Facial reanimation with end-to-end hypoglossofacial anastomosis: 20 years' experience.

OBJECTIVE: This study aimed to evaluate retrospectively the results of experience with end-to-end anastomosis of cranial nerves VII and XII, performed due to transection of the facial nerve during acoustic neuroma removal. METHODS: We assessed the facial reanimation results of 33 patients whose facial nerves had been transected during acoustic neuroma excision via a retrosigmoid approach, between 1985 and 2006, and who underwent end-to-end hypoglossofacial anastomosis. We compared the facial nerve functions of patients receiving short term (two to three years) and long term (more than three years) follow up, and we assessed any complications of the anastomosis. RESULTS: A House-Brackmann grade III facial function was achieved in 46.2 and 86.4 per cent of the patients in the short and long term, respectively. House-Brackmann grade IV facial function was achieved in 53.8 and 13.6 per cent of the patients in the short and long term, respectively. There was a statistically significant difference between the facial recovery results, comparing the short and long term follow-up periods (p = 0.03). Disarticulation was the most common complication, seen in 19 (57.6 per cent) patients; numbness of the tongue was the next commonest (10 (30.3 per cent) patients). None of the patients developed dysphagia. CONCLUSION: Despite such morbidities as disarticulation and tongue numbness, end-to-end hypoglossofacial anastomosis is still an effective procedure for the surgical rehabilitation of static and dynamic facial nerve functions. Significant improvement in facial nerve function can occur more than three years post-operatively.

Impact of prognostic factors on recovery from sudden hearing loss.

OBJECTIVE: To define the impact of patient-related and audiovestibular parameters on the prognosis of sudden hearing loss. METHODS: Eighty-three patients were included in this retrospective study. All were treated medically. We recorded the patients' demographic parameters, systemic diseases, time elapsed between onset of sudden hearing loss and initiation of treatment, tinnitus, vestibular symptoms, type of initial audiogram, pure tone averages and speech discrimination scores. For all patients, audiological measurements were performed on initial admission and at the completion of treatment on the 10th day. RESULTS: There was no correlation between the hearing gain and recovery rate scores and patients' gender or age (p>0.05). However, a correlation was found between gender and relative hearing gain. Vertigo was not correlated with hearing gain and recovery rate scores (p0.05); time elapsed between onset of sudden hearing loss and initiation of treatment (p>0.05); type of audiogram on initial admission (p>0.05), except for midfrequency type of audiogram; and tinnitus (p>0.05). CONCLUSIONS: The outcome of sudden hearing loss was unaffected by systemic disease, tinnitus or type of audiogram (except for midfrequency type). The following were poor prognostic factors in the outcome of sudden hearing loss: female gender, presence of vertigo, initiation of treatment more than seven days after onset of hearing loss, and >40 dB hearing loss on admission.

Effect of positional change and inhalant anesthesia on parameters of acoustic reflectometry.

OBJECTIVE: Purpose of this study was to find out the effect of positional change and inhalant anesthesia on acoustic reflectometry (AR) parameters (reflectivity and curve angle). METHOD: AR parameters were measured on 58 ears with otitis media in sitting position before anesthesia and in supine position under inhalant anesthesia, subsequently. RESULTS: Under anesthesia, ears with effusion disclosed more changes in reflectivity (Chi-squared analysis, chi2-test; P<0.05) and curve angle (P>0.1) than those without effusion. Further, inhalant anesthesia caused more changes in the false negative ears (63.63%) than in those with effusion having positive test before anesthesia (12.90%) (P<0.001). CONCLUSIONS: From the data of this study, it could be said that reflectivity shows changes according to the amount of effusion which is in contact with the tympanic membrane under anesthesia, and that curve angle becomes more sensitive to detect effusion when anesthetic gas diffuses into the middle ear with effusion, probably due to the pushing of effusion towards the tympanic membrane.

Tympanometry and acoustic reflectometry in ears with chronic retraction without effusion.

OBJECTIVE: Purpose of this study was to find out test accuracy and predictivity of tympanometry (TYMP) and parameters (reflectivity and curve angle) of acoustic reflectometry (AR) in the ears with prior clinic and otoscopic evidences of effusion in which no effusion was detected by myringotomy, by comparing with the data found in normal ears and in those with effusion. METHODS: While study group included 31 ears with chronic retraction in which no effusion was detected by myringotomy, control group included 150 fully normal ears and 150 ears with effusion confirmed by myringotomy. B tracings in TYMP, and values of reflectivity higher than 5 and curve angle lower than 75 degrees in AR were accepted as indicators of effusion; in the combined test, the ears with non-B tracings in which curve angle higher than 75 degrees were accepted as those without effusion. RESULTS: False positivity values of TYMP, reflectivity and curve angle and the combined test found in the ears with chronic retraction without effusion (29, 23, 19 and 35% respectively; chi(2)-test, P > 0.1) were significantly higher than normal ears (chi(2)-test, P < 0.001), but lowe than those of effusion (chi(2)-test, P<0.0001). Further, although negative predictivity values of TYMP, reflectivity and curve angle were found to be lower in these ear, compared to normal ears (chi(2)-test, P < 0.01), the combined test reached to a perfect negative predictivity, as much as in normal ears. On the other hand, positive predictivity values were decreased in the ears with chronic retraction without effusion by only reflectivity. CONCLUSIONS: By both TYMP and AR alone, it is more difficult to find out the ears without effusion among the ears clinically and otoscopically diagnosed as otitis media than to find out normal ears. Therefore, in clinical work, false positivity of these devices were higher, and their specificity and negative predictivity were lower; although the combined test solved problem of low negative predictivity, high number of false positive ears in clinical work, that is lower specificity, continues to be an unsolved problem by either TYMP or AR alone, or both together.

Endoscopy of the posterior fossa and dissection of acoustic neuroma.

OBJECT: The authors evaluated the importance of endoscopes in eliminating the disadvantages of the posterior fossa approach, such as the lack of adequate visualization of the lateral aspect of the internal acoustic canal (IAC). METHODS: Between 1989 and 1998, 32 patients underwent removal of acoustic neuroma (AN) via a combined retro-sigmoid-retrolabyrinthine approach. Endoscopes were used at different stages of the operation, and their use was evaluated with regard to elimination of the disadvantages of the posterior fossa approach. All patients in whom AN had been diagnosed underwent surgery in which a standard retrosigmoid-retrolabyrinthine approach was used. Standard sinus endoscopes of 0 degree, 30 degrees, and 70 degrees were introduced into the cerebellopontine angle before debulking the tumor, and the IAC was inspected at the end of the operation. Neurovascular integrity as well as the relationship between the AN and surrounding structures were evaluated. The IAC was inspected for residual tumor, and if any was found, endoscopically guided tumor dissection was performed. CONCLUSIONS: Endoscopes have facilitated an understanding of the anatomy between an AN and neighboring neurovascular structures. For surgery in which the posterior fossa approach is used, endoscopes can make operations safer by eliminating the disadvantages of the approach. In addition to allowing inspection of the fundus, it is possible to perform endoscopically guided tumor dissection within the IAC.

Posterior fossa vestibular nerve section for the management of peripheral vertigo.

Patients with vertigo resistant to conservative treatment require surgical management. Between March 1991 and August 1996, vestibular nerve sections were performed in 108 patients with peripheral vertigo not responding to conservative treatment. The diagnoses were classic Ménière's disease in 96 patients and recurrent vestibulopathy in 12 patients. Combined retrosigmoid retrolabyrinthine (n = 106) and retrolabyrinthine (n = 2) approaches were used. Patients were grouped according to follow-ups of less than 2 years and more than 2 years. In the former group (n = 49), hearing preservation and vertigo control were achieved in 93.9% and 100%, respectively. In the latter group (n = 59) the rates were 89.8% and 96.6%, respectively. Overall complications were uncommon. Three patients had cerebrospinal fluid leakage and one had total hearing loss. According to our results, posterior fossa vestibular nerve section was found to be an effective treatment for the management of patients with intractable vertigo.

Predictive value of acoustic reflectometry (angle and reflectivity) and tympanometry.

OBJECTIVE: Tympanometry and acoustic reflectometry are suggested tools for confirmation of otoscopic diagnosis of secretory otitis media. The issues on sensitivity and specificity of both devices are contradictory. In this study, our purpose was to compare sensitivity and specificity of both devices and to look for whether it is possible to reach higher values by combining them. METHODS: This study included 150 normal ears and 150 ears with chronic effusion. In tympanometry, only B tracings were accepted as predictor of effusion. In acoustic reflectometry, reflectivity (cut point: 5) and curve angle with two cut-points (75 degrees and 90 degrees) were used. RESULTS: Acoustic reflectometry presented higher specificity by both reflectivity (cut point: 5) and by curve angle (cut point: 75 degrees) (99.33% by both) than tympanometry (92%) (chi2 analysis, P < 0.001). But, their sensitivities (65.33 and 78%) were lower than tympanometry (96%) (chi2 analysis, P < 0.001). With curve angle of 90 degrees, specificity of acoustic reflectometry decreased to 85.33%, sensitivity increasing to 97.33%, which was not different from tympanometry (chi2 analysis, P > 0.1). When data of curve angle and tympanometry were combined, specificity and sensitivity of the combined test were found to be 91.33 and 100%, respectively. CONCLUSIONS: (i) Acoustic reflectometry should not be proposed as a better device than tympanometry, because its test efficiency was not higher than tympanometry. (ii) The only advantage of AR (reflectivity > or = 5 and curve angle < or = 75 degrees) was its high specificity to effusion. In addition, higher curve angles than 90 degrees were found to be highly predictive for normal ears as much as tympanometry. But, predictivity of curve angle between 76 degrees and 90 degrees was low. (iii) When tympanograms and curve angle were combined, it was found that prediction of this combination for curve angles between 76 degrees and 90 degrees was perfect. (iv) We consider that both test devices provide complementary data to each other, which would be particularly important for screening studies and that they are good tools for confirmation of clinical impression, particularly for less experienced clinicians.

[Middle ear ossicular replacement prostheses: cause of failure]. / Prothèses ossiculaires d'oreille moyenne: causes d'échec.

There are various prostheses used for ossiculoplasty in chronic middle ear disease. Plastipores are one of the most commonly used prostheses. We performed ossiculoplasty with plastipores in 237 ear operations in a five years period. The results of the operations were summarized and causes of prosthesis failure were discussed. In 55 (23.2%) patients, tympanic membrane perforation recurred. Cholesteatoma recurrence was encountered in 16 (6.8%) cases. The extrusion of prosthesis was observed in 10 (4.2%) cases. The underlying ear disease was cleaned in 156 (65.8%) patients. An air-bone gap to within 20 dB was achieved in 87 (55.8%) ou of 156 patients. In 69 (44.2%) the gap closure was more than 20 dB. The experience of the surgeon in otologic surgery, severity of the chronic ear disease, status of the eustachian tube, extention of the ossicular chain disruption, type of surgery and characteristics of the prosthesis are critical for ossiculoplasty.

Functional results of Plastipore prostheses for middle ear ossicular chain reconstruction.

OBJECTIVE: Assessment of plastipore prostheses for middle ear ossicular chain reconstruction. Hearing results with total and partial Plastipore ossicular replacement prostheses (TORP and PORP) were evaluated in open- and closed-cavity operations. STUDY DESIGN: A retrospective review of 237 patients who underwent operation for chronic ear disease as well as ossiculoplasty with plastipore prostheses. In order to assess the functional results, only 156 of 237 patients were included in the study. Follow-up ranged from 6 to 46 months. METHODS: Canal wall up and canal wall down operations were performed. Either TORP or PORP ossiculoplasty was performed in each operation. An airbone gap closure to within 20 dB was considered successful. RESULTS: With TORPs, the airbone gap closure to within 20 dB was achieved in 43.1%, and similar results were obtained with PORPs in 63.3%. In canal wall down and canal wall up operations, the success rates were 55.8% and 55.7%, respectively. The best results were obtained with PORPs in canal wall down operations, with a success rate of 82%. The extrusion rate of the prostheses was 4.2%. CONCLUSION: Hearing results of PORPs are better than TORPs. In canal wall up and canal wall down operations similar hearing results are obtained. PORP ossiculoplasty in a canal wall down operation yields the most favorable hearing result.

Radiographic evaluation of children with nasopharyngeal obstruction due to the adenoid.

The adenoidal-nasopharyngeal ratio (ANR) was proposed as a convenient and practical method to evaluate adenoidal enlargement. We analyzed cephalometric radiographs of 150 children divided into 6 subgroups according to clinical assessment (possible adenoidectomy candidates [PACs] and controls) and age. Our purpose was to investigate the predictive reliability of different ANRs calculated on the same reference line. Each of the ANRs described in this study presented statistically significant differences between PACs and control groups, and highly significant correlations with clinical symptoms of nasal obstruction. Further, the mean adenoidal depth was significantly larger in PACs than in normals, and it was found that the adenoidal depth in PACs did not show a significant decrement with age. in contrast to normals. On the other hand, although nasopharyngeal depth was not different between PACs and normals, an age-dependent increment was observed in PACs, in contrast to normals. Thus, it could be said that the ANR is a more reliable method for determining whether adenoidal hyperplasia is clinically significant or not, rather than the size of the adenoid or nasopharynx.