Rate of persistent perforation after elective tympanostomy tube removal in pediatric patients.

This study was performed to determine the rate of persistent perforations according to age, tube type and duration of intubation in children who underwent elective tympanostomy tube removal. Our retrospective analysis of hospital and clinic charts included all patients who underwent elective tube removal from July 1995 to December 1997 at our institution. Information from the chart review included patient age at time of tube removal, type of tube removed, duration of intubation, presence of granulation tissue/polyps, and concomitant paper patch placement. The outcome of each surgical removal was determined by examining follow-up clinic charts. A patient was deemed to have a persistent perforation if the eardrum had not adequately healed within 3 months after surgery. Data on 201 patients were gathered. These patients had 273 tube removals. Eleven percent of ears (29/273) had persistent perforations. According to tube type, no perforations (0/48) occurred with Collar Bobbin tubes, 6% (3/50) with Tytan tubes, 7% (3/44) with Duravent tubes, and 22% (16/74) with Paparella II tubes. Three percent (3/101) of tubes in place for <3 years and 15% (26/172) of tubes in place for >3 years showed persistent perforations after removal. Ears with granulation polyps had a 9% (18/203) rate of perforations, whereas those without granulation polyps had a 16% (11/70) rate of perforations. Forty percent (4/10) of ears were treated with paper patches at the time of tube removal showed persistent perforations. Our data indicate that the rate of persistent perforation (11%) after elective tympanostomy tube removal is high. The factors associated with higher rates of persistent perforation (P<0.05) include duration of intubation >3 years prior to removal and the use of long-term Paparella II tubes.

Value of intraoperative threshold stimulus in predicting postoperative facial nerve function after acoustic tumor resection.

OBJECTIVE: The objective of this study was to determine the predictive value of intraoperative threshold stimulus and postoperative facial nerve outcome in acoustic neuroma surgery. This is a retrospective case review of 116 consecutive procedures to remove acoustic neuromas using either a retrosigmoid or translabyrinthine approach. STUDY DESIGN: Retrospective study. SETTINGS: The Tertiary Referral Center at The California Ear Institute in Palo Alto, California. PATIENTS: These were consecutive presenting patients with acoustic neuroma in the senior author's practice. Patients were not categorized into age, sex, race, or other demographic features. INTERVENTION: All patients had acoustic neuromas detected via magnetic resonance imaging, and they underwent surgery at the hands of the same neurootologic team, Drs. Nissen and Welsh. MAIN OUTCOME MEASURE: The electrophysiological monitoring reports of 81 cases of acoustic tumors. Measures in which intraoperative facial nerve monitoring was performed provided the data for this article. RESULTS: The patients were categorized by postoperative facial nerve function evaluated a minimum of 6 months after surgical removal. Group I was composed of those patients with facial nerve grades of I or II. The median threshold stimulus voltage required to produce measurable facial nerve activity at the root entry zone (REZ) immediately after tumor removal in this group was 0.100 V. Patients in group II had postoperative facial nerve grades of III to VI. Median threshold stimulus in this group was 0.7250 V. The difference in median threshold stimulus voltage at the REZ after tumor removal between these two groups was found to be statistically significant in using the nonparametric Mann-Whitney U test. CONCLUSIONS: The results of this study strongly support the continued use of intraoperative facial monitoring as a predictor of postoperative facial nerve outcome after acoustic tumor surgery.

A multifactorial analysis of facial nerve results in surgery for cerebellopontine angle tumors.

Preserving the function of the facial nerve remains a paramount objective in acoustic neuroma surgery. This study was undertaken to determine the influence of four independent variables on facial nerve outcome by means of a retrospective review of 111 surgical cases: 1) tumor size; 2) use of intraoperative facial nerve monitoring (IFNM); 3) completeness of tumor resection; and 4) surgical approach used. Partial tumor resection appeared to result in improved facial nerve outcome for patients with large tumors. Results indicated that tumor size did not correlate with facial nerve functional outcome, with no statistically significant differences observed among the three size categories. Facial nerve function was not found to depend on selection of either a translabyrinthine (n = 47) or a suboccipital (n = 55) surgical approach in that results were similar for both groups. Outcome data showed a trend in support of the use of IFNM, especially for large tumors, even though the differences between monitored and unmonitored groups were not statistically significant. This study describes the independent impact of the four factors generally thought to affect facial nerve outcome and, in addition, recommends the use of data stratification in reporting facial nerve function results.

Use of the KTP-532 laser in acoustic neuroma surgery.

The potassium titanyl phosphate (KTP-532) laser has been applied to otologic surgery with a proven record of both safety and efficacy. The aim of this study was to demonstrate the use, safety, and advantages of laser dissection in the surgical treatment of acoustic neuromas. The authors' experience with 111 patients in whom laser surgery was used in acoustic neuroma is presented, with emphasis on surgical technique employed and facial nerve functional outcome. The method of laser dissection did not result in deleterious neurologic sequelae or laser-specific complications. In addition, laser dissection afforded certain advantages to traditional techniques, especially in larger tumors. The facial nerve functional outcome as assessed by the House-Brackmann grading system revealed that 90.2% of small tumors, 72.2% of medium tumors, and 75.0% of large tumors achieved satisfactory (grades I and II) functional results. These results compare favorably with the literature describing nonlaser dissection techniques. The observations and results reported in this article demonstrate the safety of the KTP-532 laser in the posterior cranial fossa, and specific advantages that this technology may offer to the surgical armamentarium of the neuro-otologist are outlined.

Complications of chronic otitis media.

In summary, recent literature indicates that the complications of chronic otitis media have been decreasing. However, even with the advent of modern and more powerful antimicrobials and aggressive surgical eradication of disease, the morbidity and mortality are still high. Some complications may initially be quite obvious and some complications may be quite subtle. Therefore, the most important tools in making early diagnosis are careful history and physical examination, and a high index of suspicion for impending complications.

Primary schwannoma of the petrous apex.

We present two patients with primary petrous apex schwannoma. These tumors were centered on the petrous carotid artery and are thought to have originated from the deep petrosal nerve. This would account for the paucity of neurologic deficits in these patients. Imaging findings and surgical treatment of primary petrous apex schwannomas are discussed.

Fibrin glue in otology and neurotology.

The recent development of simple, low-cost methods for producing autologous fibrin glue have given rise to a variety of uses in routine otologic and neurotologic procedures. Some of the current applications used by the authors are discussed, and a brief review of the literature is presented. Included are methods of positioning and securing implants, closure of wound edges, and application as an adjunct to achieving watertight dural closures with intracranial procedures. Representative cases are presented. No adverse reactions or specific problems related to the glue have been noted. A simple production method is included, as well as comparison with other commonly available tissue glue products.

Magnetic resonance imaging of brain herniation into the middle ear.

Four patients with cholesteatoma were shown to have a large area of eroded tegmen tympani on computed tomography (CT). Magnetic resonance imaging (MRI) in the coronal and sagittal plane showed temporal lobe herniation in three cases and cholesteatoma with abscess elevating the dura in one case. In the patient with a cholesteatoma and an eroded tegmen tympani on CT, MRI is indicated to rule out brain herniation into the middle ear.

The use of fibrin glue in intracranial procedures: preliminary results.

Intracranial procedures always have the potential of cerebrospinal fluid (CSF) leakage postoperatively. Sealing all routes of CSF drainage to the outside of the intracranial contents is essential. This is usually achieved with muscle and fat plugs, homograft dura, fascia, and suture. The use of a fibrin glue might affect and lessen the likelihood of a CSF leak. Eight clinical cases of various intracranial procedures using a simple, two-part patient autologous cryoprecipitate fibrinogen and bovine thrombin glue are described. Preliminary results of up to 1 year show no CSF leakage nor adverse reactions to the fibrin glue. The production method and material characteristics are briefly compared with other currently described autologous fibrin glue formulations. This version is similar in strength to other formulations, yet is simpler and more convenient to produce. The use of this autologous fibrin glue appears to provide an adjunct to commonly employed packing techniques in a convenient and effective manner. With more experience, fibrin glue might become an even more important tool in intracranial procedures.

Open mastoid procedures: contemporary indications and surgical technique.

The history of the management of chronic ear disease with and without cholesteatoma is dominated by a canal wall down philosophy. The implication is that such an open procedure insures disease control and an uncomplicated future. In point of fact, problem canal wall down procedures can be fraught with as many serious complications as their more controversial canal wall up counterpart is alleged to propagate. Such problem cavities most commonly result from poor execution of basic technique. The objective of this paper is to identify what constitutes a problem cavity and to describe the authors' techniques to avoid such difficulties. A technique has evolved which not only eradicates disease, but which is self-cleansing and of minimal impact on the patient's lifestyle. The authors' experience with canal wall down procedures is reviewed.

Diagnosis and management of catecholamine secreting glomus tumors.

The clinical and diagnostic features of catecholamine secreting glomus tumors are reviewed. Three cases are reported, including the first documented case of a dopamine secreting glomus jugulare tumor. Based on this experience, the authors have outlined the indications for selective venous catheterterization studies and for pharmacologic blockage in the management of these patients. In addition to routine urinary screening, a high index of clinical suspicion is needed to avoid the complications associated with catecholamine secreting tumors.

Use of full thickness skin grafts in canalplasty.

Split thickness skin grafts have uniformly been used in the past as the tissue of choice to line the external auditory canal during canalplasty. The success rate of STSG has been reported to be approximately 95%. From our experience with institutionalized patients and their special problems, we have observed that STSG appears to have a greater degree of postoperative contracture, exposing epithelialized bone which has less resistance to trauma than the normal tissue of the EAC. With this in mind, a full thickness skin graft was utilized to line the EAC in conjunction with canalplasty. The use of FTSG in the institutionalized mentally retarded patient has shown no evidence of restenosis or recurrent infection, and we feel it is the treatment of choice in this type of patient and should be considered in the occasional patient who fails a split thickness skin graft canalplasty. Longer term follow-up is required to determine whether FTSG should supplant STSG as the tissue of choice in canalplasty.

Clinical aspects of osseous hemangiomas of the skull base.

Osseous hemangiomas are distinctly unusual tumors of the skull base. They clinically mimic other, more common lesions in this region, and their diagnosis is rarely made preoperatively with currently available techniques. Three cases of osseous hemangiomata, 2 involving the geniculate region and 1 arising from the jugular bulb, are described in relation to the perioperative assessment and management of these lesions. A review of 21 previously reported skull base hemangiomas is included.

Potential complications of unrecognized cerebrospinal fluid leaks secondary to mastoid surgery.

Unrecognized cerebrospinal fluid (CSF) drainage from a dural tear created during mastoidectomy rarely occurs, but when it does the consequences may be catastrophic. The potential complications discussed in this article are CSF otorrhea, meningitis, pneumocephalus, and hydrocephalus. The pathophysiology and diagnosis of these complications are individually discussed. The medical management and surgical procedures required to treat such complications are reviewed using a case presentation as an illustration. In addition, a flow sheet detailing the interrelationship between these potential complications and their treatment is outlined.

Management of congenital ear malformations.

In spite of modern diagnostic and surgical techniques, the results of congenital ear malformation surgery are often disappointing. Not only are hearing results less than expected, but also postoperative canal stenosis is a significant problem. This paper reviews the historical development of atresia surgery, the various classification systems, and the management of congenital ear malformations at The Otology Group. The authors' surgical technique is described and the postoperative results of 33 ear operations are discussed. Twenty-two of 33 cases showed some improvement in hearing. Postoperative stenosis occurred in 42% of atresia cases.

Ossicular chain reconstruction: the TORP and PORP in chronic ear disease.

The traditional objectives of tympanoplasty are infection control, closure of the ear by grafting techniques, and hearing rehabilitation via ossicular reconstruction. The multiplicity of contemporary prostheses and surgical options available would seem to underscore the magnitude of the ossicular reconstruction problem in the difficult chronic ear relative to all else. The success of stapedectomy has led to great expectations for all problems of ossicular reconstruction. The circumstances of the chronic ear is a milieu hostile in comparison and precludes any such comparison. Multiple sites of ossicular pathology, variations in mucosa health, inconsistent middle ear aeration and the overall complexity of the chronic ear present the otologist with a physiodynamic problem the solution of which is far from simplistic. The TORP and PORP have been enthusiastically endorsed in this regard, as a very suitable answer. Such enthusiasm, however, has been largely derived from data accumulated in the short term, often in less than a year's follow-up. This report reviews the authors' results in 141 patients in whom 86 TORPs and 55 PORPs were employed. For comparison, hearing data in 276 ears in which the fitted incus prosthesis, the authors' preferred reconstruction format, was used. Success for TORP reconstruction was assessed as air-bone gap closure to within 30 dB and for PORP, to within 20 dB. This was accomplished in 85% and 49% respectively. Extrusion rate, overall, was 10%. Relative advantages and disadvantages of the TORP and PORP are discussed and serve as a basis for the decision to continue to use this method of ossicular reconstruction. This data is put into perspective in acknowledging that the TORP and PORP are not the ultimate solution to this problem. When employed in combination with newer techniques in cartilage tympanoplasty, further improvement is expectant.

Nasal turbinate resection for relief of nasal obstruction.

Surgical correction of mechanical nasal airway obstruction is commonly attempted by means of septoplasty or submucous resection. In spite of these procedures, patients continue to present postoperatively with inadequate nasal airflow due to hypertrophied turbinates. Partial resection of turbinate mucosa, submucous turbinate resection, electrocautery and outfracture of turbinates provide additional improvement but are incomplete procedures. Total inferior turbinectomies have been performed on 40 patients over the past 5 years; 29 of these patients have been followed from 2 to 60 months postoperatively by clinical examination and by formal questionnaire. Twenty-five patients described a marked improvement of their nasal breathing, 3 had mild improvement, and 1 had no improvement at all. Only 1 patient, 1 year postoperatively, described excessive dryness, 2 described mild dryness, 3 described excessive secretions and none complained of foul smell or pain postoperatively. All patients had patent airways by clinical examination by at least 2 otolaryngologists. The inferior turbinates play a role in humidification and temperature regulation of inspired air. The removal of them, however, does not seem to be fraught with the morbidity which has heretofore been attributed to this procedure.