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Preface This review focuses on older men with secondary, or late-onset hypogonadism (LOH, colloquially 'low-T'). The author resists the temptation to present a flood of information (delightful to some but [...]

Introduction: 'You never forget your first.' Case 1: In the early 1990s, a slender, older man asked Doc to help him regain some energy. He had been fatigued for nine [...]

Parts 1 and 2 of this three-part article presented the complex physiology of thyroid function, and discussed symptoms, diagnosis of hypothyroidism, and treatment., At the First Follow-Up Visit When your patient arrives feeling wonderful, simply test her blood levels after she's been on the dose for at least two weeks. However, having conservatively [...]

Part 1 of this three-part article (published May 2021) presented the complex physiology of thyroid function and discussed symptoms and diagnosis of hypothyroidism. Start T4 Treatment: Dose and Timing Despite [...]

Introduction This article reviews the functions of thyroid hormone and how to diagnose and treat its deficiency. Because the physiology of thyroid hormones is complex, featuring the processing of a [...]

References are posted online at www.townsendletter.com. Preface Twenty years ago, a middle-aged man came to see Doc for chronic fatigue. He also endured severe pain from spinal degeneration, many times-operated [...]

Otolaryngologists, like pediatricians, often see patients with chronic rhino-sinusitis and draining ears. Surgeons can offer various procedures, from simple tympanostomy tubes to advanced sinus and turbinate operations, in which significant [...]

Introduction Men and women have the same sex hormones, made from cholesterol by our ovaries or testicles and adrenal glands, also the brain... and even the skin! The body assumes [...]

Introduction Men and women have the same sex hormones, made from cholesterol by our ovaries or testicles and adrenal glands. The body assumes male and female forms depending on how [...]

Introduction Some molds release toxins, as certain snakes are poisonous. These mold toxins are diverse (1,2): They can activate or Impair our innate immune system, may provoke disabling chronic inflammation, [...]

Abstract We performed an observational study to determine whether allergen-specific sublingual immunotherapy (SLIT) is as effective as allergen-specific subcutaneous injection immunotherapy ( SCIT). Our study population was comprised of 66 [...]

Although total excision is accepted as the standard of care in the treatment of acoustic neuromas, for the elderly patient this approach is modified. Small tumors which cause only eighth nerve symptoms of hearing loss and tinnitus can be followed radiologically while larger tumors with brain stem compression may be subtotally excised through the translabyrinthine route. Our standard treatment for Meniere's disease—that is re-factory to medical management—has been vestibular nerve section through a retro-labyrinthine approach. In the event of bilateral Meniere's disease or Meniere's disease in an only hearing ear, treatment with low-dose intramuscular injections of streptomycin sulfate is preferred. Two elderly patients are discussed, each of whom has an acoustic neuroma in one ear and Meniere's disease in the other. These patients' histories, diagnostic evaluations, treatment rationale, and follow-up data are presented to illustrate the decision-making process and the management of complicated and unusual cases.

The cochlear and vestibular nerves rotate 90 degrees from the inner ear to the brain stem. Most of the rotation occurs within the internal auditory canal (IAC); only minimal rotation occurs in the cerebellopontine (CP) angle. At the labyrinthine end of the IAC, the cochlear nerve—which at first lies anterior to the inferior vestibular nerve (saccular nerve)—rapidly fuses with the inferior vestibular nerve. It then rotates to become inferior as the nerves leave the porus acousticus. The cochleovestibular (C-V) cleavage plane lies in a superior-inferior direction in the lateral IAC and rotates to become anterior-posterior in the CP angle. In 25% of patients in whom no C-V cleavage plane can be seen, it is not possible to completely transect all vestibular fibers. The surgical implications are that (1) the most complete vestibular neurectomy can be done only in the lateral IAC, (2) the cochlear and inferior vestibular nerves, because of their intimate association, should not be separated in the mid-IAC, in order to prevent damage to the cochlear nerve, and (3) to create a complete denervation of the vestibular labyrinth, only the posterior ampullary nerve along with the superior vestibular nerve should be transected.