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During a 10-year period (1984-1994) 1229 stapes operations for otosclerosis were performed at our respective institutions by experienced surgeons well trained in the various techniques. Procedures included 691 stapedectomies, 234 small-fenestrae stapedotomies, and 304 revision operations. These primary and revision cases resulted in 20 ears with severe sensorineural hearing loss or anacusis noted during the immediate postoperative period. This article will critically evaluate those procedures that resulted in profound hearing loss and attempt to determine possible reasons for this occurrence. It is hoped that these data will allow surgeons to identify before and/or during surgery patients at risk for development of this complication and therefore decrease the overall morbidity rate of this exacting procedure.

Chylous fistulas are an infrequent result of injury to the thoracic duct during radical neck dissection. Leakage of lymph from a fistula which is allowed to persist will cause such serious postoperative problems as metabolic deficiencies, flap elevation, suture breakdown with hemorrhage, and infection. There appears to be no valid justification for extended conservative management if it fails to slow the leak within 48 hours. We recommend prompt exploration of the wound with an operating microscope and microsurgical ligation of the lacerated duct with nonabsorbable sutures.

Utrasonic irradiation of the labyrinth via the round window is effective in controlling otological vertigo. This method of surgical management for incapacitating vertigo is presented with demonstrative intraoperative electronystagmograms and irradiated cat neuro-epithelium. Such data suggest that more intense irradiation doses than previously reported should be applied to effectively destroy the diseased labyrinthine end organs. Precise end points of destructive irradiation are defined by characteristic intraoperative electronystagmograms. The authors suggest this is an ideal procedure when the situation of an unaffected cochlea, coexisting with a diseased labyrinth, requires a minimally invasive, destructive procedure which preserves hearing while eradicating vertigo.

Anesthesia of the tympanic membrane and ear canal by the use of iontophoresis of local anesthetics is a painless and safe method of anesthesia for office myringotomy and polyethylene tube insertion, and possibly for surgical use as well. With the use of guinea pig models, the introduction of 4% lidocaine hydrochloride solution in the middle ear space with iontophoresis revealed no toxic effects on the eighth nerve, and epinephrine hydrocloride potentiates the effects of lidocaine and has no protective mechanism on the eighth nerve function.

Diagnostic levels of pulsed ultrasound were applied abdominally over the uteri of pregnant rats for five minutes daily during the first 20 days of gestation. The average energy output of the ultrasound machine at the optimum focal length of the transducer (5.4 cm) was 7.2 mW/sq cm. Postnatal auditory evoked potentials demonstrated a significant alteration in the offspring of the treated animals when compared with similarly treated, but nonexposed controls. This alteration only occurred in the high frequency range. Neither light nor electron microscopy revealed significant morphologic alterations in the cochlear elements of the exposed offspring. Although a cochlear deficit occurred in a range known to be important to the rat's hearing, several issues make this data reassuring to clinicians using diagnostic levels of pulsed ultrasound: the total amount of ultrasound exposure was higher than would be expected with human use, the defect was mild, and the absence of clear-cut morphologic abnormalities may indicate the presence of a minimal, or even reversible, defect.

By retrospective analysis of 35 surviving gunshot injuries to the temporal bone and by presentation of 6 representative cases, the management and reconstructive procedures of these injuries in the Tulane University affiliated hospitals are presented. The most frequent single injury was facial nerve paralysis (16 cases), followed by external canal injury and conductive hearing loss. Anacusis occurred in 12 cases. In conductive hearing loss the intact posterior wall tympanoplasty with mastoidectomy (16 cases), or the modified radical mastoidectomy (5 cases), allowed middle ear reconstruction. Transmastoid facial canal decompression, combined with the above procedures or with a middle fossa craniotomy, was performed in 6 cases. Delayed facial reconstruction (5 cases) utilized microneural anastomosis between facial-facial and hypoglossal-facial nerves and fascia lata slings. Intracranial complications of thrombosis of internal carotid artery, dural venous lacerations, temporal lobe aphasia, bitemporal hemianopsia, cerebral abscesses and meningitis are also discussed.

This paper describes the experience with subtotal supraglottic laryngectomy for laryngeal carcinoma at the Department of Otolaryngology of the Tulane University School of Medicine. Of 36 patients, 32 (89%) had local control of diseases at one year. Of 27 patients followed up for at least three years, 22 (81%) are free of disease. Postoperative aspiration was the most frequent complication, but was a serious problem in only one patient. Because of the significant functional advantage of partial laryngectomy, the high rate of disease control, and an acceptable complication rate, we believe supraglottic laryngectomy is the procedure of choice for laryngeal carcinoma in selected patients.

This case of otitic hydrocephalus emphasizes a complication of ear disease which is rarely seen in modern otologic practice. The diagnosis and treatment of this entity have been reviewed in detail. Although the mechanism of this hydrocephalus is unknown, several theories have been presented.

A series of 54 patients treated for frontal sinus fractures at Charity Hospital, New Orleans, from 1967-77 is presented. There were a large number of suppurative complications related to the various medical and surgical managements. Initial treatments included: observation (15), exploration and open reduction (22), obliteration (16), and ablation (1). Four patients with open fractures were not explored and developed recurrent frontal sinusitis; one progressed to an osteomyelitis. Two with posterior table fractures were not explored and developed meningitis (one was then obliterated and developed an epidural abscess). Three patients developed frontal sinus abscesses after obliterations for anterior wall fractures. Fat gave fewer complications than the other commonly used materials. Exploration is advocated for most frontal sinus fractures. Obliteration should be avoided when possible. Fat is the material of choice when obliteration is required.

Seven cases are presented to illustrate four cervical surgical approaches to the upper mediastinum and thorax. These surgical approaches are described and illustrated, and we have termed these the retrosternal, retroclavicular, posterior, and lateral approaches. Two cases of thymic cyst, one of recurrent metastatic pretracheal adenopathy, a case of tracheal stenosis, a foreign body of the left subclavian artery, a large Zenker's diverticulum, and a neoglottic reconstruction are presented to illustrate the surgical anatomy, dissection technique, and postoperative complications.

Epitympanic fixation of the incus and malleus may be surgically corrected by transcanal atticotomy and removal of the fixed incudomalleolar mass. Restoration of serviceable hearing has resulted in five of six cases by repositioning the natural incus or using a homograft incus.