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Background: Acute mastoiditis persists as a serious infection despite a dramatic decline in incidence coincident with the introduction of antibiotic therapy. Objective: To assist the contemporary practitioner in the recognition and management of acute mastoiditis through the assessment of a large series of patients. Design: Retrospective case series comprising 124 patients with acute mastoiditis. Setting: Pediatric and adult otology referral center. Main Outcome Measures: Selected clinical parameters. Risk factors for necessity of surgical intervention and for increased length of hospitalization were analyzed by a stepwise logistic regression model. Results: A history of antecedent acute otitis media was absent in 45% of patients. Pain (98%) was the most common presenting symptom. Physical signs included an abnormal-appearing tympanic membrane (88%), fever (83%), a narrowed external auditory canal (80%), and postauricular edema (76%). Streptococcus pneumoniae was the most commonly isolated organism. Mastoid surgery was required in 62% of the patients. An elevated white blood cell count (relative risk [RR], 7.4; P P =.03), and fever on admission (RR, 7.3; P =.05) were risk factors for surgical intervention. All 33 patients with complications (27%) proceeded to surgical intervention. The average length of hospital stay was 7.9 days. The strongest predictor for an increased length of hospital stay was whether the patient required surgery (RR, 3.7; P =.002). Conclusions: Acute mastoiditis remains a potentially serious otologic infection. Not all patients present with a classic history or physical examination. Therapeutic mastoidectomy is often required. (Arch Otolaryngol Head Neck Surg. 1996;122:135-139)

The advent of magnetic resonance imaging has allowed otologists to focus on the early removal of acoustic neuromas with the goal of hearing preservation. Clearly, there are some unpredictable factors, such as placement of the tumor in the medial vs the lateral segment of the internal auditory canal and the capricious nature of the blood supply to these benign neoplasms, that make prediction of hearing preservation difficult. Nonetheless, the present goal of surgery for removal of acoustic tumors has changed its focus from preservation of the facial nerve alone to preservation of the facial nerve and preservation of hearing. In a patient with an only-hearing ear and a small acoustic neuroma, there is some controversy concerning whether the tumor should be removed early, with the goal of hearing preservation, or if the patient should be allowed to progress to a considerable hearing loss in an effort to preserve natural hearing as long as possible. We report a case in which an acoustic tumor was removed from an only-hearing ear in a patient with neurofibromatosis after hearing loss had progressed in that ear but before the development of total deafness. Postoperatively, the patient successfully underwent cochlear implantation. We also discuss decisions that we made during the surgical procedure, as well as the feasibility of cochlear implantation in patients with profound deafness after the excision of acoustic neuromas. (Arch Otolaryngol Head Neck Surg. 1995;121:465-468)

Importance Otolaryngology residents need concise, easily accessible modules to expand educational opportunities between surgical cases. These modules should be inexpensive to create and improve learning outcomes. Objective The purpose of this pilot study was to assess whether otolaryngology residents at multiple institutions used online video modules to supplement their studying for the Otolaryngology Training Exam, whether the modules had any effect on their Otolaryngology Training Examination Scores, and to obtain survey feedback about the modules. Design, Setting, and Participants This randomized trial was conducted in 3 academic departments of otolaryngology in the United States among 37 residents enrolled in 3 otolaryngology residency programs. Interventions Residents were randomized into 2 groups, one with access to the educational modules and the other with no access. Main Outcomes and Measures Otolaryngology training examination scores were obtained from the year prior to the intervention (2012) and the year following module access (2013). Residents with access to the modules were also surveyed to assess use and obtain feedback about the modules. Results Otolaryngology training examination scores improved significantly from 2012 to 2013 among both residents who had access to the modules and those who did not in the sections of head and neck, laryngology, and sleep medicine. However, scores in the sections of pediatric otolaryngology (8% increase,P = .03), otology (7% increase,P = .02), and facial plastic surgery (10% increase,P = .02) improved from 2012 to 2013 only among residents with access to the modules. All respondents rated the videos as very helpful, with a rating of 4 of 5 on a Likert scale. Conclusions and Relevance Online otolaryngology educational modules are an inexpensive way to expand resident learning opportunities. Despite the lack of quantifiable improvement in otolaryngology training examination scores in this study, use of online modules sends a message to otolaryngology residents that their education is a priority; self-study outside the hospital and clinics is necessary and expected; and that instructors are willing to try more nontraditional or progressive forms of education to increase resident knowledge.

Adenomas, although the most common benign tumors in the middle ear, are of low incidence. They may arise in a previously normal adult ear, causing a conductive deafness and later an aural discharge. Histologic definition may be difficult in these tumors, which are assumed to arise from middle ear epithelium. Fairly extensive surgery may be required for their eradication. Two cases are described. (Arch Otolaryngol Head Neck Surg. 1995;121:342-344)

Importance A thorough understanding of why we hold a cell phone to a particular ear may be of importance when studying the impact of cell phone safety. Objective To determine if there is an obvious association between sidedness of cell phone use and auditory hemispheric dominance (AHD) or language hemispheric dominance (LHD). It is known that 70% to 95% of the population are right-handed, and of these, 96% have left-brain LHD. We have observed that most people use their cell phones in their right ear. Design An Internet survey was e-mailed to individuals through surveymonkey.com. The survey used a modified Edinburgh Handedness Inventory protocol. Sample questions surveyed which hand was used to write with, whether the right or left ear was used for phone conversations, as well as whether a brain tumor was present. Setting General community. Participants An Internet survey was randomly e-mailed to 5000 individuals selected from an otology online group, patients undergoing Wada testing and functional magnetic resonance imaging, as well as persons on the university listserv, of which 717 surveys were completed. Main Outcome and Measure Determination of hemispheric dominance based on preferred ear for cell phone use. Results A total of 717 surveys were returned. Ninety percent of the respondents were right handed, and 9% were left handed. Sixty-eight percent of the right-handed people used the cell phone in their right ear, 25% in the left ear, and 7% had no preference. Seventy-two of the left-handed respondents used their left ear, 23% used their right ear, and 5% had no preference. Cell phone use averaged 540 minutes per month over the past 9 years. Conclusions and Relevance An association exists between hand dominance laterality of cell phone use (73%) and our ability to predict hemispheric dominance. Most right-handed people have left-brain LHD and use their cell phone in their right ear. Similarly, most left-handed people use their cell phone in their left ear. Our study suggests that AHD may differ from LHD owing to the difference in handedness and cell phone ear use. Literature suggests a possible relationship between cell phone use and cancer. The fact that few tumors were identified in this population does not rule out an association.

IDIOPATHIC SUDDEN SENSORINEURAL HEARING LOSS, OR sudden deafness, is the acute onset of hearing loss of at least 30 dB in 3 connected frequencies occurring instantaneously or over a period of up to 3 days. Sudden hearing loss is thought to be relatively rare, occurs mainly in patients between the ages of 30 and 60 years, and can be devastating for the patient. Therefore, sudden hearing loss should be treated as a medical emergency. The natural course is characterized by spontaneous recovery among approximately 50% of patients. Accurate estimates of incidence are difficult to obtain because a significant number of patients who spontaneously recover do not seek medical attention. As the term idiopathic implies, the etiology and pathophysiology of hearing loss are unknown. Possible causes include infections (especially viruses), autoimmune disease, circulatory problems, and neurological disease, including multiple sclerosis. Treatment options include oral steroids, intratympanic steroid injections, oral antivirals, vasodilators, diuretics, hyperbaric oxygen therapy, and vitamins. As a result of the high rate of spontaneous resolution, multiple potential causes, and absence of validated tests for etiological identification, the evaluation of treatment effectiveness is difficult. In this issue of JAMA, Rauch and colleagues describe the findings from the first multi-institutional study of oral vs intratympanic corticosteroid therapy for hearing loss. In this study, 2443 adult patients were assessed for eligibility at 16 different academic and community-based otology practices. Of these patients, 250 (10%) agreed to participation and were randomized to receive either 60 mg/d oral prednisone for 14 days with a 5-day taper (n=121) or four 1-mL doses of 40 mg/mL of methylprednisolone injected into the middle ear over a 2-week period (n=129). Audiometry and safety monitoring were performed at screening, and after 1 week, 2 weeks, 2 months, and 6 months of treatment. The primary study hypothesis was that intratympanic methylprednisolone is inferior to oral prednisone for the treatment of hearing loss. The investigators established an average of more than 10 dB as the clinically significant amount of audiometric difference between the 2 study groups. Subgroup analyses of patients based on the amount of hearing loss ( 90-dB or 90-dB pure-tone average [PTA]) were specified a priori. The primary finding of the study was a 2.0-dB difference in PTA between the 2 treatment groups at 2 months with a maximum difference (upper limit of the confidence interval) of 6.6 dB. This value of 6.6 dB was below the required value of 10 dB to demonstrate clinical significance and reject the null hypothesis of noninferiority (ie, intratympanic treatment is worse than oral prednisone). Among the patients who presented with hearing loss of 90 dB or greater and dizziness, came for treatment in fewer than 7 days from onset, or had no prior steroid use, the possibility of a clinically meaningful difference in hearing recovery between the 2 groups could not be ruled out. Overall, the 2 treatments were well tolerated, and the number and severity of serious adverse events and adverse events were similar between groups, as had been anticipated from prior studies. However, of the patients randomized to receive intratympanic steroids, 3.1% had persistent tympanic membrane perforation and 4.7% had persistent otitis media vs 0% and 0.8% in the oral group, respectively. At present, the emergency administration of a tapering dose of systemic steroids after hearing loss onset is widely considered standard treatment. Several uncontrolled studies suggested that intratympanic steroids have equivalent efficacy as oral steroids, while minimizing the potential adverse systemic effects of oral steroids. The practice of prescribing a tapering dose of oral steroids is largely based on the results of 1 randomized clinical study and a retrospective study. In the study by Wilson et al, patients in the steroid group had a recovery rate (61%) that was similar (65%) to untreated patients reported by Mattox and Sim

To examine if a 23-valent pneumococcal capsular polysaccharide vaccine (PPV23) reduces the risk of meningitis in healthy rats after cochlear implantation.Interventional animal study.Thirty-six rats (18 immunized and 18 unimmunized) received cochlear implantations and were then infected with Streptococcus pneumoniae via 3 different routes (hematogenous, middle ear, and inner ear) in numbers sufficient to induce meningitis.The rats with implants that received PPV23 were protected from meningitis when the bacteria were delivered via the hematogenous and middle-ear routes (Fisher exact test P.05). However, the protective effect of the vaccine in the rats with implants was only moderate when the bacteria were inoculated directly into the inner ear.Our animal model clearly demonstrates that immunization can protect healthy rats with a cochlear implant from meningitis caused by a vaccine-covered serotype. This finding supports the notion that all current and future implant recipients should be vaccinated against S pneumoniae.

Genetics and otology were the subjects of a talk by Kenneth Grundfast, MD , National Children's Medical Center, Washington, DC. Dr Grundfast presented an audiovestibular phenotype checklist to be used when evaluating patients with congenital hearing loss. The checklist includes the following: inheritance pattern, onset type, laterality, stability, audiogram configuration, and associated radiographic and/or vestibular findings. By using this checklist, the physician can more accurately describe the nature of congenital deafness for the patient and family. There has long been a controversy regarding the advisability of stapes surgery in young children. Antonio De La Cruz, MD , Los Angeles, Calif, presented the House Ear Institute's (Los Angeles, Calif) experience with stapes surgery in children . He concluded that stapes surgery could be performed safely in children and was especially gratifying in children with bilateral conductive hearing loss greater than 35 dB. He advised preoperative computed tomographic scans on all patients for assessment

Vestibular schwannomas are benign Schwann cell tumors that arise from the vestibular portion of the eighth cranial nerve. They are found within the internal auditory canal and cerebellopontine angle, and the yearly incidence is 1 per 100000. Vestibular schwannomas account for approximately 6% of all intracranial tumors, and they are the most common tumor of the cerebellopontine angle. Patients with vestibular schwannomas usually present in the fifth or sixth decade of life with a variety of complaints, including hearing loss and dizziness. Diagnostic imaging of vestibular schwannomas has evolved over the years. The gold standard for diagnosis of these tumors is gadolinium-enhanced magnetic resonance imaging, which has allowed for the diagnosis of smaller tumors than in years past. The natural history of these tumors is steady growth at approximately 2 mm per year, although an unpredictable population of tumors seems to have a faster growth rate. There are 3 main treatment plans available for patients with vestibular schwannomas: watchful waiting, microsurgery, and gamma knife radiosurgery. Watchful waiting is sometimes used for very small tumors or patients who are poor surgical candidates. The other 2 options are chosen for most patients. Surgical resection was first performed in 1894 by Sir Charles Ballance, although the morbidity and mortality rates were unacceptably high. At the turn of the century, Cushing advocated subtotal resection, which lowered the mortality rate. Dandy developed the modern suboccipital approach to the cerebellopontine angle in the 1920s and described a complete tumor resection technique that had a mortality rate of 40%. In the early 1960s, House introduced the operating microscope to surgical practice. He developed the middle fossa approach for tumor removal, and mortality dropped to 5%. Since that time, surgical techniques have been refined, and now cranial nerve preservation, rather than merely life preservation, is a realistic expectation of microsurgical removal of vestibular tumors. Lars Leksell first introduced stereotactic radiation in 1951, and he was the first physician to treat acoustic neuromas with gamma knife radiosurgery in 1969. This technique involves the single-session application of precisely collimated beams of radiation from a cobalt 60 source to a precisely controlled intracranial location. Unlike surgery, the goal of gamma knife radiosurgery is to render the tumor incapable of further growth by inducing avascular necrosis and collagen deposition. Just as diagnostic and treatment technology has changed, patient expectations have also changed. Patients have greater sophistication because of the ready availability of a wealth of information about vestibular schwannomas. The Internet has provided an avenue for several support groups and allows for easy dissemination of information. Patients are able to discuss their experiences at various treatment centers on acoustic neuroma forums, and the medical providers are able to advertise on their Web sites. For this reason, patients often present to the physician with extensive knowledge of the various treatment options for their tumors. It is the role of the physician to have a complete and balanced understanding of the treatment modalities and to guide patients in the treatment decision process. The main goal of any management plan should be safe and definitive treatment of the tumor with minimal morbidity and mortality. Definitive surgical treatment means From The Otology Group, Nashville, Tenn (Dr Kaylie), and Department of Otolaryngology–Head and Neck Surgery, Physicians’ Pavilion, Portland, Ore (Dr McMenomey). David M. Kaylie, MD

Objective To explore how rigid and flexible bronchoscopy are used in pediatric otolaryngologic practice. Design Survey. Participants Members of the American Society of Pediatric Otolaryngology who practice in the United States and Canada and were listed in the membership directory were eligible. Of the 206 members, 24 practicing outside the United States or Canada and 11 without an e-mail address or a fax machine were excluded. Hence, a questionnaire was e-mailed or faxed to 171 pediatric otolaryngologists. Main Outcome Measures Questions concerned the practice setting, type and number of bronchoscopies, indications, complications, and medicolegal cases. Results Responses were received from 120 subjects (70.2%), with 3 retired and 2 practicing only otology, leaving 115 respondents who completed at least some of the questionnaire. Rigid and flexible bronchoscopy were performed by 72.7% (56/77) of those in academic settings and by 71.1% (27/38) of those in group or solo practices. In the last 12 months, approximately 10 454 total bronchoscopies were performed, with 2052 flexible and 9117 rigid bronchoscopies. Stridor, suspected foreign body inhalation, and laryngomalacia were the most common indications for bronchoscopy. Of the 83 respondents practicing rigid and flexible bronchoscopy, 25 (30.1%) used both instruments to manage complex or repeated foreign bodies, 25 (30.1%) used both to manage patients with cystic fibrosis, and 15 (18.1%) used both to manage simple foreign bodies. Complications were reported by 15.7% of the respondents, the most common being arrhythmia. Familiarity with a case resulting in medicolegal action was reported by 32.2% of the respondents. Conclusions Rigid and flexible bronchoscopy have multiple uses in pediatric otolaryngologic practice. Also, flexible bronchoscopy appears to be emerging as a more frequently used diagnostic and therapeutic tool.

I appreciate the opportunity to respond to Dr Levine's letter. As he did during his residency, he brings up relevant and insightful points with respect to the practice of otolaryngology. However, I think that he has missed the thrust and point of my commentary. My intention was to discuss the evolution of a subspecialty (equal to ones such as otology and facial plastic surgery) that enhances all of otolaryngology. Just as Dr Levine spent 6 months working with a facial plastic surgeon during his residency so that he can perform facial plastic surgery in his practice, he benefited from 9 months working with four pediatric otolaryngologists to develop the skills and knowledge that allow him to properly care for the "bread and butter of general otolaryngology." I believe that Dr Levine is better equipped to care for these patients as a result of his pediatric otolaryngologic training. The

Otolaryngology-head and neck surgery continues to be a vibrant and exciting specialty because of the incorporation of new technology, new interest, and new knowledge. The discipline of pediatric otolaryngology, like otology, head and neck surgery, and facial plastic and reconstructive surgery, is an addition to our specialty that will enhance our ability to improve medical care to our patients. Historically, pediatric otolaryngology was spearheaded by a few individuals including Drs Charles Ferguson, Seymour Cohen, Blair Fearon, and Gabriel Tucker. In the field of surgery, Dr Robert Gross initiated the impetus for full-time subspecialization in pediatrics. This, together with many advances in technology, paved the way for pediatric subspecialization in other surgical disciplines and related fields such as anesthesia, radiology, and pathology. There emerged in the early 1970s a group of otolaryngologists who had a particular interest in the special otolaryngologic needs of children, and the Society for Ear, Nose

To the Editor. —Perilymphatic fistulas remain one of the most controversial clinical issues in diagnostic otology today. 1 The current state of the art regarding diagnosis is at best problematic. There exists no objective diagnostic testing for distinguishing the presence or absence of perilymphatic fistulas in a living human being. All clinical studies to date base their observations on subjective impressions made at the time of exploratory surgery. The science surrounding the diagnosis of perilymphatic fistulas can only move forward if other investigators are willing to accept this general lack of objectivity and shed new light on this diagnostic problem. A future state-of-the-art presentation will hopefully include objective diagnostic testing that will benefit the patient with hearing loss and/or vertigo.

According to the editorial statement, Operative Techniques in Otolaryngology—Head and Neck Surgery is dedicated to the presentation of timely, high-quality visual information on new surgical procedures and techniques as well as discussion of issues in the surgical management of problems in otology, rhinology, laryngology, reconstructive head and neck surgery, and facial plastic surgery. New nonoperative techniques will also be highlighted. The primary goal is superb, detailed illustrations, in most issues on a central theme. Several existing journals already present clinical and experimental research in this area, eg, Saunders' own Otolaryngologic Clinics of North America, Archives of Otolaryngology—Head and Neck Surgery (American Medical Association), Otolaryngology—Head and Neck Surgery (American Academy of Otolaryngology—Head and Neck Surgery), Current Therapy in Otolaryngology—Head and Neck Surgery (Decker), Head and Neck Surgery (Wiley), and Year Book of Otolaryngology—Head and Neck Surgery (Year Book). There is, however, currently no source for both multiauthored articles and pictorial presentations

It is commendable that authors from time to time attempt to distill the body of knowledge of a specialty in a single textbook, the old and traditional along with the new and experimental. This is a huge task, and not only does it help practicing physicians, but it sets the standard for current information so that future authors will have a reference when they attempt new textbooks. This single volume is intended for practicing otolaryngologists and head and neck surgeons, as well as senior residents and fellows and serious medical students and junior residents. It covers the traditional areas of otolaryngology, which include otology, neurotology, oncology, radiobiology, plastic surgery of the head and neck, oral surgery, and allergy in the upper respiratory tract. New topics, such as sleep apnea, lasers, an update of immunology, and interferon and cancer chemotherapy, have been included. Because of its size and multiple authorship, one

In an attempt to answer the aforementioned question, Edwin M. Monsell, MD, PhD, of the Chicago Otology Group, Hinsdale, Ill, and Derald Brackmann, MD, and Fred Linthicum, Jr, MD, of the Otologic Medical Group and House Ear Institute, Los Angeles, reviewed the clinical histories obtained from patients failing vestibular ablative procedures at the April meeting of the American Neurotology Society, Denver. Furthermore, vestibular nerve specimens and one temporal bone from this patient population were studied by light microscopy. The authors identified persistence of the central processes of primary vestibular neurons in three specimens obtained from patients who had ongoing symptoms and ice-water caloric responses after retrolabyrinthine vestibular neurectomy. It was their opinion that this was due to incomplete neurectomy and anatomic variations in the plane of separation of the vestibular and cochlear portions of the eighth nerve in the posterior fossa. Moreover, noting that persistent disabling unsteadiness has been reported

Glomus tumors of the temporal region and skull base can range in size from small microscopic lesions confined to the promontory to large destructive and neurologically aggressive agents of substantive incapacitation. Contemporary diagnostic and surgical technology has made definitive management of these historically dreaded management of these historically dreaded lesions confidently practical. Prompted by these advances, a new classification of glomus tumors is disclosed. The specific problem of the large chemodectoma at the skull base is addressed and a series of such cases reviewed. Surgical therapy is viewed as definitive, and the technique employed by the members of The Otology Group, PC, is described.

Introduction Tympanoplasty consists of a series of operative procedures, which not only eliminate chronic infections of the middle ear completely but also improve hearing. The purposes of tympanoplastic procedures are the elimination of inflammatory processes and postinflammatory changes in the middle ear in order to diminish ear discharge and to obtain dry ear and the reconstruction of the damaged sound-conduction mechanism in order to facilitate sound conduction to the inner ear and restore the hearing. In our experience there are cases where tympanoplasty failed to eliminate the inflammatory processes or to restore hearing in chronic otitis media. I have, therefore, clinically observed these cases of failure in order to clarify manipulation of the labyrinth windows and their surroundings and assure accomplishment of both aims of tympanoplasty. Material I examined 242 tympanoplasty cases operated on by us for chronic middle ear suppuration from October, 1957, to November, 1958. The cases included

The all too great incidence and the inherent difficulty of treatment of postauricular fistula make the subject one of prime importance to the otologist. Inasmuch as the success of any operative repair of this condition depends on complete and careful revision of the original mastoidectomy cavity as the first step, the problem is in the realm of otology rather than of plastic surgery. This paper will concern itself with a brief review of the general aspects of the subject and a more detailed description of the method I have successfully employed in treatment in 5 consecutive cases. I shall not attempt to cover thoroughly the entire literature. The very fact that so many methods of therapy have been suggested is testimony that no one has yet met with complete and constant success. There is little doubt that in many cases postauricular fistula can be prevented by the most careful and

UNDER the influence of the great masters of otology, Wittmaack, Holmgreen, and Sourdille et al, 1 whose opinion we learned to appreciate in personal contact, much of our time has been dedicated to the study of otosclerosis. As early as 1939, 2 one of us (A.S.) published his first experiences with surgical treatment of this disease, which started in 1936 immediately after the International Congress of Otorhinolaryngology in Berlin where otosclerosis was the center of interest. The present publication is a survey of our results published hitherto in German and in French. We were primarily interested in the genesis of the disease but started our investigations with the classification of the pathological processes and statistical data concerning frequency. According to the fundamental studies of Wittmaack, Mayer, 3 and especially of Nager and Meyer 4,5 and Weber, 6 otosclerosis must be considered as a fibrous osteodystrophy localized in the labyrinthine capsule.

THE PREVENTION of deafness should be a constant and major objective in otology, both before any sign of trouble is evident and after poor hearing has supervened. At all levels of hearing loss, prevention is of primary importance. At first thought it would appear that there is no problem when there is no deafness. How can one prevent something which shows no sign of appearing and, by common experience, does not therefore impend? Moreover, first signs are faint, so faint that they flash no clear warning of disaster. They may arise from many widely separated parts of the body and from many different causes, any one of which may not and generally does not cause any deafness whatsoever. Nevertheless, the sure way is to take preventive measures early and, when possible, before any signs of deafness appear. This is the challenge, and slowly but surely medical knowledge and skill have

The structure of the mastoid portion of the temporal bone has been thoroughly studied, and the nature and extent of its pneumatization are now well understood. The form, arrangement and relationships of the cells in the petrous portion have not been described with equal thoroughness. The present study finds its justification in the current demand for reliable information concerning the anatomy of this important subdivision of the temporal bone. Siebenmann1made the first painstaking study of the air cells of the temporal bone; by means of corrosion preparations he demonstrated the shape and connections of the mastoid cells and of certain lesser pneumatic spaces situated beyond the mastoid region, stating that they penetrate everywhere with the exception of the squama and the anterior wall of the external auditory meatus. Illustrations of the corrosion specimens (see also Bezold and Siebenmann2) are still being copied in textbooks of anatomy and otology. It

INTRODUCTION During the past few years America has produced a number of research workers, Shambaugh, Blast, Crow, McMahon, Hassin and Martland, whose microscopic studies, like those of Frazer, Turner and Reynolds in England, have added greatly to our knowledge of normal processes as influenced by infections. They are carrying on and enlarging the work begun by Schwartze, Gruber, Seibenmann, Politzer and Alexander. Development of Language.—In "Babel, or Language, Past, Present and Future,"1Paget suggested that all human language originated from gestures and all written language from signs similar to the original American Indian sign language. Gestures are accompanied by sounds made by associated movement of the tongue and lip. These primary sounds are the elements of all vocal language, that is, a combination of sound with gesture. Paget stated that immediately following the Norman Conquest, the language used by the conquerors consisted of Greek and Latin, from

DIAGNOSIS. Presented byDR. S.MACCUENSMITH. There should be no difficulty in establishing a diagnosis in a simple, uncomplicated involvement of the lateral sinus, but this characteristic clinical picture broadly means septicemia and must be differentiated from sepsis originating in some other part of the body, before surgical intervention is undertaken. Certain types of meningitis, central pneumonia, endocarditis, typhoid fever, malaria and pyelitis in children are to be eliminated as a causative factor when complicating an active or inactive suppurative aural disease, but once diagnosis is reasonably assured, the surgeon should lose no time in verifying his suspicions by surgical measures. A perisinuous abscess is frequently found when wholly unexpected during a mastoid operation and should not be disturbed unless definite symptoms of septicemia occur, for in many instances the mild pyemic symptoms entirely disappear following the mastoid operation. The importance of the small veins in

It seems fair to state that of all phlebitic infections, thrombosis of the lateral sinus presents the most constant features. In no other disease is one particular venous channel so regularly and consistently involved. For this reason the bacteremia which is always associated with thrombosis of the lateral sinus becomes the most important clinical finding of the disease. The recognition of the bacteremia is of paramount importance in the diagnosis of the condition and is of value in interpreting especially the course and the prognosis of the illness. In view of this, the significance of interpretation of blood cultures in cases of thrombosis of the lateral sinus deserves special consideration. Of the great contributions to otology, Libman's 1 original work on thrombosis of the lateral sinus occupies an eminent position. Further investigations on the subject have corroborated his observation that bacteremia can be demonstrated often in this disease and that the

GRADENIGO'S syndrome affords the otologist one of the few dramatic episodes in otologic practice and often causes him no little anxiety because of what it may portend. The Italian author Gradenigo was the first to establish as a clinical entity the syndrome which bears his name. Isolated paralysis of the external rectus muscle complicating acute suppuration in the temporal bone had been reported in the literature a number of times prior to his presentation of this syndrome in 1904. To acute suppurative otitis media and paresis or paralysis of the abducens nerve of the same side he added the distinctive feature of temporoparietal pain of an unusually severe and persistent type and concluded that this formidable trinity constitutes a definite symptom complex. INCIDENCE This syndrome is relatively rare, but it occurs frequently enough to warrant inclusion of the subject in textbooks of otology and ophthalmology. It is seldom encountered by

CLONICSPASMOF THE MUSCLESOF THE EUSTACHIANTUBES. ByDR.KARLMUSSER HOUSER. Politzer, Schwartze, Brunner, Todd and Boeck have observed and described this condition. Such cases are rather infrequent, and a report of such cases has not occurred in the literature of the past twelve years. The patient presented was a man, aged 24, who, for the past eight months, had experienced annoying clicking sensations in both ears, which was more marked on the right side. The onset of the condition was gradual and was not accompanied by an acute cold or sore throat. Tonsillectomy, tubal catheterization and bougienage did not give relief. The clicking sound on the right side could be heard by an observer at a distance of 4 feet from the patient. On the left it was barely audible with the auscultation tube. Movement of the drumhead could not be be seen when the

The Early History of Otolaryngology in America With Special Reference to the American Laryngological, Rhinological and Otological Society. Dr. Thomas J. Harris, New York. The American Ophthalmological Society was founded in 1864. At first it was thought that otologic subjects could be considered at the meetings of the society simultaneously with those having to do with ophthalmology, but it was soon found not feasible, and in 1868 the American Otological Society was founded, the first society of its kind in the world. The American Laryngological Association followed it ten years later. The American Otological Society and the American Laryngological Association, since their establishment, have served as forums for the presentation of many important contributions on laryngology and otology. Both societies were established when the number of those devoting themselves to these specialties was small. In one of them the membership was strictly limited by the constitution, and in the other

The belief that there is impairment of immunity to infection in the tissues of the diabetic patient has been widely held for many years. In the field of otology this concept finds expression in the doctrine that in the presence of diabetes infections in the mastoid process are associated with relatively early and extensive bone destruction and are particularly prone to intracranial complications. Recently, however, exception has been taken to this view, 1 and it has been asserted that with the present improved therapy in diabetes, with especial reference to the use of insulin and a dietary regimen, the course of mastoiditis in the diabetic patient does not differ essentially from that in one who does not have diabetes. In an attempt to clarify this matter and to obtain, if possible, a better understanding of the influence of diabetes on the clinical manifestations, pathologic changes and treatment of mastoiditis, we

The management of temporal bone infections due to Proteus vulgaris (Bacillus proteus) continues to be a perplexing problem in otology. The success of antiobiotic therapy in treating most infections of the ear is often not evident when this organism is involved. In fact our concern with P. vulgaris has not materially changed since the report 1 made in 1936. This situation is illustrated by four cases in which the usually ubiquitous saprophytic Proteus, flourishing in the confined space of a chronic otitis media extended centrally to produce a fatal intracranial complication. These cases warrant discussion for a number of reasons. Chronic otitis media is one of the major problems in otology. When P. vulgaris is implicated, because of its insidious nature, the disease becomes more complex. Also there appears to be an increased incidence of Proteus found in routine cultures of all sorts in recent years, perhaps because bacteriologists are

Considering the close proximity of the mandibular fossa to the middle ear, it is remarkable that extension of infection from the middle ear to the jaw joint does not occur more often. It is not mentioned in any of the standard texts on otology, and the literature contains only one reference to it. This report is being made because suppuration in the mandibular fossa does occur secondary to otitis media, it must be differentiated from zygomatic mastoiditis and it requires special treatment. Three patients with involvement of the jaw joint secondary to acute suppurative otitis media came under my care during a two year period. REPORT OF CASES Case1.—W. F., a boy of 7, was first seen Feb. 11, 1935, four days after the onset of earache on the right side. The right drum membrane was red, thickened and bulging; the temperature was 103 F., and the child had

IsRADIUM ACURE FORCANCER OF THELARYNX?ANINQUIRYBASED ON ASTUDY OF THEEND-RESULTS. Presented byDR.THOMASJ.HARRIS, New York City (by invitation). After a comprehensive review of the literature on this subject, Dr. Harris reported a series of sixty cases of laryngeal neoplasm in which the patients were treated with radium. Thirty were treated by Dr. Imperatori and thirty by Dr. Harris at the New York Post-Graduate Hospital. In two cases the patients remained for nearly five years. Dr. Imperatori and Dr. Harris concluded from their work with radium that it is not a cure for cancer of the larynx. The use of emanation seeds is yet too new to estimate properly the results obtained by this method of treatment. The danger of serious after-effects when radium is used in laryngeal neoplasm was discussed. Toxemia following extensive necrosis, stimulation of neoplastic

The averaged vertex response has definite but limited diagnostic uses in clinical otology. The vertex response can be used with a reasonable degree of accuracy (1) to determine objectively the thresholds of hearing in subjects who cannot be tested satisfactorily by conventional audiometric methods; (2) to differentiate conductive from sensorineural hearing loss; and (3) to differentiate organic from functional hearing impairment. Preliminary evidence suggests that the vertex response can be used to distinguish between auditory and pseudoauditory air-bone gap in patients who have been severely hard of hearing since early childhood. At the present time the vertex response has not been found to be of significant value in differentiating cochlear and retrocochlear lesions.

In January, 1931, Dr. Ralph Almour and I presented before the Section of Otology of the New York Academy of Medicine our conception of suppuration of the petrous pyramid. We then presented a study of the pathologic changes involved, the mechanics of invasion and the developmental stages of a new clinical entity. We proposed a new technic which we had successfully employed to meet the indications for surgical intervention which the pathologic changes of the lesion presented. We cited in detail our case histories and summarized the reasons for the recoveries and the deaths which occurred in the cases we studied.1 Our first presentation was also particularly concerned with clarifying a prevalent misconception which was general at that time. This misconception pertained to the underlying pathologic process which served to produce the clinical pictures rather loosely summarized as belonging to the so-called Gradenigo syndrome. We sought to establish the

Otosclerosis is still one of the important unsolved problems of otology, and any light which may be thrown on the subject is of value. Because of the tendency of the condition to occur in members of the same family, a study of the family of a person with otosclerosis has always been of interest. When, in addition, one can study a pair of identical twins suffering from otosclerosis, there is hope that something new may be learned. Few cases of otosclerosis in identical twins have been reported. The most extensive article on the subject is that of Shambaugh Jr., 1 who reported 3 instances of otosclerosis in identical twins. Shambaugh and Shambaugh 2 had previously reported 2 instances. Shambaugh Jr. 1 stated that the first report of the condition in identical twins was that by Albrecht in 1932, and the second that by Rodin in 1933. Twice he has found that the disease

Within the last decade the advances in otology have been especially marked along two lines, one of which derived its impetus from physics; the other, from the biologic sciences. The pioneer work of Seashore, who perceived the necessity of more accurately measuring and recording the minimum audibility of sound, produced the siren audiometer, which has been modified and improved during the intervening years. This was followed by the Western Electric audiometer from the scientific department of the American Telephone Company, whose investigations to perfect the methods of transmission of sound, and especially of the voice, resulted in several instruments for testing minimum audibility. From the biologic side, increased knowledge of the function of the ear has been especially associated with the names of Magnus and his co-workers in Europe and of Maxwell and others in this country. From these has come a clearer perception of the function of the complex

IT HAS often been said that the Ear, Nose, and Throat resident learns only enough about tuning fork tests to satisfy his professors and to pass the board examination, that the older otolaryngologist dwells upon these test mainly because they are pleasant reminders of the past, and that in the middle there is a large group who do not use the tests at all. And yet, often the first question asked at Thursday night chart dis cussions at the Otologic Medical Group is, "What did the fork test show?" What About The Audiogram? Tuning Forks to Audiometers and Back Again —is the title of a recent article by an PhD audiologist: "This title was a deliberate. Its purpose is to suggest to you that even though we have extremely accurate quantitative test devices, the simple tuning fork tests are still excellent clinical tools and should be a part of every

THE PURPOSE of reporting these cases is primarily as a reminder that intracranial complications of chronic suppurative otitis media still play an important part in the practice of otology. Furthermore, the antibiotics and chemotherapeutic agents, although very helpful adjuncts in therapy, are not entirely curative and may give a misleading and masked picture of the actual pathologic condition. This may unnecessarily delay surgical intervention. Lateral sinus thrombosis and thrombophlebitis are similarly affected by antibiotics and chemotherapeutic agents. Galloway, 1 as far back as 1939, stated that thrombosis of the lateral sinus probably can be dealt with successfully without chemotherapy if necessary. The chemotherapy hastens the cure and prevents local and general spread of sepsis. Cunning, 2 in discussing chemotherapy, mentions that it is of great help but that it must not take the place of surgical treatment. This impression, as well as the tendency of the antibiotics to mask the

It has been very gratifying to observe the progress that has been made with mobilization surgery. Its reintroduction by Rosen 1 has been the greatest stimulant to otology since the tremendous contributions of Lempert. At the present time, those of us who became interested in mobilization at its revival are aware that there are constant changes in ideas and concepts in this surgery. The knowledge that a fixed stapes could be mobilized has led to the development of varied techniques by the individual surgeons. Rosen's initial concept of applying pressure on the anterior aspect of the neck of the stapes in an effort to mobilize the footplate at first seemed like the logical method to reestablish ossicular conduction. It was quickly determined by others and by me that there were definite limitations in the percentage of good results obtained if this original technique was completely adhered to. Fracturing the crura

Advances that have made possible the surgical miracles of today in many areas of the body have not been wanting in the field of otology. From the dark ages of a half century ago, when improper visualization of the temporal bone frustrated surgical efforts, we have come through a period during which anatomists laid an invaluable groundwork of knowledge of the temporal bone, and researchers in fringe areas have greatly broadened the spectrum of otologic surgery. Many who can look back over several decades of practice to their graduate school days can recall the surgical technique current for temporal bone pathology and the inadequacies of visualization under which surgery was accomplished. But, with the advent of the endaural approach together with the increased magnification made possible with the operative microscope, the otologist now has every surgical advantage to increase his ability to reach a correct diagnosis and by improved surgical

LITTLE is known about tumors of the glomus jugulare (nonchromaffin paraganglioma), a condition which most otologists know only by reference, if at all, but which is not as rare as it is thought to be by Dr. Harry Rosenwasser,* who reported the first case diagnosed as such in 1945 "as a pathologic curiosity." Lately there have been more reports in the periodicals about glomus jugulare tumors, and we believe that it is rather important that one be on the look-out for these cases, some of which might not be as benign as is the general belief of the very few who have seen these cases. The first man we met who could tell us of personal experience with tumors of the glomus jugulare type was Dr. Jose Gross,† Professor of Otology of the University of Habana School of Medicine, who had had experience with a very malignant case in which

Stapes mobilization is the most important present-day interest in otology. Most otologists prefer to ascribe its discontinuance some 50 years ago to the lack of technical advantages. The many reports of success in this field would indicate that mobilization of the stapes will remain as another method for the improvement of hearing in otosclerosis. Those interested in mobilization of the stapes are trying to establish the procedure on a firm and lasting basis. However, one need only read everything that has been written on the subject since Rosen's first article appeared in 1952, and the literature of preceding years, to appreciate the many unknown or little understood factors which handicap the otologist and influence his results. Some of these are represented in the tremendous variety of histopathologic changes, their extent and location; the significance of the audiogram, the uncertain results, the incidence of recurrence, and an ignorance of the conditions

Five cases of mastoid surgery in which Korner's septum was identified have been presented. Identification of this structure insured complete exenteration of the mastoid and thus reduced the tendency of recurrent mastoid disease. The clinical significance of the duality of the antrum and the mastoid process in its relationship to disease of the middle ear and mastoid is clarified by an understanding of Korner's septum. The relationship of the parts of the temporal bone in an infant and adult skull and the process of pneumatization of the mastoid portion of the temporal bone have been reviewed. A thorough knowledge of the surgical anatomy of the temporal bone is the key for satisfactory mastoid and middle ear surgery.

Introduction Additional information concerning the function of the eustachian tube of normal and pathological ears is needed in modern otology. Poor eustachian tubal function has been implicated in the etiology of chronic diseases of the middle ear, and reconstructive surgical procedures of the middle ear require an adequately functioning eustachian tube. Previous studies of eustachian tubal function have mainly employed the technique of politzeration, which is somewhat insensitive and difficult to quantitate. The present project was undertaken to devise a method of accurately measuring the functional capacity of the eustachian tube under closely simulated physiological conditions. Such a method would be a useful addition to the present methods of evaluating eustachian tubal function. The present report describes the technique developed and analyzes normal tubal function and tubal function in ears with chronic suppurative otitis media. Methods and Materials Technique of Eustachian Tubal Testing. —The normal eustachian tube is closed at

ABSCESS OF THEBRAIN.DR.FRANCISC.GRANT. The extent of infection depends entirely on the ability of the surrounding tissue to wall it off and the result of the protective reaction is the formation of a capsule about the abscess. The two most important factors for a successful result are: the presence of adhesions obliterating the subarachnoid space and the degree of encapsulation about the infectious process. Dr. Grant considers the mortality statistics in his series discouraging, but he obtains satisfaction from the fact that a diagnosis of abscess of the brain was made in twenty-six of the thirty cases reported. The abscess was found and drained in the designated area in each of the twenty-six cases. The relatively high percentage of correct localization of the lesion of the brain was due mainly to careful neurologic investigation and exacting history taking. In twenty-seven of the thirty cases the point

The Practical Value of the Roentgen Ray in Sinus and Mastoid Conditions. Presented by Dr. Fredrick M. Law (by invitation). By personal contact between the roentgenologist and rhinologist or aurist, much more can be learned from roentgen-ray studies of the sinuses than if a less intimate relation exists. By verbal consultation, the surgeon can make the symptomatology clear in a manner that a written report cannot duplicate. To the interpreter of the roentgen-ray films this information is of extreme value, and only after possessing this knowledge can he properly estimate his findings. Technically perfect films are absolutely essential. A proper reading of such films takes into consideration two main factors: (1) anatomy, and (2) pathology. Of these, the former is the more important; more important because the pathology usually is fairly well understood before films are made, but by an accurate description of anatomic conditions the surgeon will be aided