Sam J. Marzo

Intratympanic steroid perfusion for refractory sudden sensorineural hearing loss

OBJECTIVE: Patients with sudden sensorineural hearing loss (SSHL) can benefit from systemic steroid therapy. Unfortunately, some patients are not candidates for steroid therapy due to concern over possible complications. Furthermore, not all patients will benefit from steroid administration. This study evaluates the potential benefits and safety of treating patients with SSHL refractory to oral steroids with intratympanic steroid therapy. METHODS: A retrospective case review was performed on all patients who presented with sudden sensorineural hearing loss refractory to oral steroid therapy during the past year. Seventeen patients were identified. All patients underwent intratympanic steroid administration, via MicroWick placement and/or round window catheter placement. RESULTS: Nine patients with sudden sensorineural hearing loss showed an improvement with intratympanic steroid therapy, consisting of MicroWick placement with dexamethasone drop (Decadron) administration for 1–2 weeks and/or round window catheter placement with steroid perfusion. Only one of the patients presenting with hearing loss present for greater than 8 weeks benefited from intratympanic therapy. Complications were few and included tympanic membrane perforation, chronic otitis media, dysequilibrium, and dysguesia. CONCLUSIONS: Intratympanic steroid therapy can be beneficial in treating patients with sudden sensorineural hearing loss refractory to oral steroid use. EBM rating: C.

Perioperative Complications With the Bone-Anchored Hearing Aid

OBJECTIVE: To discuss perioperative complications associated with the bone-anchored hearing aid (BAHA) and their management. STUDY DESIGN AND SETTING: A retrospective review of 58 patients who underwent implantation of BAHA for unilateral conductive, mixed, or sensorineural hearing losses was performed at a tertiary referral center. RESULTS: Between September 2003 and June 2005, 58 patients underwent implantation of a BAHA. There were 30 female and 28 male patients, with a mean age of 48 years (range 8–80 years). Complications occurred in 19% (11/58) of patients. Most adverse events were seen early in the series. The most common complication, partial or complete loss of the skin graft, occurred in 10% (6/58) of patients. These were managed successfully with local wound care. Five percent (3/58) of patients had skin growth over the abutment. Two of these cases were managed with office debridement, whereas 1 patient required revision under general anesthesia. There was implant extrusion in 3% (2/58) of patients, and both of these patients later underwent successful reimplantation. All patients had their implant activated 3 months after surgery. There were no perioperative or postoperative deaths. CONCLUSION: Complications related to BAHA implantation are relatively minor and usually involve partial or complete loss of the skin graft. Most complications were successfully managed in the office.

Facial Nerve Grading System 2.0

Objective: To present an updated version of the original Facial Nerve Grading Scale (FNGS), commonly referred to as the House-Brackmann scale. Study Design: Controlled trial of grading systems using a series of 21 videos of individuals with varying degrees of facial paralysis. Results: The intraobserver and interobserver agreement was high among the original and revised scales. Nominal improvement is seen in percentage of exact agreement of grade and reduction of instances of examiners differing by more then one grade when using FNGS 2.0. FNGS 2.0 also offers improved agreement in differentiating between grades 3 and 4. Conclusion: FNGS 2.0 incorporates regional scoring of facial movement, providing additional information while maintaining agreement comparable to the original scale. Ambiguities regarding use of the grading scale are addressed.

Electrical stimulation and testosterone differentially enhance expression of regeneration-associated genes.

As functional recovery following peripheral nerve injury is dependent upon successful repair and regeneration, treatments that enhance different regenerative events may be advantageous. Using a rat facial nerve crush axotomy model, our lab has previously investigated the effects of a combinatorial treatment strategy, consisting of electrical stimulation (ES) of the proximal nerve stump and testosterone propionate (TP) administration. Results indicated that the two treatments differentially enhance facial nerve regenerative properties, whereby ES reduced the delay before sprout formation, TP accelerated the overall regeneration rate, and the combinatorial treatment had additive effects. To delineate the molecular mechanisms underlying such treatments, the present study investigated the effects of ES and TP on expression of specific regeneration-associated genes. Following a right facial nerve crush at the stylomastoid foramen, gonadectomized adult male rats were administered only ES, only TP, a combination of both, or left untreated. Real time RT-PCR analysis was used to assess fold changes in mRNA levels in the facial motor nucleus at 0 h, 6 h, 1 d, 2 d, 7 d, and 21 d post-axotomy. The candidate genes analyzed included two tubulin isoforms (alpha(1)-tubulin and beta(II)-tubulin), 43-kiloDalton growth-associated protein (GAP-43), brain derived neurotrophic factor (BDNF), pituitary adenylate cyclase-activating peptide (PACAP), and neuritin (candidate plasticity-related gene 15). The two treatments have differential effects on gene expression, with ES leading to early but transient upregulation and TP producing late but steady increases in mRNA levels. In comparison to individual treatments, the combinatorial treatment strategy has the most enhanced effects on the transcriptional program activated following injury.

Surgical Treatment of Pediatric Cholesteatomas

Objective: Management of pediatric cholesteatomas remains controversial. We reviewed our 16‐year experience in the surgical treatment of cholesteatomas in children and describe a treatment paradigm.

Electrical stimulation facilitates rat facial nerve recovery from a crush injury

Objective To study the effect of electrical stimulation on accelerating facial nerve functional recovery from a crush injury in the rat model. Study Design Experimental. Method The main trunk of the right facial nerve was crushed just distal to the stylomastoid foramen, causing right-sided facial paralysis in 17 Sprague-Dawley rats. An electrode apparatus was implanted in all rats. Nine rats underwent electrical stimulation and eight were sham stimulated until complete facial nerve recovery. Facial nerve function was assessed daily by grading eyeblink reflex, vibrissae orientation, and vibrissae movement. Results An electrical stimulation model of the rat facial nerve following axotomy was established. The semi-eyeblink returned significantly earlier (3.71 + 0.97 vs 9.57 + 1.86 days post axotomy) in stimulated rats (P = 0.008). Stimulated rats also recovered all functions earlier, and showed less variability in recovery time. Conclusion Electrical stimulation initiates and accelerates facial nerve recovery in the rat model as it significantly reduces recovery time for the semi-eyeblink reflex, a marker of early recovery. It also hastens recovery of other functions.

Cerebrospinal Fluid Fistula after Transtemporal Skull Base Surgery

OBJECTIVES: The purpose of this article is to outline our methods for the prevention and management of cerebrospinal fluid (CSF) leak after transtemporal skull base surgery. METHODS: A total of 589 patients underwent a variety of transtemporal surgical approaches for the extirpation of skull base tumors at our institution from July 1988 to October 1999. The medical records were retrospectively reviewed to identify the tumor histology, size, and location as well as the surgical approach, defect reconstruction technique, and the incidence of postoperative CSF leak. RESULTS: The risk of CSF fistulae was greatest in utilizing the restrosigmoid approach (8%) and least in those who underwent a translabyrinthine approach (4%). Tumor size had no bearing on the incidence of the CSF leak and the overall incidence of meningitis was 1.0%. CONCLUSION: The proper surgical technique will minimize the risk of CSF leak after transtemporal skull base surgery. Immediate management of CSF fistulae helped prevent meningitis in the majority of these patients.

Accelerating functional recovery after rat facial nerve injury: Effects of gonadal steroids and electrical stimulation

Objective We investigated the combined effects of electrical stimulation and testosterone propionate on overall recovery time in rats with extracranial crush injuries to the facial nerve. Study Design Male rats underwent castration 3 to 5 days prior to right facial nerve crush injury and electrode implantation. Rats were randomly assigned to two groups: crush injury + testosterone or crush injury with electrical stimulation + testosterone. Recovery was assessed by daily subjective examination documenting vibrissae orientation/movement, semi-eye blink, and full eye blink. Results Milestones of early recovery were noted to be significantly earlier in the groups with electrical stimulation, with/without testosterone. The addition of testosterone to electrical stimulation showed significant earlier return of late recovery parameters and complete overall recovery. Conclusion Electrical stimulation may decrease cell death or promote sprouting to accelerate early recovery. Testosterone may affect the actual rate of axonal regeneration and produce acceleration in functional recovery. By targeting different stages of neural regeneration, the synergy of electrical stimulation and testosterone appears to have promise as a neurotherapeutic strategy for facial nerve injury.

Recurrent Pleomorphic Adenoma of the Parotid Gland

OBJECTIVES: To assess the long-term results in the management of 42 patients with recurrent pleomorphic adenoma of the parotid gland. STUDY DESIGN: A retrospective analysis of 42 patients who underwent parotidectomy for recurrent pleomorphic adenoma was performed to study presenting clinicoradiographic features, surgical technique, facial nerve management, and the long-term risk of recurrence. RESULTS: All 42 patients had multi-focal, nontender recurrent nodules following one to four prior surgical procedures and 6 patients underwent prior radiotherapy. Surgical procedures included subtotal parotidectomy in 12 patients, total parotidectomy in 18 patients, parotidectomy with facial nerve resection in 7 cases, and subtotal petrosectomy with facial nerve resection in 5 individuals. The 2 patients with malignant transformation died of disseminated lung and bone metastasis. Twenty-nine of the remaining 40 patients had no recurrent disease. Seven patients developed local parotid bed or cutaneous recurrent disease, 2 patients died of unrelated causes, and 2 patients were lost to follow-up. CONCLUSIONS: All 7 patients with recurrent disease underwent subtotal parotidectomy with “negative” surgical margins. Total parotidectomy or subtotal petrosectomy with facial nerve resection in selected cases may reduce the risk of multiple episodes of pleomorphic adenoma recurrence. Two of 42 patients were found to have carcinoma ex-pleomorphic adenoma, both of these patients underwent prior radiotherapy, and both died of metastatic disease.

Single session of brief electrical stimulation immediately following crush injury enhances functional recovery of rat facial nerve.

Peripheral nerve injuries lead to a variety of pathological conditions, including paresis or paralysis when the injury involves motor axons. We have been studying ways to enhance the regeneration of peripheral nerves using daily electrical stimulation (ES) following a facial nerve crush injury. In our previous studies, ES was not initiated until 24 h after injury. The current experiment tested whether ES administered immediately following the crush injury would further decrease the time for complete recovery from facial paralysis. Rats received a unilateral facial nerve crush injury and an electrode was positioned on the nerve proximal to the crush site. Animals received daily 30 min sessions of ES for 1 d (day of injury only), 2 d, 4 d, 7 d, or daily until complete functional recovery. Untreated animals received no ES. Animals were observed daily for the return of facial function. Our findings demonstrated that one session of ES was as effective as daily stimulation at enhancing the recovery of most functional parameters. Therefore, the use of a single 30 min session of ES as a possible treatment strategy should be studied in human patients with paralysis as a result of acute nerve injuries.