Emerging technologies: a glimpse into the future of neurotology--the American Neurotology Society meeting, September 18, 2004, New York City.
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Forecasting↗
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Vestibular neurotology Symposium on Vestibular Neurotology, Montreal, September 9-12, 1980.
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Humans↗
Computerized medical record in a private neurotology practice.
OBJECTIVE: To develop a computerized medical record for a private neurotology practice using a relational database with templates. BACKGROUND: Computers have been used in the medicine many years for billing, scheduling appointments, and word processing. Neurotology represents a relatively narrow field of medicine, which is particularly suited to a computerized record. A computerized medical record should allow for better data storage and retrieval as well as better documentation of the patient care given. METHODS: Using a commercially available, record-keeping software in a local area computer network. templates were developed for several common neurotologic problems. A template for a neurotologic examination was also developed. These were adapted from templates developed by a group otolaryngology practice in a neighboring city. Data entry templates for vestibular and audiologic tests were also developed. Implementation of the computerized record was accomplished in phases, allowing elimination of the paper record. RESULTS: A fully computerized medical record has been developed and maintained in a private neurotology practice over the past year. Patient response to the computerized record system has been favorable. Office personnel have adapted well to a paperless record, and referring physicians have welcomed the documents generated by the computer. CONCLUSION: Computerizing the medical records of a neurotology practice is possible and allows for improved documentation, ongoing assessment of treatment results, and improved efficiency among office staff.
Humans↗
Neurotologic follow-up after radiation of posterior fossa tumors.
OBJECTIVE: Stereotactic radiation treatment, also known as gamma knife surgery or radiosurgery, has come into acceptance as a treatment alternative to surgical removal for posterior fossa tumors. The purpose of this article is to describe the role of the neurotologist in the optimal management of neurotologic complications after stereotactic radiation, as illustrated by five patients. STUDY DESIGN: Retrospective chart review. PATIENTS: Five patients who underwent stereotactic radiation of posterior fossa tumors. MAIN OUTCOME MEASURES: Presence or absence of neurotologic complications (tumor growth, hearing loss, imbalance/ataxia, vertigo, and facial paralysis) or neurosurgical complaints (facial numbness, motor weakness, headache, hydrocephalus, and subarachnoid cysts). RESULTS: Postradiation neurotologic complaints included vertigo, imbalance/ataxia, and progressive hearing loss in four of the five patients. Continued tumor growth occurred in two patients; two patients had no growth; in one patient the tumor became smaller. The complications of facial nerve paralysis, facial numbness, motor weakness, headache, hydrocephalus, cerebellar edema, and posterior fossa arachnoid cyst formation occurred less frequently. CONCLUSIONS: Stereotactic radiation of posterior fossa tumors can produce significant neurotologic problems. It is imperative that neurotologists remain involved in the follow-up care of patients with posterior fossa tumors to offer optimal treatment alternatives for the neurotologic disorders.
Aged↗
Prevention of cerebrospinal fluid rhinorrhea in neurotologic surgery.
OBJECTIVE: To determine the efficacy and safety of quick-setting hydroxyapatite cement in eliminating cerebrospinal fluid (CSF) rhinorrhea following neurotologic surgery. STUDY DESIGN: A prospective study of 40 consecutive patients undergoing neurotologic surgery in whom the dura was opened. SETTING: All patients were treated as hospital inpatients at a tertiary referral center. PATIENTS: 25 men and 15 women between the ages of 20 and 72 years (mean age 51 years) underwent neurotologic surgery at the parent institution. INTERVENTION: Various neurotologic procedures were performed for the resection of 25 acoustic tumors, 5 meningiomas, 3 glomus tumors, 2 vestibular nerve sections, 2 chordomas, 1 epidermoid tumor, and 1 meningoencephelocele, and for 2 patients referred to our institution with known CSF leaks following acoustic tumor surgery. A new form of quick-setting hydroxyapatite cement, which that hardens within 3 to 5 minutes was used to seal the air cell tracts of the temporal bone in all cases. MAIN OUTCOME MEASURE: The presence of CSF rhinorrhea postoperatively. RESULTS: CSF rhinorrhea occurred in 2 patients following acoustic tumor surgery, the first through an occult air cell tract at the margin of the drilled internal auditory canal, and the second via an oval window fistula 1 month after a translabyrinthine approach. CONCLUSIONS: This form of hydroxyapatite cement appears safe, reliable, effective, and economical for the prevention of CSF rhinorrhea following neurotologic surgery. CSF rhinorrhea cannot be eliminated unless our ability to identify all potential air cell tract communications improves.
Adult↗
Sir Charles Alfred Ballance: contributions to otology and neurotology.
STUDY DESIGN: A review of primary and secondary historical and scientific literature concerning the life and writings of Sir Charles Alfred Ballance (1856-1936). RESULTS: Sir Charles Alfred Ballance was a pioneer in otology and neurotology, responsible for many "firsts" in the field, including the complete removal of a cerebellopontine angle tumor with significant patient survival and grafting the mastoid cavity with epithelium to speed healing. He was a strict abdicator of the complete mastoid operation with ligature of the jugular vein and drainage of the lateral sinus, and he advanced many other neurotologic procedures during his lifetime. He successfully sectioned the VIIIth cranial nerve, relieving a patient from intractable vertigo, developed a meticulous system for treating the complications of suppurative infections of the mastoid, diligently studied facial nerve reanastomosis, and was the first to perform a spinal accessory to facial nerve anastomosis for the relief of facial palsy. Ballance published over 75 original articles and was the primary author on two landmark books concerning temporal bone and neurologic surgery. He was the leader of many surgical societies and maintained a life of research and science until his death. CONCLUSION: Sir Charles Ballance was a pioneer in neurotologic and skull base surgery and greatly advanced the field during its inception. This work focuses on the otologic and neurotologic endeavors of Sir Charles Alfred Ballance, bringing his accomplishments into modern relief.
Ear Diseases↗
Image-guided surgical navigation in otology and neurotology.
OBJECTIVE: To review the impetus for the development of image-guided surgical navigation, its technologies, and the few prior outcome studies, and to make recommendations for its role in otologic and neurotologic surgery. DATA SOURCES: A literature search of English language publications by Medline from 1966 to 1998, using the key words: stereotactic, stereotaxy, navigation, intraoperative, and surgery. DATA EXTRACTION: Attempted review of the literature on image-guided surgical navigation in otology and neurotology revealed little relevant data. CONCLUSION: There are many possible applications for image-guided surgical navigation in otology and neurotology, but technologic limitations preclude its extensive application. There are no data available that assesses whether image-guided surgical navigation can reduce operative time, hospital stay, or cost. Clinical outcomes have not been studied in patients with otologic and neurotologic disease. In this scenario, image-guided surgical navigation is an adjuvant tool that aids in navigation of the skull base but is not a substitute for sound surgical principles and knowledge of microsurgical anatomy.
Bias↗
Single-photon-emission computed tomography (SPECT) in neurotologic assessment: a preliminary report.
The single-photon-emission computed tomography (SPECT) scan enables clinicians to probe dynamic and metabolic changes in brain tissue through measurement of regional cerebral blood flow (rCBF). Diagnostic benefits of the SPECT scan in clinical neurology have been demonstrated. SPECT scanning has been shown to be more sensitive than morphologic imaging techniques [magnetic resonance imaging (MRI) and computed tomography (CT)] in many conditions. However, the use of the scan in assessing neurotologic complaints remains inadequately investigated. Few studies have explored the value of SPECT in establishing the causes of dizziness, hearing loss, and tinnitus. We studied SPECT along with MRI, CT scan, electroencephalogram (EEG), and other evaluations in patients with these neurotologic complaints, SPECT abnormalities were more frequent and prominent than those visualized by other imaging modalities. Overall, 78% of SPECT scans revealed abnormalities. Abnormalities were found in 46% of MRIs, 40% of CTs, and 29% of EEGs. The disparity between SPECT scanning and other procedures was also seen once patients were divided by their chief complaints. This study illustrates the sensitivity of SPECT scanning in evaluating neurotologic complaints and highlights the need for additional research into the importance of SPECT scanning in comprehensive neurotologic evaluation.
Brain↗
Management of pseudomeningocele following neurotologic procedures.
OBJECTIVES: A pseudomeningocele results from the escape of cerebrospinal fluid through a dural defect with trapping of subarachnoid fluid in surrounding soft tissue. The present study evaluates the incidence of pseudomeningocele following neurotologic procedures and delineates an algorithm for management. METHODS: A retrospective review of 375 consecutive patients undergoing neurotologic procedures at a single institution identified 17 patients with the postoperative complication of pseudomeningocele. RESULTS: The incidence of pseudomeningocele formation was 4.5% in the present study. Fourteen pseudomeningoceles resolved with nonoperative management including pressure dressing, bed rest, and lumbar spinal drainage. Three patients failed nonoperative management and required surgical procedures for resolution. All patients ultimately had resolution of their pseudomeningocele. CONCLUSION: Skull-base pseudomeningoceles occur as a complication following neurotologic procedures and can cause complications as they enlarge. The majority of these cases can be dealt with in a nonsurgical manner, but those failing to respond to conservative management should be considered for surgical intervention.
Adult↗
The accuracy of computer-aided surgery in neurotologic approaches to the temporal bone: a cadaver study.
OBJECTIVE: To assess the accuracy of computer-aided surgery for common neurotologic approaches to the temporal bone. STUDY DESIGN AND SETTING: Cadaveric heads were dissected by using standard neurotologic approaches to the temporal bone including translabyrinthine, middle fossa, and retrosigmoid. Dissected anatomic landmarks from each approach were compared with CT images that were obtained before dissection on the VectorVision 2 system (BrainLAB Corp, Munich, Germany) and the variability measured from digital images. Each approach was performed 5 times, with each anatomic landmark measured 3 times from each approach. RESULTS: The accuracy of the computer-aided surgery system was less than 1 mm for all anatomic points measured. Forty-two of the 49 measured points were accurate to less than 0.5 mm. CONCLUSIONS: Computer-aided surgery of the temporal bone using common neurotologic approaches can be performed accurately and reliably in cadaver specimens. SIGNIFICANCE: The utility and limitations of computer-aided surgery in the temporal bone are discussed. EBM RATING: B-2.
Cadaver↗
Stereotactic radiosurgery for acoustic neuromas: a survey of the American Neurotology Society.
OBJECTIVE: The purpose of this study was to better understand the complications, outcomes, and surgical difficulties in treating acoustic neuroma patients who have undergone stereotactic radiosurgery (SRS). STUDY DESIGN: A six-page, 28-item questionnaire was mailed to 395 members of the American Neurotology Society. SETTING: The study was conducted through an academic neurotologic practice. Questionnaire respondents were neurotologic physicians in private and academic practice. PATIENTS: A total of 46 patients who had undergone SRS were evaluated. INTERVENTIONS: Twelve (26%) of the 46 patients required microsurgery after SRS. MAIN OUTCOME MEASURES: Posttreatment cranial nerve status and the development of complications such as cerebrospinal fluid leak, meningitis, and cerebrovascular accident were evaluated. RESULTS: In the group of 12 patients who underwent microsurgery after SRS, 11 patients had some form of postoperative facial paralysis. Anacusis was present in all 12 patients. Two of the 12 patients had new-onset trigeminal neuropathy postoperatively. CONCLUSION: Microsurgical resection of acoustic neuroma after SRS is technically difficult. The difficulty exists regardless of the time of microsurgical resection after SRS. Patients who underwent microsurgery after SRS had uniformly poor cranial nerve results.
Adolescent↗
Pediatric neurotology.
Pediatric neurotology is a subspecialty encompassing the medical and surgical treatment of conditions involving the middle ear, inner ear and lateral skull base. Multiple otologic and neurotologic diseases exist. In the pediatric patient the most common neurotologic conditions are vertigo, complications of otitis media, cholesteatoma, hearing loss and facial paralysis. Vertigo is differentiated into peripheral and central vestibular abnormalities. Peripheral vestibular causes include Meniere's disease, benign paroxysmal positional vertigo, vestibular neuronitis, otitis media and labyrinthitis. The predominant lesions in our field causing central vestibular disorders are brainstem and posterior fossa tumors. Mastoiditis, meningitis, petrositis, sigmoid sinus thrombosis, extradural abscess, brain abscess, otitic hydrocephalus, cholesteatoma and cholesterol granuloma are complications of otitis media and middle ear disease. Sensorineural hearing loss is now readily treated with cochlear implantation. Facial nerve paralysis may result from infectious and other etiologies.
Child↗
Neurotology of migraine.
Neurotologic symptoms are common with migraine, yet relatively little is known about the pathophysiology of such symptoms. Motion sensitivity with bouts of motion sickness occurs in about two thirds of patients with migraine. Episodes of vertigo occur in about one fourth of patients and, in some, vertigo is the only symptom (so-called "migraine equivalent"). Phonophobia is the most common auditory symptom, but fluctuating hearing loss and acute permanent hearing loss occur in a small percentage. Migraine can mimic Meniere's disease and so-called "vestibular Meniere's disease" is usually associated with migraine. The recent discovery of a mutation in a brain calcium-channel gene in families with hemiplegic migraine and in families with episodic vertigo and ataxia suggests a possible mechanism for neurotologic symptoms in patients with more common varieties of migraine. A defective calcium channel, primarily expressed in the brain and inner ear, could lead to reversible hair cell depolarization and auditory and vestibular symptoms. This hypothesis is currently being investigated in other families with migraine headaches and neurotologic symptoms. Hopefully, such studies will lead to improved diagnosis and better treatments in the future.
Brain↗
Neurotological complications after radiosurgery versus conservative management in acoustic neuromas: a systematic review-based study.
OBJECTIVE: Treatment modalities for acoustic neuroma (AN) include surgery, observation and gamma-knife surgery. The aim of this study was to compare neurotological complications resulting from two treatment alternatives to microsurgery: radiosurgery and observation. MATERIAL AND METHODS: We conducted a systematic review of the literature dealing with radiosurgery for AN and compared the rate of neurotological complications in this population with that in a cohort of patients managed conservatively. RESULTS: We found that neurotological complications, namely facial hypoesthesia (p = 0.002), hearing loss (p < 0.05) and hydrocephalus (p = 0.02), were more frequently encountered after radiosurgery than with conservative management. In contrast, we found that the risk of growth of AN is significantly higher with conservative management and that the rate of stability of the tumor did not differ significantly between the two treatments. CONCLUSION: We prefer a conservative management regimen for patients who cannot be operated on for their AN. However, there are some difficulties inherent in this conservative management policy, namely non-compliance and difficulties in establishing the evolution of the tumor.
Facial Neuralgia↗
Neurotologic skull base surgery in pediatric patients.
OBJECTIVE: Innovations in diagnosis, surgical techniques, and perioperative care have dramatically improved outcomes in lateral skull base procedures in recent years. There is a belief, however, that children with skull base tumors have yet to benefit from these technological and procedural advances. The purpose of this study is to provide a clinical review of neurotologic skull base surgery in the pediatric population. STUDY DESIGN: Retrospective case review. SETTING: Private practice tertiary referral center. PATIENTS: Eighty-nine pediatric patients undergoing 115 neurotologic procedures for lateral skull base tumors from July 1992 to September 2003. MAIN OUTCOME MEASURES: Initial clinical presentation, tumor type, pre- and postoperative hearing and facial nerve status, treatment course, complications, and functional outcomes. RESULTS: The majority of tumors in this series were vestibular schwannomas, and 65 patients were diagnosed with neurofibromatosis Type 2. Surgical approaches included 70 middle fossa, 40 translabyrinthine, 2 transcochlear, 2 infratemporal fossa, and 1 retrosigmoid craniotomy. Complete tumor removal was accomplished in the majority of cases (97%), with good preservation of facial nerve function (House-Brackmann Grade I or II) in 80% of patients. In patients undergoing middle fossa surgery for hearing preservation, measurable hearing was preserved in 61.4% of cases. The incidence of complications was low. CONCLUSION: With advances in diagnostic procedures and use of current neurotologic techniques, pediatric patients may undergo successful treatment of lateral skull base tumors, with good functional outcomes and minimal morbidity.
Adolescent↗
Epidemiology of vestibular vertigo: a neurotologic survey of the general population.
OBJECTIVE: The purpose of this study was to determine the prevalence and incidence of vestibular vertigo in the general population and to describe its clinical characteristics and associated factors. METHODS: The neurotologic survey had a two-stage general population sampling design: nationwide modified random digit dialing sampling for participation in the German National Telephone Health Interview Survey 2003 (response rate 52%) with screening of a random sample of 4,869 participants for moderate or severe dizziness or vertigo, followed by detailed neurotologic interviews developed through piloting and validation (n = 1,003, response rate 87%). Diagnostic criteria for vestibular vertigo were rotational vertigo, positional vertigo, or recurrent dizziness with nausea and oscillopsia or imbalance. Vestibular vertigo was detected by our interview with a specificity of 94% and a sensitivity of 84[corrected]% in a concurrent validation study using neurotology clinic diagnoses as an accepted standard (n = 61). RESULTS: The lifetime prevalence of vestibular vertigo was 7.4[corrected]%, the 1-year prevalence was 4.9[corrected]%, and the incidence was 1.4[corrected]%. In 80% of affected individuals, vertigo resulted in a medical consultation, interruption of daily activities, or sick leave. Female sex, age, lower educational level, and various comorbid conditions, including tinnitus, depression, and several cardiovascular diseases and risk factors, were associated with vestibular vertigo in the past year in univariate analysis. In multivariable analysis, only female sex, self-reported depression, tinnitus, hypertension, and dyslipidemia had an independent effect on vestibular vertigo. CONCLUSIONS: Vestibular vertigo is common in the general population, affecting [corrected] 5% of adults in 1 year. The frequency and health care impact of vestibular symptoms at the population level have been underestimated.
Activities of Daily Living↗
Neurotological findings in Bell's palsy and Hunt's syndrome.
Neurotological findings were analysed in 23 patients with Bell's palsy and in 25 patients with Hunt's syndrome. The incidence and extent of the auditory and vestibular pathology was high in Hunt's syndrome. Although patients had no subjective symptoms related to the auditory and/or vestibular pathology in the Bell's palsy cases, about one-third of the patients showed abnormal findings upon neurotological examination. Differentiating these two diseases is therefore considered difficult by means of neurotological examination in the same way as by serological testing as has been reported by other investigators.
Audiometry, Pure-Tone↗
Comparative study on computed tomography and neurotological findings in spinocerebellar degeneration.
The classification of SCD on the basis of the neurotological findings was with classification based on CT findings in 40 cass of SCD. The areas of pons, cerebellar hemisphere, vermis and posterior fossa on CT films were measured by craniometer, and were compared in order to estimate the degree of atrophy. From these assessments, patients were classified into 3 types as follows; (1) 14 cases of cerebellar type, (2) 9 cases of brain stem type and (3) 17 cases of combined type. The classification of SCD based on the neurotological findings including the findings of gaze test, positioning test, eye tracking test, OKN, and fixation suppression test of caloric nystagmus, was well correlated to the classification based on CT findings. From the results, neurotological examination was demonstrated to make a contribution to the estimation of lesions and types in SCD.
Caloric Tests↗