[Endoscopic technique utilized into the selective vestibular neurotomy by retrosigmoid approach].

OBJECTIVE: To investigate the micro-wound technique and the signification of reducing brain tissue oppression and complication at the surgery with utilizing endoscopic technique during the operation of selective vestibular neurotomy (SVNT) by retrosigmoid approach. METHODS: Twelve patients were preceded the SVNT by retrosigmoid approach (as routine operation group, ROG), and nine patients were utilized endoscope for review and neurotomy during the process of the SVNT by retrosigmoid approach (as endoscopic operation group, EOG). All of them were examined by auditory level, vestibular function, facial nerve function and observed of clinical situation (including complication and equilibrium function and so on) before and after operation. RESULTS: Two patients appeared cerebral edema and demanded the treatment of dehydration and depressing intracranial pressure in ROG after operation. In each group, the average auditory threshold in 2 patients rose more than 15 dB post-operation. The interval time of average equilibrium function compensation is (29.00 +/- 9.60) d in ROG and (28.56 +/- 7.91) d in EOG after surgery. Peripheral facial paralysis didn't happen to any patient in two groups. After follow-up two years post-operation, the vertigo recurred in 2 patients (4 times and 1 times, respectively) in ROG and 1 patient (2 times) in EOG. CONCLUSIONS: The SVNT by retrosigmoid approach is widespread adopted presently as expedience and safe surgery method for Ménière's disease, and could effectively eliminate vertigo and simultaneously conserve the hearing function and the integration of facial nerve. This surgery process became micro-wound, more facility and safe following the endoscopic technique utilization, which could reduce the brain tissues depression and trauma and could not cause any of complications. Therefore, the endoscopic operation of the SVNT by retrosigmoid approach is worth to clinically popularize as the therapy method of vertigo for the patients of Ménière's disease, especially who associate with contralateral sensorineural hearing loss.

[The endoscopic technique utilized in removal process of acoustic neuroma by retrosigmoid approach].

OBJECTIVE: Research into the technique and signification of reducing remnant tumor with utilizing endoscopic technique during removal of acoustic neuroma. METHOD: 15 patients proceeded the removal of acoustic tumor through retrosigmoid approach (as routine retrosigmoid-approach operation group, RRSO-G), 11 patients utilized endoscope for inspecting and eliminating remain of tumor during the proceed of the removal of acoustic neuroma through retrosigmoid approach (as retrosigmoid-approach operation combined using endoscope, RSOCE-G), all of them were examined of auditory level, vestibular function, facial nerve function, and MRI before and three months after operation. RESULT: The remain tumor were found in 3 cases of RRSO-G and no any one in RSOCE-G after operation. The rates of auditory and vestibular dysfunction, and facial paralysis have no difference between RRSO-G and RSOCE-G. CONCLUSION: It is one of expedient and safe surgery methods that the acoustic neuroma are removed through the retrosigmoid approach, and some degrees of hearing function are reserved at same time. If the endoscope is utilized during this operation, the rate of tumor remaining and neuroma recrudescing could be reduced evidently. The acoustic neuroma removed through the retrosigmoid approach combining with utilizing endoscope is a worthy method for using widely in otoneurosurgery.

Migraine and Ménière's disease: is there a link?

BACKGROUND: A possible link between Ménière's disease (MD) and migraine was originally suggested by Prosper Ménière. Subsequent studies of the prevalence of migraine in MD produced conflicting results. OBJECTIVE: To determine the lifetime prevalence of migraine in patients with MD compared to sex- and age-matched controls. METHODS: The authors studied 78 patients (40 women, 38 men; age range 29 to 81 years) with idiopathic unilateral or bilateral MD according to the criteria of the American Academy of Otolaryngology. Diagnosis of migraine with and without aura was made via telephone interviews according to the criteria of the International Headache Society. Additional information was obtained concerning the concurrence of vertigo and migrainous symptoms during Ménière attacks. The authors interviewed sex- and age-matched orthopedic patients (n = 78) as controls. RESULTS: The lifetime prevalence of migraine with and without aura was higher in the MD group (56%) compared to controls (25%; p < 0.001). Forty-five percent of the patients with MD always experienced at least one migrainous symptom (migrainous headache, photophobia, aura symptoms) with Ménière attacks. CONCLUSIONS: The lifetime prevalence of migraine is increased in patients with MD when strict diagnostic criteria for both conditions are applied. The frequent occurrence of migrainous symptoms during Ménière attacks suggests a pathophysiologic link between the two diseases. Alternatively, because migraine itself is a frequent cause of audio-vestibular symptoms, current diagnostic criteria may not differentiate between MD and migrainous vertigo.

Tilted perception of the subjective 'upright' in unilateral loss of vestibular function.

OBJECTIVE: To demonstrate that unilateral vestibular loss (UVL) may cause an erroneous perception of the subjective (bodily) vertical. STUDY DESIGN: Comparison of patients with UVL with age-matched controls. SETTING: The study was performed in a clinical neurophysiology laboratory. PATIENTS: Seven patients with unilateral, mixed acute, and chronic losses of vestibular function (six surgical), two patients with bilaterally absent vestibular function, one patient with a plugged posterior canal, and twenty-two healthy individuals. INTERVENTIONS: Subjects were seated, whole body restrained, in a flight simulator. The simulator executed intermittent stepwise tilts, in roll, up to 28 degrees that subjects had to correct to maintain an "earth upright" attitude using the joystick. Subjects performed in both "calm" conditions and also when the simulator was oscillating in roll at 1 Hz, 4 degrees peak displacement to simulate "turbulence." The purpose of the turbulence was to destabilize (or mask) somatosensory cues to uprightness. MAIN OUTCOME MEASURES: Accuracy of corrections of subjective attitude to earth upright after tilts. RESULTS: All subjects accepted the initial attitude of the simulator as "upright." In response to imposed tilts, normal subjects (n = 22) corrected their attitude to a mean 0.4 degrees SD 1.5 degrees (tilted slightly rightward) in calm and 0.7 degrees SD 1.3 degrees in turbulence. On average, corrections were normometric. All patients with UVL responded to imposed tilts by corrections that left them 'flying' tilted slightly to the side of their lesion, mean 3.2 degrees SD 2.5 degrees when calm, 6.4 degrees SD 2.7 degrees in turbulence (p<0.01). Their corrections were hypometric in response to imposed tilts to the lesioned side (i.e., undershooting true upright) and hypermetric in response to tilts to the intact side. CONCLUSIONS: Unilateral vestibular loss causes a "vestibular perception" of an erroneous tilt of the body that is probably caused by an imbalance of otolith signals and apparently never fully compensates. The tilt is enhanced when rapid perturbations of posture make somatosensory cues difficult to interpret. An erroneous perception of upright may contribute to vestibular ataxia, which is provoked when motion context involves rapid change.

Neurenteric cyst of the cerebellopontine angle: case report.

OBJECTIVE AND IMPORTANCE: We report a case of a neurenteric cyst of the cerebellopontine angle and review the five previously reported cases. The pathology and classification of these cysts are discussed. CLINICAL PRESENTATION: The patient presented with a 1-month history of nausea, vomiting, vertigo, and sudden hearing loss. INTERVENTION: The cyst was decompressed by a retrosigmoid approach. After recurrence of symptoms at 2 months, further decompression was required. CONCLUSION: The patient achieved a good outcome after the second operation, with cessation of her vomiting and vertigo, although she had residual hearing loss. Four of the five previously reported patients experienced satisfactory outcomes after surgery. The definitive diagnosis of these rare lesions is made using immunocytochemical techniques.

Medical management of Menière's disease.

The management of Meniere's disease often creates a formidable clinical challenge. Drugs may be helpful in treating the acute attacks of vertigo, and in more long-term management. These remedies are largely symptomatic and there are few properly controlled studies of their efficacy. A critical overview of the scientific and clinical basis for these various pharmacological agents is discussed.

The role of vestibular nerve section in Menière's disease.

The role of vestibular nerve section (VNS) surgery in the management of Menière's disease is considered by prospective analysis of a large series of 531 patients treated by the author over a period of 11 years. Twenty-seven percent were referred by their primary care physicians, while the rest were secondary (45.6%) or tertiary (27.3%) referrals. Overall, 62 (11.7%) Menière's patients underwent 63 VNS procedures. This surgery was undertaken more frequently in the secondary and tertiary referral patients (14.2%) than in the primary referrals (5.5%). The retrolabyrinthine technique was the preferred approach in almost 90% of ears. The results and complications of these and other surgical options are discussed in an attempt to define the present role of VNS in intractable Meniere's disease. Vertigo was abolished after VNS in 93% of cases. Compensation was significantly impaired in 12.9%. All these patients had contralateral Menière's disease or marked labyrinthine hypofunction. Although highly effective and associated with few postoperative complications, VNS is generally reserved for sac failures, though may be appropriate as a primary procedure in severe unilateral cases.

Evaluating 3D semicircular canal function by perception of rotation.

OBJECTIVE: We aimed to develop a clinical test of 3D canal dysfunction by perceptual matching of motion stimuli as an alternative to vestibular ocular reflex assessment. STUDY DESIGN: The study was a comparison with age-matched controls. SETTING: The study was performed in a clinical neurophysiology laboratory. PATIENTS: Ten patients with acute unilateral vestibular nerve section and 9 patients in the chronic stage of recovery, 2 acute-stage and 2 chronic-stage patients with posterior canal plugging, and 35 healthy individuals were studied. INTERVENTIONS: Seated on a motorized rotating chair in darkness, subjects were exposed to discrete, raised cosine velocity (60 degrees/s peak) rotations, for random displacements < or = 180 degrees rightward and leftward. They responded by rotating themselves back to the starting position with a joystick control. Horizontal canals were tested with head upright, ipsilateral versus contralateral vertical canal pairs were tested with the head down, face horizontal and co-planar anterior-posterior canal pairs were tested with the head down and turned approximately 45 degrees to the left or right. MAIN OUTCOME MEASURES: These were accuracy and symmetry of responses. RESULTS: Normal responses were approximately accurate returns to start. Nine patients with acute nerve section were hypometric (undershooting start) when displaced toward the lesion but normometric to the intact side. Eight chronic-stage nerve section patients with chronic dysfunction were hypometric to the lesion for vertical canal stimuli, but one third showed normal responses for horizontal canal testing. Patients with posterior canal plugging were hypometric specifically toward the plugged canal. CONCLUSIONS: The method reliably identifies acute and chronic dysfunction of vertical canals and acute dysfunction of horizontal canals. Dysfunction of a single canal can be specified.

Effect of olivocochlear bundle section on evoked otoacoustic emissions recorded using maximum length sequences.

Presenting clicks according to maximum length sequences (MLS) enables transient evoked otoacoustic emissions (TEOAE) to be recorded at very high stimulation rates. As the click rate is increased from 40 clicks/s up to a maximum rate of 5000 clicks/s there is a reduction in TEOAE amplitude that reaches an approximate asymptote at 1500 clicks/s. One hypothesis put forward to explain this MLS 'rate effect' is that ipsilateral efferent activity is involved. To test this hypothesis TEOAEs were recorded from both ears of five patients who had undergone a unilateral vestibular nerve section--a surgical procedure which also entails sectioning the olivocochlear bundle. TEOAEs were recorded conventionally at 40 clicks/s and using MLS stimulation at 5000 clicks/s. Increasing the rate from 40 to 5000 clicks/s was found to reduce the amplitude of the TEOAEs by equivalent amounts in ears ipsilateral and contralateral to a vestibular nerve section as well as in the ears of normal-hearing adults. Since an ear ipsilateral to a vestibular nerve section should have no efferent innervation the hypothesis that efferent activity is the major mechanism involved in the MLS rate effect is rejected. Instead, the possibility that intracochlear processes are the underlying mechanism will now be investigated.

Central nervous system complications of acute tonsillitis.

Acute tonsillitis is a common infection of early childhood which may even run a self-limiting course without antibiotic therapy in some cases. Complications are encountered infrequently and rarely assume a life-threatening propensity. Central nervous system involvement has not to our knowledge been described in association with tonsillitis without local abscess formation. We describe three cases in which acute tonsillitis/peritonsillitis was complicated by major central neurological sequelae. The neurological complications encountered in young previously healthy adults were: facial palsy and hemiplegia; superior sagittal sinus thrombosis with communicating hydrocephalus and papilloedema; Guillain-Barré syndrome and facial palsy. The pathogenesis and management is discussed. All patients made satisfactory recoveries, though with minor residual neurological disabilities.

CT screening for temporal bone abnormalities in idiopathic bilateral sensorineural hearing loss.

Bilateral sensorineural hearing loss can be caused by a variety of temporal bone abnormalities including primary cochlear otosclerosis, local and systemic bony diseases and some metabolic conditions. These may be identified using computerized tomography (CT), with attenuation recordings taken across the cochlear capsule (CT densitometry). Eighty patients with bilateral sensorineural hearing loss were screened over a period of six and a half years using this technique, and only three cases (3.8 per cent) of treatable disease were detected. Positive yields may be increased by screening selected cases with other clinical or biochemical stigmata of temporal bone disease.

Skew deviation following vestibular nerve surgery.

Eighteen consecutive patients undergoing vestibular nerve surgery underwent pre- and postoperative examination of ocular motility. Five patients developed a skew deviation following surgery, with the lower eye on the operated side and an incomitant pattern of deviation in all cases. Three patients experienced diplopia lasting from 1 day to 6 months. The magnitude of skew deviation was increased by head tilt away from the operated side in only 1 case. The development of skew deviation was not determined by preoperative ocular alignment or binocular function, or any particular type or pattern of vestibular disease. There was an association with large changes in ocular torsion and subjective visual vertical, which correlated with lesser degrees of canal paresis to preoperative caloric testing on the operated side. No patient developed a head tilt postoperatively. There is a gradation of responses to surgical vestibular deafferentation in humans, skew deviation only occurring in patients suffering marked changes in subjective visual vertical and ocular torsion.

Vestibular nerve section following previous mastoidectomy.

Vestibular neurectomy is an effective procedure in the management of vertigo due to active labyrinthine disease. Various approaches have been developed for selectively sectioning the vestibular nerve, in order to preserve serviceable hearing and avoid facial nerve injury. In patients who have a mastoid cavity, from previous surgery for chronic otitis media, the approach to the vestibular nerve has to be modified. Considerations taken into account are cavity infection, hearing status, and the presence of associated loud tinnitus. Vestibular or vestibulo-cochlear nerve section has been undertaken, by the senior author, in eight patients with a mastoid cavity from previous surgery for chronic otitis media. Translabyrinthine, retrosigmoid and middle fossa approaches have all been used; strategies for selection of each specific technique are considered, and the aetiology of post-chronic suppurative otitis media (CSOM) peripheral vestibular disease discussed.

Barotraumatic fracture of the stapes footplate.

We present a rare case in which barotrauma led to fracture of the stapes footplate and perilymph fistula, resulting in sudden severe sensorineural hearing loss and tinnitus. Surgical repair in this case resulted in excellent hearing recovery. The aetiology and management of inner ear barotrauma and stapes injury is discussed. We believe that early exploration and repair of suspected perilymph fistulae optimises hearing recovery.

Epiglottic plication for intractable aspiration.

We describe a procedure to plicate the epiglottis into a vertical tube to prevent soiling of the airway due to intractable aspiration. The procedure is combined with an extensive cricopharyngeal myotomy. This technique allows laryngeal speech, even with a tracheostomy, and in some patients may allow the reversal of the tracheostomy. It is only suitable for a small proportion of patients with marked aspiration, as most will respond to conservative treatment. Nine patients underwent this operation and six gained a satisfactory result, with two patients achieving tracheostomy reversal. There were two late post-operative deaths from infective causes which reflects the general debilitation of these patients and the risk of exacerbating concomitant broncho-pulmonary infection.

Conductive hearing loss following retrolabyrinthine surgery.

BACKGROUND: Conductive hearing loss can occur following neuro-otological procedures due to bony ossicular fixation resulting from viable bone dust remains. OBJECTIVE: To highlight the frequency and features of the complication of conductive hearing loss following retrolabyrinthine surgery. DESIGN: In a review of 77 retrolabyrinthine neuro-otological procedures, 3 cases (3.9%) of postoperative conductive hearing loss were encountered. RESULTS: Bone dust can cause a postoperative conductive hearing deficit that becomes apparent 6 months following surgery, and progressive deterioration can occur up to 18 months. The anatomical areas of ossicular fixation are the incudomalleal joint in the attic and around the stapes in the oval window niche. Excision of these bony accumulation particles does not revert the conductive hearing loss. CONCLUSIONS: We advocate the use of occlusive material in the aditus during temporal bone surgery to prevent bone dust accumulation in the attic and middle ear. In the event of such a complication, an incus transposition ossiculoplasty is recommended.

Vascular-decompression surgery for severe tinnitus.

Vascular compression of the eighth cranial nerve is increasingly recognised as a possible cause of incapacitating audiovestibular symptoms. There have been few reports of the efficacy of surgical microvascular decompression for tinnitus, and the practise is controversial. During the last 6 years, investigation by air computed tomography (CT) cisternography initially, and fast spin-echo magnetic resonance imaging (MRI) latterly has resulted in the diagnosis of cochlear nerve vascular compression in nine patients with a primary complaint of severe tinnitus who have subsequently undergone vascular-decompression surgery. The duration of symptoms ranged between 1 and 10 years, whilst their subjective tinnitus perception varied between 30 to 60 dB above threshold. Microvascular decompression was carried out by a retrolabyrinthine approach in four and by a retrosigmoid approach in the remaining five cases, with a postoperative follow-up of 1.3 to 5 years. Tinnitus was completely abolished in three (33%), very significantly improved to a sensation level of < or = 10 dB in four (33%), significantly improved to a level of 15 dB in one (11%), and unchanged in two (22%). Both failures had had tinnitus for 6 years and had transient abolition for 10 days after surgery. Subsequent revision decompression surgery was also unsuccessful. This small study suggests that cochleovestibular vascular compression may result in severe tinnitus, which can often be ameliorated surgically.

Vestibular nerve dysfunction and decompression in Engelmann's disease.

Vestibular nerve dysfunction as the major neuro-otological symptom in one of the osteopetrosis group of bone disorders is unusual. We describe a patient with Engelmann's disease who presented in this manner and who benefited from an eighth nerve decompression procedure. Surgical decompression of the internal auditory meatus to relieve vertigo has to our knowledge not been previously reported in this condition.

The pharmacological treatment of Menière's disease.

The management of Menière's disease often provides a formidable clinical challenge largely because its precise aetiology is unknown. There is no known 'cure' once the condition is established, but drugs may be helpful in treating both the acute attacks of vertigo, and in more long-term management, particularly in the earlier fluctuant stage. These remedies are largely symptomatic and there are few if any properly controlled studies of their efficacy. Suppressant drugs may act centrally at neurotransmitter sites, or peripherally on the labyrinth. Conventional diuretics and osmotically acting agents have been given to reduce the endolymph fluid volume. Histamine analogues directly reduce inner ear fluid pressure mainly by increasing the cochlear blood flow, and are probably the treatment of choice. Otovestibulotoxic drugs given systemically to cause chemical labyrinthine ablation are frequently effective in abolishing attacks of vertigo but often resulted in disabling oscillopsia and ataxia. There is now evidence that local administration by intratympanic injection may well be more efficacious resulting in selective partial end organ ablation. To date innovative immune modifying regimes have not proved helpful.