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Biomedical subjects

A De la Cruz

Publications and source records attributed to A De la Cruz.

At least 19 recordsLinked to original sources
PubMed2001

The transcochlear approach revisited.

OBJECTIVE: To evaluate the indications for, techniques used in, and patient outcomes after surgery with the transcochlear approach in the treatment of petroclival tumors. METHODS: Retrospective review of 24 cases between 1985 and 1995 at the House Ear Clinic (Los Angeles, CA, U.S.A.). RESULTS: Meningioma was the most common tumor. Complete removal was achieved in 82% of tumors after one-or two-stage surgeries (average follow-up time, 36 months). The second-stage surgery was a middle fossa transpetrous approach. Most patients had some degree of facial nerve dysfunction immediately after surgery, and 12 of 20 patients subsequently improved to House-Brackmann Grade III or better. Fifty-nine percent of patients had permanent neurologic sequelae because of either the surgery or their disease. CONCLUSION: The transcochlear approach is best suited to treating petroclival intradural tumors that extend ventrally to the brainstem in patients without serviceable hearing. Temporary facial weakness is expected as a result of posterior facial nerve transposition.

Adult↗
PubMed2000

Prognostic factors for hearing preservation in vestibular schwannoma surgery.

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

Adolescent↗
PubMed1999

Stapedectomy in children.

Stapes surgery for correction of conductive hearing loss in adults with otosclerosis is a well-established procedure. Its effectiveness in children, however, has received less scrutiny in the literature. Previous studies from our and other institutions demonstrated similar results in children and adults. Between 1980 and 1994 stapedectomies were done on 95 ears of 81 patients younger than 18 years (83 primary and 12 revisions). Data regarding age of onset, family history, associated anomalies, surgical findings, technique, hearing results, and complications were reviewed. Two groups were identified: congenital stapedial fixation and juvenile otosclerosis. Patients with congenital stapedial fixation had an earlier onset of hearing loss (3 vs 10 years, P < 0.001), a greater incidence of abnormalities of the malleus and incus (25% vs 3%, P < 0.001), and a slightly greater preoperative air-bone gap (35.2 +/- 12.9 vs 27.8 +/- 8.9, P = 0.002). Patients with otosclerosis had a greater frequency of a positive family history of deafness (53% vs 10%, P < 0.001). Overall, 79% of primary cases and 89% of revision cases had an improvement in hearing, with mean postoperative air-bone gaps of 15 dB and 22 dB, respectively. The gap did not widen significantly during the entire length of follow-up (mean 72 months). In primary cases, 59.1% obtained a postoperative air-bone gap of 10 dB or less. Eighty-two percent of children operated on for otosclerosis obtained excellent results (postoperative air-bone gap < or = 10 dB), compared with only 44% of children with congenital stapedial ankylosis (P = 0.02). In revision surgery, 29% of children obtained excellent results. Poorer results in both cases of congenital stapedial fixation and revision stapedectomy appear to be related to the greater incidence of associated anomalies of the malleus and incus. Indications, technique, complications, and considerations pertinent to childhood stapedectomy are discussed.

Audiometry↗
PubMed1999

Detection and management of childhood cholesteatoma.

Childhood cholesteatoma is an aggressive disease that demonstrates higher rates of recidivism than its adult counterpart. The priorities in ideal management include total removal, followed by hearing restoration, followed by preserving the ear anatomy. Especially in children, one must endeavor to preserve ear anatomy if it does not jeopardize total removal of cholesteatoma. Absolute indications for CWD surgery include an only-hearing ear, a severely destroyed posterior canal wall, an extremely contracted mastoid, and matrix overlying a semicircular canal fistula. Reasons for staging childhood cholesteatoma include suspected residual disease, uncertainty about total removal of cholesteatoma, severe mucosal disease, and CWU procedures in which the cholesteatoma has diffusely invaded the bone. Adequate long-term follow-up is imperative. Patients and their families should be reminded frequently of the importance of close follow-up because recidivism is frequent. Successful management of cholesteatoma in children does not involve a rigid, "one-way" approach. The surgeon must be flexible and capable of employing the most appropriate procedure for the patient.

Age of Onset↗
PubMed1998

Petrous apex lesions.

OBJECTIVE: The accurate diagnosis of different petrous apex lesions is increasingly common as a result of modern imaging techniques, combining computed tomography and magnetic resonance imaging. The clinical features, diagnostic evaluation, imaging, and treatment outcomes of patients with petrous apex lesions are reviewed. STUDY DESIGN: Retrospective case review. SETTING: Private practice tertiary otologic referral center. PATIENTS: Sixty-six patients treated at the House Ear Clinic in the last 2 decades for a lesion of the petrous apex. Lesions included cholesterol granuloma, cholesteatoma, and chondrosarcoma, among others. Mean follow-up time was 27 months and ranged from 1 month to 10 years. INTERVENTION(S): Cholesterol granulomas were treated with drainage procedures, solid tumors were surgically removed using primarily the middle fossa or infratemporal fossa approaches. RESULTS: The most common presenting symptoms were hearing loss, dizziness, headaches, and tinnitus. Decreased cranial nerve V function was present in 22%. The most common cystic lesion was cholesterol granuloma, which constituted 60% of all lesions in the study, followed by cholesteatoma (9%). Chondrosarcomas were the most common solid lesion (6% of all lesions). Asymmetric pneumatization and retained secretions give radiographic findings commonly overdiagnosed as lesions of the petrous apex. CONCLUSIONS: Lesions of the petrous apex can be diagnosed accurately by CT and MRI and can be divided into cystic and solid lesions. Cholesterol granulomas are by far the most common lesion found in this site and can be drained with minimal morbidity via the infracochlear approach. Solid tumors may require extensive exposure and a combined skull base approach for complete removal.

Adolescent↗
PubMed1996

Cerebellopontine angle epidermoids: results of surgical treatment.

Epidermoids, or congenital cholesteatomas, constitute about 0.2% to 1.5% of intracranial tumors, and 3% to 5% of tumors of the cerebellopontine angle (CPA). We review the surgical management of CPA epidermoids in 13 patients at the House Ear Clinic for the years 1978 to 1993. There were seven male and six female patients, ranging in age from 27 to 59 years (average, 40 years). Tumors ranged in size from 3.5 cm to 7.0 cm, and the surgical approach was tailored to the tumor extent and location. All patients complained at presentation of unilateral hearing loss, and nine had poor speech discrimination (less than 50%) preoperatively. Serviceable hearing was preserved in two patients. Two patients presented with facial nerve symptoms, and four cases had postoperative permanent facial nerve paralysis (House-Brackmann Grade V or VI). There were no surgical deaths. Four patients required second surgeries to remove residual cholesteatoma. Compared with prior series, we describe a higher rate of total tumor removed, as well as a higher rate of second operations, indicating a more aggressive approach to these lesions.

Journal Article↗
PubMed1995

Surgery of congenital aural atresia.

The treatment of congenital aural atresia has changed in recent years. Better imaging capabilities, the development of tympanoplasty techniques, modification of mastoid dissection, and facial nerve monitoring have resulted in greater patient benefit with less patient risk. Success rates continue to be high, and the incidence of complications has decreased. A series of cases was reported in 1985, and now the authors review 92 congenital aural atresiaplasties performed over the following 9 years. Closure of the air-bone gap to less than 30 dB was achieved in 60% of primary surgeries and 54% of revisions. The most common complications were external auditory canal stenosis and lateralization of the tympanic membrane. External auditory canal stenosis due to bony regrowth was seen in 12% of primary cases and 11.5% of revisions; soft tissue stenosis was seen in 10% of primaries and 4% of revisions. Tympanic membrane lateralization was seen in 9% of primary surgeries and in 15% of revisions. Carbon dioxide and argon lasers (HGM Medical Laboratories, Salt Lake City, Utah) and Merocel stenting wicks with split-thickness skin grafting were used to try to improve long-term hearing outcome and decrease postoperative external auditory canal stenosis. With meticulous surgical technique by an experienced otologic surgeon and appropriately selected patients, this problem can be managed effectively.

Adolescent↗
PubMed1994

Surgical management of previously untreated glomus jugulare tumors.

The treatment of glomus jugulare tumors is controversial. Changes in the surgical treatment of glomus jugulare tumors at The House Ear Clinic have allowed complete resection in 85% of patients with minimal morbidity and no surgical mortalities. Our experience with 52 previously untreated patients with glomus jugulare tumors is reviewed. Two primary surgical techniques were used. The mastoid/neck approach was used in 9 patients with small tumors limited to the jugular bulb. The infratemporal fossa approach was used in the remaining 43 tumors. Lower cranial nerve preservation was possible in the majority of patients with normal preoperative function. Modifications in the management of the facial nerve during the infratemporal fossa approach have resulted in good recovery of facial function (House grade I/VI or II/VI) in 95% of patients. Most patients (85%) were able to fully resume all preoperative activities. Our results suggest that surgical management is the treatment of choice in younger patients with glomus jugulare tumors.

Adult↗
PubMed1994

Ossiculoplasty in congenital hearing loss.

We have presented an extensive review of congenital ossicular anomalies. These deformities occur in combination with one another or as isolated problems with equal frequency. They are so rare that even the busiest otologists have limited clinical experience with them. The astute otologist will keep these facts in mind when assessing congenital middle ear problems in the office and in the operating room. Careful, detailed history taking may reveal the presence of familial conductive hearing loss or other congenital syndromes. Complete head and neck examination as well as observation of the extremities may provide clues to the otologic diagnosis. Microscopic examination of the ear reveals abnormalities of the tympanic membrane, malleus, and incus. Audiometric and radiologic evaluation augments physical examination. At surgery, the otologist must be prepared to perform a variety of possible surgical procedures, from traditional ossiculoplasty and stapedectomy to fenestration. Hearing aids are an option for patients with congenital ossicular anomalies, and the possibility of inoperability must be kept in mind; the patient must be prepared for this eventuality. Congenital ossicular anomalies present a challenge to the otologic surgeon, and their successful treatment, the greatest reward.

Child, Preschool↗
PubMed1993

Lateral extent of internal auditory canal involvement by acoustic neuromas: a surgical-radiologic correlation.

The sensitivity of gadolinium-enhanced magnetic resonance imaging (MRI) is such that inflamed areas of individual nerves can be visualized. Given this, might the lateral extent of an acoustic neuroma in the internal auditory canal be inaccurately depicted by MRI with gadolinium contrast due to variable enhancement in inflamed neural tissues? The authors studied the correlation between preoperative MRI and intraoperative observation of the lateral extent of tumor in the internal auditory canal (IAC) of 82 patients with acoustic neuromas. The surgeon made a visual determination of tumor extent when the lateral-most aspect of the tumor was exposed. The radiologist, blind to surgical findings, noted the degree of extension into the IAC based on the MRI. The majority (83%) of the tumors involved the lateral third and fundus of the IAC. Agreement between scans and surgical findings was excellent for tumors extending into the lateral third of the IAC, with a test sensitivity of 94 percent and a positive predictive value of 98.5 percent. Knowledge of the accuracy of MRI in demonstrating extent of tumor in the IAC is important in making decisions regarding surgical approach.

Animals↗
PubMed1993

Magnetic resonance angiography: analysis of vascular lesions of the temporal bone and skull base.

Contrast-enhanced, high resolution, computed tomography (CT), along with gadolinium-enhanced magnetic resonance imaging (MRI), provide the skull-base surgeon with essential information for diagnosis and surgical planning. Evaluation of skull-base vasculature has traditionally been performed with angiography. Four-vessel angiography is an invasive procedure that subjects the patient to the potential risks of vascular injury, stroke, renal damage, anaphylaxis, and radiation. The development of gradient-recall echo pulse sequence in MRI provides a means to evaluate the vasculature with a noninvasive, low-risk technique. We review the experience of the House Ear Clinic with magnetic resonance angiography (MRA) in evaluating cranial-base abnormalities including paragangliomas, aberrant vessels, and dural sinus thrombosis. Based on a review of 25 cases, we conclude that MRA is a useful procedure for evaluation of major arteries, veins, and dural sinuses. The technique has been less helpful in defining small vessel detail such as feeding blood supply and tumor staining.

Carotid Arteries↗
PubMed1988

Choroidal melanoma with pigment dispersion in vitreous and melanomalytic glaucoma.

A 39-year-old black man underwent enucleation of the left eye because of poor vision, ocular pain, and intractable glaucoma secondary to a choroidal tumor. Two diagnostic vitrectomies, performed 11 and 7 months before enucleation, had failed to disclose the proper diagnosis. Histologic diagnosis was necrotic malignant melanoma of the choroid with melanocytoma cells, extensive pigment dispersion throughout the eye, and melanomalytic glaucoma. Possible mechanisms of tumor necrosis are reviewed.

Adult↗
PubMed1985

Congenital atresia of the external auditory canal.

Children with congenital atresia of the external auditory canal require an early assessment of hearing and a determination of the degree of atresia and associated pathology by polytomography and/or high-resolution CT scanning. We analyzed the otologic findings in 302 ears (239 patients) with severe atresia of the external auditory canal. Eighty-seven primary or revision surgeries were performed. Fifty-three percent obtained a residual conductive deficit of 20 dB or less. Lateralization of the tympanic membrane graft was the primary cause of failure in obtaining good hearing results. The use of split-thickness skin graft instead of a full-thickness skin graft to cover the reconstructed external canal has decreased the incidence of restenosis and revision surgery.

Abnormalities, Multiple↗
PubMed1984

Polytomographic evaluation of the clivus and petrous apices: a new view.

The base of the skull lesions that arise anterior to the porus acusticus, clivus, or from the jugular carotid or hypoglossal canals present difficult surgical access. Plain films, arteriograms, and the conventional AP, lateral, and full base tomograms have often fallen short in allowing an easy understanding of the surgical relationships between these structures. The objectives of this thesis are 1. to present a previously unpublished tomographic view based on the surgical relationships, as encountered by the surgeon, that complement the traditional views and simplify the preoperative assessment of the lesion, 2. to review the literature on the subject, and 3. to present the author's experience with this view in use since 1976.

Adolescent↗
PubMed1981

Staging Meniere's disease and reporting results in Meniere's disease: symposium panel discussion.

At its recent spring meeting, the American Neurotologic Society devoted a portion of its program to a symposium on staging Meniere's disease and reporting results. One of the problems discussed, was which preoperative audiogram should be used for reporting results of any treatment. I think that it is very important that we, as otologists, try to look at Meniere's disease or any inner ear dysfunction in a more scientific way. Some of you may feel, on initial evaluation of this material, that it is too cumbersome to be practical in your daily clinical work. However, we feel we have put forth a reasonable staging system and method of reporting results that can be quite helpful once the simple routine of using them has become established. The vertigogram, for example, which is designed to be very simple and not require any sophisticated equipment, should be as easy to read as an audiogram. If we try to approach the vagaries of Meniere's disease or any inner ear dysfunction in a more scientific fashion, I am sure that in several years we will be in a much better position collectively to evaluate our results and to help our patients. This type of comprehensive staging system for all of the components in Meniere's disease or any inner ear dysfunction will enable us to objectify diagnoses and treatment results so that they can be easily compared. We have put forth some of the ideas and methods that we think will help us arrive at a consensus for reporting results. We encourage you to try some of the suggestions presented in this article and welcome your comments and ideas for improving this staging system and method for reporting results.

Audiometry↗