The American journal of otology最新文献

Objective: This study defines the three-dimensional location of the posterior-most point of the tympanic segment of the facial nerve (TSFN) relative to the posterior-most point of the short process of the incus, using ultrahigh-resolution computed tomography (CT) of the temporal bone.

Study design, setting, and patients: Included were patients who had been referred for CT of the temporal bone for various reasons other than suspected pathologic conditions of the middle ear. The decision whether to include a patient in the study was based on the referring physician's referral note for the examination.

Intervention: All of the patients underwent axial CT of the temporal bone, with consecutive slices of 1.1 mm width and 0.5-mm increments.

Main outcome measures: The posterior-most point of the short process of the incus was identified on axial CT and was superimposed onto a lower axial slice in which the posterior-most point of the TSFN was identified. Its shortest distance to the TSFN was measured. Afterward, the length of the TSFN that remained posterior to the perpendicular of the posterior-most point of the short process of the incus was measured by measuring the length of TSFN that could be seen posterior to the point of bisection of the line marking the shortest distance between the posterior-most point of the short process of the incus and the FN in the previous measurement. The measurements were performed on 30 normal temporal bones.

Results: The shortest distance measured between the posterior-most point of the short process of the incus and the TSFN was, on average, 3.31 mm for all 30 ears (range 2-4.8 mm). The length of TSFN that could be seen posterior to the perpendicular of the most posterior point of the short process of the incus was, on average, 2.70 mm (range 1.80-3.90 mm).

Conclusions: In addition to defining the spatial location of the posterior-most point of the TSFN, this study also offers a practical method by which the surgeon can evaluate, preoperatively, how far medial to the incus and how much posterior to the posterior-most point of the short process of the incus the facial nerve is located.

Objective: To report the otologic and audiometric characteristics of a nonsyndromic postlingual sensorineural hearing impairment in a Belgian family linked to DFNA10.

Study design: Retrospective study of the otologic and audiometric data of 17 genetically affected persons.

Setting: Tertiary referral center.

Patients: All members of a Belgian kindred who carried the haplotype linked to the inherited hearing impairment of DFNA10.

Interventions: Diagnostic otologic and audiometric analysis.

Main outcome measures: Pure-tone audiometry.

Results: To find the frequencies that were most affected by the genetic defect, the excess hearing loss of the 17 patients was calculated per frequency in comparison with the respective p50 and p95 thresholds of the normal population.

Conclusions: The genetically affected persons of a Belgian family shared a progressive symmetric sensorineural hearing loss that started in the first to fourth decade. Thirty-five percent of the affected family members had tinnitus, and only one patient had very mild vestibular complaints. At onset, hearing losses were mainly situated at the midfrequencies. With increasing age, all frequencies became affected. The hearing loss was initially mild, with a spontaneous evolution to a moderate or severe hearing impairment. The progression of the hearing loss for the pure-tone average (between 0.5 and 4 kHz) was 1.08 dB/year for this family, compared with 0.50 dB/year and 0.35 dB/year at the 95th and 50th percentiles of the normal population, respectively.

Objective: To evaluate preservation of hearing in the resection of vestibular schwannomas.

Study design: A retrospective case review.

Setting: Tertiary-care medical center.

Patients: Forty-seven patients (25 men, 22 women) were studied; mean age was 46 years, mean tumor diameter 9.8 mm (range 3-30 mm.)

Interventions: All patients underwent resection of vestibular schwannomas by the middle cranial fossa (MCF) or the retrosigmoid (RS) approach.

Main outcome measures: Hearing preservation was classified by the criteria outlined by the American Academy of Otolaryngology-Head Neck Surgery. Hearing was assessed preoperatively and postoperatively at 1 month and 1 year. Facial function was graded according to the House-Brackmann scale. Minimum follow-up was 18 months.

Results: Hearing was preserved in 69% of patients who underwent the MCF approach but in only 33% of patients for whom the RS approach was used. The RS approach was used for larger tumors (mean diameter 15 mm) and the MCF procedure for smaller tumors (mean diameter 9 mm). One hundred percent of patients had facial function H/B grade II or better, regardless of approach.

Conclusion: Hearing function can be reliably preserved in a high percentage of selected patients undergoing resection of vestibular schwannoma.

Objective: Human eustachian tubes (ET) were inspected in vivo endoscopically, and video recordings were made for careful slow-motion analysis of normal physiologic function.

Setting: Ambulatory office in a tertiary referral center.

Subjects: Thirty-four adults, 17 with no history of ET dysfunction (2 of whom had tympanic membrane perforations), 17 with known ET dysfunction.

Interventions: Transnasal endoscopic examination of the nasopharyngeal opening of the eustachian tube during rest, swallowing, and yawning.

Main outcome measures: Video analysis of ET opening movements.

Results: Normal ETs had four consistent sequential movements: (1) palatal elevation causing passive, then active, rotation of the medial cartilaginous lamina; (2) lateral excursion of the lateral pharyngeal wall; (3) dilation of the lumen, caused primarily by tensor veli palatini muscle movement beginning distally and inferiorly, then opening proximally and superiorly; and (4) opening of the tubal valve at the isthmus caused by dilator tubae muscle contraction. Dysfunctional ETs had intraluminal edema, polyps, or minimal muscle movement.

Conclusions: Slow-motion endoscopic video analysis may be a useful new technique for the study of eustachian tube physiology. Consistent muscle movement patterns were demonstrated in normal subjects but were absent in abnormal subjects. More studies of normal and abnormal patterns are needed to establish useful clinical correlates.

Objective: To develop a computerized medical record for a private neurotology practice using a relational database with templates.

Background: Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given.

Methods: Using a commercially available, record-keeping software in a local area computer network. templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record.

Results: A fully computerized medical record has been developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer.

Conclusion: Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.

Objectives: To determine the clinical significance of an isolated directional preponderance (DP) on bithermal caloric testing. An isolated caloric DP was defined as a DP, calculated according to the standard Jongkees formula, of > or = 40%, with a spontaneous nystagmus (SN) in darkness of < or = 2 degrees/s and a canal paresis (unilateral weakness) of < or = 25%.

Study design: A retrospective analysis of all 15,542 bithermal caloric tests performed in the authors' department in the previous 10 years to identify all tests with an isolated DP of > or = 40%. This was followed by a review of the clinical data on the 144 patients identified with such a result and then by a telephone or postal follow-up study of these patients. The study group eventually comprised 114 patients; these were patients in whom a clinical diagnosis could be made at the time the caloric test was done, or who responded to requests for follow-up information. The 34 patients in whom a clinical diagnosis could not be made at the time of the caloric test, and who did not respond to requests for follow-up information, were excluded.

Study setting: A balance disorders clinic in a tertiary referral hospital.

Intervention: All patients underwent standard bithermal caloric testing. Some of the patients also underwent rotational testing.

Outcome measures: A clinical diagnosis for the cause of the isolated DP, made either at the time of the caloric test or on the basis of information supplied at follow-up by the patient or by the referring physician.

Results: Of 114 patients, 39 had benign paroxysmal positioning vertigo, 14 had Ménière's disease, and 5 had migrainous vertigo. Five patients had central nervous system (CNS) disorders, and this was clinically apparent at the time of the caloric test in 4, so that only 1 patient with an isolated DP developed evidence of a CNS disorder after the caloric test was done. In the other 54 patients, no definite diagnosis could be made, but 41 of these 54 were either completely well or much better at follow-up.

Conclusions: An isolated DP on caloric testing is usually a transient, benign disorder. About half the patients with an isolated DP have either Ménière's disease or benign paroxysmal positioning vertigo; in most of the other half, no definite diagnosis is made but most of these patients will do well. Only approximately 5% have a CNS lesion and in almost all this is apparent at the time the caloric test is done. In a relapsing-remitting peripheral vestibular disorder such as benign paroxysmal positioning vertigo or Ménière's disease, the mechanism of an isolated DP could be enhanced dynamic gain of ipsilesional medial vestibular nucleus neurons, perhaps as a result of intermittent hyperfunction of primary semicircular canal vestibular afferents. The authors postulate that an isolated DP r

Objective: An attempt to settle the controversies associated with granular myringitis (GM) including incidence, etiology, pathology, presentation, relation to chronic otitis media, and treatment.

Study design: Retrospective.

Setting: Tertiary referral center and private otology practice.

Patients: 94 patients presenting with GM over 28 years.

Intervention: Diagnosis by otoscopy, audiometry, radiology, and bacteriology; long-term follow-up (6 months to 12 years); assessment of treatment results.

Main outcome measures: The pathologic states of the affected tympanic membranes were studied in both active and quiescent stages. The results of conservative versus surgical management were evaluated.

Results: The disease presents with chronic painless otorrhea, normal hearing and mastoid pneumatization, and granular areas, which may be patchy, diffuse, or segmental. The latter is the most frequent and is most commonly posterosuperior. The infecting organism is Pseudomonas aeruginosa. The pathologic process affects all drum layers and can cause a perforation. The most important predisposing factor is disturbed epithelial migration, which may be exaggerated by eustachian tube dysfunction. Of 26 cases treated conservatively, none healed without recurrence. Of 48 cases treated surgically, there were 2 recurrences.

Conclusions: Pathologically, the disease affects all drum layers. It presents with an active stage, which may be misdiagnosed as chronic otitis media or cholesteatoma, and a quiescent stage when it may be overlooked. Although distinct from chronic otitis media, it can cause a perforation. The disease responds readily to medical treatment, but recurrence is common. Radical surgery offers a curative measure in refractory cases.

Objective: Meningeal carcinomatosis is defined as the diffuse infiltration of the leptomeninges and subarachnoid space by malignant cells metastasizing from systemic cancer. The authors describe a rare case of meningeal carcinomatosis initially appearing as bilateral progressive sensorineural hearing loss.

Patient: A 57-year-old man with lung cancer was referred to the authors' clinic because of progressive hearing loss, tinnitus, dizziness, and blurred vision for 1 month.

Results: Magnetic resonance imaging revealed abnormal leptomeningeal enhancement. Meningeal carcinomatosis was diagnosed by the detection of malignant cells in the cerebrospinal fluid after lumbar puncture. The patient died 1 year after diagnosis.

Conclusions: Meningeal carcinomatosis must be considered in the differential diagnosis in cancer patients with bilateral progressive sensorineural hearing loss. Gadolinium-enhanced magnetic resonance imaging is a useful complementary diagnostic tool before lumbar puncture.