Petrous apex lesions.

OBJECTIVE: The accurate diagnosis of different petrous apex lesions is increasingly common as a result of modern imaging techniques, combining computed tomography and magnetic resonance imaging. The clinical features, diagnostic evaluation, imaging, and treatment outcomes of patients with petrous apex lesions are reviewed. STUDY DESIGN: Retrospective case review. SETTING: Private practice tertiary otologic referral center. PATIENTS: Sixty-six patients treated at the House Ear Clinic in the last 2 decades for a lesion of the petrous apex. Lesions included cholesterol granuloma, cholesteatoma, and chondrosarcoma, among others. Mean follow-up time was 27 months and ranged from 1 month to 10 years. INTERVENTION(S): Cholesterol granulomas were treated with drainage procedures, solid tumors were surgically removed using primarily the middle fossa or infratemporal fossa approaches. RESULTS: The most common presenting symptoms were hearing loss, dizziness, headaches, and tinnitus. Decreased cranial nerve V function was present in 22%. The most common cystic lesion was cholesterol granuloma, which constituted 60% of all lesions in the study, followed by cholesteatoma (9%). Chondrosarcomas were the most common solid lesion (6% of all lesions). Asymmetric pneumatization and retained secretions give radiographic findings commonly overdiagnosed as lesions of the petrous apex. CONCLUSIONS: Lesions of the petrous apex can be diagnosed accurately by CT and MRI and can be divided into cystic and solid lesions. Cholesterol granulomas are by far the most common lesion found in this site and can be drained with minimal morbidity via the infracochlear approach. Solid tumors may require extensive exposure and a combined skull base approach for complete removal.

Postoperative respiratory compromise in children with obstructive sleep apnea syndrome: can it be anticipated?

OBJECTIVE: The aim of this research was to describe the postoperative respiratory complications after tonsillectomy and/or adenoidectomy (T and/or A) in children with obstructive sleep apnea syndrome (OSAS), to define which children are at risk for these complications, and to determine whether continuous positive airway pressure (CPAP) is an effective strategy for dealing with these complications. METHODS: The data for this study were gathered through a retrospective chart review of all children 15 years of age or younger with polysomnographically (PSG) proven OSAS who had a T and/or A at Hennepin County Medical Center between January 1985 and September 1992. Particular attention was paid to factors that contributed to the OSAS, postoperative respiratory complications, and intervention strategies for dealing with these complications. RESULTS: The charts of 37 children with OSAS documented by preoperative PSG who later had a T and/or A were reviewed retrospectively. Ten of these children had significant postoperative respiratory compromise secondary to OSAS that prolonged their hospital stay from 1 to 30 days and caused symptoms ranging from O2 desaturation < 80% to respiratory failure. These children were younger and had significant associated medical problems that contributed to or resulted from their OSAS in addition to large tonsils and adenoids. The associated medical problems included craniofacial anomalies, hypotonia, morbid obesity, previous upper airway trauma, cor pulmonale, and failure to thrive. The children with postoperative respiratory complications also had more severe apnea on their preoperative PSG. One child had a uvulopalatopharyngoplasty (UPPP) in addition to the T & A. Taken together, the history, physical and neurological examination, and the PSG were able to identify successfully the children who subsequently developed respiratory compromise secondary to OSAS after a T and/or A. Nasal continuous positive airway pressure (CPAP) and bilevel CPAP was used successfully to manage the preoperative and/or postoperative upper airway obstruction in five of these children. CONCLUSIONS: Based on these findings, overnight observation is recommended with an apnea monitor and oximeter for patients undergoing a T and/or A who have OSAS and meet any of the following high-risk clinical criteria: (1) < 2 years of age, (2) craniofacial anomalies affecting the pharyngeal airway particularly midfacial hypoplasia or micro/retrognathia, (3) failure to thrive, (4) hypotonia, (5) cor pulmonale, (6) morbid obesity, and (7) previous upper airway trauma; or high-risk PSG criteria: (1) respiratory distress index (RDI) > 40 and (2) SaO2 nadir < 70%; or undergoing a UPPP in addition to the T and/or A. Nasal CPAP/bilevel CPAP can be used to manage the preoperative and/or postoperative upper airway obstruction in patients with OSAS undergoing a T and/or A.

Facial nerve stimulation produced by cochlear implants in patients with cochlear otosclerosis.

Thirty-eight adult cochlear implants have been performed at the University of Minnesota. Facial nerve stimulation by the implant in response to sound has been noted in four of these cases. Three of the four were patients whose sensorineural hearing loss was caused by cochlear otosclerosis. In each case it was possible to place the electrodes, however multiple leads had to be deprogrammed in order to avoid facial nerve stimulation. In each case characteristic radiographic findings of cochlear otosclerosis could be identified on preoperative temporal bone computed tomography scans. Although facial nerve stimulation has been described as a complication of cochlear implantation, it has not been reported to be associated with cochlear otosclerosis. Postoperative programming of the implant may be limited by facial nerve stimulation. In some cases these limits may reduce the efficacy of the device. This possibility should be taken into account during preoperative counseling of patients with cochlear otosclerosis considering cochlear implantation.

Evaluation of patients with acoustic neuroma with dynamic posturography.

The purpose of the present work was to consider the use of posture tests in patients who had known acoustic tumors. The results suggest that it might be possible to determine whether the tumor is on the inferior or superior branch of the vestibular nerve. This would have clinical significance for planning a surgical approach to the tumor.