Temporal Bone Histopathology in Alport Syndrome

OBJECTIVE

To determine the histopathologic abnormalities within the cochlea in Alport syndrome.

BACKGROUND

Alport syndrome, which manifests as hereditary nephritis and sensorineural hearing loss (SNHL), is caused by mutations in genes that code for the proportional, variant3, proportional, variant4, and proportional, variant5 chains of type IV collagen. The proportional, variant3, proportional, variant4, and proportional, variant5 chains of type IV collagen are present in the basement membrane of the organ of Corti. Previous temporal bone studies have failed to identify histopathologic correlates for the SNHL.

METHODS

We examined temporal bones from nine individuals with a clinical diagnosis of Alport syndrome. One of our cases also had genetic testing that showed a mutation in the type IV collagen proportional, variant5 chain gene.

RESULTS

By light microscopy, eight of nine cases demonstrated two unique pathologic changes: 1) a "zone of separation" between the basilar membrane and overlying cells of the organ of Corti and 2) presence of cells filling the tunnel of Corti and extracellular spaces of Nuel. The cytologic losses of hair cells, stria vascularis, and cochlear neuronal cells were insufficient to account for the observed SNHL in our cases. Electron microscopy was performed in four cases; all four demonstrated the following: 1) the zone of separation that was observed at light microscopy occurred between the basement membrane and the basilar membrane, 2) the cells within the tunnel of Corti and spaces of Nuel were morphologically similar to supporting cells, and 3) the basement membrane of strial capillaries and the spiral vessel (under the basilar membrane) were normal.

CONCLUSIONS

The histopathologic correlates of cochlear involvement in Alport syndrome are abnormalities of the basement membrane of cells of the organ of Corti and dysmorphogenesis (cellular infilling of the tunnel and extracellular spaces) of the organ of Corti. We hypothesize that these abnormalities result in SNHL by altering cochlear micromechanics.

Histologic Evaluation of the Tissue Seal and Biologic Response Around Cochlear Implant Electrodes in the Human

HYPOTHESIS

Histopathologic study of the tissue seal and biologic response around cochlear implant electrodes in patients who had received a cochlear implant during life could provide clues concerning the pathogenesis of meningitis after cochlear implantation.

BACKGROUND

Bacterial meningitis has been reported as an infrequent complication of cochlear implantation using a variety of electrode designs. The cause of meningitis in cochlear implant recipients has not been firmly established. In an analogous surgical situation, namely stapedectomy, delayed meningitis could occur as a complication of ipsilateral acute suppurative otitis media in which there was open communication between the middle ear and perilymph.

METHODS

Twenty-one temporal bones from 20 individuals who had undergone cochlear implantation during life were studied by light microscopy. All sections passing through the cochleostomy site and electrode track were examined to evaluate the tissue seal at the cochleostomy, the presence or absence of an extracochlear electrode sheath, and finally, to seek evidence of a cellular inflammatory response near the electrode. These data were compared with clinical data, including electrode system used, the number of years between implantation and death, type of tissue used at surgery, and the age and sex of the patients.

RESULTS

The 21 specimens included cases implanted with the Symbion Ineraid, Cochlear Corporation Nucleus 22-channel, Cochlear Corporation Nucleus 24-channel, a Cochlear Corporation Nucleus single channel, and Advanced Bionics Clarion C1 devices. At the cochleostomy site, and just within the cochlea, there was a robust fibrous and bony tissue response in all 21 ears and in most cases, there was a fibrous sheath surrounding the electrode in the middle ear. No recognizable open communication or potential communication between the middle ear and the inner ear was seen in any of the 21 ears. An inflammatory cellular response, including mononuclear leukocytes, histiocytes, and foreign body giant cells, were present in 12 of the 21 temporal bones (57%) and was most intense at the cochleostomy site. No statistically significant relationship was found between the presence or absence of inflammatory cells and the type of tissue graft used at surgery.

CONCLUSIONS

The histologic evidence presented in this study does not support open communication between the middle and the inner ear as part of the pathogenesis of bacterial meningitis as a late complication after cochlear implantation. Rather, the finding of a cellular inflammatory response in 12 of 21 temporal bones suggests that late hematogenous contamination and colonization of the implant is a much more likely pathogenic mechanism. This putative mechanism has implications for possible strategies to prevent meningitis after cochlear implantation.

Axial mesodermal dysplasia sequence: autopsy findings

We describe an infant with the phenotype of the "axial mesodermal dysplasia spectrum" who had the oculo-auriculo-vertebral sequence and caudal dysgenesis. Postmortem studies identified anomalies of the middle ear ossicles, and muscles, in association with microtia and atresia of the external auditory canals, but no cerebral abnormalities.

Histopathology of the inner ear in unoperated acoustic neuroma

Although hearing loss is the most common presenting symptom in patients with acoustic neuroma, the pathophysiology of hearing loss associated with acoustic neuroma is unknown. Although primary dysfunction of the auditory nerve is intuitively logical, available histopathologic and clinical data suggest that although neural degeneration is common, it alone does not adequately account for hearing loss in many cases. The purpose of this study was to evaluate 11 cases of unoperated unilateral acoustic neuromas. Temporal bones were identified by means of a search mechanism provided by the National Temporal Bone, Hearing, and Balance Pathology Resource Registry and were prepared for light microscopy by standard techniques. Quantification of spiral ganglion cells, hair cells, stria vascularis, and spiral ligament was accomplished for each specimen. In addition, the maximum diameter and volume of each tumor were calculated from histopathologic sections. Increasing tumor size did predict a reduced spiral ganglion count. However, although there was a tendency for decreasing spiral ganglion cell count and for increasing tumor size to predict a higher pure tone average and lower speech discrimination score, these correlations did not reach statistical significance. In tumor ears in which the speech discrimination score was 50% or less, there was always significant degeneration of other structures of the inner ear in addition to neurons, including hair cells, the stria vascularis, and the spiral ligament. Endolymphatic hydrops and eosinophilic precipitate in the perilymphatic spaces were found in 2 of 3 such cases. It is concluded that acoustic neuromas appear to cause hearing loss, not only by causing degeneration of the auditory nerve, but also by inducing degenerative changes in the inner ear. It is hypothesized that the proteinaceous material seen histologically may represent the products of up-regulated genes in acoustic neuroma, some of which may interfere with normal cochlear function.

Proton beam radiosurgery for vestibular schwannoma: tumor control and cranial nerve toxicity

OBJECTIVE

We sought to determine the tumor control rate and cranial nerve function outcomes in patients with vestibular schwannomas who were treated with proton beam stereotactic radiosurgery.

METHODS

Between November 1992 and August 2000, 88 patients with vestibular schwannomas were treated at the Harvard Cyclotron Laboratory with proton beam stereotactic radiosurgery in which two to four convergent fixed beams of 160-MeV protons were applied. The median transverse diameter was 16 mm (range, 2.5-35 mm), and the median tumor volume was 1.4 cm(3) (range, 0.1-15.9 cm(3)). Surgical resection had been performed previously in 15 patients (17%). Facial nerve function (House-Brackmann Grade 1) and trigeminal nerve function were normal in 79 patients (89.8%). Eight patients (9%) had good or excellent hearing (Gardner-Robertson [GR] Grade 1), and 13 patients (15%) had serviceable hearing (GR Grade 2). A median dose of 12 cobalt Gray equivalents (range, 10-18 cobalt Gray equivalents) was prescribed to the 70 to 108% isodose lines (median, 70%). The median follow-up period was 38.7 months (range, 12-102.6 mo).

RESULTS

The actuarial 2- and 5-year tumor control rates were 95.3% (95% confidence interval [CI], 90.9-99.9%) and 93.6% (95% CI, 88.3-99.3%). Salvage radiosurgery was performed in one patient 32.5 months after treatment, and a craniotomy was required 19.1 months after treatment in another patient with hemorrhage in the vicinity of a stable tumor. Three patients (3.4%) underwent shunting for hydrocephalus, and a subsequent partial resection was performed in one of these patients. The actuarial 5-year cumulative radiological reduction rate was 94.7% (95% CI, 81.2-98.3%). Of the 21 patients (24%) with functional hearing (GR Grade 1 or 2), 7 (33.3%) retained serviceable hearing ability (GR Grade 2). Actuarial 5-year normal facial and trigeminal nerve function preservation rates were 91.1% (95% CI, 85-97.6%) and 89.4% (95% CI, 82-96.7%). Univariate analysis revealed that prescribed dose (P = 0.005), maximum dose (P = 0.006), and the inhomogeneity coefficient (P = 0.03) were associated with a significant risk of long-term facial neuropathy. No other cranial nerve deficits or cancer relapses were observed.

CONCLUSION

Proton beam stereotactic radiosurgery has been shown to be an effective means of tumor control. A high radiological response rate was observed. Excellent facial and trigeminal nerve function preservation rates were achieved. A reduced prescribed dose is associated with a significant decrease in facial neuropathy.

Morphometric changes in the cochlear nucleus in patients who had undergone cochlear implantation for bilateral profound deafness

We have investigated the morphometric changes in the cochlear nucleus of patients who had undergone cochlear implantation following profound deafness. The brain stems of 11 adult patients who had undergone implantation and four non-implanted control cases with varying degrees of hearing loss were studied. The volumes of the ventral cochlear nucleus (VCN) and dorsal cochlear nucleus (DCN), and the maximal cross-sectional area and densities of cell bodies in the anterior ventral cochlear nucleus (AVCN) were measured bilaterally by light microscopy assisted by the Neurolucida 2000 image analysis system. In addition, the density of synapses on cells of the AVCN were estimated using immunostaining for the synaptosome-associated protein (SNAP-25) by light microscopy. There was no significant difference in volumes of VCN and DCN, maximal cross-sectional area and density of cell bodies of the AVCN, and SNAP-25 immunostaining between the cochlear nucleus ipsilateral and contralateral to cochlear implantation. In addition, there was no significant correlation between these morphometric parameters and clinical performance. Peripheral deafness seems to reduce the size of neurons in the AVCN in that the maximum diameter of cell bodies was greater in the ear with better hearing preoperatively (chi-square test P<0.05). However, electrical stimulation provided by the cochlear implantation did not alter these morphometric changes in adult cochlear implant patients.

Reciprocal innervation of outer hair cells in a human infant

Reciprocal synapses are characterized by the presence of both afferent and efferent types of synaptic specializations between two cells. They have been described at the neural poles of outer hair cells (OHCs) in humans with advanced age and two monkey species. Our objective was to study the innervation of the OHCs and determine if reciprocal synapses were present in a young (8-month-old infant) human subject. We studied the synaptic and cytoplasmic morphology of 162 nerve terminals innervating 29 OHCs using serial section transmission electron microscopy. Seventy-six percent of all OHCs were innervated by terminals with reciprocal synapses. This prevalence increased from the first toward the third row (p < 0.001), and 100% of OHCs in the third row demonstrated at least one reciprocal synapse. The prevalence of terminals with reciprocal synapses was higher in the human infant than in older human subjects and was very similar to what has been reported for the chimpanzee. Reciprocal synapses occur in sufficient numbers to be physiologically significant in primates. The nerve terminals were found to segregate into two groups on the basis of their cytoplasmic morphological characteristics: (1) vesicle-rich/neurofilament-poor (VR/NP) and (2) vesicle-poor/neurofilament-rich (VP/NR). All afferent and reciprocal terminals were of the VP/NR variety. The majority of the efferent terminals originated from VR/NP nerve fibers (classical olivocochlear morphology), but 23.5% of the efferent terminals were VP/NR. The hypothesis that peripheral processes of type II spiral ganglion cells form classical afferent, reciprocal, and a number of purely presynaptic terminals on OHCs is discussed. The presence of different types of synaptic specializations on OHCs formed by nerve fibers of the same type (VP/NR) suggests the existence of reciprocal neuronal circuits between OHCs sharing the dendritic arborization of a type II spiral ganglion cell.

Malleus fixation: clinical and histopathologic findings

The goals of this study were to review important clinical and histopathologic features of malleus fixation. Ten clinical cases and 10 histopathologic cases of malleus fixation were identified. For the clinical cases, preoperative clinical data, surgical findings, and preoperative and postoperative audiometric findings were reviewed. Ninety percent of the clinical cases achieved significant reduction of the air-bone gap after operation. Two thirds of these cases had an air-bone gap of 10 dB or less, and the remainder had air-bone gaps between 20 and 28 dB after operation. For the temporal bone cases, clinical data, histopathologic findings, and other otologic diagnoses were reviewed. Malleus fixation can be idiopathic or a result of trauma, chronic otitis media, or developmental anomalies. It is a cause of hearing loss that is likely to be more common than the number of diagnoses would indicate. Certain audiometric findings may lead one to suspect the diagnosis. The surgical approach used depends on the individual anatomy, and surgery is usually highly effective in improving hearing.

Axodendritic and dendrodendritic synapses within outer spiral bundles in a human

Axodendritic and dendrodendritic synapses have been described at the level of the outer spiral bundle (OSB) (Nadol, J.B., Jr., 1983. Laryngoscope 93, 780-791; Bodian, D., 1978. Proc. Natl. Acad. Sci. USA 75, 4582-4586). The objectives of this study were to quantify these synaptic interactions and to describe their ultrastructural morphology in a young human subject. The temporal bone of an 8-month old infant was processed for transmission electron microscopy and semiserial section reconstructions of the three OSBs were performed. The nerve fibers ((NFs)) forming the OSBs were found to segregate into two morphological groups: (1) vesicle-rich and neurofilament-poor (VR/NP); (2) vesicle-poor and neurofilament-rich (VP/NR). Synapses between VR/NP and VP/NR NFs and synapses between two VP/NR NFs were quantified. Presumed axodendritic synapses (i.e. between VR/NP and VP/NR NFs) were numerous and their numbers decreased from the first towards the third row. Presumed dendrodendritic synapses (i.e. between two VP/NR NFs) were also frequent but their numbers did not vary significantly among different rows. The presence of axodendritic synapses may provide the morphological basis for modulation of the function of the type II spiral ganglion cells (type II's) by the olivocochlear efferent system. Similarly, numerous presumed dendrodendritic synapses may provide a morphological substrate for interaction between dendrites of type II's.

Morphometric analysis of age-related changes in the human basilar membrane

The histopathologic correlates of presbycusis suggest several categories, including degeneration of sensory cells, neurons, or the stria vascularis. Lack of clear-cut histopathologic changes in some cases has suggested an "indeterminate category"; however, several studies have suggested that a disorder of the basilar membrane (BM) may underlie indeterminate presbycusis. The objective of the present study was to quantify age-related changes in the human BM and correlate them with audiometric patterns. Under high-resolution light microscopy, BM thickness was calculated, and the number of tympanic mesothelial cells (TMCs) lining the BM was counted, at 4 cochlear locations in 92 temporal bones. The control group (n = 80) included subjects from 10 decades of age with normal hearing and/or histopathologic findings. The indeterminate group (n = 12) consisted of elderly patients (ages 64 to 91 years) with hearing loss and no apparent histopathologic changes. Age-related BM thickening was seen in both groups, but only in the most basal cochlear region. The BM thickness in the indeterminate group was not significantly different from that of age-matched controls. Counts of TMCs showed age-related decreases in all cochlear regions in both groups; however, TMC counts in the indeterminate group were not different from those of age-matched controls. The results suggest that BM histopathology is not a common cause of presbycusis. Although age-related BM thickening, seen in both groups, could contribute to hearing loss, the extreme basal region, to which the thickening was confined, is not tested in routine audiometry.

Histopathology and molecular genetics of hearing loss in the human

Hearing loss is among the most common disabilities of man. It has been estimated that over 70 million individuals in the world are hearing impaired with pure tone averages greater than 55 dB. A genetic etiology is thought to be responsible for over half of early onset hearing loss and at least one third of late onset hearing loss. In this review, examples of the histopathology of the inner ear in known genetic syndromes in the human will be presented in order to provide a structural basis for understanding molecular mechanisms of development and maintenance in the inner ear, and to serve the essential function of validating the applicability of animal genetic models of hearing loss to the human condition.

Histopathology of cochlear implants in humans

The insertion of an intrascalar electrode array during cochlear implantation causes immediate damage to the inner ear and may result in delayed onset of additional damage that may interfere with neuronal stimulation. To date, there have been reports on fewer than 50 temporal bone specimens from patients who had undergone implantation during life. The majority of these were single-channel implants, whereas the majority of implants inserted today are multichannel systems. This report presents the histopathologic findings in temporal bones from 8 individuals who in life had undergone multichannel cochlear implantation, with particular attention to the type and location of trauma and to long-term changes within the cochlea. The effect of these changes on spiral ganglion cell counts and the correlation between speech comprehension and spiral ganglion cell counts were calculated. In 4 of the 8 cases, the opposite, unimplanted ear was available for comparison. In 3 of the 4 cases, there was no significant difference between the spiral ganglion cell counts on the implanted and unimplanted sides. In addition, in this series of 8 cases, there was an apparent negative correlation between residual spiral ganglion cell count and hearing performance during life as measured by single-syllable word recognition. This finding suggests that abnormalities in the central auditory pathways are at least as important as spiral ganglion cell loss in limiting the performance of implant users.

Otopathology in a case of type I Waardenburg's syndrome

We report a case of type I Waardenburg's syndrome that provides insight into the etiopathogenesis of sensorineural hearing loss (SNHL) in this syndrome. The subject, a 76-year-old woman with type I Waardenburg's syndrome (dystopia canthorum, heterochromia irides, and white hair), had congenital low-frequency SNHL in her right ear only, which had remained relatively stable throughout her life. Blood leukocyte DNA studies revealed a PAX-3 mutation with a 1 base pair C-to-A substitution in exon 5 at base 602. Light microscopic studies of the right cochlea showed intact neurosensory structures in only the lower basal turn, with the remainder of the cochlea showing absence of melanocytes, absence of stria vascularis, missing hair cells, dysmorphogenesis of the tectorial membrane, and lack of peripheral processes of the spiral ganglion cells. There was pathological alteration of the vestibular dark cells with marked reduction of melanocytes associated with these dark cells. The left inner ear was normal, with a full complement of neurosensory structures, including melanocytes. Because the PAX-3 gene is involved in neural crest development and melanocytes migrate from the neural crest to the ear, the findings in this case are consistent with the hypothesis that defective melanocyte migration or defective melanocyte function results in defective development of the stria vascularis (and perhaps other structures of the ear), leading to SNHL.

Temporal bone histopathologic and genetic studies in Mohr-Tranebjaerg syndrome (DFN-1)

OBJECTIVE

To describe the temporal bone histopathologic and genetic abnormalities in a case of Mohr-Tranebjaerg syndrome.

BACKGROUND

Mohr-Tranebjaezrg syndrome (DFN-1) is an X-linked, recessive, syndromic hearing loss, characterized by postlingual sensorineural hearing loss with onset in childhood, followed in adult life by progressive dystonia, spasticity, dysphagia, and optic atrophy. The syndrome is caused by mutations in the DDP (deafness/dystonia peptide) gene, which are thought to result in mitochondrial dysfunction with subsequent neurodegeneration. The temporal bone pathologic changes in this syndrome have not been reported.

METHODS

Hearing loss developed in the patient at age 4, blindness at age 48, and dystonia at age 57. Genetic studies on peripheral blood showed a l51delT mutation in his DDP gene. He died at age 66. The right temporal bone was subjected to light microscopy and polymerase chain reaction-based analysis of the DDP gene sequence.

RESULTS

There was near complete loss of spiral ganglion cells with loss of nearly all peripheral and central processes. Only 1,765 spiral ganglion cells remained (8.5% of mean normal for age). The organ of Corti (including hair cells), stria vascularis, and spiral ligament were preserved. There was also a severe loss of Scarpa's ganglion cells with preservation of vestibular hair cells. The population of geniculate and trigeminal ganglion cells appeared normal. Sequence analysis from temporal bone DNA showed the 15ldelT DDP gene mutation.

CONCLUSION

Sensorineural hearing loss in Mohr-Tranebjaerg syndrome is the result of a postnatal, progressive, severe auditory neuropathy.

Histologic Studies of the Posterior Stapediovestibular Joint in Otosclerosis

OBJECTIVE

To determine the prevalence of ankylosis or otosclerosis at the posterior stapediovestibular joint (SVJ) in temporal bones with otosclerosis, with special reference to stapes surgery.

BACKGROUND

Long-term success of the laser stapedotomy minus prosthesis (STAMP) procedure, anterior crurotomy, and similar partial stapedectomy procedures depends on lack of ankylosis and lack of otosclerosis involving the posterior SVJ. Previous work has shown that the air-bone gap in otosclerosis correlates with narrowing and loss of the SVJ space. However, the prevalence and histologic features of otosclerotic involvement of the posterior SVJ space have not been well characterized.

METHODS

Histologic assessment of serial sections through the oval window niche in 140 temporal bones with otosclerosis that had been sectioned in the axial plane (age range 20-95 years, mean 68). Bones with stapes mobilization or stapedectomy were excluded.

RESULTS AND CONCLUSIONS

Two of 140 bones had otosclerosis exclusively at the posterior SVJ. Of the remaining 138 bones, all of which had otosclerosis at the anterior SVJ, 82 bones also had otosclerosis at the posterior joint. Of the 56 bones without otosclerosis of the posterior joint, there was bony ankylosis of the posterior joint in 3 bones. Thus, 53 bones (38%) had neither ankylosis nor otosclerosis involving the posterior joint, and they would be potentially suitable for a laser STAMP or a similar procedure. There was no correlation between otosclerosis at the posterior SVJ and age, sex, or duration of conductive hearing loss. Otosclerosis at the posterior joint in one ear was significantly associated with its presence at the posterior joint in the opposite ear (p = 0.01). The audiogram could not be used to reliably predict otosclerotic involvement of the posterior SVJ or the degree of footplate pathologic changes, such as ankylosis.

Histopathology of residual and recurrent conductive hearing loss after stapedectomy

HYPOTHESIS

Histopathologic examination of temporal bones from patients who had undergone stapedectomy may provide information concerning the causes of both residual and recurrent conductive hearing loss (CHL).

BACKGROUND

Although closure of the air-bone gap to within 10 dB occurs in approximately 90% of primary stapedectomies, a residual CHL occurs in approximately 10% and recurrent CHL may occur in up to 35% of cases. Putative causes of failure of surgery as determined during revision include erosion of the incus, bony regrowth at the oval window, and displacement of the prosthesis. Most reports on the histopathologic findings of temporal bones from such patients have focused on complications of surgery, with little attempt to correlate postoperative air-bone gap with the observed histopathology.

METHODS

A retrospective review of the author's collection of temporal bones ascertained 22 cases with postoperative CHL of 10 dB or greater (air-bone gap averaged at 500, 1,000, 2,000, 3,000, and 4,000 Hz, using postoperative air- and bone-conduction levels) after stapedectomy. These temporal bones were prepared by standard methodology for light microscopy.

RESULTS

Of the 22 cases with postoperative CHL equal to or greater than 10 dB, there were 19 with residual CHL, 2 with recurrent CHL, and 1 with both residual and recurrent CHL. The most common histopathologic correlates of residual and recurrent hearing loss included resorptive osteitis of the incus (64%); obliteration of the round window by otosclerosis (23%); the prosthesis lying on a residual footplate fragment (23%); the prosthesis abutting the bony margin of the oval window (18%); adhesions in the middle ear (14%); and new bone formation in the oval window (14%).

CONCLUSIONS

Histopathologic examination of temporal bones from patients who in life had undergone stapedectomy provides useful information concerning causes of both residual and recurrent CHL. These data provide a basis for improving both surgical technique and prosthesis design.

Prevalence and ultrastructural morphology of axosomatic synapses on spiral ganglion cells in humans of different ages

Axosomatic synapses were found on human spiral ganglion cells (HSGCs). Ultrastructural characterization and calculation of the prevalence of these synapses were performed by electron microscopic semi-serial sections of both type I and type II HSGCs, in specimens from subjects of ages 1 day, 14 days, 21 years and 51 years. Synapses on type I HSGCs were extremely rare. In contrast, axosomatic synapses were present on approximately 50% of type II HSGCs of a young adult. This prevalence seemed to vary by age. Thus, no synapses were found in a 1-day old neonate, few in a 14-day old, and on approximately 15% of the type II SGCs from a 51-year old specimen. The origin of the nerve fibers synapsing on the type II HSGCs could not be determined. In view of the fact that some of the fibers projected from the intraganglionic spiral bundle, which is known to contain olivocochlear efferents, these fibers may represent an efferent pathway to the spiral ganglion. However, since there was morphological evidence of more than one type of nerve fiber synapsing on type II HSGCs, other neural origins must be considered. Although the physiological function of these synapses is unknown, they may mediate pre-synaptic neural modulation of the type II HSGCs at the level of the spiral ganglion.

Hearing preservation in acoustic neuroma surgery: middle fossa versus retrosigmoid approach

OBJECTIVE

To compare the results of the middle fossa approach with those of the retrosigmoid approach in acoustic neuroma hearing preservation surgery.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care facility.

PATIENTS

Patients of the otology service with acoustic neuromas and useful hearing. Fifteen intracanalicular tumors were removed via a middle fossa approach and matched with 15 intracanalicular tumors removed via the retrosigmoid approach. Four additional patients with larger tumors were operated on via the middle fossa approach and matched with patients having similar tumors removed via the retrosigmoid approach.

MAIN OUTCOME MEASURES

The 1994 Committee on Hearing and Equilibrium guidelines for the evaluation of hearing preservation in acoustic neuroma were applied. Facial nerve results were graded according to the House-Brackmann grading scale 3 months postoperatively.

RESULTS

In the group operated on by the middle fossa approach, the average preoperative pure-tone threshold average (PTA) was 23 dB with a word recognition score (WRS) of 79%, and the postoperative PTA averaged 49 dB with a mean WRS of 56%. In the group operated on by the retrosigmoid approach, the mean preoperative PTA was 16 dB with a WRS of 95% and a postoperative PTA value of 62 dB and WRS of 51% (hearing preservation rate of 47%). The middle fossa patients had an average change in PTA of 19 dB and an average change in WRS of 20% (hearing preservation rate of 57%). Overall, the retrosigmoid patients had an average change in PTA of 42 dB and an average change in WRS of 40%. The average change in PTA for larger tumors removed via the middle fossa approach was 32 dB, whereas all matched retrosigmoid patients lost all hearing. The rate of cerebrospinal fluid leak and facial nerve outcomes were similar between the two groups. The retrosigmoid group had a higher rate of postoperative headache.

CONCLUSIONS

Compared with the retrosigmoid approach, the middle fossa approach for hearing preservation surgery yields better hearing results for intracanalicular tumors and also has a lower incidence of postoperative headache.

Outcomes assessment for chronic otitis media: the Chronic Ear Survey

Analysis of outcomes in chronic otitis media has in the past been limited to audiological measurement or physical examination. The Chronic Ear Survey (CES) is an instrument to measure the impact of chronic otitis media and its treatment. The survey provides information regarding total ear-specific health, as well as subscore information regarding activity restriction, symptoms, and medical resource usage attributable to chronic otitis media Application of the CES to a prospective, nonrandomized series of 147 patients revealed that patients with chronic otitis media have significantly decreased CES scores compared with unaffected controls and that surgical intervention provides a significant improvement in ear-specific outcomes.