Histopathological features of a cochlear implant and otogenic meningitis in Mondini dysplasia

The temporal bones of a 6-year-old boy with a cochlear implant for profound hearing loss associated with Mondini dysplasia were studied histopathologically. Despite having severe Mondini dysplasia, he was able to detect sound with the implant. On histological examination of the temporal bone, he had more than 10000 spiral ganglion cells. Histopathological changes in the inner ear associated with the cochlear implant were minimal. Patients with severe Mondini dysplasia and profound hearing loss may, therefore, benefit from cochlear implantation. In the contralateral ear, the patient had suppurative labyrinthitis and meningitis associated with chronic otitis media. Histopathological evidence of inflammatory necrosis of the round window membrane was consistent with suppurative labyrinthitis secondary to otitis media.

The functionally and physiologically plastic adult auditory system

The potential for functional and underlying physiological change in the adult auditory system is examined through review and evaluation of several sets of literature including auditory deprivation and recovery, auditory learning after hearing aid fitting, auditory abilities of normal listeners exposed to masking noise, and neural plasticity in the sensory and motor systems of animals. This tutorial review is meant for the reader who may be interested in auditory learning and who would like to have a summary and evaluation of the various findings to date. The focus of the review is the effect that various findings of auditory learning may have on hearing aid fitting and selection.

Induction of immune-mediated hearing loss in SCID mice by injection of MRL/lpr mouse spleen cells

Induction of immune-mediated hearing loss in SCID mice by injection of MRL/lpr mouse spleen cells The MRL/lpr mouse, which has a mutation in the Fas gene encoding a cell-surface receptor for apoptosis, shows an accumulation of abnormal immunocompetent cells and SLE-like disease. It has recently been reported that this mouse also manifests sensorineural hearing loss (SHL) with cochlear pathology at 20 weeks of age. We examined the effects of injecting MRL/lpr spleen cells on the development of SHL in severe combined immunodeficient (SCID) mice, which originally develop neither SHL nor cochlear pathology. Immune-mediated SHL and cochlear pathology were, indeed, transferred to the SCID mice by the injection of spleen cells from the MRL/lpr mice. These findings suggest that cell-mediated immunity is involved in the development of SHL and cochlear pathology.

Neuronal responses across cortical field A1 in plasticity induced by peripheral auditory organ damage

The adult auditory cortex is capable of a plastic reorganization of its tonotopic map after damage to restricted parts of the cochlear sensory epithelium. We examine the precise conditions of cochlear damage required to demonstrate such plasticity in the primary auditory cortex (A1) of the cat and the changes observed in neuronal responses in the A1 which has reorganized in plasticity of the tonotopic map. From these data we attempt to predict the conditions required for similar plasticity to occur in humans after cochlear damage.

Development of cochlear sensitivity to aminoglycoside antibiotics

This study examined the temporal relationship between aminoglycoside ototoxicity and the onset of auditory function in the rat. A single dose of gentamicin sulfate (200 mg/kg) and furosemide (100 mg/kg) was administered on postnatal day 6 (P6), P7, P8, P9, or P10, just before the onset of auditory function. Ototoxicity was assessed by the elevation of auditory brain stem response (ABR) thresholds, recorded once the rats had matured. The ABRs were evoked by acoustic clicks and tone pips. The thresholds of control and P6- and P7-treated animals did not differ significantly from each other. Thresholds of some P8- and all P9-treated animals were elevated. The P10-treated animals were deafened, according to these ABR criteria. These data suggest that the potential for aminoglycoside ototoxicity develops rapidly between P8 and P10, just before the onset of auditory function.

Trichloroethylene ototoxicity: evidence for a cochlear origin

Trichloroethylene (TCE) is known to produce an unusual pattern of hearing impairment in laboratory animals marked by a preferential loss of threshold sensitivity at midfrequencies. The purpose of this research was to determine whether the TCE-induced auditory deficit results from cochlear dysfunction. Adult Long Evans hooded rats were exposed via inhalation to either 0 (clean air) or 4000 ppm TCE (6 h/day for 5 days). Auditory thresholds for 1-40 kHz tones were determined 3 weeks after exposure using reflex modification audiometry (RMA; n = 12/group). Cochlear electropotentials were measured during subsequent testing (n = 3-10/group) 5 to 7 weeks after exposure, including thresholds for cochlear action potentials (CAP) and the 1-microV cochlear microphonic for 2-40 kHz tones, and the N1 amplitude intensity function (40-90 dB SPL). Cochlear histopathology was assessed in midmodiolar preparations of a separate set of animals, exposed as before (n = 4/group). RMA testing confirmed a TCE-induced loss in midfrequency threshold sensitivity (8 and 16 kHz). CAP thresholds were elevated at midfrequencies (8 and 16 kHz) among TCE-treated subjects, along with a suppression of the N1 amplitude from 50 to 90 dB SPL. The cochlear microphonic, a nonpropagated ac potential generated largely by the outer hair cells, was not affected by the TCE treatment. Cochlear histopathology revealed a loss of spiral ganglion cells that was significant in the middle turn, but not in the basal turn. There was an inconsistent loss of hair cells among treated subjects. The data suggest strongly that the behaviorally determined loss in auditory function can be accounted for by a cochlear impairment and that the spiral ganglion cell may be a prominent target of TCE.

Effects of noise on inferior colliculus evoked potentials and cochlear anatomy in young and aged chinchillas

Like many aging humans, the aging chinchilla tends to lose high-frequency sensitivity at a faster rate than low-frequency sensitivity. This feature, combined with its excellent low-frequency hearing, makes the chinchilla attractive as an animal model for studying the relationship between noise-induced hearing loss (NIHL) and age-related hearing loss (AHL). In the present study, we examined susceptibility to noise in 15 aged (10-15 years old) and 15 young chinchillas. Two levels of noise were used, with the aim of determining whether age-related differences exist in the magnitude and rate of recovery from temporary threshold shifts produced by a moderate-level (95 dB) noise exposure, or in susceptibility to permanent threshold shifts and cochlear damage caused by a high-level (106 dB) noise exposure. Thresholds and response amplitudes at 0.5, 1, 2, 4, 8 and 16 kHz were determined from evoked potentials recorded from the inferior colliculus. Cochlear histology was performed on animals exposed to high-level noise. The results suggest that older animals are equally vulnerable to moderate-level noise, but may be slightly more vulnerable to high-level noise. For moderate-level exposures, there appears to be a simple additive relationship (in dB) between AHL and NIHL. For high-level exposures, the relationship may be more complex.

Role of glutathione in protection against noise-induced hearing loss

A potential mechanism of hearing loss due to acoustic overstimulation is the generation of reactive oxygen species (ROS). ROS not removed by antioxidant defenses could be expected to cause significant damage to the sensory cells of the cochlea. We studied the influence of the antioxidant glutathione (GSH) on noise-induced hearing loss by using l-buthionine-[S,R]-sulfoximine (BSO), an inhibitor of GSH synthesis, and 2-oxothiazolidine-4-carboxylate (OTC), a cysteine prodrug, which promotes rapid restoration of GSH when GSH is acutely depleted. Pigmented female guinea pigs were exposed to broadband noise (102 dB SPL, 3 h/day, 5 days) while receiving daily injections of BSO, OTC, or saline. By weeks 2 and 3 after noise exposure, BSO-treated animals showed significantly greater threshold shifts above 12 kHz than saline-treated subjects, whereas OTC-treated animals showed significantly smaller threshold shifts at 12 kHz than controls. Histologically assessed noise-induced damage to the organ of Corti, predominantly basal turn row 1 outer hair cells, was most pronounced in BSO-treated animals. High performance liquid chromatographic analysis showed that OTC significantly increased cysteine levels, but not GSH levels, in the cochlea. These findings show that GSH inhibition increases the susceptibility of the cochlea to noise-induced damage and that replenishing GSH, presumably by enhancing availability of cysteine, attenuates noise-induced cochlear damage.

Long-term in vivo cochlear transgene expression mediated by recombinant adeno-associated virus

Adeno-associated virus (AAV) integrated transgene expression within guinea pig cochlea has been previously documented. This article extends these studies by characterizing the AAV-mediated gene transfer for duration of transgene expression within the cochlea and its effect upon cochlear cytoarchitecture over a period of 6 months. All animals infused with AAV expressed the transgene product, bacterial beta-galactosidase (beta-gal) enzyme, in the spiral limbus, spiral ligament, spiral ganglion cells and the organ of Corti at 2-24 weeks after infusion. However, the level of beta-gal expression, as determined from intensity of immunoreactivity, was relatively lower at 24 weeks as compared with 2 weeks. The cellular and tissue architecture within the AAV-beta-gal perfused cochleae, harvested 2-8 weeks after AAV infusion, was generally intact, ie free from inflammation and cellular degeneration. However, cellular degeneration and degradation was apparent in the cochleae of some but not all animals harvested at 12 and 24 weeks after AAV infusion.

Morphometric changes in the chick nucleus magnocellularis following acoustic overstimulation

The present investigation considered the effects of cochlear damage caused by exposure to intense sound on the nucleus magnocellularis of the chick. Neonatal chicks exposed to intense sound were separated into four groups with post-exposure recovery durations of 0, 15, 27, and 43 days. Four age-matched, non-exposed control groups were also formed. At each recovery interval, the control and exposed birds were sacrificed and their brains prepared for paraffin embedding. The brain stem region containing the nucleus magnocellularis (NM) was serially sectioned in the coronal plane. All sections containing NM cells were identified and then coded in terms of their percentile distance from the most caudolateral section. Sections along the nucleus at the 15th, 30th, 50th, 65th, 80th, and 95th percentile positions were selected for evaluation, and the cross-sectional areas of individual NM cells in these sections were then measured. Cell areas were corrected for the bias introduced by eccentricity of the nucleus. The number of NM cells per 1,000 microm2 was also calculated at the 50th and 65th percentile positions. These procedures were repeated for the age-matched, non-exposed control animals. The cross-sectional cell area in exposed animals, immediately after the exposure, was reduced significantly at all positions, but returned to near normal by 43 days of recovery. However, the coronal area of NM in the sections at the 50th and 65th percentile position, as well as NM cell density, were unaffected by the exposure at all recovery intervals. The observation of structural recovery in NM cells at 43 days post-exposure was remarkable because it occurred at least 4 weeks after complete functional restoration of single-cell activity in the NM. The shrinkage in NM cell size throughout the nucleus may be due to a general reduction in spontaneous activity in the cochlear nerve fibers caused by the acoustic injury to the chick basilar papilla.

ABR and DPOAE detection of cochlear damage by gentamicin

Auditory brainstem responses (ABR) and distortion product otoacoustic emissions (DPOAE) have been applied to the evaluation of peripheral auditory function. To date, no comparison of their relative sensitivities to aminoglycoside toxicity has been reported. The purpose of this study was to compare click evoked ABR testing and 2f1-f2 DPOAEs as detectors of cochlear damage induced by gentamicin treatment in guinea-pigs. ABR thresholds to click stimuli were recorded. DPOAE amplitude input/output functions were recorded using three different primary tone level conditions. In one condition, L1 was changed relative to a fixed L2. In the next condition, L2 was changed relative to a fixed L1. In the third condition, L1 and L2 were both changed while maintaining a consistent L1-L2 difference. Baseline L1-L2 differences were determined by adjusting L2 to produce the maximum DPOAE amplitude in each ear of each subject. Guinea-pigs were treated for a four week period with intramuscular injections of gentamicin. ABRs and DPOAEs were monitored and compared to baseline recordings or untreated control groups. DPOAE testing detected cochlear damage earlier than ABR testing. Changes in DPOAE input/output functions were noted after two weeks of treatment while changes in ABR threshold were not identified until after three weeks of treatment. The sensitivity of the DPOAE testing was related to the stimulus conditions utilized. L1-L2 differences were determined in the control group and for the initial test session by fixing L1 at 75 dB SPL and lowering L2 until the maximum DPOAE amplitude was obtained for each ear. All subsequent testing was begun using the optimal L1-L2 difference for each ear. The stimulus condition in which only L1 was changed and L2 was fixed resulted in the least sensitive DPOAE indicator of cochlear damage. The condition in which both L1 and L2 were changed, but the L1-L2 difference remained constant, resulted in the most sensitive indicator of damage. The onset and degree of cochlear damage secondary to gentamicin treatment was subject dependent. This study demonstrates that 2f1-f2 DPOAE testing is preferable to click evoked ABR testing for early detection of gentamicin toxicity of the cochlea. It also indicates that DPOAE stimulus parameters must be considered when developing test protocols. Specifically, recording the DPOAE amplitude input/output function while maintaining an effective L1-L2 difference is preferable to changing either L1 or L2 individually.

Cochlear otosclerosis 30 years after stapedectomy confirmed by CT, MRI

A 64-year-old Japanese male patient, status post-stapedectomy, presented with progressive, bilateral SNHL of 30 years' duration. CT showed extensive demineralization of the otic capsule, suggestive of otospongiotic change in both ears. There were no hyperostotic lesions found, which would have been suggestive of otosclerotic change. MRI showed a morphologically intact membranous labyrinth in both ears, with no obstruction of the cochlear lumen. It was concluded that the patient has progressive otospongiotic change of the otic capsule, but no otosclerotic change.

Induction of labyrinthitis ossificans after pneumococcal meningitis: an animal model

Newly formed disorganized bone fills the open spaces within the otic capsule in various pathologic conditions, resulting in labyrinthitis ossificans. The pathologic mechanisms of this disease remain poorly understood. To better study the sequence of events and contributing mechanisms involved in labyrinthitis ossificans, an animal model was developed. Three groups of Mongolian gerbils received either an intralabyrinthine injection of normal saline solution (group 1) or Streptococcus pneumoniae polysaccharide capsule antigens (groups 2 and 3). The temporal bones were harvested after 3 months and serially sectioned. None of the eight control animals (group 1), which received intralabyrinthine injections of normal saline solution had any histologic changes in their temporal bones. Nine of the surviving 19 animals in groups 2 and 3 had fibrosis or evidence of early ossification. A fourth group of Mongolian gerbils received two intrathecal injections of live S. pneumoniae organisms. The temporal bones were harvested after 3 months and serially sectioned. Fourteen of the surviving 15 animals had fibrosis or ossification or both. This animal model will provide a method for study of the mechanisms of labyrinthitis ossificans.

[The study of ototoxicity in Gallus domesticus by recording distortion products]

Distortion products (DP) were recorded and a morphological cochlear study was made of a sample of 60 ears from chickens (Gallus domesticus. Leghorn breed) and the ages of 15, 23, 29 and 60 days, after intoxication by intramuscular gentamicin injection (40 mg per kg weight and day for 8 days). Spontaneous or transitory otoacoustic emissions were not obtained in any case. DP recordings showed a 2F1-F2 response in every frequency band ranging from 0.7 to 6 KHz. The DP incidence shifted with the age of the chickens and differed significantly (p < 0.001) in the groups of 29 and 60 day-old chickens (m = 100%) and in the 29-day-old (m = 64%) and 60-day-old (m = 62%) intoxicated chickens. We found no significant differences in DP amplitude in subpopulations. In the intoxicated groups, the proximal segment of the ototic membrane disappeared in the macula lagenae and a loss of contact with the hair cells appeared. Degenerative vacuolar phenomena were observed in the support cells and cellular loss in the spiral ganglion.

Supplemental iron exacerbates aminoglycoside ototoxicity in vivo

There is increasing evidence to suggest that free radical generation is central to a variety of pathological processes, including drug toxicity. Studies demonstrating the ability of gentamicin to facilitate the generation of radical species suggest that this process plays an important role in aminoglycoside-induced ototoxicity. Because transition metals, particularly iron, play an important role in the production of free radicals and the generation of reactive oxygen species, we sought to determine whether gentamicin-induced ototoxicity is exacerbated by increases in serum iron levels. To this end, we assessed the effects of supplemental iron administration (2 mg/kg/day and 6 mg/kg/day) on changes in auditory function induced by co-administration of gentamicin (100 mg/kg/day for 30 days). Experiments were carried out on pigmented guinea pigs initially weighing 250-300 g. Changes in cochlear function were characterized as shifts in compound action potential (CAP) thresholds, estimated every third day throughout the treatment period by use of chronic indwelling electrodes implanted at the round window, vertex, and contralateral mastoid. Results showed that animals receiving iron in combination with gentamicin demonstrated a more rapid and profound elevation in CAP thresholds compared with animals receiving gentamicin alone. This effect occurred in a dose-dependent manner. Animals receiving supplemental iron alone maintained normal CAP thresholds throughout the treatment period. There was no statistically significant difference in serum gentamicin levels between groups receiving gentamicin alone or gentamicin plus iron. These results provide further evidence of the recently reported intrinsic role of iron in aminoglycoside ototoxicity, and highlight a potential risk of aminoglycoside administration in patients with elevated serum iron.

Bacterial cytolysin perturbs round window membrane permeability barrier in vivo: possible cause of sensorineural hearing loss in acute otitis media

The passage of radioiodinated streptolysin-O (SLO) and albumin through the round window membrane (RWM) was studied in vivo. When applied to the middle ear, SLO became quantitatively entrapped in this compartment and no passage to the cochlea occurred. However, flux of radioiodinated albumin through the toxin-damaged RWM was observed. We propose that the passage of noxious macromolecules, such as proteases, from a purulent middle-ear effusion may be facilitated by pore-forming toxins, resulting in cochlear damage and sensorineural hearing loss.

Age-related changes in the cochlea and cochlear nuclei of dogs

To study the underlying morphological changes of presbycusis, cochlea and cochlear nuclei from twenty three dogs, ranging in age from 3 days to 17 years, were examined histologically. Dogs used in this study were house dogs kept in an environment similar to that of humans. Four types of histological changes reported in human presbycusis, that is, loss of spiral ganglion cells, atrophy of the organ of Corti, atrophy of the stria vascularis, and thickening of the basilar membrane were observed in dogs. The changes were prominent at the base of the cochlea. Less intense changes were also observed in the apex of the cochlea. The degree of these changes appeared to progress as a function of age. All four types of changes with varied intensity were found in all dogs over 12 years old. In addition to the changes in the cochlea, cochlear nuclei changes including nerve cell loss, astrogliosis and ubiquitin deposition were found in dogs over 10 years old. Hearing dysfunction was accompanied by the morphological changes, though the degree of the hearing dysfunction did not always parallel to that of morphological changes. The morphological changes seen in the cochlea and cochlear nuclei of dogs were qualitatively and quantitatively similar to those reported in aged humans, indicating that otopathologic changes in the inner ear may be due to aging plus exposure to certain environmental ototoxic factors.

Retinocochleocerebral vasculopathy

We report 10 patients with retinocochleocerebral vasculopathy and review the clinical and diagnostic considerations in previously reported patients with this uncommonly recognized disease. The clinical manifestations include acute and subacute multifocal and diffuse encephalopathic symptoms, hearing loss, and visual loss attributable to microangiopathy affecting the arterioles of the brain, retina, and cochlea. Diagnosis is facilitated by demonstration of retinal arteriolar occlusions without uveitis or keratoconjunctivitis, mid- to low-frequency unilateral or bilateral sensorineural hearing loss, and numerous small foci of increased signal in the white and gray matter on T2 weighted brain magnetic resonance imaging. Because many conditions may produce any combination of strokelike cerebral symptoms, encephalopathy, hearing loss, and visual loss, the differential diagnosis for retinocochleocerebral vasculopathy includes connective tissue disease, demyelinating disease, procoagulant state, infection, neoplasm, and more routine mechanisms of cerebral and retinal ischemia. Brain biopsy specimens demonstrate only minimal nonspecific periarteriolar chronic inflammatory cell infiltration with or without microinfarcts. The demonstration of subclinical arteriolar microangiopathy in muscle biopsy specimens, documented in 3 of our patients may assist in making the diagnosis. The clinical course appears to be monophasic. In addition to corticosteroids, treatment options include immunosuppressant agents (cyclophosphamide or azathioprine) aspirin, calcium channel blockers (nimodipine), intravenous immunoglobulin, and plasmapheresis. The etiology of the disease is unknown, but histopathologic and laboratory evidence suggests that an immune-mediated mechanism may be involved.

Studies of cochlear blood flow in guinea pigs with endolymphatic hydrops

Laser Doppler flowmetry was used to assess cochlear blood flow (CoBF) in guinea pigs with experimental endolymphatic hydrops following intravenous infusion of 5 types of drugs: 50% glycerol, 70% isosorbide, 20% mannitol, 7% sodium bicarbonate, and 1% diphenidol. The magnitude of the CoBF changes following infusion tended to be smaller in the hydropic ears than in the normal control ears. A significant reduction in CoBF changes was observed in hydropic ears infused with isosorbide and sodium bicarbonate. These results suggest that the cochlear microvascular sensitivity to various stimuli such as drug infusion is reduced in hydropic ears. This may result from atrophy of the stria vascularis which is often observed in the hydropic ears of guinea pigs. Thus it seems likely that the same reaction occurs in the inner ear of patients with Ménière's disease in whom atrophy of the stria vascularis is also presumed to exist in conjunction with extensive endolymphatic hydrops. Therefore, it seems probable that the function of the microvasculature of the stria vascularis is impaired in the inner ear of patients with Ménière's disease, resulting in the slow progressive deterioration of the inner ear with time.

A major gene affecting age-related hearing loss in C57BL/6J mice

A major gene responsible for age-related hearing loss (AHL) in C57BL/6J mice was mapped by analyses of a (C57BL/6J x CAST/Ei) x C57BL/6J backcross. AHL, as measured by elevated auditory-evoked brainstem response (ABR) thresholds, segregated among backcross mice as expected for a recessive, primarily single-gene trait. Both qualitative and quantitative linkage analyses gave the same genetic map position for the AHL gene (Ahl on chromosome 10, near D10Mit5. Marker assisted selection was then used to produce congenic lines of C57BL/6J that contain different CAST-derived segments of chromosome 10. ABR test results and cochlear histopathology of aged progenitors of these congenic lines are presented. Ahl is the first gene causing late-onset, non-syndromic hearing loss that has been reported in the mouse.

Interaction between hypertension and diabetes mellitus in the pathogenesis of sensorineural hearing loss

The purpose of this study is to support the hypothesis that diabetic end-organ damage of the cochlea is augmented in the setting of hypertension. A historical perspective reviewing the effects of diabetes and hypertension as causative factors in the development of sensorineural hearing loss, as well as the basic epidemiology and pathophysiology of the renal and vascular effects of diabetes and hypertension, is presented. The results of audiologic findings in insulin-dependent diabetic patients, both normotensive and hypertensive, were analyzed and correlated with the results of animal studies to support the hypothesis that sensorineural hearing loss in patients and cochlear hair cell loss in animal studies result from the effects of hypertension in conjunction with insulin-dependent diabetes mellitus.

Macrophage activity in organ cultures of the avian cochlea: demonstration of a resident population and recruitment to sites of hair cell lesions

The factors that regulate the repair and regeneration of the sensory hair cells of the inner ear are not understood. Previous studies of hair cell injury in the lateral line sensory organs of amphibians and the cochleae of mammals have demonstrated that macrophages and other leukocytes are recruited to sites of hair cell lesions. The present study examined the distribution and activity of macrophages in organ cultures of the avian cochlea, a system whose regenerative abilities have been widely studied. Cochleae were removed from chicks and placed in organ culture, and precise hair cell lesions were created using a laser microbeam. Macrophages in the cultures were identified using histochemical, immunocytochemical, and morphologic criteria. It was found that (a) cultured cochleae contained a resident population of macrophages, and (b) increased numbers of macrophages were recruited to the sites of hair cell lesions. Furthermore, the latency of macrophage recruitment to lesions is consistent with a suggested role for macrophages in the initiation of hair cell regeneration.

Intact canal wall drill-out procedure for implantation of the totally ossified cochlea

OBJECTIVE

To describe a simplified drill-out technique for insertion of a multichannel electrode in the completely ossified cochlea without radical mastoidectomy and obliteration.

STUDY DESIGN

Description of a new surgical technique and case report.

SETTING

Temporal bone dissection laboratory and tertiary referral center.

PATIENTS

Adult and pediatric cochlear implant (CI) recipients.

MAIN OUTCOME MEASURES

Access for circum-modular drill-out and electrode insertion without radical mastoidectomy and adequate function of multichannel CI.

RESULTS

Dissection of 10 cadaver temporal bones demonstrated feasibility of this technique. Highlights include facial recess cochleostomy and 8 mm tunnel; elevation of superiorly based tympanomeatal flap; removal of incus, cochleariform process, and tensor tympani; and identification of carotid canal and use of facial nerve monitor. A case report of an 11-year-year old child with total cochlear ossification and previous failure of a short (8 electrode) CI electrode insertion is presented. Complete insertion of a 22-channel electrode was successful and open-set word recognition is commencing.

CONCLUSIONS

The canal wall-up drill-out procedure allows complete electrode insertion without mastoid obliteration in patients with obliterated cochleas. Appropriate attention to the carotid artery and facial nerve is essential.