The clinical findings to notice mild elevation of intracranial pressure in an otology clinic

Mildly elevated intracranial pressure appears to be a distinct pathology separate from idiopathic increased intracranial pressure and migraine. Many patients present with head fullness-pressure and dizziness, which is often suggestive of a clinical diagnosis of vestibular migraine. These patients may additionally have episodic vertigo as seen in endolymphatic hydrops and positional vertigo in addition to feeling dizzy. In most cases, hearing is normal. A long duration of the condition or a presence of associated ear pathologies, i.e., dehiscence, fistula, hypermobile footplate, or history of chronic ear infections can add hearing loss to clinical presentations. Low-pitch pulsatile tinnitus, when present, is an important symptom. The neuroimaging findings such as partially empty sella, blockage of the dural venous sinus or sigmoid sinus wall defects are frequently observed. The condition is diagnosed by measuring the lumbar puncture opening pressure. Typically, patients have normal cerebrospinal fluid chemistry and microscopy. Lowering the pressure during the lumbar puncture will resolve the patient's symptoms temporarily. Medical therapy is typically successful using carbonic anhydrase inhibitors and corrections of medical disorders that may be contributing to the increased pressure. A few require shunting or stenting procedures. In this review article, we define the condition in detail with illustrative cases that we collected from our practices.

Why should multiple dehiscences of the otic capsule be considered before surgically treating patients with superior semicircular canal dehiscence? A radiological monocentric review and a case series

This review aims to draw attention to the multiple ipsilateral otic capsule dehiscences (OCDs), which may cause therapeutic failure in operated patients. A series of six severely disabled patients with symptoms and signs consistent with a superior semicircular canal dehiscence (SSCD) diagnosis, confirmed by a high-resolution CT scan, is presented here. Five of the patients underwent surgery, and in four of the cases, the postoperative results were poor and/or disappointing. The ethical principles underlying modern medicine encourage medical staff to learn from past experience even when the results are modest despite the accuracy of the treatment applied to a patient. Consequently, we reviewed the radiological records of symptomatic and asymptomatic patients diagnosed or referred to our center for confirmation over the past 5 years to determine the incidence of multiple OCD in this population. Multiple localizations of suspected OCD in the ipsilateral ear did not appear to be rare and were found in 29 of 157 patients (18.47%) in our retrospective review using high-resolution thin-sliced CT scans. The decision to perform surgery for a documented symptomatic superior SSCD should be made with caution only after ruling out concomitant lesser-known variants of OCD in the ipsilateral ear.

Post-concussive Dizziness: A Review and Clinical Approach to the Patient

Dizziness is a frequent complaint after head trauma. Among patients who suffer a concussion (mild traumatic brain injury or mTBI), dizziness is second only to headache in symptom frequency. The differential diagnosis of post-concussive dizziness (PCD) can be divided into non-vestibular, central vestibular and peripheral vestibular causes with growing recognition that patients frequently exhibit both central and peripheral findings on vestibular testing. Symptoms that traditionally have been ascribed to central vestibular dysfunction may be due to peripheral dysfunction. Further, our ability to test peripheral vestibular function has improved and has allowed us to identify peripheral disorders that in the past would have remained unnoticed. The importance of the identification of the peripheral component in PCD lies in our ability to remedy the peripheral vestibular component to a much greater extent than the central component. Unfortunately, many patients are not adequately evaluated for vestibular disorders until long after the onset of their symptoms. Among the diagnoses seen as causes for PCD are (1) Central vestibular disorders, (2) Benign Paroxysmal Positional Vertigo (BPPV), (3) Labyrinthine dehiscence/perilymph fistula syndrome, (4) labyrinthine concussion, (5) secondary endolymphatic hydrops, (6) Temporal bone fracture, and (7) Malingering (particularly when litigation is pending). These diagnoses are not mutually exclusive and PCD patients frequently exhibit a combination of these disorders. A review of the literature and a general approach to the patient with post-concussive dizziness will be detailed as well as a review of the above-mentioned diagnostic categories.

Comorbidities confounding the outcomes of surgery for third window syndrome: Outlier analysis

Objective

Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors.

Study Design

Observational analytic case-control study in a tertiary referral center.

Methods

Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro-ophthalmologist), and a psychologist clinician-investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis-Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction.

Results

There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug-induced Parkinson-like syndrome and idiopathic progressive neurological degenerative process.

Conclusions

Components of the Millon Behavioral Medicine Diagnostic, PHQ-9 and GAD-7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities that could confound outcomes. The identification of these comorbid psychological as well as other neurological degenerative disease processes led to alternate clinical management pathways for these patients.

Level of Evidence

2b.

Viral titers and delayed facial palsy after acoustic neuroma surgery

OBJECTIVE

Delayed facial palsy (DFP) after acoustic neuroma surgery has been reported to occur in up to one third of cases. Reactivation of latent virus has been proposed as an etiology for DFP. However, only retrospective case reports and case series have offered data to support this theory. The objective of this study was to correlate DFP with change in viral titers.

PATIENTS AND METHODS

Twenty consecutive patients who underwent acoustic neuroma surgery were prospectively evaluated for viral titers immediately preoperatively and at 3 weeks postoperatively. Viral titers measured included herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella zoster virus (VZV) and included both IgG and IgM titers. The status of facial nerve function was documented preoperatively and throughout the postoperative period. Patients were categorized according to the presence or absence of DFP.

RESULTS

Seven patients developed DFP after acoustic neuroma surgery, while the remaining 13 patients did not. There was no difference in preoperative and 3-week postoperative IgG titers for any of the 3 viruses tested. However, IgM titers were much higher postoperatively in DFP patients for all 3 viruses tested. The average HSV-1 IgM titer rose 92% in DFP patients compared with only 4.5% in the patients who did not develop DFP. Average HSV-2 IgM titers rose 70% compared with a decline of 8.5% in non-DFP patients. Most strikingly, VZV IgM titers rose an average 495% postoperatively among DFP patients compared with a decline of 14% in the non-DFP patients.

CONCLUSION

Elevation of the IgM titers of the viruses measured in this study implies that recrudescence of the virus has occurred. The absence of this rise among patients who did not develop DFP implies that viral recrudescence plays a role in the etiology of DFP. These findings support treatment or prophylaxis of DFP with antiviral therapy.

Transtympanic steroids for treatment of sudden hearing loss

OBJECTIVES

To determine whether transtympanic steroid administration may be an effective treatment for sudden onset sensorineural hearing loss (SSNHL) in patients for whom systemic steroid treatment has failed or who were not candidates for systemic steroids.

METHODS

The standard medical regimen for SSNHL usually involves systemic steroid therapy. Unfortunately, some patients do not respond successfully to or are poorly tolerant of systemic steroids. Transtympanic administration of steroids has been suggested as an alternative to systemic therapy. A prospective study was designed to evaluate the hearing outcomes in SSNHL patients treated with transtympanic steroids. Patients received transtympanic steroids if oral steroids had failed to work or if they were not able to tolerate oral steroids. Transtympanic steroids were administered through a ventilation tube placed with the patient under local anesthesia. Steroid administration was performed on 4 separate occasions over the course of 10 to 14 days. Hearing was assessed immediately before therapy and within 1 to 2 weeks after therapy.

RESULTS

Hearing improvement was documented in 10 of 23 patients (44%) who underwent transtympanic steroid administration. This represents a 44% hearing salvage in patients for whom steroid treatment would otherwise have been considered a failure.

CONCLUSION

Transtympanic steroid therapy may be an alternative treatment for patients with SSNHL for whom systemic steroid therapy had failed or who could not tolerate systemic steroid therapy.

Coronal computed tomography of the normal vestibular aqueduct in children and young adults

OBJECTIVE

To characterize the appearance of the normal vestibular aqueduct on coronal computed tomography (CT).

DESIGN

Retrospective evaluation of routine CT images of the temporal bones.

SETTING

Private tertiary care center.

PATIENTS

Twenty-four children and young adults (14 females and 10 males), aged 2 to 24 years (average age, 10 years).

MAIN OUTCOMES MEASURES

Axial CT images were evaluated for the size of the vestibular aqueduct as previously described. On coronal CT images the vestibular aqueduct was evaluated for shape, dimensions, and angle. These measurements were made posteriorly, at the first point of vestibular aqueduct definition, and anteriorly, where the vestibular aqueduct abuts the posterior semicircular canal.

RESULTS

We were able to measure the vestibular aqueduct on 100% of the anterior coronal views, 77% of the midisthmus axial CT images, and 53% of posterior coronal CT images, (P<.001). The shape of the vestibular aqueduct on coronal CT scans varied posteriorly to anteriorly from being a slit to being an oval or round. The dimensions (mean + SD) of the isthmus on the anterior coronal views were 3.1 + 1.8 mm long by 1.6 + 0.8 mm wide. The upper limits of normal, as defined by the mean + 2 SDs, are 6.8 x 3.3 mm.

CONCLUSIONS

We have easily and consistently identified the vestibular aqueduct on coronal CT images; in fact, we found the vestibular aqueducts more consistently measurable on coronal CT scans than on axial CT scans. The addition of these views may improve the sensitivity of the CT scan in the evaluation of sensorineural hearing loss in children.

Primary meningioma of the fallopian canal

Meningiomas are slow-growing lesions that represent approximately 20% of all intracranial tumors and are the second most common tumor of the cerebellopontine angle. In contrast, primary extracranial meningiomas are found relatively infrequently, and most cases have inadequate radiologic studies to determine if they were actually an extension from a primary intracranial source. Meningiomas of the intratemporal segment of the facial nerve have also been reported, but they are exceedingly rare and their pathophysiology remains unclear. We report a case of a meningioma of the facial nerve in the fallopian canal of a 7-year-old girl and review pertinent literature.

Meniere's disease

Meniere's disease is an idiopathic disorder of the inner ear characterized by the syndrome of endolymphatic hydrops, episodic vertigo, fluctuating hearing loss, tinnitus, and aural fullness. People with this disorder may be severely disabled. Medical therapy exists in the form of diuretics and dietary restriction of salt to minimize the fluid pressure in the labyrinth and cochlea. Treatment of allergies with desensitization and steroids has also shown to be effective in selected patients. Surgical therapies exist in two categories, conservative and ablative. Endolymphatic sac decompression with or without shunt placement remains highly effective and we feel that it should be the first line surgical therapy for patients who fail medical therapy. Ablative therapies include labyrinthectomy (medical or surgical) and vestibular neurectomy. Both of these procedures control the episodic vertigo by destroying vestibular function in the affected ear and should be reserved for patients who have persistent vertigo in spite of more conservative treatments.

Epidural Abscess Masquerading as Lateral Sinus Thrombosis

Controversy regarding the use of anticoagulants, the evacuation of the sinus, or the use of medical treatment alone surrounds the treatment of lateral sinus thrombosis. Treatment of an epidural abscess associated with coalescent mastoiditis is much less controversial-drainage is usually recommended. The differing treatments of these complications mandate accurate diagnosis. The advent of more sophisticated radiological studies has facilitated diagnosis of these complications; however, tests are not infallible. We present three cases in which preoperative imaging demonstrates an epidural abscess mimicking lateral sinus thrombosis by compression of the vessel. A false-positive computed tomography (CT) or magnetic resonance imaging (MRI) study may lead to the wrong diagnosis and, consequently, improper treatment. In light of this possibility, we recommend surgical exploration in all such cases.

Avoiding transfusion in head and neck surgery: feasibility study of erythropoietin

OBJECTIVE

To determine the feasibility of perioperative erythropoietin to avoid blood transfusion in head and neck cancer surgery.

STUDY DESIGN

Retrospective chart review.

METHODS

Ninety-nine patients undergoing surgical resection of head and neck tumors at our institution were assessed for demographic data, nutritional parameters, tumor/surgical information, hematological/transfusion data, and contraindications to erythropoietin. Each transfusion was classified as to its appropriateness, and the potential benefit of erythropoietin was assessed in each patient. A cost analysis was also performed.

RESULTS

Most transfused patients (63%) received too many units. A subgroup at high risk of transfusion was identified who would benefit most from perioperative erythropoietin. Assuming that perioperative erythropoietin therapy is equivalent to the transfusion of 4 units, we estimate that the majority (741%) of transfused patients would not have required a transfusion if more stringent transfusion criteria were followed and those at high risk were given perioperative erythropoietin. Although the cost for transfusing 4 units is equivalent to that of a perioperative course of erythropoietin, the overall direct cost of erythropoietin treatment would actually have been more expensive.

CONCLUSIONS

Perioperative erythropoietin therapy may be appropriate for a subgroup of head and neck cancer patients, but a prospective randomized controlled study in such a subgroup is needed to better define those most likely to benefit from it and to assess actual cost/benefit ratios.

Superior semicircular canal dehiscence: a new cause of vertigo

There are many known causes of vertigo, but many cases remain unexplained. Sound-induced, pressure-induced, or positional vertigo caused by bony dehiscence of the superior semicircular canal into the middle cranial fossa is a newly described etiology of vertigo. Three case studies of patients with CT evidence and surgical confirmation of bony dehiscence of the superior semicircular canal with variable presentations are described. The history, symptoms, CT findings, vestibular studies, and method of surgical repair are presented. Two patients had disabling vertigo and one had no vestibular symptoms. All underwent exploration via a middle cranial fossa approach with repair of the dehiscence. The bony dehiscence of the superior semicircular canal of the asymptomatic patient was identified and closed at the time of an encephalocele repair procedure. All patients did well postoperatively and both patients with vertigo improved. Bony dehiscence of the superior semicircular canal may cause vertigo or be asymptomatic and should be added to the differential diagnosis of vertigo.

The efficacy of hyaluronic acid foam as a middle ear packing agent in experimental tympanoplasty

The efficacy of hyaluronic acid (HA) foam in the prevention of middle ear adhesions and other structural abnormalities in guinea pigs undergoing experimental tympanoplasty was investigated. Postoperative changes in the middle ear were evaluated by light microscopy after 6 weeks. The presence of adhesions, diminution of airspace, new bone formation, tympanic membrane (TM) formation, and mucosal inflammation was characterized by an objective grading system. Results were compared to absorbable gelatin sponge (AGS) and a control group (no middle ear packing). The control group showed the best average scores for all parameters tested except for adhesion formation. However, these results were statistically significant only when compared with those of the AGS group for airspace preservation, new bone formation, and TM formation. Although the HA foam group showed better average results than did the AGS group for all parameters tested, none were statistically significant. Although HA foam appears to be a promising middle ear packing agent, further experimental trials are warranted before any firm conclusions may be made.

Early post-laser stapedotomy hearing thresholds

OBJECTIVE

Auditory testing is not routinely performed within 4-6 weeks after stapedotomy, because hearing acuity is thought to be transiently depressed. In rare circumstances, postsurgical auditory and vestibular complaints may lead one to test hearing soon after stapedotomy. The early postoperative effects of carbon dioxide (CO2) and potassium titanyl phosphate (KTP) lasers, which now are routinely used to perform stapedotomies, have not been reported. The purpose of this report is to present normative data for auditory thresholds measured within 2 weeks of laser stapedotomy.

STUDY DESIGN

The study design was a prospective, unblinded study.

SETTING

The study was conducted at three academic medical centers.

PATIENTS

Thirty-six subjects undergoing 38 stapedotomies for otosclerosis by 5 surgeons participated.

MAIN OUTCOME MEASURES

Behavioral audiometry was performed using standard techniques beginning before surgery and continuing through > 1 year after surgery.

RESULTS

The CO2 laser was used in 26 stapedotomies and the KTP laser was used in 12. Nine cases were revision procedures. Bone conduction pure-tone averages and speech discrimination scores did not worsen during the early postoperative period. Bone conduction at 250 and 4,000 Hz dropped slightly within the first 2 weeks (-4.3 and -6.7 dB) but recovered thereafter. Bone conduction at 1,000 Hz actually improved within the first week after surgery (+6.2 dB, p = 0.021). Significant improvements in air conduction thresholds (and air-bone gap) were seen at the second week and late audiometry. The results for CO2 and KTP laser-treated groups were not significantly different.

CONCLUSIONS

Cochlear function is not significantly depressed in the early postoperative period after laser (CO2 or KTP) stapedotomy.

Sac-vein decompression for intractable Meniere's disease: two-year treatment results

Surgical intervention has been offered to patients with Meniere's disease who have failed medical treatment and have disabling symptoms. Surgical options have included labyrinthectomy (mechanical and chemical), vestibular neurectomy, and endolymphatic sac surgery with or without shunting. We present a modification of endolymphatic sac decompression surgery that includes wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac (sac-vein decompression). Thirty-five patients underwent 37 primary procedures with 2 years of follow-up. Patients were evaluated according to the 1985 American Academy of Otolaryngology-Head and Neck Surgery criteria for assessing Meniere's disease. Vestibular symptom severity was resolved or mild in 92% and disability severity was none or mild in 95% of patients at 2 years after surgery. Vertigo control was complete or substantial in 85% and 100% of patients at 1 and 2 years after surgery. Audiologic data showed stable or improved hearing in 86% and 85% of patients at 1 and 2 years after surgery. In summary, wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac offers improved control of vertigo and hearing stabilization for intractable Meniere's disease compared with simple endolymphatic sac decompression or shunt surgery.

Triple semicircular canal occlusion versus labyrinthectomy in the cat

HYPOTHESIS

We have theorized that surgical occlusion of all three semicircular canals (TCO) may be an effective means to treat vestibular pathology limited to semicircular canal dysfunction while preserving hearing and otolithic function.

BACKGROUND

A procedure that would eliminate vertigo while preserving hearing and minimizing postoperative dysequilibrium would be desirable.

METHODS

Staged bilateral TCO was performed on four cats and compared to staged bilateral labyrinthectomy in four cats. Balance and gait analysis were performed for 3 weeks after each surgical procedure--a total of 6 weeks of testing.

RESULTS

Balance testing, gait analysis, and righting reflex were found to be better among the cats undergoing TCO compared to labyrinthectomy.

CONCLUSIONS

Compared to labyrinthectomy in the cat, TCO appears to have advantages for vestibular compensation after unilateral and contralateral surgery.

Congenital aural atresia

Congenital aural atresia is viewed by many physicians as a poorly characterized, arcane, clinical entity associated with a variety of hearing deficits. In fact, congenital aural atresia represents a disease spectrum predicated on the reliable embryological development of the first and second branchial apparatus. All degrees of microtia, canal atresia, and middle ear structure malformation are identified by this disease process. Many classification schemata have been proffered since the turn of the century to assist the otologist with a better means of assessing the patient's suitability as a surgical candidate. Clinical, audiological, and radiographic evaluation of congenital aural atresia is essential in selecting the appropriate candidates for surgery or hearing amplification. The high resolution CT scan has advanced the understanding and preoperative assessment of this condition. Surgical repair of the external ear and middle ear malformations is effective in properly selected patients. Essential background information, relevant embryology, patient evaluation, treatment, and current controversies related to congenital aural atresia are discussed.

Eustachian tube dysfunction

The eustachian tube has several functions that are important in maintaining the normal state of the middle ear. The ability of the eustachian tube to carry out these functions changes with age. Certain pathophysiologic mechanisms may affect the normal state of the eustachian tube and predispose people, especially children, to otitis media.

Delayed facial palsy after acoustic neuroma resection: the role of viral reactivation

Delayed facial palsy after acoustic neuroma resection may occur in up to 15% of cases. Prognosis is generally good if the palsy does not progress to total paralysis. However, a delayed palsy with subsequent total paralysis has a more variable final outcome, which ranges from normal function to permanent total paralysis. This delayed paralysis has been attributed to edema from surgical manipulation of the facial nerve. Steroids and intraoperative decompression of the meatal foramen have been used with some success, but some cases remain refractory to these measures. Herpes simplex virus and varicella-zoster virus are ubiquitous in the population and remain in a latent state in neural ganglia. These viruses are reactivated during times of stress. Trigeminal nerve surgery (partial sensory rhizotomy and microvascular decompression) stimulates reactivation of herpes simplex with manifestations in the sensory distribution of the trigeminal nerve in 38-94% of procedures. Prevention of this reactivation has been demonstrated in placebo-controlled trials by using prophylactic acyclovir. We present a patient who underwent translabyrinthine resection of an intracanalicular acoustic neuroma and in whom developed otalgia, vesicles on the ear canal and the ipsilateral buccal mucosa, and progressive facial palsy the week after surgery. Serologic evaluation confirmed the diagnosis of herpes zoster oticus. Reactivation of latent virus apparently occurred as a result of surgical manipulation of the facial nerve. This parallels viral reactivation seen in trigeminal nerve surgery. We propose a new theory for an additional cause of delayed facial palsy after acoustic neuroma resection-reactivation of latent herpesvirus resulting from surgical trauma. Acyclovir should be evaluated in clinical trials for a prophylactic role in patients undergoing acoustic neuroma resection or a therapeutic role in patients in whom a delayed postoperative facial palsy develops.

Pediatric tympanoplasty: the role of adenoidectomy

A chronic dry perforation in a child presents a dilemma with regard to timing of intervention or whether intervention is appropriate at all. Many studies have looked at elements associated with eustachian tube function in hopes of finding prognostic factors. Adenoidectomy has been shown to be very effective in the treatment of chronic and recurrent otitis media. Intuitively, it would seem to play a role in pediatric tympanoplasty; however, no study has thoroughly investigated this issue to date. To evaluate the role of adenoidectomy in pediatric tympanoplasty, we performed a retrospective review of all patients younger than 18 years who had a simple dry perforation and underwent a Wullstein's type I tympanoplasty. Thirty-six patients were identified for review during the 7-year study period. The patients were grouped into those who had previous adenotonsillectomy (n = 12), those who had prior adenoidectomy alone (n = 10), and those who had neither (n = 14). Initial success of tympanoplasty was noted to be high in all three groups. However, at 6-month follow-up, the success for the group who had not had prior adenoidectomy or tonsillectomy dropped dramatically (14.3%), whereas the other two groups maintained success rates in excess of 75% (p = 0.002). This relationship remained fairly constant throughout the 2 years of follow-up. Although our population under study is somewhat small, the results support a potentially advantageous role of adenoidectomy for pediatric tympanoplasty. These results and their implications will be discussed.

Pediatric Tympanoplasty: The Role of Adenoidectomy

A chronic dry perforation in a child presents a dilemma with regard to timing of intervention or whether intervention is appropriate at all. Many studies have looked at elements associated with eustachian tube function in hopes of finding prognostic factors. Adenoidectomy has been shown to be very effective in the treatment of chronic and recurrent otitis media. Intuitively, it would seem to play a role in pediatric tympanoplasty; however, no study has thoroughly investigated this issue to date. To evaluate the role of adenoidectomy in pediatric tympanoplasty, we performed a retrospective review of all patients younger than 18 years who had a simple dry perforation and underwent a Wullstein's type I tympanoplasty. Thirty-six patients were identified for review during the 7-year study period. The patients were grouped into those who had previous adenotonsillectomy ( n = 12), those who had prior adenoidectomy alone ( n = 10), and those who had neither ( n = 14). Initial success of tympanoplasty was noted to be high in all three groups. However, at 6-month follow-up, the success for the group who had not had prior adenoidectomy or tonsillectomy dropped dramatically (14.3%), whereas the other two groups maintained success rates in excess of 75% ( p = 0.002). This relationship remained fairly constant throughout the 2 years of follow-up. Although our population under study is somewhat small, the results support a potentially advantageous role of adenoidectomy for pediatric tympanoplasty. These results and their implications will be discussed.

Hearing results in surgery for primary petrous apex lesions

Hearing preservation is a frequently mentioned phrase in the growing field of skull base surgery. Many authors have attempted to identify prognostic factors for successful hearing preservation, and many have suggested alternative procedures for preserving serviceable hearing. Few have mentioned hearing improvement with skull base surgical procedures. In this article we present the hearing results of 25 surgical procedures for primary petrous apex lesions. These include 13 cholesterol granulomas, 5 cholesteatomas, 4 mucoceles, and 3 eosinophilic granulomas. Surgical approaches included 14 transmastoid/infralabyrinthine, 6 transphenoid, 3 suboccipital, and 2 transmastoid/translabyrinthine. Hearing was maintained in 14 patients (56%), improved in 9 patients (36%), and worse in 1 patient with nonserviceable hearing before surgery (4%); 1 patient had profound hearing loss before surgery (4%). Results of this review should have significant implications on the choice of surgical approach for petrous apex lesions. Additionally, the standard method of determining salvageable hearing for most skull base procedures may not apply for this specific group of lesions. Implications for future treatment plans will be discussed in detail.

Intracranial complications of sinusitis

While once a significant risk of sinusitis, the incidence of intracranial complications has decreased remarkably since the advent of antibiotics. This article reviews the intracranial complications of chronic sinusitis, their incidence, clinical manifestations, radiographic evidence, and treatment options.

Crohn's disease of the larynx

Extraintestinal involvement of Crohn's disease is becoming more readily identified. Laryngeal involvement by Crohn's disease, however, has been reported in only five cases in the medical literature. We present the sixth case as well as an analysis of the prior reports.

Recurrent respiratory papillomatosis: juvenile versus adult forms

Recurrent respiratory papillomatosis (RRP) has been described to have a juvenile or aggressive form and an adult or less aggressive form. However, the aggressive form may occur in an adult and vice versa. Some authors have reported a quiescence in the juvenile form with the onset of puberty. In order to further characterize these two forms of RRP and to analyze the effects of puberty, we reviewed the records of 32 patients treated for RRP at our institution over a 10-year period. We found that the aggressive form typically occurs in the very youngest of patients (average of 2 years old as compared to an average of 17 years old in the less aggressive form). Although subglottic involvement universally occurred in our group with aggressive disease, approximately 40% developed subglottic disease very early as compared with 20% of patients with less aggressive disease. Additionally, our data do not support the theory of spontaneous regression with the onset of puberty. These and other findings will be discussed in detail. We also propose a new classification for RRP to eliminate confusion.

Diagnosis and management of hemoptysis

Hemoptysis may present in patients both young and old, and its causes are numerous. The origin of the bleeding can be anywhere from the lips to the lung pleura, and a precise history and physical examination are essential in narrowing the search for the etiology. The chest film can effectively identify or exclude most lung neoplasms, but further evaluation is needed in those patients at high risk for cancer. The etiologies of hemoptysis are reviewed; emphasis is placed on a thorough history; the utility of diagnostic studies are explained; and efficient management is outlined.

Perilymphatic fistulas

Perilymphatic fistula (PLF) is an abnormal connection between the inner ear and middle ear space which allows the escape of perilymph and may result in disorders of hearing, balance, or both. This entity has received considerable attention and is a major area of interest and controversy in modern otology. The clinical manifestations of this condition are variable and encompass the whole spectrum of audiovestibular signs and symptoms. The diagnostic criteria have yet to be established. Currently there is no consistent objective preoperative test to diagnose PLF. Definitive diagnosis is made on middle ear exploration and rests on the observation of the surgeon. There is no objective intraoperative test to confirm the presence of PLF. The purpose of this paper is to present the classification system and current understanding of the pathogenesis of PLF. In addition, clinical manifestations, evaluation, and management of patients with this otologic entity will be reviewed.

Petrous apex lesions

The purpose of this article is to detail our experience in treating 69 patients over the past 6 years with pathologic processes involving the petrous apex. These included 25 (36%) primary petrous apex lesions, 40 (58%) lesions that involved the petrous apex by direct invasion from an adjacent region, and four (6%) lesions that were the result of metastatic spread from a distant site. Although lesions of the petrous apex are uncommon, they may present significant morbidity to the patient. The symptoms elicited by these lesions are usually vague and nonlocalizing in the early stages but may progress to include multiple cranial neuropathies. Successful results are contingent on early diagnosis, which requires a high index of suspicion and use of appropriate imaging modalities. Thorough preoperative assessment with use of computed tomography, magnetic resonance imaging, and carotid arteriography is essential to plan the surgical approach. We present this collection of patients in order to aid in the further preoperative characterization of the differences in primary and secondary lesions of the petrous apex.

Carcinoma of the oral tongue

Carcinoma of the oral tongue is the second most common malignancy of the oral cavity. Major risk factors include tobacco and alcohol usage. Early diagnosis is the cornerstone of successful management. Comprehensive evaluation and treatment modalities are reviewed. For early lesions, surgery or radiation therapy may be employed with equal efficacy. For advanced lesions, combination radiotherapy and surgery are advocated. Chemotherapy is still experimental, but continues to undergo multicenter investigations for treatment of oral tongue carcinoma.

Craniocervical necrotizing fasciitis

Craniocervical necrotizing fasciitis is a serious, life-threatening infection affecting fascial planes within the head and neck. Frequently the result of odontogenic origin, these polymicrobial infections, often involving group A beta hemolytic streptococcus acting in synergy with an anaerobe, can spread rapidly, causing significant morbidity and mortality, and must be diagnosed as early as possible. Treatment consists primarily of appropriate intravenous antibiotics and aggressive surgical debridement.

Necrotizing external otitis

Necrotizing external otitis is a severe osteomyelitis of the temporal bone principally affecting elderly diabetics. It is caused by the gram negative bacillus, Pseudomonas aeruginosa. Clinical findings and diagnosis are reviewed. Long term therapy with intravenous antibiotics is recommended for cure, although newer antimicrobial agents give promise of being successful when administered orally.

Velopharyngeal insufficiency

Velopharyngeal insufficiency (VPI) is a relatively uncommon diagnosis and requires an understanding not only by the otolaryngologist but also by primary care physicians who are often the first to recognize its presence. An appreciation of the speech pathology that occurs in VPI assists in the often challenging diagnosis. Although VPI is more commonly seen in the pediatric population, there are multiple causes for its presence in adults and children. We review the anatomy of the velopharynx and the etiology of VPI, as well as the evaluation and the management of these patients.

Laryngeal papillomatosis

The papilloma is one of the most common benign neoplasms of the larynx. Laryngeal papillomatosis is a disease of widespread papilloma formation that most commonly affects the larynx but may involve multiple areas of the aerodigestive tract. Typically, onset of disease during childhood is associated with much more aggressive disease. The etiology of this disease is the human papillomavirus. Diagnosis is often delayed because the symptoms mimic a variety of other diseases. Laryngeal papillomatosis can also be extremely frustrating to treat since the lesions are most often recurrent and aggressive. This article reviews laryngeal papillomatosis, its differential diagnosis, presentation, and classifications as well as its treatment past, present, and future.

B-mode ultrasonography of the paranasal sinuses compared with CT findings

Ultrasound as a diagnostic aid in the evaluation of the sinuses has been a controversial issue. Sensitivities have been reported from 29% to 100% and specificities from 55% to 99%. These wide variations in results from previous studies may have resulted from technical differences. However, the "gold standard" most often used for comparison has been a Water's view radiograph, which has been shown to correlate poorly with intraoperative and CT scan findings. To our knowledge, no one in the English language literature has evaluated sonography of the sinuses with computed tomography as the gold standard. In addition, evaluation of the ethmoid sinus has been neglected by previous studies that have primarily assessed the maxillary sinus. We report the results of a blinded, prospective trial comprised of 41 patients examined by B-mode ultrasound with comparison to computed tomography. Frontal and maxillary sinuses were examined with traditional sonographic techniques and the ethmoid sinuses were scanned with a transglobe technique not previously evaluated in the English language literature. Excluding isolated mucous retention cysts and focal minimal mucosal thickening (defined as < 4 mm), sensitivities for ultrasound of the maxillary, frontal, and ethmoid sinuses were 100% each. Specificities were 98% for the maxillary sinus, 100% for the frontal sinus, and 94% for the ethmoid sinus. Technical aspects and implications of this and previous reports will be discussed.

Composite Tumor of the Larynx

Composite tumor of the larynx has been described as a mixed squamous cell and oat cell carcinoma originating in the larynx. Only eight cases of composite tumor of the larynx have been described in the world medical literature. We present the ninth case ever reported. Therapy for this very aggressive malignancy is with a combined approach - surgery, radiation, and chemotherapy. A common etiology for both squamous cell and oat cell carcinoma has been proposed. Recommendations for diagnostic evaluation as well as therapeutic intervention will be discussed.

Cervical lymph node biopsy

Controversy among head and neck oncologists has centered for many years around the appropriate and inappropriate use of cervical lymph node biopsy. Many authors contend that untimely cervical node biopsy, at best, is unnecessary, and, at worst, may lead to early recurrence and death. More recent data show that adjuvant radiation therapy may ameliorate the adverse effects of lymph node biopsy. At present, although cervical lymph node biopsy is not recommended for the diagnosis of head and neck cancer, it does not appear to shorten survival if appropriate management is administered subsequently.

Composite tumor of the larynx

Composite tumor of the larynx has been described as a mixed squamous cell and oat cell carcinoma originating in the larynx. Only eight cases of composite tumor of the larynx have been described in the world medical literature. We present the ninth case ever reported. Therapy for this very aggressive malignancy is with a combined approach--surgery, radiation, and chemotherapy. A common etiology for both squamous cell and oat cell carcinoma has been proposed. Recommendations for diagnostic evaluation as well as therapeutic intervention will be discussed.

Retropharyngeal space infection: changing trends

Retropharyngeal space infection, now a rare entity since the introduction of modern antibiotic chemotherapy, has traditionally been described to occur in children less than 4 years of age with suppurative disorders of the ear, nose, and throat. Recent reports suggest a changing trend in the epidemiology, bacteriology, diagnostic imaging, treatment, and clinical course of this entity. However, the medical literature concerning this topic over the last two decades has consisted mainly of case reports. We reviewed eight cases of retropharyngeal space infection at our institutions over a 15-year period, representing one of the largest clinical series of its kind in the last 20 years. Patient ages ranged from 3 months to 41 years. Findings of these cases and 13 cases from similar reports obtained by a MEDLINE computer search of the recent literature were analyzed. Results show a trend toward occurrence in older age groups, polymicrobial infections, successful use of CT scan as a diagnostic modality, and fewer patients requiring incision and drainage. These findings will be discussed and contrasted to conventional wisdom.

Vascular malformation of the sphenoid sinus

Isolated sphenoid sinus lesions are usually inflammatory lesions or mucoceles. We report an unusual case of a thrombosed arteriovenous malformation presenting as a unilateral primary vascular malformation of the sphenoid sinus. To the best of our knowledge, no one has ever reported such an entity in the medical literature. Differential diagnosis of sphenoid sinus lesions and possible etiologies for this case will be detailed.