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Perilymph sampling from the cochlear apex: a reliable method to obtain higher purity perilymph samples from scala tympani.

Measurements of drug levels in the fluids of the inner ear are required to establish kinetic parameters and to determine the influence of specific local delivery protocols. For most substances, this requires cochlear fluids samples to be obtained for analysis. When auditory function is of primary interest, the drug level in the perilymph of scala tympani (ST) is most relevant, since drug in this scala has ready access to the auditory sensory cells. In many prior studies, ST perilymph samples have been obtained from the basal turn, either by aspiration through the round window membrane (RWM) or through an opening in the bony wall. A number of studies have demonstrated that such samples are likely to be contaminated with cerebrospinal fluid (CSF). CSF enters the basal turn of ST through the cochlear aqueduct when the bony capsule is perforated or when fluid is aspirated. The degree of sample contamination has, however, not been widely appreciated. Recent studies have shown that perilymph samples taken through the round window membrane are highly contaminated with CSF, with samples greater than 2microL in volume containing more CSF than perilymph. In spite of this knowledge, many groups continue to sample from the base of the cochlea, as it is a well-established method. We have developed an alternative, technically simple method to increase the proportion of ST perilymph in a fluid sample. The sample is taken from the apex of the cochlea, a site that is distant from the cochlear aqueduct. A previous problem with sampling through a perforation in the bone was that the native perilymph rapidly leaked out driven by CSF pressure and was lost to the middle ear space. We therefore developed a procedure to collect all the fluid that emerged from the perforated apex after perforation. We evaluated the method using a marker ion trimethylphenylammonium (TMPA). TMPA was applied to the perilymph of guinea pigs either by RW irrigation or by microinjection into the apical turn. The TMPA concentration of the fluid sample was compared with that measured in perilymph prior to taking the sample using a TMPA-selective microelectrode sealed into ST. Data were interpreted with a finite element model of the cochlear fluids that was used to simulate each aspect of the experiment. The correction of sample concentration back to the perilymph concentration prior to sampling can be performed based on the known ST volume (4.7microL in the guinea pig) and the sample volume. A more precise correction requires some knowledge of the profile of drug distribution along the cochlear prior to sampling. This method of sampling from the apex is technically simple and provides a larger sample volume with a greater proportion of perilymph compared to sampling through the RW.

Animals↗

Retraction cholesteatoma of the sinus tympani.

Posteromedial retraction of the tympanic membrane, between the oval window superiorly and the round window niche inferiorly, results in the formation of an epithelium-lined pocket within the sinus tympanic recess. Failure to recognize posterior invagination of the tympanic membrane intraoperatively leads to inadvertent tearing of the tympanomeatal flap at the level of the annulus with epithelial seeding of the middle ear and probably cholesteatoma recurrence. This article focuses on the clinical manifestations and radiographic findings suggestive of sinus tympanic epithelial retraction of the pars tensa and provides direct correlation between human cross-sectional temporal bone anatomy and otomicroscopy. The surgical management of these challenging lesions includes initial endaural access, external meatal bone removal posteromedial to the tympanic annulus and anterior to the vertical portion of the facial nerve, and middle ear ventilation after marsupialization of the epithelial retraction. Although early tympanic membrane retraction can be treated with a ventilation tube, deep epithelial pockets may require additional surgical treatment. A method for the management of sinus tympanic cholesteatomas is demonstrated.

Cholesteatoma↗

Spontaneous perilymphatic fistula: electrophysiologic findings in animals and man.

The case against the occurrence of spontaneous perilymphatic fistulas is presented. Electrophysiologic findings both in animals and in man suggest that small holes in either the round or oval window are not associated with any significant hearing loss. Removal of perilymph may cause some changes in the electrocochleogram that can be reversed when the perilymph is replaced. Tympanotomy surgery, especially when performed with the injection of local anesthetic solutions may result in transudates in the middle ear that are difficult to differentiate from perilymph leaking out from the inner ear. Perilymphatic fistulas were excluded by performing a posterior myringotomy under general anesthesia in 162 congenitally deaf ears. If fluid was present it was suctioned, and if no change occurred on the intraoperative electrocochleogram, it was concluded that no fistula existed. Based on the electrophysiologic findings and the clinical observations in over 240 ears, it was concluded that spontaneous perilymphatic fistulas do not exist. The author accepts that perilymphatic fistulas occur after surgery, especially after stapedectomy, and that they can occur after head injury or barotrauma. However, these should heal readily; persistent or intermittent fistulas are an otologic rarity.

Adult↗

Cochlear microphonics recorded from fetal and newborn sheep.

PURPOSE: Sounds present within the uterus stimulate the fetal inner ear and central auditory pathway. This study was undertaken to determine the efficiency of transmission of exogenous airborne stimuli to the fetal inner ear. In this way, we may quantify the extent to which the fetal auditory system is isolated from sounds produced outside the mother. MATERIALS AND METHODS: Cochlear microphonics were recorded from fetal and newborn sheep to evaluate the extent to which the fetus is isolated from sounds exogenous to the ewe. Electrodes were surgically placed in contact with the round window membrane in nine near-term fetal sheep. Cochlear microphonics were recorded in response to 1/3 octave-band noises (0.125 to 2.0 kHz) delivered through a loudspeaker 1.8 m from one side of the pregnant ewe. Sound pressure levels generated by the noises were simultaneously recorded ex utero with a microphone and in utero with a hydrophone previously sutured to the fetal neck. After cochlear microphonic amplitudes were recorded, the fetus was delivered through an abdominal incision. Recordings were repeated from the newborn lamb. Fetal sound isolation was calculated as the difference between the sound pressure levels that were necessary to evoke equal cochlear microphonic amplitudes from the fetus and from the newborn lamb. RESULTS: The sound attenuation observed was variable for all frequencies. The fetus was isolated from external sounds by 11.1 dB for 0.125 kHz, 19.8 dB for 0.25 kHz, 35.3 dB for 0.5 kHz, 38.2 dB for 1.0 kHz, and 45.0 dB for 2.0 kHz. CONCLUSIONS: Other investigators have demonstrated that the immature auditory system is more susceptible to damage produced by noise exposure than is the mature auditory system. Low-frequency noise produces damaged cells that later in life code higher frequencies. A possibility of fetal hearing loss produced by intense noise exposure needs more careful evaluation.

Animals↗

Vestibular pathophysiologic changes in experimental perilymphatic fistula.

An animal model of experimental perilymphatic fistula (EPLF) was developed in the guinea pig in order to study vestibular pathophysiology. In experimental animals, 4 microL of perilymph was suctioned from one cochlea via the round window membrane. Changes in vestibular function were as follows. 1) During the acute stage (5 hours postoperatively), spontaneous nystagmus directed toward the normal side was noted in 57.4% of the EPLF animals. This lasted less than 24 hours. 2) One week postoperatively, direction-fixed positional nystagmus toward the lesioned ear was present in 22.7% of the EPLF animals, especially when the lesioned ear was positioned inferiorly. 3) With the ice water caloric test, no response was present in 58.1% of the EPLF animals and an irregular response was found in 22.6% of them, 1 week postoperatively. These results tend to indicate that tests of vestibular function may differentiate between patients with Meniere's disease and those with perilymphatic fistula. Histologic findings indicate that a floating labyrinth is the cause of positional nystagmus and caloric irregularity. The absence of caloric responses was associated with collapse of the vestibular labyrinth.

Animals↗

Effect of corticosteroid treatment on salicylate ototoxicity.

Our previous studies showed that salicylate ototoxicity is associated with decreased levels of prostaglandins (PGs) and elevated levels of leukotrienes (LTs) in the perilymph. The purpose of this study was to determine whether or not pretreatment with corticosteroid, which suppresses both PGs and LTs in arachidonic acid metabolism, prevents salicylate ototoxicity. Salicylate ototoxicity was induced in chinchillas with or without treatment with dexamethasone. Hearing thresholds were measured by auditory brain stem response, and perilymph samples were assayed by high-performance liquid chromatography. Dexamethasone pretreatment, given by either systemic or local round window membrane application, partially prevented salicylate-induced hearing loss. Prevention of salicylate ototoxicity by dexamethasone seems to be correlated with increased PG levels and decreased LT levels in the perilymph. This is another piece of evidence that salicylate ototoxicity may be mediated by abnormal arachidonic acid metabolism in the inner ear.

6-Ketoprostaglandin F1 alpha↗

[Exploratory tympanotomy for suspected traumatic perilymphatic fistula].

UNLABELLED: Firstly reported after stapedectomy, perilymph fistula (PLF), may occur due to trauma. AIM: Preoperative symptoms and therapeutic results are described and analyzed after exploratory tympanotomy for traumatic PLF. MATERIAL AND METHODS: Traumatic PLF was investigated in 90 patients (97 examinations) by exploratory tympanotomy at the Nantes University Hospital from 1995 to 1999. Preoperative symptoms were recorded and compared to results of tympanotomy to determine their diagnostic value. Similarly post-operative recovery was compared to results of tympanotomy. RESULTS: This study showed the value of two symptoms: aural fullness and balance disturbance. During each surgical procedure, systematic grafting was performed even if fistulization was unapparent. The best results were achieved for vestibular symptoms and concerned more vertigo than auditory symptoms. There was no significant difference in postoperative symptoms, between patients with a leak and patients without a leak. CONCLUSION: This demonstrates that the oval and round window should be grafted with connective tissue when an exploratory tympanotomy is performed.

Adult↗

Lasers for otosclerosis: CO2 vs. Argon and KTP-532.

The concept of using laser energy to perform stapedotomy and stapedectomy revision is an attractive one. Precision of vaporizing a perfectly round 0.6- to 0.8-mm hole in the stapes footplate, regardless of its thickness or degree of fixation, would introduce an elegant simplicity to a sometimes difficult operation while eliminating mechanical trauma to the inner ear. When revising a previously failed stapedectomy, lasers should enable the otologic surgeon to atraumatically vaporize the obliterating oval window tissue and thus precisely diagnose the cause of the failure. A laser stapedotomy could then be performed in the membranous oval window, thus minimizing the risk of recurrent prosthesis migration. To accomplish these objectives, lasers must possess physical properties which permit the precise controlled delivery of laser energy to the microscopic operative field. Tissue characteristics of this laser energy should permit the vaporization of the stapes footplate or oval window soft tissue without thermal effect to the vestibule and without passing through the perilymph to damage the delicate structures of the inner ear. Two types of lasers have been successfully used for otosclerosis surgery: the visible lasers (Argon and KTP-532) and the invisible CO2 laser. This paper explores relative merits and disadvantages of each. The visible lasers possess ideal optical properties for microsurgery and, until recently (1984), were the only group of lasers optically precise enough for safe use on the oval window. Unfortunately, the short wavelength of these visible lasers (0.5 mu) impart tissue properties which are less than ideal for otosclerosis surgery. Visible laser is only partially absorbed by the white stapes footplate and readily passes through the perilymph to be absorbed by pigmented tissue of the inner ear (blood vessels, neuroepithelium, etc.). Therefore, the Argon and KTP-532 lasers should be used with caution while performing stapedotomies. Visible lasers should not be used for stapedectomy revisions since direct application of visible laser energy to the open vestibule produces dramatic temperature rises (up to 175 degrees C) in the vestibule at the level of the utricle and saccule. The long wavelength of the invisible CO2 laser (10.6 mu) imparts many optical problems which limit its precision for microscopic surgery. Until recently, the CO2 laser was too inaccurate for otosclerosis engineering advances for CO2 microsurgery. A newly designed microslad optical delivery system could deliver a 0.3-mm spot size CO2 beam at 250-mm focal length which was satisfactorily par-focal and coaxial with the aiming HeNe beam.(ABSTRACT TRUNCATED AT 400 WORDS)

Argon↗

Magnetic susceptibility artifacts on high-resolution MR of the temporal bone.

PURPOSE: To determine whether signal variations and subtle anatomic deformities observed in high-resolution MR studies of temporal bones were caused by the large susceptibility differences at air-fluid interfaces near the round and oval window. METHODS: A systematic study of healthy subjects and plastic phantoms was conducted. The phantom consisted of a series of cylindrical holes of various small sizes within a solid block of plastic. These holes were partially filled with water and then covered with a reservoir of gelatin to simulate the otic capsule air-water interfaces. On a 1.5-T system, T2-weighted fast spin-echo images and three-dimensional Fourier transform gradient acquisition in steady state images were obtained using dedicated phased-array radio frequency coils. The directions of the frequency and in-plane phase-encoding gradients were swapped, and the receiver bandwidth was changed to demonstrate the dependence of the artifacts on these parameters. RESULTS: The phantom images confirmed and characterized artifacts consistent with magnetic susceptibility differences at the air-water interfaces. There is a combination of signal loss, misregistration in the frequency-encoding direction, and high signal foci related to the air-water interfaces. Furthermore, the artifacts were worse with narrower receiver bandwidth. Similar consistent artifact patterns were seen near the oval and round windows in studies of healthy subjects. CONCLUSIONS: In high-resolution MR imaging there are significant deformities in the display of the normal anatomy because of magnetic susceptibility.

Adolescent↗

Endolymphatic pressure in experimental hydrops.

Perilymphatic and endolymphatic pressures were consecutively measured by means of a servomechanical nulling pressure system through the round window and basilar membrane one to 2.5 months after obliteration of the left endolymphatic sac and duct in seven guinea pigs. The position of the pipette was monitored by the simultaneous recording of the direct current potential through the micropipette used for the pressure measurement. (1) The perilymphatic and endolymphatic pressures of the control ears were equal. (2) The histological evaluation showed that the ears operated on had a significantly greater endolymphatic space than the control ears. (3) The endolymphatic pressure of the ear operated on was significantly higher (0.78 +/- 0.32 mm Hg) than that of the perilymph. (4) The endolymphatic direct current potential was equal in both ears.

Animals↗

Application of argon laser to the inner ear.

The effects of argon laser irradiation on the inner ear were studied morphologically. The stria vascularis showed focal coagulation, vesicle formation, perforation and atrophy after irradiation through the otic capsule. These changes vary according to the power and duration of irradiation. Atrophy of the stria vascularis can be produced without injuring the organ of Corti, by suitable application of the laser beam. The round window membrane transmits the argon laser. Tissues in the hook region and a part of the lower basal turn demonstrated changes of varying degree. Loss of the nerve fibres was observed in the osseous spiral lamina, which was fractured and dislocated. Irradiation through the stapedectomized oval window destroyed the macula sacculi without rupturing the saccular wall.

Animals↗

[When to suspect a perilymphatic fistula?].

INTRODUCTION: The diagnosis of perilymphatic fistula (PLF) is difficult since no single clinical situation gives the diagnosis for sure. The goal of this study is to clarify the clinical situations where you must suspect a PLF. METHODS: Retrospective study of 20 patients that had an exploratory tympanotomy with a PLF confirmed peroperatively. An analysis of the symptoms, signs and complementary exams was done. The surgical findings and the postoperative evolution were noted. RESULTS: 100% of patients reported a hearing loss, 80% vertigo, 70% a tinnitus and 35% equilibrium problems. Every patient had an etiological event to explain the PLF (trauma 85%), stapedotomy (10%), other ear surgeries. Five patients had a positive fistula or Vasalva test. All patients except one had an hearing loss on the audiogram (sensorineural, mixte or conductive). 50% had a CT scan, 70% of which were abnormal. A VNG was done on 3 patients. The sites of the PLF were as follows: 90% oval window, 5% round window and 5% both windows. The hearing got better or was stabilised in 95% of patients after the operation. 64% saw an improvement of their tinnitus and 87% of their vertigo. CONCLUSION: The diagnosis of PLF is difficult and a high index of suspicion is mandatory. One must look for an etiologic situation to explain the PLF. The audiogram is almost always modified, a mixte hearing loss being common due to the high incidence of ossicular trauma associated with PLF. The clinical clinical situations where you must suspect a PLF were identified as follows: An old trauma, a recent trauma, a history of otologic surgery particularly on the stapes and a preexisting hearing loss that aggravates. A diagnosis scale to evaluate the risk of PLF, based on clinical situations, physical exam and complementary exams was done to help the clinician in the evaluation of PLF.

Adolescent↗

Round window rupture secondary to acoustic trauma.

Perilymph fistulas are a known cause of sudden hearing loss. The two cases presented illustrate round window ruptures secondary to acoustic trauma. The important considerations are early diagnosis and treatment, the possibility of associated congenital anomalies, and future protection against sound.

Adult↗

Auditory brain stem response changes after application of endotoxin to the round window membrane in experimental otitis media.

The effects of endotoxin (purified Escherichia coli lipopolysaccharide 0111:B4) on cochlear function in normal and otitis media animals were evaluated. Two types of experimental otitis media models were developed in guinea pigs: eustachian tube obstruction and intratympanic injection of endotoxin. In normal animals, three different concentrations (0.01, 0.1, or 1.0 mg/ml) of endotoxin were applied onto the round window membrane, and auditory brain stem responses were recorded at 1, 3, 6, and 12 hours and 1, 2, 3, and 14 days after the application of endotoxin. Concentrations of 0.01 and 0.1 mg/ml of endotoxin did not affect the auditory brain stem response thresholds, whereas a concentration of 1.0 mg/ml resulted in elevation of the auditory brain stem response thresholds. Alteration of the auditory brain stem response threshold began at 3 hours, reached a peak at 24 or 48 hours, and returned to a normal level 2 weeks after the application of endotoxin. However, when the same concentration (1.0 mg/ml) of endotoxin was applied to the round window membranes of animals that underwent eustachian tube obstruction or intratympanic injection of endotoxin, the endotoxin did not cause any alteration of the auditory brain stem response threshold compared with normal animals.

Animals↗

Alterations of CAP audiogram by increased endolymphatic pressure and its relation to hydrops.

Most current theories regarding the inner ear pathology of Menières disease assume that there is an augmentation of the endolymphatic pressure due to the presence of hydrops. In this study normal hearing pigmented guinea pigs were employed to investigate the effect of increased endolymphatic pressure on the compound action potential (CAP) audiogram. All animals were implanted with an electrode on the round window and the CAP audiogram was determined prior to further surgery. The endolymphatic canal was then visualised by a posterior fossa intra-dural surgical approach. A hole was pierced in the canal and a cannula inserted. The CAP audiogram was again determined before, and at frequent intervals after, the application of hydrostatic pressure (0.5-1 cm Hg). A similar sequence of CAP sensitivity losses was observed within 2 h for 0.5 cm Hg or 15 min for 1 cm Hg. There was at first a very high frequency loss, followed by a very low frequency loss and finally a mid frequency sensitivity loss rendered the audiogram flat and lying around 50 dB sound pressure level. Given that the first characteristic index for experimental hydrops is a low frequency loss the present data suggest that an increase in endolymphatic pressure, as in these experiments, is likely to be a rather late pathological feature of hydrops. Indeed we have shown that a high frequency loss develops at a second phase during the evolution of hydrops.

Action Potentials↗

Identification of photoacoustic transients during pulsed laser ablation of the human temporal bone: an experimental model.

Laser ablation of hard tissues during neurotologic operations has been accomplished with continuous-wave (CW) lasers in the visible and midinfrared spectrum. The mechanism of ablation at these wavelengths is secondary to photothermal-induced tissue destruction. As a result, significant thermal damage to surrounding tissue may occur. Pulsed ultraviolet (UV) lasers have been suggested as an alternative to the argon, KTP-532, and CO2 lasers currently used in clinical practice. The pulse length of Excimer lasers are considerably shorter than the thermal diffusion time of bone tissue, and as a consequence thermal injury is minimal. This makes pulsed lasers an attractive tool for tissue ablation in the ear: in essence a "cold knife." However, the short pulse width of Excimer lasers (typically 10-150 ns) can create large thermoelastic stresses in the ablation specimen. This study identifies the presence of these photoacoustic waves during the Excimer laser treatment of the cadaveric human temporal bone. A XeCl (lambda = 308 nm, tau p = 12 ns) excimer laser was used to ablate hard tissue surrounding the oval window and facial ridge with energies of 75, 45, 25, and 12 mJ/pulse. Spot size was estimated to be 0.5 mm2. Custom high-frequency polyvinyldifluoride (PVDF) piezoelectric film transducers were fabricated and attached to the promontory, round window niche, and facial ridges. The signals were amplified using a low-noise preamplifier and recorded on a digitizing oscilloscope. Photoacoustic waves were clearly identified. Notably, large acoustic waves were measured on the promontory and on both sides of the facial ridge. The implications and clinical relevance of these findings is discussed and compared to findings obtained from a model system.

Acoustics↗

Free amino acid analysis of guinea pig perilymph: a possible clinical assay for the PLF enigma?

Controversy prevails regarding the accuracy of the clinical diagnosis of perilymphatic fistula (PLF). The diagnosis of PLF has been based on the subjective evaluation of vestibular function tests and the intraoperative macroscopic visualization of "clear fluid" from the oval/round windows at the time of exploratory tympanotomy. However, the subjective visual characterization of PLF varies among observing surgeons. Furthermore, perilymph can be "contaminated" with serum, blood, cerebrospinal fluid (CSF), and local anesthesia. This article presents a scientific biochemical microassay for the free amino acid profile of perilymph. Microaliquots of uncontaminated perilymph were sampled from the bilateral round windows (scala tympani) of 20 guinea pigs and analyzed for 19 free amino acid concentrations (FAAC) by high-performance liquid chromatography (HPLC). These samples were compared with the FAAC of guinea pig serum samples. Perfect predictor value ranges were nonoverlapping for 12 of 19 free amino acids in perilymph vs. plasma. Amino acid microassay of middle ear fluid for verification of "true" perilymph vs. nonperilymph fluids by the identification of nonoverlapping FAA markers may allow scientific verification of the existence of PLF in "suspected" patients.

Amino Acids↗

A new autologous fibrinogen-based adhesive for otologic surgery.

Many middle ear reconstructive procedures would be facilitated by use of a relatively safe surgical adhesive. A fibrinogen-based adhesive (Tisseel) has been effective in otologic surgery in Europe, but because it is derived from pooled human blood, it carries a risk of transmitting hepatitis, acquired immune deficiency syndrome, and other illnesses. This report details a new procedure for creating an autologous fibrinogen-based adhesive, obviating these risks. The fibrinogen and factor XIII component of the adhesive was isolated by polyethylene glycol precipitation from human plasma within a few hours, and was used either immediately or frozen for use up to 3 weeks later. Fifteen chinchillas had either the single donor adhesive, the commercial European adhesive, or saline placed on the oval and round windows, and no evidence of cochlear, mucosal, or ossicular damage was seen by light microscopy 30 days later. Auditory brain stem response thresholds remained stable, except in three animals that developed otitis media. Based on this investigation, autologous fibrinogen-based adhesive appears promising as a relatively safe, biological bonding material for otologic surgery, and is worthy of further study.

Animals↗