Otoendoscopy in the Office and Operating Room.

Since its introduction into the field of otology in 1967 endoscopes are gaining acceptance in evaluation and treatment of middle ear disease. Endoscopes offer a wide field view enabling looking "around the corner" with reduced need for soft tissue and bone removal. Outcomes of middle ear surgery for cholesteatoma and need for second-look procedures are improving because of the addition of endoscopic evaluation. Trainee education using the endoscope improves knowledge of middle ear anatomy. The portability of the endoscopic unit allows performing ear surgery in remote locations.

Meniere's disease: importance of socioeconomic and environmental factors.

STUDY OBJECTIVES: 1. Describe the prevalence of Meniere's disease in the United States. 2. Recognize important patient and environmental factors in Meniere's disease. METHODS: • Discharge data from the Nationwide Inpatient Sample, the largest US all-payer inpatient care database was analyzed for Meniere's disease between 2008 and 2010 in patients > 10 years old. Patient characteristics including prevalence, age, sex, race, household income, and geographic location were studied to determine any correlation with disease prevalence. • T-test, Chi-square and logistic regression testing was used to compare the differences between groups for continuous and categorical data. RESULTS: • The lower limit of Meniere's prevalence in the United States population was 73 per 100,000, females 84 per 100,000 compared to 56 per 100,000 among males (OR = 1.51, 95% CI 1.48-1.54, P < 0.01). • Prevalence was highest in Caucasians 91 per 100,000, and was significantly higher than other ethnic groups (P < 0.05). • Prevalence increased as age with the highest prevalence found in 81-90 year age group. • Midwest prevalence (94 per 100,000) was significantly higher than other regions (P < 0.001). • Meniere's is more common in less populated locations and the prevalence decreased as population increased. • Meniere's prevalence increased with household income. The highest prevalence was found among the 76th-100th quartile with rates of 86 per 100,000 for MD. CONCLUSIONS: Environmental factors, race and ethnicity, gender and age appear to be important factors in the prevalence of Meniere's disease.

Effect of cochlear window fixation on air- and bone-conduction thresholds.

HYPOTHESIS: In the absence of patent cochlear windows, cochlear fluid inertia depends on the presence of a "third window" as a major component of the bone-conduction response. BACKGROUND: Studies have shown conflicting results regarding changes in air and bone conduction whenever, the round window, oval window, or both windows were occluded. METHOD: The study was performed in a tertiary university-affiliated medical center. Auditory brain responses to clicks and 1-kHz tone bursts delivered by air and bone conduction were tested in 5 adult-size fat sand rats. The round window membrane (total, 7 ears) was sealed with Super Glue, and auditory brain response testing was repeated. Thereafter, the stapes footplate was firmly fixated, and auditory brain responses were recorded for a third time. RESULTS: Round-window fixation induced a significant increase in air-conduction thresholds to clicks from 36.4 ± 0.9 to 69.3 ± 4.1 dB SPL, with no significant change in bone-conduction thresholds. When the stapes footplate was immobilized as well, air conduction increased by another 20 dB, on average, with no change in bone conduction. A similar deterioration was seen in response to 1 kHz stimulus. CONCLUSION: These findings support and complement earlier studies in the same animal model, suggesting that when the pressure outlet through the cochlear windows are abolished, still bone conduction displaces the cochlear partition probably because of a functioning "third window."

Air-bone gap component of inner-ear origin in audiograms of cochlear implant candidates.

BACKGROUND: Experimental studies have shown that creating a window in the bony cover of the cochlea and vestibular parts of the inner ear, with preservation of membranous and middle-ear functions, induces an air-bone gap (ABG). This study sought to determine if a similar mechanism explains the ABG frequently observed in audiograms of cochlear implant candidates. METHOD: The study group included 47 candidates for a cochlear implant (94 ears) attending a university-affiliated tertiary medical center who had an ABG component in the audiogram in the absence of external or middle-ear abnormalities. Air- and bone-conduction thresholds on pure-tone audiometry were analyzed for 250 to 8,000 Hz and 250 to 4,000 Hz, respectively. In the 25 patients operated on during the study period, differences in the ABG and in cerebrospinal fluid (CSF) leak were compared between those with and without anomalies on computed tomography. RESULTS: Imaging revealed an abnormal inner-ear structure in 46% of cases, mostly a large vestibular aqueduct, alone or combined with other cochlear or vestibular malformations. ABG was evident over high and low frequencies and was significantly larger at low frequencies and in ears with structural anomalies. A high rate of CSF leak was observed in patients with an ABG and structural anomalies imaging as well as in those with an ABG and normal imaging findings. CONCLUSION: In cochlear implant candidates, the presence of a third window could cause an ABG because of stapes motion-induced shunting of acoustic energy outside the cochlear duct in response to air-conducted stimuli while bone conduction is preserved.

Early tongue carcinoma: analysis of failure.

BACKGROUND: Failure rate of surgery for early tongue carcinoma remains high. We sought to identify patterns of failure and recurrence risk factors. METHODS: Data review was carried out on 50 patients treated for early tongue carcinoma (T1/2N0M0); surgery was unsuccessful in 11 of these patients. All patients underwent transoral resection of the tongue tumor and prophylactic neck dissection (supraomohyoid). RESULTS: Tumor recurred within 3 to 18 months. Nine died of disease. Four had failure in neck level 4, 6 in level 1, and 1 simultaneously in level 1 and locally. Most tumors were moderately differentiated. Average depth was 6.64 mm. CONCLUSIONS: We report 11 patients with early tongue carcinoma who failed local excision with neck dissection. Failures occurred in level 4 (4 patients) and level 1 (7 patients). This group may benefit from extended neck surgery. Sex, age, stage, and depth of tumor were not significantly different in the group with treatment failure. Tumors in the group with treatment failure were more poorly differentiated.

Squamous cell carcinoma of the oral tongue in patients over 75 years old.

BACKGROUND AND AIMS: Squamous cell carcinoma (SCC) of the oral tongue is one of the most frequent head and neck cancers. The over-70-year age group is the fastest growing segment of the population. Age, however, is not considered a prognostic factor in oral tongue SCC. This study investigated the clinical and histopathological characteristics, disease course, and outcome of SCC of the oral tongue in patients over 75 years old compared with younger patients. METHODS: We reviewed the files of 85 patients with histologically proven SCC of the oral tongue who were treated in our department in 1992-2007 and followed for a minimum of 2 years. Findings were compared between those aged 75 years or more and younger patients. RESULTS: Twenty-eight patients (33%) were aged 75 to 94 years (average 80.5±4.5 yrs), including 14 who were over 80 years old, and 57 patients were aged 15-74 years (average 51.1±18.2 yrs). No statistically significant differences were found between the groups in clinical or histopathological characteristics or patient outcome. The 5-year disease-free survival rate was 65% for patients over 75 and 58% for younger patients. Corresponding rates for 5-year disease-specific survival were 69% and 70%. These differences were not statistically significant. CONCLUSIONS: Patients over 75 with oral tongue SCC should be managed like younger patients in terms of clinical staging and co-morbidities. They should be given a chance for treatment, as their prognosis is no different from that of younger patients.

Superior canal dehiscence effect on hearing thresholds: animal model.

OBJECTIVE: Superior semicircular dehiscence syndrome is associated with vestibular symptoms and an air-bone gap component in the audiogram, apparently caused by the creation of a pathological bony "third window" in the superior semicircular canal. The aim of this study was to evaluate changes in auditory air- and bone-conduction thresholds to low- and high-frequency stimuli in an animal model of a bony fenestration facing the aerated mastoid cavity. STUDY DESIGN: Anatomic, audiological. SETTING: Tertiary university-affiliated medical center. ANIMALS: A small hole was drilled in the bony apical portion of the superior semicircular canal facing the mastoid bulla/cavity, with preservation of the membranous labyrinth, in 5 adult-size fat sand rats. MAIN OUTCOME MEASURES: Auditory brain stem responses to clicks and 1-kHz tone bursts delivered by air and bone conduction before surgery, after opening the bulla, and after fenestration. RESULTS: After fenestration, a significant air-bone gap was measured in response to clicks (mean ± standard deviation, 37 ± 5.8 dB) and bursts (mean ± standard deviation, 34 ± 14.5 dB). The gap was attributable solely to the significant deterioration in air-conduction thresholds, in the absence of a significant change in bone conduction thresholds. The pattern of auditory brain response changes closely resembled that reported for middle ear dysfunction, namely, an increase in absolute latency of waves I, III, and V without significant alterations in interpeak latency differences. CONCLUSIONS: Bony fenestration of the superior semicircular canal toward an aerated cavity in a rodent model mimics the auditory loss pattern of patients with superior semicircular dehiscence syndrome. The dehiscent membrane accounts for the auditory changes.

Malignant external otitis: analysis of severe cases.

OBJECTIVE: To study the effect of specific clinical, laboratory, and imaging parameters on the course of severe (type 1) malignant external otitis (MEO). STUDY DESIGN: Case series with chart review. SETTING: Tertiary, university-affiliated medical center. SUBJECTS AND METHODS: Fifty-seven patients hospitalized with severe MEO were followed for disease course and survival in a tertiary center between 1990 and 2008. RESULTS: In 20% of patients, disease was persistent and/or aggressive despite prolonged and extensive treatment. Of this subgroup, 45% died of the disease. Prognostic factors of persistent/aggressive disease were facial nerve paralysis, bilateral disease, and significant major computed tomography findings (temporomandibular joint destruction, infratemporal fossa or nasopharyngeal soft tissue involvement). Cultures grew fungi in 5 patients, and follow-up imaging revealed disease progression. The overall 5-year survival was 55% for patients with short-term disease and 40% for patients with persistent/ aggressive disease (P = .086). By age, 5-year survival was 75% in patients younger than 70 years old and 44% in older patients (P = .029). CONCLUSIONS: A significant subset of patients with MEO has a prolonged, aggressive, and highly fatal disease that needs to be identified early. These patients more frequently have bilateral disease, cranial nerve paralysis, and positive computed tomography findings. Their follow-up should routinely include imaging studies to evaluate disease progression, and every effort should be made to identify and treat underlying fungal infection.

Fungal malignant external otitis.

OBJECTIVE: To investigate the clinical characteristics and outcome of fungal malignant external otitis (MEO). METHODS: The files of 60 patients treated for MEO in 1990-2008 at a tertiary medical center were reviewed for clinical characteristics and outcome, and findings were compared between patients with fungal and nonfungal infection. RESULTS: Mean duration of follow-up was 4 years. Nine patients (15%) had fungal disease; the main pathogen was Candida spp. Compared with the nonfungal MEO group, patients with a fungal infection were younger at diagnosis (average 68 vs. 74 years, p = 0.01) and had more facial nerve palsies (55% vs. 14%, p = 0.01), fewer positive bacterial cultures at presentation (33% vs. 75%, p = 0.02), and higher rates of surgery (78% vs. 18%, p = 0.0008) and hyperbaric treatment (78% vs. 4%, p = 0.0001). Eighty-nine percent had persistent infection (>2 courses of systemic antibiotics before antifungal treatment) compared with 12% in the nonfungal group (p = 0.0001). Fungal disease was associated with more persistently positive imaging findings (87.5% vs. 25%, p = 0.0001). There was no significant between-group difference in survival. CONCLUSION: Fungal MEO probably occurs secondary to prolonged antibiotic treatment for bacterial MEO. The fungal disease is more invasive than the bacterial disease, although survival is the same. Treatment should be aggressive and hyperbaric oxygen therapy should be considered.

Animal model of cochlear third window in the scala vestibuli or scala tympani.

HYPOTHESIS: The auditory impact of a cochlear third window differs by its location in the scala vestibuli or scala tympani. BACKGROUND: Pathologic third window has been investigated primarily in the vestibular apparatus of animals and humans. Dehiscence of the superior semicircular canal is the clinical model. METHODS: Fat sand rats (n = 11) have a unique inner-ear anatomy that allows easy surgical access. A window was drilled in the bony labyrinth over the scala vestibuli in 1 group (12 ears) and over the scala tympani in another (7 ears) while preserving the membranous labyrinth. Auditory brain stem responses to high- and low-frequency stimuli delivered by air and bone conduction were recorded before and after the procedure. RESULTS: Scala vestibuli group: preoperative air-conduction thresholds to clicks and tone-bursts averaged 8.3 and 9.6 dB, respectively, and bone-conduction thresholds, 4.6 and 3.3 dB, respectively; after fenestration, air-conduction thresholds averaged 40.4 and 41.8 dB, respectively, and bone-conduction thresholds, -1 and 5.6 dB, respectively. Scala tympani group: preoperative air-conduction thresholds to clicks and tone-bursts averaged 8.6 dB each, and bone-conduction thresholds, 7.9 dB and 7.1 dB, respectively; after fenestration, air-conduction thresholds averaged 11.4 and 9.3 dB, respectively, and bone-conduction thresholds, 9.3 and 4.2 dB, respectively. The changes in air- (p = 0.0001) and bone-conduction (p = 0.04) thresholds were statistically significant only in the scala vestibuli group. CONCLUSION: The presence of a cochlear third window over the scala vestibuli, but not over the scala tympani, causes a significant increase in air-conduction auditory thresholds. These results agree with the theoretic model and clinical findings and contribute to our understanding of vestibular dehiscence.

A third window of the posterior semicircular canal: an animal model.

OBJECTIVES/HYPOTHESIS: A third window in the vestibular apparatus has been investigated in both animals and humans, specifically in superior semicircular canal dehiscence. There are as yet no animal model studies of the effect of a third vestibular window of the posterior semicircular canal. STUDY DESIGN: Original basic research study. METHODS: A fenestration was drilled in the bony labyrinth over the posterior semicircular canal, preserving the membranous labyrinth, in seven healthy, 6-month-old, fat sand rats (total 10 ears). Auditory brain stem responses to low- and high-frequency acoustic stimuli delivered by air conduction and bone conduction were recorded before and after fenestration. RESULTS: On the preoperative auditory brainstem recordings, air-conduction thresholds to clicks and tone bursts averaged, respectively, 6.5 dB and 7.5 dB, and bone-conduction thresholds, 8 dB and 4.5 dB. Postoperatively, air-conduction thresholds averaged 14.5 dB, and bone-conduction thresholds 10.5 dB and 5 dB. The change in air-conduction thresholds was statistically significant (P < .01), whereas the bone conduction thresholds remained unchanged. CONCLUSIONS: A vestibular third window in the posterior semicircular canal decreases the sensitivity to air-conducted sound stimuli, raising the air-conduction threshold. There is no change in the bone-conduction threshold. These findings agree with the theoretical model and clinical findings.

Cochlear third window in the scala vestibuli: an animal model.

BACKGROUND: Pathologic third window has been investigated in both animals and humans, with a third window located in the vestibular apparatus, specifically, dehiscence of the superior semicircular canal, serving as the clinical model. HYPOTHESIS: The present study sought to examine the effect of a cochlear third window in the scala vestibuli on the auditory thresholds in fat sand rats that have a unique anatomy of the inner ear that allows for easy surgical access. METHODS: The experiment included 7 healthy 6-month-old fat sand rats (a total of 10 ears). A pathologic third window was induced by drilling a hole in the bony labyrinth over the scala vestibuli, with preservation of the membranous labyrinth. Auditory brainstem responses to high- and low-frequency acoustic stimuli delivered via air and bone conduction were recorded before and after the procedure. RESULTS: In the preoperative auditory brainstem response recordings, air-conduction thresholds (ACTs) to clicks and tone bursts averaged 9 and 10 dB, respectively, and bone-conduction thresholds averaged 4.5 and 2.9 dB, respectively. Postfenestration ACTs averaged 41 and 42.2 dB, and bone-conduction thresholds averaged 1.1 and 4.3 dB. The change in ACT was statistically significant (p < 0.01). CONCLUSION: The presence of a cochlear third window in the scala vestibuli affects auditory thresholds by causing a decrease in sensitivity to air-conducted sound stimuli. These findings agree with the theoretical model and clinical findings.

Antiestrogen therapy for hereditary hemorrhagic telangiectasia: a double-blind placebo-controlled clinical trial.

OBJECTIVES/HYPOTHESIS: Hereditary hemorrhagic telangiectasia (HHT) is associated with recurrent epistaxis in 90% of cases. Good response to hormone treatment has been documented, although its use remains controversial. The aim of this study was to examine the efficacy of an antiestrogenic agent, Tamoxifen, in the treatment of HHT-associated epistaxis. METHODS: Twenty-five patients (11 men, 14 women; mean age 51 years) with a diagnosis of epistaxis due to HHT were randomly assigned to receive treatment with oral tamoxifen 20 mg/d or placebo for 6 months. Follow-up consisted of physical examination and once-monthly blood tests. RESULTS: The groups were similar in age and sex distribution. Of the 21 participants who completed the trial, alleviation of the epistaxis was noted in 9 of 10 tamoxifen-treated patients and 3 of 11 placebo-treated patients (including 2 with only temporary improvement). The difference between the groups at the trial end point was significant for both frequency (P = .01) and severity (P = .049) of the disease. Hemoglobin concentration rose in 4 tamoxifen-treated patients and decreased in 5 controls. CONCLUSIONS: Tamoxifen appears to be an effective agent for the treatment of epistaxis due to HHT.