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Objective: To characterize the incidence and complications resulting from venous insufficiency after neurotologic-skull base surgery., Study Design: Retrospective case review of >3,500 cases., Setting: Tertiary referral center, inpatient surgery., Patients: Six patients: four with complications related to chronic venous insufficiency and two with complications related to acute venous insufficiency., Intervention(s): Medical (steroids, acetazolamide, hyperventilation, mannitol) and surgical (lumboperitoneal shunt, optic nerve decompression, embolectomy) interventions were undertaken., Main Outcome Measure(s): Chronic venous insufficiency: nonobstructive hydrocephalus manifested by headache, disequilibrium, and papilledema with resultant visual loss. Acute venous insufficiency: acute nonobstructive hydrocephalus resulting in mental status abnormalities in the postoperative period., Conclusions: (1) Incidence of 1.5 per 1,000 cases. (2) Acute and chronic forms with different pathogenesis. (3) Acute form presents postoperatively with change in consciousness and herniation, and may proceed to death. (4) Chronic form presents months or years postoperatively with headache, disequilibrium, and visual changes from papilledema. (5) Occurs almost solely in patients with preoperative abnormalities of the venous collecting system. (6) Causes mental status changes postoperatively.

Objective: To define the indications for surgery in lesions of the internal auditory canal (IAC) and cerebellopontine angle (CPA) in an only hearing ear., Study Design: Retrospective case series., Setting: Tertiary referral center., Patients: Seven patients with lesions of the IAC and CPA who were deaf on the side opposite the lesion. Five patients had vestibular schwannoma (VS), and one each had meningioma and progressive osseous stenosis of the IAC, respectively. The opposite ear was deaf from three different causes: VS (neurofibromatosis type 2 [NF2]), sudden sensorineural hearing loss, idiopathic IAC stenosis., Intervention(s): Middle fossa removal of VS in five, retrosigmoid resection of meningioma in one, and middle fossa IAC osseous decompression in one., Main Outcome Measure: Hearing as measured on pure-tone and speech audiometry., Results: Preoperative hearing was class A in four patients, class B in two, and class C in one. Postoperative hearing was class A in three patients, class B in one, class C in two, and class D in one., Conclusions: Although the vast majority of neurotologic lesions in an only hearing ear are best managed nonoperatively, in highly selected cases surgical intervention is warranted. Surgical intervention should be considered when one or more of the following circumstances is present: (1) predicted natural history of the disease is relatively rapid loss of the remaining hearing, (2) substantial brainstem compression has evolved (e.g., large acoustic neuroma), and/or (3) operative intervention may result in improvement of hearing or carries relatively low risk of hearing loss (e.g., CPA meningioma).

Objective: To determine whether prognostic indicators for hearing preservation could be identified in patients with vestibular schwannoma undergoing middle fossa craniotomy resection., Study Design: Prospective case review., Setting: Private practice tertiary referral center., Patients: 333 patients with serviceable hearing and vestibular schwannoma resected by middle fossa craniotomy from 1992 to 1998., Main Outcome Measures: Potential prognostic indicators, including tumor size and nerve of origin, preoperative pure-tone average, speech discrimination, distortion product otoacoustic emission testing, age, auditory brainstem response (ABR), and electronystagmography., Results: Postoperative hearing near preoperative levels was attained in 167 patients (50%), with an American Academy of Otolaryngology-Head and Neck Surgery Class A hearing result in 33% and a Class B result in 26%. Comparison of potential prognostic indicators between groups with hearing preserved and the group with no measurable hearing revealed significant differences in preoperative hearing, ABR, and tumor origin data. Better preoperative hearing, shorter intraaural wave V latency, shorter absolute wave V latency, and superior vestibular nerve origin were associated with higher rates of hearing preservation., Conclusions: Preoperative hearing status, ABR, and intraoperative tumor origin data were shown to be of value as prognostic indicators.

Objective: Although transposition of the facial nerve is crucial in infiltrative vascular lesions involving the jugular foramen, the objective was to show that a conservative approach to management of the facial nerve is sufficient with jugular foramen neuromas because of their noninfiltrative, less vascular nature and medial location in the jugular foramen., Study Design: Retrospective case review., Setting: Tertiary, private, multiphysician, otologic practice., Patients: Sixteen patients with jugular foramen schwannoma (18 procedures) treated between January 1975 and October 1995. The 8 male and 8 female patients ranged in age from 13 to 66 years (mean age 47.7 years)., Intervention: One-stage, total jugular foramen neuroma removal without transposition of the facial nerve, using a variety of surgical approaches., Main Outcome Measures: Facial nerve transposition (yes or no), House-Brackmann facial nerve grade, lower cranial nerve status, complications., Results: One-stage total tumor removal was accomplished in all the cases. In 13 (72%) of the neuromas, removal was accomplished without facial nerve transposition. Transposition was performed in 2 revision cases in which scar tissue from a previous operation prevented complete control of the carotid artery and safe removal, 2 cases with large tumor extension anteriorly to the petrous apex, and 1 case with extensive involvement of the middle ear. A House-Brackmann facial nerve Grade I or II was obtained in 16 of the 18 procedures, with 1 Grade III and 1 case that remained Grade V, as it was preoperatively., Conclusions: One-stage, total tumor removal can be achieved with excellent control of the important vascular structures and without transposition of the facial nerve in a majority of jugular foramen schwannomas.

Background: Knowledge of acoustic neuroma (AN) growth is essential for treatment planning., Methods: A retrospective analysis of 119 patients with AN (mean age, 65 years; range, 37-84 years) followed with interval magnetic resonance imagings (MRIs) was performed. Change in maximum tumor dimension as a function of follow-up period was analyzed., Results: Overall, maximum tumor dimension increased >2 mm in only 30% of patients. Of those that grew, the mean growth rate was 3.8 mm/year (maximum, 25 mm/year). Age, gender, and laterality did not predict growth. Most tumors that grew (86.1 %) were <20 mm at presentation. However, tumors >20 mm were statistically more likely to grow (71%, p =0.028)., Conclusions: Most ANs followed with periodic MRIs do not grow. Available clinical information usually cannot predict growth. Serial MRIs are advocated for all patients treated with observation.

Background: Corticosteroids are frequently used for the prevention and treatment of neural edema. Although perioperative steroid therapy has been used in patients undergoing acoustic neuroma removal, the efficacy of such therapy has not been previously documented., Methods: A retrospective review of 169 patients who underwent acoustic neuroma surgery with (n = 75) or without (n = 94) a single dose of intraoperative corticosteroids was performed. Tumor size ranged from 0.4 cm to 6 cm (mean, 2.1; SD, 1.0) The translabyrinthine approach was used in 85% of the patients, and the middle cranial fossa approach was used in 13%. Data were analyzed for differences in postoperative facial function and complication rates., Results: After controlling for differences in tumor size, no significant effects of steroid therapy were found for any of the outcome variables., Conclusions: This retrospective study showed no apparent benefit from intraoperative steroid use in acoustic neuroma surgery. A prospective, randomized, placebo-controlled trial should be performed to confirm these findings.

Objective: The aim of the study was to provide a clinical review of the middle fossa approach for hearing preservation in patients with neurofibromatosis type 2 (NF2)., Study Design: The study design was a prospective case review., Setting: The study was conducted at a private practice tertiary neurotologic referral center., Patients: Eighteen patients diagnosed with NF2 underwent 23 middle fossa procedures between 1992 and 1996 for removal of an acoustic neuroma. The nine males and nine females ranged in age from 11-73 years with a mean age of 28 years. Tumor size ranged from 0.5-2.5 cm with a mean of 1.1 cm., Main Outcome Measures: House-Brackmann facial nerve grade was measured. In addition, hearing level was classified both by the American Academy of Otolaryngology-Head and Neck Surgery criteria for reporting results of hearing preservation surgery and by comparison with preoperative level (15 dB/15%)., Results: Measurable hearing was preserved in 65%, 48% within 15 dB of preoperative pure-tone average (PTA) and within 15% of preoperative speech discrimination. Bilateral hearing preservation occurred in five patients. Excellent facial nerve function (House-Brackmann grades I-II) was obtained in all patients with normal preoperative facial nerve function., Conclusions: In this series of patients with NF2, outcomes in hearing and preservation of preoperative facial nerve function are similar to results seen in patients suffering a sporadic unilateral acoustic neuroma. However, early intervention is crucial in obtaining such favorable outcomes.

Objective: This study aimed to provide a clinical review of middle fossa approach for hearing preservation in acoustic neuroma surgery., Study Design: This was a prospective case review., Setting: The study was performed in a tertiary referral center of a private otologic practice., Patients: One hundred fifty-one consecutive middle fossa approaches for removal of acoustic neuroma were used. The 91 males and 60 females ranged in age from 10-72 years with a mean age of 48 years. Tumor size ranged from 0.5-2.5 cm, with a mean of 1.2 cm., Main Outcome Measures: House-Brackmann facial nerve grade and hearing level classified both by the American Academy of Otolaryngology-Head and Neck Surgery criteria for reporting results of hearing preservation surgery and by comparison with preoperative level (15 dB/15%) were the main outcome measures., Result: Measurable hearing was preservation in 68%, with 52% within 15 dB and 15% discrimination. Excellent facial function (House-Brackmann grade I-II) was obtained in 95% of patients., Conclusion: The middle fossa craniotomy approach for acoustic neuroma is a reliable approach with a good hearing preservation rate and excellent facial nerve function outcome. Complications are minimal in this group of patients.

Objective: To determine whether preoperative electroneuronography (ENoG) predicts facial nerve outcome in patients undergoing acoustic neuroma surgery., Study Design: Prospective, consecutive patients undergoing surgery for acoustic neuroma., Setting: A private tertiary otology and neurotology practice., Patients: One hundred consecutive patients presented for surgical removal of an acoustic neuroma between May 1992 and September 1993. The mean patient age was 49 years (range 17-77). Forty-three percent were male and 57% were female. The mean tumor size was 1.77 cm (range 3 mm to 5 cm). The tumors were removed by a translabyrinthine approach in 59% of patients, via the middle fossa in 40%, and retrosigmoid in 1%. The facial nerve was anatomically intact at the conclusion of the operation in all but one patient., Intervention: Preoperative ENoG in all patients undergoing surgical removal of their acoustic neuromas., Main Outcome Measures: Facial nerve outcome was measured using the House-Brackmann scale immediately after the operation. 5-7 days after surgery, and > 1 year after surgical resection., Results: Preoperative ENoG had no predictive value in determining immediate or eventual facial nerve outcome., Conclusions: ENoG has no value in predicting the facial nerve outcome in acoustic neuroma patients. The results of this study are similar to reports with smaller series in the literature. Preoperative ENoG has proven useful, in another study from this institution, in predicting the possible presence of a facial nerve neuroma. This test may be helpful in determining the possible etiology of an intracanalicular mass.

Objective: To present the clinical, surgical and histopathological manifestations of meningioma intrinsic to the geniculate ganglion., Study Design: Retrospective study of outcome., Setting: Three private tertiary and one university (otology/neurotology) referral centers., Patients: Six patients with cranial nerve VII paresis underwent magnetic resonance imaging and/or high-resolution computed tomography for subsequently histologically proven intrinsic meningioma of the geniculate ganglion. An additional six cases were identified in the literature. Most patients were female and ranged in age from 5 to 40 years., Intervention: Total tumor removal via middle fossa and mastoid exposures followed by cable graft VII-VII neuroanastomosis., Main Outcome Measure: Meningioma can occur intrinsic to the geniculate ganglion and produces gradual VIIth nerve paresis as its first symptom. Other sites of predilection may occur extrinsically within the temporal bone or along intracranial venous sinuses at sites of arachnoid villi., Results: Hearing was maintained in each patient, and postoperative House-Brackmann grade III-V facial nerve function was achieved., Conclusions: Intrinsic meningiomas of the geniculate ganglion rarely occur. However, this entity should be included in the differential diagnosis of a slowly progressive VIIth nerve paresis, especially in young females. Surgical removal and cable graft VII-VII neuroanastomosis is the treatment of choice. Long-term follow-up should be maintained because of the potential for von Recklinghausen's disease.

Magnetic resonance imaging (MRI) has been contraindicated for users of cochlear implants because of the internal magnet and other possible interactions. Users of the Nucleus Mini-22 Cochlear Implant (CI) or the experimental Multichannel Auditory Brainstem Implant (ABI) may have other disorders that are best diagnosed by MRI. The CI and ABI were modified by replacing the internal magnet and integrated circuit lid with nonmagnetic material. Tests were conducted in a 1.5-T MRI machine. Safety tests for force, heating, induced current, unintentional implant output, and implant damage were conducted by using various phantom models. Image distortion was evaluated in two subjects with implants. The maximum force measured was 2,818 dynes. There was < 0.1 degree C temperature increase in the vicinity of the implant. The maximum induced charge was > or = 667 times less than the minimum charge for auditory stimulation. There was no unintentional output during MRI scans and no change in implant function after 10 repeated scans. Image distortion consisted primarily of darkening and was worst in the axial plane, where it extended 1-2 cm medially and inferiorly from the receiver/stimulator. Compatibility-test results were acceptable, with a large margin of safety. Image distortion is limited to darkening in the immediate vicinity of the implant.

Thirty-five patients with recurrent acoustic tumors have been studied before, during, and after revision surgery. Each had their original surgery via a suboccipital approach. Six patients had undergone multiple suboccipital surgeries. Revision surgery was accomplished using a translabyrinthine approach in all patients. Total tumor removal was possible in 33 patients. No second recurrences have occurred to date among the patients with total tumor removal. Anatomic facial nerve integrity was maintained in 24 patients. All recurrent tumors were present in the lateral internal auditory canal. Direct tumor access in this area is not possible with the suboccipital approach without entering the vestibular labyrinth. The suboccipital approach to acoustic neuromas is contraindicated if tumor extends to the fundus of the internal auditory canal. Translabyrinthine resection is the treatment of choice for recurrence of acoustic neuroma after primary suboccipital resection.

The outcome of acoustic neuroma (vestibular schwannoma) surgery continues to improve rapidly. Advances can be attributed to several fields, but the most important contributions have arisen from the identification of the genes responsible for the dominant inheritance of neurofibromatosis types 1 (NF1) and 2 (NF2) and the development of magnetic resonance imaging with gadolinium enhancement for the early anatomic confirmation of the pathognomonic, bilateral vestibular schwannomas in NF2. These advances enable early diagnosis and treatment when the tumors are small in virtually all subjects at risk for NF2. The authors suggest that advising young NF2 patients to wait until complications develop, especially hearing loss, before diagnosing and operating for bilateral eighth nerve schwannomas may not always be in the best interest of the patient. To the authors' knowledge, this is the first reported case of preservation of both auditory and vestibular function in a patient after bilateral vestibular schwannoma excision.

Stereotactic irradiation has been proposed as an alternative to surgical intervention for the treatment of acoustic neuromas. The authors present their experience with five patients previously treated with stereotactic irradiation who had progression of symptoms due to tumor enlargement. Intraoperatively, the tumors were severely scarred to the facial nerve. Histopathologic examination demonstrated viable cells typical of schwannomas. Two patients received auditory brainstem implants; neither received benefit from the implant. Three of the patients had House-Brackmann grade VI facial nerve function preoperatively, and all four patients with greater than 1 year follow-up had a grade VI postoperatively. It is concluded that, with stereotactic irradiation, surgical morbidity is increased, brainstem implant results are poor, and viable tumor persists.

Auditory brainstem response (ABR) audiometry is said to be 90% sensitive in the diagnosis of acoustic neuromas. Since gadolinium-DTPA was introduced, magnetic resonance imaging (MRI) is capable of detecting acoustic neuromas as small as 3 mm. Early diagnosis is important, because hearing can frequently be preserved with resection of tumors smaller than 2 cm. At the same time, cost-containment has become a pressing issue in medicine. Auditory brainstem response, although considerably less expensive than MRI, may not be as sensitive as previously thought, particularly for small tumors. Of 753 acoustic neuromas treated at the House Ear Clinic from January 1988 through March 1993, 197 had ABR data available. The 98 males and 99 females ranged in age from 13 to 78 years with a mean of 48 years. The overall sensitivity of ABR was 92.3% using an interaural latency difference for wave V of more than 0.2 ms, and was 81.6% using waveform morphology. There was a statistically significant difference in sensitivity with respect to tumor size. Auditory brainstem response interaural latency difference sensitivity ranged from 100% in tumors larger than 3.0 cm to 83.1% in tumors 1.0 cm or smaller. Waveform morphology was abnormal in 100% of tumors larger than 2.0 cm but in only 76.5% of tumors 1.0 cm or smaller.

Cerebrospinal fluid (CSF) otorhinorrhea may be a result of infection, congenital abnormality, trauma, or it may be iatrogenic. Despite its etiology, most cases of CSF otorhinorrhea resolve spontaneously or with conservative management. For those instances where the leak does not resolve, a large variety of drainage, packing, and obliteration procedures have been developed in an attempt to stop the CSF drainage and prevent the development of meningitis. Seven cases are reviewed that resulted in complete control of the leak with minimal morbidity. The authors' approach to difficult cerebrospinal fluid otorhinorrhea is presented and described in detail.

With the increased use of gadolinium-enhanced magnetic resonance imaging studies to detect acoustic neuromas, smaller tumors are discovered more frequently. The middle fossa craniotomy approach for removal of small tumors is ideal for hearing preservation. The authors report hearing preserved at or near the preoperative levels in 71 percent of a series of 24 consecutive patients in whom the middle fossa craniotomy approach was employed. Several technical modifications, including more extensive bony exposure medially, tumor dissection in a medial-to-lateral direction, and topical application of papaverine to the cochlear nerve at the modiolus, have enhanced the ability to preserve hearing.

Management of the mastoid in cases of chronic otitis media with cholesteatoma remains controversial. Whether to leave the canal wall up or perform a cavity technique continues to be debated. The author reviewed his personal cases of surgery for chronic otitis media over a 5-year period and studied 108 cases without prior surgery who required tympanoplasty with mastoidectomy for cholesteatoma. Thirty-two percent of the cases were in children 15 years of age and under. Over two thirds of the procedures were canal wall up, and the remainder of patients underwent a canal wall down technique with obliteration. There was little difference in the results between children and adults, with the exception of there being a tendency for a greater degree of ossicular destruction in the children and a greater incidence of residual disease at second stage surgery. There was a 3 percent incidence of recurrent cholesteatoma. It appears that the intact canal wall technique is preferable in both children and adults, when circumstances are favorable.

Selective vestibular nerve section is effective in relieving intractable vertigo while preserving hearing. Histologic study demonstrated overlap of the cochlear and vestibular fibers at the cochleovestibular cleavage plane within the posterior fossa. In the hopes of improving surgical results by sectioning these overlapping vestibular fibers, the technique of sectioning the vestibular division of the eighth nerve was modified to include a small portion of the cochlear division. We have evaluated 143 cases of retrolabyrinthine vestibular nerve section in which this technical modification was employed. A patient questionnaire was used to examine control of vertigo as well as changes in tinnitus, unsteadiness, and disability. Hearing preservation and incidence of complications were also reviewed. Resolution or improvement of vertigo occurred in 93 percent of Menièré's cases and 74 percent of non-Menièré's cases as compared to 97 percent and 68 percent, respectively, in the pre-1986 series.

This study reviewed the technique and outcome of facial nerve repair in cases of cerebellopontine angle (CPA) tumor that resulted in transection of the facial nerve. Between January 1982 and December 1989, the facial nerve was preserved in over 97.7 percent of 1110 cases of CPA tumor resection. Facial nerve repair was performed in 23 patients. The nerve repair was accomplished with either suture anastomosis or support with microfibrillar collagen. In the cases repaired with sutures, reanastomosis to a proximal facial nerve stump at the brain stem was performed with a single suture, while stabilizing the nerve with a fenestrated suction. Direct facial nerve neurorrhaphy or anastomosis with a greater auricular nerve interposition graft was successful in restoring tone and some degree of voluntary motion in 18 of the 21 patients with follow-up available (86%) and acceptable function (grade IV/VI or better) in 12 of 21 (57%). The degree of recovery of facial function was significantly better in patients without preoperative facial nerve symptoms and patients in whom the tumor did not arise from the facial nerve itself. We conclude that in cases of facial nerve transection in the CPA, good results are obtained by immediately reestablishing anatomic continuity of the nerve with direct reanastomosis or with a greater auricular nerve graft.

Accurate preoperative diagnosis of petrous apex lesions is critical because the surgical approaches used for this region are different depending upon the specific disease process involved. While CT and MRI have each improved the accuracy of preoperative diagnosis of petrous apex pathology, these imaging studies are most helpful when used in conjunction with one another. When systematically applied, the combination of CT with contrast and MRI (with and without gadolinium) permits accurate differential diagnosis of primary petrous apex lesions. This review presents the imaging approach employed at the House Ear Clinic for the differential diagnosis of primary lesions of the petrous apex.

This is a review of the English literature relative to acoustic tumors from 1983 through 1988. In January of 1984, a similar article was published in this journal which reviewed the literature from 1979 through 1982. We have selected what we consider the most important articles from the hundreds that were published on this subject. Many other significant papers are not discussed. The material is presented in 11 categories: diagnosis, histopathology, treatment, hearing preservation, facial nerve preservation and repair, von Recklinghausen's disease and bilateral tumors, nonacoustic cerebellopontine angle tumors, instrumentation, basic research, complications of surgery, and miscellaneous topics. In each section the articles are briefly reviewed, and sometimes our personal point of view is expressed.

Tympanometric results were reviewed for 341 cases of Meniere's disease and 200 cases of sensorineural hearing loss of unknown causes. The results indicate that the incidence of Eustachian tube dysfunction in patients with Meniere's disease is nearly the same as in a control group of patients with sensorineural hearing loss of unknown causes: The percentage of patients with Meniere's disease having Eustachian tube dysfunction was similar to the percentage of normal-hearing listeners with Eustachian tube dysfunction reported by Jerger.

Thirty-three (16.5%) of the first 200 patients who presented to the Otologic Medical Group with acoustic tumors underwent surgery for their subtotal removal. These 33 patients, operated on between 1964 and 1967, were followed for clinical evidence of recurrent tumor for a period ranging from 2 to 20 years. Twelve patients required further surgery for recurrent tumor and three of these repeat surgery patients died as a result of their tumors. Case reports of six patients who underwent partial resection are presented with recent computed cranial tomographic follow-up.

A 40-year-old male presented with a 2-month history of sudden hearing loss and tinnitus in his left ear. Mild vertigo was present initially but disappeared spontaneously without treatment. Facial nerve paralysis and retroauricular pain appeared 3 months after the onset of hearing loss on the same side. Computerized tomography and magnetic resonance imaging demonstrated a 1-cm mass in the left internal auditory canal. Translabyrinthine removal of tumor revealed metastatic adenocarcinoma. The patient died 3 months postoperatively from multiple metastatic deposits. A primary tumor was never found. The course of illness in this patient differs significantly from the typical course of other conditions involving the internal auditory canal. A metastatic work-up should be considered for patients with a similar history before a craniotomy is performed.

This is a review of the English literature relative to acoustic tumors from 1979 through 1982. I have selected what I consider the most important articles. Many other significant papers are not discussed. The material is presented in ten categories: diagnosis, histopathology, surgical approaches, facial nerve preservation and repair, von Recklinghausen's disease and bilateral tumors, nonacoustic cerebellopontine angle tumors, instrumentation, basic research, complications of surgery, and miscellaneous topics. In each section the articles are briefly reviewed, and sometimes a personal point of view is presented.

Facial nerve repair during translabyrinthine tumor surgery was performed in twenty-four patients. Nineteen patients (79 percent) had return of facial function. Different techniques of facial nerve anastomosis were evaluated. Suture anastomosis was more reliable than other anastomotic methods, especially if cable nerve grafts were used. Facial function began to return within twelve months in all patients whose function returned.

Forty-eight patients with facial nerve neuromas were treated at the Otologic Medical Group Inc. between 1974 and 1985. The most common presenting symptoms were hearing loss and tinnitus. Facial paralysis occurred in 22 patients (46%). A mass behind the tympanic membrane was seen on otoscopy in 14 patients (29%). These tumors typically involved more than one segment of the nerve and eroded otic capsule bone in 14 patients (29%). High resolution computed tomography (CT) was highly accurate in determining the extent and location of these tumors. Restoration of the continuity of the nerve was undertaken at the time of tumor removal. The major determinant of the ultimate status of facial nerve function was the duration of preoperative paralysis.

Xanthomata are soft tissue tumors composed of lipid-laden "foamy" histiocytes associated with cholesterol clefts and inflammation. They are considered to be specialized granuloma rather than true neoplasms and are usually associated with disorders of lipid metabolism, most commonly one of the hyperlipoproteinemia syndrome. A rare case of a xanthoma involving the temporal bone and causing extensive destruction of the skull base is presented. Otalgia and infection are the most common presenting symptoms of this disorder, with multiple cranial nerve palsies resulting in some cases. Treatment includes conservative surgical debulking, dietary restriction of fat and cholesterol, and pharmacologic reduction of serum lipids.

The senior author has performed 346 endolymphatic sac operations since 1971. Questionnaires were sent to these patients to evaluate the results of this surgery. One hundred ninety-six questionnaires were returned and formed the basis for this report. The results of surgery are reported by the new American Academy of Otolaryngology--Head and Neck Surgery criteria as well as by the older method of reporting. There is no significant difference in results between the endolymphatic subarachnoid shunt and the endolymphatic mastoid shunt. Because of the lower morbidity of the latter procedure the authors prefer the endolymphatic mastoid shunt. The new method of reporting is superior to the older method.

Retrolabyrinthine vestibular neurectomy preserves hearing and relieves intractable vertigo emanating from the inner ear. However, this approach must be modified in patients with prior "canal-wall-down" procedures. Traversing an exteriorized mastoid cavity risks bacterial contamination of the subarachnoid space. Three patients seen at the Otologic Medical Group with prior canal-wall-down procedures required vestibular neurectomy for persistent vertigo. Using the retrosigmoid approach, the vestibular nerve was sectioned without sacrificing hearing and without traversing a potentially infected mastoid cavity. It is recommended that this approach be considered in patients with intractable vertigo, serviceable hearing, and exteriorized mastoid cavities.