Wesley W. O. Krueger

Anterior Canal Benign Paroxysmal Positional Vertigo: An Underappreciated Entity

Objective: Evaluate the frequency and characteristics of benign paroxysmal positional vertigo (BPPV) arising from involvement of the anterior semicircular canal (AC) as compared with the posterior canal (PC) and horizontal canal (HC). Study Design: Prospective review of patients with BPPV. Setting: Tertiary referral center. Patients: A total of 260 patients who were evaluated for vertigo were identified as experiencing BPPV. Interventions: Standard vestibular assessment including the use of electrooculography (EOG) or video-oculography (VOG) was completed on all patients. Based on EOG/VOG findings, the BPPV origin was attributed to AC, PC, or HC involvement secondary to canalithiasis versus cupulolithiasis. Treatment was performed with canalith repositioning maneuvers (CRMs) appropriate for type of canal involvement. Results: For the 260 patients, the positionally induced nystagmus patterns suggested the canal of origin to be AC in 21.2%, PC in 66.9%, and HC in 11.9%. Cupulolithiasis was observed in 27.3% of the AC, 6.3% of the PC, and 41.9% of the HC patients. Head trauma was confirmed in the history preceding the onset of vertigo in 36.4% of the AC, versus 9.2% of the PC and 9.7% of the HC patients (p < 0.001). The number of CRMs completed to treat the BPPV did not differ between canals involved (1.32 for AC, 1.49 for PC, and 1.34 for HC). Conclusion: The direction of subtle vertical-beating nystagmus underlying the torsional component is critical in differentiating AC versus PC origin; EOG/VOG aids in accurate assessment of the vertical component for the diagnosis of canal involvement. AC involvement may be more prevalent than previously appreciated, particularly if the examiner does not appreciate the vertical component of the nystagmus or the diagnosis is made without the assistance of EOG/VOG. Head trauma history is significantly more frequent in AC versus other forms of BPPV, and patients with a history of head trauma should be examined closely for AC involvement. CRM is as successful for treatment of AC BPPV as for other types of BPPV.

Preliminary ossiculoplasty results using the Kurz titanium prostheses

Objective Limitations in biocompatibility and hearing improvement with ossicular chain reconstruction prostheses are addressed with new, lightweight titanium prostheses designed to maximize visualization of the capitulum and footplate regions. The effectiveness of these new prostheses is being tested in a prospective multicenter study. Study Design Prospective case series. Setting Multicenter (8 sites), primarily tertiary private practice or academic otologic clinics. Patients A convenience sample of 31 patients undergoing ossiculoplasty, with 16 partial ossicular chain reconstructions using the Bell prosthesis and 15 total reconstructions using the Aerial prosthesis. Intervention Ossiculoplasty using new Kurz titanium prostheses. Cartilage was interposed between the tympanic membrane and the prosthesis. Main Outcome Measures Air-bone gap for pure tone average and 3,000 and 4,000 Hz, assessed preoperatively and 3 months, 6 months, and 12 months postoperatively; percent of patients obtaining an air-bone gap of ≤20 dB; high-frequency average (1,000, 2,000, and 4,000 Hz) to evaluate sensorineural hearing loss; and extrusion rate. Results A postoperative air-bone gap of ≤20 dB was obtained in 81% of Bell prosthesis patients and 67% of Aerial prosthesis patients at 3 months. The results were stable to improved for later time intervals. High-frequency gaps were similar to the pure tone average gap. To date, there have been no instances of extrusion, and all the surgeons found the prostheses easy to use and thought that the design characteristics facilitated accurate placement. Conclusions Initial evaluation of the Kurz titanium prostheses produced low extrusion rates (none to date) with excellent hearing results, including good high-frequency conduction. Good visualization and accurate placement were easy to achieve. Further studies are needed to confirm long-term efficacy.

Bone cement reconstruction of the ossicular chain : A preliminary report

Objective: To determine the feasibility and efficacy of using a bone cement, Oto‐Cem, to reconstruct the ossicular chain.

Plexiform neurofibroma of the head and neck.

Ten patients with plexiform neurofibroma of the head and neck were observed at M.D. Anderson Hospital between 1956 and 1978. The clinical presentation and the long-term follow-up of the most interesting cases are presented. This is a chronic disease that causes cosmetic and functional deformity because of the size or the position of the tumor, or both. No patient exhibited malignant transformation. Because all of the disease cannot be removed, the surgical procedures should not be radical but should be designed to relieve symptoms or improve cosmesis.

Work-related, noise-induced hearing loss: evaluation including evoked potential audiometry.

This article reviews the evaluation of 246 workers (492 ears) who underwent otologic and audiologic testing as part of a workers compensation claim for work-related, noise-induced hearing loss. Tinnitus was present in 58% of the patients, but was rarely a major symptom. Other otologic symptoms or a history of ear disease were virtually nonexistent. Standard audiometry showed a downsloping, high-frequency sensorineural hearing loss in 85% of the ears tested, with only 37% having a characteristic “noise notch” at 4000 or 6000 hertz. Asymmetric hearing loss was not uncommon, with 48 patients (20%) undergoing magnetic resonance scanning, all of whom showed no central lesion responsible for the loss. Proven malingering was surprisingly uncommon (9%). In this study, evoked response audiometry was a valuable adjunct to confirm behavioral thresholds in the evaluation of possible work-related, noise-induced hearing loss. The middle latency response was more effective than the auditory brainstem response as a result of the high-frequency steepness of the audiometric curve.

Fibroblast implantation enhances wound healing as indicated by breaking strength determinations.

Irradiation of normal tissues at the dose/time factor employed in the treatment of solid tumors impairs the subsequent healing of surgical wounds made in those tissues. Irreversible radiation damage to regional fibroblasts is one cause of impaired healing. This study was conducted to determine whether syngeneic guinea pig fibroblasts, harvested from tissue culture when injected into irradiated guinea pig skin at the time of wound closure, could improve wound healing. Breaking strength determinations indicate that irradiated wounds demonstrate enhanced wound healing if implanted with fibroblasts.

A comparison of screening methods in school-aged children☆

OBJECTIVE: We sought to compare the findings of 3 different hearing screening methods in school-aged children. STUDY DESIGN AND SETTING: Prospective testing of second- and third-grade students in their schools was carried out. METHODS: Three hundred children (599 ears) were screened by using 3 test modalities, pure-tone audiometry, distortion product otoacoustic emissions (DPOAE), and tympanometry. RESULTS: All of the tests were normal in 532 ears (89%), and all were abnormal in 12 ears (2%). Tympanometry yielded the most abnormalities (8.3%), and pure-tone testing demonstrated the fewest (3.3%), with a positive rate of 6.3% for DPOAE testing. False-positive rates were 1.2%, 4.2%, and 6.4% for pure tones, DPOAE, and tympanometry, respectively, when normal results on pure-tones or DPOAE were taken to represent true hearing. CONCLUSION/SIGNIFICANCE: We continue to recommend pure-tone testing as an effective screening method, with follow-up by using otoacoustic emissions in those who fail the pure-tone test.

Ossiculoplasty with Polymaleinate Ionomeric Prosthesis

With the continued concern over the possible transmission of viral infections through homologous middle ear implants, there is increasing pressure to develop a truly biocompatible alloplastic middle ear prosthesis. The polymaleinate ionomer, which has been used in dentistry as a filling and luting material for more than 15 years, has recently been used to construct total and partial ossicular replacement prostheses. In an attempt to evaluate these new implants, a multicenter prospective clinical trial was initiated. To date, 92 patients have undergone implantation. The follow-up interval ranged from 3 months to 22 months. Although it is premature to discuss the long-term results, the preliminary surgical experience and audiometric data with these implants are reviewed. From a surgical perspective, the ionomeric prostheses were easily contoured with a diamond burr and were not prone to shattering. Preliminary follow-up audiometric data were available on 80 patients (59 partial ossicular replacement prostheses and 21 total ossicular replacement prostheses). Of the 59 partial ossicular replacement prostheses the air-bone gaps (average of 500 Hz, 1 kHz, 2 kHz and 3 kHz) were as follows: 0 dB to 10 dB, 15 (25%) of 59; 11 dB to 20 dB, 20 (34%) of 59; 21 dB to 30 dB, 11 (19%) of 59; and greater than 30 dB, 13 (22%) of 59. Of the 21 total ossicular replacement prostheses the air-bone gaps were as follows: 0 dB to 10 dB, 6 (29%) of 21; 11 dB to 20 dB, 6 (29%) of 21; 21 dB to 30 dB, 5 (24%) of 21; and greater than 30 dB, 4 (19%) of 21.

Controlling motion sickness and spatial disorientation and enhancing vestibular rehabilitation with a user-worn see-through display†

An eyewear mounted visual display (“User‐worn see‐through display”) projecting an artificial horizon aligned with the users head and body position in space can prevent or lessen motion sickness in susceptible individuals when in a motion provocative environment as well as aid patients undergoing vestibular rehabilitation. In this project, a wearable display device, including software technology and hardware, was developed and a phase I feasibility study and phase II clinical trial for safety and efficacy were performed.

ELECTROCOCHLEOGRAPHY IN RETROSIGMOID VESTIBULAR NERVE SECTION FOR INTRACTABLE VERTIGO CAUSED BY MENIERE'S DISEASE

Interest in electrocochleography has increased in recent years because of the discovery of an elevated summating potential to action potential amplitude ratio (SP/AP ratio) in patients with endolymphatic hydrops caused by Menieres disease or perilymph fistula. It was the purpose of this investigation to determine whether the intraoperative SP/AP ratio will decrease after vestibular nerve section in patients with intractable Menieres disease. Fourteen patients with medically intractable classic Menieres disease underwent retrosigmoid vestibular nerve section. Intraoperative transtympanic electrocochleography was performed with alternating click stimuli presented at 95 dB HL. In all patients the SP/AP ratio was recorded before the skin incision (“baseline” condition) and after the dura was closed (“closing” condition). Statistical analysis was applied to the recorded data. In 11 (79%) patients, the SP/AP ratio was found to be elevated above 0.30 in the baseline state. In 13 (93%) patients, the SP/AP ratio decreased more than 25% after the nerve was sectioned. These results were highly statistically significant (p < 0.001). We conclude that the SP/AP ratio does decrease in patients with Menieres disease after undergoing retrosigmoid vestibular nerve section and offer a possible explanation. (Otolaryngol Head Neck Surg 1997;116:593–6.)