Bilateral cholesterol granulomas of the temporal bone.

Cholesterol granulomas of the temporal bone without clinical symptoms of chronic otitis media may result from an indolent inflammatory process caused by a congenitally blocked group of air cells. A unique case of giant bilateral cholesterol granulomas of the temporal bone is presented to support this theory. Management allowed bilateral surgical removal with hearing preservation. The differentiation between cholesterol granuloma, giant cholesterol cyst and other lesions of the temporal bone is discussed. The presumed pathogenesis of this condition is reviewed.

Meningitis after cochlear implantation in Mondini malformation.

Although the potential for CSF leakage and subsequent meningitis after cochlear implantation in the malformed cochlea has been recognized, this complication has not been previously reported. We report a case of CSF otorhinorrhea and meningitis after minor head trauma developing 2 years after cochlear implantation in a child with Mondini malformation. Leakage of CSF was identified from the cochleostomy around the electrode of the implant, and this leak was sealed with a temporalis fascia and muscle plug. Although this complication appears to be rare, care must be taken to seal the cochleostomy in children with inner ear malformations at the initial surgery, and any episode of meningitis after surgery must be thoroughly investigated to rule out CSF leakage from the labyrinth.

Development of the facial recess: implications for cochlear implantation.

More attention is being focused on the growth and development of the facial recess because of the use of cochlear implantation in children over 2 years of age and the prospect of using implants in even younger children. The facial recess and the extended facial recess were measured in 123 temporal bones from 73 individuals ranging in age from 8 weeks in utero to 7 years after birth. The goals were to trace the development of the facial recess and to determine whether this area continues to grow into childhood. The facial recess enlarges throughout fetal life with the development of the facial canal and the tympanic annulus. Reichert's cartilage, seen early in utero in the facial recess, gradually resorbs but may persist in the newborn. In full-term infants, the facial recess reaches 3.25 mm at the oval window and 2.62 mm at the round window. The extended facial recess reaches 3.79 mm at the oval window and 3.04 mm at the round window. No statistically significant growth of the facial recess after birth could be demonstrated in this study. The data suggest that the facial recess is probably adult sized at birth and should allow surgical access for cochlear implantation in very young children.

Nasal inverted papilloma with involvement of middle ear and mastoid.

Inverted papillomas of the paranasal sinuses have been characterized by their unusually benign histologic features, their ability to grow rapidly with bony destruction, and their tendency to recur if not adequately treated. The association of inverted papilloma with squamous cell carcinoma is well described, but malignant transformation is relatively rare. We report a case of a multiply recurrent inverted papilloma that spread to the middle ear and mastoid and eventually underwent malignant transformation with skull base invasion. Pathologic examination demonstrated many of the characteristics associated with malignant transformation. In addition, progesterone receptors were demonstrated that may have stimulated this tumor during the patient's pregnancy. To our knowledge, no similar cases have been reported in the literature.

Analysis of the efficiency of retrocochlear screening.

The auditory brainstem response (ABR), as well as associated audiologic and radiographic studies of 175 patients suspected of having cerebellopontine angle tumors were reviewed. The majority of patients presented with asymmetric hearing loss. Eight acoustic neuromas were identified. All eight had abnormal ABRs. The false-positive rate was 22%. Rollover and acoustic reflex testing played a minimal role in the decision as to whether or not an ABR was ordered and, as a result, are not important in the search for retrocochlear disease. The cost per tumor diagnosed was roughly $7600. A rational approach to tumor screening based on the efficiency and cost of the screening tests, the frequency of abnormal ABRs, and the cost per tumor diagnosed is presented.

Facial nerve management in temporal bone hemangiomas.

Eight patients with intratemporal hemangiomas involving the facial nerve are reported to present their symptoms, pathology, surgical management, and results. These unusual tumors have a predilection to involve the facial nerve, usually at the geniculate ganglion, internal auditory canal, or middle ear. Patients presented with facial palsy that was sudden, gradual in onset, recurrent, or associated with hemifacial spasm. Symptoms often progressed for years before the diagnosis was made. In two cases the tumor caused bony remodeling with an expansile honeycombed appearance, but no neoplastic production of bone. The facial nerve was comprised either by tumor compression or nerve invasion, as seen in two of our patients. Complete removal of the tumor and rehabilitation of the facial nerve function was attained in each case. Because of the destructive nature of these benign tumors, intratemporal facial nerve grafting was required in five of the eight cases. Results of facial nerve repair were good except in cases of long-standing facial dysfunction.

Stimulus repetition rate effect on the auditory brainstem response in systemic lupus erythematosus.

Neuropsychiatric involvement is common in systemic lupus erythematosus (SLE), but, in early half of cases, indications are not present on examination. Auditory brainstem response (ABR) measures using differential stimulus repetition rates have been reported as sensitive indicators of subclinical central nervous system (CNS) disorders associated with SLE. In the present study, ABRs were measured in a group of normal-hearing subjects with SLE, as well as in a group of subject controls. Differences in interpeak latency (IPL) measures obtained using low- and high-stimulus repetition rates did not reach statistical significance (P greater than .05). Clinical utility of ABRs using high- and low-stimulus repetition rates for the identification of occult CNS disorder in patients with SLE was not demonstrated.

Repair of mandibular fractures: plating vs. traditional techniques.

The treatment of mandibular fractures is a challenge for the otorhinolaryngologist-head and neck surgeon. Recent technologic advances have resulted in the development of rigid fixation techniques that hold promise for the early and optimal restoration of mandibular structure and function. The purpose of this article is to review the dental and orthopedic principles used in our mandibular fracture management, describe compression plating methodology, and discuss optimal techniques for its use. Results using rigid fixation procedures were compared with those using a variety of more traditional techniques in a retrospective analysis of 57 cases. The advantages, limitations, and indications for use of plating technology are discussed, and prevention of complications is emphasized.

New aspects of facial nerve pathology in temporal bone fractures.

Electron microscopic examination of intratemporal facial nerve segments removed from 12 patients with persisting facial paralysis following temporal bone fractures revealed that traumatic injury at the geniculum induces retrograde degeneration through the labyrinthine and distal meatal segments of the facial nerve. Fibrosis may occur in the traumatized labyrinthine segment and block regenerating motor fibers. The surgical treatment of traumatic facial nerve injuries should be aimed to avoid or eliminate fibrosis within the labyrinthine segment of the Fallopian canal.

Angioedema from angiotensin converting enzyme inhibitors: a cause of upper airway obstruction.

Angiotensin-converting enzyme (ACE) inhibitors have several side effects of concern to the otolaryngologist. Angioedema is a rare, but potentially lethal adverse effect when associated with upper airway obstruction. Four cases of ACE-inhibitor-induced angioedema, three with significant upper airway obstruction, are reported. Angioedema secondary to ACE inhibition appears to be mechanism based. The probable link is the potentiation of bradykinin, which results in vasodilation, increased vascular permeability, and angioedema. Since angioedema can progress to upper airway obstruction, otolaryngologists must be aware of this association. The differential diagnosis and treatment of this adverse effect is discussed, as well as a review of ACE inhibitors and other causes of angioedema.

Intratemporal facial nerve anastomosis: a temporal bone study.

The temporal bone findings in a patient who suffered a transverse temporal bone fracture and subsequently underwent intratemporal facial nerve anastomosis are presented. The patient returned a year after surgery with otorrhea and partial return of facial function that was documented clinically, and by electromyograph 12 days before death. The temporal bone shows breakdown of the posterior external canal wall and infection of the surgical cavity. At the facial nerve anastomosis, there is a fibrosis and lack of myelination in the few regenerating nerve fibers. These results demonstrate a seldom-mentioned complication of the translabyrinthine approach, and suggest changes in the technique of facial nerve anastomosis to improve the results.

Advances in otologic microsurgery.

Recent advances in otologic microsurgery have brought progress in the improvement of hearing impairment, alleviation of vertigo, and removal of skull base tumors. Refinement of stapedectomy techniques, use of new biocompatible prostheses, and other advances promise improved results with established otologic procedures. In addition, implantable hearing aids and cochlear implants will increasingly improve hearing in patients who previously could not be helped. The surgical methods for vestibular nerve section continue to be refined to help the surgeon and minimize risk to the patient. The challenging new field of skull base surgery has been opened through the combined efforts of otologists and other specialists. The recent advances in these fields are reviewed.

Adenomas of the temporal bone.

Three cases of primary adenomas of the petrous bone are presented and compared to an adenoma arising from the external ear canal. In contrast to other adenomatous tumors, these caused slowly progressive inner ear symptoms without other signs, hence making differentiation from other benign lesions difficult. In one case, association with von Hippel-Lindau disease is suspected because of a strong family history and recent discovery of a similar lesion in the opposite ear. Bone destruction was found radiographically and clinically with vascular tumor tissue and cysts permeating the bone, causing adjacent bone destruction and remodeling. The histopathologic examination demonstrated this to be a benign process, however, with no direct tumor invasion or other signs of malignancy. Subtotal petrosectomy is a proven approach for complete removal of these tumors. Review of the literature revealed no previous reports of benign adenomas originating in the petrous bone.

Histopathology of the facial nerve after longitudinal temporal bone fracture.

The temporal bone histopathology in a patient who suffered repeated head trauma and a longitudinal temporal bone fracture shows unusual features associated with the facial nerve. In the distal meatal segment, a type of traumatic neuroma was found with disorganized nerve bundles and distinct areas of Schwann's cell proliferation but lacking fibrosis. Periosteal new bone formation in the labyrinthine segment narrows the fallopian canal and protrudes into the nerve, which completely fills the canal. The tympanic and mastoid segments of the nerve show severe degeneration of nerve fibers and an increase in connective tissue between fascicles. An attempted facial nerve decompression did not reach the area of primary pathology in the labyrinthine and meatal segments of the nerve, which could have been exposed by the transtemporal supralabyrinthine approach.

Experimental cochlear hydrops in cats.

An experimental model of cochlear hydrops was created in cats. Ten cats underwent surgical procedures to obliterate the saccule, and their temporal bones were studied by light microscopy after sacrifice at 10 weeks. In one group the saccules were destroyed by maceration and aspiration. However, in these ears the saccular lumens were not obliterated and endolymphatic hydrops did not develop. Obliteration of the saccules was achieved in the second group after fascia was introduced into the area of the injured saccules. Cochlear endolymphatic hydrops was a consistent finding in these ears except when a fistula of the membranous labyrinth was present. However, in addition to fibrosis and new bone formation in the vestibules there were also degenerative changes in the hair cells, tectorial membranes, and striae vasculares of these cochleae. The results supported the longitudinal flow theory of endolymph and are consistent with the reported examples of cochlear endolymphatic hydrops in man.

Postnatal growth of the human temporal bone. Implications for cochlear implants in children.

Recent interest in cochlear implantation for children has made it important to understand how postnatal growth of the ear will affect such devices. In this study, the postnatal growth of the labyrinth, middle ear, and mastoid was measured in three dimensions using radiographic and temporal bone data. Measurements were made from histologic sections of 48 temporal bones from children and compared to adult temporal bones. Radiographic measurements were made from 253 sets of skull radiographs of children and compared to adult skull series. In the three dimensions measured, there was no postnatal growth of the labyrinth and little variation in size between individuals. Measurements of the middle ear showed greater variation between individuals than measurements of the inner ear, but growth only in the distance from stapes footplate to the tympanic membrane. The mastoid showed growth in all three dimensions: length, width, and depth. The pattern of growth for mastoid length and width appears to follow a double logistic model, with differences between males and females. The growth in mastoid depth is smaller and appears to follow a single exponential curve. The implications for cochlear implantation in children are discussed.