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The technique of inferior mastoidectomy-hypotympanic dissection, with preservation of the middle and inner ear structures, has been established for radical surgical removal of glomus tumors involving the skull base. In order to study the gross anatomic differences and correlate with the computed tomography (CT) scan, 20 human temporal bones were dissected and accurate measurements between vital structures were made. This study revealed a wide variation in distances between the neurovascular structures, whereas the distances between inner ear structures were not statistically different. This original study of critical distances of gross topographic anatomical structures and CT correlation is very helpful indeed in the understanding of variations found in the surgical removal of lesions involving this important and challenging area of the skull base. The inferior mastoidectomy-hypotympanic dissection has been performed in the removal of six suitable tumors involving the jugular bulb area. This technique, combined with upper cervical dissection, is very useful for the radical removal of such neoplasms with preservation of external and middle ear structures as well as the function of the facial, eighth, and other lower cranial nerves. [ABSTRACT FROM AUTHOR]

Background: The U.S. relies far too heavily on punitive criminal justice strategies to address problems that are better prevented and resolved through social and health services. The resulting harms are especially large and longstanding for people trapped in the failed War on Drugs. Philadelphia launched a Police Assisted Diversion (PAD) program to address the highest rates of poverty, incarceration, and fatal overdose among large cities in the U.S. PAD enables police officers to connect people with supportive services in many instances that would otherwise result in arrest or through outreach when no crime is suspected., Methods: We conducted semi-structured interviews with 30 clients, 15 police officers, and 12 other personnel involved with the program. Data were gathered in 2019 and 2020 and analyzed using standard qualitative methods., Results: PAD represents a new less-punitive model for responding to illegal purchasing of drugs, possession of drugs, prostitution, and retail theft in Philadelphia. Clients reported mostly positive experiences with the program, identifying the primary benefits as avoided arrest and relational support from affiliated service providers. Police officers expressed support for the program in principle but skepticism about its effects in practice, questioning the quality of available services. Program personnel and police officers described multi-sectoral collaboration as essential to addressing frequent and diverse logistical challenges, including overly restrictive eligibility criteria, mistrust between police and service providers, and coordination across different neighborhoods. Finally, all three groups suggested that people can only benefit from service linkages when they are ready to engage and that inadequate access to resources like housing limits program effectiveness., Conclusions: The PAD program is a promising public health intervention for diverting people away from punishment and towards services to address unmet social and health needs. But increasing investments in training and in other supportive services is essential to sustainable and transformational change., Competing Interests: Declarations of Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2021. Published by Elsevier B.V.)

Objective: Menière's disease (MD) is characterized by episodes of vertigo, tinnitus, and sensorineural hearing loss. In the setting of bilateral deafness due to MD alone or contralateral pathology, cochlear implantation (CI) improves hearing. Active MD is characterized by fluctuating auditory symptoms and vertigo; whereas remittance of vertiginous symptoms and severe, permanent sensorineural hearing loss characterizes the inactive disease state. This study evaluates outcomes for MD patients compared with the general CI population and assesses if disease activity affects implant outcomes., Study Design: Retrospective chart review., Setting: Tertiary referral center., Patients: Twenty-four patients with MD that received CI (7 active, 16 inactive, and 1 Probable Menière's), and 24 age-matched controls., Interventions: Cochlear implantation., Main Outcome Measures: Word Recognition Score, Sentence Recognition Score (SRS), and Speech Reception Threshold., Results: Best-aided preoperative and postoperative audiometric data were compared per ear between MD patients and controls and stratified by disease status using descriptive statistics with mixed-effects modeling. Patients with MD derived significantly more benefit from CI than controls when comparing differences between preoperative and postoperative levels for Word Recognition Score (12.2%, p = 0.0236), SRS (12.8%, p = 0.0375), and Speech Reception Threshold (-14.4 dB, p = 0.0188). Active disease status does not negatively impact CI outcomes and patients with active MD may benefit from greater gains in SRS (23.5%, p = 0.0107)., Conclusions: CI provides greater gains in functional hearing for patients with MD compared with age-matched controls. Patients with active MD seem to perform better with respect to SRS following CI than patients with inactive status.

Objective: To investigate any meaningful differences in hearing between patients with unilateral and bilateral enlarged vestibular aqueduct (EVA). EVA is a common radiological finding in children presenting with hearing loss. We hope to provide insight into the pathogenesis of EVA and provide further guidelines for unilateral EVA management. We hypothesized that hearing loss in unilateral EVA would be similar to that seen in bilateral EVA., Methods: A longitudinal retrospective study design was used. Three measures of hearing, pure tone average (PTA) word recognition score (WRS) and speech awareness threshold (SAT) and radiologic morphologies were tested for difference across unilateral versus bilateral ear EVA status. Linear mixed effects models were used to identify differences while accounting for time and multiple measurements per ear., Results: Using Cincinnati criteria, 89 ears fit inclusion criteria, 75 of which were from patients with bilateral EVA compared to 14 ears from patients with unilateral EVA. No significant differences across bilateral status were observed in audiological measurements. Models showed that speech recognition threshold (SRT) (p = 0.925), word recognition score (WRS)(p = 0.521) and pure tone average (PTA) of air and bone conduction from 250 to 4000 Hz (p = 0.281-0.933) were not statistically different with respect to bilateral status. Wilcoxon rank-sum tests showed no statistical difference in vestibular aqueduct width or operculum size (VA)(p = 0.234, p = 0.623). Each year after the first audiogram was associated with significantly greater SRT (p = 0.003) decreased WRS (0.014) and increased PTA (0.003.). Greater midpoint width was associated with significantly lower SRT (p = 0.004) WRS (<0.001) and PTA (<0.001.) CONCLUSION: Our results indicate no statistically significant difference in hearing ability with respect to bilateral EVA status, suggesting that unilateral EVA patients require close follow-up. Our results also demonstrate the progressive nature of EVA and a relationship between VA midpoint width and hearing loss severity., (Copyright © 2018 Elsevier B.V. All rights reserved.)

Purpose: The purpose of this work is to explore audiometry following cochlear implantation (CI) in patients with enlarged vestibular aqueduct (EVA) and to investigate the effects of inner ear morphological variation on post CI audiometry., Methods: This was a retrospective review of both natural and cochlear-implant-aided audiometry results, using all available measurements in a mixed-effects model accounting for longitudinal change and the grouping structure of ears. Patients who visited our tertiary academic medical center between 2000 and 2016 were identified as having EVA according to Cincinnati criteria on radiological examination; patients eligible for CI were then selected for analysis., Results: Multivariable modeling showed a statistically significant hearing improvement in ears with EVA undergoing CI with regards to pure tone average (-64.0 dB, p < 0.0001), speech reception threshold (-57.90 dB, p < 0.0001), and word score (34.8%, p > 0.0001). Vestibular aqueduct midpoint size and the presence of incomplete partition type II (IP II) did not have significant independent associations with audiometric findings. However, multivariable modeling revealed a statistically significant interaction between IP II and CI such that IP II ears demonstrated a decrease in WS improvement of 30.2% (p = 0.0059) compared to non-IP II ears receiving CI., Conclusion: There is a statistically significant audiometric benefit to ears with EVA receiving CI. Morphology, specifically the presence of IP II, may hinder CI benefit in terms of word score however this finding needs clinical validation. This data improves personalization of surgical counseling and planning for patients with EVA considering CI., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Purpose: The purpose of this work is to identify the role of incomplete partition type II on hearing loss among patients with enlarged vestibular aqueduct (EVA)., Background: EVA is a common congenital inner ear malformation among children with hearing loss, where vestibular aqueduct morphology in this population has been shown to correlate to hearing loss. However, the impact of incomplete partition between cochlear turns on hearing loss has not been, despite meaningful implications for EVA pathophysiology., Methods: A retrospective review of radiology reports for patients who had computed tomography (CT) scans with diagnoses of hearing loss at a tertiary medical center between January 2000 and June 2016 were screened for EVA. CT scans of the internal auditory canal (IAC) for those patients with EVA were examined for evidence of incomplete partition type II (IP-II), measurements of midpoint width and operculum width a second time, and patients meeting Cincinnati criteria for EVA selected for analysis. Statistical analysis including chi-square, Wilcoxon rank-sum, and t-tests were used to identify differences in outcomes and clinical predictors, as appropriate for the distribution of the data. Linear mixed models of hearing test results for all available tests were constructed, both univariable and adjusting for vestibular aqueduct morphometric features, with ear-specific intercepts and slopes over time., Results: There were no statistically significant differences in any hearing test results or vestibular aqueduct midpoint and operculum widths. Linear mixed models, both univariable and those adjusting for midpoint and operculum widths, did not indicate a statistically significant effect of incomplete partition type II on hearing test results., Conclusions: Hearing loss due to enlarged vestibular aqueduct does not appear to be affected by the presence of incomplete partition type II. Our results suggest that the pathophysiological processes underlying hearing loss in enlarged vestibular aqueduct may not be a result of cochlear malformation, and instead are more likely to involve vestibular aqueduct or cellular and molecular-level mechanisms of hearing loss., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Importance: Elucidating the relationship between vestibular aqueduct size and hearing loss progression may inform the prognosis and counseling of patients who have an enlarged vestibular aqueduct (EVA)., Objectives: To examine the association between vestibular aqueduct size and repeated measures of hearing loss., Design, Setting, and Participants: For this retrospective medical record review, 52 patients with a diagnosis of hearing loss and radiologic diagnosis of EVA according to the Valvassori criterion were included. All available speech reception threshold and word recognition score data was retrieved; mixed-effects models were constructed where vestibular aqueduct size, age at diagnosis of hearing loss, and time since diagnosis of hearing loss were used to predict repeated measures of hearing ability. This study was performed at an academic tertiary care center., Exposures: Variable vestibular aqueduct size, age at first audiogram, length of time after first audiogram., Main Outcomes and Measures: Speech reception threshold (dB) and word recognition score (%) during routine audiogram., Results: Overall, 52 patients were identified (29 females [56%] and 23 males [44%]; median age at all recorded audiograms, 7.8 years) with a total of 74 ears affected by EVA. Median (range) vestibular aqueduct size was 2.15 (1.5-5.9) mm, and a median (range) of 5 (1-18) tests were available for each patient. Each millimeter increase in vestibular aqueduct size above 1.5 mm was associated with an increase of 17.5 dB in speech reception threshold (95% CI, 7.2 to 27.9 dB) and a decrease of 21% in word recognition score (95% CI, -33.3 to -8.0 dB). For each extra year after a patient's first audiogram, there was an increase of 1.5 dB in speech recognition threshold (95% CI, 0.22 to 3.0 dB) and a decrease of 1.7% in word recognition score (95% CI, -3.08 to -0.22 dB)., Conclusions and Relevance: Hearing loss in patients with an EVA is likely influenced by vestibular aqueduct midpoint width. When considering hearing loss prognosis, vestibular aqueduct midpoint width may be useful for the clinician who counsels patients affected by EVA.

Background: Tinnitus is a source of considerable morbidity, and neuromodulation has been shown to be a potential treatment option. However, the location of the primary auditory cortex within Heschl gyrus in the temporal operculum presents challenges for targeting and electrode implantation., Objective: To determine whether anatomic targeting with intraoperative verification using evoked potentials can be used to implant electrodes directly into the Heschl gyrus (HG)., Methods: Nine patients undergoing stereo-electroencephalogram evaluation for epilepsy were enrolled. HG was directly targeted on volumetric magnetic resonance imaging, and framed stereotaxy was used to implant an electrode parallel to the axis of the gyrus by using an oblique anterolateral-posteromedial trajectory. Intraoperative evoked potentials from auditory stimuli were recorded from multiple electrode contacts. Postoperatively, stimulation of each electrode was performed and participants were asked to describe the percept. Audiometric analysis was performed for 2 participants during subthreshold stimulation., Results: Sounds presented to the contralateral and ipsilateral ears produced evoked potentials in HG electrodes in all participants intraoperatively. Stimulation produced a reproducible sensation of sound in all participants with perceived volume proportional to amplitude. Four participants reported distinct sounds when different electrodes were stimulated, with more medial contacts producing tones perceived as higher in pitch. Stimulation was not associated with adverse audiometric effects. There were no complications of electrode implantation., Conclusion: Direct anatomic targeting with physiological verification can be used to implant electrodes directly into primary auditory cortex. If deep brain stimulation proves effective for intractable tinnitus, this technique may be useful to assist with electrode implantation., Abbreviations: DBS, deep brain stimulatorEEG, electroencephalographyHG, Heschl gyrus.

There is a need for high-quality implantable microphones for existing semiimplantable middle-ear hearing systems and cochlear prosthesis to make them totally implantable, thus overcoming discomfort, inconvenience, and social stigma. This paper summarizes and compares the results of an in-vitro study on three design approaches and the feasibility of using microelectromechanical system acoustic sensors as implantable microphones to convert the umbo vibration directly into a high-quality sound signal. The requirements of sensors were selected including the ability to withstand large body shocks or sudden changes of air pressure. Umbo vibration characteristics were extracted from literature and laboratory measurement data. A piezoelectric vibration source was built and calibrated to simulate the umbo vibration. Two laboratory models of the acoustic sensor were studied. The model-A device, using electrets-microphone as the sensor, was designed and tested in the laboratory and on temporal bones. The results verify that the laboratory measurement is consistent with the temporal bone characterization and achieves a near flat frequency response with a minimum detectable signal of a 65-dB sound-pressure-level (SPL) at 1 kHz. The model-B sensor was then designed to increase the sensitivity and provide an easy mounting on umbo. The model-B device can detect 40-dB SPL sound in the 1-2 kHz region, with 100-Hz channel bandwidth. The results of model-A and model-B displacement sensors and the acceleration sensor are summarized and compared. A preliminary design of the implantable displacement sensor for totally implantable hearing-aid systems is also presented.

Objective: This study evaluates the U.S. experience with the first 40 patients who have undergone audiologic rehabilitation using the BAHA bone-anchored hearing aid., Study Design: This study is a multicenter, nonblinded, retrospective case series., Setting: Twelve tertiary referral medical centers in the United States., Patients: Eligibility for BAHA implantation included patients with a hearing loss and an inability to tolerate a conventional hearing aid, with bone-conduction pure tone average levels at 60 dB or less at 0.5, 1, 2, and 4 kHz., Intervention: Patients who met audiologic and clinical criteria were implanted with the Bone-Anchored Hearing Aid (BAHA, Entific Corp., Gothenburg, Sweden)., Main Outcome Measures: Preoperative air- and bone-conduction thresholds and air-bone gap; postoperative BAHA-aided thresholds; hearing improvement as a result of implantation; implantation complications; and patient satisfaction., Results: The most common indications for implantation included chronic otitis media or draining ears (18 patients) and external auditory canal stenosis or aural atresia (7 patients). Overall, each patient had an average improvement of 32+/-19 dB with the use of the BAHA. Closure of the air-bone gap to within 10 dB of the preoperative bone-conduction thresholds (postoperative BAHA-aided threshold vs. preoperative bone-conduction threshold) occurred in 32 patients (80%), whereas closure to within 5 dB occurred in 24 patients (60%). Twelve patients (30%) demonstrated 'overclosure' of the preoperative bone-conduction threshold of the better hearing ear. Complications were limited to local infection and inflammation at the implant site in three patients, and failure to osseointegrate in one patient. Patient response to the implant was uniformly satisfactory. Only one patient reported dissatisfaction with the device., Conclusions: The BAHA bone-anchored hearing aid provides a reliable and predictable adjunct for auditory rehabilitation in appropriately selected patients, offering a means of dramatically improving hearing thresholds in patients with conductive or mixed hearing loss who are otherwise unable to benefit from traditional hearing aids.

We conducted a retrospective study of 29 patients who had undergone stapedectomy for otosclerosis to determine how well their subjective perceptions of hearing improvement correlated with objective audiometric measurements. Patients expressed their assessments of hearing function by completing two versions of the Hearing Disability and Handicap Scale (HDHS). One version of the HDHS was based on patients' retrospective recollections of their hearing impairment prior to surgery, and the other reflected their assessment of their current function. We evaluated these HDHS data both separately and in conjunction with pre- and postoperative audiometric findings. Following surgery, the group's mean pure-tone average improved significantly, from 58 to 27 dB--that is, the average patient had a moderately severe hearing loss preoperatively and only a mild hearing loss postoperatively. Significant improvement was also reflected in the difference between the mean pre- and postoperative HDHS scores, although some patients indicated that they experienced almost no improvement. Overall, our findings indicated that there was a relationship between objective and subjective assessments of hearing improvement following surgery, but that it was weak. Although most patients perceived significant improvement, the degree of that perceived improvement cannot be predicted from the pure-tone audiogram. We conclude, therefore, that a significant difference between audiometric findings and HDHS self-assessments is useful in identifying patients who might benefit from additional counseling and/or aural rehabilitation.

Background: Outpatient tympanomastoidectomy is common in many medical centers. However, failure of same-day discharge is often the result of postoperative nausea and vomiting (PONV). Many times this leads to hospital admission after tympanomastoidectomy, and it is often difficult to predict before surgery whether PONV will be an issue that impedes same-day discharge., Objective: To determine the clinical factors correlated with the incidence of PONV requiring hospital admission after chronic ear surgery by hypothesizing that the complexity of a particular case, as measured using a 10-point scale, is predictive of surgical time or failure of same-day hospital discharge., Study Design: Retrospective medical chart review of 103 patients having mastoidectomy with tympanoplasty for chronic otitis media over a 2-year period., Methods: We recorded patient age, clinical data, surgical times, types of agents used for induction and maintenance of anesthesia, use of prophylactic antiemetic drugs, types and doses of analgesic agents, and PONV. Univariate and multivariate logistic regression analyses were performed to determine which variables were associated with PONV that required hospital admission., Results: One third of patients studied were safely discharged from the hospital the day of surgery, and 92% were discharged within 23 hours. The most common cause for observation admission to the hospital was PONV. The only variable in multivariate analysis that significantly correlated with PONV mandating hospital admission after tympanomastoid surgery was a history of motion sickness or PONV (odds ratio, 5.21; P =.02). Although severity of disease did not correlate with length of hospital stay, it directly correlated with length of surgery., Conclusions: A history of PONV or motion sickness is predictive of PONV and length of hospital stay. Routine planning for a 23-hour overnight observation stay seems warranted for all patients undergoing tympanomastoidectomy, despite severity of disease.

Spondyloepiphyseal dysplasia is a disorder characterized by abnormalities of growth. Previous studies of this disorder have identified a significant incidence of associated hearing loss. Hearing loss has been reported to occur in 25 to 30% of affected patients. To date, all reports of associated hearing loss have indicated the presence of a sensorineural component. In this article, we report the case of a child who was diagnosed with spondyloepiphyseal dysplasia congenita and who was found to have a significant conductive hearing loss with a Carhart's notch, indicating the likely presence of stapes footplate fixation. We also review the diagnosis of this condition and the literature associated with hearing loss as it occurs with this disorder.

Tissue engineered human cartilage is presently being utilized in clinical research programs in a variety of medical disciplines including otolaryngology, urology, and orthopedics. In this study, we present a new methodology for auricular cartilage harvest that can be applied to tissue engineering. Eight 16-week-old pigs were subjected to a traditional open cartilage harvest technique involving suture closure, while the other ear was subjected to the closed stitchless cartilage harvest, using a 12-gauge core biopsy needle. Surgical time was significantly (p < 0.0001) shorter (3.5 +/- 2.8 min for closed vs. 14.4 +/- 5 min for open), and no sutures where utilized in the closed technique. Sample weights were significantly (p < 0.00001) greater (0.115 +/- 0.028 g vs. 0.045 +/- 0.005 g) for the closed techniques. However, the minimally invasive closed technique had fewer incidents of bruising, hematoma, long-term stitch abscess, and scarring. Cell culture data shows no disadvantage to either technique with regards to cell growth characteristics. Final histological data from donor ears indicates favorable results with the minimally invasive technique. This technique preserves cell viability and isolation efficiency while decreasing surgical time and lessening postoperative complications.

Objective: To assess the practicality and utility of the traditional classification system for temporal bone fracture (transverse vs. longitudinal) in the modern Level I trauma setting and to determine whether a newer system of designation (otic capsule sparing vs. otic capsule violating fracture) is practical from a clinical and radiographic standpoint., Methods: The University of Massachusetts Medical Center Trauma Registry was reviewed for the years 1995 to 1997. Patients identified as sustaining closed head injury were reviewed for basilar skull fracture and temporal bone fracture. Clinical and radiographic records were evaluated by using the two classification schemes., Results: A total of 2,977 patients were treated at the trauma center during this time. Ninety (3%) patients sustained a temporal bone fracture. The classic characterization of transverse versus longitudinal fracture (20% vs. 80%, respectively) was unable to be determined in this group; therefore, clinical correlation to complications using that paradigm was not possible. By using the otic capsule violating versus sparing designation, an important difference in clinical sequelae and intracranial complications became apparent. Compared with otic capsule sparing fractures, patients with otic capsule violating fractures were approximately two times more likely to develop facial paralysis, four times more likely to develop CSF leak, and seven times more likely to experience profound hearing loss, as well as more likely to sustain intracranial complications including epidural hematoma and subarachnoid hemorrhage., Conclusion: The use of a classification system for temporal bone fractures that emphasizes violation or lack of violation of the otic capsule seems to offer the advantage of radiographic utility and stratification of clinical severity, including severity of Glasgow Coma Scale scores and intracranial complications such as subarachnoid hemorrhage and epidural hematoma.

Purpose: To report an unusual case of an intracranial extension of Merkel cell carcinoma originating in the external ear canal and causing neurological deficits., Case Report: An 86-year-old woman, with a 16-month history of an external auditory canal mass, presented with hemiparesis, facial paralysis, and obtundation. Radiographic images showed an intracranial mass extending into the petrous bone., Method: The patient had a craniotomy for intracranial tumor resection with concurrent mastoidectomy for facial nerve decompression and obtundation and hemiparesis were resolved. Residual tumor was subsequently treated with adjuvant radiation therapy, and facial nerve function consequently improved., Conclusion: Merkel cell tumors rarely invade the intracranial compartments. Residual tumor and neurological deficits may respond to adjuvant radiation therapy.

Injury to the facial nerve in the temporal bone presents a challenge to the recovery of nerve function, in that the fallopian canal in which it lies is poorly vascularized. This study was designed to determine if wrapping an intratemporal facial nerve defect repaired with a cable graft with a well-vascularized temporoparietal fascial (TPF) flap would improve facial nerve regeneration. To evaluate this question, a defect was created in the intratemporal left facial nerve of 10 rabbits. All nerves were repaired using cable grafts. In 5 animals, the nerve graft was wrapped with temporoparietal fascia, whereas in the other 5 rabbits it was not. Three additional animals underwent exposure only. The contralateral nerve served as a control in all animals. Quantitative analysis of the nerve graft 12 weeks after repair revealed greater recovery of original fiber diameter and myelin sheath thickness in TPF flap-wrapped repairs. Histological evidence of improved neural regeneration and functional nerve recovery was also seen in the repairs where the TPF flap was utilized. Nerve conduction and electromyographic studies of the cable-grafted nerve at 6 and 12 weeks were equivocal, however.

Intralabyrinthine schwannoma (ILS) is an infrequent tumor that arises in isolation within the periphery of the temporal bone. Only 32 cases have been reported to date in the literature, of which 12 were discovered at autopsy. Prior to the advent of gadolinium-enhanced magnetic resonance imaging (Gd-MRI), only 1 ILS had been diagnosed preoperatively. However, after Gd-MRI became a common modality, 5 ILSs were imaged. Two additional cases are reported that were discovered during labyrinth-destructive surgery despite normal Gd-MRI findings. Possible explanations for and potential ramifications of nonenhancing ILS are discussed.

Sporadic reports throughout the literature have documented the spontaneous return of facial function following deliberate intraoperative sacrifice of the facial nerve. Trigeminal reinnervation of the facial muscles has been suggested as one possible mechanism for this occurrence. Evidence for the phenomenon of trigeminal neo-neurotization has been documented experimentally. The case of a 62-year-old woman who underwent total left parotidectomy with transection of a large facial nerve segment is presented in order to provide further clinical evidence supporting trigeminal neo-neurotization of the facial nerve. Despite the lack of any efforts to reinnervate the patient or graft the facial nerve defect, the patient spontaneously developed return of facial function. Postoperative clinical and electrical testing in this case supports trigeminal-facial reinnervation as the cause for return of facial function. The case report is summarized with a brief discussion, and the relevant literature is thoroughly reviewed.

Objective: This article highlights the clinical presentation and treatment issues of ganglionic hamartoma of the internal auditory canal and emphasizes the similarity of this lesion to acoustic neuroma regarding its audiologic and radiographic characteristics., Study Design: This article is composed of case reports and a literature review., Setting: The study was performed at a university hospital/tertiary referral center., Patient: A patient with biopsy-proven ganglionic hamartoma of the acoustic nerve was studied., Intervention: Intervention consisted of surgical therapy., Main Outcome Measure: The main outcome measure was clinical evaluation., Results: The result was successful removal of lesions with facial nerve preservation., Conclusions: An intracanalicular ganglionic hamartoma resulted in progressive sensorineural hearing loss and magnetic resonance imaging findings suggestive of small acoustic neuroma. This lesion, composed of an admixture of ganglion cells, fibroadipose-tissue, and normal myelinated axons, although rare, should be added to the differential diagnosis of internal auditory canal lesions.

The subtemporal transpetrous approach to the petroclival region uses a combination of techniques, including a petrosectomy and a subtemporal and suboccipital craniotomy. Ligation of the greater petrosal sinus, sigmoid sinus, and retraction of the temporal lobe affords wide exposure to the petroclival region and ventral brainstem and minimizes the need for facial nerve translocation. This approach has been successfully used in the management of 10 large tumors of the region, including chondrosarcomas, chordomas, meningiomas, and schwannomas. The history and evolution of this technique and its relation to other similar approaches is discussed.

Patients with satisfactory facial nerve function [House-Brackmann (HB) grade I or II] immediately after acoustic neuroma surgery are at risk for delayed facial paralysis. To study this problem, 255 consecutive patients who underwent acoustic neuroma excision with facial nerve preservation were identified. Delayed facial paralysis occurred in 62 (24.3%) patients; 90% ultimately recovered to their initial postoperative HB grade, and 98.3% recovered to within one grade of their initial HB level. Paralysis occurred at an average of 3.65 postoperative days (range, 1-16 days). The average time to maximal recovery for those with changes of 1, 2, 3, and 4 HB grades was 5.6, 21.5, 39.8, and 50.5 weeks, respectively. The early onset of paralysis (< 48 h after surgery) resulted in shorter average recovery times. Of patients who demonstrated nerve deterioration to grades IV-VI, 20 of 38 required tarsorrhaphy or gold-weight placement. We conclude that the over-whelming majority of patients with delayed facial paralysis after acoustic neuroma surgery do eventually recover to their postoperative HB grade. The magnitude and timecourse of delayed facial paralysis are predictive factors for subsequent recovery.

Asymmetric or unilateral sensorineural hearing loss is an important hall-mark of various forms of sensorineural hearing loss. Animal research regarding the etiology and mechanism of these disorders often requires hearing estimates in each ear of experimental animals. Monaural auditory testing of animals with experimentally induced unilateral hearing loss therefore requires prior knowledge of interaural attenuation (IAA) to facilitate contralateral masking. The purpose of this study is to describe a method of determining frequency-specific IAA data and to present relevant information obtained in the rats--a frequently used animal in studies of acquired sensorineural hearing loss. A custom-made sound source was designed to accomplish threshold determination at important frequencies in the dynamic range of rats. Six male Long-Evans rats were surgically monauralized by ablation/obliteration of the cochlea. Auditory brainstem response (ABR) thresholds were determined for ipsilateral and contralateral presentations of 2-kHz, 10-kHz, and 40-kHz toneburst. IAA was calculated by subtracting the frequency-specific ABR threshold obtained from the normal ear from that obtained following tone presentation to the 'dead' ear, and was found to average 65.0 +/- 10.5 dB at 2 kHz, 45.0 +/- 8.4 dB at 10 kHz, and 47 +/- 15.1 dB at 40 kHz (+/- standard deviation). Using data obtained from the animal demonstrating the smallest IAA, masking is not needed until a threshold asymmetry of 50 dB at 2 kHz and 30 dB at 10 and 40 kHz is observed. In order to obtain bilateral auditory threshold information in any animal model of asymmetric hearing loss, data regarding IAA are needed in order to know when to apply contralateral masking and therefore avoid crossover stimulation of the non-test ear. The protocol presented herein provides guidelines for use in any animal model of sensorineural hearing loss which may demonstrate unilateral or asymmetric deficits.

After routine canal wall down mastoidectomy, local muscle flaps with and without bone paté, cartilage and fascia are the standard techniques available to otologists wishing to obliterate the mastoid and reconstruct the external auditory canal. Reconstructive options for temporal bone defects after extirpative surgery for cancer, osteoradionecrosis, and revision surgery for chronic granulomatous otitis media, however, are few. Although the neighboring temporoparietal fascia flap (TPFF), based on the superficial temporal vessels, has been frequently employed for auricular reconstruction, its versatility in temporal bone reconstruction has not been widely explored. The TPFF has recently been employed at our institution in 11 patients who presented with a variety of reconstructive problems, including defects after temporal bone resection, surgery for malignant otitis externa, and revision mastoid surgery. Follow-up in these patients ranged from 1 to 43 months (average 18.4 months) and surgical objectives of achieving a dry mastoid bowl, fully epithelialized canal, and/or reduction of mastoid cavity volume was attained in 100% of cases. The TPFF offers many advantages to the otologic surgeon when faced with reconstruction dilemmas that center around a poorly vascularized mastoid cavity and temporal bone. The TPFF is a reliable source of local well-vascularized tissue that is extremely pliable and facilitates both hearing and nonhearing preservation temporal bone reconstruction.

Deleterious effects of Teflon strand placement during microvascular decompression (MVD) for hemifacial spasm are rare. In this report, a patient who had previously undergone suboccipital MVD for hemifacial spasm presented 3 years postoperatively with a progressive asymmetric sensorineural hearing loss and magnetic resonance imaging evidence of an enlarging ipsilateral gadolinium enhancing 1-cm cerebellopontine angle lesion. At surgery a granuloma was found displacing the structures of the internal auditory canal. Histologically, evidence of a Teflon fiber-induced giant cell granuloma was identified. This paper reviews the literature of Teflon-induced histopathology as it relates to posterior fossa MVD surgery, as well as its relation to this previously unreported complication.

Temporalis muscle transposition is a reliable surgical technique for the reanimation of patients with long-standing facial paralysis. It is often employed when facial nerve reinnervation via crossover or cable grafting is not possible. Temporalis muscle transposition can also be used for the immediate treatment of complete facial paralysis due to insults leaving the facial nerve anatomically intact but requiring a prolonged recovery time (more than 1 year). Because temporalis muscle transposition does not interfere with neuronal regeneration, it may be employed early in the management of complete facial paralysis when recovery is predicted to be extended and incomplete. The authors report their experience with early temporalis muscle transposition in the management of facial paralysis in 56 patients with an anatomically intact facial nerve. More than 90% of these patients achieved improved symmetry at rest as well as purposeful movement at the corner of the mouth. In the last 30 patients, the temporoparietal fascial flap was simultaneously harvested and successfully used to obliterate the donor site defect. In conjunction with the immediate implantation of a gold weight in the ipsilateral upper eyelid, this approach to the early management of facial paralysis helps reduce the period of facial disability from years to weeks in a select group of patients.

The term "endolymphatic sac tumor" (ELST) was coined to identify the likely origin of aggressive papillary tumors of the temporal bone. To evaluate the validity of this designation, the temporal bone collection at the Massachusetts Eye and Ear Infirmary was accessed in an effort to determine the pathologic relationship between these tumors and the endolymphatic sac. The search resulted in the identification of a de-novo papillary epithelial lesion arising within the confines of the endolymphatic sac in a patient with von Hippel-Lindau (VHL) disease who harbored a large, destructive ELST in the opposite temporal bone. This finding provides the most substantial evidence to date regarding the origin of the ELST and the accuracy of its nomenclature. Seven additional clinical cases of ELST were identified and analyzed in order to define the natural history of these tumors. All patients had a history of sensorineural hearing loss diagnosed an average of 10.6 years prior to tumor discovery. The presence of a polypoid external auditory canal mass, facial paralysis, and evidence of a destructive mass arising on the posterior fossa surface of the temporal bone were common physical and radiographic findings. The management of these patients, as well as those who are probably prone to such tumors (i.e., VHL patients), is discussed.

monostotic. Although most patients had a conductive hearing loss, 17% of patients demonstrated profound sensorineural hearing loss ascribable to the lesion, and facial nerve sequelae were noted in nearly 10% of cases. Cholesteatoma complicated almost 40% of cases, usually in the form of a canal cholesteatoma. Ten new cases of temporal bone fibrous dysplasia are described not only to further clarify the spectrum of otologic sequelae but also to help illustrate available treatment options. In addition, this report documents, in three new cases, the previously undescribed progression of conductive hearing loss to profound sensorineural deafness secondary to fibrous dysplasia.

Objective: Photodynamic therapy (PDT) is a promising new treatment modality for head and neck cancer that is based on the uptake of a systemically administered photosensitizer in tumor tissue and local illumination of the lesion by a high-intensity visible light source, typically a tunable argon-pumped dye laser. We developed a new photosensitizer named silicon phthalocyanine [SiPc(OH) OSi(CH3)2(CH2)3N(CH3)2, abbreviated as SiPc IV], which yields superior PDT responses in vitro and in vivo compared with other clinically used photosensitizers. However, tumor regrowth following SiPc IV-based PDT is still a therapeutic problem. The benzamide derivatives, for example, have been shown to enhance tumor ablation when used during radiotherapy and chemotherapy. Therefore, we used metoclopramide hydrochloride, a benzamide derivative, to evaluate its effects on PDT response., Design: Intradermally injected human squamous cell carcinoma cells were grown to 40 to 80 mm3 in athymic nude mice and irradiated with 675-nm light (75 J/cm2, 75 mW/cm2) 24 hours after the intraperitoneal injection of SiPc IV (1.0 mg/kg). Metoclopramide hydrochloride (2 to 48 mg/kg) was injected intraperitoneally 1 hour before and 24 and 48 hours after irradiation., Results: Tumors exposed to PDT alone showed 80% to 90% tumor regression with regrowth in most animals within 20 days. Tumors treated with metoclopramide hydrochloride (48 mg/kg) plus PDT demonstrated 100% tumor regression without regrowth up to the time of killing (150 days). No observable toxic effects were clinically apparent with the high doses of metoclopramide., Conclusions: Our results show that administering metoclopramide in combination with PDT may be a promising approach to the management of head and neck cancer.

Lichtenstein [1] in 1938 coined the term fibrous dysplasia to describe a disorder characterized by the progressive replacement of normal bone elements by fibrous tissue. Histopathologically, these lesions consist of an abnormal proliferation of fibrous elements intermixed with haphazardly arranged trabeculae of woven bone. The disease can involve any bone in the body. In the head and neck, the skull and facial bones are involved in 10-25% of cases of monostotic fibrous dysplasia and in 50% of the polyostotic variety. Involvement of the temporal bone, however, is relatively rare, and only 53 cases have been reported. The three major radiographic classifications of fibrous dysplasia are pagetoid, sclerotic, and cystic. Any of these types may involve the temporal bone and related structures, including the external canal, middle ear, jugular foramen, or, rarely, the otic capsule. In this essay, we illustrate the radiographic features of the disease based on our experience with seven cases, seen at our institution since 1977, of fibrous dysplasia involving the temporal bone.

Pulsatile tinnitus, hearing loss, lower cranial nerve deficits, and radiographic evidence of a vascular lesion of the jugular foramen have been considered diagnostic of a glomus jugulare tumor. Angiographic evidence of a blood supply from the external carotid artery system, including the ascending pharyngeal artery, further substantiates this diagnosis. This diagnostic algorithm for tumors of the jugular fossa is usually followed by either a surgical exenteration of a presumed glomus jugulare tumor via an infratemporal fossa approach or radiation therapy in selected patients. Pre-treatment biopsy of such lesions is typically not done, nor is it recommended widely in the literature. As demonstrated in this report, a number of lesions, including hemangiopericytoma and extramedullary plasmacytoma presenting in the jugular foramen can mimic glomus jugulare tumors in all aspects of their clinical and radiographic presentation. Omission of a pre-treatment biopsy can lead to a treatment plan appropriate for glomus tumors but suboptimal for these rare pathologic entities. A pre-treatment biopsy of lesions of the jugular foramen by exploratory tympanotomy or postauricular mastoidotomy provides a pathologic diagnosis on which to base treatment of lesions of the jugular foramen, without adding substantial morbidity or decreasing the chances of cure.

During the years 1980 through 1990, 247 patients underwent parotidectomy at our institution for the removal of primary parotid lesions. Charts were reviewed in an effort to document the distribution of pathology in patients undergoing parotidectomy and the histopathology from each case was organized and tallied by virtue of the final specific diagnoses. An additional goal of this study was to evaluate the efficacy of pre-operative fine-needle aspiration biopsy (FNAB) and frozen section pathology in accurately predicting final histopathology. In our series, 86.7% of lesions were found to be benign and 13.3% were malignant in nature. When compared to final pathologic findings, FNAB yielded a diagnostic accuracy rate of 89.3% with a 2.1% false negative rate with regards to pre-operative detection of malignancy. Frozen section biopsy was found to have a diagnostic accuracy of 94.1% and also demonstrated a 2.1% false-negative rate. We believe these studies are indeed complementary to each other, as reflected in the 96.2% diagnostic accuracy achieved with a combination of FNAB and frozen section biopsy information. This report will review the patterns of misdiagnosis for each modality of diagnostic testing and present the parotid histopathology found over a 10-year period.