Annals of Otology,Rhinology & Laryngology

The clear advantage accruing from the use of tympanostomy tubes in the treatment of otitis media with effusion is immediate improvement in hearing; there are also disadvantages entailed, such as scarring of the drum, risk of continuing otorrhea and interference with the patient's normal physical activities. All possible forms of medical treatment should be exhausted (antihistamine decongestants, politzerization) before resorting to tympanostomy tubes. There is a small group of children with severe chronic nasal obstruction and otitis media with effusion for whom adenoidectomy is likely to be required.

Experiences with tympanostomy tubes extending over a period of 29 years are compared with the computer-assisted analysis of a questionnaire that was submitted to 500 otolaryngologists. Ventilating tubes are being used by 99.4% of the respondents in the group and are estimated to achieve good to excellent results in 90% of patients treated. Appropriate use of tympanostomy tubes has significantly reduced the incidence of chronic ear disease. A comparison of prophylactic antibiotics and prophylactic ventilating tubes for the prevention of acute otitis media showed that 91 % of the participants in the survey found ventilating tubes to be more effective than antibiotics. Benefits from ventilating tubes far outweigh the small number of tube-induced complications.

Tympanostomy tubes (TT) are frequently employed as treatment for otitis media (OM) although there is little clinical or experimental evidence of their efficacy. Potential detriments of TT include cost, risk of inhalation anesthesia, intraoperative complications, and tympanic membrane (TM) damage. Potential benefits include elimination of the conductive hearing loss (CHL), reduction in the occurrence of acute purulent OM, and avoidance of sequelae. The cost/benefit ratio of TT has never been accurately determined and morbid complications of inhalation anesthesia and the surgical procedure appear to be rare. There is evidence that TT significantly reduce the CHL of OM as well as reduce the incidence of recurrent acute purulent OM and help avoid sequelae. It is therefore determined that the risk of TT insertion for middle ear effusion (occasional TM changes) can be justified, in properly selected patients, by the benefits (immediate improvement in hearing and reduction in the incidence of recurrent acute purulent OM).

The present study was designed to determine whether auditory processing disorders are present in children with documented middle ear effusion (MEE) that required surgical treatment. Children with previous MEE and control subjects, in two age groups, were studied using five tests of auditory processing abilities: low-pass filtered speech, staggered spondaic word test, speech in noise, auditory sequential memory, and sound blending. Results found differences in groups at mean age 7 on the filtered speech test, but no statistical differences were found on any other test at age 7 or on any test at mean age 9. The results indicate that well-managed MEE appears to have no long-term effects on children acquiring this disease.

Eighteen healthy, normal hearing (PTA≤15dB, better ear), neurologically intact, 8 to 11-year-old children who had documented histories of middle ear effusion (MEE) before the age of five years were evaluated by a battery of audiological, psychological, language and achievement tests. Each was compared to his/her non-MEE sibling who was tested at the same age. All the children (n = 36) tested in the bright normal range of verbal ability (WISC-R) and none had been diagnosed previously as learning disabled. Paired comparison of sibling data revealed that the effusion subjects had deficits in verbal ability, auditory decoding and spelling skills when compared with their control siblings. Significant strength in visual sequential memory in the MEE subjects suggests the availability of compensatory strategies for auditory deficits. Data analysis on the basis of sex and/or birth order differences could not explain the differences between siblings.

Eustachian tube (ET) dysfunction is the most important factor in the pathogenesis of otitis media and related conditions. The importance of the function of the ET in relation to the middle ear-mastoid air cell system is compared to the critical role that laryngeal function has in its relation to the tracheobronchial-pulmonary system. However, because of its obscure location, the ET is not as easily assessed by clinical or laboratory methods as is the larynx, and therefore, its function is not as well understood. Most clinicians do not include ET function testing as part of their evaluation of patients with middle ear (ME) disease. Pneumatic otoscopy, the Toynbee test, tympanometry, the 9-step inflation-deflation tympanometric test, and the patulous tube test can be performed when the tympanic membrane is intact. The modified inflation-deflation test employing the pump-manometer of the electroacoustic impedance bridge can assess the function of the ET when the tympanic membrane is not intact. These tests are helpful in the diagnosis of the presence or absence of abnormal ET function; if a dysfunction is present, these tests help to determine whether or not the tube is obstructed (mechanically or functionally) or abnormally patent, and in some instances, the degree of the malfunction. Even though testing of the function of the ET in the clinical setting has severe limitations at present, and further research is needed, information can be gained which is useful in the diagnosis and management of ME disease. Failing to recognize and assess the function of the ET in relation to the ME and mastoid in selected patients is as irrational as ignoring the function of the larynx in patients with disease of the lower respiratory tract.

This paper reviews the concepts, attitudes and experience at the Otologic Medical Group (OMG) in regard to testing eustachian tube function. At OMG eustachian tube function tests are not performed prior to reconstructive surgery in cases of chronic otitis media and the reasons for this are reviewed. The lack of significant incidence of serous otitis media in postoperative patients substantiates the conclusion that there is no rationale for preoperative eustachian tube function tests in patients who are to undergo reconstructive surgery for chronic otitis media.

This study was designed to investigate the neuroanatomic connections between the middle ear (ME), eustachian tube, and brain. The neural tracer, horseradish peroxidase (HRP), was injected into the promontory mucosa of the ME in six adult rabbits. Following a 24–48 hour survival, the brain was perfused with fixative and the HRP reacted by the tetramethylbenzidine (TMB) blue reaction process. Two groups of HRP-labeled neurons were noted in the ipsilateral brainstem: 1) a well-defined cluster of HRP-labeled neurons in the nucleus of the solitary tract, and 2) a more widely scattered group of labeled neurons in the inferior salivary nucleus. The labeled neurons in the solitary tract may represent the direct central sensory projections of the glomus tympanicum. In a second set of animals HRP was injected into both the tubal and palatal muscles to identify the motor innervation of the eustachian tube musculature; HRP-labeled motoneurons were noted in the trigeminal motor nucleus and nucleus ambiguus, respectively. Assuming that the glomus tympanicum cells can sense changes such as oxygen concentration in their immediate environment in the ME like the related glomus cells in the carotid and aortic bodies which also project to the solitary tract, then the neuroanatomic relationships of the HRP-labeled neurons in this study to other respiratory neurons in the medulla suggest the possibility of a polysynaptic ME aeration reflex. The relevance of these results to the pathogenesis of otitis media with effusion is discussed.

Decompression of the facial nerve for 200 patients with Bell's palsy has been performed by the author during the past 17 years. These procedures were accomplished without injury to the facial nerve or inner ear. In no case was the incus removed nor the tympanic membrane or posterior bony canal wall disturbed with the exception of two translabyrinthine procedures in which the incus and inner ear were removed. Of 34 patients with normal nerve excitability preoperatively all had 100% recovery of facial motion. In 147 others followed for one year or more and whose nerve excitability was absent preoperatively, there was obtained an average of 80% recovery of motion and usually some degree of synkinesis. One patient who had a missing segment of nerve and a nerve graft performed failed to obtain any facial motion. Biopsy of facial nerve fibers during surgery has been found to be a feasible and useful technique. There is still no way to establish a prognosis when one still has a chance to avoid a bad result. The best one can do is to carefully follow serial electrical tests and perform surgery at the time when electrical studies begin to deteriorate. It is hoped that deterioration will develop slowly enough that a third degree injury will not have developed by the time that surgery is performed. Considering the results of this series of cases it would seem that the best results can be obtained by early surgical decompression for Bell's palsy. The patient must be informed of the possibility and the decision regarding the nature and timing of treatment should be a subjective one made after a careful analysis of the available facts and each patient's own circumstances. The availability of a promptly accomplished and precisely performed facial nerve decompression allows every patient to have a minimal risk of disabling permanent facial deformity.

In light of current research the classic theory on the vicious circle of Bell's palsy has to be reconsidered. New findings through electron microscopy and biochemistry concerning the structure and metabolism of cells have presented aspects which have consequences for treatment of the disease. These aspects deal mainly with the pathomechanisms of cell metabolism whose interactions also cause a vicious circle, leading to a breakdown of microcirculation and ultimately to the death of the cells due to hypoxia and acidosis. It is therefore suggested that the aim of an effective therapy must be the early normalization of cell metabolism by improving microcirculation. A fitting treatment protocol is presented and the extraordinarily good results are discussed.

Groups of chinchillas were given a series of noise exposures of approximately equal energy ranging from 22 minutes at 120 dB SPL to 150 days at 82 dB. For all exposures involving levels of 112 dB or less, the same average permanent hearing losses (15–20 dB) and degree of outer hair cell destruction (8–10%) resulted, thus confirming the validity of the total energy principle for assessing the hazard associated with single continuous exposures at moderate levels. The 22-minute, 120-dB exposure, however, produced a 60-dB hearing loss and massive hair cell destruction (70–80%), indicating that some critical level had been exceeded, thus producing acoustic trauma. Further histological study suggests that the massive destruction is a result of breaks in the organ of Corti, produced by severe mechanical stress, that permit the mixture of endolymph with perilymph, thus creating a hostile environment for the hair cells.

Recordings were made from the auditory nerve near its entrance into the brainstem during neurosurgical operations for cranial nerve disorders. The recorded compound action potentials in response to 2000 Hz tonebursts at 90 dB were characterized by a negative peak with a latency of 3.0 to 3.7 ms. When these compound action potentials were compared with the brainstem evoked potentials (BSEP) recorded from the scalp during the operation or before the operation, it was found that the latency of the main peak of the compound action potential matched the latency of the vertex negative wave located between waves II and III (P₂) and the potentials recorded from the nerve were found to match the N₂P₂N₃ complex of the scalp-recorded BSEP. The results indicate that the auditory nerve is the neural generator of the two first peaks in the human BSEP, in contrast to the results of experiments in animals which show that the second peak originates in the cochlear nucleus.

At the Otologic Medical Group, we see many patients complaining of tinnitus. Because tinnitus is a symptom the underlying cause and disease process must be identified and evaluated. Most patients complaining of tinnitus will not require special treatment. In this paper we discuss the treatment of patients who are severely disturbed by their tinnitus. We also discuss the effects of surgery on tinnitus. This surgical treatment includes stapedectomies, translabyrinthine eighth nerve sections and translabyrinthine removal of acoustic neuromas. In patients with tinnitus as a primary complaint, stapedectomy can be expected to improve the tinnitus in 50%. In patients undergoing translabyrinthine section of the vestibular nerve, 45% reported improvement and 55% reported the tinnitus to be the same or worse. Following translabyrinthine removal of acoustic tumors, 40% felt that their tinnitus was better, 50% said it was worse and only 10% felt it was the same preoperatively. When the patients' symptoms are severe, we have recommended biofeedback training, tinnitus maskers, and, when appropriate, hearing aids. Of 132 patients undergoing biofeedback training, 77% of the patients reported some degree of relief. No patients were worse. Our acceptance and utilization of the tinnitus maskers has not been as successful. Of 42 patients undergoing tinnitus masker evaluations, only 17% eventually purchased the maskers. We have found that patients with some degree of hearing loss benefit greatly from the use of hearing amplification.

Medical treatment is presented as the best hope of the various treatment methods available for the management of tinnitus. A test dose of 100 mg lidocaine given rapidly intravenously will give good or partial temporary relief to approximately 80% of patients with tinnitus. More permanent relief can then be achieved by the oral anticonvulsants carbamazepine or primidone but the side effects of these drugs are occasionally too severe to justify their use. Three preliminary clinical studies of the oral amide of lidocaine, tocainide hydrochloride, were conducted and results with 600 mg four times daily are very promising. Further long-term clinical trials with tocainide will be started soon. It would appear that local anesthetics when given intravenously block the multisynaptic slow pathways in tinnitus as well as in chronic pain, with which there are many other similarities. The delay in wave V in the BSER and the sudden sleep induced in patients with a good response to intravenous lidocaine further confirm the site of action of these drugs in the brainstem and reticular formation. Until tocainide is available for general use it is possible to control tinnitus with large doses of intravenous lidocaine, 100 mg given rapidly and 400 mg slowly with EKG monitoring each day for several days, and then at weekly intervals, as in the treatment of clausalgia. Because patients with disabling tinnitus, as with chronic intractable pain, are rigid, insecure, chronically depressed and fatigued, a mood-elevating tranquilizer drug combination such as perphenazine-amitriptyline is of great value in maintaining these patients. While medical treatment is not the final answer it is the best treatment available and it offers a promising direction for further study.

It is our hypothesis that the primary goal of endolymphatic sac surgery in cases of intractable Menière's disease or syndrome is for the purpose of enhancing absorption of endolymph. Our experience includes 251 cases over a period of 15 years. In this report we discuss rationale, current methods, and results in a series of 176 cases since 1974.

Pollution in the bloodstream by abnormal amounts of metabolites (sugar, insulin, triglycerides and cholesterol) over an extended period of time will have an adverse effect upon the small blood vessels: the arterioles, capillaries and venules. If the microcirculation of the inner ear becomes afflicted, it may produce endolymphatic hydrops. Control of blood pollution can usually be achieved by intelligent dietary management; and, in the case of Menière's disease, the clinical relief is gratifying. Carbohydrate and lipid metabolism is complicated. If the new insulin-glucose tolerance test is used, it will detect many more cases of glucose intolerance. Fifty consecutive cases of Menière's disease were studied for abnormal levels of metabolites. Thirty-eight (76 %) of these cases had either an abnormal glucose tolerance test (using the Wilkerson point system) or at least borderline insulin levels: a) abnormal insulin levels, 35 cases; b) borderline insulin values, 3 cases; c) abnormal glucose tolerance with normal insulin values, no cases; d) both normal glucose tolerance and normal insulin production, 12 cases.

Herniation of the jugular bulb into the middle ear is uncommon. Extension of a jugular bulb diverticulum into the petrous pyramid is rare. In ten previously reported cases in the literature, only the radiographic appearance of the lesion was stressed. Of interest to otolaryngologists is the fact that in seven of the cases there was an ipsilateral sensorineural hearing loss. Other symptoms included tinnitus and vertigo. One patient had been diagnosed as having Menière's disease. We document an additional case (a patient who had “classical Menière's disease”) and report the first known surgical exploration of this venous anomaly. The diverticulum extended high into the petrous bone and was found to obliterate the distal segment of the endolymphatic duct. To our knowledge, this is the first time that a cause and effect relationship has been recognized between endolymphatic hydrops and a jugular bulb diverticulum. We propose that the diverticulum, by obstructing the endolymphatic duct, was directly responsible for the Menière's-like symptoms.

Central vestibular signs are sensitive indicators of lesions in the posterior fossa. With the availability of computerized tomography and computerized tomography-regional blood brain circulation, the identification of suspected retrolabyrinthine lesions has improved considerably. This is a report about the reliability of central vestibular signs in predicting posterior fossa lesions.

The concept of total footplate removal in stapedectomy surgery is recommended as the preferred technique providing that the surgery is atraumatic. Only that part of the footplate which can be removed easily should be removed; in 4,761 consecutive stapedectomies a total footplate removal could be accomplished in 74%. Total and partial footplate removal necessitates a connective tissue graft to seal the oval window and must be coordinated with a suitable prosthesis which is efficient, functional and self-centering. The successful results between total and partial footplate removal are not statistically significant when employing the criteria of air-bone gap closure to within 10 dB but when comparing the complete air-bone gap closure rate there is a statistically significant difference with total footplate removal providing a more favorable hearing result.

A biostatistical study of the results of 280 consecutive operations for clinical otospongiosis are analyzed over a seven-year period. One hundred forty-one (141) operations were done utilizing the “total stapedectomy” technique, and 139 were done utilizing the “small fenestra” technique. The auditory acuity of the two groups is compared with reference to conductive and sensorineural performance. All the surgery was performed by the authors, the data was collected by a third party and analyzed by a statistician. All audiograms were performed by the same audiologist under the same conditions. The data indicates that the preferred operation for this clinical disease is the small fenestra technique.

A small hole stapedectomy with an unprotected piston is contraindicated in an ear subjected to excessive pressure changes whether these are excessive fluid pressure changes which occur in the inner ear or excessive air pressure changes in the middle ear. Excessive fluid pressure changes in the inner ear may be the result of an overly patent aqueduct of the cochlea or a permeable internal auditory canal. These excessive fluid pressure changes may produce fistulas or a dilated blister around the piston called a tented piston. Excessive air pressure changes in the middle ear will produce excessive excursions of the tympanic membrane which may result in vertigo or a dislocated piston.

The suitability of different ceramic materials for reconstructive middle ear surgery was examined in extensive animal experiments. Since 1978 we have used more than 250 aluminum oxide ceramic implants for ossicular chain reconstruction. The excellent tolerance of this bioinert material was confirmed. The ease and precision with which these implants can be drilled during the operation is especially advantageous. The indications and techniques for the use of the aluminum oxide ceramic implants are described. Our short-term results stimulated the further development of bioinert ceramic implants and our surgical techniques. The special characteristics of bioactive ceramics are such that they can form a tight bond to osseous bone. They are intended for filling bone cavities (porous tricalcium phosphate ceramic) and for reconstruction of the posterior canal wall.

Thin-section (1.5 mm) high-spatial-resolution computed tomography (CT) in combination with computerized high-resolution image reconstruction is an effective, noninvasive means of studying patients with a variety of temporal bone abnormalities. To determine what degree of definition and anatomic accuracy could currently be obtained by using these techniques, we performed thin-section CT and high-resolution image reconstruction with use of two fresh-frozen cadaver head specimens. We then compared these images with the actual anatomic macrosections subsequently obtained from the specimens. We concluded that high-resolution CT scans of the temporal bone can produce accurate, highly detailed, diagnostic images of the internal auditory canal, vestibule, cochlea, vestibular aqueduct, semicircular canals, ossicles, and middle ear space.