T. Oma Hester

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.

Preservation of the stapedius tendon in laser stapes surgery

Objectives/Hypothesis: The stapedius tendon is routinely transected during stapes surgery. The objective of this study was to evaluate the technique of stapedial tendon preservation during stapes surgery and to compare results of these cases with cases where the stapedial tendon was not preserved. Study Design: Retrospective study. Methods: Four groups of patients were evaluated. Two groups had undergone stapes surgery with preservation of the stapedial tendon. One of these groups underwent a laser stapedotomy minus prosthesis (laser STAMP) procedure, while the other group had a prosthesis inserted. The other two groups had undergone laser stapedotomy with one of two different prostheses being used. Audiometric data were obtained and reviewed both preoperatively and at approximately 6 weeks postoperatively. Results: All groups had overall successful results demonstrating that stapedial tendon preservation is technically possible and does not compromise outcomes. Conclusions: Based on the results, it is recommended that the stapedius tendon be preserved whenever possible during laser stapes surgery. Reasons justifying its preservation are discussed. Laryngoscope, 108:1453–1458, 1998

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

CERVICOTHORACIC CHORDOMA PRESENTING AS PROGRESSIVE DYSPNEA AND DYSPHAGIA

Chordomas are generally considered rare primary osseous neoplasms of the basiocciput and axial skeleton that account for approximately 1% to 4% of the malignant neoplasms of bone. 1 These neoplasms grow slowly but have a strong tendency toward local invasion, and although they were once thought to have a low incidence of metastatic spread, recent reviews are demonstrating a more significant metastatic potential. 2-5Approximately 50% of chordomas arise from the sacrococcygeal area of the axial skeleton, 35% are found in the basiocciput area in the region of the clivus, and the remaining 15% arise from the true vertebrae cephalad to the sacrum. 6 Of those arising in the vertebrae, a predilection for the cervical spine has been reported. 7

Cyclandelate in the management of tinnitus: A randomized, placebo-controlled study

Cyclandelate is a vasodilating agent that, like papaverine, acts directly on the smooth muscles of blood vessels. The drug has been used primarily as an adjunctive treatment for various peripheral vascular diseases; some studies advocate its use for treating ischemic cerebrovascular disease. Early nonrandomized and uncontrolled studies suggest that cyclandelate is efficacious in treating tinnitus. Recent personal communications regarding cyclandelates effectiveness in treating tinnitus prompted this study. Fifty-nine adult patients with constant tinnitus for more than 1 year were randomly selected for this prospective, placebo-controlled, double-blind study with a treatment period of 3 months. Audiometric testing with tinnitus pitch and loudness matching was performed before initiation of treatment and at the end of treatment, and frequent questionnaire evaluations were performed during the treatment period. Four patients in the cyclandelate group and three in the placebo group reported a subjective reduction in the loudness of their tinnitus. Audiologic testing before and after treatment showed no significant changes in tinnitus pitch or loudness. Although cyclandelate treatment was beneficial for some patients and the decrease in subjective loudness scoring was significant for the cyclandelate group, the impact of its effect did not appear to warrant its continued use by those patients. A significant percentage of patients could not tolerate the drug because of side effects.

Stapes footplate fistula and recurrent meningitis.

tion. Physical examination was unremarkable except for complete right nasal obstruction. A CT scan revealed an expansile soft tissue density within a dilated right maxillary sinus. MRI demonstrated hyperplastic mucosal thickening of the right maxillary antrum consistent with a mucocele. The patient underwent a combined, endoscopic right anterior ethmoidectomy and right Caldwell-Luc antrostomy for evacuation of the cyst. Pathologic analysis revealed fragments of mucosa consistent with the diagnosis of mucocele. Results of a chloride sweat test were negative for CF. A review of the literature to date concerning mucoceles in the pediatric population will be presented. Further discussion will focus on the clinical presentation, etiology, and pathogenesis of mucoceles as related to this most unusual and previously undocumented case.

Clindamycin as initial treatment of peritonsillar abscesses that fall treatment with penicillin

Objective: Penicillin has long been considered the drug of choice for the medical management of peritonsillar abscess (PTA). Several studies have reported varying degrees of penicillin resistance in organisms obtained from aspirates of such abscesses, but the evidence has not been compelling enough to recommend a change in first-line antibiotic coverage. No studies have looked at choice of antibiotic alone as it impacts treatment outcome. The purpose of this study was to examine the relationship between antibiotic choice and outcome for patients with PTA. Methods: A retrospective chart review of more than 100 consecutive patients treated for a PTA at our institution for the past 7 years was performed. Parameters measured included treatment failures, length of hospitalization, recurrence rate, need for Quinsy tonsillectomy, and antibiotic side effects. Results: There was a significant difference in outcome measures shown when primary outpatient treatment of PTA with penicillin was compared with similar treatment with clindamycin. Conclusions: The results of this study have modified our first-line antibiotic choice for these patients. The significant difference in treatment failures when penicillin is used as a first-line antibiotic, combined with differences in length of hospitalization, recurrence rates, and need for tonsillectomy, make clindamycin a prudent and cost-effective initial antibiotic for PTA.

Facial Nerve Monitoring under Neuromuscular Blockade.

The characteristics of facial nerve electromyography at various levels of neuromuscular blockade are unclear. Partial blockade is well known to facilitate anesthetic safety and management. However, the use of neuromuscular blockage in many skull base procedures is avoided to allow intraoperative facial nerve monitoring.We studied the influence of various levels of neuromuscular blockade on facial nerve stimulation in the New Zealand white rabbit. The facial nerve was exposed in the middle ear of six rabbits. Using electromyographic-type facial nerve monitor, we recorded the facial electromyography signals in these rabbits at increasing levels of vecuronium-induced neuromuscular blockade. All animals demonstrated reliable facial electromyography response at all levels of partial neuromuscular blockade (P < .02). Five of the six animals could be monitored throughout complete blockade. These results clearly demonstrate that rabbit facial electromyography monitoring is possible under neuromuscular blockade. The effect of neuromuscular blockers on facial electromyography monitoring deserves further study, as partial blockade would greatly facilitate the management of anesthesia in otologic, neurotologic, and skull base surgery.

Cyclandelate in the Management of Tinnitus: A Placebo-Controlled Study

the physic;_an evaluating a patient with signs and symptoms suggestive of retrocochlear pathology. Cost-per-tumor analysis reveals a significant expense if standard, full-head magnetic resonance imaging (MRI) is routinely applied in every patient with such findings. Although less expensive, an ABRbased diagnostic scheme risks missing up to 24% of small tumors. This study reviews a 1-year experience with a diagnostic scheme for cerebellopontine angle evaluation on the basis of screening, enhanced MRI. Our imaging protocol includes Tt-weighted, 3-ram contiguous slices through the internal auditory canal and the region of the cerebellopontine angle. Total scanning time is about 11 minutes, with an estimated cost of approximately

Nasopharyngeal Masses Presenting as Obstructive Sleep Apnea Syndrome

300 including contrast. Compared with ABR, screening MRI offers advantages of a near-zero false-negative rate and markedly improved specificity. By el iminat ing the need for follow-up audiometric or electrophysiologic studies, a screening MRI-based diagnostic scheme is actually more effective on a cost-per-tumor basis as well as a cost-per-diagnosis basis. We conclude that a screening MRI-based diagnostic scheme without ABR offers a definitive and cost-effective diagnostic approach for patients with possible retrocochlear pathology.