Browse Health
Otolaryngologist (ear, nose, throat)
32 years of experience
Video profile
Accepting new patients

Education ?

Medical School Score Rankings
University of Michigan Medical School (1978)
  • Currently 4 of 4 apples
Top 25%

Awards & Distinctions ?

Awards  
One of America's Leading Experts on:
Auditory Tumor (Acoustic Neuroma)
Cerebrospinal Fluid Otorrhea
Facial Paralysis
Meniere Disease
U.S. News Top Doctors (2011)
Detroit Hour Magazine's Top Docs (2010)
Hour Detroit Magazine's Top Docs (2010), U.S. News Top Doctors (2011)
Hour Detroit Magazine's Top Docs (2010)
Appointments
Wayne State Universityotolaryngology (2010 - Present)
Associations
American Academy of Otolaryngology: Head and Neck Surgery
American Board of Otolaryngology

Affiliations ?

Dr. Kartush is affiliated with 13 hospitals.

Hospital Affilations

Score

Rankings

  • Beaumont Hospital,Troy
    Otolaryngology
    44201 Dequindre Rd, Troy, MI 48085
    • Currently 4 of 4 crosses
    Top 25%
  • Providence Hospital and Medical Center
    Otolaryngology
    16001 W 9 Mile Rd, Southfield, MI 48075
    • Currently 4 of 4 crosses
    Top 25%
  • University of Michigan Hospitals & Health Centers
    Otolaryngology
    1500 E Medical Center Dr, Ann Arbor, MI 48109
    • Currently 4 of 4 crosses
    Top 25%
  • Beaumont Hospital, Grosse Pointe
    Otolaryngology
    468 Cadieux Rd, Grosse Pointe, MI 48230
    • Currently 4 of 4 crosses
    Top 25%
  • Saint Joseph Mercy Hospital
    Otolaryngology
    505 E Huron St, Ann Arbor, MI 48104
    • Currently 3 of 4 crosses
    Top 50%
  • Beaumont Hospital, Royal Oak
    Otolaryngology
    3601 W 13 Mile Rd, Royal Oak, MI 48073
    • Currently 3 of 4 crosses
    Top 50%
  • St John Detroit Riverview Hospital
    7733 E Jefferson Ave, Detroit, MI 48214
    • Currently 3 of 4 crosses
    Top 50%
  • Providence Park Hospital
    47601 Grand River Ave, Novi, MI 48374
  • Royal Oak (19 Years
  • Oakwood Hospital
  • Providence Hospital - Southfield *
  • Beaumont Affiliation & Years on StaffRoyal Oak
  • Royal Oak
  • * This information was reported to Vitals by the doctor or doctor's office.

    Publications & Research

    Dr. Kartush has contributed to 69 publications.
    Title Otologic Effects of Topical Mitomycin C: Phase I-evaluation of Ototoxicity.
    Date September 2005
    Journal Otology & Neurotology : Official Publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology
    Excerpt

    HYPOTHESIS: To determine ototoxicity of topical mitomycin C when placed in the middle ear at varying concentrations. BACKGROUND: Despite meticulous surgical technique and diligent postoperative care, some patients develop excessive scar and granulation tissue in the middle ear or mastoid cavity. Poor wound healing may result in infection, tympanic membrane perforation, or conductive hearing loss, which may necessitate further surgery. Use of topical mitomycin C in the ear may be beneficial in reducing scar and granulation tissue formation. This phase of the study was developed to determine the safety of topical mitomycin C in the rat model relative to ototoxicity. METHODS: Twelve Sprague-Dawley rats were evaluated with auditory brainstem response testing before and after treatments. Topical mitomycin C was injected in the middle ear of the right ear of eight animals. Varying concentrations of 0.125 to 0.5 mg/ml were used. Saline was injected in the left ear of each animal to serve as a control. Four separate animals were evaluated with placement of topical mitomycin C on Gelfoam into the middle ear. In two animals, Gelfoam was placed in the middle ear for 1 minute and then removed. In two animals, Gelfoam was placed in the middle ear and left in place. Auditory brainstem response testing was performed at 4 weeks and at 8 weeks. RESULTS: Using a high concentration of mitomycin C (>0.25 mg/ml) resulted in ototoxicity, with an increase in the auditory brainstem response threshold at 4 weeks and at 8 weeks. At low concentrations (<0.20 mg/ml), no change in auditory brainstem response threshold was noted. Animals treated with Gelfoam soaked in mitomycin C showed no change in auditory brainstem response threshold. CONCLUSION: The results of this study indicate that topical mitomycin C on Gelfoam applied in the middle ear appears safe when low concentrations are used, even in the rat, which has a higher susceptibility to gentamycin toxicity than humans. Higher concentrations may lead to ototoxicity based on changes in Wave V on auditory brainstem response. This treatment may prove to be an important option for patients suffering from chronic granulation tissue or scar tissue in the external or middle ear.

    Title Staged Resection of Large Acoustic Neuromas.
    Date February 2005
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVE: Surgical removal of large (>3 cm) acoustic neuromas is associated with poor long-term facial nerve function results and higher complication rates. This study analyzes whether long term facial nerve function and the incidence of neurological and vascular complications is improved by resection of large acoustic neuromas in 2 or 3 stages. PATIENTS AND METHODS: Among 660 patients who underwent surgical resection of acoustic neuromas between 1989 and 2002 by the senior author (J.M.K.), 34 (5%) patients underwent a staged resection of their large-sized tumors: stage I via a retrosigmoid craniotomy and stage II via a translabyrinthine approach. A retrospective chart review was performed. Tumor size, completeness of tumor removal, tumor recurrence, facial nerve function, and any complications were noted. RESULTS: The average tumor size was 4.4 cm with a mean postoperative length of follow-up of 6 years after the last surgery. Thirty-one patients underwent a 2-staged resection and 3 patients underwent a 3-staged resection. After their last surgery, 32 (94%) patients had excellent long-term facial function grades of House-Brackmann (H-B) I, one was H-B III, and one was H-B VI. All patients had a total or near-total (>98%) resection. There were no tumor recurrences on follow-up MRI scans. From these 71 operations, no patients required reoperation for a CSF leak. There were no deaths, strokes, hydrocephalus, or meningitis. CONCLUSION: In conjunction with the reported technical refinements, staged resection of large tumors significantly reduces morbidity and improves long-term facial nerve function. EBM rating: C.

    Title Oral Dextromethorphan Reduces Perioperative Analgesic Administration in Children Undergoing Tympanomastoid Surgery.
    Date January 2005
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVE: To determine whether oral dextromethorphan (1 mg/kg) given one hour prior to surgery decreases opioid administration in the perioperative period in children undergoing tympanomastoid surgery. METHODS: This was a prospective randomized double-blinded and placebo-controlled study in which 20 male and 18 female children (age 11.5 +/- 3.5 years) were enrolled. Nineteen children received dextromethorphan (DM), while the other 19 received placebos. Postoperative pain was assessed using a visual analogue scale and a pain score of > or =5 was treated with intravenous morphine sulfate. Patients were discharged home on oral oxycodone. RESULTS: The total doses of fentanyl administered during surgery were higher in the placebo group compared to the DM group (4.1 +/- 2 vs 2.6 +/- 1.4 microg/kg, P = 0.02) and the total doses of intravenous morphine administered in the postoperative period were also higher in the placebo group compared to the DM group (150 +/- 80 vs 73 +/- 56 microg/kg, P = 0.004). The placebo group had a higher pain score at the time of admission to the Day Surgery Unit (DSU) and a higher maximum pain score, compared to the DM group, during their combined stay in the Post-Anesthesia Care Unit and DSU (7.3 +/- 1.5 vs 3.1 +/- 2.6, P = 0.001). CONCLUSIONS: Premedication with DM reduces the need for opioid administration in the perioperative period in children undergoing tympanomastoid surgery. EBM rating: A.

    Title Endolymphatic Sac-vein Decompression for Intractable Meniere's Disease: Long Term Treatment Results.
    Date June 2003
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVES: We sought to determine the long-term efficacy of endolymphatic sac-vein decompression surgery on patients with classic Meniere's disease. STUDY DESIGN AND SETTING: Using the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium criteria, starting stage, functional level, vertigo class, and hearing results were addressed. We studied 68 patients with classic Meniere's disease from a tertiary, private otology-neurotology practice. Patient data were gathered by retrospective chart review, questionnaire, and patient interview. All patients underwent endolymphatic sac-vein decompression with an average follow-up period of 55 months. RESULTS: Median functional level before surgery was level 4, improving to level 2 after surgery. Eighty-one percent of patients showed improvement in functional level, 12% remained stable, and 7% declined. Long-term vertigo control was 47% in class A, 25% in class B, 9% in class C, 3% in class D, and 16% in class F. Twenty percent of patients were in hearing stage I Meniere's disease; 31%, stage II; 44%, stage III; and 5%, stage IV. Eighteen percent of patients showed improvement in hearing class, 64% were stable, and 18% declined. CONCLUSION: Endolymphatic sac-vein decompression surgery is a safe, nondestructive surgical option for Meniere's disease that offers durable control of vertigo and stabilization of hearing for the majority of symptomatic patients. SIGNIFICANCE: The beneficial long-term outcome of the endolymphatic sac-vein decompression supports its continued use as a first-line treatment option in intractable Meniere's disease.

    Title Round Window Gentamicin Absorption: an in Vivo Human Model.
    Date November 2002
    Journal The Laryngoscope
    Excerpt

    OBJECTIVE/HYPOTHESIS: Using a novel human labyrinthine sampling model, in vivo gentamicin absorption through the round window can be measured. STUDY DESIGN: A prospective study. METHODS: Gentamicin was delivered either transtympanically (preoperative) or through a facial recess approach (intraoperative). The lateral semicircular canal and vestibule were opened, and by means of a microsyringe, labyrinthine fluid was aspirated. A sample of serum was also drawn. In all patients cerebrospinal fluid was also drawn. The samples were analyzed using a standard chemistry analyzer. RESULTS: Intratympanic gentamicin diffused through the round window membrane and achieved concentrations in the labyrinthine fluid ranging from 0 to 16 mg/L. Intratympanic gentamicin was absorbed into the systemic circulation in 4 of 11 patients with serum levels ranging from 0.3 to 0.4 mg/L. No gentamicin was detected in the cerebrospinal fluid. CONCLUSIONS: Intratympanic gentamicin diffuses rapidly through the round window membrane and achieves significant levels in the inner ear. Thus, this new model can be used to assess round window permeability to clinically relevant medications such as steroids and ototopical antibiotics.

    Title Rapid Elevation of Gentamicin Levels in the Human Labyrinth Following Intravenous Administration.
    Date September 2002
    Journal The Laryngoscope
    Excerpt

    HYPOTHESIS: Adequate quantities of labyrinthine fluid can be sampled from the human labyrinth to perform quantitative analysis of medications. A rapid elevation of intralabyrinthine gentamicin levels after intravenous administration can be measured. A model for the sampling of human inner ear fluid in this manner is described. BACKGROUND: The risk of aminoglycoside ototoxicity has been a long-standing concern. The kinetics of gentamicin diffusion into the inner ear have been extrapolated to humans from various animal models. The validity of extrapolation to humans is unknown. We have developed a new model to measure the uptake of gentamicin in vivo. METHODS: A single intravenous dose of gentamicin (80 mg) was given perioperatively to 13 patients undergoing translabyrinthine acoustic neuroma surgery. The lateral semicircular canal and vestibule were opened and a microsyringe was used to obtain a sample of labyrinthine fluid concomitant with a serum sample. The gentamicin concentration of the labyrinthine fluid and serum was analyzed using a standard chemistry analyzer. RESULTS: After parenteral administration of gentamicin, fluid was obtained from the inner ear of 13 acoustic neuroma patients. Inner ear concentrations were between 1.0 and 3.8 mg/L. Serum gentamicin levels ranged from 1.2 to 10.5 mg/L. CONCLUSIONS: This method allows the sampling of intralabyrinthine fluid in humans. Gentamicin was noted immediately in the labyrinth after intravenous administration. This model may be expanded to measure other compounds given either by intravenous or transtympanic routes.

    Title Over-under Tympanoplasty.
    Date August 2002
    Journal The Laryngoscope
    Excerpt

    OBJECTIVE: Common techniques of tympanic membrane repair include underlay and overlay grafting. The over-under tympanoplasty, an innovative method for tympanic membrane repair, will be described as a reliable alternative that has advantages over traditional procedures. STUDY DESIGN: This study was a retrospective case review. SETTING: Tertiary referral center with hospital-setting surgery and outpatient ambulatory patient visits. PATIENTS: One hundred twenty patients who underwent over-under tympanoplasty were included in this study. Average follow-up was 1.8 years. INTERVENTION: Over-under tympanoplasty is performed by placing the graft over the malleus and under the annulus. This technique was used for patients undergoing ear surgery for chronic otitis media, perforations, cholesteatoma, and/or conductive hearing loss. All degrees of ear pathology were included. MAIN OUTCOME MEASURES: Main outcome measures were graft success (no perforation, atelectasis, or lateralization within 6 mo) and improvement of hearing. Patients were stratified by severity of disease (according to the Middle Ear Risk Index), cholesteatoma presence, and type of mastoidectomy. RESULTS: All 120 patients had successful grafts. Lateralization of the grafted drum did not occur. Seventeen patients had late atelectasis, and 12 patients had late perforations; nearly all of these were noted more than 1 year after surgery and were attributed to persistent eustachian tube dysfunction or infections. Average improvement in air-bone gap for all patients was 5.3 dB, whereas speech reception threshold improved by 5.9 dB. CONCLUSION: Over-under tympanoplasty has an excellent success rate while being technically easier than lateral tympanoplasty. Thus, it is a useful method for practitioners of all levels.

    Title Intratympanic Ciprofloxacin and the Human Labyrinthine Sampling Model.
    Date August 2002
    Journal The Laryngoscope
    Excerpt

    OBJECTIVE: The aim of the study was to investigate the potential absorption of intratympanic ciprofloxacin through the human round window membrane. STUDY DESIGN: A prospective study. METHODS: Ciprofloxacin was instilled into the middle ear of 10 patients undergoing acoustic tumor removal. The lateral semicircular canal and vestibule were subsequently opened and, using a microsyringe, labyrinthine fluid was aspirated. A sample each of serum and cerebrospinal fluid was also drawn. RESULTS: Into each middle ear, 0.5 mL ciprofloxacin (0.3%) was instilled. The time interval between the ciprofloxacin application to the round window membrane and sampling of labyrinthine fluid and plasma ranged from 9 to 120 minutes. There was no measurable ciprofloxacin in the labyrinthine fluid, cerebrospinal fluid, or serum of 10 patients. CONCLUSION: The lack of measurable absorption of intratympanic ciprofloxacin into the inner ear indicates that the chance of ototoxicity when ciprofloxacin is used clinically, even in the presence of a tympanic membrane perforation, is low.

    Title Smoking and Tympanoplasty: Implications for Prognosis and the Middle Ear Risk Index (meri).
    Date February 2002
    Journal The Laryngoscope
    Excerpt

    OBJECTIVES/HYPOTHESIS: The objectives of this study are to review the effects of smoking on preoperative middle ear disease severity, long-term surgical outcome, type and extent of surgery required, the need for ossicular chain reconstruction, and the long-term hearing results. STUDY DESIGN: A retrospective chart review. MATERIALS AND METHODS: The charts of 74 smokers and non-smokers who underwent over-under tympanoplasty were reviewed. An analysis of the disease severity (using the Middle Ear Risk Index [MERI]) at presentation and type of surgery was performed. A review of graft take and delayed failure (late perforation or atelectasis after 6 mo) and audiologic data were performed. RESULTS: Fifteen patients smoked a mean of 20 cigarettes daily for a mean of 15 years. The MERI was well matched for both groups. There was a trend toward smokers having a higher incidence of otorrhea preoperatively and requiring a more extensive surgical procedure. All patients had full take of the tympanic membrane graft at 6 months; however, delayed surgical failure was seen in 20% of non-smokers compared with 60% of smokers (P = .050). No statistically significant difference was seen in hearing outcome. CONCLUSIONS: Cigarette smoking is associated with more severe middle ear disease preoperatively. More extensive surgery is often needed in smokers to eradicate the disease. Most significantly, smoking is associated with a threefold increase in the chance of long-term graft failure. Based on the results of this study, the MERI has been revised to include smoking as a risk factor.

    Title Implications of Sound Levels Generated by Otologic Devices.
    Date December 2001
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    OBJECTIVE: Exposure to loud noise can result in sensorineural hearing loss. In otology, a wide variety of devices are used that have significant noise output, both to the operator and the patient. This study quantifies and compares the sound pressure levels (SPL) of a variety of otologic instruments. METHODS: Using a calibrated sound pressure level meter, the peak and impulse sound pressure levels of several otologic instruments were determined at 1 cm from their application to human temporal bones. Devices measured were an air-powered drill with a cutting burr, an electric micro-drill, and KTP, CO(2), and erbium lasers. RESULTS: Impulse sound pressure levels for the KTP laser, CO(2) laser, microdrill, air-powered drill and erbium laser were 67, 71, 90, 105, and 105 dBA, respectively. Peak sound pressure levels were 81, 89, 102, 118, and 132 dBA, respectively. CONCLUSIONS: Use of the KTP laser, CO(2) laser, and microdrill result in impulse levels of less than 100 dBA. Although the impulse levels of the erbium laser and the air-powered drill were equivalent, the peak sound pressure levels of the erbium laser were significantly higher. These high sound pressure levels may increase the chance for hearing loss. Like any tool, lasers and drills have benefits and risks. The results of this study demonstrate significant differences in SPLs of common otologic lasers and drills. Although noise-induced hearing loss is a function of both SPL and duration of exposure, surgeons should consider these differences when selecting and applying these tools, especially when used on or adjacent to the ossicular chain and stapes footplate.

    Title Tympanic Membrane Patcher: a New Device to Close Tympanic Membrane Perforations in an Office Setting.
    Date February 2001
    Journal The American Journal of Otology
    Excerpt

    OBJECTIVE: To assess a new device intended to cover tympanic membrane (TM) perforations in an office setting. STUDY DESIGN: Not all patients with TM perforations require or choose tympanoplasty surgery. Alternatives to surgery (e.g., paper and plastic onlay) have limitations that prompted a need for an alternative method. A new, simple device, designed to be inserted into the perforation, is made out of a very soft silicone in the shape of a sealed tympanostomy tube. The TM Patcher is self-stabilizing without adhesives. SETTING: An outpatient office. PATIENTS: Twenty-nine patients with 30 consecutive dry TM perforations, who volunteered to participate in the study. Patients with known cholesteatomas or persistent drainage were excluded. INTERVENTIONS: In the office, patients had the Patcher inserted into their dry TM perforation. No anesthetics were needed. MAIN OUTCOME MEASURES: Hearing was tested before and after patching by conventional audiometry. The ears were assessed for Patcher position, perforation status, and infection. RESULTS: Patients with normal ossicular chains had immediate improvement of hearing. No patient experienced hearing loss. Twenty-six of 30 patients (87%) were free of infection. Two patients (7%) with persistent drainage were taken to surgery and were found to have mastoid disease (cholesteatoma or granulation tissue). Three patients (10%) had rare otorrhea after patching and were treated by drops or temporary removal of the Patcher. Two of these three ears subsequently became dry and then healed. Small perforations often healed or became smaller (46% of 3-mm perforations) despite failure of tympanoplasty or conventional office patching with a flat piece of paper or plastic. Perforations >5 mm did not heal; however, these patients simply continued wearing their Patcher and benefited by protection of their middle ear, typically with improved hearing and resolution of tinnitus. Occasional spontaneous lateralization was allowed to occur in the small perforations, which often later healed. In larger perforations, the Patcher was simply repositioned. CONCLUSIONS: The Patcher is a safe and effective alternative for office patching of dry perforations when surgery is contraindicated or is refused by the patient. New materials should increase healing rates when applied to a Phase II Patcher.

    Title Ossicular Chain Reconstruction Using a New Tissue Adhesive.
    Date August 2000
    Journal The American Journal of Otology
    Excerpt

    HYPOTHESIS: A new medical-grade cyanoacrylate tissue adhesive will improve the results of ossicular chain reconstruction in a rat model. BACKGROUND: An ideal tissue adhesive has long been awaited by otologists. Studies examining the older cyanoacrylates have demonstrated variable efficacy and toxicity. Octylcyanoacrylate is a new tissue adhesive that has many ideal properties for otologic surgery. METHODS: Thirteen female C-D rats were anesthetized, and preoperative auditory brainstem response (ABR) testing was performed. A left antrotomy was performed, and the incus was removed. In the adhesive group, the incus was dipped in octylcyanoacrylate and interposed between the tympanic membrane and the stapes; no adhesive was used in the control group. At 8 weeks, postoperative ABR was performed, the integrity of the ossicular chain inspected, and histopathologic analysis of the temporal bones performed. Statistical comparison of ABR results was performed with the Mann-Whitney test. RESULTS: Seven rats were randomized to the adhesive group and six to the control group, of which four survived. There were no histopathologic differences in the temporal bones of the animals other than the presence of mild foreign body reaction around the ossicular chain of the animals in the adhesive group. The ossicular chain was not intact in two of the four controls, whereas the rest were intact at 8 weeks. Postoperative air conduction ABR results (mean dB sound pressure level) (62.5 control versus 34.3 adhesive, p = 0.010) and air-bone gaps (47.5 control versus 18.9 adhesive, p = 0.008) were significantly better in the adhesive group. CONCLUSIONS: This new medical-grade tissue adhesive improves the hearing results of ossicular chain reconstruction, with no apparent histotoxicity in this animal model.

    Title Octylcyanoacrylate: a New Medical-grade Adhesive for Otologic Surgery.
    Date August 2000
    Journal The American Journal of Otology
    Excerpt

    HYPOTHESIS: The adhesive octylcyanoacrylate is not associated with significant inner ear toxicity in a guinea pig model. BACKGROUND: Many cyanoacrylate adhesives have been investigated for use in otologic surgery, but variable ototoxicity has been reported. Octylcyanoacrylate is a medical-grade adhesive with many properties that make it ideal for use in the ear. It is free of contaminants; it forms a strong, flexible bond; and it inhibits the growth of gram-positive organisms in culture. This is the first study to assess the ototoxicity of this new adhesive. METHODS: Fourteen adult guinea pigs were used. Preoperative auditory brainstem responses (ABRs) were determined. Bilateral antrotomies were performed, and the ears were randomized to adhesive and control (saline) groups. In the adhesive ears. 0.5 or 0.1 mL of octylcyanoacrylate was instilled into the middle ear. Eight weeks later, postoperative ABRs were determined, the animals were killed, and the temporal bones were removed. Middle ear changes were noted, and the ossicular chain was assessed. Cochlear hair cell analyses were performed. Histologic assessment of the middle ear mucosa was performed. RESULTS: There was a higher incidence of conductive hearing loss in the adhesive group secondary to fixation of the ossicular chain, but there was no significant difference in bone conduction thresholds. The median postoperative bone conduction thresholds (dB peak sound pressure level) was 15.0 in the control group and 17.5 in the adhesive group, p = 0.89. There was also no significant difference in inner hair cell counts (0.4% vs. 0.5% median hair cell loss, p = 0.72) or outer hair cell counts (3.7% vs. 3.0% median hair cell loss, p = 0.23) for the adhesive and control groups, respectively. Histopathologic analysis of the middle ear mucosa demonstrated variable mild to moderate foreign body reaction with no evidence of mucosal ulceration or necrosis. CONCLUSIONS: A large amount of octylcyanoacrylate placed in the middle ear of the guinea pig did not cause any morphologic or functional evidence of inner ear toxicity. This new adhesive is a promising tool for otologic surgery.

    Title Tympanic Membrane Perforation Repair Using Alloderm.
    Date August 2000
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    BACKGROUND: Some patients lack quality autologous tissue for tympanic membrane (TM) grafting. AlloDerm (LifeCell Corp, The Woodlands, TX) is a preserved allograft that has been effective in nonotologic applications. OBJECTIVE: The goal of this study was to investigate AlloDerm in the repair of chronic TM perforations. METHODS: Ten adult chinchillas underwent a controlled, 2-stage procedure for creation and repair of bilateral TM perforations. Myringoplasties were performed. The control side (left) was repaired with autologous fascia; AlloDerm was used in all right ears. Grafts were assessed at 3 to 8 weeks. RESULTS: Complete TM perforation closure was noted in 9 of 10 (90%) control ears and 8 of 10 (80%) AlloDerm-treated ears. Fascia and AlloDerm integrated consistently with host tissues. No variables demonstrated statistical significance. CONCLUSIONS: AlloDerm appeared to be an ideal substitute for grafting of the TM. It was equally effective as fascia. Clinical trials in human beings appear warranted. Potential health care savings are discussed.

    Title Intra-operative Monitoring in Acoustic Neuroma Surgery.
    Date December 1998
    Journal Neurological Research
    Excerpt

    Intra-operative neurophysiologic monitoring (IOM) is rapidly evolving as an important adjunct during acoustic neuroma surgery to reduce the incidence of neurologic deficits. Monitoring alerts the surgeon to ongoing changes in neural function. The benefit of facial nerve monitoring in reducing the incidence of facial palsy during acoustic tumor resection appears clear and is now recommended by the National Institutes of Health (Consensus Development Conference on Acoustic Neuroma, 1991). Auditory monitoring is not as effective as facial monitoring but hearing preservation can be enhanced particularly if used with facial monitoring because the latter alerts the surgeon to traumatic manipulations that may affect both facial and cochlear nerves. Monitoring is not a replacement for surgical experience. 'Poor monitoring is worse than no monitoring'.

    Title Early Post-laser Stapedotomy Hearing Thresholds.
    Date October 1998
    Journal The American Journal of Otology
    Excerpt

    OBJECTIVE: Auditory testing is not routinely performed within 4-6 weeks after stapedotomy, because hearing acuity is thought to be transiently depressed. In rare circumstances, postsurgical auditory and vestibular complaints may lead one to test hearing soon after stapedotomy. The early postoperative effects of carbon dioxide (CO2) and potassium titanyl phosphate (KTP) lasers, which now are routinely used to perform stapedotomies, have not been reported. The purpose of this report is to present normative data for auditory thresholds measured within 2 weeks of laser stapedotomy. STUDY DESIGN: The study design was a prospective, unblinded study. SETTING: The study was conducted at three academic medical centers. PATIENTS: Thirty-six subjects undergoing 38 stapedotomies for otosclerosis by 5 surgeons participated. MAIN OUTCOME MEASURES: Behavioral audiometry was performed using standard techniques beginning before surgery and continuing through > 1 year after surgery. RESULTS: The CO2 laser was used in 26 stapedotomies and the KTP laser was used in 12. Nine cases were revision procedures. Bone conduction pure-tone averages and speech discrimination scores did not worsen during the early postoperative period. Bone conduction at 250 and 4,000 Hz dropped slightly within the first 2 weeks (-4.3 and -6.7 dB) but recovered thereafter. Bone conduction at 1,000 Hz actually improved within the first week after surgery (+6.2 dB, p = 0.021). Significant improvements in air conduction thresholds (and air-bone gap) were seen at the second week and late audiometry. The results for CO2 and KTP laser-treated groups were not significantly different. CONCLUSIONS: Cochlear function is not significantly depressed in the early postoperative period after laser (CO2 or KTP) stapedotomy.

    Title Endolymphatic Sac Surgery in Meniere's Disease.
    Date March 1998
    Journal Otolaryngologic Clinics of North America
    Excerpt

    Despite the controversy that surrounds sac surgery for Meniere's disease, it remains in the forefront of surgical intervention for the refractory patient. This article reviews the literature for all types of sac surgery, with emphasis on wide sac-vein decompression as performed at the Michigan Ear Institute.

    Title Sac-vein Decompression for Intractable Meniere's Disease: Two-year Treatment Results.
    Date February 1998
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Surgical intervention has been offered to patients with Meniere's disease who have failed medical treatment and have disabling symptoms. Surgical options have included labyrinthectomy (mechanical and chemical), vestibular neurectomy, and endolymphatic sac surgery with or without shunting. We present a modification of endolymphatic sac decompression surgery that includes wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac (sac-vein decompression). Thirty-five patients underwent 37 primary procedures with 2 years of follow-up. Patients were evaluated according to the 1985 American Academy of Otolaryngology-Head and Neck Surgery criteria for assessing Meniere's disease. Vestibular symptom severity was resolved or mild in 92% and disability severity was none or mild in 95% of patients at 2 years after surgery. Vertigo control was complete or substantial in 85% and 100% of patients at 1 and 2 years after surgery. Audiologic data showed stable or improved hearing in 86% and 85% of patients at 1 and 2 years after surgery. In summary, wide decompression of the sigmoid sinus, posterior cranial fossa dura, and endolymphatic sac offers improved control of vertigo and hearing stabilization for intractable Meniere's disease compared with simple endolymphatic sac decompression or shunt surgery.

    Title Triple Semicircular Canal Occlusion in the Guinea Pig.
    Date December 1997
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Hearing preservation is possible with translabyrinthine procedures, but the optimal means of sealing the remaining labyrinth has not been determined. The purpose of this study was to compare the effects of mechanical and nonmechanical (CO2 laser-assisted) triple semicircular canal occlusion on hearing in the guinea pig. All three semicircular canals of 19 guinea pigs were treated with one of four techniques: fenestration without packing (control), fenestration with packing, CO2 laser coagulation of the membranous canal without packing, or laser coagulation with packing. Six weeks postoperatively, electrocochleographic thresholds were significantly elevated in one of five ears treated with packing alone, in one of five ears treated with laser and packing, in two of five ears treated with the laser alone, and in all four control ears. Thresholds were significantly elevated in control versus occluded ears (p < 0.05). There were no significant differences between the ears treated with laser or packing. These findings suggest that hearing can be preserved in triple canal occlusion by means of sealing the membranous labyrinth with either CO2 laser coagulation or mechanical packing. Further study on the feasibility of hearing preservation with complete labyrinthectomy is warranted.

    Title Triple Semicircular Canal Occlusion Versus Labyrinthectomy in the Cat.
    Date March 1997
    Journal The American Journal of Otology
    Excerpt

    HYPOTHESIS: We have theorized that surgical occlusion of all three semicircular canals (TCO) may be an effective means to treat vestibular pathology limited to semicircular canal dysfunction while preserving hearing and otolithic function. BACKGROUND: A procedure that would eliminate vertigo while preserving hearing and minimizing postoperative dysequilibrium would be desirable. METHODS: Staged bilateral TCO was performed on four cats and compared to staged bilateral labyrinthectomy in four cats. Balance and gait analysis were performed for 3 weeks after each surgical procedure--a total of 6 weeks of testing. RESULTS: Balance testing, gait analysis, and righting reflex were found to be better among the cats undergoing TCO compared to labyrinthectomy. CONCLUSIONS: Compared to labyrinthectomy in the cat, TCO appears to have advantages for vestibular compensation after unilateral and contralateral surgery.

    Title Errors in Otology.
    Date January 1997
    Journal Ear, Nose, & Throat Journal
    Excerpt

    Practicing medicine successfully requires that errors in diagnosis and treatment be minimized. Malpractice laws encourage litigators to ascribe all medical errors to incompetence and negligence. There are, however, many other causes of unintended outcomes. This article describes common causes of errors and suggests ways to minimize mistakes in otologic practice. Widespread dissemination of knowledge about common errors and their precursors can reduce the incidence of their occurrence. Consequently, laws should be passed to allow for a system of non-punitive, confidential reporting of errors and "near misses" that can be shared by physicians nationwide.

    Title Delayed Facial Palsy After Acoustic Neuroma Resection: the Role of Viral Reactivation.
    Date December 1996
    Journal The American Journal of Otology
    Excerpt

    Delayed facial palsy after acoustic neuroma resection may occur in up to 15% of cases. Prognosis is generally good if the palsy does not progress to total paralysis. However, a delayed palsy with subsequent total paralysis has a more variable final outcome, which ranges from normal function to permanent total paralysis. This delayed paralysis has been attributed to edema from surgical manipulation of the facial nerve. Steroids and intraoperative decompression of the meatal foramen have been used with some success, but some cases remain refractory to these measures. Herpes simplex virus and varicella-zoster virus are ubiquitous in the population and remain in a latent state in neural ganglia. These viruses are reactivated during times of stress. Trigeminal nerve surgery (partial sensory rhizotomy and microvascular decompression) stimulates reactivation of herpes simplex with manifestations in the sensory distribution of the trigeminal nerve in 38-94% of procedures. Prevention of this reactivation has been demonstrated in placebo-controlled trials by using prophylactic acyclovir. We present a patient who underwent translabyrinthine resection of an intracanalicular acoustic neuroma and in whom developed otalgia, vesicles on the ear canal and the ipsilateral buccal mucosa, and progressive facial palsy the week after surgery. Serologic evaluation confirmed the diagnosis of herpes zoster oticus. Reactivation of latent virus apparently occurred as a result of surgical manipulation of the facial nerve. This parallels viral reactivation seen in trigeminal nerve surgery. We propose a new theory for an additional cause of delayed facial palsy after acoustic neuroma resection-reactivation of latent herpesvirus resulting from surgical trauma. Acyclovir should be evaluated in clinical trials for a prophylactic role in patients undergoing acoustic neuroma resection or a therapeutic role in patients in whom a delayed postoperative facial palsy develops.

    Title Mechanical Versus Co2 Laser Occlusion of the Posterior Semicircular Canal in Humans.
    Date December 1996
    Journal The American Journal of Otology
    Excerpt

    The purpose of this study was to compare the effectiveness of mechanical and laser-assisted posterior semicircular canal occlusion (PCO) for the treatment of intractable benign paroxysmal positional vertigo (BPPV). Twelve consecutive patients with intractable BPPV underwent PCO by three surgeons, six with mechanical PCO and six with CO2 laser-assisted PCO. PCO eliminated positional vertigo in all patients treated with the laser and five of six patients treated without the laser. Dysequilibrium was present in all patients immediately postoperatively. This resolved in all patients treated with the CO2 laser but in only two of six patients treated without the laser (p = 0.03). Patients were hospitalized for dysequilibrium for an average of 5.2 and 2.8 days for the mechanical and laser-assisted groups, respectively. Preoperative and postoperative hearing was not significantly different between the groups. No clinically significant postoperative hearing loss was encountered in either group. These results suggest that PCO is an effective treatment for intractable BPPV. The incidence of dysequilibrium that persists following PCO may be reduced by using the CO2 laser to seal the membranous canal prior to occluding the bony canal.

    Title Temporal Bone Encephalocele and Cerebrospinal Fluid Leaks.
    Date December 1996
    Journal The American Journal of Otology
    Excerpt

    Nineteen cases of temporal bone brain herniation and cerebrospinal fluid (CSF) leaks in 17 adult patients since 1987 are reviewed. Of these 19 cases, 11 were spontaneous CSF leaks, 6 were related to chronic otitis media, and 2 were posttraumatic. Among the 10 women and 7 men, the average age was 51.2 years, with average follow-up time of 2 years, 7 months. Two cases were repaired by a middle fossa craniotomy approach, 1 case by a transmastoid approach, and 16 by a combined transmastoid and middle fossa approach. Ten cases utilized the preferred technique of fascia-bone-fascia to repair the defects. The diagnosis was made on clinical grounds in 18 of the 19 cases, with ancillary diagnostic test providing little useful information. There were no postoperative surgery-related complications, and definitive repair was accomplished in one stage in all cases.

    Title Acoustic Neuroma Update.
    Date November 1996
    Journal Otolaryngologic Clinics of North America
    Excerpt

    We have described refinements and alternative techniques in the management of acoustic neuromas. The outcome for patients with both unilateral and bilateral tumors continues to improve.

    Title Meatal Facial Nerve Decompression in Acoustic Neuroma Resection.
    Date March 1996
    Journal The American Journal of Otology
    Excerpt

    Delayed facial palsy occurs after approximately 15% of acoustic neuroma resections. Whereas in most cases facial nerve function recovers satisfactorily, in about 12% of cases delayed facial palsy may have a poor functional recovery. The fate of facial nerve function was studied in 55 consecutive translabyrinthine acoustic neuroma resections, 23 of whom underwent meatal facial nerve decompression (MFND) at the time of tumor resection. The facial nerve results also were reviewed in 19 middle cranial fossa resections, of whom 14 underwent MFND. There was a bimodal distribution of the delayed palsies, with one group having the onset of palsy within hours to 2 days after surgery and the second group having onset of palsy up to 17 days after surgery. The poorest recoveries were seen in the first group. Although the effect was not statistically significant due to the small sample size, the chance of facial weakness in patients who underwent MFND after translabyrinthine surgery was about 40% less than in those who did not undergo decompression. The apparent protective effect of MFND was increased when the confounding factors of tumor size and degree of resection were taken into account, although the effect was not statistically significant. The duration of palsy was shorter and ultimate recovery better among the patients who underwent facial nerve decompression than in those who did not. Of the translabyrinthine patients who underwent MFND, 100% had House-Brackmann grade I-II function at 2 years, whereas 87% of patients who did not have MFND had grade I-II function and 13% had grade III-IV function. Without MFND, 57% of translabyrinthine patients whose onset of facial palsy was within 2 days of surgery had grade III-IV facial nerve function.

    Title Intraoperative Facial Nerve Monitoring in Chronic Ear Surgery: a Resident Training Experience.
    Date March 1996
    Journal The American Journal of Otology
    Title Carbon Dioxide Laser Occlusion of the Guinea Pig Posterior Semicircular Canal.
    Date November 1995
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Preservation of hearing is possible with selective ablation of the vestibular system and mechanical occlusion of the semicircular canals. Complete ablation of all three canals would improve exposure of the internal auditory canal fundus (e.g., for acoustic tumor exposure), but mechanical packing of the vestibule would disrupt normal sound transduction. This study was designed to assess the feasibility of preserving hearing with CO2 laser occlusion, without mechanical packing of the posterior semicircular canal membranous labyrinth. Twenty adult Hartley guinea pigs underwent occlusion of the right posterior semicircular canal with one of three techniques: mechanical packing, laser coagulation, or laser coagulation with mechanical packing. Electrocochleographic thresholds to clicks and 1-kHz and 8-kHz tone bursts did not change significantly 6 weeks after posterior semicircular canal occlusion with any of these techniques. Histopathologic examination revealed complete canal occlusion with all methods. These findings suggest that mechanical occlusion and CO2 laser occlusion of the posterior semicircular canal do not significantly affect cochlear function in the guinea pig. CO2 laser occlusion of the membranous labyrinth may prove useful for more extensive selective vestibular ablation by obviating the need for mechanical packing of the labyrinth.

    Title Use of Intraoperative Neuromonitoring to Prevent Orbital Complications in Ethmoid Sinus Surgery.
    Date August 1995
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Orbital injury is one of the most serious complications in sinus surgery. Although these injuries are generally infrequent, there is a considerable increased risk for orbital complications during procedures in which anatomic landmarks are distorted because of the severity of disease or prior surgery. Currently there are no methods to detect early defects in the lamina papyracea or to prevent continued resection until orbital fat or periorbita is seen. Thirteen New Zealand white rabbits were studied by use of a nerve monitor to identify the periorbita and orbital fat in surgically created lamina defects. Evoked potentials were measured at the medial orbit when the lamina papyracea, periorbita, and orbital fat were stimulated at current intensities ranging from 0.25 to 1.00 mA. Stimulation of the lamina at 0.8 and 1.0 mA resulted in response amplitudes that were significantly lower compared with those of periorbita stimulation (means at 1 mA, 38.26 microV vs. 117.85 microV; p < 0.01). Stimulation of the orbital fat also resulted in higher potentials (mean, 59.47 microV) than those of the lamina papyracea (mean, 38.26 microV) but did not reach statistical significance. The statistically significant difference in response amplitudes between the lamina papyracea and the periorbita indicate that intraoperative monitoring may be useful in identifying early lamina defects, which could in turn reduce the risk of orbital injury during sinus surgery.

    Title Electromagnetic Ossicular Augmentation Device.
    Date June 1995
    Journal Otolaryngologic Clinics of North America
    Excerpt

    Conventional hearing aids have a number of limitations inherent to amplifying sound in the narrow confines of the external auditory canal. Disadvantages include acoustic feedback, poor fidelity, and the stigmata of aging. Since 1986, Michigan Ear Institute and Smith and Nephew Richards Company have been investigating the feasibility of a new device that converts sound to an electromagnetic field. The efficacy and safety of electromagnetic-induced hearing was sufficient enough to have the Federal Food and Drug Administration approve a pilot study of ten patients with a sensorineural hearing loss in whom a target magnet is implanted beneath the tympanic membrane. A status report of this study and a review of our preceeding investigations are presented in this article.

    Title Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo--co2 Laser-assisted Technique: Preliminary Results.
    Date April 1995
    Journal The Laryngoscope
    Excerpt

    Benign paroxysmal positional vertigo (BPPV) is a common vestibular end-organ disorder that in the majority of patients resolves with conservative management. In the occasional patient who has unremitting BPPV despite conservative treatment, posterior semicircular canal occlusion (PCO) may be effective in eliminating symptoms. In an attempt to minimize the risk of hearing loss, a modified procedure was developed that uses the CO2 laser to shrink the membranous vestibular posterior semicircular canal prior to mechanically plugging the canal. Preliminary results of this CO2 laser-assisted occlusion technique used in four patients are presented.

    Title Ossicular Chain Reconstruction. Capitulum to Malleus.
    Date December 1994
    Journal Otolaryngologic Clinics of North America
    Excerpt

    Ossicular chain reconstruction is most commonly performed for an absent or diseased incus. Reestablishing continuity by placing a strut prosthesis between the stapes capitulum and malleus handle minimizes the possibility of extrusion and displacement. Strut prostheses are made of hydroxyapetite, which is a highly biocompatible material that bonds to living bone.

    Title The Role of Ktp Laser in Revision Stapedectomy.
    Date December 1993
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    In recent years, the safety and efficacy of revision stapedectomy has come under scrutiny. Experienced surgeons report that the results of such surgery are often worse than the results after primary surgery and that the risks of sensorineural hearing loss, tinnitus, and vertigo are increased. With the addition of laser technology to revision stapes surgery, the procedure to open the neomembrane over the oval window and gain access to the inner ear can now be performed safely. This allows positive identification of the oval window and assures placement of the prosthesis through the fenestra rather than on an intermediate segment of scar or bone in the region of the footplate. Our studies have shown the laser to be an important tool that enhances the safety and efficacy of revision stapedectomy.

    Title False-positive Mr Imaging in the Diagnosis of Acoustic Neurinomas.
    Date November 1992
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Title Facial Nerve Outcome in Acoustic Neuroma Surgery.
    Date August 1992
    Journal Otolaryngologic Clinics of North America
    Excerpt

    Patients consider facial paralysis the most concerning sequelae following acoustic tumor resection. Surgical and anesthetic refinements have lowered operative mortality to allow the surgeon to focus on preserving facial nerve function. Tumor size, microsurgical technique, and intraoperative monitoring are the most important factors that define the risk of postoperative facial paralysis. A protocol for uniform surgical reporting is proposed.

    Title Patterns of Vestibular Function Following Vestibular Nerve Section.
    Date May 1992
    Journal The Laryngoscope
    Excerpt

    Bithermal caloric irrigations, low-frequency rotational chair stimulation, and posturography were performed on 20 patients before and after vestibular nerve section. Twelve patients demonstrated acute postoperative spontaneous nystagmus and rotational vestibulo-ocular reflex (VOR) asymmetry. Eight patients demonstrated minimal acute postoperative spontaneous nystagmus and VOR asymmetry. Four patients had suppression of all vestibular function characterized by an absent contralateral caloric response, low VOR gain, and falls on posturography when required to rely solely on vestibular input to maintain posture. Four patients had a severe preoperative vestibular loss and no acute change in vestibular function following surgery. Over time, 5 patients continued to manifest elevated spontaneous nystagmus, 2 patients manifested a persistent rotational VOR asymmetry, and 5 patients exhibited a return of caloric function in the operated ear. It is suggested that multiple clinical factors contributed to the variable vestibular responses demonstrated in this study.

    Title Mri Not Contraindicated Following Gold or Spring Implantation to the Upper Eyelid for Facial Reanimation.
    Date March 1992
    Journal The American Journal of Otology
    Title Testing Facial Nerve Function.
    Date February 1992
    Journal Otolaryngologic Clinics of North America
    Excerpt

    A variety of facial nerve tests are now available. These tests can aid the clinician in discerning the site of lesion, estimating prognosis, assessing evidence of neoplastic or infectious involvement, and assisting in intraoperative facial monitoring.

    Title Clinical Assessment of Postural Stability Following Vestibular Nerve Section.
    Date October 1991
    Journal The Laryngoscope
    Excerpt

    Little is known about the recovery of postural control in patients following acute vestibular loss. This paper reports on the results of moving-platform posturography to assess the recovery of postural stability in 24 patients following vestibular nerve section. Posturography was abnormal prior to surgery in 17% of the patients. Seven days following surgery, 44% of the patients demonstrated vestibular deficit patterns, while 56% of the patients had normal posturography. Posturography was normal in all patients 1 month following surgery. Abnormal posturography was subsequently noted in 21% of the patients between 3 and 20 months following surgery. Each of the patients with abnormal preoperative posturography subsequently demonstrated abnormal late postoperative posturography. These results suggest that perioperative posturography may be useful in the evaluation and counseling of patients considering ablative vestibular surgery.

    Title Electromagnetic Semi-implantable Hearing Device: Phase I. Clinical Trials.
    Date October 1991
    Journal The Laryngoscope
    Excerpt

    Conventional hearing aids have improved significantly in recent years; however, amplification of sound within the external auditory canal creates a number of intrinsic problems, including acoustic feedback and the need for a tight ear mold to increase usable gain. Nonacoustic alternatives which could obviate these encumbrances have not become practical due to inefficient coupling (piezoelectric techniques) or unfeasible power requirements (electromagnetic techniques). Recent technical advances, however, prompted a major clinical investigation of a new electromagnetic, semi-implantable hearing device. This study presents the details of clinical phase I, in which an electromagnetic driver was coupled with a target magnet temporarily affixed onto the lateral surface of the malleus of six hearing aid users with sensorineural losses. The results indicate that the electromagnetic hearing device provides sufficient gain and output characteristics to benefit individuals with sensorineural hearing loss. Significant improvements compared to conventional hearing aids were noted in pure-tone testing and, to a lesser degree, in speech discrimination. Subjective responses were quite favorable, indicating that the electromagnetic hearing device 1. produces no acoustic feedback; 2. works well in noisy environments; and 3. provides a more quiet, natural sound than patients' conventional hearing aids. These favorable results led to phase II of the project, in which patients with surgically amendable mixed hearing losses were implanted with the target magnet incorporated within a hydroxyapatite ossicular prosthesis. The results of this second-stage investigation were also encouraging and will be reported separately.

    Title Meatal Decompression Following Acoustic Neuroma Resection: Minimizing Delayed Facial Palsy.
    Date July 1991
    Journal The Laryngoscope
    Title Comparison of Computerized Tomography and Magnetic Resonance Imaging for the Postoperative Assessment of Residual Acoustic Tumor.
    Date April 1991
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Ten patients with surgically confirmed residual cerebellopontine angle neuromas, imaged by both computerized tomography (CT) with iodine contrast and magnetic resonance (MR) with and without gadolinium enhancement, are reviewed to identify the strengths and limitations of MR as compared with CT imaging. MR imaging offers superior anatomic resolution in multiple imaging planes without ionizing radiation, but it is expensive and has adverse effects on some patients. CT imaging offers good anatomic resolution, but in only one or two planes. CT is both less expensive and generally well tolerated, but allergy to the iodine contrast is not uncommon. The cases presented demonstrate the adequacy of CT imaging of residual tumor. However, in some cases MR imaging provided important additional detail. MR imaging also demonstrated postoperative changes within the brain stem and cerebellum. In our experience, CT imaging remains a satisfactory, unambiguous approach to the assessment of known postoperative residual cerebellopontine angle neuromas. MR imaging provides superior resolution, however, and should be used when better definition of tumor detail is needed for management decisions or when multiple follow-up scans are anticipated, so that the exposure to ionizing radiation is limited. MR is also useful to investigate postoperative neurologic dysfunction. Postoperative changes and residual tumors are more difficult to interpret on MR than on CT. Guidelines are proposed to help distinguish residual tumor from postoperative changes and scarring.

    Title Electromagnetic Semi-implantable Hearing Device: an Update.
    Date April 1991
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Title Early Gold Weight Eyelid Implantation for Facial Paralysis.
    Date February 1991
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Facial paralysis can result in serious keratopathy because of corneal exposure and inadequate lacrimation. Thirty-seven patients underwent thirty-eight gold weight upper lid implants to rehabilitate paralysis of the eyelid from various causes. When indicated, implantation was combined with lower lid ectropion repair, medial canthoplasty or brow lift. Because of encouraging results in patients with longstanding facial paralysis, "early" implantation (within 1 month of paralysis) was offered to patients with severe lagophthalmos in whom (1) a severe neural injury was documented at the time of transtemporal surgery or (2) delayed, incomplete return of function was expected. Gold weight implantation resulted in excellent eyelid closure, protection, and cosmesis. There were no infections or extrusions. Lagophthalmos and exposure keratitis resolved or were significantly improved in all patients, and most were able to dispense with eyedrops and salves. Visual acuity improved in 95% of patients--a benefit even those without preoperative keratitis often achieved. A mild worsening of one patient's pre-existing astigmatism developed, which resolved after reimplantation with a lighter weight. The implant is easily removed from those patients who, having undergone early implantation, eventually recover adequate function. Gold weight loading has become our procedure of choice for eyelid rehabilitation.

    Title Laser-stapes Surgery.
    Date January 1990
    Journal The Laryngoscope
    Title Promontory Stimulation Following Labyrinthectomy: Implications for Cochlear Implantation.
    Date January 1990
    Journal The Laryngoscope
    Excerpt

    Transtympanic electric promontory stimulation is a psychoacoustic test used to assess residual acoustic neurons in profound sensorineural hearing loss. The test was performed in six patients who had previously undergone transmastoid (N = 5) or transcanal-oval window (N = 1) labyrinthectomy as a means of determining the feasibility of future cochlear implantation. Four patients had unilateral Meniere's disease, one had labyrinthitis, and one had delayed onset vertigo. All patients perceived a definite auditory sensation in the labyrinthectomized ear during stimulation. The results of threshold, dynamic range, and difference limen testing were similar to those obtained during preoperative stimulation of cochlear implant candidates (N = 12) who subsequently became successful users. There was no evidence of response degradations as the time following labyrinthectomy increased. The results of this study suggest the possibility of successful cochlear implantation following labyrinthectomy. Supporting histologic data are reviewed.

    Title Total Facial Nerve Decompression for Recurrent Facial Paralysis: an Update.
    Date November 1989
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Recurrent facial paralysis (RFP) is a rare disorder that in some individuals may lead to worsening sequelae. Melkersson-Rosenthal syndrome is a variant of RFP that is associated with recurrent facial edema. In the past, decompression of the mastoid segment of the facial nerve has not been successful in preventing recurrences. In 1981 we began performing total facial nerve decompression for RFP and in 1986 reported its efficacy in one patient with Melkersson-Rosenthal syndrome and in another in whom both nerves were decompressed for alternating bilateral paralysis. An additional four cases with 3 to 8 years of followup demonstrate no recurrences in any patient. Total facial nerve decompression for RFP in selected patients appears efficacious in preventing recurrences. Decompression will remain investigational until further followup is obtained. Furthermore, its salutary effect should not be extrapolated to Bell's palsy without further study.

    Title Electroneurography and Intraoperative Facial Monitoring in Contemporary Neurotology.
    Date November 1989
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Electrodiagnostic testing of the facial nerve has evolved beyond prognostic and topognostic testing to include preoperative assessment and intraoperative monitoring. The state of the art in facial nerve testing is herein reviewed. Electroneurography is described as a means of preoperative assessment to detect subclinical neural degeneration for temporal bone tumors, malignant external otitis, and recurring facial paralysis. Techniques of intraoperative facial nerve monitoring are presented with clinical correlation of the facial evoked responses. Finally, recent advances in electrodiagnostic testing, including antidromic recording and transtemporal magnetic stimulation of the facial nerve, are discussed.

    Title Magnetic Stimulation of the Facial Nerve.
    Date June 1989
    Journal The American Journal of Otology
    Excerpt

    Electrical testing of the facial nerve has evolved into an important means of assessing neural injury. However, the inability to stimulate the intratemporal facial nerve electrically results in a delay in diagnosis, because axonal degeneration must progress distal to the stylomastoid foramen before testing can be meaningful. To circumvent this problem, we began an investigation of magnetic stimulation of the facial nerve, because pulsed magnetic fields can pass unattenuated through all body structures, including bone. Normal volunteers and one patient with acute facial paralysis were studied with both magnetic and electric stimulation of the facial nerve. The results indicate that (1) magnetic stimulation was more comfortable because high current levels were not required at the skin surface to assure indepth stimulation, (2) magnetic and electric stimulation of the extratemporal facial nerve resulted in nearly identical compound muscle action potentials, indicating that the sites and mechanisms of neural depolarization are similar, and (3) transtemporal magnetic stimulation appears to allow depolarization of the proximal intratemporal nerve. These preliminary results are encouraging and indicate that magnetic stimulation of the facial nerve warrants further investigation.

    Title Neurography for Intraoperative Monitoring of Facial Nerve Function.
    Date March 1989
    Journal Neurosurgery
    Title Use of Bacitracin for Neurotologic Surgery.
    Date November 1988
    Journal The Laryngoscope
    Excerpt

    Wound infection, cerebrospinal fluid leak, and meningitis are serious potential complications of neurotologic procedures that transgress the posterior cranial fossa dura. A study of 236 patients was made to determine the effect of perioperative intravenous antibiotics and topical bacitracin irrigation on the incidence of these complications. Of the 236 patients, 170 (72%) underwent translabyrinthine resection of acoustic tumors, while 66 (28%) underwent retrolabyrinthine vestibular nerve section. Patients were divided into four groups: those who received no antibiotics, those who received perioperative intravenous antibiotics only, those who received topical bacitracin irrigation only, and those who received a combination of perioperative intravenous antibiotics and topical bacitracin irrigation. There were no untoward effects of either perioperative intravenous antibiotics or topical bacitracin. The results indicate that bacitracin irrigation reduced the incidence of wound infection from 9% to 2% (p less than 0.05); of cerebrospinal fluid leak from 12% to 5% (p less than 0.04); and of all targeted complications combined from 22% to 9% (p less than 0.006). Furthermore, the topical bacitracin irrigation only group showed a statistically significant reduction in wound infections compared to the perioperative intravenous antibiotic only group (p less than 0.02). The incidence of meningitis was statistically unaffected by any of our treatment protocols.

    Title Bioactive Glass Ceramic in Ossicular Reconstruction: a Preliminary Report.
    Date August 1988
    Journal The Laryngoscope
    Excerpt

    Current techniques for ossicular reconstruction include ossicular autografts and homografts, and plastic and ceramic prostheses. Experimental testing of ceramic materials has led to the development of a nonporous, bioactive form of glass ceramic (Ceravital) for tympanoplastic reconstruction. To determine the clinical usefulness of these implants, Ceravital ossicular reconstructions were evaluated in 37 patients treated at the University of Michigan Medical Center during an 18-month period. Thirty-two patients (86%) with chronic ear disease underwent Ceravital ossicular reconstruction with tympanoplasty with or without mastoidectomy. Five other patients (14%) underwent ossicular reconstruction--2 for congenital anomalies, 2 for temporal bone trauma, and 1 patient for glomus tympanicum removal. Patient follow-up ranged from 2.2 to 3.8 years, with a mean follow-up period of 2.9 years. Prosthesis extrusion occurred in one case (3%). Mean preoperative and postoperative (2-year) pure tone air-bone gaps were 41.6 dB and 21.3 dB, respectively. Hearing was improved in 35 of 37 patients (95%). Postoperative pure tone air-bone gap was closed to 20 dB or less in 23 patients (62%). Hearing gains were greater with partial rather than total reconstructions (p = 0.14) and significantly greater with intact canal wall rather than canal wall down tympanoplasties (p less than 0.05). Initial results obtained with the Ceravital ossicular prosthesis compare favorably with those obtained using other methods of alloplastic reconstruction. These preliminary data suggest that Ceravital is an effective alternative prosthetic material for ossicular reconstruction.

    Title Electroneurography: Preoperative Facial Nerve Assessment for Tumors of the Temporal Bone.
    Date November 1987
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Tumors of the temporal bone and cerebellopontine angle may be associated with subclinical facial nerve degeneration, despite clinically normal facial function. To determine if preoperative neurophysiologic testing might predict postoperative facial function after tumor surgery, preoperative facial electroneurography (ENoG) was performed in 82 patients with confirmed tumors of the temporal bone and cerebellopontine angle. In patients with acoustic neuroma, preoperative ENoG amplitude reduction varied directly with tumor size. In addition, a statistically significant association between impaired postoperative facial function and acoustic neuroma size greater than 2.5 cm was found. However, preoperative ENoG amplitude reduction did not accurately predict postoperative facial function. These findings suggest that factors, such as the type and size of tumor, the microanatomic relationship between the facial nerve and the neoplasm, and/or desynchronization of the evoked motor-unit volley, may effect results obtained with ENoG in this setting.

    Title The Source of Far-field Antidromic Facial Nerve Potentials.
    Date October 1987
    Journal American Journal of Otolaryngology
    Excerpt

    Most electrodiagnostic tests of facial nerve function are based on recordings of the distal muscle action potentials evoked by a proximal electrical stimulus. In contrast, retrograde or antidromic nerve action potentials can be recorded by near-field (directly from the nerve) or far-field (scalp) techniques. Clinical and surgical applications of far-field antidromic recording recently have been suggested because of such potential benefits as obviating the need to await axonal degeneration distal to the stylomastoid foramen. Critical to far-field recording is an understanding of the source from which the distant response is derived. This study was undertaken to identify the generator sites of the far-field antidromic facial nerve response in dogs. The results suggest the following for the montage and stimulus protocol employed: 1) the far-field antidromic response is a volume-conducted nerve action potential generated primarily from the mastoid segment, 2) complete transection of the facial nerve at the cerebellopontine angle has little effect on the responses, and 3) there appears to be no significant supranuclear generator site.

    Title Intraparotid Facial Nerve Neurofibroma.
    Date March 1987
    Journal The Laryngoscope
    Excerpt

    Neurogenic neoplasms of the intraparotid facial nerve are uncommon and are usually diagnosed intraoperatively by tissue biopsy. Fifty-six cases of primary neurogenic neoplasms involving the facial nerve have been reported. The majority of these have been schwannomas. A case of a solitary neurofibroma involving the main trunk of the facial nerve is presented. Schwannomas and neurofibromas have distinct histological features which must be considered prior to the management of these tumors. The management of neurogenic tumors associated with normal facial function is a particularly difficult problem. A new approach for the diagnosis and management of neurogenic neoplasms is described utilizing electroneurography.

    Title Electroneurography: Preoperative Facial Nerve Assessment in Acoustic Neuroma Surgery: a Preliminary Study.
    Date December 1986
    Journal The American Journal of Otology
    Excerpt

    Preservation of facial nerve function during acoustic tumor resection is an important goal. Patients with acoustic tumors who present with facial weakness may be at increased risk of postoperative facial paralysis. Subclinical tumor involvement of the facial nerve may be more frequent than is commonly recognized. A preliminary study was undertaken to assess the incidence of subclinical involvement of the facial nerve and to discern if such involvement had prognostic implications. Preoperative facial electroneurography (ENoG) was performed in thirteen patients undergoing surgical resection of acoustic tumors. Three of thirteen patients demonstrated preoperative facial weakness and ENoG was abnormal in all three of these patients. Of the ten patients with normal facial function preoperatively, eight revealed amplitude reduction on ENoG testing. Further study is required to discern the prognostic value of preoperative ENoG abnormalities.

    Title Anatomic Basis for Labyrinthine Preservation During Posterior Fossa Acoustic Tumor Surgery.
    Date October 1986
    Journal The Laryngoscope
    Excerpt

    Earlier diagnosis of acoustic tumors promises to increase our opportunity to identify patients with serviceable hearing. Critical to a posterior fossa transmeatal approach for acoustic tumor resection is preservation of the underlying labyrinth. Although the labyrinth has been recognized as a limiting factor in exposure of tumor in the internal auditory canal, few reports have detailed the microscopic surgical anatomy posterior to the internal auditory canal. An anatomic study was undertaken to determine consistent relationships between critical structures within the temporal bone relevant to hearing preservation surgery. The results of this study indicate that, whereas topographic landmarks are helpful for orientation, the more consistent relationship of the labyrinth to the vestibular aqueduct and singular canal allows a more accurate localization of the underlying labyrinth. Although the vestibule frequently prevents direct visualization of the transverse crest, a dissection based upon the microsurgical anatomy will maximize visualization of the lateral fundus while preserving the integrity of the labyrinth.

    Title Spontaneous Encephalocele of the Temporal Bone.
    Date May 1986
    Journal Archives of Otolaryngology--head & Neck Surgery
    Excerpt

    Postsurgical and posttraumatic encephaloceles of the tegmen tympani and tegmen mastoideum are well-recognized occurrences. Less frequently recognized, however, is the spontaneous occurrence of an encephalocele associated with cerebrospinal fluid otorrhea or rhinorrhea. This cerebral herniation into the middle ear and the mastoid cavity in adults is associated with a loss of both bony and dural support, and surgical management must deal with both the cerebrospinal fluid leak and herniation of the brain.

    Title Pneumocephalus Following Treatment of a Stapes Gusher.
    Date January 1986
    Journal The American Journal of Otology
    Excerpt

    A case history is presented of a patient who underwent stapedectomy complicated by a cerebrospinal fluid (CSF) gusher. A persistent postoperative CSF leak was controlled by elevation of the head and spinal drainage. Retrograde passage of air through a labyrinthine fistula, however, resulted in pneumocephalus and transient neurologic deficit. This is a rare but serious complication of treatment of a stapes gusher which demonstrates the potential for entry of air intracranially in the presence of a perilymph fistula.

    Title Antidromically Evoked Facial Nerve Response.
    Date January 1986
    Journal American Journal of Otolaryngology
    Excerpt

    Facial nerve electrodiagnostic tests that are currently available indirectly assess the severity of injury to the intratemporal facial nerve. Antidromic conduction testing is an alternate approach that, if feasible, could provide direct and immediate assessment of proximal facial nerve function. This possibility was tested in a guinea pig model, in which near-field (intracranial) and far-field (extradural) recording techniques were used to assess antidromically evoked facial nerve activity. Response characteristics, topographical distribution, and lesion effects suggest that the recorded potentials represent antidromic activation of the facial nerve. If response amplitude and/or latency can be correlated with the functional state of the nerve, antidromic testing may provide a useful means of assessing proximal facial nerve function in pathologic states.

    Title Intraoperative Facial Nerve Monitoring: a Comparison of Stimulating Electrodes.
    Date January 1986
    Journal The Laryngoscope
    Excerpt

    Preservation of the facial nerve during acoustic neuroma resection may be enhanced by the use of intraoperative electrical stimulation. Although stimulation of the extratemporal facial nerve is an effective and established procedure, anatomic differences of the intradural facial nerve and its microenvironment demand more exacting stimulus protocols. The absence of epineurium may make the intradural nerve more susceptible to mechanical or electrical trauma while intermittent pooling of cerebrospinal fluid (CSF) at the cerebellopontine angle may shunt current away from nerve. Four stimulus configurations were examined under varying conditions simulating CSF pooling. The results indicated that: 1. insulation of stimulating electrodes prevents CSF current shunting and allows utilization of a constant current source, and 2. monopolar and bipolar configurations demonstrate significantly different electrical characteristics which may be employed selectively based upon specific clinical goals.

    Title The Giant Cholesterol Cyst of the Petrous Apex: a Distinct Clinical Entity.
    Date December 1985
    Journal The Laryngoscope
    Excerpt

    The giant cholesterol cyst (GCC) of the petrous apex may now be considered a distinct clinical entity and should be considered in the differential diagnosis of lesions of the midcranial skull base. This benign cystic lesion of the petrous apex gradually enlarges and may produce progressive bone erosion and serial neurologic deficits of the cranial nerves within the temporal bone and jugular foramen. We report here five instances of this lesion (3 patients with unilateral and 1 patient with bilateral petrous apex lesions) and describe the natural history, diagnostic evaluation, pathology, and surgical management.

    Title Orbital Wall Thickness and the Spread of Infection from the Paranasal Sinuses.
    Date December 1985
    Journal Clinical Otolaryngology and Allied Sciences
    Excerpt

    Ninety-three human skulls (80 adults and 13 children) have been examined and the extent of thin bone in the party walls between the orbit and the frontal, ethmoidal and maxillary sinuses has been assessed. Translucent bone is most often present in the lateral wall of the ethmoidal labyrinth and least often in the floor of the frontal sinus. In children such bone is present significantly less often in the roof of the maxillary sinus (P less than 0.001) than in adults. Computerized tomography scans and clinical data from 6 patients with orbital cellulitis were reviewed. In one of these an inferolateral subperiosteal abscess of the orbit was associated with a defect in the roof of the maxillary sinus. Two patients had a medial subperiosteal abscess associated with ethmoiditis and in one there was direct continuity between the abscess and the adjacent ethmoidal cells. In another case a superolateral abscess was demonstrated in continuity with a surgical defect in the floor of the frontal sinus. We conclude that the ethmoidal, frontal or maxillary sinuses may be sources of orbital infection and that spread occurs either by direct extension through the sinus wall or by local thrombophlebitis.

    Title Epidermoidomas of the Cerebellopontine Angle and Temporal Bone: Ct and Mr Aspects.
    Date November 1985
    Journal Radiology
    Excerpt

    Epidermoidomas were found in four locations within and adjacent to the temporal bone: cerebellopontine angle, petrous apex, facial geniculate ganglion region, and tympanic-mastoid cavity. Lesions in each of these locations presented different clinical and imaging characteristics. Cerebellopontine angle epidermoidomas were seen on computed tomography (CT) as low-attenuation masses in the posterior fossa. Petrous apex and geniculate ganglion region lesions destroyed and expanded the bone of their respective regions. Tympanic-mastoid cavity epidermoidomas were relatively nonspecific, soft-tissue masses. CT study of the brain and temporal bone was the single most informative imaging procedure in the preoperative evaluation of these lesions. Magnetic resonance images complemented CT scans for evaluation of the size and extent of the abnormality but were relatively nonspecific and did not allow preoperative differentiation of epidermoidomas from other temporal bone lesions.

    Title Facial Electroneurography: Clinical and Experimental Investigations.
    Date November 1985
    Journal Otolaryngology--head and Neck Surgery : Official Journal of American Academy of Otolaryngology-head and Neck Surgery
    Excerpt

    Facial electroneurography (ENoG) appears to be a reliable prognostic test for intratemporal facial nerve paralysis. ENoG is objective and allows a permanent record to be maintained. Nonetheless, occasional inconsistencies in clinical correlation may diminish the utility of ENoG. A qualitative study was undertaken to identify the possible reasons for the inaccuracy of ENoG in some patients. Four clinical groups and one experimental group were studied: (1) normal subjects, (2) patients with acute facial palsy, (3) patients with progressive facial palsy, (4) patients with temporal bone tumors and normal facial function, and (5) animals in which one facial nerve was crushed and repaired. The reliability of ENoG is dependent on careful interpretation of data obtained by optimal electrode placement and stimulus duration.

    Title The Arcuate Eminence. Topographic Orientation in Middle Cranial Fossa Surgery.
    Date March 1985
    Journal The Annals of Otology, Rhinology, and Laryngology
    Excerpt

    The superior semicircular canal (SSC) is an important landmark in the middle cranial fossa approach to the temporal bone. This landmark is frequently located by its topographic association to the arcuate eminence. An anatomic study is reported which examines the relationship of the arcuate eminence to the SSC. Techniques for orientation to the internal auditory canal by the middle cranial fossa approach are reviewed and a technique for localizing the SSC when no arcuate eminence is discernible is presented. 1) In 15% of temporal bone specimens, no arcuate eminence was discernible. 2) Of those specimens with an arcuate eminence, 50% demonstrated that the arcuate eminence was rotated posteriorly from the SSC. 3) Despite displacement of the arcuate eminence, the SSC tended to remain perpendicular to the petrous ridge and 60 degrees from the internal auditory canal. 4) Because of their variable relationship, the arcuate eminence should not be used as a substitute for the SSC in the topographic orientation to the internal auditory canal. 5) A technique for locating the SSC when the arcuate eminence is indiscernible is presented.

    Title Salivary Gland Choristoma of the Middle Ear: a Case Report and Review of the Literature.
    Date March 1984
    Journal The Laryngoscope
    Excerpt

    Salivary gland choristomata are heterotopic rests which have rarely been reported in the middle ear. A case report of a salivary gland choristoma of the middle ear is presented and the literature reviewed. The frequent association of ossicular chain and facial nerve anomalies is emphasized.

    Title Jugular Foramen Schwannomas: Diagnosis and Suggestions for Surgical Management.
    Date
    Journal Skull Base Surgery
    Excerpt

    Schwannomas arising in the parapharyngeal space are rare lesions; however, those originating in the jugular foramen are even less common. Two cases, each with marked intra- and extracranial extensions, are discussed. Clinical presentation and preoperative evaluation emphasizing computerized tomographic and magnetic resonance imaging will be presented. An aggressive two-stage surgical approach consisting of a retrosigmoid craniectomy combined with infratemporal removal is advocated for those lesions arising within the jugular foramen.

    Title Intraoperative Cranial Nerve Monitoring During Posterior Skull Base Surgery.
    Date
    Journal Skull Base Surgery
    Excerpt

    Intraoperative monitoring of neurophysiologic function is rapidly evolving as an important adjunct during skull base surgery to reduce the incidence of neurologic deficit. Facial nerve monitoring is an excellent model, since electrical and mechanical evoked potentials can be directly presented to the surgeon in real-time through an acoustic loudspeaker display. The lower cranial nerves may also be monitored using similar electromyographic techniques. Auditory system monitoring is more difficult due to the low amplitude response that requires averaging and filtering to extract the evoked potential. In conjunction with auditory monitoring, improved hearing preservation may be further enhanced by concomitant facial nerve monitoring, since the surgeon is alerted to traumatic manipulations that may affect both facial and cochlear nerves. Techniques and interpretative issues are presented to maximize the efficacy and safety of cranial nerve monitoring.

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