Tympanic membrane grafting with alloderm.

OBJECTIVE/HYPOTHESIS: The purpose of this work is to evaluate the performance of an acellular dermal allograft (AlloDerm; LifeCell Corp., The Woodlands, TX) in tympanic membrane (TM) grafting. STUDY DESIGN: A retrospective review of 20 consecutive tympanoplasty surgeries using temporalis fascia and 20 consecutive procedures using AlloDerm. METHODS: The charts of 20 consecutive adults who underwent tympanoplasty surgery were reviewed to evaluate graft take and hearing results. Similarly, 20 consecutive patients who had TM grafting with AlloDerm were reviewed. Pre- and postoperative air-bone gaps (ABG) at 500 Hz, 1000 Hz, 2000 Hz, and 4000 Hz were compared. RESULTS: There were no graft failures in either the temporalis fascia group or the AlloDerm group. No statistically significant difference was noted in hearing results when comparing the residual conductive loss in both postoperative groups. CONCLUSIONS: AlloDerm is a suitable material for TM grafting. This product is especially valuable in revision surgery in which the availability of appropriate autologous grafting material is limited.

Combined transcervical transmastoid approach to giant parotid pleomorphic adenoma: a case report.

Although rare, giant major salivary gland pleomorphic adenomas are among the most astonishing patient presentations. Patients may ignore these slow-growing, benign lesions until significant functional impairment occurs. Complete tumor excision and facial nerve preservation in these cases are challenging requirements and are greatly aided by combined transcervical and transmastoid approaches to these lesions. In the presented case, facial nerve monitoring accurately identified the collateralization between the upper and lower divisions of the facial nerve and allowed the required sacrifice of the lower division without the need for facial nerve grafting or reconstruction. The patient recovered full function of all branches.

Current perspective on temporal bone trauma.

The improved survival of patients sustaining massive head injuries has increased the number of temporal bone fractures being managed by otolaryngologists and neurosurgeons. We performed a prospective analysis of 35 patients with head injury with temporal bone trauma. The major emphasis of this study was to investigate the incidence, management, and outcome of facial nerve injury in such patients and to evaluate the importance of electrodiagnostics in the surgical management of the facial nerve. The results of this study indicate an incidence of fracture type, hearing loss, and facial nerve paralysis similar to that already recorded in the literature. This study underscores the importance of evoked electromyography, or electroneuronography, in assessing facial nerve function. Electroneuronography provided the indications for surgical intervention for facial paralysis. All patients having surgery for facial paralysis as determined by electroneuronographic findings had pathology of the facial nerve.

Myringoplasty: the lateral graft technique with fascia.

Grafting the tympanic membrane can be successfully accomplished by a number of techniques. The otologic literature is replete with descriptions of methods, materials, and results in myringoplasty. It is generally agreed that whatever method and materials are used to graft the tympanic membrane, the graft take-rate should be at least 90%. The key to obtaining a 90% take rate is not the technique employed, but how well the surgeon performs the technique. This article describes the lateral graft technique with fascia. This is the author's preferred myringoplasty procedure. When properly implicated, the lateral graft technique provides reproducible results in any pathologic condition. Excellent hearing and morphologic results can be obtained with few complications.

Primary surgical management for rehabilitation of the paralyzed eye.

Protection of the eye is the primary concern in managing the patient with facial paralysis; however, the aesthetic consequences cannot be overlooked. Lagophthalmos has traditionally been treated with frequent ocular lubrication, medical eye care, and tarsorrhaphy. This approach is fraught with the difficulties of poor patient compliance and unacceptable cosmesis. We suggest a protocol for the complete ocular management with emphasis on immediate rather than delayed surgical rehabilitation as a primary therapy in facial paralysis. Gold weight implantation to the upper lid and tightening of the lower lid at the lateral canthus are simple and reliable procedures that provide immediate functional and aesthetic improvement. This surgical technique has extremely low morbidity and is reversible should facial function return. We have used this protocol in more than 30 patients with excellent results.

Surgery for non-Menière's vertigo.

Neurootologists are fortunate in having a considerable number of surgical options available to them for the treatment of patients with disabling vertigo. Most surgery for vertigo is performed on patients suffering from the ravages of Meniere's disease. In addition, other forms of disabling peripheral vertigo may also be surgically managed. Over a 3 year period, the author performed surgery on 14 patients suffering from disabling non-Meniere's vertigo. During the same period, 60 patients with Meniere's disease underwent surgical treatment. There were three non-Meniere's conditions for which surgery was performed: chronic vestibular neuronitis, delayed onset vertigo (after sensorineural hearing loss), and labyrinthine injury following temporal bone fracture. Two surgical operations were utilized: transmastoid labyrinthectomy and selective vestibular neurectomy. At 1 year follow-up all of the patients involved in this study enjoyed either total relief of symptoms or marked improvement, demonstrating that satisfactory surgical results can be obtained for non-Meniere's vertigo. However, surgeons must exercise extreme caution in selecting non-Meniere's patients for surgery. Moreover, proper patient selection, accurate diagnosis and the exclusion of central disease are crucial in obtaining good surgical results.

Facial nerve dysfunction in osteopetrosis.

When facial nerve dysfunction occurs in conjunction with one of the rare temporal bone dysplasias, the physician faces a therapeutic dilemma. There is no consensus in the literature regarding the management of facial paralysis or facial spasm under these circumstances. During the past 2 years, four patients were seen with forms of osteopetroses and neurotologic symptoms. A patient with malignant, recessive osteopetrosis and a patient with Engelmann's disease were surgically managed for facial paralysis and facial spasm. The outcome of the treatment is discussed as well as the available literature on this subject. A new complication of facial nerve decompression in children with osteopetrosis is described, as well as appropriate caveats in the management of facial nerve disorders in the osteopetroses.

Electroneurography: electrical evaluation of the facial nerve.

This article provides an introduction, anatomic considerations, and description of technique for the performance of electroneurography. Two case studies are provided as illustrations.

Anatomic importance of the retrofacial air tract.

The retrofacial air tract is a constant and relevant anatomic landmark for the temporal bone surgeon. By purposefully dissecting this space, one is able to safely identify the facial nerve, endolymphatic sac, and jugular bulb. The retrofacial air tract also provides access to the petrous apex. Forty temporal bones of varying degrees of pneumatization were dissected in order to study the retrofacial air tract. A well-developed air tract was easily identified in all specimens. We describe our anatomic findings and discuss the surgical relevance and important of the retrofacial air tract.

Association of facial paralysis with HIV positivity.

Facial paralysis, although a rare complication of AIDS related complex (ARC) or AIDS, may well be the presenting symptom of HIV positivity. A case report of facial paralysis followed closely by discovery of HIV positivity is described, along with a pertinent and extensive literature review. Seroconversion to HIV-positive status should be suspected in any high-risk patient presenting with idiopathic facial paralysis. HIV testing should be included in the evaluation of Bell's palsy and other idiopathic forms of facial paralysis in the at-risk patient.

Intraoperative facial nerve monitoring: prognostic aspects during acoustic tumor removal.

Intraoperative facial nerve monitoring with electrical stimulation (IFNMES) has become an integral part of acoustic tumor surgery. We reviewed the records of fifty-six patients who underwent translabyrinthine acoustic tumor removal with IFNMES. There was excellent correlation between intraoperative facial nerve activity and immediate postoperative facial nerve function (24 hours after surgery and at hospital discharge). Our data would suggest that patients who exhibit less than 500 microvolts of ongoing EMG activity during surgery, and who yield at least a 500-microvolt contraction when stimulated with 0.05 milliamps at the brainstem after tumor removal, can expect an excellent immediate facial nerve result (grade I or II).

Chondrogenic potential of tragal perichondrium: a cause of hearing loss following stapedectomy.

Tragal perichondrium is a widely used tissue seal in the oval window following stapes surgery. Autogenous and easily accessible, it is a suitable substance to cover the vestibule in total stapedectomy, and to seal around the prosthesis in small-fenestra stapedotomy. The incidence of complications from the use of perichondrium in this manner is exceedingly low. We report a case where tragal perichondrium in the oval window resulted in the proliferation of cartilage. The cartilage displaced the stapes prosthesis, resulting in a conductive loss. Although the chondrogenic potential of perichondrium is known, we are not aware of other reports implicating this as a cause of failure in stapes surgery. The pertinent clinical and experimental literature regarding chondrogenesis is reviewed. This information suggests that the formation of cartilage from perichondrium in the oval window might be influenced by mechanical trauma and tissue orientation.

Consequences of middle ear bone dust during neurotologic surgery.

Most otologists are cautioned at some point in their training that if bone dust is allowed to enter the middle ear while the mastoid is being drilled, there may be adverse consequences. Two cases of ossicular fixation and conductive hearing loss after retrolabyrinthine vestibular nerve section prompted us to examine the issue of bone dust in the middle ear. In a study of 13 temporal bones that had undergone neurotologic surgery, we found 11 that showed evidence of viable bone dust in the middle ear, and three that had ossicular fixation. Viable bone dust was always encased in a mucous membrane lining. These findings suggest that bone dust that enters the middle ear may indeed remain viable and cause ossicular fixation. The surgeon should therefore take every precaution to prevent bone dust from entering the middle ear during neurotologic procedures in which conservation of hearing is attempted.