A novel electroneurography method in facial palsy.

CONCLUSION: The novel midline electroneurography (ENoG) method may have advantages over the standard method in terms of ease of electrode setting, and the ENoG value may be a useful prognostic factor. OBJECTIVE: We compared ENoG performed in patients with facial palsy using two different methods--the new midline method and standard method--in terms of the amplitudes of the compound muscle action potentials(CMAPs) and relationship between the ENoG value and clinical course. METHODS: A total of 64 patients with facial palsy were enrolled. CMAPs were recorded using the midline method, in which the recording electrodes were placed on the mental protuberance and philtrum over the orbicularis oris muscle, and the standard method, in which the recording electrodes were set close to the nasolabial fold. Percutaneous electrical stimulation was applied to the main trunk of the facial nerve.The amplitudes of the CMAPs and the relationship between the ENoG value and the period to full recovery from the facial palsy were compared. RESULTS: The midline method had larger CMAP amplitudes on both sides and a stronger negative correlation in the relationship between the ENoG value and period to full recovery from palsy than the standard method statistically.

Postoperative aeration in the middle ear and hearing outcome after canal wall down tympanoplasty with soft-wall reconstruction for cholesteatoma.

OBJECTIVE: Canal wall down (CWD) tympanoplasty with soft-wall reconstruction (SWR) is a unique technique for cholesteatoma surgery. The external auditory canal shape after surgery-retracted like a radical mastoid cavity or preserved intact-depends on postoperative aeration in the mastoid cavity. However, the relationship between postoperative middle ear aeration and hearing outcome with this procedure is unknown. We characterized this relationship and propose an ideal state of middle ear aeration to obtain satisfactory postoperative hearing after CWD tympanoplasty with SWR. STUDY DESIGN: Retrospective case series. PATIENTS: Seventy-eight patients (78 ears) with fresh cholesteatomas treated surgically at our hospital by planned 2-stage CWD tympanoplasty and SWR were included. MAIN OUTCOME MEASURES: Postoperative middle ear aeration was scored 1 year after second-stage surgery by computed tomography. The patients were divided into 4 bins according to postoperative audiometric air-bone (A-B) gaps: 0-10, 11-20, 21-30, and greater than 30 dB. RESULTS: Postoperative middle ear aeration was significantly greater in the smaller gap bins (0-10 and 11-20 dB) compared with the larger A-B gap bins (21-30 and >30 dB). In contrast to the larger A-B gap bins, those with smaller A-B gaps showed reaeration of the antrum and mastoid cavity. No significant differences were observed in postoperative middle ear aeration or hearing outcome between the 2 cholesteatoma types. CONCLUSION: Promoting postoperative aeration of the entire middle ear is necessary to achieve better hearing outcome in patients undergoing CWD tympanoplasty and SWR for cholesteatoma.

Canal wall-down tympanoplasty with soft-wall reconstruction using the pedicled temporoparietal fascial flap: technique and preliminary results.

OBJECTIVES: We compared the use of the pedicled temporoparietal fascial flap (TPFF) with the use of free deep temporal fascia (DTF) in soft-wall reconstruction after canal wall-down tympanoplasty. METHODS: In the TPFF group (6 ears), the pedicled TPFF that includes the superficial temporal artery and vein was raised ipsilaterally and rotated into the eradicated mastoid cavity. The tympanic membrane and external auditory canal (EAC) were reconstructed by gluing one side of the TPFF to the mucosal layer of the tympanic membrane and the reverse side of the posterior EAC skin. In the DTF group (21 ears), reconstruction was performed similarly with free DTF. The postoperative period for epithelialization of the tympanic membrane and EAC skin, postoperative complications, and reaeration in the middle ear revealed by computed tomography were reviewed in both groups. RESULTS: In the TPFF group, the mean (+/- SD) period to epithelialization was 25.5 +/- 2.8 days versus 38.4 +/- 12.0 days in the DTF group; the two groups differed statistically (Welch's t-test, p = 0.0002). No postoperative complications occurred in the TPFF group, whereas 2 patients in the DTF group underwent graft necrosis with infection. Three of the 6 patients in the TPFF group showed reaeration not only in the tympanic cavity, but also in the mastoid cavity. However, no statistical differences between the two groups were observed in terms of postoperative complications or reaeration of the mastoid cavity. CONCLUSIONS: Our preliminary findings suggest that the pedicled TPFF has positive effects on quick epithelialization. Further prospective studies are needed to reveal the superiority of the pedicled TPFF over free DTF with regard to postoperative infection and recovery of mastoid aeration.

Residual cholesteatoma: incidence and localization in canal wall down tympanoplasty with soft-wall reconstruction.

OBJECTIVE: To compare the incidence and localization of residual cholesteatomas in canal wall down tympanoplasty with soft-wall reconstruction with results with the canal wall down and open tympanoplasty or canal wall up tympanoplasty. DESIGN: Retrospective case-series study. SETTING: Tertiary care university hospital. PATIENTS: Eighty-five patients (85 ears) with fresh extensive cholesteatomas who underwent canal wall down tympanoplasty with soft-wall reconstruction as first-stage surgery and a second operation after 1 year to confirm residual cholesteatomas and perform ossiculoplasty. MAIN OUTCOME MEASURES: The incidence and localization of residual cholesteatomas in the middle ear were compared between surgery using the canal wall down and open tympanoplasty and canal wall up tympanoplasty. Possible technical causes of the residua were reviewed in a retrospective videotape analysis of the first-stage operations. RESULTS: Of the 85 ears operated on, 18 had residual cholesteatomas, for an overall incidence of 21%, with 1 residuum per ear. Six cholesteatomas were located in the epitympanum (33%), 3 in the sinus tympani (17%), 3 in the antrum (17%), 2 on the stapes (11%), 2 on the tympanic membrane (11%), 1 on the tympanic portion of the facial canal (6%), and 1 just under the skin of the external auditory canal (6%). The retrospective videotape analysis revealed that the main cause of residual cholesteatomas in the epitympanum and sinus tympani was incomplete removal of the matrix under an indirect surgical view because of insufficient drilling. Residual matrix in a bony defect in the middle cranial fossa or facial canal was the cause of residual cholesteatomas in the antrum or facial canal. Inappropriate keratinizing epithelium rolling during tympanic membrane or external auditory canal reconstruction was the cause of residual cholesteatomas in the tympanic membrane or external auditory canal. CONCLUSIONS: The incidence of residual cholesteatomas in patients who underwent canal wall down tympanoplasty with soft-wall reconstruction was similar to that in patients who underwent surgery involving the canal wall down and open tympanoplasty or canal wall up tympanoplasty. In terms of localization, with canal wall down tympanoplasty with soft-wall reconstruction, there is the possibility of residua not only in the tympanic cavity but also in the antrum or mastoid cavity, as with the canal wall up method. Results of this study suggest that in patients with extensive cholesteatoma, canal wall down tympanoplasty with soft-wall reconstruction should be followed by a second procedure to detect any residual cholesteatomas in the tympanic cavity, antrum, or mastoid cavity.

A new method for measuring compound muscle action potentials in facial palsy: a preliminary study.

To establish a simple, reproducible procedure for studying facial motor nerve conduction (MNC), we determined the optimal electrode position to record evoked compound muscle action potentials (CMAPs) from perioral muscles in normal subjects. We examined three new electrode positions in which the electrode connected to the one input of the amplifier was placed on the mental protuberance, and the one connected to the other input was placed on the skin over the orbicularis oris muscle (the philtrum, mouth angle, or lower lip). We then compared the morphology and amplitudes of the CMAPs, right-left differences, and the reproducibility of CMAP amplitudes with recordings taken from the standard electrode position in which one electrode was placed on the nasolabial fold closely lateral to the ala nasi, and the other was placed on the skin over the orbicularis oris. Percutaneous supramaximal electrical stimulation was applied to the main trunk of the facial nerve. All three of the new recording positions showed greater amplitudes and more obvious biphasic CMAPs than the standard method. Positioning the electrode connected to the negative input on the philtrum was optimal in terms of right-left differences and the reproducibility of CMAP amplitudes. Therefore, this midline recording is a simple, reproducible method for calculating the CMAP amplitude ratio. However, prior to clinical use of this procedure, analyses of patients with facial palsy are required.

Prognosis for Bell's palsy: a comparison of diabetic and nondiabetic patients.

CONCLUSION: The present study indicates that recovery from Bell's palsy in a diabetic group (DG) is delayed, and the facial movement score remains low in comparison with a nondiabetic group (NDG). More aggressive treatments, such as higher-dose corticosteroid administration and/or facial nerve decompression surgery, might be considered in diabetic patients with severe Bell's palsy. OBJECTIVES: The purpose of this study was to reveal prognostic differences for Bell's palsy in the DG and NDG. PATIENTS AND METHODS: The grades of facial palsy in 19 diabetic and 57 nondiabetic patients with Bell's palsy were assessed using the House-Brackmann grading system (HB system). Recovery was defined as grade I. The average of HB system grades and recovery rates were compared in the DG and NDG at the start of the treatment, and 1 month, 3 months, and 6 months after onset. RESULTS: There were no differences in the HB system between the DG and NDG at the start of treatment and at 1 month after onset. However, facial movement in the DG was poorer than that in the NDG at 3 months and 6 months after onset. In terms of the recovery rate, the rate in the DG (52.6%) was much lower than that in the NDG (82.5%) at 6 months after onset.

Surgical technique in endoscopic posterior septoplasty for an adult patient with choanal stenosis.

The technique in endoscopic posterior septoplasty for the case of a female aged 49 with bilateral choanal stenosis is presented. This female had undergone endoscopic nasal surgery for stenosis twice before the posterior septoplasty. However, restenosis of the choanae had arisen within 2 weeks after each surgery. This patient underwent the endoscopic posterior septoplasty under general anesthesia. After removal of the cartilage and bony structures of the nasal septum, the posterior one-third of bilateral septal membranes was excised. This technique is to enlarge the choanal opening obliquely. Excellent visualization for the septoplasty using the endoscope was obtained. Sufficient patency of the choanae was achieved using this technique. There still is no restenosis of the choanae observed and the rhinomanometry shows extreme decrease of nasal airway resistance 1 year after this surgery. It is considered that endoscopic posterior septoplasty for choanal stenosis is an effective procedure with low morbidity and long-term patency.