species generation. This study investigated the ability of a spin trap, α-phenyl-tert-butyl-nitrone (PBN), to prevent acute aminoglycoside antibiotic drop-induced cochlear dysfunction. Guinea pigs were monitored for compound action potential thresholds and 1.0 μV root-mean-square cochlear microphonic isopotential curve values, then injected intraperitoneally with PBN (60 mg/kg) or saline solution. After 10 minutes, 50 μl of PBN (100 mmol/L) or artificial perilymph was applied to the round window membrane, followed after 10 minutes with artificial perilymph or aminoglycoside antibiotic drops (50 μl). From 10 to 60 minutes after exposure, mean compound action potential thresholds progressively increased in the artificial perilymph-aminoglycoside antibiotic drop group, beginning with high frequencies and later including ever-lower frequencies. These threshold shifts in compound action potentials were significantly greater (p < 0.05) than those seen in the artificial perilymph-artificial perilymph or PBN-aminoglycoside antibiotic drop groups. This finding indicates that PBN provided protection against acute aminoglycoside antibiotic drop-induced compound action potential threshold sensitivity loss. Mean cochlear microphonic shift values at 60 minutes in the artificial perilymph-aminoglycoside antibiotic drop group significantly exceeded those of the other groups only at the highest frequencies. These data suggest that acute aminoglycoside antibiotic drop-induced cochlear disruption primarily affects high frequency compound action potential function and may be partially reactive oxygen species-mediated and preventable

Long-term hearing results in gamma knife radiosurgery for acoustic neuromas.

Objectives: There are many studies that have examined functional outcomes following Gamma Knife treatment; however, few have reported long‐term audiometric data. This study analyzed the long‐term hearing results of Gamma Knife radiosurgery in the treatment of acoustic neuromas.