Different treatment modalities of tinnitus at the EuromedClinic.

A retrospective study at the ear, nose, and throat department of the EuromedClinic showed considerable improvements immediately after the end of the treatments for acute and for chronic tinnitus. Eighty percent of our patients suffering from acute tinnitus showed an improvement with intravenous medication without hyperbaric oxygen treatment, and 65.7% showed improvement with infusion therapy and hyperbaric oxygen. However, at 3 months and then later (long-term results), the figures decreased to 67% and 46%, respectively. In the chronic tinnitus group, the therapeutic effect dropped from 66.7% to 34% (with only intravenous medication) and from 60% to 28% (with combined therapy). These facts can explain the importance of beginning the treatment of patients suffering from tinnitus as early as possible (i.e., acute stage).

[What should be recommended to a patient with a small radiologically suspected acoustic neuroma?]. / Was soll man einem Patienten mit radiologischem Verdacht auf ein kleines Akustikusneurinom raten?

OBJECTIVE: Criteria for therapeutic decision-making for intrameatal acoustic neurinomas that are suspected radiologically. DESIGN: Retrospective evaluation. PATIENTS: 114 surgically treated patients of the ORL Dept. of the University Erlangen-Nuremberg. OUTCOME MEASURES: Rate of complications. Preservation of facial nerve function and hearing. Preoperative time course of hearing. Reliability of radiological examination. Progression of symptoms and tumor growth. THERAPY: Surgical exposure and complete removal by the enlarged middle cranial fossa approach. RESULTS: In 47% of cases surgery confirmed a neurinoma limited to the internal auditory meatus. In 41%, tumors were larger than expected and had protruded into the cerebellopontine angle, indicating preoperative tumor growth during an average period of 5.4 months before surgery could be completed. The remaining 12% of patients were found to have a facial neurinoma, meningioma or non-tumorous lesion of the internal auditory canal. No permanent neurological deficits or fatalities occurred in any of the patients treated. Facial function was favorable in 88% and moderate pareses or synkineses occurred in 12%. The degree of hearing preservation depended on the preoperative situation. When the preoperative pure-tone average (at 0.5, 1, 2 and 4 kHz) was 30 dB or less, hearing levels of less than 90 dB could be preserved in 70% of cases. Findings also demonstrated that the complication rate and success of function preservation were similar to younger patients in patients older than 60 years (n = 21). Without surgery auditory acuity decreased by 10 dB per year. The volume of intrameatal neurinomas in 7/10 cases followed by MRI doubled during a median following time of 32 months. CONCLUSIONS: Acoustic neurinoma surgery by the enlarged middle cranial fossa approach is a safe procedure with low complication rates. The percentages of preservation of facial function and hearing can be excellent in cases with small tumors and good preoperative hearing. To date no parameter has been found to predict tumor growth or the time course for hearing loss in individual cases. Surgical ablation of radiologically suspected, small acoustic neurinoma by the transtemporal approach is recommended.

[Vestibular lesion in sudden deafness: a prognostic criterium for therapeutic success]. / Vestibularisläsion beim Hörsturz: Ein prognostisches Kriterium für den Therapieerfolg.

The influence of vestibular dysfunction on severity of initial hearing loss and success of therapy was evaluated in a retrospective study with 142 patients suffering from idiopathic sudden hearing loss. In 48% of these patients combined cochleovestibular disorders were found. In this group mean hearing loss was significantly higher (45 dB versus 32 dB) and hearing recovery after therapy (25% versus 38%) less pronounced. 83% of patients with high grades of vestibular disorders (Vestibular Index: > or = 9) showed a decrease of hearing function between 50 dB and 130 dB compared to 32% in the group with signs of low vestibular dysfunction. Additional vestibular lesion in patients with sudden deafness can be used as a criteria for prognosis. High grade vestibular lesion reduce the probability of complete hearing recovery.

Facial nerve involvement in patients with acoustic neurinomas. Examination with magnetic single- and bi-stimulation.

The diagnosis of acoustic neurinomas is usually made by auditory and vestibular testing and magnetic resonance imaging. As clinical involvement of the facial nerve is infrequent, occurring only in large tumours, only little is known about the subclinical involvement of the facial nerve. Transcranial magnetic stimulation of the VIIth cranial nerve in the temporal bone, adjacent to acoustic neurinoma growth, seems to be an adequate instrument for electrophysiological measurements of minimal nerve lesions without clinically obvious facial palsy. In 70% out of 97 patients with surgically and histologically confirmed acoustic neurinomas, obvious elongation of the intratemporal conduction time of the facial nerve was found. This affection was dependent on tumour size. No correlation was found to preoperative or postoperative facial nerve function and hearing function. The latencies of the conduction time showed a tendential increase in patients with a more difficult grade of surgery and of facial nerve preparation due to fibrous adhesions and nerve spreading on the tumour capsule. A completely new stimulation modality, the application of two magnetic stimuli in quick succession, was applied for the first time in acoustic neurinoma patients, and revealed facial nerve involvement by acoustic neurinoma growth. Facial nerve involvement in acoustic neurinoma can be detected by transcranial magnetic stimulation even in patients with small and medium sized tumours but with clinically normal facial function.

Clinical survey of Meniére's disease: 574 cases.

Only 27% out of 574 patients suffering from Meniére's disease initially started with the typical Meniére's triad. A great advantage in order to diagnose Meniére's disease can be established with the telemetric-ENG. With this equipment it is possible to verify a nystagmus outside the clinic (at home, at work) at any time in patients suffering from vertigo attacks. Most of our patients showed an omnifrequent sensorineural hearing loss on the affected side. Many of our patients with Meniére's disease suffered from internal diseases (e.g. hypotonia, hyperlipidemia, diabetes mellitus), allergy or an affection of the paranasal sinuses, which may constitute co-factors triggering Meniére's disease.

[Intraoperative monitoring of the facial nerve in transtemporal surgery of acoustic neurinoma]. / Intraoperatives Monitoring des Fazialisnervs bei der transtemporalen Chirurgie des Akustikusneurinoms.

Acoustic neuroma ablation by the enlarged middle cranial fossa approach results in a low incidence of postoperative facial nerve dysfunction. In 25 consecutive patients with tumors in the cerebellopontine angle with a diameter up to 2.3 cm, intraoperative monitoring of the facial nerve was evaluated. The facial nerve was monitored electrophysiologically with recordings of the spontaneous EMG and electrically evoked potentials (CMAP) from at least three groups of facial muscles. In 4 cases monitoring was helpful for identification and delineation of the facial nerve. The mechanically elicited potentials during tumor preparation and CMAP after electrical stimulation close to the brain stem were compared with the postoperative facial nerve function and the time course of recovery. If the ongoing EMG recordings resulted in potentials below 0.5 mV and the CMAP at the end of tumor preparation was higher than 0.5 mV, facial nerve function was normal in 9 of 10 cases on the first postoperative day. One patient had mild facial palsy. Poor results could be predicted if numerous discharges with amplitudes higher than 0.5 mV and affected CMAP after stimulation near the brain stem were found at the end of surgery. All 3 patients with these findings had facial paralysis at hospital discharge (an average of 9 days after the operation). Recovery from the palsies was found to be prolonged. Intraoperative monitoring of the facial nerve is now used routinely in surgery of the cerebellopontine angle and the internal auditory canal.

[Clinical experiences with dehydrated temporalis fascia in tympanoplasty. Early and late results]. / Klinische Erfahrungen mit der dehydratisierten Fascia temporalis in der Tympanoplastik. Früh- und Spätergebnisse.

Dehydrated temporalis fascia, an allograft transplant tissue, is very useful in tympanoplasty and tympanomeatoplasty. In 87% of cases tympanic membrane grafts placed in patients with severe chronic otitis media have remained healed without change 4-6 years after surgery. All grafts also remained in position when placed on the posterior wall of the external auditory canal. Good healing was always seen without complications or inflammations. By using these grafts the duration of surgery could be reduced and the cosmetic risk of extending pre- or postauricular incisions to obtains autologous temporalis fascia was unnecessary, especially in revision surgery. The allograft is very easy to handle and is malleable and flexible. The main indications for use of allograft temporalis fascia are patients with chronic otitis media, traumatic tympanic membrane perforations or malformations of the middle ear (such as congenital atresias) requiring tympanic membrane replacement and lining of the posterior wall of the external auditory canal.

Advantages of the enlarged middle cranial fossa approach in acoustic neurinoma surgery. A review.

Utilizing an enlarged middle cranial fossa approach to the cerebello-pontine angle without destruction of the labyrinth or cochlea the authors have since 1981 operated on 263 unilateral acoustic neurinomas. Tumour sizes ranged between 3 mm intrameatal and 35 mm within the cerebello-pontine angle. Complete tumour removal was accomplished in 96%. There was one postoperative mortality, and only rarely neurological complications. Excellent function of the facial nerve was obtained in 78% (in small and medium sized neurinomas 90% House I and II) and severe paralysis persisted in only 6%. Preservation of hearing was possible in 70% of the small tumours, and in 50% of the total group. Against this background comparable data of the literature are reviewed, and the indications for the enlarged midfossa approach analyzed.

Posture and central compensation after acoustic neurinoma surgery.

After acoustic neurinoma surgery via the enlarged middle cranial fossa approach the patients usually benefit from a good prognosis of the vestibular compensation, almost independent of the size of the tumour and of the patient's age, if the central vestibular pathways were not injured. Only 8% of the patients showed a reduced vestibular compensation. The success and gradation of the vestibular compensation in diseases with a permanent labyrinthine loss, even though after acoustic neurinoma surgery, can easily be classified by the so-called vestibular-index.

"Telemetric" electronystagmography: a new method for examination of nystagmus outside the clinic.

The diagnosis of the vestibular system is expanded by an newly developed system. It offers mainly two additional ways for the examination of eye movements: 1) Time and place independent, telemetric ENG recording by the patient himself. 2) Simultaneous visual examination of the nystagmus and ENG recording in clinic and surgery. The device contains of special, handy ENG recorder with digitalized storing of ENG curves. For easy application, special goggles with pre-installed electrodes have been combined with modified Frenzel's glasses. The recorded curves can be evaluated with the aid of a regular personal computer.

Topographical anatomy of the internal auditory canal. Implications for functional surgery in the cerebello-pontine angle.

For exposure of the cerebello-pontine angle by an enlarged middle-fossa approach without destruction of the inner ear, bone removal anterior and posterior to the internal auditory meatus (c.a.i.) can be performed with orientation at landmarks. Based on the experience of more than 300 interventions and documented by a series of 10 temporal bone micro-dissections, rules have been established for reliable localization of the following structures: geniculate ganglion, Fallopian canal, vertical crest at the fundus of the c.a.i., basal coil of the cochlea, and ampulla of the superior semicircular canal. The surgical technique has enabled the authors to remove acoustic neurinomas of up to 3.5 cm with preservation of hearing in 51%.