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Chronic otitis external (COE) is occasionally refractory to treatment and may persist for years. In such cases, a dermatophytid (id) reaction from a fungal infection in a remote location should be suspected. Immunotherapy with dermatophyte (Trichophyton, Oidiomycetes, and Epidermophyton [T.O.E.]) extracts and dust mite, based on serial endpoint titration skin test results, as well as a yeast elimination diet, is the treatment of choice. Fourteen cases of id reaction are described. The primary fungal source was not always obvious, but immunotherapy and diet led to complete resolution of the COE in 8 cases (21.4%). Some case reports illustrate presentation, treatment, and outcome. [ABSTRACT FROM AUTHOR]

Objective: Evaluate long-term prevalence of tumor growth and need for further treatment in patients with a vestibular schwannoma treated with conservative management., Study Design: Retrospective chart review., Setting: Private neurotologic tertiary referral center., Patients: Vestibular schwannoma patients undergoing conservative management and previously studied (N = 114). Mean time to last magnetic resonance imaging was 4.8 years and to last follow-up was 6.4 years (maximum, 18.5 yr)., Intervention: Serial gadolinium-enhanced magnetic resonance imaging with size measurement., Main Outcome Measures: Change in maximum tumor dimension of 2 mm or higher (growth), further treatment, audiologic measures-pure-tone average, word recognition, AAO-HNS (American Academy of Otolaryngology-Head and Neck Surgery) hearing class., Results: Thirty-eight percent of tumors demonstrated growth; an average of 6.5 mm (SD, 3.8) at a mean rate of 3.1 mm per year. Of patients with no growth at 1 year or less, 20% grew by last follow-up. Overall, 31% had further treatment after a mean of 3.8 years (SD, 3.5; maximum, 18.5 yr). Of those followed for 5 to 10 years, 18% eventually had further treatment. Only 56% of growing tumors had further treatment by last follow-up; 14.8% with nongrowing tumors also had further treatment. Pure-tone average declined more in tumors that grew (mean Δ = 28.8 dB) than those that did not (mean Δ = 16.5 dB) (p ≤ 0.025), but there was no correlation between the amount of change in hearing and in the size of the tumor. Of patients with an initial AAO-HNS hearing Class A, 85.7% retained serviceable hearing., Conclusion: For patients electing an observation approach to treatment of vestibular schwannoma, about 31% may eventually undergo further treatment. Of those followed for 5 to 10 years, 18% eventually had further treatment. However, some patients are followed with radiologic evaluations for many years without necessity for further treatment.

Objective: To demonstrate that sudden sensorineural hearing loss is possibly of viral origin rather than vascular., Study Design: The histopathologic morphology in 7 temporal bones with known vascular impairment due to surgical interventions was compared with that of 11 bones with a history of idiopathic sudden sensorineural hearing loss (ISSNHL). Attention was paid to the spiral ligament, stria vascularis, organ of Corti hair cells, tectorial membrane, ganglion cell population, and degree of perilymph fibrosis and the auditory nerve., Setting: A temporal bone laboratory that has been in operation for more than 50 years and includes a database consisting of clinical and histopathological information that facilitates quantitative and qualitative analysis., Subjects: Eight hundred forty-nine individuals who pledged their temporal bones for scientific study, of which 18 were selected for this study by means of the database criteria of sudden sensorineural hearing loss and postmiddle fossa and retro sigmoid sinus tumor removal or vestibular nerve section., Results: Sudden sensorineural hearing loss bones exhibited no perilymph fibrosis compared with 6 of 7 vascular cases with fibrosis (P ≤ .001), exhibited less loss of ganglion cells (P ≤ .026), exhibited greater survival of spiral ligament (P ≤ .029), and averaged twice the survival of hair cells and more widespread tectorial membrane abnormalities., Conclusion: Analysis of human temporal bones from patients with a sudden sensorineural hearing loss does not support a vascular insufficiency but is more suggestive of a viral etiology.

Objective: To evaluate ease of use and compliance with dietary modification in the treatment of vertigo in patients with Ménière's disease., Study Design: Mailed patient retrospective questionnaire and chart review., Setting: Tertiary referral neurotologic private practice., Subjects: 136 patients with Ménière's who returned a mailed questionnaire. Mean age at first clinic visit was 53 years, and at questionnaire was 62 years, with 54.4% female subjects. Median initial hearing was AAO-HNS Stage 1. Most patients also received diuretics and/or other treatments., Intervention: Reduced sodium and caffeine-free diet., Main Outcome Measures: Ratings of diet difficulty, length of use, compliance level and nutritional understanding, and AAO-HNS vertigo class and functional rating before and with nutritional intervention., Results: 46.3% of the respondents received written diet guidelines; only 3.2% were referred for nutritional counseling, and another 7.8% sought counseling independently. 77.8% and 84.7% rated a low sodium and a caffeine-free diet, respectively, as manageable or easy to follow; 77.9% followed the diet for 1 year or greater, but only 10.3% could list 5 "correct" foods to eat and 26% 5 foods to avoid. Those who followed the diet greater than 6 months had larger improvement in number of spells and functional rating and a higher rate of Class A/B vertigo outcome (p ≤ 0.01, p = 0.012, and p = 0.038, respectively). Knowledge of foods to eat and avoid correlated with vertigo class (rho = -0.21, p ≤ 0.029 and rho = -0.26, p ≤ 0.01, respectively); the more foods correctly listed, the better the AAO-HNS class)., Conclusion: Nutrition education by referral to a registered dietitian may improve outcomes in the medical treatment of Ménière's disease.

Severe palmoplantar hyperhidrosis both affects activities of daily living and diminishes quality of life. This study evaluated overall safety and efficacy of endoscopic lumbar sympathectomy (ELS) using a clamping method in a large series of consecutive patients. Patient data were routinely entered into a prospectively designed database. Plantar sweating was graded as cured, improved, or unchanged. ELS (using 5-mm titanium clips) was performed in 154 patients, 68.2 per cent at the third lumbar vertebrae and 31.8 per cent at the fourth lumbar vertebrae. Follow-up averaged 15 months and ranged up to 4.7 years. Anhidrosis was achieved in 97.4 per cent of patients with the remainder reporting major reduction in symptoms. All patients were discharged home within 24 hours of surgery, requiring only oral analgesics, if any. There were two surgical complications (lymphatic leak and misidentification of genitofemoral nerve for sympathetic nerve). Six early patients required conversion to an open surgical procedure. Partial recurrence, usually mild, occurred in 4.5 per cent with 2.6 per cent requiring revision surgery. Severe plantar hyperhidrosis can be safely and effectively treated by endoscopic lumbar sympathectomy using the clamping method. It can be accomplished on an outpatient basis with low morbidity, complete resolution of symptoms, and a significant improvement in quality of life.

Ménière's disease (MD), which by definition is idiopathic, has been ascribed to various causes, including inhalant and food allergies. Patients with MD report higher rates of allergy history and positive skin or in vitro tests compared with a control group of patients with other otologic diseases and to the general public. Recent immunologic studies have shown higher rates of circulating immune complexes, CD4, and other immunologic components in patients with MD compared with normal controls. Published treatment results have shown benefit from immunotherapy and/or dietary restriction for symptoms of MD in patients who present with allergy and MD., (Copyright 2010 Elsevier Inc. All rights reserved.)

The most common nonsurgical modern treatments for hyperhidrosis include topical treatments such as aluminum chloride, iontophoresis (usually with tap water), oral medications such as anticholinergics, and BTX-A. Topical treatments should always be first-line therapy. For those who fail such treatment, iontophoresis is typically recommended for those with palmar or plantar hyperhidrosis, whereas BTX is often considered as first- or second-line therapy in severe axillary hyperhidrosis. Oral anticholinergics are considered after failure of all other nonsurgical treatments.

Objective: Persistent vertigo and imbalance can occur after surgery for vertigo regardless of surgical approach. This study explored for factors affecting outcome of vertigo surgery., Study Design: Patient survey and chart review., Setting: Tertiary referral neurotologic private practice., Patients/intervention: Of 111 patients (57.7% female; mean age, 52.3 yr), 59 underwent vestibular nerve section (middle fossa, retrolabyrinthine, and translabyrinthine), 25 underwent transmastoid labyrinthectomy, and 27 underwent endolymphatic sac shunt. Eighty-three percent had Ménière's disease. Mean follow-up was 4.3 years., Main Outcome Measures: Primary outcomes included American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) vertigo score and class, number of spells per month, current and change in AAO-HNS disability rating, vertigo and imbalance severity ratings, and frequency of imbalance., Results: Three preoperative factors were consistently related to outcome: AAO-HNS disability rating, imbalance frequency rating, and duration of first symptom ([rho] = 0.19-0.51; all p's < 0.05). Greater disability and more frequent imbalance related to poorer outcome, but longer duration of disease related to better outcome. Presurgery vertigo characteristics were generally not related to outcome. Ménière's patients were more likely to have improvement in imbalance, as were those with no other significant disease and no allergy. The presence of tinnitus in the contralateral ear was associated with poorer outcomes, including a lower rate of results of Classes A and B (p = 0.023). Vertigo as a first symptom and the presence of eye disease also showed relationships to poorer outcome., Conclusion: Those rating themselves as more disabled before surgery are less likely to achieve the best outcomes, whereas frequency and severity of preoperative vertigo are not predictive. Several possible prognostic factors were identified that warrant future prospective study.

Ménière's disease (MD), which by definition is idiopathic, has been ascribed to various causes, including both inhalant and food allergies. Patients with MD report higher rates of allergy history and positive skin or in vitro tests compared to a control group of patients with other otologic diseases and to the general public. Recent immunologic studies have shown higher rates of circulating immune complexes, CD4, and other immunologic components in patients with MD compared to normal controls. Published treatment results have shown benefit from immunotherapy and/or dietary restriction for symptoms of MD in patients with both allergy and MD.

Objective: Analyze differences in outcomes between labyrinthectomy with and without vestibular nerve section, including characteristics of symptoms and time course for improvement., Study Design: Patient survey., Setting: Tertiary referral neurotologic private practice., Patients/intervention: Twenty-five patients who underwent transmastoid labyrinthectomies and 17 who underwent translabyrinthine vestibular nerve section (TLVNS). Patients with a diagnosis of Meniere's disease comprised 64.0 and 64.7% of the two groups, respectively., Main Outcome Measures: A mail questionnaire assessed frequency, severity, interference, and disability for both vertigo ("spinning dizziness") and dysequilibrium ("imbalance/unsteadiness") before and after surgery as well as the time course of improvements., Results: Approximately 24% of each group still has vertigo (spinning dizziness). On average, both groups indicated resolution of vertigo at 2 to 3 weeks on average (longer for imbalance). There were no significant differences between groups in vertigo characteristics, but TLVNS did show advantages in imbalance outcomes. American Academy of Otolaryngology-Head and Neck Surgery functional disability showed improvement in 73 and 52% of the TLVNS and labyrinthectomy groups, respectively. The TLVNS group was more likely to have improved imbalance (81.3 versus 45.8%, p 85% Class A or B). However, patients undergoing TLVNS were more likely to show improvement in imbalance and functional disability. This difference was less pronounced in patients with Meniere's disease.

Objectives: To assess surgical treatment of vertigo by patient ratings of postoperative vertigo, imbalance, and timing of symptom improvement., Methods: A total of 3637 surgeries for vertigo were performed since 1974. Questionnaires sent to a random sample of patients operated since 1994 were completed by 28 endolymphatic sac shunt (ES), 54 vestibular nerve section (VNS), and 14 labyrinthectomy patients., Results: All groups rated current vertigo characteristics and AAO-HNS disability as improved (all P

Objective: Determine the prevalence and time interval for conversion from unilateral to bilateral involvement in Meniere's disease and cochlear hydrops., Study Design and Setting: Retrospective chart review in a tertiary otologic referral center., Patients: 232 patients diagnosed with Meniere's Disease (n=186) or cochlear hydrops (n=46) between 1959 and 2001, who visited the clinic over a five-year period between 1997-2001 and have at least 2 audiograms more than 12 months apart., Main Outcome Measures: Prevalence of cochlear hydrops relative to Meniere's Disease, rate of progression from unilateral to bilateral involvement; interval between unilateral onset of symptoms and bilateral involvement; and rate of progression from cochlear hydrops to Meniere's disease., Results: Initial diagnosis was Meniere's disease in 71% and cochlear hydrops in 29% of all 950 hydropic patients presenting between 1997 and 2001. In the study sample, Meniere's disease was bilateral at presentation in 11%; an additional 12% (14% of unilaterals) became bilateral during the follow-up period. At presentation, 6.5% of cochlear hydrops patients were bilateral, with another 26% becoming bilateral. Conversion from cochlear hydrops to Meniere's disease occurred in 33% and some of these are included among the bilateral. The average time interval for conversion from unilateral to bilateral Meniere's was 7.6 years (SD=7.0 years)., Conclusion: Most otologists are aware of the potential for contralateral ear involvement and conversion from cochlear hydrops to Meniere's disease after diagnosis. These changes are significant, require long-term follow-up for detection, and may necessitate further treatment. Patients should be counseled regarding this potential when interventions are considered, especially with respect to ablative treatments.

Objectives/hypothesis: Compare vestibular schwannoma (VS) surgical outcome between patients with prior irradiation and those not previously treated., Study Design: Retrospective review with matched control group., Methods: Review of tumor adherence to the facial nerve, facial nerve grade, and complications in 38 patients with radiotherapy as a primary procedure before VS surgical removal and a matched random sample of 38 patients with primary surgery. The majority of the irradiated group had gamma knife radiation therapy. Mean time from irradiation to surgical salvage was 3.3 years (SD = 3.2), with a minimum of 5.2 months and a maximum of 15.8 years. Most (89.5%) patients in each group underwent a translabyrinthine approach. Mean tumor size at surgery was 2.6 cm in each group., Results: The irradiated group had more moderate to severe adherence of tumor than the controls (89% vs. 63%, P < or = .01). They also had a lower rate of good facial function (House-Brackmann grade I/II) (37% vs. 70%) and a higher rate of poor function (grades V or VI) (50% vs. 18%) at follow-up (P < or = .019). Results were similar when including only those with good preoperative function (50% vs. 72% and 32% vs. 15%) but did not achieve statistical significance. Surgical time and complications did not differ., Conclusion: Patients who have undergone irradiation for VS and require surgical salvage may have a more difficult surgery and poorer outcomes than those not previously irradiated. When making their initial choice of treatment, patients should be counseled that surgery might be more difficult after failed stereotactic irradiation.

Allergy may affect the outer, the middle, or the inner ear. Although the otologic manifestations of allergy are not by themselves diagnostic, the history, including family history and associated symptoms in other target organs, will often help lead to the correct diagnosis and institution of therapy. Patients with significant and chronic symptoms, including those with labyrinthine symptoms of allergy, respond well to specific immunotherapy or dietary elimination.

Objective: We asked patients with allergies to complete the SF-36 Health Survey, a health-related quality-of-life (QOL) measure, to determine the impact of allergy on QOL., Study Design and Setting: In total, 377 adults-140 men (37%) and 237 women (63%)-seen in a tertiary care private neurotologic practice allergy clinic completed the questionnaire before beginning immunotherapy and dietary management. One hundred patients completed both initial and 1-year follow-up questionnaires. The SF-36 measures 8 health concepts ranging from physical to mental health, and scale scores range from 0 to 100., Results: Initial mean scores ranged from a high of 79.1 for the physical functioning scale to a low of 47.2 for the vitality scale, lower (poorer) on all scales than norms for the general US population. Significant improvement occurred from initial to follow-up on all scales. The largest improvements were in role functioning-physical, role functioning-emotional, and social functioning., Conclusion: Findings suggest that allergy symptoms can affect QOL and that treatment with specific immunotherapy and/or dietary management may lead to measurable improvements., Significance: The significant impact of allergy must be recognized, and treatment should be offered. The SF-36 can be used to evaluate treatment outcome.

Objectives: The goal of this study was to determine the prevalence of allergy in a population of patients with Meniere's disease., Methods: A survey was mailed to all patients with Meniere's disease seen at our institution from 1994 to July 1998 (n = 1490). As a control group, 172 patients with otologic problems other than Meniere's disease completed the same survey., Results: Of 734 respondents with Meniere's disease, 59.2% reported possible airborne allergy, 40.3% had or suspected food allergies, and 37% had had confirmatory skin or in vitro tests for allergy. These prevalence rates were significantly higher than those found in the control group, of which 42.7% reported having or suspecting airborne allergies and 25% had or suspected food allergies (differences all significant at P< or =0.005)., Conclusion: The prevalence of allergy appears to be much higher in patients with Meniere's disease than in the general population or the population of patients visiting an otologic clinic for other symptoms.

Background: Knowledge of acoustic neuroma (AN) growth is essential for treatment planning., Methods: A retrospective analysis of 119 patients with AN (mean age, 65 years; range, 37-84 years) followed with interval magnetic resonance imagings (MRIs) was performed. Change in maximum tumor dimension as a function of follow-up period was analyzed., Results: Overall, maximum tumor dimension increased >2 mm in only 30% of patients. Of those that grew, the mean growth rate was 3.8 mm/year (maximum, 25 mm/year). Age, gender, and laterality did not predict growth. Most tumors that grew (86.1 %) were <20 mm at presentation. However, tumors >20 mm were statistically more likely to grow (71%, p =0.028)., Conclusions: Most ANs followed with periodic MRIs do not grow. Available clinical information usually cannot predict growth. Serial MRIs are advocated for all patients treated with observation.

Background: Corticosteroids are frequently used for the prevention and treatment of neural edema. Although perioperative steroid therapy has been used in patients undergoing acoustic neuroma removal, the efficacy of such therapy has not been previously documented., Methods: A retrospective review of 169 patients who underwent acoustic neuroma surgery with (n = 75) or without (n = 94) a single dose of intraoperative corticosteroids was performed. Tumor size ranged from 0.4 cm to 6 cm (mean, 2.1; SD, 1.0) The translabyrinthine approach was used in 85% of the patients, and the middle cranial fossa approach was used in 13%. Data were analyzed for differences in postoperative facial function and complication rates., Results: After controlling for differences in tumor size, no significant effects of steroid therapy were found for any of the outcome variables., Conclusions: This retrospective study showed no apparent benefit from intraoperative steroid use in acoustic neuroma surgery. A prospective, randomized, placebo-controlled trial should be performed to confirm these findings.

Allergy may affect the outer, the middle, or the inner ear. Although the otologic manifestations of allergy are not by themselves diagnostic, the history, including family history and associated symptoms in other target organs, will often help lead to the correct diagnosis and institution of therapy. Patients with significant and chronic symptoms, including those with labyrinthine symptoms of allergy, will respond well to specific immunotherapy and/or dietary elimination.

Objective: This study aimed to evaluate the outcome of long-term hearing benefits of plasmapheresis (PMP) in presumed autoimmune inner ear disease (AIED)., Study Design: The study was a case series, with retrospective chart review, written questionnaire, telephone interview, and follow-up examination., Setting: It was performed in a private practice otology and neurotology referral center., Patients: Sixteen patients (5 males, 11 females) whose symptoms were compatible with the diagnosis of AIED, who underwent PMP, and who had 2-year or later objective follow-up. Age ranged from 8-62 years, with a mean of 40.9 years. Follow-up ranged from 2-12 years, with a mean of 6.7 years., Intervention: Plasmapheresis at one or more times during the active phase of disease., Main Outcome Measure: Stability of hearing, defined according to the American Academy of Otolaryngology-Head and Neck Surgery recommended criteria for reporting hearing results in Meniere's disease, was used as the main outcome measure., Results: Eight (50%) of 16 patients had improved or stable hearing in 1 or both ears. Eleven (39.3%) of 28 ears with measurable hearing pre-PMP were improved or stable. Only 25% of patients required continued use of immunosuppressive drugs., Conclusion: Plasmapheresis may be beneficial as an adjunctive therapy for maintaining hearing in some patients with AIED. Cost and reimbursement factors are major obstacles in the use of this therapy. The overall success rate and individual patient results warrant further study of PMP in the treatment of AIED.

Objective: The objective of this study was to describe the characteristics and response to specific allergy therapy of patients with clinically significant eustachian tube dysfunction secondary to allergy., Study Design: This was a retrospective case review conducted in the setting of a private otologic practice (tertiary referral)., Patients: The study population was composed of 151 patients presenting with eustachian tube dysfunction who had evidence of allergy and had undergone allergy testing and treatment. The 105 females and 50 males ranged in age from 2.8 to 84 years (mean 41.8 +/- 17.3)., Interventions: Interventions used included diagnostic allergy testing (inhalants and food) and treatment with immunotherapy and diet., Main Outcome Measures: The main outcome measures were descriptive characteristics and ratings of fullness, allergy symptoms, and well-being rated as "improved," "no change," or "worse.", Results: All patients had reactivity to inhalants, and 92.3% were positive to one or more foods. Nearly half of the patients (49.4%) had undergone at least one advanced test beyond an audiogram as part of their diagnostic evaluation before referral to a tertiary center for treatment. Forty percent had undergone radiological assessment. Nearly all had used one or more other treatments without success before allergy therapy. The majority were rated as improved on all three symptoms (fullness 70.9%; allergy symptoms 82.8%; and well-being 80.2%). Adherence to the recommended elimination diet was significantly related to outcome., Conclusions: Eustachian tube dysfunction may be due to underlying inhalant and/or food allergies. Even patients with refractory cases of patulous eustachian tube and eustachian tube obstruction who have not responded to traditional medical and surgical management may do well on specific allergy therapy.

Purpose: Findings of a prior study indicated that neither choice of pre- versus postoperative bone-conduction scores nor choice of frequencies to include in averaging makes a substantial difference in reported outcomes of chronic ear surgery., Methods: In this study, audiologic data from 240 stapes surgery patients at three different institutions were used to generate a variety of outcome measures., Results: Use of preoperative rather than postoperative bone-conduction values in computing postoperative air-bone gap resulted in an approximately 5-dB smaller mean gap and a 2% higher success rate. Frequencies included in averaging made little difference in mean computed air-bone gap, although success rate (gap < or = 10 dB) was lower by 6% when 4 kHz was used in a four-frequency average rather than 3 kHz. Results for air conduction were similar to those for air-bone gap regarding choice of frequencies to include in averaging. When we used air-conduction pure-tone average (PTA) as the outcome measure, those with normal preoperative sensorineural hearing had a > 20% higher success rate than the general population of patients with stapes surgery., Conclusions: The greatest differences in success rate were based on definition of and criteria for success. Success rate was higher when based on air-bone gap than when based on air-conduction PTA. As in the prior chronic ear study, differences in outcome were more drastically affected by criteria for "success" than by frequencies included. Unlike similar data from chronic ear surgery, however, success rate differed depending on choice of air-bone gap or air-conduction PTA as the definition for success. Further, air and bone scores from the same test interval must be used accurately to reflect air-bone gap in stapes surgery.

Choice of outcome measure in reporting hearing results following otologic surgery, including the frequencies used and use of pre- or postoperative bone thresholds, varies from author to author. In this study, data from 550 ossicular reconstruction and pediatric tympanoplasty surgery patients were used to generate a variety of outcome measures, including pure-tone thresholds for frequencies from 0.5 kHz to 8 kHz and different frequency combination pure-tone averages (PTAs) and air-bone gaps. There were no significant differences between mean pre- and postoperative bone conduction thresholds for any of the frequencies from 0.5 to 4 kHz nor for a PTA of 1, 2, and 4 kHz. Mean postoperative air-bone gap differed by no more than 2 dB across six different frequency combination PTAs. If "success" is defined as a postoperative air-bone gap of less than 20 dB, the largest difference in success rate across the six frequency combinations was 5%. There was also little difference in mean postoperative air conduction PTAs for any of the combinations that include frequencies through 4 kHz. Choice of a more conservative or more liberal definition of success was more important than whether air-bone gap or air conduction PTA was used. The authors recommend that a standard reporting procedure be adopted that ensures presentation of the results in a format such that more direct comparisons can be made within the published literature.

Postoperative facial function was compared for middle cranial fossa and translabyrinthine removal of acoustic tumors. Included were 164 primary acoustic tumor surgeries performed between 1988 and 1991 in patients with normal preoperative facial function; postoperative House-Brackmann facial function grade available immediately postoperatively, at time of discharge and at 1 year or more postoperatively; and a tumor 1.5 cm or smaller. There were 116 translabyrinthine surgeries and 48 middle fossa surgeries. There was no significant difference in facial function results between the two surgical approaches at any of the three postoperative time intervals. Immediate postoperative facial function grade I or II was present in 90 percent of patients who underwent the middle cranial fossa approach, and in 90 percent of those with translabyrinthine surgery. By long-term follow-up, grade I or II function was recorded after 96 percent of middle fossa, and 91 percent of translabyrinthine surgeries. Results were similar when evaluating subgroups of those with tumors measuring 1.0 or smaller and 1.1-1.5 cm. There was also no difference in facial function result between superior and inferior vestibular nerve tumors with either approach. The authors conclude that, in an experienced center, long-term postoperative facial function outcome is not a basis for selecting surgical approach for tumors measuring 1.5 cm or less.

High-resolution computed tomography (HRCT) is important in the evaluation of cochlear implant candidates. This study examines the accuracy of radiological assessment of cochlear patency in relation to findings at the time of surgery. Older and newer HRCT methods and attending and senior radiologist interpretations are compared in a large series of cochlear implant patients. Subjects were 50 adults (22 to 74 years) and 31 children (2.4 to 11.7 years) who received either a 3M/House or a Nucleus 22-channel cochlear implant. Attending radiologist reports were obtained by chart review and the scans were re-reviewed for this study by a senior radiologist. Accuracy in detecting cochlear ossification ranged from 86.4 per cent for attending radiologists, with all HRCT scans, to 94.7 per cent for the senior radiologist with newer HRCT scans. False positives were rare, but false negatives did occur. Overall, best results were obtained with newer HRCT scans and a senior radiologist. Knowledge of the presence and extent of cochlear ossification is important to the implant surgeon and for patient counselling. Technical guidelines and a check list for interpretation of results are presented.

Objective: Recently, nonsurgical treatment of acoustic tumors has been advocated as an alternative to surgical resection. Because of the relatively short follow-up in reported series of radiation-treated acoustic tumors, the lack of growth of some tumors may merely reflect the variable biologic growth potential of these tumors and not the result of treatment. DNA flow cytometry has been used to predict biologic activity in other solid tumors. It is applied in this study to assess the variability of growth potential in a typical acoustic tumor population and to determine whether relationships exist between flow cytometric data and clinical characteristics of acoustic tumors., Design: DNA flow cytometry techniques were used to evaluate formalin-fixed, paraffin-embedded tissue previously obtained from patients who were surgically treated for acoustic neuromas. Relationships between flow cytometry data and historical data were also statistically evaluated., Setting: Tissue samples were from patients of a large private otologic practice., Patients: Subjects were a convenience sample of 49 patients (26 female and 23 male) with a mean age of 59 years who had undergone surgical removal of an acoustic neuroma. None of the patients had other stigmata of neurofibromatosis or tumor recurrence. All tissue specimens were pathologically confirmed acoustic neurons, with a range in tumor size from 1 to 6 cm., Main Outcome Measures: The measures included DNA ploidy and S-phase fraction. Historical data included age, sex, size of tumor, presenting symptom, and symptom duration., Results: All 49 tumors showed a diploid distribution, with S-phase values ranging from 1.07% to 20.74% (mean +/- SD, 6.30 +/- 4.24). The ploidy and S-phase data compare favorably with previously published data in which fresh tissue was used. There were no statistically significant relationships between S-phase value and historical data., Conclusions: The wide range of S-phase values is consistent with a large variation in tumor growth potential and suggests caution in interpreting the results of radiation treatment of acoustic tumors when follow-up relatively short.

Tinnitus is common in patients with acoustic tumors and may be the initial symptom leading to diagnosis. We might anticipate that tumor removal would alleviate preoperative tinnitus. However, few have studied this systematically. Further, the effect of tumor removal in those with no preoperative tinnitus has rarely been examined. In this study, a questionnaire was sent retrospectively to patients who had undergone surgical removal of an acoustic tumor, addressing the characteristics of tinnitus, and asking whether surgery had directly affected tinnitus. A total of 134 questionnaires were returned. Those who indicated preoperative tinnitus tended to show small but statistically significant improvements in the perceived severity of the tinnitus after surgery, although the symptom rarely resolved entirely. Those with no preoperative tinnitus have an approximately 50 percent chance of developing it following surgery.

Eight investigational sites are involved in clinical trials of the 3M/House cochlear implant for children. Statistical analyses have been performed to examine differences between investigators in patient populations selected for implantation and in the results achieved. Important characteristics of the subjects from different investigational sites were compared for House, Maddox, and all "others" combined. There were no differences between investigators in sex, age at surgery, or duration of deafness of the children enrolled in the study. For age at onset, House and Others had higher proportions of postlingually deaf subjects than Maddox (16% for House and 18% for Others, compared with less than 2% for Maddox). However, all investigators had some subjects in every category: postlingual, prelingual, and congenital. Auditory discrimination and speech production scores for subjects from the three groups were compared using analysis of variance techniques. A few interaction effects between time interval and investigator indicated that not all investigator groups performed similarly over time for all measures. However, postimplant scores were always significantly higher than preimplant scores for all investigators. Differences that did occur appeared to be attributable to differences in subject characteristics.

Data on 265 children with the 3M/House single-channel cochlear implant have been collected and analyzed for presentation to FDA. Significant improvements from preimplant to postimplant in auditory detection, auditory discrimination/identification, and speech production have been demonstrated. Some children also demonstrate the ability to recognize words and sentences without the aid of speechreading.

The cochlear implant offers an alternative to selected profoundly deaf patients in whom conventional treatments or prostheses have been unsuccessful. Substantial benefits have been obtained by patients, with apparently minimal risk. There have been no serious surgical complications and only a few postoperative problems, which were remedied satisfactorily. The device has continued to function in patients over a period of years, and in cases of internal coil failure it has been removed and replaced. Replacement devices seem to function as well as the patient's first device. There has been no evidence of any decrement in performance after years of electrical stimulation or any measurable adverse effects. The cochlear implant is now widely available and should be considered an option to be offered to appropriate patients.

Many clinicians feel that single-channel cochlear implants are limited in the information they can provide. This has led to some common misconceptions regarding single-channel and multichannel systems. At the House Ear Institute, a growing number of children with the 3M/House single-channel implant are demonstrating open-set understanding of speech on measures designed to test such abilities in children. As a result, we have revised our thinking regarding the potential of this device.

The results to date with the 3M/House cochlear implant in children have been extremely encouraging. Statistically and clinically significant changes show that the implant can provide improvements in auditory detection and discrimination as well as in speech production. As with any intervention, results range from outstanding for some children (open-set speech discrimination and/or intelligible speech) to minimal for others (no stimulation or little improvement in speech). Until long-term studies can be completed, the implant will undoubtedly remain controversial. However, professionals involved in the care of a child who is hearing-impaired should be informed that the field of cochlear implantation is rapidly expanding. A number of different cochlear implants are currently undergoing clinical trials in adults. Besides the 3M/House device, the FDA has recently approved a second device, the Nucleus Multichannel Cochlear Implant, for investigation in children. The treatment of profound deafness is changing in children with the cochlear implant as an option for those not benefiting significantly from hearing aids. However, some important aspects of a deaf child's management have not changed and will not change: the need for early diagnosis and multidisciplinary management. The first five years of life are the language acquisition years. Proper management during these years is critical if the hearing-impaired child's handicap is not to dominate his or her future and limit potential for a successful, happy life.

Cochlear implants have been used in investigational studies with profoundly deaf children aged 2 to 18 years. Results with the 3M/House implant indicate that this device is safe and effective. The implant provides auditory detection of much of the acoustic speech signal, significant improvement in auditory discrimination compared with preimplant with hearing aids, and improved speech production skills. A longitudinal control-group study of auditory discrimination and a cross-sectional study of speech using age-matched controls support the interpretation that these improvements are due to the cochlear implant. In addition, 26 of 50 children (52%) tested for open-set word recognition and 17 of 41 (41.5%) tested for open-set sentence comprehension demonstrated such abilities using the cochlear implant. Adverse effects have been minimal. Early results from three children with the Nucleus multichannel cochlear implant clearly indicate the efficacy of that device.

Extensive clinical investigation of the cochlear implant, both in adults and children, has provided evidence of significant benefit with relatively minimal risk. Work is in progress worldwide to develop improved cochlear implant devices. Meanwhile, an auditory prosthesis is now available for the profoundly deaf patient who could not be successfully treated in the past.