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Background: Aesthetic facial appearance following neurosurgical ablation of frontal fossa tumors is a primary concern for patients and neurosurgeons alike. Craniofacial reconstruction procedures have drastically evolved since the development of three-dimensional computed tomography imaging and computer-assisted programming. Traditionally, two-stage approaches for resection and reconstruction were used; however, these two-stage approaches have many complications including cerebrospinal fluid leaks, necrosis, and pneumocephalus. Case Description: We present two successful cases of single-stage osteoma resection and craniofacial reconstruction in a 26-year-old female and 65-year-old male. The biopolymer implants were preselected and contoured based on imaging prior to surgery. The ideal selection of appropriate flaps for reconstruction was imperative. The flaps were well vascularized and included a pedicle for easy translocation. Using a titanium mesh biopolymer implant for reconstruction in conjunction with a forehead flap proved advantageous, and the benefits of single-stage approaches were apparent. The patients recovered quickly after the surgery with complete resection of the osteoma and good aesthetic appearance. The flap adhered to the biopolymer implant, and the cosmetic appearance years after surgery remained decent. The gap between the bone and implant was less than 2 mm. The patients are highly satisfied with the symmetrical appearance of the reconstruction. Conclusions: Advances in technology are allowing neurosurgeons unprecedented opportunities to design complex yet feasible single-stage craniofacial reconstructions that improve a patient's quality of life by enhancing facial contours, aesthetics, and symmetry.

Despite efforts at public health awareness and stringent industrial standards for hearing protection, noise-induced hearing loss (NIHL) remains a formidable public health concern. Although many antioxidants have proven to be beneficial in the laboratory for prevention of permanent NIHL, low-dose combinations of compounds with different biochemical mechanisms of action may allow long-term administration with fewer side effects and equal efficacy. The mixture of D-methionine and N-acetyl-L-cysteine administered at levels less than 10% of standard dosing has not been previously reported.Twenty-six female adult Chinchilla laniger were placed in 4 study groups, consisting of (1) a group receiving combination 12.5 mg/kg each D-methionine and N-acetyl-L-cysteine (DMET/NAC group), (2) a group receiving 12.5 mg/kg D-methionine (DMET-only group), (3) a group receiving 12.5 mg/kg N-acetyl-L-cysteine (NAC-only group), and (4) saline controls.Laboratory.All groups received twice-daily intraperitoneal injections 2 days prior to noise exposure, 1 hour before and after exposure on day 3, and for 2 days subsequently, totaling 10 doses of 125 mg/kg for each antioxidant over 5 days.Although NAC-only animals paralleled saline control recovery during 3 weeks, the DMET-only group revealed gradual improvement with statistically significant recovery in the middle frequencies. The DMET/NAC group showed significant improvement at most frequencies compared with controls (P.001 and P.05).Significant recovery of hearing was observed following continuous noise exposure with either DMET only or a combination of low-dose DMET/NAC, demonstrating a considerably lower dose of antioxidants required than previously reported for hearing recovery following acoustic trauma.

(1) To measure the peak-to-peak displacement of the round window membrane (RWM) prior to blunting procedure. (2) To evaluate the impact of blunting the anterior tympanomeatal angle (ATA) on middle ear sound transfer function.Basic science study. Setting. Cadaveric temporal bone research laboratory.Six fresh human temporal bones were prepared using a mastoidectomy and facial recess approach. Baseline RWM peak-to-peak displacements were obtained by single-point laser Doppler vibrometry (LDV) at 90-dB sound pressure level over a spectrum of 250 to 8000 Hz. Temporalis muscle was harvested and then fashioned into a graft for each temporal bone, mimicking ATA blunting. RWM displacement responses with the blunted ATA were measured using the LDV to judge the impact on middle ear transfer function.For each of the 6 temporal bones, the average displacement decreased across all sound frequencies with the ATA blunting when compared with baseline (no blunting). Baseline velocity measurements for all sound signals averaged 4.5 × 10(-3) ± 1.892 × 10(-3) (mean ± SEM) mm/s, while measurements averaged 2.2 ± 6.62 × 10(-4) mm/s with blunting of the ATA (P.001). This amounted to a 52% decrease in velocity of the RWM following blunting of the ATA.Blunting of the ATA decreases the sound transfer function of the tympanic membrane and middle ear. Prevention of blunting at the ATA during tympanoplasty should be emphasized.

OBJECTIVE: The aim of this study was to characterize our clinical population of patients suffering with post-traumatic migraine-associated dizziness (PTMAD) and determine any associations with medical interventions and vestibular testing metrics to help predict response to treatments. STUDY DESIGN: Retrospective chart review. SETTING: Tertiary referral center. SUBJECTS AND METHODS: The electronic medical records of 83 patients presenting to a tertiary referral center who were given a diagnosis of PTMAD and who had been treated were retrospectively reviewed. General characteristics, clinical treatment, pre- and post-vestibular therapy testing metrics, and success and failure outcomes were assessed. Patients were assigned into responder and nonresponder groups related to their headaches and evaluated at two specific time points. Medication failures and vestibular test metrics were compared to identify and predict clinical outcomes. RESULTS: Seventy-two of 82 patients (88%) were analyzed at two time points. Use of verapamil, topiramate, gabapentin, amitryptiline, and valproic acid showed no comparative treatment benefit in responders compared to nonresponders (P = 0.294). Findings associated with successful treatments include response to initial medication (P = 0.001), final dynamic gait index (DGI) scores (P = 0.029), final vertical dynamic visual acuity test (DVAT) scores (up, 0.007; down, 0.006), and both final and change in computerized dynamic posturography-sensory organization test (CDP-SOT) scores (P = 0.001, P = 0.032). The antipsychotic quetiapine was specifically associated with outcome failures (P = 0.003). CONCLUSION: Specific prophylactic antimigraine medications were not associated with improved outcomes in PTMAD patients. Initial clinical responses and vestibular test metrics may guide physicians to predict successful outcomes.

OBJECTIVE:: To characterize vestibular and related symptoms seen after blast exposure. STUDY DESIGN:: Prospective single-subject design. SETTINGS:: Tertiary care facility and military field hospital. PATIENTS:: Active-duty US Military personnel exposed to blast(s) in Iraq and/or Afghanistan. INTERVENTIONS:: Vestibular function tests, auditory tests, and a structured history and physical examination. RESULTS:: Blast exposure induced vestibular disorders, and related symptoms are significantly different than those seen in blunt head trauma. The vestibular characteristics and objective tests of vestibular function significantly worsen in blast-exposed patients as a function of time between injury and presentation. CONCLUSION:: Blast exposure produces a unique set of vestibular disorders and associated symptoms that progress over time. Understanding the characteristics of these symptoms as they vary over time may be critical in designing treatment strategies that modify long-term outcome. Language: en

Objective The purpose of this study was to determine the efficacy of treating chronic ear disease by performing a single surgical intervention in the austere environment of a developing nation. Subjects and Methods Data were collected from retrospective chart reviews on 121 patients who underwent surgical treatment of chronic ear disease during humanitarian surgical missions in South and Central America. Surgical outcomes and clinical course were assessed at 10 to 12 months after the initial surgery. Results A total of 117 patients were included in the study. Follow-up records were available for 75 patients (64%). A total of 20 surgeries were performed for dry perforations (group 1), 30 for chronically draining ears (group 2), and 25 for cholesteatomas (group 3). Surgical success was determined as 60 percent, 74 percent, and 92 percent for groups 1, 2, and 3, respectively. Conclusions Surgical results during international otologic outreach missions to developing nations fall within the results expected in developed nations.

This study examined the association between ultrahigh-frequency (UHF) hearing sensitivity and distortion-product otoacoustic emission (DPOAE) levels at conventional frequencies. Behavioral thresholds were measured from 2 through 16 kHz, and DPOAE levels were measured at discrete f2 frequencies between 2 through 8 kHz in 553 young normal-hearing adult male participants. A DPOAE frequency sweep was measured with primary stimulus levels of L1/L2 = 65/55 dB SPL and an f2/f1 of 1.2. Significant negative correlations, although weak, were found between UHF behavioral thresholds and DPOAE levels. As UHF behavioral thresholds worsened, DPOAE levels decreased at all frequencies. When the data were categorized into two groups, “better” and “worse” UHF behavioral thresholds, significant differences were apparent between the two groups for DPOAEs. Additionally, those with better UHF thresholds had better conventional thresholds compared to those in the worse UHF threshold group. The results of this age-restricted, large-sample-size study confirm and augment findings from earlier studies demonstrating that UHF hearing sensitivity has some influence on DPOAE measures at frequencies from 2 through 8 kHz with moderate stimulus levels. However, because those with better UHF thresholds also had better conventional thresholds and the significant correlations found were weak, this work supports the importance of UHF hearing testing in conjunction with otoacoustic emission measures to identify basal cochlear insults not evident from behavioral testing at conventional frequencies. Este estudio examinó la asociación entre la sensibilidad auditiva a ultra-alta frecuencia (UHF) y los niveles de las emisiones otoacústicas por productos de distorsión (DPOAE) en las frecuencias convencionales. Se midieron los umbrales conductuales desde 2 y hasta 16 kHz, y los niveles de la DPOAE se midieron a frecuencias discretas f2 entre 2 y 8 kHz en 553 adultos jóvenes masculinos oyentes normales. Se registró un barrido frecuencial de DPOAE con niveles primarios de estímulo de L1/L2 = 65/55 dB SPL y un f1/f2 de 1.2. Se encontraron correlaciones negativas significativas, aunque débiles, entre los umbrales conductuales de UHF y los niveles de las DPOAE. Conforme los umbrales conductuales de UHF se deterioraron, los niveles de DPOAE disminuyeron en todas las frecuencias. Cuando los datos se categorizaron en dos grupos – umbrales conductuales de UHF “mejores” y “peores” – se hicieron aparentes diferencias significativas entre los dos grupos para las DPOAE. Adicionalmente, aquellos con los mejores umbrales UHF tuvieron mejores umbrales convencionales, comparados con aquellos en el grupo de los peores umbrales UHF. Los resultados de este estudio con restricción de edad y con una muestra de gran tamaño confirman y destacan los hallazgos de estudio anteriores que demostraban que la sensibilidad auditiva en UHF tiene alguna influencia sobre las mediciones de las DPOAE, en las frecuencias de 2 a 8 kHz, con niveles moderados de estímulo. Sin embargo, dado que aquellos con mejores umbrales UHF también tenían mejores umbrales convencionales y que la correlación significativa encontrada era débil, este trabajo apoya la importancia de la evaluación de la audición en UHF en conjunto con mediciones de emisiones otoacústicas para identificar insultos cocleares basales, no evidentes en la evaluación conductual en frecuencias convencionales.

Noise-induced hearing loss (NIHL) is an important etiology of deafness worldwide. Hearing conservation programs are in place and have reduced the prevalence of NIHL, but this disorder is still far too common. Occupational and recreational pursuits expose people to loud noise and ten million persons in the US have some degree of noise-induced hearing impairment. It is estimated that 50 million in the US and 600 million people worldwide are exposed to noise hazards occupationally. Noise deafness is still an important and frequent cause of battlefield injury in the US military. A mainstay of hearing conservation programs is personal mechanical hearing protection devices which are helpful but have inherent limitations. Research has shown that oxidative stress plays an important role in noise-induced cochlear injury resulting in the discovery that a number of antioxidant and cell death inhibiting compounds can ameliorate deafness associated with acoustic trauma. This article reviews one such compound, N-acetylcysteine (NAC), in terms of its efficacy in reducing hearing loss in a variety of animal models of acute acoustic trauma and hypothesizes what its therapeutic mechanisms of action might be based on the known actions of NAC. Early clinical trials with NAC are mentioned.

Inner ear medical therapy has been gaining increasing popularity during the last 2 decades. Despite the increased use of this therapy,basic questions regarding this type of treatment have not been answered. The authors have used a variety of sustained-release devices in the laboratory to begin to answer some of these basic questions. This article discusses the results of this work and the application and use of sustained-release devices in patients.

Chronic suppurative otitis media frequently results in disruption of the ossicular chain. Once disease has been eradicated, the next goal of surgery is reconstitution of an intact sound conduction mechanism from the tympanic membrane to the inner ear. Many surgical techniques and prostheses have bee

The use of transtympanic gentamicin has become a popular method of treating Meniere's disease; nevertheless, many questions still remain regarding this therapy. Until investigators can control the exact amount of medicine that is administered to the ear and have an understanding of the kinetics of gentamicin, therapy will continue to rely on empirical data. Previously we described the use of a fibrin-based sustained-release vehicle impregnated with gentamicin in the middle ears of chinchillas. With this model a kinetics curve of gentamicin was defined. The inner ears of these animals were submitted for immunohistochemical and histologic analysis. We discuss the ultrastructural changes seen and correlate this to our kinetics data. We also examine measurement of hair cell damage with heat shock protein levels. By better understanding the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population.

Inner ear delivery of medicines has been a rapidly expanding field in otolaryngology. This technique provides a minimally invasive way of managing a number of otolaryngologic diagnoses and promises to provide a therapeutic option for previously untreatable disorders. The purpose of this review is to examine the literature that has been published recently (since January of 2005) in this field and to explore how this new literature has impacted on current practices.While there was a significant volume of work done in this area from 1995 to 2004, publication in this area has slowed considerably. The literature focuses on two areas: the treatment of Ménière's disease with gentamicin and the treatment of sudden sensorineural hearing loss with steroids. The most promising area in this field, which is the development of new medicines to treat a variety of disorders, has not progressed over the last 2 years.Recent peer-reviewed publications have not had a significant impact on the transtympanic treatment of Ménière's disease or sudden sensorineural hearing loss. We will review the current practices in these two areas, discuss the newest developments and examine how we can progress the field over the next several years.

Over the years, a variety of empirical regimens have evolved using intratympanic gentamicin to treat the vertigo associated with Meniere's disease. Although these regimens have been effective, their application is not without risk. Many of the problems associated with intratympanic medications could be overcome with the use of a sustained release vehicle. This article examines the role of such vehicles in the treatment of Meniere's disease and how sustained release vehicles might impact future treatment for this disabling disease.

Program Description:After our nation’s longest period of conflict, it is important to look for experience and medical advances that might improve our care of the injured patient. Targeting general otolaryngologists, we will present an overview for otologic care of the trauma patient presenting to your office. Emphasis will include an update on surgical management of facial nerve injury, manifestations and treatment of balance disorders after concussion and head trauma, repair of traumatic tympanic membrane perforations, and hearing loss.Educational Objectives:1) Articulate timing and indications for surgical treatment of facial nerve injury. 2) Describe treatment principles and best practice for post–head trauma balance disorders. 3) Recognize treatment of traumatic perforations and hearing injury.

(1) Evaluate the sound transfer impact of removal of the incus body in ossicular chain reconstruction (OCR) using an incus strut prosthesis. (2) Provide basic science data to assist clinical decision making in ossiculoplasty.Basic science.Cadaveric temporal bone research laboratory.Ossicular chain reconstruction with an incus strut prosthesis was performed on 7 human temporal bones with and without the incus body. The difference in round window membrane (RWM) peak-to-peak displacements (90-dB sound pressure level, 250-8000 Hz) using single-point laser Doppler vibrometry (LDV) was compared with observed baseline, intact ossicular chain values.Comparing OCR using an incus strut prosthesis to an intact ossicular chain across all 7 temporal bones, the largest differences in RWM velocity occurred at 1011 and 2011 Hz. With increasing frequencies, RWM velocities of the OCR approached the intact ossicular chain. Using a Wilcoxon rank-sum test comparing the ossicular chain with and without the incus body showed no statistically significant difference across all frequencies (P = .925). Removing the incus body resulted in improved median RWM velocity (× 10(-2) mm/s) by 0.6 at 1011 Hz and a decrease of 0.6 at 2011 Hz. A rank-sum test to evaluate the difference at 1011 and 2011 Hz did not demonstrate statistical significance.Removal of the incus body in OCR using an incus strut prosthesis did not significantly change sound transfer function of the middle ear relative to its preservation. Our data suggest the impact of the retained mass in OCR to be minimal.

Mild traumatic brain injury (mTBI) caused by blast-related and blunt head trauma is frequently encountered in clinical practice. Understanding the nuances between these two distinct types of injury leads to a more focused approach by clinicians to develop better treatment strategies for patients. In this study, we evaluated two separate cohorts of mTBI patients to ascertain whether any difference exists in vestibular-ocular reflex (VOR) testing (n = 55 enrolled patients: 34 blunt, 21 blast) and vestibular-spinal reflex (VSR) testing (n = 72 enrolled patients: 33 blunt, 39 blast). The VOR group displayed a preponderance of patients with blunt mTBI, demonstrating normal to high-frequency phase lag on rotational chair testing, whereas patients experiencing mTBI from blast-related causes revealed a trend toward low-frequency phase lag on evaluation. The VSR cohort showed that patients with posttraumatic migraine-associated dizziness tended to test higher on posturography. However, an indepth look at the total patient population in this second cohort reveals that a higher percentage of blast-exposed patients exhibited a significantly increased latency on motor control testing as compared to patients with blunt head injury (p.02). These experiments identify a distinct difference between blunt-injury and blast-injury mTBI patients and provide evidence that treatment strategies should be individualized on the basis of each mechanism of injury.

Publisher Summary This chapter explores that closed head injury (CHI) and associated traumatic brain injury (TBI) are becoming increasingly common in modern society. Faster motorized vehicles, bigger, stronger athletes, and the continued desire to push things to the extreme are just some of the many reasons that more individuals are affected by CHI now than in the past. The chapter discusses that TBI can be divided into three classes: mild, moderate, and severe. It reviews the classification scheme as it applies to all classes of head injury. It describes how neurophysiologic testing plays a role in assigning individuals into diagnostic categories and aids in the treatment of this group of patients. Often, due to cognitive deficits, these head injury patients do not get the care they need for their vestibular disorder. The chapter concludes that understanding how to best use technology to diagnose and treat these patients is critical in their management, and essential if hope to return these individuals to a normal life.

ObjectiveThe efficacy of the Otologics Fully Implantable Hearing Device (MET) was assessed in adult patients with bilateral moderate to severe sensorineural hearing loss.MethodsSurgical insertion of this totally implanted system was identical to the Phase I study. A repeated-measures within-subjects design assessed aided sound field thresholds and speech performances with the subject's own, appropriately fit, walk-in hearing aid(s) and the Otologics Fully Implantable Hearing Device.ResultsSix- and 12-month Phase II data will be presented. Ten patients were implanted and activated as part Phase II clinical trial. Three patients were lost to long term follow-up due to two coil failures and one ossicular abnormality preventing proper device placement. No significant differences between preoperative (AC = 59 dB, BC = 55 dB) and postoperative (AC = 61 dB, BC = 54 dB) unaided pure tone averages were noted (p < 0.05). Pure tone average implant aided thresholds (41 dB) were equivalent to that of walk-in-aided (37...

ProblemDo migraine prophylactic medications effect the vestibular rehabilitation of individuals with Post-Traumatic Migraine Associated Dizziness (PTMAD)?MethodsTraumatic Brain Injury (TBI) is a co...

The purpose of this study was to evaluate the possible effects of risk factors on distortion product otoacoustic emissions (DPOAEs) in young adult men with normal hearing. Four hundred thirty-six United States Marine recruit men (mean age = 19.2 years ± 1.8 years; age range = 17 - 29 years) participated in this study. Questionnaires were given to each recruit to obtain demographic data and history of noise exposure, solvent exposure, smoking history, and hearing-related histories. Otoscopy, tympanometry, pure-tone air-conduction audiometry (2.0 – 8.0 kHz) and DPOAEs (2.3 - 8.0 kHz) were measured. DPOAE levels were lower in Not Hispanic or Latino recruits, in heavy smokers, in recruits who reported loud live music exposure and ringing in their ears after noise exposure. These differences were not statistically significant at all frequencies. Recruits with multiple risk factors had the lowest DPOAEs as compared to recruits with fewer, or no, risk factors; these differences were not statistically significant. Obtaining risk factor data as part of an audiometric evaluation is important even though the individual may have normal hearing. El propósito de este estudio fue evaluar los posibles efectos de los factores de riesgo sobre las emisiones otoacústicas por productos de distorsión (DPOAE) en hombres adultos jóvenes con audición normal. Cuatrocientos cuarenta y seis reclutas masculinos de la Marina de los Estados Unidos (edad media de 19.2 años ± 1.8; rango de edad = 17 - 29 años) participaron del estudio. Los cuestionarios se entregaron a cada recluta para obtener datos demográficos e historias de exposición a ruido, exposición a solventes, historia de fumado, e historias relacionadas con la audición. Se realizaron otoscopias, timpanometrías, audiometrías de tonos puros por vía aérea (2.0 – 8.0 kHz) y DPOAE (2.3 – 8.0 kHz). Los niveles de las DPOAE fueron más bajos en reclutas no hispánicos o no latinos, en fumadores fuertes, en reclutas que reportaron exposición a música fuerte en vivo, y ruidos en los oídos después de exposición a ruido. Estas diferencias no fueron estadísticamente significativas en todas las frecuencias. Los reclutas con múltiples factores de riesgo tuvieron las DPOAEs más bajas, comparados con los reclutas con menos o ningún dato de factores de riesgo; estas diferencias no fueron estadísticamente significativas. Obtener datos de factores de riesgo como parte de una evaluación audiométrica es importante aunque los individuos tengan audición normal.

OBJECTIVE To assess the safety of the Otologics fully implantable hearing system after 1 year of use in a Phase I clinical trial. STUDY DESIGN Repeated-measures within-subjects design. SETTING Procedures were performed in a variety of facilities, including a university, military, and private hospital's ambulatory surgical center and outpatient clinical audiologic test facilities. PATIENTS Adult patients with bilateral moderate to severe sensorineural hearing loss. INTERVENTION(S) Surgical insertion of this prosthesis included an atticotomy to expose the incus, securing the transducer to the mastoid bone, attaching the transducer tip to the incus via insertion into a laser-drilled hole, and postauricular implantation of the microphone/battery/electronics capsule. MAIN OUTCOME MEASURE(S) Subjective patient benefit, aided sound field thresholds, and speech discrimination with the subject's own, appropriately fit, walk-in hearing aid(s) and the prosthesis were assessed. RESULTS There were no pre-post-implant differences noted for bone conduction: slight differences were noted in the pre-post-implant air conduction results (p < 0.05). These differences were attributed to the healing process and reversed to almost preimplant assessment levels by the third-month evaluation. Pure-tone averages and monaural word recognition scores were slightly better for the walk-in-aided condition (p < 0.05), whereas the patient benefit scales favored the postoperative implant-aided conditions.Adverse effects of the implant were encountered on 14 occasions after the implantation of the 20 subjects. With the exception of partial device extrusions (that occurred later), all were rectified by the time of initial activation. At the 12-month data collection point, problems that had been encountered by subjects included 1) partial device extrusion (3 subjects), necessitating explantation in 2; 2) loss of external communication (2 subjects), resulting in 1 explantation; and 3) increased charging times beyond 1.5 hours (7), resulting in 3 explantations and 2 patients not using their device while awaiting explantation. CONCLUSION Phase I trial results provide evidence that this fully implantable device can provide sound amplification to sensorineural hearing loss patients, with performance results similar to the patients' walk-in hearing aids.

Head trauma is being more frequently recognized as a causative agent in balance disorders. Most of the published literature examining traumatic brain injury (TBI) after head trauma has focused on short-term prognostic indicators and neurocognitive disorders. Few data are available to guide those individuals who see patients with balance disorders secondary to TBI. Our group has previously examined balance disorders after mild head trauma. In this study, we study all classes of head trauma. We provide a classification system that is useful in the diagnosis and management of balance disorders after head trauma and we examine treatment outcomes. As dizziness is one of the most common outcomes of TBI, it is essential that those who study and treat dizziness be familiar with this subject.

This article provides a review of studies investigating the pharmacological treatment of tinnitus. Tinnitus continues to be a significant and costly health problem without a uniformly accepted treatment. A wide variety of studies exploring prescription, supplement, and vitamin therapies are assessed for efficacy of treatment and for establishing consistencies in symptom definition, assessment, and outcome measures. This review reveals no compelling evidence suggesting the efficacy of any pharmacological agent in the treatment of tinnitus. Analysis of prior investigations provides insight to appropriate methods for future work, which are outlined.

Objective To study the role of vestibular rehabilitation is treating patients with Meniere’s disease. Methods We examined all Meniere’s patients presenting to our tertiary care specialized vestibular clinic during a 1-year period. All patients underwent a standardized history and physical examination, a complete auditory-vestibular test battery, and a set of physical therapy tools to measure balance function. Results A subset of patients suffered from disequilibrium or unsteadiness between attacks. Once the acute fluctuating symptoms of Meniere’s were controlled in this group of individuals, all of them underwent vestibular physical therapy and demonstrated significant improvement in balance function on both objective and self-report tests. Conclusions Due to the fluctuating nature of the disorder, vestibular physical therapy has had a limited role in the treatment of Meniere’s disease. In general, rehabilitation has been used only as a postoperative treatment for the acute vertigo seen after vestibular neurectomy or labyrinthectomy. This is the first report advocating the role of vestibular physical therapy in a group of patients receiving medical therapy of intraear medicines (other that gentamicin).

Vestibular disorders are becoming an increasingly more common medical problem. As society ages and modern entertainment and recreational activities progress the impact of dizziness on the population is become even more significant. Dizziness not only interferes with the performance of daily activities, but it also represents a serious health problem. Over the last several years, many new diagnostic and treatment modalities have been developed to help manage the dizzy patient. Otolaryngologists occupy a prime position in the treatment algorithm. Otolaryngologists are capable of diagnosing disorders of balance, prescribing medical therapy, performing surgical procedures, or directing the patient to the appropriate rehabilitation regimen. As with any field the development of new diagnostic and treatment procedures has been accompanied by controversies. Over the past several years, the equilibrium committee of the academy has been charged with examining these controversies. This symposium will present some of the controversies in the management of the dizzy patient. After the presenters discuss each issue, there will be an opportunity for audience participation. The controversies to be discussed include: the use of vestibular test apparatus in diagnosing the dizzy patient; the role of vestibular rehabilitation therapy in managing the dizzy patient; the role of medicines in treating patients with a variety of vestibular disorders Meniere’s disease; and what to do next when conservative medical therapy fails.

Transtympanic medical therapy is becoming an increasingly popular modality for the treatment of "inner-ear disorders." While investigators continue to examine the best dosing paradigms for gentamicin in the treatment of Ménière's disease and for steroids in the treatment of hearing loss, they have also begun to focus on the use of other agents. In particular, transtympanic therapy has been advocated as a plausible route for the treatment of tinnitus. Transtympanic therapy for tinnitus is not new, and a number of groups have reported success in the past. Despite this success, a number of laboratories have been focusing on newer agents that might yield higher success rates in the treatment of tinnitus and other inner-ear disorders. Many of these agents could have systemic side effects when delivered in high enough doses; therefore, they are ideal candidates for transtympanic administration. The goal of this study is to begin to define the effects of one of these agents--leupeptin, a calpain antagonist--on the normal inner ear of an animal model. In this investigation, we demonstrate the effects of sustained-release delivery of leupeptin (2.5 micrograms/ml) on the hearing of chinchillas. The medicine produced no hearing loss at the early time points but did produce some hearing loss at later time points. We discuss these results and begin to outline the next steps in the investigation of this agent.

The objectives of this study were to characterize patterns of dizziness seen after mild head trauma and to examine the diagnosis and treatment of this disorder.Prospective patient registry.Tertiary referral center.Fifty-eight cases of active duty and retired military personnel who sustained mild head trauma and had resultant dizziness.Vestibular evaluation, characterization by group, and treatment.Outcome measures include characterization of diagnosis types, patient distribution by diagnosis type, and patient outcome.Individuals suffering from dizziness after mild head injury were divided into three diagnostic groups. Forty-one percent of the individuals suffered from posttraumatic vestibular migraines, 28% of the individuals had posttraumatic positional vertigo, and 19% of the individuals were classified as posttraumatic spatial disorientation. The remaining 12% of the patients could not be characterized. The positional group had objective physical examination findings, which cleared with treatment in all cases. The migraine group of patients and the disorientation group of patients had distinct abnormalities of the vestibulo-ocular reflex (VOR) and the vestibulo-spinal reflex (VSR). Eighty-four percent of the migraine group demonstrated an improvement of these test results as compared with 27% of the disorientation group. Mean time to return to work was less than 1 week for the positional group, 3.8 weeks for the migraine group, and greater than 3 months for the disorientation group.Using our patient registry of individuals suffering from dizziness after mild head trauma, we were able to characterize the majority of these cases into one of three more specific diagnostic groups. We present diagnostic criteria, suggested treatment guidelines, and our prognostic data.

The search for a safe, effective treatment for the vertigo associated with Meniere’s disease has long been an important topic in otolaryngology. In recent years many groups have begun using intratympanic gentamicin to treat this vertigo. Although reported cure rates are as high as 90%, many questions remain regarding this type of treatment. Current limitations are the necessity for repeated treatments and a lack of clear dosing guidelines. In addition, the gentamicin must be delivered in a manner that allows maximal vestibulotoxic effect without injury to hearing. Until investigators can control the exact amount of medicine that is placed in the ear and have an understanding of the kinetics of gentamicin absorption, adequate dosing guidelines will be difficult to establish, and therapy will continue to rely on empiric data. We describe the use of a fibrin-based sustained-release vehicle, impregnated with gentamicin, injected into the middle ear of chinchillas. This allows for a prolonged effect without repeated dosing. Using this model, we studied the absorption kinetics of gentamicin at time points ranging from 8 hours to 1 week after injection. We used our findings to create a kinetics curve of gentamicin absorption. We discuss the shape and characteristics of this kinetics curve and examine the effects of the fibrin-based sustained-release vehicle and gentamicin on the middle ear. We noted no absorption in the contralateral (untreated ear) or blood. Through better understanding of the actions of gentamicin in this animal model, we hope to facilitate safer use of intratympanic medicines in our patient population and initiate programs for the use of this sustained-release vehicle in human beings. (Otolaryngol Head Neck Surg 1998;119:427-31.)