Abstract Otology 2000 A01-1

G. Scott Giebink MD

ORL University of Minnesota, UMHC P.O.Box 296 USA-Minneapolis MN

Considerable evidence in human clinical trials and animal models suggests that acute otitis media (AOM) can be prevented by systemic immunization. Building on the highly effective Haemophilus influenzae type b (Hib) conjugate vaccine technology, pneumococcal conjugate vaccines are being developed to circumvent T-independence of these antigens and provide durable immunity at a very young age. Several pneumococcal conjugate vaccines are currently in clinical trials. Potential vaccine antigens of nontypable H. influenzae (NTHi) include outer membrane proteins (OMP), high molecular weight proteins (HMW), pili and fimbriae. Several OMPs show extensive homology among strains, but surface determinants are highly variable so that antibodies to surface epitopes of one strain will not bind to surface epitopes of another. Several Moraxella catarrhalis OMP and HMW antigens have vaccine potential, but no functional correlates of protection have been identified, and there is no clear evidence that bactericidal antibody to M. catarrhalis is associated with OM protection. Attenuated viral vaccines also hold promise of preventing childhood otitis media. Two clinical trials with killed influenza vaccines have shown a significant reduction in OM among vaccine recipients compared to control children during periods of high influenza disease activity in the community. Passive immunoprophylaxis also has potential for preventing otitis media. Human bacterial polysaccharide immune globulin was protective for pneumococcal OM in children and in the chinchilla OM model. High-dose respiratory syncytial virus-enriched immunoglobulin reduced the incidence and severity of RSV lower respiratory tract infection in high-risk children. Passive immunoprophylaxis may also be effective in children with specific immune deficiencies, such as IgG2 deficiency, and patients who fail to respond to future vaccines.

Abstract Otology 2000 A02-1

Alan G. Kerr MD (1), Bernard Fraysse MD (2), Jan Helms MD (3), John S. May MD (4), Saumil N. Merchant MD (5), F. Erwin Offeciers MD (6)

(1) Eye and Ear Clinic Victoria H IRL-Belfast
(2) Service ORL CHU Purpan F-Toulouse Cedex
(3) HNO-Klinik Julius-Maximilians-Universität D-Würzburg
(4) Otolaryngology, Head&Neck Surg. Wake Forest University USA-Winston-Salem, NC
(5) Department of Otolaryngology and Eaton Peabody Lab. of Aud.Physiol. Mass. Eye and Ear Infirmary USA-Boston MA
(6) Univ. Dept. of Otolaryngology St. Augustinus Hospital B-Wilrijk

The first half of the session will cover important topics of ossiculoplasties. These include "indications and contraindications with special reference to the other ear", patient consent issues, middle ear mechanics in relation to ossicular reconstruction, types of materials used and classification of ossicular problems with reference to prognosis. The second half of the session will be spent in discussion of the problems arising in specific cases.

Abstract Otology 2000 A03-1

Karl-Bernd Hüttenbrink MD (1), Cor W.R.J. Cremers MD (2), Alex M. Huber MD (3), Anthony J. Maniglia MD (4), Benno P. Weber MD (5), Naoaki Yanagihara MD (6), Hans Peter Zenner MD (7)

(1) HNO-Klinik Univ.-Klinik der TU D-Dresden
(2) ENT-Deptmt. Academisch Ziekenhuis Nijmegen Postbus 9101 NL-Nijmegen
(3) ENT Department University Hospital CH-Zürich
(4) Department of Otolaryngology University Hospitals of Cleveland USA-Cleveland OH
(5) HNO-Klinik Med.Hochschule D-Hannover
(6) Dep. of Otolaryngology Takanoko Hospital 525-1 Takanoko-cho J-Ehime-ken
(7) Department of Otorhinolaryngology University of Tübingen D-Tübingen

This panel presents our actual knowledge on the state-of-the-art of implantable hearing aids, followed by a discussion on different aspects of this topic. The history, development and concepts of implantable hearing aids will be presented, followed by experimental evidence of efficacy and risk control. Indications and criteria for candidate selection will be discussed and experience with three devices currently in use will be described (RION, Symphonix soundbridge, TICA). Additional questions, which the otologist (the audience) will ask himself prior to the recommendation of such a device will cover problems of indication, audiologic topics, side-effects, biotechnical aspects and socio-ethical aspects. Hopefully the result of this panel session will be a critical but optimistic presentation of this promising new technique in otology.

Abstract Otology 2000 A03-2

Anthony J. Maniglia MD

Department of Otolaryngology University Hospitals of Cleveland USA-Cleveland OH

The advantages and disadvantages of implantable middle ear hearing devices will be reviewed. Experimental and clinical results of a contactless semi-implantable electronic middle ear hearing device will be briefly reported and compared with a state-of-the-art conventional hearing aid. Probably, the semi-implantable technology will be short-lived (four to five years). The long-term gain results will be modest, at best. Patients who are candidates for this type of implantation have other conventional hearing aid alternatives which may very well supplant the risks and benefits of the semi-implantable device. Unilateral implantation of a device may not be more efficient than binaural digital conventional hearing aid fitting. Perhaps, the highest yield is to concentrate, focus, and apply resources on the development of a totally implantable cochlear implant with a lithium ion rechargeable battery, using the middle ear as a bioelectronic microphone. In this device, the incus is removed and a transducer is implanted on the head of the malleus. A new totally implantable cochlear implant will be presented. If successful (long-term results), similar technology and bioelectronic microphone will be applicable to the totally implantable device for the treatment of partial sensoneural hearing loss.

Abstract Otology 2000 A03-3

Benno P. Weber MD, B. Strauchmann MD, Guido Temme M.Sc., Thomas Lenarz MD

HNO-Klinik Med.Hochschule D-Hannover

Implantable hearing aids are being developed for moderate to severely hearing impaired patients who have difficulties with conventional hearing aids. Some key questions during the development of implantable hearing aids are: Is the system potentially dangerous for the already unhealthy inner ear? Is the system transmitting a high quality sound equivalent? Is it coupled to the ossicles in an adequate and longterm stable manner? How does the system behave if there are biologic changes of the environment, such as otitis media? To evaluate these and other questions, extensive bench testing for example with optical measuring methods, need to be performed to collect sufficient baseline data for further testing. In temporal bones various features, such as the coupling mechanisms or feedback in case of fully implantable hearing devices can be tested. Acute animal experiments allow the evaluation of all aspects of such devices in living beings and enable the preparation of acute human experiments. Chronic animal experiments evaluate the longterm stability. Electrophysiological and safety investigations test the function of the implant over time. Finally, morphological studies evaluate the inner ears, the coupling sites and the environment of the implants. The absolute necessity for thorough experimental evaluation of implantable hearing aids will be demonstrated. The report will be based on long term animal experiments with Implex ( Munich) prototypes of an fully implantable hearing aid (n=22, 1995-1996) and various types of prototypes of an implantable sensor and actor system built by St Croix Medical (Minneapolis, 1998-1999).

Abstract Otology 2000 A03-6

Hans Peter Zenner MD

Department of Otorhinolaryngology University of Tübingen D-Tübingen

Since 1998 we use the totally implantable electronic hearing implant Implex TICA according to Leysieffer-Zenner for the surgical treatment of SNHL (Lancet 352 (1998) 1741, HNO 46 (1998) 844; www.hno-tuebingen.de) The majority of patients with SNHL suffer from a cochlea amplifier (CA) failure which is discernible by a positive recruitment and loss of otoacoustic emissions (OAE). Therefore, the electronic implant is expected to partially replace functions of the CA. Thus, the implant is thought to function as a CAI (cochlea amplifier implant). The implant consists of a piezoelectrical transducer, a microphone, a digitally programmable 3-channel audioprocessor and a battery with all components implantable. It is a low energy consuming (LEC), broad-band implantable system for patients with sensorineural hearing loss. Routine surgical treatment of patients with sensorineural hearing loss revealed that TICA combines distinct acoustic superiority with invisibility (end of stigmatization), an open ear canal, and the end of feedback whistling. Data from an ongoing prospective case control study are reported.

Abstract Otology 2000 A04-1

Mansfield F.W. Smith MD (1), Jean Bernard Causse MD (2), Ugo Fisch MD (3), John William House MD (4), Gordon B. Hughes MD (5), Per Möller MD (6)

(1) Past-President USA-San Jose CA
(2) Chirurgie de la Surdité F-Beziers Cedex
(3) ORL-Klinik Universitätsspital CH-Zürich
(4) House Ear Clinic USA-Los Angeles, CA
(5) Otolaryngology The Cleveland Clinic Foundation USA-Cleveland OH
(6) ENT Department Haukeland Sykehus N-Bergen

Format: All comments by panelists will relate to presentations of controversial cases of otosclerosis. Each panelist is prepared to respond spontaneously and may use slides and videos to provide their opinion. We are indeed privileged to have such distinguished, talented and experienced round table participants.

Abstract Otology 2000 A05-1

Daniel Simmen MD (1), Robert A. Jahrsdoerfer MD (2), Thomas Linder MD (1), Ralf Siegert MD, PhD (3), Ad Snik Ph.D. (4), Anders Tjellström MD (5)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Dept. of Oto-HNS Univ. of Virginia Medical Center USA-Charlottesville VA
(3) Univ HNO Klinik Medizinische Universität D-Lübeck
(4) KNO Acad. Ziekenhuis Postbus 9101 NL-Nijmegen
(5) Deptmt. Otolaryngology University of Goteborg Sahlgrens Hospital S-Göteborg

This Round Table will highlight the current opinion on middle ear reconstruction as well as the aesthetic reconstruction of the atretic ear. The alternative treatment with bone anchored hearing aids and the bone anchored epithesis will also be demonstrated. All faculty members will present the surgical technique and their results. Then a moderated discussion with case demonstration will highlight some further points of interest in this challenging field. The "How I do it Session" in the evening is to present video tapes on different surgical techniques that have been presented during the Round Table and a further discussion with the faculty members is possible.

Abstract Otology 2000 A05-5

Anders Tjellström MD

Deptmt. Otolaryngology University of Goteborg Sahlgrens Hospital S-Göteborg

One of the indications for a Bone Anchored Hearing Aid, BAHA, is the patient with bilateral external ear canal atresia. In most of these patients the cochlea reserve is normal or near normal which is of great advantage. The degree of atresia is of no importance for the function of the BAHA as the air - bone gap is of no significance, only the level of the bone conduction. This fact makes the BAHA unique among available hearing aids. The surgical technique is still a two stage procedure with three months between implant insertion and connectionof the BAHA coupling. In the young children with atresia the amount and quality of the bone available at the implant site may call for special consideration. The use of Gore-Tex membrane technique to improve the bone volume in the very thin skull will be discussed. The youngest child we have treated so far is a boy with Treacher Collins syndrome who was only 18 months at time of implant surgery. Reconstructive surgery in the very young child is difficult and the chance for a good and lasting result might be better if the surgery could be performed when the child is older. During this time the child could benefit from a BAHA. Surgery for BAHA will not jeopardise later reconstruction of the external ear canal or the middle ear. If the implant site for the BAHA is carefully selected even external ear reconstruction with autogenous tissue will not be put at risk.

Abstract Otology 2000 A10-1

Matthew W. Yung PhD, FRCS, DLO

Consultant ENT Surgeon The Ipswich Hospital NHS Trust GB-Ipswich Suffolk

The outcome of OME in children is generally quite good. However, it is less clear in adults. To investigate that, all adult patients who had ventilation tube (VT) inserted for OME at the Ipswich Hospital between 1996 and 1997 were studied. The patients were assessed at 15 to 27 months following VT insertion. Patients with head and neck tumour were excluded. Of 53 patients studied, 49 had adult onset OME and 4 had recurrent OME started since childhood. 28 out of 53 patients already had VT insertion before. Furthermore, at the time of the assessment, 19 out of 31 patients already had a recurrence of OME following VT extrusion. Endoscope examination revealed that many patients still had pathologies in the nose and sinuses (30%) and at the eustachian tube orifice (50%). The study also demonstrates a strong association between adult onset OME and atopy. 23 out of 53 patients (43%) had a known history of atopy. More importantly, 30 out of 53 patients (57%) had a positive skin prick allergy test, with the commonest allergy being house dust mite, pollen, wheat, animals, alternaria and aspergillus. This study showed that many patients with adult onset OME have persistent pathologies that could lead to recurrence of OME following VT extrusion.

Abstract Otology 2000 A10-2

Aruna Visvanathan M.B., M.S., F.A.G.E.

Vikram Hospital & Ear Research Inst IND-R.S. Puram, Coimbatore

Middle ear effusion (MEE) and atelectasis with eustachian tube dysfunction is a multifactorial, multifaceted disease that manifests in the middle ear, mastoid and eustachian tube. Understanding the mechanisms of this disease, the presentation, and issues involved in management, allows for the most optimal outcomes. Several pioneers including Politzer himself have contributed tremendously to the evolution of the diagnosis and management of this entity. This 10 year retrospective study of 178 patients is from a leading otology research institute in India. It briefly overviews the aetiological mechanisms, the course and clinical presentation, and primarily focuses on the long term results of various surgical modalities and their outcome. The ultimate goal is to treat MEE medically, reserving surgery for the restoration of function and for the eradication of disease. Surgery for an atelectatic tympanic membrane ranges from a spectrum of techniques starting from a ventilation tube insertion to several others. The basic objectives are (1) to reinforce or replace an exceedingly weak tympanic membrane which is usually collapsed and not uncommonly attached to the medial wall of the middle ear, (2) to inspect the middle ear cavity, repair ossicles and lyse adhesions, and (3) to re-establish the middle ear space by placement of a silastic film and cartilage palisades. This study is being presented to evaluate the current status of surgery for middle ear atelectasis, and in the hope of paving the way for even better and newer approaches.

Abstract Otology 2000 A10-3

Hans Rudolf Briner MD, Thomas Bischoff Dr.med., Thomas Linder MD

ENT Department University Hospital CH-Zürich

Treatment of acute otitis media (AOM) with a 10-day course of antibiotic drugs was recommended for many years. This treatment concept, however, was challenged in recent years, argueing that there is no need for antibiotic treatment in AOM at all. Whereas the incidence of complications from acute middle ear infections has markedly decreased, antibiotic resistance of middle ear pathogens has emerged over time. The proponents of a vigorous antibiotic regimen argue that the risk of acute mastoiditis - one of the most frequent complications of AOM - can be reduced by early antibiotic treatment. To evaluate a possible impact of antibiotic pretreatment on the occurrence of acute mastoiditis, 48 patients with acute mastoiditis referred to the Department of Otorhinolaryngology of the University Hospital Zürich between 1992 and 1999 were reviewed retrospectively. Special emphasis was made to analyze antibiotic pretreatment, intraoperative and microbiological findings. The 33 male and 15 female patients had a mean age of 11.2 years (range 5 months to 56 years). Twenty-three Patients (48%) had antibiotic treatment before admission to the hospital, whereas 25 patients (52%) had none. The group of patients with antibiotic treatment was older than the group of patients without antibiotics (mean age of 17.6 years vs. 5.9 years) and admission to the hospital after the first signs of an acute mastoiditis was delayed in comparison to the non-treated group (average of 4.8 days vs. 2.6 days). Acute mastoiditis may be the first sign of an ear infection, especially in very young patients (< 12 months).

Abstract Otology 2000 A10-4

Stan Cotulbea MD (1), Ghe. Iovanescu MD (2), Stelian Lupescu MD (2)

(1) University of Medicine ROM-Timisoara
(2) ENT Department University Hospital ROM-Timisoara

The authors present a retrospective study over a period of 5 years (1993-1997) about the incidence of subperiostal abcess in chronic otomastoidittis. In this period of time the Otolaringology Departament of the Medical University of Timisoara has admitted and operated on a number of 169 patients suffery from ear cholesteatoma. The diagnosis has been established after the clinic and radiologic examination and in some selected cases by TC. From the 169 patients that were operated 28 (16%) presents extracranial complication and 9 (5,52%), intracranial complications. The extracranial complications were represented by 11 subperiostal abcess (4 zigomatics, 6 retroauricular, and one Bezold abcess), 9 with facial paralysis and 14 labyrinth fistula. All cases with intra and extracranial complications presented with extensive cholesteatoma and polyps or/and granulations. All patients who presented subperiostal absess were children and young people, who were admitted in hospital in the emergency service, presenting high temperature of over 38°C and a constitued mastoidian abcess. The treatment was intense from the very begining. Combined antibiotics were administered with effects on the Gram + and Gram - microbial flora. All the patients presenting abcesses were treated surgically with radical mastoidectomy. The postoperatory evolution was favorable for all patients.

Abstract Otology 2000 A10-5

J.Y. Sichel MD, Y. Priner MD, Sharon Freeman Ph.D., S. Weiss M.A., H. Levy M.A.

Dept. of Otolaryngology Head & Neck Surgery Hadassah University Hospital IL-Jerusalem

Introduction: Tympanometry is well established as a means to assess the presence of fluid in the middle ear. The type B tympanogram is usually considered a unique entity, however its shape may vary from a rounded type B with a "pseudo peak" to completely flat curve. Objective: To compare the shape of the B curve (static admittance, area under the curve) to the viscosity of middle ear fluid and to the air bone gap (ABG). Material and Methods: Tympanograms were recorded from 90 patients prior to insertion of ventilating tubes. When possible, according to the age of the patient, ABG was also measured (64 ears). These patients were further divided into 2 different sub-groups, one with low ABG (=20 dB) and the other with high ABG (> 20 dB). During the tube insertion, middle ear fluid was sampled and its viscosity measured by viscosimetry and ultra sound absorption. Results: There was no correlation between the viscosity and the ABG or the shape of the tympanogram. The shape of the tympanogram was compared between the two groups with different ABG, and was found to be significantly different (area; P<0.0005; static admittance; p<0.0025). Discussion: The shape of the B curve and the magnitude of ABG seem mainly dependent on the amount of middle ear fluid and not on the fluid viscosity. Tympanometry may be used as an objective measure to estimate the degree of hearing loss (ABG) especially in young children, where this measure may be difficult.

Abstract Otology 2000 A10-6

Kazuhiro Aoki MD, Yukie Mitani MD, Tomihiko Tuji MD, Yukio Hamada MD, Hiroya Utahashi MD, Hiroshi Moriyama MD

ENT Department Jikei University School of Medicine J-Tokyo

Objectives: Our earlier study on children with otitis media with effusion (OME) revealed that the more severe the inflammatory change of the middle ear mucosa, the greater the decrease in the middle ear total pressure (METP) being caused by gas migration. However, this decreased METP came to show a significant increase when the period of tube indwelling exceeded 18 months, and beginning from this point in time, the rate of recurrence of the disease after extubation came to show a marked decrease. We hypothesized that the impairment of this METP is a factor of clinical tendency toward intractability, and we conducted this study to investigate the relationship between the degree of METP and the rate of recurrence of the disease after extubation. Materials and Methods: In 42 children with OME for which a tympanic ventilation tube (TUBE) had been indwelt , the peak value of METP at the time of extubation was measured, and the rate of recurrence of OME after one year of extubation were compared with the peak value. Result: The mean peak value was 42.0 mmH2O in 30 cases without the recurrence of the disease, and was 15.58 mmH2O in 12 cases with the recurrence or the remnant of tympanic perforation. The difference of the peak value between the two groups was significant (p< o.o1). Conclusion: It was confirmed that measurement of the METP is an important test method for evaluation of the degree of improvement in the pneumatic cavity mucosa and the patological state of otitis media.

Abstract Otology 2000 A10-7

Yang Sun Cho MD, Suk-Joo Ko MD, Hyo Chang Woo MD, Won Ho Chung MD

Department of ORL-HNS Samsung Medical Center Sungkyunkwan University ROK-Seoul

External ear resonance (EER) can normally increase the sound pressure level at the tympanic membrane by as much as 20 dB between 2 and 4 kHz. Pathologies such as middle ear effusion (MEE) or perforation of tympanic membrane (TMP) may alter the gain of resonance. Also, surgical modifications of external auditory canal by ventilation tube (VT) insertion or tympanoplasty may further change the resonance characteristics. The first part of the study was comprised of 30 ears of children with MEE and 58 control ears. They were all managed with VT insertion. EER was measured with probe tube microphone. The gain was higher in the MEE group than the control group. The insertion of VT decreased the gain to the same level as the control group and created negative peaks of around 1000 Hz. The second part of the study was comprised of 89 ears with TMP which received tympanoplasty ± canal wall-up mastoidectomy and 96 control ears. Preoperative EERs were checked and compared with the control group. Postoperatively, EER was measured at 3, 6, 9, 12 and more months and compared during the follow-up periods. The peak gain and frequency were not different in the TMP group as compared to the control group. However, peculiar negative peaks appeared around 1500 Hz in half of these ears. When tympanoplasty was performed using the temporalis fascia, the peak gain increased markedly at 3 months postoperatively. These increments diminished over time, but the peak gain did not equalize to the control's data even after 2 years. In conclusion, some additional gain should be considered in the frequency of around 1 kHz for hearing aid users with TMP or VT. We could expect alterations of EER after tympanoplasty, suggesting that these changes should be considered in the fitting of the hearing aids.

Abstract Otology 2000 A11-1

Albert Mudry MD

ENT Department University Hospital CHUV CH-Lausanne

Purpose of study: To study the historical development of the binocular microscope and to understand the resulting revolution in auricular surgery. Method: Compilation of the texts of the era, books dealing with auricular surgery and a revue of the international litterature on the subject. Results: The first descriptions of the microscope date back to the 17th century, but it was not until 1921 that it was really used for the first time in auricular surgery by a Swedish otologist: Olaf Nylen. This monocular microscope was rapidly replaced by a binocular microscope developed in 1922 by Gunnar Holmgren. Due to a limited field of vision, a very short focal distance, bad light quality, and an unstable fixation this microscope was used very little to start with. Despite many differing models being developed, it was only in 1953 that a new model appeared, perfected by Littmann and the company Zeiss. It was this model which was to progressively replace all other models, thanks to its easy use and the possibility of changing the magnification without modifying its focal distance. It allowed for the development of new techniques in tympanoplasties and interposition. The microscope continued to be improved, notably by the addition of a zoom system and the possibility of connecting a photographic camera. Conclusion: Auricular surgery would not really have been conceived if it had not been for the binocular microscope. Without it, auricular surgery would not be what it is today.

Abstract Otology 2000 A11-2

Hartmut Meister MD, A. Mickenhagen MD, M. Walger PhD, Hasso Von Wedel Prof.Dr., Eberhardt Stennert Prof.Dr.

ENT-Department University of Cologne D-Köln

Several methods to evaluate the sound transmission properties of middle ear implants are established. On the one hand, mathematical simulations based on finite element methods or circuit models can be used to estimate acoustical parameters. Computer-based models allow accurate approximations, but a large number of parameters is required, all of which have to be determined first. On the other hand, measurements with temporal bone preparations can be performed. Those experiments consider various anatomical properties but a large number of parameters influence the outcome of measurements. Additionally, a marked interindividual variability can occur. To facilitate standardized measurements we developed a mechanical middle ear model which can be used to evaluate the transfer function of middle ear implants on defined conditions, comparable to coupler measurements with conventional hearing aids. A number of experiments was carried out which focused on the fundamental sound transmission properties. Several commercially available prostheses were examined. They differed mainly in the high-frequency range corresponding to their mass. The outcome of the measurements has been confirmed by a simple theoretical model. The mass of the prosthesis had the strongest influence on sound conduction. Middle ear implants should be as light as possible to allow optimum high-frequency-transmission which is important for consonant discrimination and speech perception in noise.

Abstract Otology 2000 A11-3

Frank Böhnke PhD, Wolfgang Arnold MD

HNO-Klinik Univ.-Klinik Rechts der Isar D-München 80

The success of stapedectomy/stapedotomy surgery depends on the surgeons expertise and on the type of prosthesis used. In order to develop the most ideal prosthesis a three-dimensional numerical simulation of the transition mechanics between the stapes footplate and the cochlea is done, which leads to a certain geometry regarding the boundary surface between prosthesis and the connecting perilymph. The perilymph is idealized as a compressible and inviscous fluid. The modulus of elasticity of the annular ligament is chosen as 650 kPA which is the value for elastin. The results show that an increase in the surface size of the stapes footplate from 3 mm2 to 3.9 mm2 ( 30 % ) can produce an increase in perilymphatic pressure of about 6.8 dB ( F = 2.18 ), i.e. more than twice as much. The increase is limited to frequencies up to 2 kHz which is in agreement with experimental results. Since the result is accompanied by an increase in the maximal basilar membrane displacement and provided that certain boundary conditions discussed are fulfilled, we predict an improvement in the hearing threshold of patients on whom a stapedectomy was performed using the appropriately improved prosthesis. Examples how the ideal prosthesis should look like are given.

Abstract Otology 2000 A11-4

Sugata Takahashi MD (1), Shigehisa Hashimoto MD (2), Yutaka Yamamoto MD (3), Hitoshi Satoh MD (3)

(1) Department of Otolaryngology Niigata University School of Medicine J-Niigata
(2) Department of Otolaryngology Niigata Univ. School of Medicine J-Niigata
(3) Department of Otolaryngology Niigata University School of Medicine J-Niigata

Ceramic ossicular prostheses available in Japan include aluminum oxide ceramics [Al2O3, CORP] and hydroxyapatite ceramics [Ca10(PO4)6(OH)2, Apaceram]. Tympanoplasty with these ceramic prostheses was performed in91 ears of 83 patients at the Niigata University Hospital. CORP was utilized in 67 ears and Apaceram in 24 ears. The mean follow-up period was 6 years and 3 months. Extrusion of the prosthesis to the external auditory canal was recognized in 15 cases (16%), 14 cases of CORP and 1 of Apaceram. The overall mean period of extrusion was 2 years and 6 months (range from 1 month to 7 years and 8 months). Diseases of the ceramic extrusion consisted of 8 of 55 cases of cholesteatoma, 4 of 27 cases of chronic otitis media, 3 of 4 cases of adhesive otitis media and 0 of 4 cases of ossicular malformations and 1 case of one traumatic ossicular disruption. Prosthetic dislocation in the middle ear cleft was recognized in 20 cases (22%), 18 cases of CORP and 2 of Apaceram. An air bone gap closure, less than 20 dB of the pure tone average, was achieved in 14 ears (21%) of the CORP and 13 ears (54%) of Apaceram.

Abstract Otology 2000 A11-5

Hidemitsu Sato MD (1), Kiyofumi Gyo MD (1), Goran Bredberg MD (2)

(1) Department of Otolaryngology Head and Neck Surgery Ehime Univ. School of Medicine J-Onsen-Gun Ehime
(2) Audiology Department Karolinska Institute Stockholm Soder Hospital S-Stockholm

Partially implantable hearing aid (PIHA) has been implanted in the patients with conductive or mixed deafness. Generally, hearing afforded by PIHA is highly affected by mobility of the stapes. Therefore, implantation of the PIHA in patients with stapes fixation has been the problem. In this paper we studied a new surgical technique for PIHA implantation by using animals with experimental stapes fixation. Eight rabbits with normal hearing were used in this study. Tympanic membrane and ossicles except stapes were removed to set the vibrator of the PIHA. Cochleostomy was performed on the basal turn of the cochlea by 0.5 mm width with preserving membranous labyrinth. Stapes fixation was made by cementing the stapes with glass cement. The stapes and the opening of cochlea were stimulated by the vibrator and hearing thresholds were measured respectively. This study showed no hearing loss by cochleostomy and good sensitivity of the vibrator in stimulating the opening of cochlea even in stapes fixation. We concluded that cochleostomy was a possible procedure for implantation of the PIHA in patients with stapes fixation.

Abstract Otology 2000 A11-6

Elena Dimeska MD, Ilija Filipche MD, PhD, Marina Chakar MD, PhD, Aleksandrova Merzuha MD

ENT Department University Hospital MAZ-Skopje

This paper reports on the reconstruction of the sound-conducting system in the middle ear in those ears in which the incus and the stapes suprastructure are either absent or inadequate as after prior otitis media or tympanoplasty/stapedectomy. In these situations, the Teflon malleus attachment piston in 38 operations over an 6-year period. The hearing results show that a closure of the pure-tone average air bone gap to within 10db was possible in 73.6% (28/38) and to within 20db in 84.2% (32/38). A residual air bone gap of 30 db was seen in two cases. Sensoneural hearing loss of 10db not occur and there was no decline in speech discrimination. We believe that the malleus attachmet piston has a big part and role in the reconstruction of the conducting mechanism of the middle ear in cases of absent or damage incus, congenital malformation and epitympanic fixation of the incus and malleus.

Abstract Otology 2000 A11-7

Matthew W. Yung PhD, FRCS, DLO

Consultant ENT Surgeon The Ipswich Hospital NHS Trust GB-Ipswich Suffolk

It has long been recognised that a technically successful hearing restorative procedure may not always produce a grateful patient. Numerous methods have been proposed to predict the patient benefit following ear surgery, such as the Belfast rule of thumb and the Glasgow benefit plot. Most reports on surgical outcome following tympanoplasty is based on audiometry. At the Ipswich Hospital, the social hearing handicap index has also been used to measure the patient benefit following tympanoplasty since 1995. It is a set of questionnaires originally designed for hearing aid users to test their ability to hear conversation in quiet and noisy environments. The response to the questionnaires can be developed into a score (handicap score), this enables the pre-operative and post-operative hearing ability to be compared. 110 patients with tympanoplasty were studied. All the patients had a pure tone audiogram and the handicap score recorded before the operation and also 12 months after the operation. The relationship between the improvement in hearing threshold and the handicap score was studied in the following situations: 1. Bilateral hearing loss with the operation on the better hearing ear. 2. Bilateral hearing loss with the operation on the worse hearing ear. 3. Symmetrical hearing loss; operation on one ear only. 4. Normal hearing in one ear with operation on the opposite hearing impaired ear. The result showed that operation on patients with unilateral hearing loss yield as much hearing benefit as operation on patients with bilateral hearing loss.

Abstract Otology 2000 A12-1

Joachim Müller MD, Ch. Milewski MD, Jan Helms MD

Department of ENT-HNO Julius-Maximilians-Universität D-Würzburg

The diagnosis and the management of chronic otitis and cholesteatoma in childhood remains controversial. The results of tympanoplasties in children are outlined based on the evaluation of more than 8000 tympanoplasties done in chronic otitis media and in cholesteatoma cases. The paper tries answer the question if tympanoplasty is different in children and in adults. Also smilarities to tympanoplasties in adults are shown. The paper discusses the audiological results of different grafting materials, the influence of age at surgery, the best age for surgery, questions of adenoidectomy prior to tympanoplasty and other factors influencing the outcome.

Abstract Otology 2000 A12-2

Manuel Bernal-Sprekelsen MD, PhD (1), M. Tomás-Barberán MD, PhD (2), F. Lorenzo MD (2)

(1) Jefe de Servicio de ORL Hospital Clinic E-Barcelona
(2) Hospital Son Dureta E-Palma de Mallorca

In a retrospective study, 299/321 tympanoplasties and tympanomastoidectomies using partial or total autologous cartilage palisade grafts associated with the reconstruction of the ossicular chain, operated in a tertiary referral center from October 1, 1992 to October 31, 1997 were evaluated anatomically and functionally after a mean follow-up of 42,4 months (range 12  75; median 49,2). Data was processed SPSS. Average ratings were taken for each audiometry of measurements carried out at 0,5 KHz, 1KHz, 2 KHz, and 4 KHz. Groups were distributed in steps of 10 dB (0-10; 11-20, 21-30, and >30 dB) considering those having an air-bone GAP <30 dB to have a social hearing. 157 (525%) left and 142 (47,5%) right ears were operated for different indications. 147 cases (49,2%) were revision surgery, primary surgery was performed in 152 ears. 152 ears (50.8%) had a radical procedure (CWD) and 147 a conservative (CWU) one. Closure of the tympanic membrane could be achieved in 98% of the cases, that is, 6 reperforations could be observed. There were statistically significant differences (2-tail Sig, t-Student p< 0,05) between preop and postop hearing levels. Better results were obtained for ossicular reconstructions between stapes and tympanic membrane, than from the footplate, with a statistically significant difference (p<0,001). CWU technique achieved a statistically significant difference (p<0,007) compared to CWD procedures, whereas no statistically significant difference could be found between primary and revision surgery. Cartilage, used as a palisade technique, similar to the original description of Heermann, is able to provide excellent long-term anatomical and functional results.

Abstract Otology 2000 A12-3

Yasuo Mishiro MD (1), Masafumi Sakagami MD, PhD (2), Yoshifumi Takahashi MD (3), Takeshi Kubo MD (1)

(1) Department of Otolaryngology Okayama University Medical Sch. J-Osaka
(2) Dept. ORL Hyogo College of Medicine J-Hyogo
(3) Department of Otolaryngology Osaka University J-Osaka

Chronic otitis media (COM) is divided into cholesteatomatous and noncholesteatomatous types.The aim of this paper is to analyze the results of noncholesteatomatous COM managed by tympnoplasty with and without mastoidectomy to estimate the role of mastoidectomy in tympnoplasty for noncholesteatomatous COM. Three hundred eighty-eight ears with noncholesteatomatous COM were operated on by a single surgeon at Osaka Rosai Hospital and Osaka University Medical School Hospital, Japan between April 1987 and December 1997. One hundred five ears operated on with endaural simple underlay techinque (Yuasa`s method ) and 58 ears with follow-up less than 1 year were excluded from this study. Two hundred twenty-five ears with follow-up with 12 and 123 months were reviewed. The patients were divided into two groups. Group A (n=144) consisted of cases of COM treated by tympanoplasty with mastoidectomy (TLWM). Group B (n=81) consisted of cases of COM treated by tympanoplasty without mastoidectomy (TLWOM). In group A, 40 ears were discharging and 104 ears were dry at the time of operation . In group B, 12 ears were discharging and 69 ears were dry at the time of the operation. Graft success rates of group A and group B were 91.7% and 95.1%. There was no statistical difference between group A and group B. Graft success rates of discharging ears and dry ears were 94.2% and 92.5%. There was no statistical difference between discharging ears and dry ears. Graft success rates of discharging ears and dry ears in group A were 97.5% and 90.4%. There was no statistical difference between discharging ears and dry ears in group A. Graft success rates of discharging ears and dry ears in group B were 91.7% and 95.7%. There was no statistical difference between discharging ears and dry ears in group B. Mastoidectomy is not necessary for tympanoplasty for noncholesteatomatous COM.

Abstract Otology 2000 A12-4

Joachim Müller MD, Ch. Milewski MD, M. Scharfenberger MD, F. Schön MD, Jan Helms MD

Department of ENT-HNO Julius-Maximilians-Universität D-Würzburg

Nowadays middle ear surgery is not only done to treat mastoiditis and to prevent its complications, which are highly dangerous. Middle ear surgery is also done to restore the hearing. Ojala summed up the situation in the seventies when he stated that hearing after tympanoplasty usually does not improve (and in some cases even deteriorates). Since Wullstein (Würzburg) discribed the basic principles of tympanoplasty in the early 50ties, many other otologists made additional contributions to our current knowledge of tympanoplasty. The aims of tympanoplasty have been and still are: · the elimination of the pathological changes · to create stable conditions and easy access for postoperative care · to reconstruct the sound conduction mechanism. Numerous grafting materials have been recommended for the closure of tympanic membrane perforations. This paper evaluates three different grafting materials for the reconstruction of the tympanic membrane: · Pericondrium · Cartilage · Perichondrium-Cartilage Composite Graft The study is based on a computerized documentation system called Würzburger Ohrbogen. This system includes now more than 8000 patients records. The database comprises information on surgical details (324 items) and patients follow up. All patients included in the study were operated from January 1988 to April 1999 and had a minimum follow up of 6 months. The aim of the study was to analyse the audiological results of different grafting materials, which were combined with ossicular chain recon-struction. In general, the audiological results achieved in ears which needed a tympanoplasty type I or III showed postoperatively for 80 % of the patients an improved hearing compared to preoperatively. The best hearing results were achieved in those ears in which primary tympano-plasty type I was per-formed without ossicular chain reconstruction (type I tympano-plasty). The grafting materials we used (peri-chondrium, cartilagee pallisades, perichondrium-cartilage composit graft (PCCG)) showed 6 months post-operative a similar air bone gap. The audio-grams were measured for the fre-quencies from 0.5 kHz to 8 kHz. Hearing re-sults were best at 2 kHz. As expected, those patiens who requiered type III TORP tympanoplasty enjoyed less hearing recovery than those who required a type I tympanoplasty or a PORP. Perichondrium and the cartilage techniques led to simular results. It should not be unmentioned that reperferations occured. The perforation closure rate in type III tympanoplasties was 92.3%, the total repreferation rate was 7.7 %. Basd on temporal bone studies using a laser doppler vibrometer also the influence and the audiological quality of different middle ear protheses is discussed. The results of the temporal bone study as well as the initial clinical findings using a new light titanium (n=396) prostheses are discussed. Surprisingly the combination or different graft materials and different protheses led to similar clinical results except in type III TORP tympanoplasty. In these type of tympanoplasty with a reconstruction of the ossicular chain between stapes footplate and reconstructed eardrum significant better results were obtained when using cartilage. A limited number of surgeons was permitted to use a new titanium prostheses. The following data are based on the results of 3 surgeons. Surprinsingly the titanium prosthesis turned to be up to 8 dB better compared with the Ionomeric cement prostheses which showed no difference whether the tympanic membrane was reconstructed with perichondrium or cartilage. The Titanium Prostheses showed a post-operative air-bone gap between 12 and 8 dB. Also the TORP prosthesis showed an advantage for the titanium prosthesis for the low frequencies. Based on our data we can conclude that tympanoplasty nowadays is able to improve the hearing. The initial results of the new titanium prostheses are promising. This protheses opens new possibilities to improve hearing. We hope to report further good results from more patients with a long term follow up in the future.

Abstract Otology 2000 A12-5

Etsuo Yamamoto MD, Jun Tsuji MD, Shogo Shinohara MD, Yuki Muneta MD, Makito Tanabe MD, Tatsunori Sakamoto MD, Tesu Kim MD

Department of Otolaryngology Kobe City General Hospital J-Chuo-Ku Kobe

Terudermis(Terumo, Tokyo) is a lyophilized collagen sponge made from a mixture of fibrous and heat-denatured bovine athelocollagen stabilized by dehydrothermal cross linking. It shows a decreased foreign body reaction and has greater stability. Terudermis(r) was originally developed to cover deep dermo-periosteal defects caused by burns, trauma or surgery, but has recently been evaluated for a broader range of indications. We have obtained good results by applying this material in middle ear surgery and now report on our experience in using it for this purpose. This material has been used as a substitute material for the following defects. (1) Dermal defect of the external auditory meatus. This material was grafted on to the exposed bone of the external meatus in cases where the residual skin of the meatus was insufficient and there was an exposed area of bone which could not be covered by a fascia graft during myringoplasty. (2) Mucosal defect in the attic and/or mastoid antrum. This material was grafted into the attic and/or mastoid cavity in caseswhere a diseased mucous membrane had been completely removed. (3) Tissue defect of the tympanic membrane. This material was placed on the tympanic annulus as a support for temporal fascia before grafting during myringoplasty in cases with large perforation of the ear drum. This technique makes it easier to place fascia and prevents its retraction once grafted. As described above, this material is considered to be very useful in middle ear surgery.

Abstract Otology 2000 A12-6

Muaaz Tarabichi MD

Section of Otolaryngology American Hospital Dubai UAE-Dubai

Objectives: Wide and complete view of the tympanic ring is an essential element in Sheehy's lateral graft tympanoplasty. This is usually accomplished by enlarging the ear canal and through postauricular exposure. The endoscope offers a comparable wide view of the operative field through transcanal approach. This report describes and evaluates endoscopic transcanal lateral graft tympanoplasty. Methods: 46 procedures of transcanal endoscopic lateral graft tympanoplasty were performed. Ossicular chain reconstruction were performed in 21 patients. All procedures were performed on an out-patient basis and the majority were performed under local anesthesia. Results: Endoscopic transcanal exposure was adequate to perform the procedure in all patients without the need for postauricular approach. Follow-up at 1-2 months showed closure of perforation in 45 ears. One year follow-up was obtained in 22 ears, showing blunting of the anterior sulcus in three ears and development of a small TM epithelial pearl in one ear. 13 ears had closure of air-bone gab to <10 dB and to <20 dB in 18 ears (pure tone average of 0.5,1, and 2 kHz). Conclusions: Endoscopic technique allows wide transcanal view of the operative elements in lateral graft technique and should increase utilization of transcanal tympanoplasty without reducing the success rate.

Abstract Otology 2000 A12-7

Radu Barbos MD, Carmen Barbos MD

ENT Dept Municipal Clinic Hospital ROM-Timisoara

Middle ear endoscopy should be an alternative method to microscopic surgical exploration for middle ear pathology. We examined 30 selected patients with Stortz 2.7mm rigid endoscopes. Anatomical and pathological findings are demonstrated. The authors present also their results of the endoscopic guided surgery with video monitoring. The method provides excellent view to explorate and for preoperative assesment of middle ear disseases.

Abstract Otology 2000 A13-1

Geoffrey R. Ball Dr., Bob H. Katz

Symphonix Devices Inc. USA-San Jose, CA

Implantable hearing devices used for treatment of sensorineural hearing loss have now been successfully developed. This new class of implantable medical devices, called soundbridges, utilizes mechanical energy to directly drive the human ear. The potential benefits of such systems over acoustic devices include improved sound quality, the elimination of occlusion and feedback as well as improved comfort and cosmetic appearance. The focus of this paper is to describe the transducer used in our system to convert electrical energy into vibrational energy. The development of our novel device involved the implementation of a new electromagnetic design that resulted in what is now called the Floating Mass Transducer® (FMT). The design of the FMT was based on studies of the frequency response characteristics of the human ear. By characterizing the biomechanical displacements of live human ears we were able to develop a model that can be used to evaluate system performance of implantable devices in the laboratory. The frequency response characteristics of the FMT have been designed to mimic the native middle ear response to constant sound pressure. The output characteristics for the system were derived from detailed analysis of human temporal bones prior to the initiation of clinical studies. This work made it possible for the initiation of clinical trials. To date, more than two hundred patient's hundred patient's have been implanted.

Abstract Otology 2000 A13-2

Geoffrey R. Ball Dr.

Symphonix Devices Inc. USA-San Jose, CA

This paper describes measurements of the vibratory motion of the incus made with a scanning laser Doppler vibrometer. Previously we reported on the vibration of the middle ear ossicular chain driven by a middle ear implant. This previous work was completed with ears that had the tympanic membrane dissected for improved view of the entire ossicular chain. Now we report on the results obtained in the intact middle ear when driven with sound and with a middle ear implant. Detailed three-dimensional images will be presented showing the incus vibrating in response to sound and with a Floating Mass Transducer® (FMT). When the incus is driven with the FMT, the vibratory pattern closely mimics the results obtained with sound. The results obtained from this study will be presented in animated form. The implications of this work for hearing loss treatment and implantable middle ear transducer design will also be discussed.

Abstract Otology 2000 A13-3

Rüdiger Junker MD, Thomas Wilhelm MD, Arne Ernst MD

Dept. Otolaryngology Unfallkrankenhaus Berlin D-Berlin

We report on the experiences with selecting and counselling patients for implantable middle ear devices (Symphonix, Soundbridge). Two different patient populations were screened. In the first group, 45'000 patients with SNHL of different origin and in the second one, 350 patients with only noise-induced hearingloss (NIHL) were investigated. The screening process consisted of three different steps. At first, the exsisting patients´ pure-tone audiogramms (PTAs) were checked. In the second step, the patients were interviewed (motivation, concomitant diseases, acute diseases, "ear problems", i.e. ekzema, otorrhoe etc.). Finally, the patients were audiometrically tested and the recent test results used for the evaluation. In essence, a total of 346 patients from group 1 (0.8%) were good candidates for an implantable middle ear device (255 Vibrant P, 91 Vibrant HF). In group 2, the motivation of the patients was quite low because their everyday life was less impaired by their NIHL handycap. However, 5 patients were good candidates and also interested in the operative rehabilitation. Implantable hearing devices seem to become a challenging alternative to conventional hearing aids in the near future with careful evaluation of the patients.

Abstract Otology 2000 A13-4

Terry B. Nunn , Karen Archer , Alex Fitzgerald O'Connor M.B. Ch. B. F.R.C.S, Esther Griffiths , Catherene J. McKinney BSc.

Audiology Department St. Thomas Hospital GB-London

This study attempts to quantify the benefits provided by the Symphonix Vibrant Soundbridge implantable middle ear prosthesis over standard linear analogue amplification in nine patients implanted at St. Thomas' Hospital, UK. Prior to fitting with the Vibrant Soundbridge three patients wore binaural hearing aids, and six unilateral hearing aids. Subsequent to surgery, four patients received the Vibrant P audio processor, and five patients received the Vibrant HF audio processor. In order to quantify whether the Symphonix device provided any benefit over their linear analogue aids, the following measurements were made with the patient's hearing aids, and repeated with the Vibrant Soundbridge device: (1) functional gain and frequency response using free-field aided thresholds (2) speech intelligibility in quiet and noise using an automated sentence test (FAAF) and BKB sentences (3) qualitative benefit using the Abbreviated Profile of Hearing Aid Benefit (APHAB) and an abridged version of the Hearing Device Satisfaction Scale (HDSS) The results of these outcome measures using the two devices will be presented. Implications for the management of patients will be discussed.

Abstract Otology 2000 A13-5

Thomas Lenarz MD

HNO-Klinik Medizinische Hochschule Hannover D-Hannover

Conventional hearing aids have substantial disadvantages in terms of sound quality, feedback, distortion, occlusion effect and cosmetic appeal. Most of these problems are related to the small transducers located in the external auditory canal. Electromagnetic transducers which are directly coupled onto the ossicular chain have been developed to overcome these problems. Two systems are available for human use: the Symphonix soundbridge system and the Otologics Middle Ear Transducer (MET). 32 patients have been implanted with the Symphonix device since 1997, 5 patients have been implanted with the MET. The main selection criteria include moderate to severe sensorineural bilateral hearing loss, recurrent external otitis, monosyllable word understanding under best aided conditions below 50 % or insufficient functional gain with conventional hearing aids. The majority of the patients report improved sound quality and superior comfort with the devices. The lack of feedback and occlusion and reduced distortions are key advantages. The functional gain varies substantially between patients. The same holds true for improvement in speech understanding. Compared to conventional hearing aids the best results are seen in patients who have not used hearing aids for a longer period prior to surgery. 50 % of the patients continue to wear their conventional hearing aid on the contralateral side. Side-effects are uncommon. One patient had substantial sensorineural hearing loss postoperatively in the high frequency region. Conclusion: Semi-implantable hearing aids are a new treatment modality for patients suffering from moderate to severe sensorineural hearing loss. They provide superior sound quality and better speech understanding in noise. They allow easy upgrade due to technological development by exchange of the external audio processor. Long-term results are so far encouraging with no deterioration of performance over time and no medical complications.

Abstract Otology 2000 A13-6

Stefan Dazert MD, Wafaa E. Shehata-Dieler MD, PhD, Ralf J. Dieler MD, Jan Helms MD

Dept. of ORL-HNS University of Würzburg D-Würzburg

About 14 million people in Germany suffer from a sensorineural hearing impairment. The adequate therapy for these patients consists of a supply with electronic hearing devices. Conventional hearing aids are often not well tolerated because of insufficient amplification in the high frequency range, problems with the ear mold (feed back, occlusion, external otitis) or distortion of sound signals with an "unnatural" hearing impression. The partially implantable middle ear device Vibrant Soundbridge (VS) (Symphonix Devices AG, Basel, CH) provides a sound wave conversion into mechanical vibrations at the middle ear ossicles using the so called "Floating Mass Transducer" (FMT). The audiological advantages are due to a direct moving force of the perilymph. The VS system is indicated in patients with a middle to severe symmetrical sensory hearing loss and physiological middle ear conditions. Prior to surgery, patients undergo a fitting procedure with a conventional hearing aid and need to be unsatisfied with the device. The expected advantage of the VS system does not justify a surgical implantation procedure in patients who are happy with conventional hearing aids. At the Department of ORL-HNS, University of Würzburg, five patients have been provided with the VS system. These patients report a "natural" quality of speech and sounds, an improved speech understanding in noise, a better hearing perception at high frequency sounds and the absence of the feed back phenomenon. Audiological investigations and questionnair results support the subjective hearing impression of the patients.

Abstract Otology 2000 A13-7

Marcus M. Maassen MD, PhD (1), Peter K. Plinkert MD, PhD (1), Hans Leysieffer PhD (2), Hans Peter Zenner MD (1)

(1) Department of Otolaryngology University Hospital of Tübingen D-Tübingen
(2) Implex AG Hearing Technology D-München

The electronic hearing system Implex TICA is a totally integrated hearing implant for the treatment of sensorineural hearing loss. It consists of three components: (1) a microphone (0,4g) for subcutaneous implantation into the posterior canal wall, (2) a retroauricular, subcutaneously placed electronic module containing a digitally programmable three-channel audioprocessor and an accumulator and (3)a piezoelectric transducer. The transducer (0,4g) has a titanium coupling rod, which transfers mechanical oscillations to the incus body and from there to the inner ear. After the transducer is fixed with a special osteosynthesis plate, the integrated micromanipulator allows movement in all directions in the mastoid cavity. The presentation shows the surgical technique with a total mastoidectomy, a trepanation of the posterior canal wall and the implantation of the three TICA-components.

Abstract Otology 2000 A14-1

Gábor Katona MD, István Lellei MD

ENT Department Heim Pál Hospital for Sick Children H-Budapest

Authors administered oral corticosteroid (methylprednisolon) in a daily dose of 1 mg/kg for 33 consecutive children suffered from otitis media with effusion. The duration of the therapy was 1 week. Aim of the study was to assess corticosteroid effect on hearing and tympanic pressure of chronic OME children. Previous adenoidectomy without tympanostomy tube and age range of 2-10 years were inclusion criteria. No antibiotics, not any other treatment was recommended. Exclusion criteria were: varicella infection or incubation, hypertension, diabetes mellitus. Children with sensorineural hearing loss were also excluded. Hearing assessment (audiometry) and tympanometry was carried out before treatment, at the end of treatment (one week) and 1 month after treatment. 10 age-matched OME children without any treatment served as a control group. A total of 29 children's hearing improved at on week control, at least 10 dB on at least 2 frequencies on al least one ear. On the follow up (1 month ) the improvement of hearing could be detected on 18 children. Effusion recurred on 11 children (17 ears). In the control group 3 improvement ( 5 ears) have been measured 1 month after the first observation. (difference is significant p<0.05). Conclusion: Oral corticosteroid treatment could be a useful alternative treatment for children with OME. With short-term therapy side effects can be avoided. Further data collection is necessary to determine its role among other treatment regimen (antibiotics, tube, etc).

Abstract Otology 2000 A14-2

Norihiko Murai MD (1), Etsuo Yamamoto MD (2)

(1) Department of Otolaryngology Matsue City Hospital J-Matsue, Shimane
(2) Department of Otolaryngology Kobe City General Hospital J-Chuo-Ku Kobe

Allergic otitis media (ALOM) is caused by entry of antigens into the middle ear via the Eustachian tube or a perforation of the tympanic membrane. We report two patients with ALOM whose clinical features differed according to the route of entry of antigens. The first case was a 64-year-old woman with a past history of bronchial asthma who complained of hearing loss. Her tympanic membranes were retracted bilaterally. Myringotomy revealed gummy secretions. After closure of the myringostoma, her right tympanic membrane bulged and became pale and hypertrophic. A ventilation tube was inserted. However, frequent relapses of otorrhea occurred simultaneously with attacks of asthma. Microscopic examination of the gelatinous material obtained from her middle ear disclosed numerous eosinophils. Since the clinical course and findings were compatible with those of ALOM of tubotympanic type, anti-allergic drugs were given orally. This treatment was successful. The other case was a 44-year-old man with a past history of asthma and allergic rhinitis who visited our hospital because of otorrhea and hearing loss. Otoscopy revealed a large aural polyp. He underwent tympanoplasty. Removal of the polyp disclosed a perforation of the tympanic membrane, through which the polyp exhibited continuity with granulation tissue in the middle ear. Histologic examination of the polyp revealed infiltration of eosinophils. RAST revealed positive scores for house dust, mites, silk, and other antigens. Since he exhibited neither otorrhea nor relapses of the aural polyp once the perforation was closed, we surmised that the antigen had entered his middle ear via the perforation.

Abstract Otology 2000 A14-3

Mila Bojanovic MD, MA, Milan Stankovic MD, PhD, Miodrag Dinic MD, MA, Ljiljana Milisavljevic MD, PhD, Emilija Zivkovic MD, MA, Ankica Stefanov MD

ORL Clinic University of Nis YU-Nis

Secretory otitis media (SOM) is a common condition among children and is characterized by non-purulent fluid in the middle ear and fluctuacting conductive hearing loss. Most children will spontaneously regain normal air-filled middle ears, but a certain number will have persistant problems. This study was performed to investigate the course of recovery from SOM in children treated in various ways. A total of 53 children, 29 boys and 24 girls, 3-11 years of age, with SOM were enrolled in randomised, controlled studies: one trial evaluating the efficacy of antihistamine/mucolytic combination for SOM and one trial evaluating efficacy of antibiotic (Amoxicillin and clavulanic acid) therapy for SOM. The patients were followed for 3 monts. During the follow-up period, clinical examination and impedancemetry were performed in all patients. Statistical significance was determined by use of x2 test. No side effects of therapy were noted. A significant difference (p<0.01) was found in the group treated with antihistamine/ mucolytic combination after 2 months. Antibiotic therapy had effect on recovery of SOM, but not significant.

Abstract Otology 2000 A14-4

V. Ivanovska MD, Marina Cakar MD, Elena Bogeska MD, Lidija Dubrovska MD

ENT Department University Hospital MAZ-Skopje

The authors of this study tried to evaluate the applicability of tympanoemtry in the younger age groups and to make an epidemiological study of the distribution of tympanogram types in group of preschool children. In a period of one month we examined 240 children between two and three years age in limited geographic area. 456 ears in 23o children (95,8 of those invited) were completely investigated with tympanometry and otoscopy. 54,5% of the ears showed type A tympanometric curves, 32.1% type B and 12,4% type C. In 112 (46,6%) children we found bilateral type A tympanograms. The prevalence of abnormal tympanometry proved to be unexpectedly high in both sexes. These findings will be subject of further discussion.

Abstract Otology 2000 A14-5

Hamad Al Muhaimeed Prof., Siraj M. Zakzouk Prof.

Department of ORL King Abdul Aziz Univ. Hospital SA-Riyadh

A survey to identify the aetiology of hearing impairment among Saudi children was carried out. Children were divided into two groups according to presence or absence of laboratory evidence of toxoplasmosis 'at risk' and 'at not risk'. Serological tests for toxoplasmosis were done to 1054 children. We found positive IgM antibody against Toxoplasma gondii in the blood of 70 of the 1054 children (6.6%) (age ranged between 12 months and 14 years). Forty nine of the seventy infected children (70%) were found to have bilateral sensorineural hearing loss (11 of 19 children of the 'at risk group' and 38 of 51 from the 'not at risk' group). Hearing impairment was bilateral in all cases, profound in 9, moderate to severe in 29 and mild in 11. Known causes of hearing impairment were excluded. The high prevalence of hearing impairment among children due to toxoplasmosis is presented.

Abstract Otology 2000 A14-6

Giovanni Carlo Modugno MD, Domenico Saggese MD, Giorgio Magnani MD, Antonio Pirodda MD, Alberto Rinaldi Ceroni MD

ENT Department University of Bologna I-Bologna

Despite a wide international experience on the treatment of chronic ears, the problem of obtaining a satisfying, long-lasting functional recovery still remains largely unsolved. For this reason, an attempt to find out some predictive factors depending on both the anatomic conditions and the surgical procedures was made: a multivariate analysis was carried out on a group of 120 patients who underwent a tympanoplasty between 1987 and 1993. All the cases had a follow- up of 5 years at least. The great majority of cases had a cholesteatoma (90.8%) and was operated on by a closed technique (89.1%). The ossicular reconstruction was mostly made with plastipore prostheses (93.3%), under unfavorable conditions: only a mobile footplate in 49.1% of cases, while a mobile intact stapes in absence of the other ossicles was found in 34.2% of cases. In 42.4% of cases a satisfactory result (air-bone gap <20dB) was achieved; an initial extrusion of the prosthesis was observed in 12.5% of cases. The multivariate analysis (logistic regression) demonstrated that age, staged surgery, tubal function, mesotympanic extent of the cholesteatoma, surgical management of the fenestral areas, procedures in order to keep a correct tympanic ventilation, interposition of inert materials between tympanic membrane and prosthesis had no influence on the functional results; the only factors which proved to be significantly and independently related to a satisfactory functional result were the good late postoperative anatomic condition of the tympanic membrane, the eradication of cholesteatoma, the preoperative condition of the ossicular chain (intact malleus and stapes), the surgical technique (closed tympanoplasty).

Abstract Otology 2000 A14-7

Walter Livi MD, N. Zuccarini MD, D. Limoni MD, Desiderio Passàli MD

ENT Dept University Hospital I-Siena

Elective material for ossicular chain reconstruction is autologous ossicle, but it is not always available because the ossicles are often damaged (erosion!). For several years the authors (A.A.) took advantage of plastipore and cartilaginous prostheses for the ossiculoplasty, instead of autologous ossicles. Plastipore prostheses showed good functional results, but they are not excellent for extrusion problem. The results about biocompatibility and functionality were better when A.A. performed ossiculoplasty with cartilaginous prostheses. In E.N.T. Dept of University of Siena, from January 1978 through December 1998, 1045 patients (698 males, 347 females; age range 12-68 years) were operated for middle ear pathologies. 327 of these patients underwent an ossiculoplasty using biocompatible materials (plastipore, hydroxiapatite and homologous cartilage. The records of 168 timpanoplasty patients who underwent an ossicular reconstruction with plastipore and cartilaginous prostheses were reviewed. Our data showed the extrusion of the prosthesis in 15 % of the cases, while this complication was absent using rib cartilaginous prostheses. The A.A. advice cartilaginous prostheses to reconstruct ossicular chain when ossicles are not available.

Abstract Otology 2000 A14-8

Gürol Gültekin MD, Levent Olgun MD, Ibrahim Cukurova MD, Erdal Gül MD, Ilker Nalbant MD, Sezaver Alper MD

SSK Izmir Educational HDSP TR-Izmir

In this study early results of Titanium-gold TORP were invastigated. The study was done on 12 chronic cholesteatoma cases. The operation was wall down tympanoplasty in all cases. A titanium-gold total ossicular replacement prosthesis covered with a otograft cartilage plate used as a columella. Graft take was excellent at 6-10 months. There were not any extrusion and hearing results were comparable with historic controls of clinic. Titanium-gold TORP found to be satisfactory at least in short term.

Abstract Otology 2000 A14-9

Pingling Kwok MD, Jürgen Strutz Prof.Dr.med.

HNO-Klinik Universität Regensburg D-Regensburg

The surface condition of a stapes prosthesis is an essential factor for the mobility of the prosthesis in the stapedotomy opening. Thus, it is a determinant for the success in surgical hearing improvement. A rough surface structure of the prosthesis results in increased friction and resistance during movement of the prosthesis piston and leads to conducting hearing impairment. Gold-, teflon-, and titanium pistons were examined for their surface structure with the electron microscope. The overall results show that gold pistons have the smoothest surface, followed by titanium pistons which have a scaly appearance. The teflon pistons are provided with horizontal parallel grooves showing a clear fibrous texture at a high magnification.

Abstract Otology 2000 A14-10

Pingling Kwok MD, Annette Waldeck MD, Jürgen Strutz Prof.Dr.med.

HNO-Klinik Universität Regensburg D-Regensburg

As magnetic resonance imaging (MRI) has become one of the most important investigations in the medical field, it is necessary to know whether patients with metallic middle ear implants may undergo this examination. We studied four different stapes prosthesis (gold, titanium, teflon-platinium and teflon-steel), a titanium TORP, and two kinds of grommets (titanium and silver-goldplated) for their MRI-suitability. The objects were put in front of the MRI-scanner opening a) laid in a petri-dish and b) hung up on a thin thread. c) The light objects (teflon and titanium prostheses) were also put afloat in a petri dish filled with water to detect also small forces that might act upon the implants. d) All objects were placed in a petri dish filled with Gadolinium to find out what kind of artefacts they might produce on the final image. None of the implants moved when placed in a petri dish or when they were hung up on a thin thread. The teflon-platinum and teflon-steel stapes prostheses adjusted their direction and floated towards the MRI-scanner when put close enough to the Scanner opening. All implants showed as little artefacts that would still make the evaluation of the surrounding tissue possible.

Abstract Otology 2000 A14-11

Deborah A. Arthur M.A.

Vice-President, Clinical Affairs Symphonix USA-San Jose, CA

The Vibrant P soundbridge began clinical trials in the United States in mid-1998 with subject enrollment completed by early 1999 Test results indicate no changes in residual hearing and functional gain measures obtained at 250 Hz through 8KHz indicate mean improvements (over acoustic hearing aid) <10dB above 1KHz with individual improvements as much as 25 dB.

Abstract Otology 2000 A14-12

Akihide Ichimura MD, Mamoru Suzuki MD

ENT Department Tokyo Medical University Hospital J-Tokyo

The effects of surgical manipulation to the vestibular system have not fully been elucidated. This study was designed to investigate the effects of tympanoplasty on positional nystagmus. Materials and methods: The study was conducted on a total of 36 cases of tympanoplasty. There were 23 cases of cholesteatoma and 13 cases of chronic otitis media. The cases with vertigo and labyrinthine fistula were excluded. Types of tympanoplasty were type I (7 cases), type III (24 cases) and type IV (5 cases). The cases which underwent intensive manipulation around the stapes or the round window niche were excluded. The positional nystagmus was monitored and video-recorded using an infrared CCD camera before surgery, one day and every several days after surgery until it disappeared. Results: Postoperative nystagmus was observed in 13 out of 30 cases which showed no nystagmus prior to surgery. Direction and type of the nystagmus varied. It was toward the surgical side in 8 cases, downbeat nystagmus in 3 and apogeotropic direction-changing positional nystagmus in 2. In the sitting position, no nystagmus was observed. Most of the nystagmus was present even after the canal packing was removed. Conclusion: Tympanoplasty has a significant effect on the vestibular system. Mechanical vibration by drilling to the inner ear, especially to the otolithic organs possibly plays a major role in emergence of the positional nystagmus.

Abstract Otology 2000 A14-13

Chul-Ho Jang MD, Jin O. Kim MD, Seung T. Park MD

Dept. of ENT Wonkwang Medical School ROK-ChunBuk

After traumatic perforation of the tympanic membrane(TM), healing occurs spontaneously in most cases, but sometimes the perforation fails to heal and myringoplasty is required. We carried out a study of transforming growth factor-a(TGF-a) distribution to clarify the reason for the accelerated epidermal cell proliferation occuring after traumatic tympanic membrane perforation of rat. Comparative findings were noted between normal and perforated tympanic membrane. TGF-a was not found in the normal TM , but its expression was observed over the whole TM. Most of perforations had closed by 10 days. In the healed perforation, prominent reduction of expression was observed.

Abstract Otology 2000 A14-14

Yoshiro Yazawa MD, Mikio Suzuki MD, Hiroya Kitano MD, Kazutomo Kitajima MD

Dept Otolaryngology Shiga University of Med. Science J-Otsu

A number of techniques have been designed to avoid the problem associated with an exteriorized mastoid cavity. We performed a simple method of posterior canal wall reconstruction using only remnant external canal skin and temporalis fascia (Smith et al, 1986) after canal wall down tympanoplasty in 45 ears with cholesteatoma as a one-stage procedure. They include 41ears of primary surgery and 4 ears of revision surgery. The age of patients ranged between 9 and 71 years. The postoperative period to attain dry ear ranged from 7 to 31 days (mean, 13.2 days). During the follow-up period between 15 and 54 months (mean, 32.3 months), we had a case of residual cholesteatoma, a case of recurrent cholesteatoma and a case of perforation of the reconstructed canal wall. All these 3 failure cases (7%) were observed in children. The postoperative air-bone gap of < 30 dB was reached in 36 cases (80%) at 1 year after surgery. The mean number of dB of closure of the air-bone gap was 12.7 dB. The positive values (less gap) of this number were obtained in 35 cases (78%), the negative values (worse gap after surgery) were in 6 case (13%) and 0 values (no change) were in 4 cases (9%). Slight to moderate retraction of the reconstructed posterior canal wall were observed in 42 cases (96%) and the aeration of the mastoid cavity were confirmed in 9 cases (20%) by CT. The results seem to be much better than the other reconstruction methods.

Abstract Otology 2000 A14-15

Navin L. Hiranandani MD

Oto Rhino Laryngology Nair Hospital Inmedical College IND-Bombay

The hearing process in tympanoplasty is a complex depending on several factors. This depends on the type of ossicular reconstruction which is done in a particular operation. The other factor is the presence of disease process. Cholesteatoma often erodes the ossicular chain and depending on the amount of destruction of ossicles, reconstruction has to be made. Even small cholesteatomas may require removal of parts of the ossicular chain. Since the deconstruction in cholesteatoma can be also extensive, the reconstruction becomes more elaborate. There may be widespread destruction of bone in cholesteatoma requiring bony reconstructive procedures. The removal of the ossicles also depends on the extent of cholesteatoma. Mere destruction of the ossicles is not sufficient to remove the ossicles. If cholesteatoma is extending to accessible places like the attic, the removal of even normal or partially abnormal bones becomes necessary to remove the disease process.

Abstract Otology 2000 A14-16

Domenico Saggese MD, Giovanni Carlo Modugno MD, Francesco Soprani MD, Antonio Pirodda MD, Alberto Rinaldi Ceroni MD

ENT Department University of Bologna I-Bologna

The unanswered problems related to the treatment of children cholesteatoma can raise additive difficulties in obtaining a stable satisfactory result from a functional point of view. This is the reason why this particular topic deserves in our opinion to be separately analyzed: in order to give a cognitive contribution a retrospective study was made concerning 64 ears operated on between 1975 and 1992 and followed up for 5 years at least. Despite the frequent unfavorable anatomical preoperative conditions (absence of malleus and incus in 32.9 % of cases; absence of malleus , incus and crura in 40.6 % of cases), a good result (air-bone gap <20dB) was achieved in 60.9 % of cases. A multivariate analysis, carried on according to the logistic regression method, showed the importance of number of operations for recurrence, conditions of the ossicular chain, allergy, late postoperative conditions of the tympanic membrane, and myringostapedopexy in influencing long-term functional results.

Abstract Otology 2000 A14-17

Emilija Zivkovic MD, MA, Milan Stankovic MD, PhD, Ljiljana Milisavljevic MD, PhD, Mila Bojanovic MD, MA, Ankica Stefanov MD

ORL Clinic University of Nis YU-Nis

The degree of ossicular destruction in chronic suppurative otitis media (CSOM) depends not only on the nature of the pathological process (cholesteatoma or granulation tissue) but also on the intensity of the pathological process. This paper presents the results of a review of 39 patients suffering from CSOM with granulation tissue. All the patients were treated both medically and surgically. We compared the number of the inflammatory cells and the number of the blood vessels in cholesteatoma and granulation tissue, depending on their localization and intensity. We established that the activity of the pathological process was far more significant than its type and localization. Due to antibiotic treatment the number of the inflammatory cells was reduced in the granulation tissue from 1406.33 ± 36.41 to 858.67 ± 306.90 in granulations localized in the posterior part of the cavum, from 2606.5 ± 573.5 to 2059.33 ± 511.20 in granulations localized in the cavum and from 3022.67 ± 364.46 to 2298.33 ± 620.03 in extensive granulations. The administration of adequate antibiotics based on the antibiogram significantly reduces the intensity of the infection, making the surgical procedure more successful.

Abstract Otology 2000 A15-1

Ilija Filipche MD, PhD, Elena Dimeska MD, Marina Chakar MD, PhD, Sijavush Javari MD

ENT Department University Hospital MAZ-Skopje

The purpose of this study is to examine and compare the results in pediatric patients who have undergone stapes surgery for otosclerosis and tympanosclerosis. Twenty seven patients were evaluated for preoperative and postoperative air-bone gaps, preopeartive and postoperative speech reception tresholds, postoperative air conduction hearing improvement and preoperative and postoperative speech discrimination. Children with otosclerosis who undervent stapedotomy had an average preoperative and postoperative air bone gap of 15db with an average air conduction hearing improvement of 18db. Children with tympanosclerosis who undervent stapedotomy or stapedectomy had an average air bone gap of 11db with an average air conduction hearing improvement of 24db. We believe that the stapes surgery is a safe and effective treatment for otosclerosis and tympanosclerosis in pediatric patients.

Abstract Otology 2000 A15-2

Yutaka Yamamoto MD, Hitoshi Satoh MD, Shigehisa Hashimoto MD, Sugata Takahashi MD

Department of Otolaryngology Niigata University School of Medicine J-Niigata

Twenty three ears of 20 children who underwent stapes surgery between 1984 and 1997 were investigated. Their ages at the time of operation ranged from four to 14 years. Intraoperatively, fixation of stapes was identified in all cases, complicated missing of the long process of the incus in three cases and abnormal facial nerve running in two cases. In 18 ears, a Teflon piston-wire was inserted into fenestrated stapes. The wire was directly connected to the mallear handle in one case. Combined procedure of total stapedectomy and ossicular reconstruction with a cortical bone in three cases, stapes mobilization and ossicular reconstruction with a cortical bone in one case, and stapes mobilization alone in one case were performed. Mean value of preoperative air conduction hearing level (average 500, 1000 and 2000 Hz) was 55.4 dB, and that of air-bone gap was 42.0 dB. These values were 33.8 and 20.4 dB six months after the operation. The ears that underwent conventional stapes surgery of piston-wire insertion achieved satisfactory long-term hearing results, however the hearing level in ears which received other procedures due to complex ossicular abnormalities tended to deteriorate.

Abstract Otology 2000 A15-3

Gül Oezbilen Acar MD (1), Alex M. Huber MD (2), Ugo Fisch MD (2)

(1) A-32/A D:12 7-8 TR-Ataköy-Istambul
(2) ENT Department University Hospital CH-Zürich

80 consecutive cases of revision stapes surgery performed during the last 5 years were evaluated retrospectively in this study. 71 of the cases underwent a functional revision procedure as a malleo-stapedotomy (56,79%) or an incus-stapedotomy (15,21%). The most common causes of failure of primary surgery were the displacement of the prothesis (37,49%), the undiagnosed fixation of malleus or incus (37,49%) and the incus erosion (30,47%). The detection of a large number of malleus fixations was the result of the use of a large tympano-meatal flap with superior canalplasty for exposure of the anterior malleolar process and ligament. The functional success rate of malleo-stapedotomy (closure within 10 and 20dB) was found statistically significantly better than that of traditional incus-stapedotomy (<0.05). In our series, closure of the airbone gap within 20 dB occured in 79% of the patients. Overclosure was seen in 12 patients (16%) ans a significant sensoneural hearing loss in 3 patents (4%). There was no dead ear in this series. A 0.4 platinum teflon prosthesis was used in 62 cases (87%), a titanium prosthesis in 9 cases (13%). The postoperative hearing results of first revision surgery were better than those of multiple surgeries (p<0.05).

Abstract Otology 2000 A15-4

Aruna Visvanathan M.B., M.S., F.A.G.E.

Vikram Hospital & Ear Research Inst IND-R.S. Puram, Coimbatore

The stapedius tendon is routinely sectioned during stapes surgery. Preservation of stapedius tendon has several advantages including protection from acoustic trauma and better hearing in a noisy situation. Some of the other functions of the stapedius include decreasing the middle ear resonance, improving noise localisation, and regulating inner ear operations. It has been experimentally demonstrated that the middle ear reflex serves to reduce a temporary threshold shift caused by fatigue. This report reviews our technique of stapedius tendon preservation in both mechanical and laser stapes procedures. Our institute being a referral centre in an area endemic for otosclerosis, has facilitated a long term study of hearing results with and without tendon preservation. Demonstration of our technique of tendon preservation should enhance the myriad technical nuances of stapes surgery.

Abstract Otology 2000 A15-5

Daqing Li MD (1), Yulin Cao MD (2)

(1) ORL - Head & Neck Surgery Univ. of Maryland School of Medicin USA-Baltimore
(2) Department of Otolaryngology The Fourth People's Hospital of Shanghai RC-Shanghai

A retrospective review of stapes surgery performed at authors' institution in Shanghai during the period of 1962 to 1979 was undertaken. Of 1023 cases, 26 percent (266 cases) were primarily operated with stapedectomy, and 74 percent (757 cases) with stapedotomy. The underlying disorder was in all cases otosclerosis that was surgically confirmed. There were 66.8% males and 33.2% females. Using the hearing of the average for 500, 1000 and 2000Hz, the criteria for success, were defined as closure of the air-bone gap to 10 dB or less. In the present study, success was achieved in 84.1% of the cases after 1-5 years, 82.5% of the cases after 5-10 years, 79.2% of the cases after 10-16 years. The present study, for the first time, reports the largest series of cases with stapes surgery in China. Our data, for the first time, reveal significant differences between sexes as evidenced by males to be affected twice as often as females. Our results strongly support that stapes surgery should be the preferred surgical technique in the treatment of otosclerosis.

Abstract Otology 2000 A16-1

Myroslav B. Krouk MD, PhD, MDSc, Myroslav M. Krouk MD

ENT Department Medical University UKR-Lviv

Various factors cause the development of the middle ear deseases (MED): upper respiratory infection, paranasal sinusitis with allergy, Disfunction of the Eustachian Tube (DET), et other. We had investigated 200 patients with paranasal sinusitis and allergy without otical symptoms. For diagnostic function State of the Eustachian Tube (FSET) we used: Tympanometry in dynamic, sonotubometry, optical nasopharyngoscopie, planumetry of the pneumatisation of air cells of Mastoid by M.Tos (PACM). In 86% cases we had revealed DET, which correlated with lower degree PACM. We considered that group patients as a the risk-group for development of MED. Simultaneously with treatment of the sinusitis and for prevention of MED we used: topical corticoid Beconase (aqueous suspension of Beclomethasone Dipropionate BP 0,05% w/w), nasal spray antihistaminic drug Histimet (levocabastin 0,5 mg/ml), oral antihistaminic Semprex (acrivastin) during 1,5 month; vibromassage pharyngeal orifice of ET, Kinesitherapy of the muscle of ET with acupuncture, phytoimmunostymulate drugs (Imod Zubitsky). After treatment functional State of the Eustachian Tube had improved in 58% cases.

Abstract Otology 2000 A16-2

Murray N.H. Waldron Prof.Dr., I.J.M. Johnson Prof.Dr.

Dept. of Otolaryngology Freeman Hospital GB-Newcastle-upon-Tyne

Introduction The effect otitis media with effusion (OME) has on the balance system of children has long been debated. Studies using force platforms have suggested OME caused limited effects. Sway magnetometry (SM) has been validated as a reliable and reproducible (<5% error) device in this field and has been shown to be more sensitive than force platforms (1).Sway results are reported as pathlength per unit time which is the most accurate method of measurement (2). Objective To establish wether OME has any effect on balance as assessed by sway magnetometry. Method Phase I: Data was collected from normal children (with OME and no other otological problems), age range 5-15 years. SM was undertaken in 4 states with eyes open and closed (to reduce optic fixation) whilst standing off and on foam (to reduce propiocetion). Adult normal range data has already been established. Phase II: Children with clinically, audiometrically and surgically proven bilateral OME, age range 6-10 years, underwent SM using the same protocol. SM was performed immediately prior to the insertion of grommets and also post-operatively (3-10 days). The delay allowed the anaesthetic to clear. Each child therefore acted as their own control. Results Phase I: Results from 18 children standing off foam showed an average pathlength of 198 (range 115-324) with eyes open and 258 (range 172-400) with eyes closed. This compares with the adult results of 140 and 200 respectively. Phase II: Children with bilateral OME showed increased pathlenghts. Insertion of gommets and resolution of the effusions almost universally reduces the pathlength to the normal range. The average pathlengths in 10 children whilst standing off foam reduced from 255 (range 134-414) to 199 (129-336) with the eyes open, and from 336 (range 187-441) to 265 (range 158-378) with the eyes closed. Conclusion OME does have an effect on balance in children and this can be demonstrated with sway magnetometry. References 1. Johnson, IJM; Clifford, E.; Hughes, R. & Birchall, J. 1998. Sway Magnetometry: evidence for the timing of vestibular recovery following stimulation. Clin. Oto. 23: 282-283. 2. Fitzgerald, J.; Murray, A.; Elliot,C. & Birchall, J. 1994. Comparision of body sway analysis techniques. Acta. Otolaryngol. (Stockh.) 114: 115-119. Conflict of Interest None.

Abstract Otology 2000 A16-3

Nikolas H. Blevins MD, Collin S. Karmody MD

Department of Otolaryngology-HNS Tufts University School of Medicine New England Medical Center USA-Boston MA

Chronic myringitis (myringitis chronica granulosa, tympanic membrane epithelitis) is an often-overlooked condition characterized by the loss of surface epithelium of the lateral tympanic membrane. The incidence and etiology of chronic myringitis (CM) are poorly defined, with the literature paying relatively little attention considering the condition+s apparent frequency. CM is often asymptomatic, although it may be associated with malodorous drainage, pruritis, or otalgia. CM may affect any portion of the tympanic membrane, and may extend to involve adjacent canal skin. The lines of demarcation are usually well defined, with variable amounts of granulation tissue seen in affected areas. Tympanic membrane thickening may result in conductive hearing loss. Although the clinical course is often indolent, CM can result in tympanic membrane perforation and chronic suppuration. Resulting scar formation may contribute to an acquired aural atresia. CM may be confused with chronic suppurative otitis media, and such misdiagnosis may result in needless tympanomastoid surgery. We review our experience with CM over the last 5 years. A retrospective chart review of patients seen in one academic otology practice revealed a prevalence of CM of approximately 1% (about 1/10th as frequent as the diagnosis of chronic otitis media). We discuss etiologic factors (otitis externa, otitis media, previous otologic surgery), clinical presentation, radiology, audiometric findings, and clinical course. Pathology specimens from a number of cases are reviewed. Definitive treatment of CM has yet to be defined, although prolonged topical therapy can be effective. Surgical intervention is used only in a small minority of refractory cases.

Abstract Otology 2000 A16-4

Duc M. Bui MD, Tam M. Bui MD

Westminster Ear Nose Throat Clinic USA-Westminster, MD

In chronic ear disease, a thorough evaluation of the middle ear is very important. The microscope with its straigth light beam is unable to reach the deep recesses of the middle ear. Using small telescopes, endoscopy might preferably be used in the out patient clinic to evaluate the mesotympanum. Sixty-five patients with perforation of the tympanic membrane due to chronic otitis media underwent endoscopy of the middle ear in the out patient clinic. The procedure was performed without anesthesia. Under direct television monitoring, the 2.4mm diameter telescope is introduced carefully through the perforation without touching the rim or the ossicles. The areas to be observed are the posterosuperior aspect of the mesotympanum, the attic floor, the Eustachian tube orifice and the supratubal recess. The evaluation is adequate with moderate size perforations. Central perforations are most indicated for this procedure. Two cases were aborted dure to bleeding at the rim of the perforation and one case was interrupted due to pain. No iatrogenic complication was encountered in our series. The hidden areas are much better visualized with this technique than with the microscope. Endoscopy of the middle ear could be performed safely without anesthesia in ambulatory setting with excellent results.

Abstract Otology 2000 A16-5

A.B.R. Desai MD, Ashim A. Desai MD

Laud Mansion IND-Bombai

The restoration of hearing in tympanosclerosis is dependent upon many factors: the ossicular fixation (single, double or triple ossicular fixation), the sensoneural component and the function of the other ear. Triple ossicular fixation by tympanosclerosis in cases of CSOM is very common in India possibly because of persistent low-grade infection due to improper primary level management. When the stapes is fixed a two-stage operation is required, therefore a gelfoam patch (not paper patch) test can help us to predict to the patient the possibility of a second stage surgery. Tympanosclerosis beeing sub-endothelial, mere peeling off the plaques during surgery always leaves bare bone, so mobilisation is often followed by refixation. At the first stage, a cortical mastoidectomy extending into the anterior attic is performed. The Incus is removed and the malleus head is rotated out of the attic on the axis of the tensor tympani. Tympanosclerosis deep to the ossicles is then removed and the malleus and incus replaced back in their position on a bed of silastic and gelfoam. The perforation is closed using temporalis fascia using the interlay technique. At the second stage the stapes superstructure is removed with a laser and a small-fenestra stapedotomy and teflon piston with vein interposition is performed. In those cases where a discrete hole in the footplate is not possible, stapedotomy with cartilage on vein technique is performed. The results are presented.

Abstract Otology 2000 A17-1

Tapio S. Karhuketo MD, J.J. Ilomäki MD, P.S. Dastidar MD, E.M. Laasonen Prof., H.J. Puhakka Prof.

ENT Department Tampere University Hospital SF-Tampere

Surgery of aural atresia is a demanding otological procedure. The complex and varying temporal bone anatomy associated with atresia is a challenge for otosurgery. A good understanding of the anatomy of an atretic ear will help a surgeon decide whether an operation is indicated, and is also beneficial in operative planning. We studied twenty-six congenital aural atresia ears (twenty-five patients) with two different imaging technologies in order to determine if it was possible to improve the anatomical overview of the atretic ears by combining the imaging methods. High-resolution computed tomography (HRCT) gave good cross-sectional images of the tympanic cleft. Then, a superfine microvideoendoscope (SFV) was introduced via a nostril and through the Eustachian tube into the middle ear so that a topographic view of the middle ear structures could be visualized. Some structures were visualized more clearly with SFV than with HRCT, and vice-versa. We concluded that the combined information of the two imaging technologies provided a better understanding of the structural anatomy and more indicators to help decide on future operations of atretic ears.

Abstract Otology 2000 A17-2

Klavdia Z. Borisova Prof.Dr.med., Helen Borisova Dr.med., G.G. Boyadjan Dr.

ENT Postgraduate Med. Institute RU-Novokuznetsk

The aim of this study is to report our methods of diagnosis, surgical treatment and hearing rehabilitation in children with developmental defects of the ear combined with severe hearing loss. 35 patients under 16 years (19 of them aged 3 to 7 years, including 25 boys and 10 girls) formed the basis of the study. For a proper diagnosis and treatment control we used otomicroscopy, audiological tests and CT scan. 9 patients had a bilateral and 17 a unilateral microtia/atresia syndrome, two patients of 4 and 6 years had a normal little auricle and absent bony part of ear canal. The osseus malformation was present in all cases of ear canal atresia/aplasia. The malformation consists of undeveloped ossicles, ankylosis of stapes, or the absence of superstructure of stapes. The opening of theEustachian tube seemed to be normal with an unchanged epithelium. CT scan and functional investigation helped in choosing patients for surgery and adequate surgical approach. We used different parts of bone part of surgery which provided security, visual control of the tympanic cavity and reconstruction of ossicle chain. After a transcortical antromastoidotomy in large mastoid cavities we partially obliterated mastoid to create approximately normal architectonics of the ear canal. In other cases we formed the canal by opening of mastoid cells. The tympanic cavity was opened consequently during an anterior attico-adito-tympanotomie. We report the stages of restorative reconstruction, its clinical and functional effectiveness in relation with different initial conditions of the patients.

Abstract Otology 2000 A17-3

Shigehisa Hashimoto MD (1), Yutaka Yamamoto MD (2), Hitoshi Satoh MD (1), Sugata Takahashi MD (1)

(1) Department of Otolaryngology Niigata Univ. School of Medicine J-Niigata
(2) Department of Otolaryngology Niigata University School of Medicine J-Niigata

Fifty-two ears of auditory ossicular malformations with normal tympanic membrane that underwent ossicular reconstruction and stapes surgery were evaluated. The patients ages ranged from 6 to 55 years (mean 18 years). The subjects consisted of 28 males (30 ears) and 21 females (22 ears). Classification of the pathologic condition based on surgical findings showed separation of the incudo-stapedial (I-S) joint in 21 ears (40%), fixation of the malleus and/or incus in 4 ears (8%), fixation of the stapes in 24 ears (44%), and separation of the I-S joint with fixation of the stapes in 4 ears (8%). Ossicular reconstruction was performed by type I method in 1 ear, type III with ossiculoplasty in 8 ears and type IV with ossiculoplasty in 16 ears. During stapes surgery, 20 ears underwent small-fenestra stapedectomy, 4 ears total stapedectomy, and 3 ears mobilization of stapes, respectively. An air-bone gap closure of less than 20dB was achieved in 92% of ossicular reconstruction and 85% of stapes surgery.

Abstract Otology 2000 A17-4

Matti Raivio MD (1), Eero Akaan-Penttilä MD, PhD (2)

(1) ENT Department Central Hospital SF-Mariehamn
(2) The Finnish Federation for Hard of Hearing SF-Helsinki

As help for the severe bilateral conductive hearing loss and cosmetic handicap caused by bilateral microtia and other aural anomalies, bone conduction hearing aids and the aural prostheses have since late 1970's undergone remarkable developement based on Brånemark's discovery of osseointegrated titanium implants. In order to outline and suggest a management program usable in the Finnish circumstances with only five new cases/year we collected two groups of five children and young adults requiring help both for their hearing and cosmetic handicap. BAHA for the conductive hearing loss, and bone anchored epistheses for the cosmetic handicap were the only methods used. Nine of ten patients received BAHA, four accepted and received the suggested epistheses. When closing this project, we could say that we had established these methods in Finland. The main emphasis in our work was however in recognizing and analyzing the psychosocial problematics within the handicapped and in his/her family. Our multiprofessional team had much of previous experience from working with groups of families. Developing a holisitc approach covering the process from birth till late follow-up of the habilitation became thus quite self-evident aim. From the preoperative assessment to the follow-up stage the management was proceeded in two groups consisting the patients withat least one family memmber present. On basis of this project during 1993-1996 we now present our suggestions for future management program within the Finnish health care organization.

Abstract Otology 2000 A17-5

Klavdia Z. Borisova Prof.Dr.med., Helen Borisova Dr.med.

ENT Postgraduate Med. Institute RU-Novokuznetsk

The aim of this investigation is to report our observations of three patients with unilateral anomalies. The first and second branchial arches syndrome coexisted with a cholesteatoma located in the bony monolith of the undeveloped external ear canal. The common features of two girls and one boy, which were aged 11-13 years, were a microtia with an absence of the tragus, the rising part of helix, deformities of aurical cartilage and undeveloped cavitas conchae. The deformed conchae turris into the narrow ear canal, 8mm in length and 1,5mm in diameter, that ended blindly in the monolith. All the patients had mixed severe to profound hearing loss mostly of conductive character. In 2 cases cholesteatoma was infected and formed fistulas in the bone which opened into the ear canal. Surgical findings were also similar. The cholesteatoma was located in the bony cavity, which did not contact with the tympanic cavity and themastoid. The rudimentary tympanic cavity contained malformed ossicles and fibrous tissue, which blocked the aditus. There was an osteitis in the mastoid air cells. Surgical treatment and intraoperative findings, postoperative and longterm results draw the complete picture of the severe ear dysgenesia.

Abstract Otology 2000 A18-1

Srecko Branica MD, PhD, Nikola Sprem MD, PhD, Ljubimko Simicic MS, Ivica Klapan MD, PhD, Krsto Dawidowsky MD

ORL Klinika Zagreb Clinical Hospital & Univ. CRO-Zagreb

Standard two-dimensional (2D) high quality CT or MRI provides valuable information on anatomical relationships between important structures in temporal bone, but this 2D CT or MRI displays some shortcomings. If two important anatomical structures are not on the same CT or MRI scan, it is not always easy to understand their relationship. Also, we can not sometimes judge the depth of the field. The aim of our study was to design a computer program for 3D imaging of anatomical structures of temporal bone. Procedure steps: 1. Transmission of video or digital signal from CT device to the computer; 2. Transmission of that signal using computer network to different locations; 3. Special software for 3D modelling, partially created and modified by ourselves for 3D computer assisted surgery; 4. Connection of the 3D-digitalizer with computer and multimedia navigation through computer during the surgery. Performing our 3D-approach in computer assisted temporal bone surgery, we were able to "look inside" the patient during surgical planning as well as at the time of the surgery.

Abstract Otology 2000 A18-2

Vasile Ciuchi MD, PhD

ENT Clinic Central Military Hospital ROM-Bucharest

The use of laser in middle ear surgery in the last 25 years was a technical progress for otologic surgery. The lasers have series of properties that depend on the wavelength, therefore with different advantages and disadvantages. The Er : Yag laser has a light emission in the infrared scale with a wavelength of 2940 nm, which doesn't penetrate liquids and doesn't produce any thermic effect on the tissue. The focused spot up to 330 µm allows very precisely applications with the micromanipulator and delicate bone cuts. In the middle ear surgery, the author used the Er:Yag laser advantages in the functional reconstruction surgery for different disease. There are presented the qualities of the laser for the otologic surgery and many of the technical possibilities that were tested in myringoplasties, osiculoplasties, tympanosclerosis and stapes surgery, Goodhill syndrome, and other reconstructions. The absence of local negative effects and the advantages of the Er:Yag laser recommend it to promote new surgical techniques and to improve the results.

Abstract Otology 2000 A18-3

Erdal Gül MD (1), Levent Olgun MD (2), Zafer Eryilmaz MD (2), Gürol Gültekin MD (2), Güldeniz Güler MD (1), Süleyman Aslanalp MD (1)

(1) Ali Cetinkaya Bulvari No:34/1 TR-Izmir
(2) SSK Izmir Educational HDSP TR-Izmir

In this video show, technique of rigid system stapedioplasty for otosclerosis will be presented and rules, hits and important points of technique will be emphasized.

Abstract Otology 2000 A18-4

Caglar Batman MD, Selcuk Inanlý MD, Alper Tutkun MD, Mehmet Ali Pehitoglu MD

ENT Department Marmara University Hospital KBB Klinigi TR-Marmara-Altunizade

Ten patients with ossicular chain defects espacially involving the long process of the incus during tympanoplasty or stapedectomy were treated using a bone cement to reconstruct the ossicular chain continuity. Preoperative audiograms were compared with 1 and 6 months after reconstruction. There was a mean pure tone average (PTA) improvement of 18-dB in patients undergoing the long process of incus to stapes suprastructure reconstruction with the bone cement. In one patient who underwent stapedectomy teflon prothesis in a short incus was supported by the bone cement experienced 12-dB improvement. Although our limited patients, the bone cement reconstruction in foreshortened incus in the middle ear surgery demostrated its feasibility and effectiveness. There was a substantial hearing improvement in all the patients.

Abstract Otology 2000 A19-1

Daniela Soldati MD, Albert Mudry MD

ENT Department University Hospital CHUV CH-Lausanne

Objective: The aim of this study was to determine the origin and to evaluate the treatment applied to acute otitis media with labyrinthisation at our institution. Material and Methods: Between January and June 1997, and between January and June 1998, 16 cases of adults' acute otitis media with labyrinthisation were documented. The charts of the 16 patients were reviewed, and data about laboratory results, treatment, audiological evolution, and follow-up examinations were collected. Results: All patients suffered from acute otitis media, with a sensorineural hearing loss and a pathological otoscopy. We performed 11 mastoidectomies, whereas 5 patients only received conservative treatment; all the operated cases showed a good hearing improvement after surgery. Audiometrical improvement in non operated patients took much more time and was never as good as for operated patients. A viral origin (Influenza, Picorna, Coksakie virus) was confirmed in 25% of the cases by the serological tests done on these patients. Conclusion: We believe that mastoidectomy is the treatment of choice for a labyrinthisation complicating an acute otitis media. In the past two years, an unusual large number of adult patients with labyrinthisation of an acute otitis media was seen at our outpatient care unit: in the preeceding 10 years (1987-1996), only one case per year had been recensed. We therefore tried to understand the reasons for this remarquable increase of complicated otits media. A viral origin of the disease, rarely reported in the literature, must be suspected if efficient oral antibiotics don't help in preventing labyrinthitis.

Abstract Otology 2000 A19-2

Thomas Bischoff MD, Hans Rudolf Briner MD, Thomas Linder MD

ENT-Department University Hospital CH-Zürich

Sensorineural hearing loss (SNHL) is a well known complication of acute otitis media (AOM). The high frequency loss is thought to occur due to diffusion of toxic substances through the round window membrane. The treatment goal is therefore to release toxic substances from the middle ear and to prevent further accumulation of inflammatory products in the round window niche. In a retrospective analysis, the treatment and outcome of patients with AOM and SNHL was reviewed. Between 1992 and 1999 a total of 21 patients (25 ears) with a mean age of 38 years (15-74) were assessed. Twenty four ears were treated surgically, in more than half of them (56%) an epitympanotomy and posterior tympanotomy was performed. A serous effusion was found in 72%, however viral cultures assessed in ten ears were all negative. Audiometric findings showed a predominantly high frequency SNHL. Seventeen patients (81%) recovered completely whereas 4 patients (19%) with severe preoperative hearing impairment showed persistent SNHL. Overall, postoperative hearing thresholds have significantly improved at all frequencies (p<0,01), except at 250Hz. This observation supports the hypothesis of the toxic pathway through the round window membrane, and therefore it confirms the treatment concept of maximal surgical drainage of the middle ear including the round window niche by epitympanotomy and posterior tympanotomy.

Abstract Otology 2000 A19-3

V.F. Voronkin PhD, F.V. Semenov PhD, Anatoly K. Volik MD

ENT Department Kuban Medical Academy RU-Krasnodar

Krasnodar ENT-centre is unique in Russia independent (not included in structure of other medical establishment) specialised clinic of treatment of the patients with ear, nose and throat diseases. Otogenic intracranial complications are one of directions of scientific researches of clinic during last 50 years. Structure and outcome of infectious otogenic intracranial complications in two last decades are submitted in table (omitted). Despite of surgical activity increasing in the last decade concerning treatment of the patients with chronic otitis media, frequency and the structure of infectious otogenic intracranial complications do not vary very much. At the same time there is a decrease of mortality, that is connected with reduction of preoperative time, introduction of new diagnostic methods, application of new antibiotics. CT of unusual sites of brain abscess will be submitted.

Abstract Otology 2000 A19-4

Dmitry I. Zabolotny MD, Svetlana E. Yaremchuk MD

Research Inst. of Otolaryngology Prof. Kolomiychenko Research Inst. UKR-Kiev

When choosing the antibacterial remedy, of paramount importance is taking into account not only bacterial sensitivity to an antibiotic, but also the presence of such qualities as high bioavailability, low toxicity and low incidence of few adverse effects. It is DURACEF (cefadroxil), that qualifies for all the mentioned favorable properties and is being successfully used for treatment of patients with otitis media. The mechanism of bactericidal properties of DURACEF involves the interference with the bacterial cell wall synthesis. We reviewed our experience with 30 patients admitted between 1997-1999 with otitis media. On discharge from the clinic, all patients underwent repeated external auditory canal culturing. The results yielded have demonstrated that 86.6% of patients were free from pathogenic organisms, while in 13.4% of patients the numbers of pathogenic agents were significantly decreased. Thus, DURACEF administration in patients with otitis media. Broad bactericidal spectrum, easy-to-use formulations, insignificant adverse effects allow for using DURACEF safely in this category patients.

Abstract Otology 2000 A19-5

Dmitry I. Zabolotny MD, Svetlana E. Yaremchuk MD

Research Inst. of Otolaryngology Prof. Kolomiychenko Research Inst. UKR-Kiev

Fungal infection is a serious complications following radio- and chemotherapy in case of malignant tumor of the ear. Development of such disorder results in depression of immunological system. As a rule Aspergillus invasion occurs in such cases. Spores often contaminant the upper respiratory tract and grow as parasites in external auditory canal. The treatment Aspergillus disorders in such patients is more difficult. We examined 10 patients with malignant tumor in ear and after long-term course of radio- and chemotherapy. Whose in external auditory canal there have been revealed such fungi as A. fumigatus - 7 persons, A. niger - 2 persons, A. flavus - 1 person. All patients received Diflucan 50 mg/day orally for 15 days and local into postoperative cavities on gause strips during 7 days. None of the examined patients had revealed fungi after treatment. Thus, antifungal Diflucan can be appropriately used in complex treatment of fungal complication after radio-chemotherapy and in course of long term used antibiotics and corticosteroids.

Abstract Otology 2000 A19-6

M. Aleksandrova MD (1), M. Mitrovska MD (1), Elena Dimeska MD (1), Olivera Miskovska MD (2), Z. Maksimovic MD (3)

(1) ENT Department University Hospital MAZ-Skopje
(2) ENT Department Medical Center Bitola MAZ-Bitola
(3) HNO-Abteilung Klin. Krankenhasu Osijek CRO-Osijek

Chronic Otitis media represents disease with still unexplained etiology. Anyway in chronic suppurative otitis media many microbiological agents were isolated as one of its supporting factors. During our clinical experience in the past few years we noticed some changes in microbiological flora as well as its sensitivity to usually administered antibiotic groups. Our poster represents 50 swab cultures with related antibiotic sensitivity. This study showed appearance of six different microorganisms and the most represent of them was Staphylococcus aureus.

Abstract Otology 2000 A19-7

Alexei Gagauz Prof.Dr.

ENT University Hospital MD-Chishinev

Chronic purulent otitis with polyps or granulation tissue in the external canal or the middle ear cavity is managed by using laser (coagulation, carbonisation) with contact, distant shooting or combined regimens. In presence of cholesteatoma, laser is applied after creating the surgical cavity. Laser's energy is provided by using fibers of different diametes (0,2-0,6mm) and with variable shapes of tips. The power and exposure time varies individually. The aim of this study is to focus on potentials of ND-YAG laser while treating patients with chronic purulent otitis media.

Abstract Otology 2000 A19-8

Hiroshi Ogawa MD (1), Yasuhiro Tada MD (2), Iwao Ohtani MD (1)

(1) ENT Department Fukushima Medical University J-Fukushima
(2) Dept. of Otolaryngology Fukushima Medical University School of Medicine J-Fukushima

Recurrent cholesteatoma is the most important problem after a intact canal wall tympanoplasty. In order to prevent this problem we have performed the tympano-mastoid blockage. The surgical procedure is to intercept aeration route completely between the tympanic cavity and mastoid cavity with small bone pieces and moreover is to fill up the mastoid cavity with bone pate and fibrin glue. From January 1985 to December 1995, for 206 cases suffering from cholesteatoma otitis, intact canal wall tympanoplasty was undergone. In 52 cases we performed the tympano-mastoid blockage. The tympano-mastoid blockage is the most effective preventive technique in intact canal wall tympanoplasty against recurrent cholesteatoma, even in ears with severe retraction or adhesion of the tympanic membrane due to eustachian tube insufficiency.

Abstract Otology 2000 A19-10

Navin L. Hiranandani MD

Oto Rhino Laryngology Nair Hospital Inmedical College IND-Bombay

Cholesteatoma is still a fairly common condition affecting the middle ear and mastoid cavity. It produces various types of lesions. Mastoid abscess and mastoid fistulae occur in this condition. Attico-antrae pathology occurs frequently. Facial paralysis still occurs specially in middle ear cholesteatoma. Labyrinthitis is frequent. Brain abscess although reduced due to antibiotics occurs occasionally. The variegated pathology of cholesteatoma offers interesting lesions.

Abstract Otology 2000 A19-11

Stan Cotulbea MD, Stelian Lupescu MD, Ghe. Iovanescu MD

University of Medicine ROM-Timisoara

The surgical management of labyrinthine fistulas caused by cholesteatoma remains controversial. Forteen cases of labyrinthine fistulas were revised. This represented 8.46% of our total series of cholesteatomas in adults and children (169 cases). Clinical presentation, extent of disease, results of fistula testing and audiometric studies and radiographic findings were analysed. A canal wall-down procedure was performed. Generally an attempt was made to completely remove the cholesteatoma, to graft the fistulous area. The matrix was preserved in patients with large fistulas where the involved ear was the only hearing one, when the matrix was adherent to the underlying optic duct and in selected elderly persons. Long-term following did not reveal a significant difference in hearing, degree of vertigo, incidence of recidivism when those patients in whom the matrix was removed were compared with those in whom the matrix was preserved. The importance of recognizing the presence of a labyrinthine fistula preoperatively is stressed, along with the need to be prepared for an unexpected fistula. Operative management is described.

Abstract Otology 2000 A19-12

Chul-Ho Jang MD, Tae W. Choi MD, Young H. Kim MD

Dept. of ENT Wonkwang Medical School ROK-ChunBuk

Fourty two cases of labyrinthine fistulae secondary to cholesteatoma managed by the author between 1992 and 1997 were reviewed. A fistula was defined as invasion of the bony otic capsule. The cholesteatoma matrix was removed in all cases and the underlying fistula repaired primarily using bone pate with perichondrium. All cases have had no further difficulty with vertigo beyond the immediate postoperative period. Among this patients, 15 cases had one follow-up high-resolution computerized tomography at 6 months to 2 years after surgery. The postoperative CT showed the closure of the previously visulised defect of the wall of the horizontal semicicular canal. The surgically created wall of the horizontal semicircular canal appeared smooth in all cases and could not be distinguished from the surround bone of the otic capsule.

Abstract Otology 2000 A19-13

Chul-Ho Jang MD

Dept. of ENT Wonkwang Medical School ROK-ChunBuk

The operative findings of 95 patients who underwent revision tympanomastoid surgery for recurrent and residual cholesteatoma were analyzed for the cause of failure. Recurrent and residual cholesteatoma was found in 38% of the open cavity and 85% of the closed cavity procedures requring revision. The canal down mastoidectomy was selected. High facial ridge, narrow external auditory canal and incomplete mastoidectomy were most common causes. The complete canal down mastoidectomy with lowering the facial ridge as lowest as possible was necessary for thorough exentration of mastoid cells. The 4mm 30 degree telescope was very good for the dissection of tympanic sinus. The mastoid obliteration was done using hydroxyapatite granules and musculoperiosteal flap. Revision surgery was successful in providing the patient with a safe, dry ear in 88 ( 93%) of 95 cases. Surgical principles and hearing results are presented.

Abstract Otology 2000 A19-14

Dragoslava R. Djeric MD, R. Radulovic MD, S. Jesic MD, A. Jasovic MD, N. Arsovic MD, V. Djordjevic MD

Institute of Otolaryngology Clinical Center of Serbia YU-Belgrad

A retrospective analysis was performed of 255 children surgically treated for chronic suppurative otitis over the past 20 years. In 18 children the disease was bilateral, thus, the analysis comprised of 273 operated ears. The first group consists of 135 children (142 ears) treated for cholesteatoma, and the second group included of 120 children (131 ears) who had chronic otitis without cholesteatoma. The data obtained from both group were analysed and compared. In the majority of children, the cholesteatoma was enlarged (45%) involving the tympanic cavity and mastoid spaces. The auditory ossicles are ussually damaged (87%). Two or all ossicles are affected, and the bony walls of the middle ear are changed in more than a quarter of the cases. In cases of chronic otitis media without cholesteatoma osteitic lesions of ossicles and the bone walls of the middle ear were less frequently found. According of this series, we can review the data of the literature, and analyse the different points of view.

Abstract Otology 2000 A19-15

Sertac Yetiser MD, Mustafa Kertmen Prof.Dr.med., Yalcin Ozkaptan Prof.Dr.med., Ahmet Dundar Prof.Dr.med.

Dept. of ORL & HNS Gulhane Medical School TR-Etlik, Ankara

In surgical treatment of chronic otitis media, after a complete eradication of the disease, it is imperative to establish a safe ear for long-term and it even has priority to the reconstruction of hearing. If this is not accomplished, any effort to rebuild the ossicular continuity will be useless due to recurrent infection. Even the hearing has been brought to a level better than the preoperative threshold. This is frequently practised in patients who have undergone canal wall down surgery. Lack of self-cleansing mechanism needs periodical care of the cavity. Otherwise, the ear is prone to develop ear discharge. Since 1985 our technique in canal wall down procedure is a combination of the creation of a wide mastoid cavitiy, a wide meatoplasty, the removal of the mastoid tip, the quite lowering of the facial ridge and the obliteration of the mastoid cavity with postero-inferior based periostal flap (arterial supply from a branch of posterior auricular artery). This provides a considerable decrease in size of the cavity due to new bone formation which eliminates the need of cavity care after 6 months. The aim of this study is to present long-term results of this technique in 120 patients. Hearing gain with regard to ossiculoplasty technique and the type of material used has been reviewed. The relation between the status of the cavity and the diameter of conchomeatoplasty, the volume of the cavity and the height of the facial ridge on CT have been documented. It was found that 5.7% of the patients underwent a revision mastoid surgery due to either cholesteatoma recurrence, recidive or just failure or the previous inadequate technique. It has been found that the diameter of meatoplasty is between 1.7-2.6 cm in an early postoperative period. There are 4-6 mm decrease in dimension within a year. The diameter is less than 1.5 cm in the majority of draining ears postoperatively. The volume of the cavity ranges between 18 ml to 4 ml (Av. 6.8 ml) in the first month. There is a considerable dicrease in volume in the first 3 to 6 months due to osteoneogenesis demonstrated by CT (Av. 2.15 ml) in non-draining ears. There is a negligable change in dimension of the cavity in 1 to 5 years. In draining ears, the decrease in volume of the cavity within 3-6 months (Av.4.9 ml) is less than in non-draining ears probably due to flap necrosis although they have a large cavity in first month (Av. 8.2 ml). It has been found that the height of the facial ridge has no major role in the success of the surgery.

Abstract Otology 2000 A19-16

Chih Ying Su MD

Chief of Dept. Otolaryngology Chang Gung Memorial Hospital TWN-NiaoSung HsiangKaohsiung Hsien

The cleft palate population has a high prevalence of otitis media with effusion. It is believed that one of the pathogenetic factors of eustachian tube dysfunction in the cleft palate patients is an inability of the paratubal muscles to dilate the eustachian tube actively during swallowing. This study was designed to evaluate the swallowing and phonation contraction activities of the tensor and levator veli palatini muscles which were recorded by a transnasal electromyographic(EMG) recording method. Twenty cleft palate patients with forty sides of tensor and levator muscles were involved in this study. The results revealed that the swallowing and phonation contraction EMG activities of levator muscles in cleft palate palate patients were markedly decreased. The duration of swallowing EMG activities of the levator muscle was shorter than that of the normal controls. However, the swallowing EMG activities of tensor muscle in cleft palate patients presented normal and even increased. These results suggested that eustachian tube dysfuncton in cleft palate patients may be not due to a poor contractility of the tensor muslce.The velopharyngeal insufficiency of cleft palate patients was closely related to not only the clefting of the palate but also the poor contractility of the levator muscle.

Abstract Otology 2000 A20-1

Ugo Fisch MD

ORL-Klinik Universitätsspital CH-Zürich

no abstract

Abstract Otology 2000 A21-1

Mansfield F.W. Smith MD (1), Ugo Fisch MD (2), J.B. Causse MD (3), John William House MD (4)

(1) Past-President USA-San Jose CA
(2) ORL-Klinik Universitätsspital CH-Zürich
(3) Centre de Recherches L'OREAL F-Aulnay sous bois
(4) House Ear Clinic USA-Los Angeles, CA

The indications and results of stapes surgery will be discussed during the Round Table A4 (Controversies in stapes surgery) discussion. This instructional course will focus on the surgical techniques presented by three distinguished surgeons. Surgical tips and pitfalls will be presented and each panelist will briefly show their technique, preferred prosthesis and surgical instruments. (A similar course will be held on Wednesday during Session C22)

Abstract Otology 2000 A22-1

John S. May MD (1), Jan Helms MD (2), Gregorio Babighian MD (3), Ulf Mercke MD (4)

(1) Otolaryngology, Head&Neck Surg. Wake Forest University USA-Winston-Salem, NC
(2) HNO-Klinik Julius-Maximilians-Universität D-Würzburg
(3) Divisione ORL Ospedale Civile di Venezia I-Venezia
(4) Dept. ORL Univ. Hosp. Lund S-Lund

Otologists dealing with hearing reconstruction following canal-wall-down or canal-wall-up mastoidectomy often face the situation of a missing incus or absent stapes suprastructure. How to handle these situations will be presented by three prominent surgeons. Using temporal bone specimens, each panelist will perform their favorite mode of reconstruction.

Abstract Otology 2000 A23-1

Alex Fitzgerald O'Connor M.B. Ch. B. F.R.C.S (1), Arne Ernst MD (2), J.P. Lavieille MD, PhD (3), Thomas Linder MD (4)

(1) Dept. of Otolaryngology St Thomas Hospital GB-London
(2) HNO-Klinik Unfallkrankenhaus Berlin D-Berlin
(3) ENT Dept, Service ORL CHU de Grenoble F-Grenoble Cedex
(4) ORL-Klinik Universitätsspital CH-Zürich

The indications and results for various implantable hearing aids will be discussed during the Round Table A3 discussion. This instructional course will focus on the surgical techniques presented by three prominent surgeons. Currently the only commercially available and CE-marked certified implant is the VORP by Symphonix. The surgical approach, tips and pitfalls for the fixation of the FMT will be discussed. This instructional course will take place at the Anatomy Department (follow the signs). Only a limited number of participants can be accepted on a first come basis.

Abstract Otology 2000 A24-1

Daniel Simmen MD (1), Robert A. Jahrsdoerfer MD (2), Ralf Siegert MD, PhD (3), Anders Tjellström MD (4)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Dept. of Oto-HNS Univ. of Virginia Medical Center USA-Charlottesville VA
(3) Univ HNO Klinik Medizinische Universität D-Lübeck
(4) Deptmt. Otolaryngology University of Goteborg Sahlgrens Hospital S-Göteborg

During this session video tapes on different surgical techniques that have been discussed during the Round Table session A05 will be presented. Further discussion with the faculty members is possible.

Abstract Otology 2000 B01-1

Julia K. Terzis MD, PhD

Eastern Virginia Medical School USA-Norfolk, Virginia

Facial paralysis is a devastating condition seriously handicapping an afflicted individual. Restorative microsurgery has expanded our capacity to obtain results approaching a satisfactory degree of symmetry and facial expression. In acute lesions of the facial nerve, basic principles of neural microsurgery lead to an acceptable outcome. These techniques include microneurolysis, end-to-side repair o nerve grafting. In long standing facial paralysis, facial reanimation is a multi stage procedure. Depending on the presentation of the patient, the first stage cross facial nerve grafting procedure is established. Thus, if there is lagopthalmos, a cross facial nerve graft dedicated to eye reanimation is placed. If there is paresis of the nasolabial fold a dedicated cross facial nerve graft is placed for smile restoration. The "baby-sitter" principle is another technique introduced by the author to salvage the denervated facial musculature while waiting for the cross facial nerve grafts to cross the face. In a second stage free muscle transfers or secondary microcoaptations are carried out for the substitution of weak or denervated facial targets. The pectoralis minor, introduced in 1981 by the author, provides an optimal muscle for facial reanimation in young children. The gracilis muscle also has been used and is a reliable free muscle which can be trimmed and sculptured to address the requirements of the paralyzed face. The art of facial reanimation requires always a final stage of revisions. This is extremely important to convert an acceptable to a beautiful result. Conclusion: A combination of neural microsurgery and free muscle transplantation techniques along with aesthetic final revision provides rewarding results for the afflicted patient.

Abstract Otology 2000 B02-1

Kris Moe MD (1), François Disant MD (2), Wolfgang Draf MD, PhD, FRCS (3), Ph. Pasche MD (4), William H. Slattery MD (5), Julia K. Terzis MD, PhD (6)

(1) Department of Surgery 8895 University of California, San Diego USA-San Diego, CA
(2) Dép. ORL Hôpital Edouard Herriot Pavillon U F-Lyon Cedex 03
(3) Department of ENT-Diseases, Head Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda
(4) Service ORL CHUV CH-Lausanne
(5) House Ear Clinic USA-Los Angeles, CA
(6) Eastern Virginia Medical School USA-Norfolk, Virginia

This panel consists of an international collection of experts on facial reanimation. The format will include short presentations on several and controversial topics in the field, as well as specific case illustrations for the demonstration of how experts deal with challenging problems. Among the topics that will be discussed are: 1. Indications for facial reanimation 2. Choice of appropriate procedure (dynamic vs static) 3. Options in static procedures (forehead/eyebrows, eyelids, cheeks, mouth) 4. Options in dynamic procedures (re-anastomosis, interposition grafting, 7-12 anastomosis, cross-facial grafting, free-muscle transfer, etc) 5. Personal "tricks" and techniques 6. How to avoid complications 7. How to manage complications 8. What is on the horizon for the 21st Century 9. Question and answer period The discussions will be interesting to those of all levels of clinical experience, but will be particularly directed to those who manage these problems on a regular basis and have advanced surgical skills.

Abstract Otology 2000 B02-4

Ph. Pasche MD, B. Jaques Dr,

Service ORL CHUV CH-Lausanne

Patients who have a congenital facial paralysis or a paralysis for longer than two years and who have no evidence of muscle activity are usually candidates for regional muscle transfers or static suspension which provide symmetry at rest, limited voluntary movements, but no emotional expression. Microvascular muscle transfer and reinnervation usually with the contralateral facial nerve is a technique which restores also the involuntary movements, so important to express emotion. The reconstruction involves two procedures spaced one year apart. A cross-face nerve graft is necessary in unilateral facial paralysis to provide facial nerve input from the contralateral side. After one year, when the reinnervation of the nerve graft is archieved, a segmental section of the gracilis muscle with its neurovascular pedicle is transferred to the face and fixed to the residual musculature of the upper lip and to the zygomatic arch. Microvascular anastomosis with the facial vessels is carried out, and nerve repair is done between the recipient nerve in the face and the motor nerve of the gracilis muscle. Reinnervation takes place within 6 to 9 months. Active exercise program helps to maximize strength, excursion, and coordination. Functional improvement can occur for up to two years after the muscle transfer. Although the procedures are complex and technically demanding, it is a valuable alternative to static suspension, especially for young patients when the paralysis affect their self-confidence and social interaction. The autors report their experience about two cases, one for a congenital facial paralysis and one for a Bell's palsy.

Abstract Otology 2000 B03-1

Bruce J. Gantz MD (1), Robert Charachon MD (2), John Hamilton MD (3), Klaus Jahnke MD (4), Stephan Schmid MD (5), Jean-Marc Thomassin MD (6)

(1) Dept.Otolaryngology,Head and Neck Univ. of Iowa Hospitals USA-Iowa City, Iowa
(2) Clinique ORL CHU Grenoble B.P. 217 F-Grenoble Cedex 09
(3) Dept. of Otolaryngology Glousestershire Royal Hospital GB-Gloucester
(4) HNO-Klinik Univ. Essen D-Essen
(5) ORL-Klinik Universitätsspital CH-Zürich
(6) Srv ORL Hôpital Sainte Marguerite F-Marseille Cedex 5

There is still a big controversy how an open cavity should be created to achieve a dry, self-cleansing cavity. In this panel we will present the different methods, how to solve this problem in the daily work. Then we will discuss the indications for a reconstruction or an obliteration of the open cavity as well as the functional results after a canal wall down procedure.

Abstract Otology 2000 B04-1

Ugo Fisch MD (1), Bruce J. Gantz MD (2), Thomas Linder MD (1), Gerald M. O'Donoghue M.Ch FRCS (3), Naoaki Yanagihara MD (4)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Dept.Otolaryngology,Head and Neck Univ. of Iowa Hospitals USA-Iowa City, Iowa
(3) ENT Department University Hospital Queen's Medical Centre GB-Nottingham
(4) Dep. of Otolaryngology Takanoko Hospital 525-1 Takanoko-cho J-Ehime-ken

Surgical versus non-surgical treatment of Bells' palsy continues to be an extremely controversial subject. In addition, the effectiveness of any medical management is debatable as long as the exact pathogenesis remains unclear. How to manage a patient with idiopathic facial paralysis will be discussed among the panelists. Facial nerve injury due to closed head trauma also represents a therapeutic challenge. The timing of the surgery, the surgical approach and the handling of the injured facial nerve will be analyzed in this round table discussion.

Abstract Otology 2000 B10-1

Daniela Soldati MD, Albert Mudry MD

ENT Department University Hospital CHUV CH-Lausanne

Objective: The aim of this study is to understand the historical development of the knowledges on the pathogenesis of cholesteatoma. Material and Methods: Review of the literature published between 1800 and 1998 and concerning the date-related knowledges about cholesteatoma. Results: In 1683, Duverney first described a temporal bone tumor probably corresponding to a cholesteatoma. Until 1838, as Müller first named it cholesteatoma, nothing new appeared in medical publications. After 1838, three main theories about its pathogenesis were published : the first, form Virchow in 1855, considered the cholesteatoma as a tumor arising from mesenchymal cells which had undifferenciate and then redifferenciate to epidermal cells and begun to grow as tumoral cells. The second, of Toynbee, in 1857, considered cholesteatoma as the result of immigration of the external ear canal epidermis in the tympanic cavity via a marginal perforation following an acute or chronic otitis. The third, of Wendt and von Troeltsch, in 1868, considered the cholesteatoma as the result of a metaplasia of tympanic mucosa into a malpighian epithelium, which desquamated and produced cholesteatoma because of chronic inflammation. It took 40 years of discussions about theese three theories, to finally confirm that Toynbee was right. Conclusion: Knowledges about cholesteatoma have evolved with other medical branches. As otologists begun to follow their patients « in vivo », not limiting their observations to temporal bones' dissections, the genesis of cholesteatoma became well understood. Today, with immunology and new histopathological techniques, we will certainly learn much more about cholesteatoma.

Abstract Otology 2000 B10-2

Eric Truy MD, MSc (11), Sonia Ayari MD (1), Christian Dubreuil MD (2)

(11) Service ORL, Pavillon U Hôpital Edouard Herriot F-Lyon Cedex 03

The authors present a 25 cases series of intratemporal bone cholesteatomas . Symptoms are described: all types of hearing losses can be observed (conductive, mixed, total deafness) and also facial palsy, which is a very suggestive sign. The natural history is various and will be developped. This allowed us to make differences between congenital and acquired cholesteatomas. No parallelism exists between the signs, the otoscopic aspect of the tympanic membrane and the extension of the tumor. So, the accent is stressed on the importance of the medical imaging including CT-Scan, and MRI in some cases to precise the limit of the lesion with the labyrinth and/or the dura. The imaging allowed us to classify the extension according to Hawthorne and Fisch. The extensions are supralabyrinthine, infralabyrinthine, posterior peri- and translabyrinthine, and in some rare cases involving quite entirely the totality of the temporal bone. Of course, findings of medical imaging lead to an appropriate surgical approach. Indications of these different approaches (infratemporal, translabyrinthine, transcochlear, and of the middle fossa) are discussed. The problem of the choise between the closing or the opening of the cavity is to be considered in light of the extension of the cholesteatoma, the risk of recurrence, the exposition of the dura, and of the possibilty to keep a functional hearing.

Abstract Otology 2000 B10-3

Hiromi Ueda MD, PhD, Seiji Nakata MD,PhD, Tutomu Nakashima MD,PhD

ENT Department Nagoya University School of Medicin J-Showa-ku, Nagoya

From 1982 to 1997, 52 children (54 ears) with cholesteatoma had underwent surgery in our department. In the early period (1982-1990), the open method was performed in 47% (17 ears) of the ears and the closed method in 53% (19 ears). Cholesteatoma recurred more frequently in the closed method group than in the open method group (58% vs. 12%). Other postoperative complications, such as erosion of the mastoid cavity, otorrhea, perforation of the ear drum, occurred more often in the open method group than the closed method group. In the later period (1991-1997), 18 ears with cholesteatoma had underwent surgery. The closed method was performed in 16 ears. In the closed method group, 10 ears had underwent one-stage surgery. Planned staged tympanoplasty was completed in 6 ears. After one stage surgery, 4 of 10 ears had underwent residual cholesteatoma. Two of the recurrent ears had underwent planned staged tympanoplasty. As revealed by postoperative computed tomography (CT) image, 11 of 14 ears had aeration in the attic and antrum as well as in the tympanic cavity. In these cases, no attic retraction pocket formation was observed. Our strategy for pediatric cholesteatoma in the future is to use the closed method as often as possible. If aeration in the attic and antrum is seen to exist by preoperative CT-scan image, the one-stage surgery will be chosen. If not, planned staged tympanoplasty will be needed. By this choice, a high incidence of aeration of the attic and antrum will occur and we will be able to prevent the attic retraction pocket and detect residual cholesteatoma early by postoperative CT scan.

Abstract Otology 2000 B10-4

Ulf Mercke MD

Dept. ORL Univ. Hosp. Lund S-Lund

Material and method Middle ear cholesteatoma in 131 patients was treated surgically by eradicating the cholesteatoma after a canal wall down procedure had been performed. During the same session the canal wall was rebuilt, the tympanic membrane repaired and the mastoid cavity and epitympanic space obliterated. One year later a second look and an ossiculoplasty with a short or long columella was performed. The patients have then been checked regularly with microscopic and audiologic examinations for a minimum of 5 years after the second look operation. The audiological findings after 5 years are reported. Results At the 5 years postoperative check all patients were free from recurrent and residual cholesteatoma. At that check 110 audiograms were available for analysis (i.e. in 90% of the total material) making possible to follow the changes in hearing from before the eradicating operation up to 5 years after the second look operation. No patient manifested a sensori-neural hearing loss, mean bone conduction level before the eradicating operation was 10dB and 5 years after second look 10.6dB. Patients with a real qualification for normal postoperative hearing are those with a normal preoperative bone conduction level (BC=/< 15dB), this was found in 82 patients. In 65 of these cases, i.e. 80%, a social hearing (AC=/< 30dB) was reached at the 5 year postoperative check. ABG is in this group -/< 20dBin 92,3%. The results are distinctly betterwhen a short columella can be used instead of a long one, social hearing beeing reached in 90,7% and 57,1% respectively. Conclusions A middle ear cholesteatoma operated with obliteration technique and staging is 5 years after second look 1) free from cholesteatoma and has 2) a social hearing in 80% of those cases where the bone conduction level is normal preoperatively.

Abstract Otology 2000 B10-5

Atsushi Haruta MD, PhD (1), Hirokazu Kawano MD, PhD (2), Tetsuya Tono MD, PhD (1), Tamotsu Morimitsu MD, PhD (1), Shizuo Komune MD, PhD (1)

(1) ENT Department Miyazaki Medical College J-Miyazaki
(2) ENT Department Miyazaki Medical College J-Miyazaki

Sixty three cases of open mastoidectomy ear with persistent ear discharge and/or hearing disorder were treated with a reconstruction of posterior wall of the external canal. Three different types of reconstruction method of rebuilding of posterior wall by cortical bone grafting (38 cases), mastoid obliteration with bone tips (10 cases) and T-shape assembled cortical bone grafting (10 cases) were employed. Clinical results in our department were summarized from 1987 to 1997. Aural discharge was arrested in 87%. Hearing was restored in 60%. No difference was found in these results among three reconstruction methods. However, long term observation revealed an apparent difference in three methods. 56% cases reconstructed by rebuilding of posterior wall developed a re-retraction of it. On the other hand, 30 % cases by mastoid obliteration with bone tips and T-shape assembled cortical bone grafting produced re-retraction of posterior wall. Our results indicated that reconstruction of posterior wall against open mastoidectomy is efficient in restoration of persistent ear discharge. To set a single bony plate grafting alone employed in 38 cases is not sufficient to prevent re-retraction of posterior wall of external canal.

Abstract Otology 2000 B10-6

Milan Stankovic MD, PhD

University ENT Clinic Medical Faculty YU-Nis

The incidence of postoperative complications after some operations for middle ear cholesteatoma is high. It is supposed that the localization of disease and the type of surgical operation can significantly influence on the success of such operations. To study the results of cholesteatoma surgery we reviewed 197 cholesteatoma cases that were divided in three groups: attic, sinus and tensa cholesteatoma. Each group was subdivided in cases operated using canal wall down (CWD) and intact canal wall technique (ICW). All the patients were followed for at least three years. The results of the operations were analyzed according to postoperative air-bone gap, and the presence of residual or recurrent disease. Audiological results were comparable in all the groups and air-bone gap in over 80% was achieved, especially in attic cholesteatoma group. The rate of residual cholesteatoma was less than 10% no matter localization. However, CWD technique gave significantly higher incidence of recurrent disease (13,2% for attic, 9,9% for sinus, and 9,9% for tensa cholesteatoma) in comparison to ICW technique (3,3%, 3,3% and 13,2% respectively). The significance of these results for surgical therapy of cholesteatoma is discussed.

Abstract Otology 2000 B10-7

Peter G.B. Mirck MD

Department of ENT Academic Medical Center NL-DE Amsterdam

Surgery for cholesteatoma is traditionally divided in canalwall-up and canalwall-down procedures. Keystone in selecting one technique over the other is the potentiality to remove all matrix. Taking down the posterior-superior canalwall creates the best opportunities to remove matrix from otherwise hidden areas i.e. the tympanic sinuses, facial recess, epitympanic space and cell tracts in the peritubal and hypotympanic areas. But the resulting cavity needs postoperative care for a lifetime and is susceptible for caloric stimulation during swimming. Preserving the canalwall creates better possibilities for ossicular chain reconstruction, but is more difficult and needs a second stage procedure any how . In the present operative technique the posterior-superior bony canalwall is taken out temporary in one piece, to create access to the mentioned hidden areas. At the end of the operation it will be replaced and fixated by its bevelled shape only. This operative technique pretends to combine the advantages of a canalwall-up procedure with the easy of access in a canalwall-down technique. A second stage operation is indicated to check for recurrent or residual cholesteatoma and to perform an ossicular chain reconstruction. In a series of 40 cases we found a residual cholesteatoma in 2 patients (5%) and a recurrence in 1 patient (2,5%). Finally 93% of the patients are free from cholesteatoma and got a tympanoplasty with TORP (Spandrel after Fisch) or incustransposition. Only 7% got a canalwall down procedure at second stage surgery (follow up 2-12 years). The surgical technique and the audiological results will be presented.

Abstract Otology 2000 B11-1

Euan Murugasu MD

California Ear Institute atStanford Dr. Joseph Roberson USA-Palo Alto, CA

The cochlea is the most sophisticated mechano-sensory transducer in our body, regulated by the voltage-dependent motility of its outer hair cells (OHCs). Anatomically, impressive boutons of the olivo-cochlear bundle (OCB) terminate on the OHCs. It is believed that, by modifying OHC electro-mechanical properties, the OCB may regulate feedback gain and control the sensitivity and frequency selectivity of the cochlea. Tone-evoked basilar membrane (BM) displacements were measured in-vivo with a laser diode interferometer in the basal turn of the guinea pig cochlea. The OCB was electrically stimulated via electrodes placed along the floor of the fourth ventricle. For tones close to the characteristic frequency (CF), OCB stimulation linearized the highly compressive displacement-level functions and displaced the steep, low-level region toward higher intensities along the intensity axis by < 27 dB SPL. This shift resulted in a desensitization of the tip of the BM displacement tuning curve, but there was no associated broadening of the tuning curve, changes in the phase response or BM motion at frequencies in the low-frequency tail. These effects were abolished by perfusing the scala tympani with 1mM strychnine. For the first time, we show that the OCB can directly influence cochlear mechanics and postulate that the OCB-OHC complex provides a template for higher auditory centres to orchestrate frequency focusing within the cochlea, by way of a highly accurate yet mobile "acoustic fovea" adjusting instantaneously through OCB-OHC interaction. If so, it would be prudent for surgeons to try and preserve the OCB efferents whenever possible.

Abstract Otology 2000 B11-2

Saumil N. Merchant MD, Michael E. Ravicz M.S., John J. Rosowski Ph.D.

Department of Otolaryngology and Eaton Peabody Lab. of Aud.Physiol. Mass. Eye and Ear Infirmary USA-Boston MA

We have utilized quantitative physics-based models and acoustic measurements in cadaveric temporal bone preparations to improve our understanding of structure-function relationships in the middle ear. This paper will discuss recent information about middle-ear mechanics and some acoustical principles that can be used by otosurgeons, along with illustrative clinical cases. Four major points will be discussed: (1) The air-bone gap after middle-ear surgery can be predicted by the interaction of ossicular coupling, acoustic coupling and stapes-cochlear input impedance. (2) In the normal ear, middle-ear sound pressure gain is frequency dependent and only 20-25 dB at its maximum (which is less than generally believed). Therefore, the air-bone gap can be closed to within 20 dB in certain circumstances even with less-than-optimal tympanic membrane/ossicle configurations (type II and type III) or in ears without ossicles (type IV). (3) In the normal ear and after most tympanoplasties, the difference in phase between the sound pressures at the oval and round windows is much less important than the difference in magnitude. Hearing can be improved in certain cases by simply increasing the acoustic shielding of the round window in order to decrease the magnitude of the round-window sound pressure without regard to phase (e.g., type IV, type Va, type Vb). (4) The mechanics of ossicular reconstruction depend on a number of factors including stiffness, mass, positioning, tension, coupling as well as middle-ear aeration. The effects of these will be discussed.

Abstract Otology 2000 B11-3

Alex M. Huber MD, Christoph Schwab MD, Mattia Ferrazzini Dipl.Ing.ETH, Thomas Linder MD, Ugo Fisch MD

ENT Department University Hospital CH-Zürich

The Laser Doppler Interferometer (LDI) is a device which allows contact-free analysis of vibration with a high degree of accuracy. Its potential for measuring the mobility of the tympanic membrane in response to defined acoustic signals has been documented. Although LDI has been used in the research of middle ear mechanics, it was not yet introduced in clinical practice as an adjunctive test for otological work-up. The aims of this study were to evaluate the LDI as a diagnostic tool in the clinical sphere and to investigate whether 1. the measurements are practical 2. sensitive parameters can be identified to distinguish different pathologies 3. additional information over the standard audiometric tests can be obtained. A measurement system was developed based on a scanning He-Ne laser Doppler Interferometer (Polytec GmbH). The study included more than 100 subjects that were divided into 3 groups: (a) normal subjects, (b) patients with sensorineural and (c) conductive hearing loss. All the patients suffering from conductive hearing loss underwent ossiculoplasty, which allowed confirmation of the final diagnosis, and patients were assigned accordingly to subgroups. The modified LDI system allowed complete bilateral tympanic membrane evaluation of a subject within 30 minutes. No significant difference between normal subjects and patients having sensorineural hearing loss were found. However, it was possible to distinguish between normal subjects and patients with conductive hearing loss. Furthermore, it had the ability to differentiate between various middle ear pathologies. These groups differed significantly in terms of manubrium vibration amplitude and resonance frequency as well as tympanic membrane amplitude and modes. Our modified LDI is applicable in clinical otological practice and serves as a valuable addition to the routine audiological investigations for preoperative evaluation of the mobility and integrity of the ossicular chain. The future goal of diagnostic LDI measurements is to identify partial ossicular fixation as a possible cause for poor results after ossiculoplasty and thereby assist in improving hearing results after otosurgery.

Abstract Otology 2000 B11-4

Sébastien Schmerber MD, J.P. Lavieille MD, PhD, M. Feige , Robert Charachon MD

Service ORL CHU de Grenoble F-Grenoble Cedex 09

The Vibrant Soundbridge is a partially implanted hearing device intended for patients with symetrical, bilateral moderate, to moderate-severe sensorineural hearing loss. The surgical implantation of the Vibrant Soundbridge is familiar to otologic surgeons performing cochlear implants. Each patient was evaluated against the selection criteria to determine suitability for implantation. 10 patients were implanted, 8 with Vibrant P Soundbridge and 2 with Vibrant Soundbridge HF. There was no acute per-operative or post-operative complication. In one patient, a delayed uncomplete Bell's palsy appeared 2 weeks after surgery, and recovered a normal facial function within 2 months.. The first fitting test session was conducted at 8 weeks post-surgery and the review fitting test session 4 weeks later. The audiologic tests were conducted by unaided air-conduction thresholds under headphones, in free field, and bone-conduction thresholds, and by Soundbridge aided air-conduction thresholds in free field. The patient's subjective comments were noted. The maximum and average functionnal gain at each frequency was calculated. Audiologic results and subjective impressions are discussed. In conclusion, The Vibrant Soundbridge seems to provide most patients with adequate functionnal gain in the speech frequencies.

Abstract Otology 2000 B11-5

Thomas Wilhelm MD (1), Rüdiger Junker MD (11), Dirk Hardick Dr.med. (1), Manfred Gross Prof.Dr. (2), Arne Ernst MD (1)

(1) Dept. Otolaryngology Unfallkrankenhaus Berlin D-Berlin
(11) Dept. Otolaryngology Unfallkrankenhaus Berlin D-Berlin

Since 1996, implantable hearing aids are commercially available. More than 200 patients were implanted world-wide with an electromagnetic device, attached directly to the ossicular chain (Symphonix Soundbridge). In October 1998 a newly developed high frequency-audioprocessor (Vibrant HF) permitted the rehabilitation of high and mid-frequency hearing losses. In a pilot study we have implanted five patients (3 male, 2 female) with an average age of 60 years and long-term SNHL. Conventional hearing aids did not more yield a sufficient gain. The surgical procedure was similar to a cochlear implant operation. Postoperative PTA showed stable inner ear function. After fitting of the audioprocessor, all patient reported improved benefit, especially for hearing-in-noise. Audiological and psychometric data (A-PHAB US) will be presented. We conclude that this audioprocessor might be advisable to patients with high-frequency SNHL.

Abstract Otology 2000 B11-6

Christophe Vincent MD, PhD (1), Henri Urgell MD (1), Christine Laroche MD (1), Jean-Noël Hanson MD (1), Armand Angot MD (1), François-Michel Vaneecloo MD (2)

(1) Service d'Otologie et d'Oto-Neurol. CHRU de Lille Hôpital Salengro F-Lille Cedex
(2) Service d'Oto-Rhino-Laryngologie Hôpital Claude Huriez F-Lille Cedex

By now, we have implanted 7 patients with the Vibrant Soundbridge Device. In order to compare between this new system and conventional hearing aid, post-op audiological tests have been done on the implanted ear. These tests, performed in silence and noise, comprise vowel and consonant recognition test as well as word and sentence recognition tests. The results of these tests were compared to the possibilities of audiological correction with the Vibrant Soundbridge device and the conventional hearing aid. Preliminary results indicate that most of our Vibrant Soundbridge implanted patients are able to perform better with the Symphonix device, especially in noise.

Abstract Otology 2000 B11-7

Bernard Fraysse MD (1), Olivier Sterkers MD (2), Thierry Houliat MD (1), Oliver Deguine MD (1), Corinne Berges MD (1)

(1) Service ORL CHU Purpan F-Toulouse Cedex
(2) Service d'ORL, Hôpital Beaujon Faculté Xavier Bichat Université Paris 7 F-Clichy

The authors report their experience in patients suffering from severe sensorineural hearing loss. - First, with a group of 20 patients having less than 30 % residual hearing at 70 dB with hearing aid. This group has cochlear implant. The results on open set word recognition and sentences will be presented. Secondly, with a group of 10 patients having discrimination between 50 % and 100 % at 65 dB with hearing aid. This group has received middle ear Symphonix® implant. The authors discuss the indications of both technique.

Abstract Otology 2000 B12-1

Naoaki Yanagihara MD (1), Shingo Murakami MD (1), Naohito Hato MD (1), Nobumitu Honda MD (2)

(1) Dep. of Otolaryngology Takanoko Hospital 525-1 Takanoko-cho J-Ehime-ken
(2) Department of Otolaryngology Ehime University School of Medicine Takanoko Hospital J-Ehime

Following results of our investigations have provided a reliable evidences indicating herpes simplex viralas a causative agent of Bell's palsy. 1. Assay of serum neutralization antibody titer (NAT) to herpes simplex virus (HSV).is most sensitive and specific in detecting infection of HSV. In 41 patients with Bell's palsy of recent onset 7 (16%) showed significant changes in the NAT. Geometric mean of the NAT in all the patients was higher than that of normal control population. 2. Genomes of HSV-1, varicella zoster virus and Epstain-Barr virus in the clinical samples of endoneurial fluid and posterior auricular muscle were analyzed using polymerase chain reaction (PCR) followed by hybridization with Southern blot analysis. The samples were obtained from 14 patients with Bell's Palsy, 9 patients with Hunt's syndrome, and 12 other controls during decompression operation. HSV type I genomes were detected in 11 of 14 patients with Bell's palsy (79%) but not in patients with Hunt's syndrome and in other controls. 3. We have succeeded in producing an animal model of acute and transient facial palsy due to reactivation of HSV-1. 4. Facial grading scores in the 53 patients with Bell's palsy treated by acycrovir and predonisone treatment were compared with 385 patients treated by predonison alone. Acycrovir and predonisone therapy was superior to the conventional predonisone therapy in so far as the treatment started within 3 days at latest. The result is reasonable because acyclovir is a suppressive rather than a virucidal agent.

Abstract Otology 2000 B12-2

Nobumitu Honda MD (1), Naohito Hato MD (2), Hirotaka Takahashi MD (3), Hiroyuki Wakisaka MD (2), Shingo Murakami MD (2), Kiyofumi Gyo MD (2), Naoaki Yanagihara MD (2)

(1) Department of Otolaryngology Ehime University School of Medicine Takanoko Hospital J-Ehime
(2) Department of Otolaryngology Ehime University School of Medicine Takanoko Hospital J-Ehime
(3) ENT Department Ehime University School of Medicine J-Ehime

Bell's palsy is the most common cause of the peripheral facial nerve paralysis. Although herpes simplex virus type 1 (HSV-1) infection has been strongly suggested as a cause of Bell's palsy, details of the mechanism remains unclear. Previously, we had succeeded in producing an animal model of acute and transient facial paralysis by inoculating HSV-1 into the auricle of mice, simulating Bell's palsy. The purpose of the present experiment is to clarify the mechanism of the facial nerve paralysis by examining a trigemino-facial reflex (blink reflex) and electroneuronography (ENoG) in the above animal model followed by the histopathological study of the facial nerve. The blink reflex and ENoG were examined twice; during facial paralysis at 10th day after virus inoculation and at 17th day after virus inoculation, after complete recovery. R1 latency of the blink reflex was well corresponded to the state of facial nerve function. It was prolonged or disappeared on the paralyzed side during facial paralysis, and recovered in all animals when the paralysis diappeared. On the other hand, ENoG values were inconsistent during the paralysis and did not recover when the facial nerve paralysis recovered completely. Histopathological studies demonstrated that the nature of the nerve damage was a mixture of demyelination and axonotomesis, although demyelination was dominant. These findings suggested that the facial nerve paralysis caused by HSV-1 infection is mainly due to demyelination of the nerve, which was represented as conduction block by electrophysiological testings.

Abstract Otology 2000 B12-3

Naoaki Yanagihara MD (1), Shingo Murakami MD (1), Naohito Hato MD (1), Nobumitu Honda MD (2)

(1) Dep. of Otolaryngology Takanoko Hospital 525-1 Takanoko-cho J-Ehime-ken
(2) Department of Otolaryngology Ehime University School of Medicine Takanoko Hospital J-Ehime

From April 1976 to March 1994, we treated 1,492 patients with Bell's palsy. The grade of each patient's facial palsy was assessed using Yanagihara's Facial Score and H-B grading system. The grade of denervation was estimated with an electroneuronography and a nerve excitability test. Of the 1,492 patients, 101 (6.8%) met the following criteria and were included in this study: 1) Adult over 16 years of age. 2) The worst score of facial palsy at early examinations was less than 10/40, which was equivalent to H-B grade V or VI. 3) The degree of denervation exceeded 95%. 4) Steroid treatment, was given within a week of the onset and continued for two weeks. 5) Patients had no systemic disease affecting their prognosis. In 58 patients (Group A) transmastoid decompression from the labyrinthine segment to the stylomastoid foramen was performed while the remaining 43 (Group B) were followed up without decompression. There was a statistically significant difference in the final facial score of the two groups. The decompression operation had a therapeutic effect within 3 months of the onset of the palsy. Within the scope of this study the transmastoid decompression operation following steroid treatment is said to be a choice as a treatment of Bell's palsy. However further effort is needed to obtain definitive evidence to show the benefit of the operation because we were unable to randomize and homogenize the two groups with respect to age due to clinical and ethical consideration.

Abstract Otology 2000 B12-5

Jona Kronenberg MD, Tal Dagan MD, MA

ENT-Department Sheba Medical Center University of Tel Aviv IL-Tel Hashomer

Hypoglossal facial anastomosis (HFA) is accepted as the treatment of choice in facial paralysis in which the proximal segment of the facial nerve is absent. New central nuclear connections between the hypoglossal, trigeminal and facial nuclei were described after HFA. The neo-central integration may explain the results obtained following HFA and be demonstrated by examining the facial reflexes. We describe the results and complications in a group of 23 patients who underwent HFA in our department and were followed up over a period between one and eleven years. Facial nerve activity was grade II and III (according to House Brackmann grading) in 65% of post-operative patients. Synkinesis and mass movement were demonstrated in 48% and 52% of patients, respectively. Positive corneal reflex was found in 39%. The amount of training following HFA seems to have an effect on both the rate and quality of recovery of facial muscle activity. We describe a rehabilitation program designed in our department combining patient exercise and electro-biofeedback therapy.

Abstract Otology 2000 B12-6

Kiril Haralampiev MD (1), B. Ristic MD (1), Miodrag Dinic MD, MA (2), Bozidar Jakovljevic MD (1)

(1) ENT Department Military Medical Academy YU-Belgrad
(2) ORL Department Military Hospital / Vojna Bolnica YU-Nis

In the period from 1990 to 1994, 52 facial nerve gunshot injuries were managed. Their features (location, severity and extensivness) were correlated with nerve injuries in blunt head trauma with temporal bone fracture. In the blunt head injures, 81.1% patients were with the nerve lesion in the area of the geniculate ganglion ( labyrinthine and tympanic segments). Compression of nerve with bone fragments of fallopian canal was found in 56.8% cases, the cleft of neural sheath and intraneural hematoma were rare ( 10.8%), while the nerve tear was not found in any case. The distal part of mastoid and begining part of parotid nerv segment were injured in over 70% cases of gunshot injuries, and in 38.5% cases the injury was in more than one location. Dirct suture of the stumps without tension was performed in 8 nerve injuries, nerve grafting- in 6, and the other injuries were treated by skeletonize of fallopian canal, nerve decompression or some other microsurgical procedure. Microsurgical repair was performed 7-14 days after the injury.

Abstract Otology 2000 B12-7

Haruo Saito MD, Mitsuru Iwai MD, Masashi Hamada MD, H. Nakatani MD

ENT Department Kochi Medical Scool J-Kochi

Antidromic facial nerve response is a method for direct monitoring of the intratemporal facial nerve. Our animal experiment showed that the site of the lesion was detectable using wave-forms relative to the recording site. The wave-form is triphasic in a far proximal lesion, biphasic in a near proximal lesion, monophasic at the recording site, and flat in a distal lesion. On clinical application, big electric resistance of the skin disturbs clear recording of the far-field potential. We stimulate the facial nerve through Stensen's duct to avoid bigelectric resistance and record the response from the tympanic annulus close to the pyramidal segment. This method enables us to record clear response and to analyze progression of the facial nerve damage in the temporal bone with wave-form changes with repeated tests. We will present evaluation of the results of 65 cases tested more than twice until 7th day of the palsy. No triphasic wave has been recorded. The initial lesion starts not far from the pyramidal segment. Cases gained complete recovery kept biphasic wave-form (98%). In cases resulted in poor out-comes, the wave form changed to monophasic and flat, 8% of which kept biphasic wave until 5th day. Because the lesion approached to the recording site and intact fibers decreased in the poor out-come cases, amplitudes of the first positive phase increased and negative phase decreased. P1/N increase was the characteristic change in poor out-come cases. The antidromic facial nerve response is a good tool for make indication of decompression.

Abstract Otology 2000 B13-1

Muaaz Tarabichi MD

Section of Otolaryngology American Hospital Dubai UAE-Dubai

Direct line access to cholesteatoma is necessary in microscopic procedures and is usually provided through postauricular approach. In contrast, the wide-angle view of the endoscope allows transcanal access to the attic and antrum and transforms the advancing cholesteatoma sac into a mere extension of middle ear disease. This report describes transcanal endoscopic management and surveillance of cholesteatoma. 83 ears with acquired cholesteatoma underwent endoscopic transcanal tympanotomy and extended atticotomy to access and completely remove the sac. After removal of disease, reconstruction with composite tragal graft were performed in the majority of patients. In patients with extensive disease, access to the attic and antrum were further enlarged and the cavities were packed open. Most patients were done under local anesthesia and on an outpatient basis. 3 cases were converted into postauricular tympanomastoidectomy. There were no iatrogenic facial nerve injuries. Bone thresholds were stable, except in one patient with perilymphatic fistula. 19 ears were followed for five years with 6 ears requiring revision surgery. Endoscopic technique allows transcanal, minimally invasive, management and surveillance of cholesteatoma with long term results that compare well to postauricular methods. Continuous postoperative office based endoscopic surveillance and procedures are critical to the success of this approach.

Abstract Otology 2000 B13-2

Yasuyuki Hinohira MD, Naoaki Yanagihara MD

Department of Otolaryngology Takanoko Hospital 525-01 Takanoko-cho J-Ehime-ken

Because of its excellent magnified view on the TV screen endoscope assissted middle ear surgery is useful particularly for cholesteatoma operation to remove the matrix in the blind area under a conventional operation microscope. This video shows our surgical technique of the cholesteatoma surgery using endocscope which enables the operation less invasive and secures safe and complete removal of the matrix keeping the bony external ear canal. We use endoscopes of 0 or 30 degrees with a diameter of 1.9 mm incorporated with a 3CCD camera. Through a retroauricular incision a guide hole is created on the mastoid cortex which allows the endoscopic view of the antrum and posterior aspect of the attic and the ossicular chain. When there is no cholesteatoma beyond the aditus, a transcanal removal of the cholesteatoma matrix in the attic is possible with the aid of endoscope. When cholesteatoma extends deep into the antrum, a mastoidectomy with a posterior hypotympanotomy is made and the incus together with the head of malleus is removed. With the endoscope all the hidden area is inspected and a sheet of silastic is placed beneath the ear drum to create an aerated middle ear cavity. After about 9 months a second stage operation is performed. The endoscopic exploration to check a residual or a recurrent disease is extremely important to prevent future recurrence.

Abstract Otology 2000 B13-3

Ch. Milewski MD

Department of ENT/HNO Julius-Maximilians-Universität D-Würzburg

In cholesteatoma surgery complete removal of the disease and preservation of anatomic structures are conflicting counterparts. Mostly it is not predictable from the otoscopic aspect of the ear, how far the cholesteatoma has grown. Mainly two approaches had been advocated for eradication. In canal up technique the intact canal wall provides better hearing results and easy postoperative care, taking a higher rate of residual cholesteatoma into purchase. On the other side canal down technique may result in a discharging cavity and incomplete closure of air-bone gap in several cases. The Attico-Antrotomy, proposed by Wullstein, followes the cholesteatoma sac from inside out. Bone is as much removed from the posterior canal wall as is needed to expose the sac, starting from the posterior upper quadrant of the eardrum. After cholesteatoma removal the wall is reconstructed with cartilage, i.e. Perichonrium/cartilage-island technique (PCI). Only in cases with extended cholesteatoma a radical cavity has to be created. The surgical technique as well as anatomical and functional results with a follow up of 10 years will be presented. The Attico-Antrotomy of Wullstein together with modern cartilage reconstruction combines the security of an open approach with the advantages of the closed technique.

Abstract Otology 2000 B13-4

Yoshio Honda MD

ENT Dept Ohta General Hospital J-Kawasaki, Kanagawa

Severe tympanic membrane lateralization occurs in association with canal-up surgery, and we recommend the method below to treat it based on the results of trying a variety of different operations. 1. Removal of the existing tympanic membrane. 2. Enlargement of the external ear canal and preservation of the tympanic annulus. 3. Opening of the attic, and mastoid lowering the facial ridge. 4. Making the remnant ossicle the stapes or foot plate alone. 5. Making a flat protuberance in the attic with bone pate and using it as the bed of the new tympanum. After carrying out the above preparations, we proceed to reconstruct themiddle ear and the external ear canal. 6. Next we use fascia to create a new tympanic membrane, and make it flat by using the tympanic annulus, the bone pate ridge, and the facial ridge. Naturally, we perform ossiculoplasty at ht same time. 7. In order to prevent relateralization of the new tympanic membrane and recurrent cholesteatoma, we create a posterior wall by standing the auricular cartilage plate on the lateral aspect of the ridge of bone pate and the lateral aspect of the facial ridge and filling the back of the auricular cartilag plate with bone pate. 8. We transplant several small free grafts in the skin defect area of the external ear canal, and ensert a tampon into the canal for three weeks. The postoperative self-cleansing activity of the external ear canal is favorable, and hearing also improves. The important parts are shown in the video.

Abstract Otology 2000 B13-5

Walter Livi MD, N. Zuccarini MD, D. Limoni MD, Desiderio Passàli MD

ENT Dept University Hospital I-Siena

Stapedotomy is considered one of the best surgical procedure to treat otosclerosis because of the lowest incidence of cochlear damage. Since 1987 the Authors (A.A.) performed this technique instead of stapedectomy. Stapedotomy can be performed using both the classic and innovative changed technique "with inversion of surgical steps". This one is to be preferred to the classic for some advantages. First of all, basing on our experience, beside an excellent improvement of hearing loss, this technique allows to discharge the patient the morning after surgery because the post-surgical vertigo is very rare. In this video the A.A. present: 1)surgical highlights of stapedotomy with inversion of surgical steps (Rosen endoaural approach; tympanomeatal flap; atticotomy; stapedotomy with Shea microdrill "Skeeter" 0,6 mm; Sanna's (Steel Wire-Fluoroplastic Shaft 0,5 mm) and Causse's prostheses (Fluoroplastic piston 0,4 mm) and 2) their results basing on the evaluation of 684 patients (231 males, 453 females; age range 8-79 years) operated from January 1987 to December 1998. Considering all available prostheses, the A.A. prefer the Causse's and Sanna's because of their weight (3,2 mg and 2,4 mg respectively) and morphometric peculiarities. The post-surgical functional results were measured by analyzing the average air-bone gap at 250 Hz, 500 Hz, 1000 Hz, 2000 Hz, 4000 Hz in five different group of patients. Furthermore, performing this technique for several years they did not find early post-surgical complications as vertigo and cochlear damage. Thus the A.A. prefer stapedotomy with inversion of surgical steps because of the best results (audiological and clinical findings); this is due to the fact of place the prosthesis in a rigid system substained by the anterior branch of the stapes.

Abstract Otology 2000 B13-6

Wolfgang Draf MD, PhD, FRCS, Frauke Hilterhaus MD, Evelyn Bryson MD

Department of ENT-Diseases, Head Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda

Besides complete tumor removal and maintainance of facial nerve function preservation of hearing in general is an important goal of acoustic neuroma surgery. Early diagnosis and hearing preservation may become essential if the ipsilateral ear is the last hearing one or if as in neurofibromatosis the acoustic tumor is bilateral. The video demonstrates two exemplary cases treated successfully by the enlarged middle fossa approach.

Abstract Otology 2000 B13-7

Danko Cerenko MD, PhD, Jacques Dion MD

Department of Otolaryngology Emory University Hospital USA-Atlanta GA

Immediatelly after the incision was made while performing the right ear myringotomy in a 5 year old male, profuse bleeding occured and the ear canal was packed. Following removal of the packing the next day, intermittent oozing of blood was observed by the parents on a daily basis for almost two months. CT of temporal bones was then obtained which suggested presence of a right aberrant internal carotid artery (ICA). At our University Hospital, clinical exam demonstrated blood clots and a pulsating reddish mass filling most of the external ear canal. The angiogram confirmed presence of a pseudoaneurysm in the middle ear and external ear canal originating from an aberrant ICA. The pseudoaneurysm was immediatelly occluded with detachable platinum coils, thus eliminating imminent danger of rupture. Three days later the child passed the balloon test occlusion of the right ICA without developing clinical signs of neurological impairment, while the SPECT study was less then 10% asymmetric. When contemplating the definitive treatment, the permanent occlusion of the ICA, and surgical excision were considered. Based on excellent contralateral circulation, permanent occlusion of the right ICA below and above the pseudoaneurysm was performed, which the child tolerated without any neurological deficits. One month later the child underwent resection of the pseudoaneurysm, removal of the coils, and tympanoplasty. More then a year later, the child is experiencing normal hearing and development, and has an intact tympanic membrane.

Abstract Otology 2000 B14-1

Sofija Tudzarova Kradzinova MD, Gordana Mladenovska MD

Clinic of Oto-Rhino-Laryngology Faculty of Medicine University St. Cyrilus MAZ-Skopje

We present our result from the surgical correction of a congenital paralysis of the facial nerve in a nine-year-old child. Surgical intervention consisted of a two stage surgical intervention. In the first stage we implanted a gold bar in the upper eyelid with concomitant local suspension of the oral angle. Postoperative result revealed excellent closure of the eyelid with adequate correction of the oral angle. In the upcoming second stage we plan to correct the facial musculature with Fascia Lata. Conclusion: Surgical correction of the congenital paralysis of the facial nerve is possible even at younger age since it restores the function of the upper eyelid and mouth, thus reducing the psychological trauma in the child and at the same greatly improving the functional and esthetic function of the eye and mouth.

Abstract Otology 2000 B14-2

Marcel Cosgarea MD, E. Tomescu MD

ENT Clinic ROM-Cluj-Napoca

Facial palsy is a serious and disabling deformity, severely affecting appearance, emotional response, mastication and eye function.The present study shows 9 cases ( 3 children, 6 adults) on whom an interposition graft with the great auricular nerve was applied, nerve having the right diameter and being accessible to prelevate. The facial nerve interposition graft was carried out in the mastoidian portion, in 7 cases in the first 72 hours after trauma, in one case - three months later and in one case, twelve months later. The operation was successful in so far function and cosmetic are concerned. But on incomplete recovery of the maxillary branch, especially in its dynamics was noticed. In 3 pacients the temporal branch was also incompletely rehabilitated, so that additional rehabilitation procedures were used such as: dynamic or static slings, eyelid weights. The present study points out that the sooner the interposition graft technique is used in post-traumatic facial palsy, the more valuable the outcomes are. The great auricular nerve proved to be a suitable material for facial plastic surgery.

Abstract Otology 2000 B14-3

Militsa E. Kubatchenko MD, Alexander A. Lantsov MD

St. Petersburg State Medical Acad. RU-St. Petersburg

Steady palsy of the mimic muscles is a severe trauma, which makes the face ugly and causes hard psychic experiences in patients. Uneffectiveness of the peripheral facial palsy conservative treatment, particulary of its severe forms, was the reason for searching of the new way therapy of this disease. On our opinion the beginning stage of Bell's palsy is the most feeble link of the traditional scheme of its conservative treatment. In spite of medical remedies and methods abundance, dehydration of intratrunk oedema of the facial nerve turned out to be uneffective. That is why we suggested intraosseous method for treatment of this disease. The objective was to find highly effective and non-traumatic method. Developing of the problem was conducted in two directions: firstly experimental and secondary, clinical. The pathways of contrast mediums, tinted masses, injected by intraosseous way, have been examined in the experimental part of the study on vast cadaver's material, using of anatomical and histological techniques and making serial histotopografal cuts. It was established that through the system of osseous anastomoses the drugs, injected intraosseously, are spreading directly to the venous network of the facial nerve. Topical zone, injections in which guarantee the most effective spreading of medicine to the pathological hearth of the facial nerve in temporal bone have been established. Intraosseous infusion treatment of Bell's Palsy showed wonderful results in the extremely severe forms of this disease, both on early and late stages, when the electrical responce of the facial nerve and muscles was absent. The use of this method allows to reach complete recovery of all such patients, to avoid operative decompression of the facial nerve and to keep hearing of the patients invariable.

Abstract Otology 2000 B14-4

Hirotaka Takahashi MD, Nobumitu Honda MD, Naohito Hato MD, Hiroyuki Wakisaka MD, Shingo Murakami MD, Kiyofumi Gyo MD, Naoaki Yanagihara MD

ENT Department Ehime University School of Medicine J-Ehime

Administration of anti-viral agent such as acyclovir is supported to be effective in the treatment of Bell's palsy, since it is caused by reactivation of herpes simplex virus type 1 (HSV-1). At present, however, details of its effects concerning when and how apply remain unclear. The purpose of the present experiment is to clarify the effect of acyclovir to the facial nerve paralysis in animal model which is produced by inoculating HSV-1 in the retroauricular skin of the mouse. Facial nerve paralysis usually occurred on the 7th day after virus inoculation, continued for 7 days, and then recovered spontaneously. In this study, acyclovir was administered for 5 days from before and after the incidence of facial nerve paralysis. Control was administration of PBS. When acyclovir was administered before the incidence of paralysis occurred in 6.3% (1/16). In control, it occurred in 70%(7/10). Recovery period of facial nerve paralysis was shorter in the former than the later. Electron microscopic finding of the facial nerve will be presented.

Abstract Otology 2000 B14-5

Anita Pollak MD, Thomas Spillmann MD

ENT-Department University Hospital CH-Zürich

Dehiscences of the Fallopian canal and anomalous course are usually unsuspected findings during middle ear surgery, where they have to be detected and identified correctly in order to avoid trauma with subsequent facial paralysis. We present a case of a 72y old airport employee with moderate bilateral cochlear hearing loss due to noise trauma and presbyacusis. Audiogram and impedance tests at 66 years revealed a sensorineural hearing loss with slight conductive component and absent stapedial reflexes. The reason for the apparent middle ear component has been unclear. The histological examination of the temporal bones revealed an unexpected finding of such a facial nerve. A dehiscent canal and bulging facial nerve touching the posterior crus could be found which might have been causing the conductive hearing loss component. To our knowing, no temporal bone reports of this finding have been presented as yet.

Abstract Otology 2000 B14-6

Kei Saito MD, Michio Isono MD, Kiyotaka Murata MD

ENT Department Kinki University School of Medicine J-Osaka

In order to quantitatively evaluate facial expression movements, we analyzed with an infrared camera and a computer system several facial movements. However, these movements are not natural and do not appear in usual daily life. In the present study, we tried to establish a new evaluation standard by monitoring muscle movements around the lips while pronouncing the usual vowel sounds "a, i, u, e, o". These sounds were selected because the lip movements are close to those used in the Yanagihara's 40 points system, smiling and whistle. In order to establish a reliable system with a high reproducibility of the results, regular wave-patterns of the lip movements in healthy persons while they pronounced these sounds were examined. As a result, detected wave-patterns were almost regular. They are two peak wave-patterns. We concluded this method is applicable in the analysis of facial expression movements.

Abstract Otology 2000 B15-1

Bernard Ars MD, PhD

Consultant University Hospital Researcher University Antwerp Temporal Bone Foundation B-Bruxelles

Tympanic membrane retraction pocket as well as cholesteatoma, are both expressions of chronic middle ear disease. In case of retraction pocket, we observe a dysfunction, and in case of cholesteatoma, a bad localisation of the stratified squamous epithelium which plays a crucial role in the development of this pathology. The author evokes analyses the moment and reason for the transformation of a tympanic membrane retraction pocket into cholesteatoma. In accordance with the literature, he explains the mechanism as follows : a local additional irritation process should trigger the keratinocytes of the bottom of the bony canal, and raise the control processes which put a brake on the epithelium of the bottom of the bony canal, during his unrestrained growth forwards, into the middle ear cleft, leading to cholesteatoma.

Abstract Otology 2000 B15-2

Ch. Milewski MD, Joachim Müller MD, S.Y. Park MD

Department of ENT/HNO Julius-Maximilians-Universität D-Würzburg

After complete removal of the cholesteatoma matrix, reconstruction of the tympanic membrane and the posterior canal wall may be needed, together with repair of the ossicular chain. Following Attico-Antrotomy (Wullstein) we reconstructed the eardrum or posterior canal wall by autologeous cartilage, using a composite graft of perichorium and cartilage from the tragus. The anatomical and functional results of 174 surgical procedures, 92 radical cavities and 82 reconstructions of the posterior wall will be presented. All operation were carried out by one surgeon (senior author), the mean postoperative survey was two years.

Abstract Otology 2000 B15-3

Levent Olgun MD, Erdem Cetinkaya MD, Erdal Gül MD, Gürol Gültekin MD, Sezaver Alper MD, Türkan Bakalim MD

SSK Izmir Educational HDSP TR-Izmir

In this study, late results of functional surgery done for attic cholesteatoma were presented. Thirty cases operated on between 1992 and 1993 were evaluated in 1998. Otomicroscopy and hearing results were recorded and compared with the preoperative data. The operation was wall down surgery in 18 cases and closed surgery in 12 cases. In 22 cases any kind of ossicular reconstruction were done. Tympanic membrane was intact in 29 out of 30 cases. In that 29 cases air conduction thresholds were 7-35 dB higher than preoperative levels. Otolog incus transposition, Wehrs incus-stapes prosthesis and incus replacement prosthesis gave the best results. Both open and closed techniques were found to be safe and reliable in attic cholesteatoma cases.

Abstract Otology 2000 B15-4

Kee Hyun Park MD, Ph.D.

Department of Otolaryngology Ajou University School of Medicine ROK-Suwon

The goal of the surgery for cholesteatoma in the middle ear is to provide the patient with a dry, safe ear and good hearing. An additional goal is not only to maintain a normal ear canal contour, that is, avoiding cavity problems, but also to minimize the need for long-term care of the operated ear. There are some attic cholesteatomas in which the middle ear is aerated and free of significant disease. So attic cholesteatoma surgery is thought to be reconstructive rather than destructive and it can be a prophylactic operation. In this study, I attempted to describe prerequisites for atticoplasty for attic cholesteatoma, which is one of the reconstructive surgical procedures for the middle ear. During the last 10 years, I managed surgically about 200 cases of attic cholesteatoma, among which there were 30 cases of atticoplasty, about 30 cases of mastoid obliteration, about 30 cases of intact canal wall mastoidectomy, and about 110 cases of open cavity mastoidectomy. I analysed 30 cases of atticoplasty with special reference to period of postoperative care and hearing results, as compared to cases with mastoid obliteration and open cavity mastoidectomy. I concluded that the prerequisites for atticoplasty during surgery for attic cholesteatoma were as follows; (1)no otorrhea at the time of operation; (2)intact posterior mesotympanum in the operation field; and (3) removal of incus and malleus head during the operation.

Abstract Otology 2000 B15-5

Masafumi Sakagami MD, PhD, Mieko Sone MD, Yasuo Mishiro MD

Dept. ORL Hyogo College of Medicine J-Hyogo

The purpose of this study is to assess clinical and surgical findings of acquired bilateral cholesteatoma with special reference to habitual sniffing. Twenty-eight cases of bilateral choleateatoma were treated at the department of Hyogo College of Medicine from 1995 to 1998, which were 12.7% of all operated cholesteatomas (n=221). They were 12 males and 16 females with mean age of 43.7 years old. They consisted of 33 ears of pars flaccida type, 17 ears of pars tensa type and 6 ears of unclassified postoperated ear. Preoperative hearing level was 46.3 dB in air conduction and 23.2 dB in bone conduction, while postoperative air conduction hearing level was 49.4 dB. Habitual sniffing was observed in 19 ears of pars flaccida type (57.6%), in 6 ears of pars tensa type (37.5%). 36 ears were operated on in our department. Surgical techniques were canal wall up in 8 ears, canal reconstruction and obliteration in 21 ears and canal wall down in 8 ears. Most of the ears treated with canal wall up showed retraction of the ear drum postoperatively. The concept that closing failure of the Eustachian tube and consequent inclination to sniff habitually are closely related to the pathogenesis of middle ear diseases was first introduced by Magnusson (1978) and later by Kobayashi et al. (1991). The present study suggested that canal wall down method was recommended in patients with bilateral cholesteatoma because they had high risk of retraction of the ear drum by habitual sniffing.

Abstract Otology 2000 B16-1

Rudolf Kuhweide Dr.med., Geert Vanhooren Dr.med., Jan W. Casselman Dr.

ENT Department AZ St.Jan Hospital B-Brugge

Low-frequency sensorineural hearing loss and tinnitus have recently been recognized as a mostly temporary complication after lumbal puncture, myelography or spinal anesthesia. The presumed mechanism involves a persistent cerebrospinal fluid leak from the dural puncture site and a patent cochlear aqueduct, which transmits the intracranial hypotension to the inner ear. The lowering of the perilymphatic pressure relative to the endolymphatic pressure would induce a compensatory elevation of the endolymphatic pressure, resulting in a clinical picture of cochlear Ménière's disease. Spontaneous intracranial hypotension is a rare condition with less than a hundred cases reported, limited to the neurological literature. As gadolinium-enhanced MRI reveals a striking and initially perplexing meningeal enhancement, it is being increasingly diagnosed. The accepted pathogenic hypothesis is a minor trauma- or pressure-related cerebrospinal fluid leak from a spinal meningeal defect. It characteristically induces postural headache. Associated symptoms include postural tinnitus, vertigo and hearing loss. Treatment is empirical with emphasis on strict bed rest. In the majority the disease is self-limiting, reserving epidural blood patching or saline infusion for refractory cases. We believe the following case of spontaneous intracranial hypotension to be unique, in that it is - to the best of our knowledge - the first one reported to the otolaryngologic community, that the patient presented with ear symptoms rather than headache, and that by using her audiogram (peak-type) we can complete the neurological literature and clarify the ear symptoms by postulating a mechanism similar to the one seen in post dural puncture endolymphatic hydrops.

Abstract Otology 2000 B16-2

Gregor Bachmann Dr.med., Jiping Su Dr.med., Christoph Zumegen Dr.med., Claus Wittekind Dr.med., Olaf Michel MD

HNO-Klinik Universität D-Köln

Prednisolone is the drug of first choice for the treatment of acute cochleovestibular disorders, such as sudden hearing loss. By intravenous administration, the drug efficient levels to be achieved in inner ear fluids are limited. Aim of the study was to determine the concentration of prednisolone-21-succinate in the perilymph, which was applied on the round window membrane. Levels of prednisolone-21-succinate in perilymph of the guinea pig were measured by isocratic HPLC. Variable was the time between application to the round window and taking specimens of perilymph from the cochlea. Application of prednisolone (5 mg in 0.1 ml) to the round window membrane was performed in anesthesia under microscopic view. Specimens of perilymph were obtained after 15, 20, 80, 180, 330 and 960 min (each group 10 specimens, n=60) by dissecting the cochlea and opening the apex cochleae. The highest levels of prednisolone-21-succinate were found after 180 min 952.3 mg/l (95% confidence interval: 382.7). After 960 min the level was 18.72 mg/l (95% confidence interval: 16.9). The results demonstrate that high levels of prednisolone-21-succinate in perilymph are achievable by local application of a single dose. Therefore, a selective therapy of the inner ear using prednisolone-21-succinate is possible by application to the round window membrane.

Abstract Otology 2000 B16-3

Alexis Bozorg Grayeli MD, P. Palmer MD, Patrice Tran Ba Huy MD, J. Soudant MD, Olivier Sterkers MD, P. Lebon MD, E. Ferrary MD, PhD

INSERM U. 426 Faculté Xavier Bichat Université Paris 7 F-Clichy

The hypothesis of a persistent infection by the measles virus in otosclerosis has been postulated based on electron microscopy observations, immuno-histochemical studies, and PCR techniques. The aim of the present work was to confirm the role of the measles virus in the etiology of otosclerosis. Pathologic stapes samples were obtained from 36 patients suffering from otosclerosis. The measles virus detection was realised by: i. assessment of cytopathogenic effect during 4 weeks in cocultures of VERO (monkey kidney) cells and primary cell cultures of bone samples (n=6), ii. immunohistochemical study of these cocultures (n=3) using monoclonal antibodies against measles virus and other paramyxovirus, iii. reverse transcription and polymerase chain reaction (RT-PCR) on RNA directly obtained from fresh frozen samples (n=30) and on RNA extracted from cultures (n=2). For each sample, two different viral genomic regions coding for N protein (nucleoprotein) and M protein (matrix) were amplified by separate PCR. These amplified regions are known to be highly conserved in different acute and persistent infection strains. PCR sensitivity tests were realised on an Edmondson B laboratory strain yielding 0.1 TCID50 for the protein M and 0.01 TCID50 for the protein N. A single step PCR amplifying GAPDH, an ubiquitous enzyme, was used as positive control. Southern-blot assays were performed on PCR products to enhance sensitivity and specificity. We could not evidence the presence of the measles virus in any of our 36 stapes samples by the different methods described. Our observations do not confirm the hypothesis of persistent measles virus infection in otosclerosis. This work was supported by a research grant from Synthélabo, Meudon-la-Forêt, France.

Abstract Otology 2000 B16-4

Poul Bretlau DMSc, MD

Dept. of Oto-laryng, Head & Neck S. Univ. Hosp. Rigshospitalet DK-Copenhagen

Clinical results in 85 Argon-laser stapedotomies and 48 Erbium-YAG-laser stapedotomies are evaluated with special attention to high tone hearing loss at 4 kHz and 8 kHz. Closure of the Air-Bone gap in 20 dB was 98% resp. 90% in the two groups with a more pronounced high tone hearing loss in the Erbium-Yag-laser treated group. Sound pressure measurements at the footplate level indicate noise induced high tone hearing loss using the Erbium-YAG-laser.

Abstract Otology 2000 B16-5

Dusan R. Milisavljevic MD, Zare Rankovic Dr., Ljiljana Milisavljevic MD, PhD, Milan Stankovic MD, PhD, Zoran Dimic MD, Zoran Radovanovic MD

University Clinic of ENT YU-Nis

Hearing loss is one of the serious complications of bacterial meningitis. The bacterial organisms most commonly associated with generalized meningitis having a sensorineural hearing loss sequela are Streptococcus pneumonia, Haemophilus influenzae, Streptococcus pyogenes, in most cases sensory neural hearing loss is bilateral and severe to profound. The audiometry and tympanometry were used to detect this complication in fifteen patients who recovered from meningitis treated at the Clinic for infectious diseases and Otolaryngology Clinic Nis in the last year. Out of 15 patients 6 were infected by Pneumococcal, 4 with H. Influenzae, 2 with Listeria and 3 with Meningecoccal. There was a high incidence of Streptococcus and H. Influenza meningitis which resulted in high incidence of hearing impairment. The degree of hearing loss was varied from mild to profound. Out of 15 patients six patients had mild hearing loss (25 to 40dB), 4 had moderate (40 to 55 dB), 2 moderately-severe (55 to 70 dB) and 3 very severe hearing loss (70 to 100 dB). The nature of antibiotic therapy, duration of illness, age and sex of patients were not significant risk factors in the development of hearing loss. The site of disease resulting in hearing loss cannot be stated with certainty, but the involvement of the inner ear or auditory nerve was suspected. Early hearing loss in purulent meningitis does not always constitute an irreversible lesion. Bacterial meningitis is the single most important cause of acquired sensorineural hearing loss in patients and every attempt should be made to assess the patients hearing as soon after their recovery possible.

Abstract Otology 2000 B17-1

Pavel Dulguerov MD, Desheng Wang MD, Thomas V. Perneger MD, Willy Lehmann MD

Division of Head & Neck Surgery Geneva University Hospital CH-Geneva

Objective: In the process of developing a simple and objective measure of facial neuromuscular function, to: 1) determine the best measures for five basic facial movements in normal patients, 2) correlate these measurements with the House-Brackmann grades (HB) in patients with various degrees of facial paralysis. Methods: Eleven facial landmarks were placed on the face and five movements (forehead lift, eye closure, nose wrinkling, lip puckering, and smiling) with maximal contraction force were requested. No specific immobilization of the head was done. The videoframes with maximal movement digitized and measurements performed with the Osiris public domain image analysis software (www.expasy.ch). For each measure the change from rest was computed. Inter- and intrasubject variability were determined through a multivariate ANOVA analysis and correlation with HB was assessed with the Pearson correlation coefficient. Results: In all movements, surfaces changes were higher than distance changes. For forehead lifting and eye closure the best measure was the "eye surface" changes (area F-Na-Io) with 12 ( 9 % and -31 ( 8 % respectively. For nasal wrinkling, lip puckering, and smiling the best measures were the paranasal area (area Na-Io-A, change: -28 ( 14 %), upper lip area (area A-Ls-M, change -23 ( 8 %), and mouth area (area Ls-Li-M, change 63 ( 21 %), respectively. Distance changes were all below 10%. Same day repeatability was below 15% and day-to-day repeatability was below 7%. In normal subjects >80% of the total variation was accounted for by the intersubject variability. An excellent correlation with HB was found ((:0.5-0.8; p<0.001). Conclusion: Videomimicography is a simple and objective linear measurement system based on facial surface changes. The measures exhibit good reliability and an excellent correlation with HB grades.

Abstract Otology 2000 B17-2

Sandro Stöckli MD (1), Henning Scriba Ph.D. (2), Claudia Dornier MD (1), Anita Pollak MD (1), Thomas Linder MD (1), Ugo Fisch MD (1)

(1) ENT Department University Hospital CH-Zürich
(2) Department of Maxillofacial Surgery University of Zurich CH-Zürich

The aim of this study was to determine the normative data in healthy subjects as well as in patients with unilateral complete facial palsy using the computer-assisted system for objective scaling of facial nerve function based on area analysis (OSCAR). The luminance in the three facial areas forehead, eye and mouth was measured digitally during wrinkling of the forehead, forced eye closure, maximal smiling and subtracted from the image at rest. The percentage of change in luminance of the "weaker" versus the "better" facial side correlates with the degree of motion and gives a Regional Symmetry Index (RSI) for each facial area separately. For clinical evaluation a Global Symmetry Index (GSI) representing the facial symmetry in one number was determined. In 20 healthy subjects the mean RSI for the three regions of interest were: forehead 91% (SD 6%; range 80-99%); eyes 93% (SD 5%; range 82-100%) and mouth 91% (SD 5%; range 79-98%), respectively. The mean GSI was 92% (SD 3%; range 88-96%). The mean RSI of 19 paralytic faces were: forehead 6% (SD 6%; range 0-22%); eyes 33% (SD 10%; range 19-56%) and mouth 4% (SD 4%; range 0-14%), respectively. The mean GSI was 16% (SD 4%: range 9-25%). These results suggest that normal facial motor function includes a mean physiologic asymmetry of 7 to 9%. In the clinically paralytic faces motion was measured during eye closure, which is attributed to passive lid closure after relaxation of the levator muscle. By excluding this motion from the analysis the GSI drops to 3.4% (SD 4%; range 0.1-13%). Using the computerized OSCAR-method we were able to measure even small physiologic asymmetries and to determine normative values for complete paralysis.

Abstract Otology 2000 B17-3

Christopher Linstrom MD, Carol A. Silverman PhD, William M. Susman PhD, Clodualdo Orquiza III MD, Douglas Colson B.S., Tina M. Presutti B.S.

Otolaryngology New York Eye and Ear Infirmary USA-New York, NY

Outcome studies on the diverse medical and surgical treatments for facial paresis and paralysis are notably lacking. The primary obstacle has been the absence of objective, reliable, and sensitive measures of the spatial and temporal aspects of facial motion at specified facial landmarks. The purpose of this study was to objectively assess facial motion, using a commercially available motion analysis system, in persons with facial dysfunction. Subjects comprised five patients with various facial disorders and two normal adults. Two of the five subjects with facial dysfunction were evaluated following facial-nerve decompression, facial-nerve reconstruction, and/or facial re-animation. Facial motion at various facial marker locations at rest and during facial expressions was assessed with a motion analysis system, which uses video and computer motion-measurement technology. The motion-analysis software automatically computed the marker motion over time. Time plots, based on the average of five repetitions of each expression, were obtained for marker displacements, velocities, and accelerations. The time plots identified and quantified one or more of the following in all of the pathologic subjects: (a) lagophthalmos and incomplete eye closure despite the subjective impression of eye closure; (b) asymmetry at rest; (c) asymmetry during facial motion but not at rest; (d) synkinesis. Lagophthalmos was revealed through the asymmetric slopes of the displacement, velocity, and acceleration time plots during the contraction phase of eye closure. These results suggest the potential feasibility of this objective approach to evaluate the efficacy of facial reconstruction and re-animation and to quantify the natural history of various facial disorders.

Abstract Otology 2000 B17-4

Kiyotaka Murata MD, Michio Isono MD, Kei Saito MD, Hiroaki Miyashita MD

ENT Department Kinki University School of Medicine J-Osaka

An objective and quantitative evaluation system must be developed to estimate synkinesis following facial nerve palsy. We developed our system using computer analysis and rating scores. The computer system included a video and infrared cameras. Markers were placed on the face. Their movements were recorded in a computer. After image processing, movements of the markers were quantitatively expressed for analysis. Using an infrared camera, the velocity of each point could be evaluated. The triangle areas made by 3 markers were measured. In a normal face, involuntary movement of the supralabial area was detected during eye closure. This area at that time became significantly smaller, while it became larger when making wrinkles on the forehead. The trajectory length of a marker was calculated . The trajectory of a supralabial marker was significantly longer in postparalytic synkinesis than in normal physiological motions. Relationship between movement of the supralabial marker during contraction of eyes and that of the palpebra marker was analyzed in mild and severe abnormal synkinetic motions. Velocity, synchronization of the movement and strength of motion between them were analyzed. The severity of synkinesis was rated using a 3-point scale ranging from 0 to 2. Velocity of the supralabial marker increasesd with an increased score. Multivariate analysis revealed that the palsy scores 2 weeks and 2 months after palsy onset were the most important predictive factors of the synkinesis.

Abstract Otology 2000 B17-5

Henning Scriba Ph.D. (1), Verena Meier-Gallati MD (2), Anita Pollak MD (2)

(1) Department of Maxillofacial Surgery University of Zurich CH-Zürich
(2) ENT Department University Hospital CH-Zürich

Using the OSCAR method (Objective scaling of facial nerve function based on area analysis) a new percentile scaling system is presented which allows to measure facial synkinesis in an objective and quantitative way. In a pilot study the movement in the mouth region of 10 patients showing partial facial palsy with synkinesis has been analyzed. By comparing synkinesis with the possible active movement a percent scale can be defined. As it is difficult to distinguish between involuntary and voluntary components, the maximal and the probable degree of synkinesis have been measured, showing values of up to 103% and 84%, respectively.

Abstract Otology 2000 B18-1

Yukihiko Kanda MD, Kouichi Motokawa MD, Toshimitsu Kobayashi MD, PhD

Department of Otolaryngology Nagasaki Univ. School of Medicine J-Nagasaki

Tinnitus is one of the most annoying symptoms affecting patients with ear problems. To date, however, there has been no curative therapy against this symptom. Using a new method developed by the first author, Kanda, a way has been found to fade out this tinnitus. Twenty patients suffering from severe tinnitus accompanied by sensori-neural hearing loss were investigated as to the effectiveness of this method. A non-linear hearing aid or a digital hearing aid was used as a tinnitus masker. All the patients were examined as to the threshold, uncomfortable level (UCL), the most comfortable level (MCL), and pitch and loudness match scaling in the sound pressure level (SPL) audiogram. [Results] In this study, 19 of 20 (95%) patients reported that their tinnitus disappeared completely, and 1 reported as considerable decrease of the tinnitus. Background noise is said to range from about 40 dB to 50 dB even in a silent home environment. It is speculated that the patient's tinnitus faded out because this silent background noise is non-linearly amplified in the pitch match frequency with tinnitus. This new Non-Linear Masking Therapy (Kanda's Method) appears to be a useful and promising treatment for tinnitus.

Abstract Otology 2000 B18-2

David W. White MD

Eastern Oklahoma Hearing and Balance Center USA-Tulsa OK

Encephaloceles of the temporal bone can occur spontaneously, be the result of trauma or infection or be caused by iatrogenic trauma to the tegmen. A technique to repair temporal bone encephaloceles has be used with good success. The technique involves harvesting bone from the superior edge of the bone flap removed during the middle fossa craniotomy. This bone has been found to have a curved shape similar to the floor of the middle fossa. This similarity in shape facilitates the placement of the bone over the tegmen defect. The technique will be discussed. Long term follow up using high resolution CT scanning will be presented.

Abstract Otology 2000 B18-3

Antje Aschendorff MD, Nikolaos Marangos MD, Roland Laszig MD

Universitäts-HNO-Klinik D-Freiburg

Dilatation of the lateral end of the internal auditory canal with missing bony separation to the basal turn of the cochlea and atypical route of the intrameatal and tympanic part of the fallopian canal is known as X-linked deafness. This malformation is associated with progressive mixed hearing loss or deafness. Attempts of stapes surgery always result in profound CSF-gusher and complete loss of labyrinth function. In these cases cochlear implant surgery was considered as contraindicated as the electrode array may be accidentally inserted into the internal auditory meatus resulting in CSF-fistula or meningitis. We report our experience and first results in using a new custom-made CI24M with curly electrodes. The specific feature of this new device is a short precurved electrode carrier that prevents insertion into the internal auditory canal. In spite of other preformed electrodes the thickness is similar to the standard electrode of Nucleus CI24M. It can be inserted via a small cochleostomy that can be sealed by the electrode array and some tissue. This is important to minimize the risk of CSF leakage and/or meningitis. Patients with this kind of malformation now have a chance of auditory rehabilitation using the cochlear implant.

Abstract Otology 2000 B18-4

R. Behr PD Dr., Joachim Müller MD, Wafaa E. Shehata-Dieler MD, PhD, Jan Helms MD, K. Roosen Dr.med.

Department of Neurosurgery University of Wuerzburg D-Würzburg

Objective: Despite progress in diagnosis and therapy of neurofibromatosis 2, deafness is still one major complication. If the cochlear nerve is destroyed, restoration of hearing can only be achieved by direct stimulation of the cochlear nucleus. Methods: After tumor resection, in cooperation of neuro- and ENT-surgeons and stimulation of the cochlear nucleus, the ABI was implanted in 7 cases. Postoperatively, the electronic fitting of the device was accomplished. Results: There were no complications directly related to implantation. In 2 patients a CSF leak occured, one of them required a vp-shunt due to aresorptive hydrocephalus. In 2 patients minor side effects of stimulation happend. The responsible electrods were switched off. Out of 12 available electrodes 5-8 were choosen for auditory stimulation. All patients fitted so far had tonotopy, sound perception, -discrimination and speech perception. Lipreading (LR) was facilitated, in 1 patient from 19% to 57%, in an other from 43% to 71%. One patient had a 82% recognition of Freiburg Numbers (FN) without LR, an other 65% FN (no LR) and a 71% open set sentence recognition (LR + ABI). Tinnitus was markedly masked by the ABI. MRI investigations are possible with imlanted device. Conclusion: The CIS-ABI is promissing for the feasibility of hearing rehabilitation in deaf NF-2 patients. Combined with a tumor resection, the implantation is a safe procedure.

Abstract Otology 2000 B18-5

Olivier Sterkers MD, Bernard Fraysse MD, D. Bouccara MD, E. Ambert MD, Jean Marc Sterkers MD, M. Kalamarides MD

Service d'ORL, Hôpital Beaujon Faculté Xavier Bichat Université Paris 7 F-Clichy

The aim of this study is to evaluate the results of Auditory Brainstem Implantation (ABI) in 8 cases with several different conditions before implantation. Seven cases were Neurofibromatosis type 2 (NF2) patients: three cases were surgically treated for bilateral acoustic neuroma and implantation was performed several years after tumors removal; in four cases the ABI was performed during the second acoustic tumor removal, three of them being treated previously by irradiation. The last patient presented post meningitis, the placement of the 21 electrodes on the cochlear Nucleus through the lateral recess of the fourth ventricle was guided by the intraoperative monitoring of electrically evalued brainstem response. The intra operative monitoring of electrically evoked brainstem response helped to the localisation of these nucleus. Post operative activation of the electrodes permitted to use 4 to 21 electrodes without indesirable effect. Long term results show benefits in five cases, with capacity to phone in two cases. In one case the benefit which was first limited now decreases and there are no auditory response without indesirable effect. The last case is too recent to be evaluated. These results show the benefit of ABI during NF2 and even in other indications when cochlear implant seems to be hazardous.

Abstract Otology 2000 B19-1

James R. Cullen MD

Department of Otolaryngology Altnagelvin Area Hospital GB-Londonderry

Idiopathic sudden sensorineural hearing loss (ISSHL) is a perplexing entity of unknown origin. Two widely proposed theories are that it is either a vascular accident akin to myocardial infarction or, that it isthe result of a viral infection. Herpes Simplex Virus type 1 (HSV1) has been suggested as a possible cause of ISSHL. This experiment attempted to produce an animal model of ISSHL. HSV1 was injected into the scala media of a test group of adult guinea pigs. Viral suspension medium only was injected into a control group. The test group were noted to have a statistically significant (p< 0.001) hearing loss at 24 hours compared with the control group. The animals were followed audiologically and histologically over a 2 week period. The hearing loss was measured and the cochlae examined at 1, 2, 4, 7 and 14 days. In a second arm of the experiment 4 groups of 10 animals each were randomly allocated to treatment with dexamethasone and acyclovir given immediately at the time of the HSV1 injection and after 24 hours. These animals had their hearing and histology checked at the same intervals as the untreated group above. Histology showed an intense inflammatory reaction in the basal turn of the scala media at 24 hours. Over the subsequent days this reaction spread to the apex of the cochlea and was noted to affect the scala vestibuli as well. An intense fibrinous exudate was seen within the cochlea which became organised and replaced by fibrous tissue from day 7. New bone formation was noted in the scala tympani beneath the basilar membrane and within the vestibule. Concentric fibrosis was also noted obliterating some scalae. Treatment with dexamethasone and acyclovir either immediately or delayed did not produce any improvement in the histological outcome.

Abstract Otology 2000 B19-2

Hamad Al Muhaimeed Prof., Siraj M. Zakzouk Prof.

Department of ORL King Abdul Aziz Univ. Hospital SA-Riyadh

A survey to identify the aetiology of hearing impairment among Saudi children was carried out. Children were divided into two groups according to presence or absence of laboratory evidence of herpes simplex virus infection 'at risk' and 'at not risk'. Serological tests for herpes simplex virus infection were performed on 1054 children. We found positive IgM antibody against herpes simplex virus, type 1 (HSV1) in the blood of 82 of the 1054 children (8 percent), and positive IgM antibody against herpes simplex virus type 2 (HSV2) in eight of hte 1054 children (0.8 percent) ages ranged between 12 months and 14 years). Forty-six of the eighty-two infected children (56 percent) with HSV1 were found to have a sensoneural hearing loss (16 of 26 children from the 'at risk' group and 30 of 56 from the 'not at risk' group). Only one case of the eight infected children with HSV2 was found to have bilateral sensoneural hearing loss of moderate degree. This case was in the 'not at risk' group. Hearing impairment was bilateral in all 46 cases, profound in seven, moderate to severe in 23 and mild in 16. Known causes of hearing impairment were excluded together with hearing impairment due to multiple TORCH agents. The high prevalence of hearing impairment among children due to herpes simplex virus infection is described.

Abstract Otology 2000 B19-3

Marina Cakar MD, Elena Bogeska MD, V. Ivanovska MD, Lidija Dubrovska MD

Clinic of Otolaryngology Medical Faculty Chef Department of Audiology MAZ-Skopje

The primary purpose of this study was to investigate the potential role of transient evoked otoacoustic emissions (TEOAEs) for screening impairment and middle ear disorders in school children. Thirty children (ages 5-10 years) participated. TEOAEs pure- tone hearing screening, acoustic immitance (single and multi-frequency tympanometry) and an otoscopic examination were done on each child. Correlations between TEOAEs veriables and immitance measures of middle ear were done. The results sugest that TEOAEs test has potential to be incorporated succesfully into hearing screening program for school children.

Abstract Otology 2000 B19-4

Enis Alpin Güneri MD, Bülent Serbetçioglu MD, Ahmet Ömer Ikiz MD, Ataman Güneri MD, Kerim Ceryan MD

Department of Otolaryngology Head and Neck Surgery Dokuz Eylul University TR-Izmir

One of the most serious side effects of Cisplatin (CP) treatment is ototoxicity. The primary target affected by CP ototoxicity is the outer hair cell population whose involvement leads to a disturbance in the mechanoelectrical transduction of sound. In this article, CP induced ototoxicity and the effects of Vitamine B treatment on ototoxicity in guinea pigs was evaluated using Transient Evoked Otoacoustic Emission technique. Our results showed that, Vitamine B preparation injections for 7 days in addition to a single large dose of CP resulted in significantly better TEOAE responses than that obtained after only CP injections (p < 0.01). Based on the results of this study, we think that further clinical investigations are needed to evaluate the preventive effect of Vitamine B preparation injections against CP induced ototoxicity.

Abstract Otology 2000 B19-5

Euan Murugasu MD

California Ear Institute atStanford Dr. Joseph Roberson USA-Palo Alto, CA

The self-mixing effect of a laser diode was used to measure frequency tuning of basilar membrane (BM) displacements in the 15 kHz region of the guinea pig cochlea whilst perfusing the scala tympani with either artificial perilymph or millimolar salicylate solutions. Following perfusion with either 2.5 or 5 mM sodium salicylate, the tips of the tuning curves became reversibly desensitized by up to 45 dB SPL, the best frequency of the tip shifted to lower frequencies by about 2 kHz, the tip became broader, and the tail of the tuning curve became sensitized by about 10 dB. These changes could be explained if salicylate caused a reduction in feedback from the outer hair cells (OHCs). An increase in the compliance of the cochlear partition, by reducing the turgidity of the OHCs, would also cause a desensitization of the tip and a shift to lower frequencies with sensitization of the tail of the tuning curve. From simultaneous measurements made at the round window at frequencies between 1 and 25 kHz, it was concluded that cochlear microphonics and the compound action potential were poor indicators of the action of salicylate on BM displacement and that salicylate probably had an additional action on the response properties of the auditory nerve. Also, the finding that salicylate-induced changes in the mechanical repsonses of the BM could recover before cochlear microphonics was taken to indicate that the OHCs may be continuously adjusting their operating conditions to optimize the sensitivity and frequency selectivity of the cochlea.

Abstract Otology 2000 B19-6

Elena Bogeska MD, Marina Cakar MD, V. Ivanovska MD, Lidija Dubrovska MD

ENT Department University Hospital MAZ-Skopje

The aim of this study was to compare TEOAEs of subjects having same auditory thresholds but different age ranges. It is well known that elevated hearing thresholds are common with increased age because of the deterioration of outer hair cells. It has also been reported that TEOAEs decrease with increased age. We divided the examined patients in two groups depending on their hearing threshold. The age of these two groups was 40-60 years. The control group of adults between 19 and 39 years was divided in the same way. Our results showed that there is not significant reduce of TEOAEs corresponding with age. Other factors such as presence of hearing loss have more influence on TEOAES than the factor of age.

Abstract Otology 2000 B19-7

Iwao Ohtani MD, Yohko Baba MD, Chiaki Suzuki MD

ENT Department Fukushima Medical University J-Fukushima

Wegener's granulomatosis is assigned to a systemic autoimmune disease that consists of three principal lesions: necrotizing granulomatous lesions of the airway, generalized focal necrotizing vasculitis, and necrotizing glomerulitis. In Wegener's granulamatosis the ear is frequently affected, and many published studies describe clinical findings in this disease. However, there have been only a few reports of histopathologic findings in temporal bones on Wegener's granulomatosis. The objective of this study is to describe the temporal bone pathology of two cases of Wegener's granulomatosis in which the initial symptoms were profound hearing loss and facial nerve palsy respectively. The first case, a woman of 44, suffered profound sensorineural hearing loss which was remarkably improved by steroid and cyclophosphamide treatment for a time, and which seemed to be caused by invasion from granulation tissue filled in the tympanic cavity. The second case was a 61-year-old woman presenting with the facial nerve palsy. The bony canal of the horizontal portion of the facial nerve was destroyed due to granulation tissue which filled in the tympanic cavity, and granulomatous involvement was observed in the facial nerve. Pathogenesis of the facial nerve palsy seemed to be related to granulomatous involvement of the facial nerve, because the palsy resolved completely by steroid and cyclophosphamide treatment.

Abstract Otology 2000 B19-8

Franziska M. Häfner MD (1), Thomas Linder MD (1), A.A. Salam MD (2), D. Balmer MD (2), A. Baumer MD (2), A. Schinzel MD (3), Thomas Spillmann MD (1), Suzanne M. Leal Ph.D. (2)

(1) ENT Department University Hospital CH-Zürich
(2) The Rockefeller University USA-New York, NY
(3) Institute of Medical Genetics University of Zürich CH-Zürich

A novel locus for non-syndromic hearing loss has been identified in a Swiss German kindred with congenital bilateral autosomal dominant sensorineural hearing loss. This kindred has a history of hearing loss that dates back to the middle of the 19th Century. Audiometric and DNA samples were obtained on a total of 56 pedigree members. Thirty family members were considered to be affected and 26 unaffected. Affected family members audiograms displayed a mild to profound hearing loss, mainly in the frequencies between 0.5 kHz and 4kHz. The affected members all had sloping audiograms affecting mainly the mid to high frequencies. Hearing impaired individuals with severe to profound hearing loss in the high frequencies also had moderate hearing loss in the mid and low frequencies. The hearing loss appears to be non-progressive with no correlation between severity of hearing loss and current age. No evidence for acquired risk factors predisposing to hearing loss was observed for any affected family members. A total of 387 polymorphic markers have been genotyped across 23 chromosomes. These markers are spaced approximately 10 cM apart. Two point linkage analysis using MLINK of the FASTLINK package was carried out. A maximum two-point lod score of 4.9 was obtained to a marker on 4q. An additional multipoint analysis was done, including flanking markers using LINKMAP of the FASTLINK package. The analysis was carried out using both equal allele frequencies and allele frequencies that were estimated from the founders of this pedigree as well as from additional Swiss German pedigrees. A multipoint maximum lod score of 6.7 was obtained when equal allele frequencies were used and 6.1 when estimated allele frequencies were used. Additional markers within the region of this locus have been selected from the Marshfield marker maps and are currently being genotyped in order to further refine the location of this locus. The next step in this study will be to isolate the gene which is responsible for DFNA24. This work was supported by the NHLBI Mammalian genotyping service, NIH grant DC03594 and the American Hearing Research Foundation.

Abstract Otology 2000 B21-1

Stephan Schmid MD (1), Bruce J. Gantz MD (2), Klaus Jahnke MD (3), Tristram H.J. Lesser MD (4)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Dept.Otolaryngology,Head and Neck Univ. of Iowa Hospitals USA-Iowa City, Iowa
(3) HNO-Klinik Univ. Essen D-Essen
(4) ENT University Hospital Aintree GB-Liverpool

The indications and results of canal-wall-down surgery will be discussed in the Round Table B3 discussion. This instructional course will focus on how to perform an open cavity to achieve a dry and safe ear. Three well-known surgeons will show their techniques and highlight the important steps of mastoid surgery.

Abstract Otology 2000 B22-1

Ugo Fisch MD (1), Emilio Garcia-Ibanez Dr. (2), Mislav Gjuric MD (3), Thomas Linder MD (4), William H. Slattery MD (5)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Ins. Otologia Garcia-Ibanez E-Barcelona
(3) Univ. HNO Klinik D-Erlangen
(4) ORL-Klinik Universitätsspital CH-Zürich
(5) House Ear Clinic USA-Los Angeles, CA

In 1961, a novel superolateral technique for exposure of the internal auditory canal, the middle cranial fossa approach, was introduced by William House. Various centers have modified his technique. These modifications range from the transtemporal-supralabyrinthine approach to the extended middle fossa approach. Distinguished surgeons from four different skull base centers will show their techniques and emphasise anatomical landmarks, tips and pitfalls of this approach. This instructional course will take place at the Anatomy Department (follow the signs). Only a limited number of participants can be accepted on a first come basis.

Abstract Otology 2000 B23-1

Jacques Magnan Prof.Dr.med. (1), Gerald M. O'Donoghue M.Ch FRCS (2), Christian Dubreuil MD (3)

(1) Dept. ORL Hôpital Nord F-Marseille Cedex 20
(2) ENT Department University Hospital Queen's Medical Centre GB-Nottingham
(3) ENT Chirurgie Cervicofaciale Centre Hôpital Lyon-Sud F-Pierre Benite Cedex

The introduction of the microscope has considerably improved the microsurgical techniques in otology and skull base surgery. The endoscopes have minimized the surgical approach and allow a close-up view of neurovascular structures. How and when to use the endoscopes will be shown and discussed by experts in this field.

Abstract Otology 2000 B24-1

Roland Laszig MD (1), Jan Helms MD (2), Richard Ramsden MD (3), W.-P. Sollmann MD (4), Jean Marc Sterkers MD (5), François-Michel Vaneecloo MD (6)

(1) HNO-Klinik und Poliklinik Albert-Ludwigs-Universität Freiburg D-Freiburg/Br.
(2) HNO-Klinik Julius-Maximilians-Universität D-Würzburg
(3) Anson Medical Centre GB-Manchester
(4) Department of Neurosurgery Klinikum Braunschweig D-Braunschweig
(5) Service d'ORL, Hôpital Beaujon Faculté Xavier Bichat Université Paris 7 F-Clichy
(6) Service d'Oto-Rhino-Laryngologie Hôpital Claude Huriez F-Lille Cedex

This instructional course will present one special part/structure of the brain, the Nucleus Cochlearis and discuss the options to approach for the placement of an Auditory Brainstem Implant. The faculty members will present their special surgical techniques for both the Nucleus and the MedEl ABI system.

Abstract Otology 2000 C01-1

Ugo Fisch MD

ORL-Klinik Universitätsspital CH-Zürich

Skull Base Surgery is essentially temporal bone surgery and was already practised by ENT surgeons in the beginning of the century. The microsocpe, the subtotal petrosectomy with obliteration of the middle ear cleft and the preservation - whenever possible - of an intact dura mater made it possible to safely remove through a system of intratemporal fossa approaches skull base lesions previously considered inoperable. A profound knowledge of anatomy, good operative skills and sufficient expertise in otologic microsurgery are the base for successful lateral skull base surgery. Temporal bone surgery is mainly an otologic exercise. Therefore, lateral skull base surgery will remain anchored in our specialty in the future but should concentrate in centers having the work load necessary to optimize proficiency training. Controversies on how much function should be sacrificed for a safe tumor removal will continue. However, evidence based on sound clinical judgement will hopefully help to avoid diasters produced by enthusiastic strives for the absolute.

Abstract Otology 2000 C02-1

Richard Ramsden MD (1), Paul A. Fagan FRCS FRACS (2), Ugo Fisch MD (3), Mislav Gjuric MD (4), Antonio Mazzoni MD (5), Anton Valavanis MD (6)

(1) Anson Medical Centre GB-Manchester
(2) St. Vincent's Hospital AUS-Darlinghurst/Sydney NSW
(3) ORL-Klinik Universitätsspital CH-Zürich
(4) Univ. HNO Klinik D-Erlangen
(5) Divisione ORL Ospedale Riuniti I-Bergamo
(6) Neuroradiologie Univ.-Spital CH-Zürich

In this panel different interesting cases with a temporal paraganglioma will be presented. The experts are asked to discuss these cases and to point out all the important questions for the optimal treatment of this callanging pathology in the temporal bone.

Abstract Otology 2000 C03-1

Heinz Stammberger MD, Friedrich Bootz MD, Marco D. Caversaccio MD, Michael Gleeson MD, Ralf Heermann MD, Salim Khan , Daniel Simmen MD

Med. Fak., HNO-Klinik Karl-Franzens-Universität A-Graz

This panel is designed to focus on the achievements and future developments with different technical devices to navigate or control the surgical field during surgery. Microscopic and endoscopic approaches are discussed as well as special indications for navigated surgical procedures and surgical interventions in the open MRI. A moderated discussion will summarize the current opinion and highlight some aspects for the near future.

Abstract Otology 2000 C04-1

Stephan Schmid MD (1), Wolfgang Draf MD, PhD, FRCS (2), Paul A. Fagan FRCS FRACS (3), Antonio Mazzoni MD (4), Pierre Rabischong Prof.Dr.med. (5), Richard Ramsden MD (6)

(1) ORL-Klinik Universitätsspital CH-Zürich
(2) Department of ENT-Diseases, Head Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda
(3) St. Vincent's Hospital AUS-Darlinghurst/Sydney NSW
(4) Divisione ORL Ospedale Riuniti I-Bergamo
(5) Centre Propara Parc Euromédecine 263 rue du Caducée F-Montpellier Cedex 5
(6) Anson Medical Centre GB-Manchester

Malignant tumors are not very frequent in the temporal bone. The symptoms are usually not typical and therefore we are likely to diagnose the cancer in an advanced stage. The classical treatment is surgery combined with postoperative radiotherapy. Because of the close neigherbourhood to other important structures such as the facial nerv, the internal carotid artery, and the dura with the brain the surgical removal of the tumor is challenging. Every panelist will present one case of malignant tumor in the temporal bone. There will be an interactive discussion with the other panelists about the decision making process. Then the important diagnostic and therapeutic steps will be discussed to give the audience an up date of the treatment of these difficult problems.

Abstract Otology 2000 C05-1

Bernard Fraysse MD (1), Heidi Felix Ph.D. (2), Wolfgang Gstöttner MD (3), Spyridon Kollias MD (4), Arvind Kumar MD (5), Thomas P. Nikolopoulos MD, PhD (6), Francis Veillon MD (7)

(1) Service ORL CHU Purpan F-Toulouse Cedex
(2) ORL-Klinik Universitätsspital CH-Zürich
(3) ENT Department University of Vienna A-Wien
(4) Neuroradiologie Universitätsspital CH-Zürich
(5) Department of Otolaryngology University of Illinois at Chicago USA-Chicago IL
(6) E.N.T Department Nottingham University Hospital GB-Nottingham
(7) Radiology I Hopital Hautepierre F-Strasbourg

This panel will cover the following topics: Correlation of morphology and anatomy of the normal imaging of the inner ear (H. Felix and S. Kollias). Interest of inner ear imaging in the evaluation of neurosensorial hearing loss in children (W. Gstöttner). Abnormal footplate and sensorineural hearing loss (F. Veillon). Diagnosis of an abnormal enhancement of the inner ear (E. Valvassori). Malformation of the inner ear and cochleovestibular dysplasia. How to evaluate? (T. Nikolopoulos).

Abstract Otology 2000 C10-1

Thomas Lenarz MD

HNO-Klinik Medizinische Hochschule Hannover D-Hannover

Apart from the development of new speech coding strategies improvements in cochlear implant systems can be achieved by new electrode concepts which provide more focused electrical stimulation at a low level of stimulus intensity. This allows an increase of the number of independent channels and electrode contacts in the cochlea, which is a prerequisite to imitate more physiological stimulation of remnant auditory nerve fibres. Several proposals have been put forward to achieve this goal. The common principle focuses on modiolus proximity and smaller contacts close to the nerve fibres. Different designs of modiolus-hugging electrodes were evaluated step by step with temporal bone studies, acute and chronic animal experiments, intraoperative measurements and clinical studies to evaluate their effectivity and safety. Electrode locations close to the modiolus result in decreased stimulus levels and power consumption and better channel separation. More patients can use simultaneous stimulation strategies, which offer new speech coding potentials. However, not all designs proved to have the level of safety required for chronic human use. Wires or strips pressed to the lateral wall and forcing the tip of the electrode towards the apex result in considerable destructin of the basilar membrane and induce cochlear obliteration. Electrodes with up to 50 contacts have been developed. They allow for tripolar, quadrupolar and jitter stimulation for pseudorandomized discharge patterns of the auditory nerve fibres to imitate the natural excitation process by acoustic stimulation. The progress in electrode development will lead to better performance in implanted patients.

Abstract Otology 2000 C10-2

Caglar Batman MD, Selcuk Inanlý MD, Alper Tutkun MD, Mehmet Ali Pehitoglu MD

ENT Department Marmara University Hospital KBB Klinigi TR-Marmara-Altunizade

Intracochlear electrode placement in cochlear implant surgery is performed to maximize the chance of stimulating auditory nerve fibres as well as spiral ganglion cells. There are various electrode insertion length of the Nucleus electrode with different approaches. It is needed to insert more length about 30 mm to reach middle and appical cochlear turns. Electrode placement in these cochlear regions would improve the probability of stimulating surviving nerve fibers and provide a better correlation to cochlear tonotopy. In our study a surgical technique is presented in the last 20 patients out of our total 52, which demonstrated the feasibility of inserting the Nucleus electrodes entirely.

Abstract Otology 2000 C10-3

Norbert Dillier Ph.D., WaiKong Lai PhD, Thomas Linder MD

Labor für Experimentelle Audiologie ORL-Klinik Universitätsspital CH-Zürich

Electrically evoked compound action potentials (EAP's) provide an objective means of assessing the condition of the auditory nerve in the vicinity of a stimulating electrodes. Neural Response Telemetry (NRT) measurements have been successfully performed with children and adults, both intra- and post-operatively. This presentation summarizes results of intraoperative measurements which were performed since October 1996 in 30 patients in the Department of Otorhinolaryngology of the University Hospital in Zürich. 26 patients (87 %) demonstrated clearly identifiable neural responses while in 4 patients no neural responses or only very small responses could be obtained at the time of surgery. Compared to EABR measurements which require a more elaborate setup, the recording of EAP's provides a significantly faster and more convenient form of objective assessment at the peripheral level. The data collection for all 22 intracochlear electrodes at three or four stimulation levels can be completed in less than 10 minutes while the calculation and extrapolation of amplitude growth functions and response thresholds can be performed automatically offline. Of particular interest are the implications of these measurements to processor fitting procedures for young children.

Abstract Otology 2000 C10-4

Thomas P. Nikolopoulos MD, PhD, Kevin P. Gibbin , D. Dyar MD, Gerald M. O'Donoghue M.Ch FRCS

E.N.T Department Nottingham University Hospital GB-Nottingham

Introduction: The Children's Implant Profile (CHIP) was developed in New York Children's Hearing Institute1 as a systematic means of assessing the children before cochlear implantation. A slightly modified version by Nottingham Paediatric Cochlear Implant Programme (ChiP) evaluates 12 pre-implant factors: chronological age, duration of deafness, medical/radiological findings, functional hearing ability, speech and language abilities, multiple handicaps, family structure and support, educational environment, availability of support services, expectations of family/child, cognitive ability, and learning style. The aim of this prospective study was to assess the value of ChiP in predicting the functional outcome following cochlear implantation. Material and methods: 64 implanted children were assessed pre-operatively with ChiP and then prospectively follow-up for 4 years after implantation with Categories of Auditory Performance (CAP), Speech Intelligibility Rating (SIR)2, and Connected Discourse Tracking (CDT). Results: Speech intelligibility at 4 years was strongly correlated with pre-operative Chip (Spearman Rank coefficient -0.53, p<0.00001). Auditory perception as measured by CAP and CDT, at the same interval, were also significantly correlated with Chip (Correlation Coefficients -0.46 and -0.67 respectively with p<0.001). The most important predictive factors of ChiP were the duration of deafness, pre-operative speech and language abilities, and the pre-operative educational environment. Conclusion: The results of the present study suggest that the pre-operative ChiP is a significant predictor of the auditory perception and speech intelligibility of implanted children, 4 years following cochlear implantation. This has important clinical impact in the pre-operative assessment of children who are candidates for cochlear implantation. References 1. Hellman SA, Chute PM, Kretschmer RE, Nevins ME, Parisier SC, Thurston LC. The development of a children's implant profile. Am Ann Deaf 1991; 136(2): 77-81. 2. Allen C., Nikolopoulos T, O'Donoghue G. Speech Intelligibility in children following cochlear implantation. Am J Otol 1998: 19(6): 742-746.

Abstract Otology 2000 C10-5

Joachim Müller MD, L. Scholtz MD, M. Herzog MD, F. Schön MD, Jan Helms MD

Department of ENT-HNO Julius-Maximilians-Universität D-Würzburg

Based on the evaluation of more than 260 cochlear implants patients the results for different subgroups are presented: Subgroup A: With improved speech understanding also the indication for a cochlear implant in patients with residual hearing must be discussed in comparison to conventional hearing aids. The results of patients with residual hearing were discussed in comparison to our results in totally deaf patients and in comparison to the literature. This patients population is divided in different groups: 1. Patients with residual hearing on one ear. Deaf ear implanted. 2. Patients with residual hearing for environmental sounds on both ears or minimal speech understanding (numbers<30%) in the best aided binaural condition. Worst ear implanted. 3. Patients with remaining open set speech understanding in both ears. One ear with remaining open set speech understanding implanted. The paper discusses the results of patients with residual hearing in detail and gives our current guide-lines for cochlear implantation in patients with residual hearing. Subgroup B: Modern cochlear implants using the fast CIS strategy improved the speech understanding in cochlear implant patients. Therefore, this improved speech understanding may help senior citizens with a long history of sensory neural hearing loss to avoid complete deafness and social isolation. The paper analyses in addition the results after the cochlear implantation in patients age 65 to 79 years in comparison to our results in younger patients and in comparison to the literature.

Abstract Otology 2000 C10-6

Jan Helms MD (1), Wolfgang Gstöttner MD (2), Wolfgang Arnold MD (3), Joachim Müller MD (1), Wolf-Dieter Baumgartner MD (2), F. Schön MD (1), S. Brockmeier MD (3), B. Stöbich MD (4), M. Zwicknagl PhD (4), Ingeborg Hochmair-Desoyer PhD (4)

(1) HNO-Klinik Julius-Maximilians-Universität D-Würzburg
(2) ENT Department University of Vienna A-Wien
(3) HNO-Klinik Univ.-Klinik Rechts der Isar D-München
(4) University of Innsbruck A-Innsbruck

Multicentric clinical studies involving 19 European cochlear implant centers are being conducted to evaluate speech perception with the MED-EL COMBI 40 and the COMBI 40+ cochlear implants in postlingually deafened adults. Data on 2-digit numbers, monosyllabic words, on everyday senctences and on HSM-sentences in quiet and for various signal-to-noise ratios (CCITT-noise) are available for up to 4 years follow up with the COMBI 40 implant and 2 years follow up with the COMBI 40+ implant. Within the study the high rate CIS strategy implemented in the body worn processor with 8 channels at 1500 pulses per second per channel (12000 pps overall) with the COMBI 40 and with 12 channels at 1500 pulses per second per channel (18000 pps overall) with the COMBI 40+ has been used. Monosyllabic word understanding in the German speaking subgroup of patients (50 for the COMBI 40 and 40 for the COMBI 40+) has been found to have a mean value of 54.4% for the COMBI 40 patients and 61.0 % for the COMBI 40+ patients at 1 year post first fitting. Both, COMBI 40 and COMBI 40+ patients, have participated in an evaluation of the new ear level speech processor TEMPO+, which has recently become available and which implements the CIS+ speech coding strategy at the same stimulation rate (12000 pps overall for COMBI 40 and 18000 pps overall for COMBI 40+) and gereral number as the body worn processor. The TEMPO+ study protocol included tests for monosyllabic words and Göttinger sentences for the body worn and the ear level speech processor at the time of TEMPO+ fitting and after using the TEMPO+ for 1 month. Because of possible ceiling effects scores were purposely reduced to around 50% by individually adding an appropriate noise level. The results show that the implementation of the CIS+ strategy in the ear level processor (including the Hilbert transform for envelope extraction, but not yet using the available possibility of a wider frequency range) leads to a statistically significant increase in scores for monosyllabic words and Göttinger sentences, both at time of TEMPO+ fitting and after 1 month of TEMPO+ use.

Abstract Otology 2000 C10-7

Thomas Pfennigdorff MD, Jan Kiefer MD, Christoph Von Ilberg Prof.Dr.

ENT Department Universität Frankfurt W-Frankfurt a. M.

Progress in cochlear implant technology, as well as further developments in speech coding strategies, has considerably increased performance levels in implanted patients. To quantify the benefit of these strategies, we present a within-subject comparision using SPEAK-, CIS- or ACE speech coding strategies with the Nucleus CI 24M cochlear implant. The performance was evaluated after optimal fitting and after at least three months experience with one of the above mentioned speech coding strategies. Following tests were performed in 10 postlingually deafened adult patients with a cochlear implant: numbers, monosyllabic words, vowels, consonants, speech perceptions in quiet and in noise with 'Innsbruck' and 'Göttinger' sentence tests. Our study was divided into two groups of patients. The first group of patients was initially fitted with SPEAK-strategies, after three months we changed to CIS- and finished with ACE speech coding strategies. In the second group, we started with CIS-strategies, changed to SPEAK- and finished with ACE speech coding strategies. Neuronal responses of the auditory nerve (NRT) were also recorded from all 10 patients. In general all of the patients reached open set speech understanding with each of the three speech coding strategies. The results showed better performance with the fast speech coding strategies CIS and ACE for most of the patients. The differences were statistically significant and were greatest for sentence tests in noise. So far, no correlation between NRT-results and performance with different speech coding strategies were found.

Abstract Otology 2000 C11-1

Nikolaos Marangos MD, Joachim Klisch MD, Martin Schumacher Prof.

HNO-Klinik Albert-Ludwigs-Universität Freiburg D-Freiburg

Internal carotid artery is usually involved in large tumours of the lateral skull base. Thus, reliable information about infiltration, flow and collateral blood supply is necessary for defining resectability. Further, tumours with high vascularity have to be embolized prior to surgery for minimizing perioperative morbidity and mortality. Superselective angiography and preoperative embolization has been performed in 18 cases (15 paragangliomas, 2 nasopharynx carcinomas, 1 malignant schwannoma). Angiography and embolization facilitated surgery and prevented blood transfusion in all cases. In one case permanent baloon occlusion was necessary for removal of a recurrent nasopharynx carcinoma infiltrating the internal carotid artery. In one case of bilateral jugularforamen paraganglioma, the detailed angiographic analysis of venous drainage after ligation of the first sigmoid sinus allowed uneventfull removal of the second tumour. In one case of paraganglioma a trancient facial palsy occured after the embolization, in another case a permanent palsy of the N. hypoglossus. Thus, angiography and embolization provides great assistance in functional preservation in skull base surgery. In many cases surgery is possible only after carefull angiographic evaluation or embolization and after cooperation of interventional neuroradiologist and surgeon.

Abstract Otology 2000 C11-2

Nikolaos Marangos MD, Wolfgang Maier MD

HNO-Klinik Albert-Ludwigs-Universität Freiburg D-Freiburg

Removal of large jugular foramen paragangliomas usually results in postoperative conductive hearing loss due to resection of the middle ear and closure of the auditory meatus. We present our results on 10 paragangliomas (3 class B, 5 class C and 2 class D) attempting preservation of middle ear function. All tumours have been embolized with microparticles that garanteed blood-free surgery. The infratemporal approach type A with rerouting of the facial nerve has been used but the posterior wall of external auditory meatus has been temporarily ventrally displaced (7 cases) or temporarily removed (3 cases). The ossicular chain could be preserved in 8 cases. Complete tumour removal could be achieved in all cases with postoperative MRI follow-up between 1 and 5 years. Facial nerve function remained normal in all cases (9 cases with grade I postoperatively and 1 case with grade III that recovered to grade II after six months). In 8 cases middle ear and normal auditory function could be preserved. In one case the middle ear had to be removed. In the last case of incomplete removal, revision surgery with exenteration of the middle ear was necessary in order to achieve complete tumour removal in second stage. Middle ear function can be maintained in most cases of large jugular foramen paragangliomas (class C), if a surgical technique is used preserving the external auditory meatus and the ossicular chain.

Abstract Otology 2000 C11-3

Bernard Fraysse MD, I. Gasfi MD, C. Cognard MD, Oliver Deguine MD, Corinne Berges MD

Service ORL CHU Purpan F-Toulouse Cedex

The authors analyze the natural evolution over 10 years ( 1989-1998) of 97 patients suffering from acoustic neurinoma, being 34 % of this patient population observed during this period of time. The reasons for conservative treatment are : surgical counter-indication for 28%, patient's preference for 24 %, patient's age for 18%, asymptomatic tumor for 9%, one ear for 8%. In the patient population monitored, 62 % were more than 60 years old and in categories I and II. The patients were clinically monitored every 6 months by cochleovestibular exploration, and by MRI or scanner between 6 and 24 months. The average time between each examination was 1.3 years ; in 83 % of the cases the comparison was MRI against MRI The average Yearly Growth was analyzed in most cases by antero-posterior and traverse measurements : in 7% of cases, analysis was by volumetric measurement. The average tumor growth in this series is 1.50 mm per year, with a minimun of -13 mm and a maximun of 18 mm No predictive factor was fond for the age, the sex or the category : 16% of the patients with a useful hearing level lost points on the auditory preservation eligibility criteria scale during monitoring. The overall cumulative results show at 31 months : 36% stable, 11% spontaneous regression, 24% slow evolution of less than 2 mm, 16% intermediate evolution of 2 to 5 mm per year, 13% rapid evolution greater than 5 mm. There is a major difficulty in the "wait and scan" policy the loss of followup will include 20 % of this population. In this study, the authors present the algorithm of decision-making data in function of the size of the tumor and patient age.

Abstract Otology 2000 C11-4

U. Schuss MD, R. Hagen MD

ENT Dept. Katharinen Hospital D-Stuttgart

Schwannomas of the facial nerve are extremely rare benign tumors. They mostly arrise without a clearly defined pattern of clinical symptoms. Thus tentative diagnosis as a presupposition for an optimal preparation of surgery (including preoperative information of the patient on the surgical risks) can be established only in a few cases. As a preexistant facial paralysis caused by a schwannoma of the facial nerve is exceptional, the definite diagnosis often becomes obvious during surgical exploration as an "unpleasant intraoperative surprise" (Charachon). Presenting 6 cases of this rare tumour entity, symptoms, clinical and radiological features as well as therapeutic options are discussed with regard to the different sites of origin. Safe tumour resection made nerve transsection necessary in all operative cases. Nerve reconstruction with a free nerve graft resulted in better postoperative function in comparision to hypoglossal-facial anastomasis.

Abstract Otology 2000 C11-5

Navin L. Hiranandani MD

Oto Rhino Laryngology Nair Hospital Inmedical College IND-Bombay

Facial nerve paralysis occurs in conditions like Bells Palsy, traumatic lesions of the petrous bone as in head injuries, viral infections and chronic infections of the middle ear and the mastoid. Chronic infections of the middle ear and mastoid is the more common etiological factor. Cholesteatoma and granulations are the causative factors. Dehiscent facial nerve is particularly succeptible. Tuberculosis of the middle ear and mastoid still occur in our country. Facial paralysis particularly in this condition occurs more easily and more common in children. In fractures of the temporal bone middle ear cranial fossa approach is used, The nerve function recovers earlier.

Abstract Otology 2000 C11-6

Milan Profant MD, PhD, Juraj Ateòo MD, PhD

Univ.Otolaryngologic Clinic SK-Bratislava

Primary or secondary petrous apex cholesteatoma is a challenge requiring surgical management. Authors describe their experience with 4 patients with cholesteatoma in the petrous apex with different surgical approach to this region. In one patient middle fossa approach with otic capsule and facial nerve leaving intact was used. Translabyrinthine - transcochlear (transotic) approach was used in the other 3 patients. In all patients the facial nerve was destroyed by cholesteatoma before the surgery. The n.VII - n.XII anastomosis was performed in 2 patients. Patients are without recurrence of cholesteatoma with improving of the facial nerve function in the first case. Authors discuss particular pathologies in the petrous apex, surgical approach to this region indicated according to the size and type of diagnosed pathology, hearing loss and facial nerve function with possible complication of this surgical procedure and their management.

Abstract Otology 2000 C11-7

Joerg Schipper MD, Wolfgang Maier MD, Josef Zentner MD, PhD

Dept. ORL&HN Medical School University of Freiburg D-Freiburg

Generally a total resection of an extended petrosal bone cholesteatoma by mastoidectomy would destroy the labyrinth. In such cases, the infratemporal approach is an alternative to preserve the cochlea. Furthermore, the infratemporal approach permits an excellent overview of the infiltrated petrosal bone for total resektion of cholesteatoma including its matrix. We report about a 62 year old woman with a leftsided facial palsy for one year and a combined hearing loss on both sides after a rightsided radical mastoidectomy. The otoscopical examination showed a regular ear drum without any defect. The CT scan indicated two extended areas of destruction in the petrosal bone, and the MRI showed an additional infiltration of the dura. Together with the department of neurosurgery, we created an infratemporal approach. The surgical procedure was controlled by an electrophysiological monitoring. The resection and reconstruction of the dura was done by the neurosurgeon. The cochlea, the facial and cochlear nerve, and the middle ear could be preserved. The mastoidectomy was done by infratemporal approach, as well.

Abstract Otology 2000 C12-1

Arvind Kumar MD, Mahmood Mafee MD

Department of Otolaryngology University of Illinois at Chicago USA-Chicago IL

In most patients, the exact cause of acquired unilateral sensori-neural hearing loss (SNHL), even after extensive investigations, remains unkown. In 1984 Hassard (1) found a tumor within the endolymphatic sac during the course of endolymphatic sac surgery for management of Meniere's disease. Sensori-neural hearing loss was a prominent symptom in this patient. Eventually this tumor was characterized as a papillary adenocarcinoma since its histologic characteristics were similar to those of other endolymphatic sac tumors studied by Heffner (2). Hearing loss, of varying degrees, presumably sensori-neural, was noted in 17 of the 20 cases he reported. The radiographic center of all these tumors appeared to be the area between the sigmoid sinus and the internal auditory canal and Heffner (2) proposed that papillary adenocarcinomas of the temporal bone arise from the endolymphatic sac. This concept received strong support from Batsakis and El-Naggar (3) and others, and today it is established dogma that papillary adenocarcinomas arise from the endolymphatic sac. Pollak et al. (4) were the first to challenge this concept based on a careful longitudinal study of a patient in whom, though the histological features were characteristic, the origin of the tumor, judged from bone destruction noted by high resolution CT scans, was the top of the jugular bulb. At surgery the lumen of the endolymphatic sac was found to be free of tumor. The purpose of this paper is to report a case of a patient with unilateral SNHL who had a small papillary adenocarcinoma arising from the area adjacent to the endolymphatic sac but not from it. This was confirmed radiologically, surgically and histologically. We therefore feel that not all papillary adenocarcinomas of the temporal bone arise from the endolymphatic sac. REFERENCES 1. Hassard AD, Boundreau SF, Cron CC. Adenoma of the endolymphatic sac. J Otolaryngol 1984; 13:213-6. 2. Heffner DK. Low-grade adenocarcinoma of probable endolymphatic sac origin. Cancer 1989;64:2292-302. 3. Batsakis JG, El-Naggar AK. Papillary neoplasms (Hefner's tumors) of the endolymphatic sac. Ann Otol Rhinol Laryngol 1993; 102:648-51. 4. Pollak A, et al. Are papillary adenomas endolymphatic sac tumors? Ann Otol Rhinol Laryngol 1995; 104:613-9.

Abstract Otology 2000 C12-2

Hiroaki Miyashita MD, Michio Isono MD, Kiyotaka Murata MD, Kazuko Nakayama MD, Kei Saito MD, Masahiro Ishikawa MD

ENT Department Kinki University School of Medicine J-Osaka

The deafness associated with the inner ear anomaly ranges extensively in its degree from complete deafness and advanced hearing disorder to asymptomatic one. For this reason, it is rather difficult, at present, to establish definite diagnosis through the functional examination such as pure tone hearing test alone, in the clinical diagnosis of inner ear anomaly. Since earlier, pathohistology has been playing a major role in the diagnosis of inner ear anomaly, and the recent advent of high resolution CT(computer tomography) for the temporal area has allowed to acquire detailed information on the inner ear anomaly in the living state. We have a lot of experience with high resolution temporal CT for cases of inner ear anomaly, and the use of 3D-CT has made it possible to look into more detailed anatomy of inner ear. The present report concerns a case of bilateral inner ear anomaly of Mondini type (complete deafness for the left ear, and 40 dB HL hearing in the conversation range for the right ear), suffering from repeated meningitis caused by leakage of cerebrospinal fluid out of vestibular window. The patient's inner ear was examined by use of 3D-MRI which allowed to visualize the stereoscopic structures of the temporal area in more detail than the examination by use of two-dimensional imaging with 2D-CT or 2D-MRI.

Abstract Otology 2000 C12-3

Euan Murugasu MD

California Ear Institute atStanford Dr. Joseph Roberson USA-Palo Alto, CA

An integral component of the pre-operative assessment for cochlear implantation is radiological imaging of the cochlea to assess patency of the cochlear duct for the insertion of the intracochlear electrode array. Such information can be obtained by using high resolution computed tomography (HRCT) or magnetic resonance imaging (MRI) using a surface coil. In this paper presentation, we report on the use of three-dimensional (3D) rendering of T2-weighted magnetic resonance (MR) images into 3D models of the inner ear. Using this technique, we illustrate a range of normal and abnormal 3D models in ten adult and paediatric subjects. These 3D models provide the implanting surgeon with precise, detailed and yet easily interpretable information about the cochlea which help either to guide surgical implantation, or in certain cases, to decide against attempting surgery in the presence of unfavourable anatomical factors.

Abstract Otology 2000 C12-4

Bernhard Schick MD (11), Dominik Brors MD (1), Oliver Koch (1), Gabriele Kahle MD (2)

(11) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda

Objectives: An extensive test battery is used in patients with audiovestibular symptoms to consider the wide field of differential diagnosis including labyrinthine and retrolabyrinthine diseases. Although the value of magnetic resonance imaging (MRI) of labyrinth in patients with audiovestibular symptoms is discussed controversial, MRI presents the diagnostic tool of choice to depict small acoustic neuromas. The study highlights on labyrinthine, internal auditory meatus, cerebellopontine angle and cerebral MRI findings in patients with acute symptoms of hearing loss, tinnitus and/or vertigo of unknown etiology. Methods: Retrospective analysis of MRI findings in 294 patients (148 male, 146 female; aged 8-85 years with an median age of 47 years) with acute hearing loss, tinnitus and/or vertigo treated at a tertiary care facility. Evaluation was performed with the statistic program SPSS 8,0. Results: Pathological findings in MRI were found in 87 (29,6%) out of 294 patients with acute audiovestibular symptoms of unknown etiology. MRI depicted in these cases 1 perilymph fistula, 1 enhancement of the cochlea, 2 labyrinthine hemorrhages, 5 acoustic neuromas, 5 inflammatory lesions and 5 loopings of the AICA in the internal auditory meatus, 45 cerebral microangiopathies, 22 cerebral gliosis, which indicated in one case multiple sclerosis, 2 meningiomas, and 1 cerebral mucoepidermoid metastasis. Cerebral hypoplasia (5), pineal cysts (4), vascular anomalies (3) and pachymeningiosis (1) were additionally found. Conclusion: Even MRI is still an expansive investigation this retrospective analysis indicates a more accurate diagnosis by MRI in patients with audiovestibular symptoms. The radiological investigation should not be limited to the internal auditory meatus and the cerebellopontine angle for acoustic neuroma detection. Additional MRI analysis of the labyrinth and brain is desirable for complete neurootologic evaluation.

Abstract Otology 2000 C12-5

Uwe Vogel PhD, Gert Hofman PhD, Thomas Zahnert MD, Karl-Bernd Hüttenbrink MD

Fraunhofer Institute for Microelectronic Circuits &Systems D-Dresden

Imaging of the temporal bone is heading towards increased spatial, temporal and functional resolution. Depending on the imaging motivation and environment (diagnostics/therapy, modeling, education) different levels of spatial resolution may be reached so far. Here a new approach to 3D imaging and derived structure differentiation of internal temporal bone components by microtomography is presented, which was focused on geometry modeling and general visualization tasks. This allows resolution in the 10 micron range and below. The related procedure is basically noninvasive and thus preserves the original morphology and position of the investigated region. By that approach the external ear canal, ossicles, tympanic cavity, and liquid-filled caves of the osseous labyrinth have been visualized clearly. Even soft tissue components (e.g., tympanic membrane, ligaments, vessels, nerves) have been detected, but with less quality and accuracy due to the radiation energy in contrast to the ordinal numbers of the chemical compartments of those tissues. The results were processed for presentation as pseudo three-dimensional images and animations, on autostereoscopic displays, or as enlarged scalable solid models from rapid prototyping respectively. Very detailed views incorporating multiple perspectives of middle and inner ear complex, ossicles including their internal structure, bony labyrinth, cochlea, or saccus endolymphaticus will be shown. The results indicate the high performance of microtomographic approaches for imaging temporal bone morphology at spatial resolution currently in the 10 micron range and capabilities for future enhancements down to the submicron level. This allowed the semi-automated derivation of individual data-based geometry models of various components relevant for the mechanics of hearing. These models have been successfully fed into FEM analysis for simulating the sound transfer through the middle ear. The upcoming introduction of new physical tomographic imaging principles promises the additional accurate detection of soft tissue components too. Alternative work is directed on in vivo applications for diagnostics.

Abstract Otology 2000 C12-6

Marco D. Caversaccio MD, Daniel Zulliger MD, Richard Bächler , Rudolf Häusler MD

Imperial College of Medicine Leukocyte biology section Biomedical sciences division GB-London

Objective: Optimal registration on the lateral skull base with different anatomical landmarks and surface matching with the frameless opto-electronic navigation surgery system developed in Berne and distributed by Medivision (Stratec Medical, CH-4436 Oberdorf) in a theoretical/practical trial and during operation. Materials and Methods: On a skull we performed an axial CT with a layer thickness of 1.5mm and a scan space of 1.5mm. Different anatomical landmarks are then taken on the skull and evaluated with our navigation system for paired-point matching with or without surface matching (2 regions). This assay was compared with the clinic. Results: The optimal matching points are presented and discussed. We found a maximal theoretical/practical inaccuracy error from the target of 1.24mm (minimum 0.56) and with surface matching a maximal error of 1.17mm (minimum 0.54). During operation we have other conditions:eg the anatomical landmarks of the bone can`t be reached with a high exactness and therefore an optimal surface matching is necessary. We found a clinical inaccuracy between 0.5-2mm. Conclusion: Optimal restricted surface matching with our system gives a good accuracy in theoretical/practical and clinical trial not only on the surface of the lateral skull base but also at the apex of the petrous bone.

Abstract Otology 2000 C12-7

Wolfgang Freysinger PhD, A.R. Gunkel MD, W.F. Thumfart MD

ENT Clinic University of Innsbruck A-Innsbruck

Even a surgeon who is highly experienced in microsurgery of the petrous bone may encounter difficult situations, especially when performing minimally invasive microscopic procedures, during which he could need additional positional and orientational information. This is provided by contemporary navigational technology. By using our armamentarium of navigational systems (Zeiss MKM and STN, ISG/ELEKTA Viewing Wand, ARTMA Virtual Patient) we have demonstrated for the first time that "almost diagnostic" CT scans of the petrous bone can be used for intraoperative 3D navigation. Depending on the patient, pathology, access route and the surgeon´s preferences the navigation system is selected. We have been able to achieve sufficient intraoperative accuracy to provide valuable position information, i.e. in the millimetric, even sub-millimetric, regime. We are now able to provide an almoust routine application of 3D navigation for microsurgery of the petrous bone. So far, we have performed 15 navigated procedures including transtemporal cholesteatoma removal, posttraumatic petrous bone revision surgery, one Cochlea implantation, one acoustic neuroma. We discuss technological issues, surgical practicability, problems and further necessary developments to create an integrated navigated microsurgical approach to the petrous bone: navigable instruments, display and tracking technologies.

Abstract Otology 2000 C13-1

Shizuo Komune MD, PhD, Koji Torihara MD, PhD, Tamotsu Morimitsu MD, PhD, Tetsuya Tono MD, PhD, Atsushi Haruta MD, PhD

ENT Department Miyazaki Medical College J-Miyazaki

Two major routes have been reported for drainage of cholesterol granuloma in the petrous apex; translabyrinthine and extralabyrinthine routes. Concerning the latter route, several approaches have been demonstrated in the literature. However, most of these approaches have the major disadvantage of the narrow route for drainage. We developed a new approach for drainage of cholesterol granuloma in the petrous apex and describe it briefly. The tympanic membrane and the skin of the external auditory canal are elevated without any injury. Antero-inferior portion of bony wall of the canal is drilled away. A large route for drainage can be made between ramus mandibulae and vaginal process without a possibility of injury to internal carotid artery. This new approach have another advantage of a large communication route for drainage, and can access to the infrapetrosal lesion easily and safely without invading internal carotid artery. Also this approach is very useful for cases with high jugular bulb which makes it difficult to access the lesion with infralabyrinthine approach.

Abstract Otology 2000 C13-2

Levent Olgun MD, Sezaver Alper MD, Gürol Gültekin MD, Erdal Gül MD, Gül Caner MD, Levent Aydar MD

SSK Izmir Educational HDSP TR-Izmir

In this video-show, 8 difficult cases chosen among 26 patients implanted in May 1998- March 1999 will be presented. Four cases were old radical cavities, 2 were very prosidan cases 1 was totally ossified cochlea and the last was Alexander-Mondini deformity. The important points in decision making in unusual cases will be emphasized.

Abstract Otology 2000 C13-3

Alexander A. Lantsov MD, Militsa E. Kubatchenko MD

St. Petersburg State Medical Acad. Postgradual Education RU-St. Petersburg

Intraosseous infusions of medicine, contrast mediums, anaesthetics and hemotransfusions have been widely used in medical practice for a long time. But in otology the intraosseous method for a present time has not been applied. The treatment of peripheral facial palsy (Bell's palsy) severe forms is to be a great problem. That is why we suggested intraosseous method for treatment of this disease. The objective was to find highly effective and non-traumatic method. According to the vast anatomical investigations, the pathways of conrtast mediums, injected intraosseously, were established. It was showed that through the system of osseous anastomoses the drugs, injected intraosseously in the temporal bone, are spreading directly to the venous network of the facial nerve. The use of this method allows to reach complete recovery of all the patients, suffered from the severe forms of Bell's Palsy with the 6 months duration of the disease , to avoid operative decompression of the facial nerve and to keep hearing of the patients invariable.

Abstract Otology 2000 C13-4

Peter G.B. Mirck MD

Department of ENT Academic Medical Center NL-DE Amsterdam

Many patients with recurrent external otitis in fact have a collapse of their external auditory canal as a result of anteroposition of the concha. Sometimes the concha even touches the ventral canalwall skin which gives rise to an intertriginous eczema. This anatomical aberration causes accumulation of earwax and debris, and prevents adequate aeration of the earcanal. Bacteria and fungi will grow in this environment very easy and will cause a chronic inflammation. Patients with this problem will visit your office almost every month for microscopically cleansing of their ears and another prescription for eardrops, which they hardly can use , because the earcanal is blocked. The "M"-Meatoplasty is the surgical solution for these patients. This easy surgical procedure can safely be performed under local anaesthesia as an outpatient procedure.

Abstract Otology 2000 C13-5

Trifon Kiratzidis MD, PhD, Athina Kotsani MD

C.I. Center Veria General Hospital GR-Veria

We present a new surgical technique for cochlear implantation, without a mastoidectomy and a posterior tympanotomy. The middle ear is exposed through the endaural approach. The anatomy of the middle ear and the route of the facial nerve is inspected to rule out any facial nerve irregularity. As a pathway to the cochlea for the active electrode, a channel is drilled through the posterior bony wall of the external auditory meatus. A temporal bone study and a HRCT study showed that the direct drilling of the channel is safe and the existence of a sufficient space for that can be preoperatively predicted. The drilling is performed through a specially designed device, wich ensures the direction, the depth and the stop-end of the drilling, avoiding any damage to the middle ear structures. In 1997 and 1998, 24 patients were operated with this technique. The advantages of this technique are: 1) less traumatic, because no mastoidectomy and posterior tympanotomy is needed, 2) better approach to the cochlea ensures proper opening and prevents malpositioning of the electrode array, 3) the second turn and the apex of the cochlea can be easily opend in in cases of obliteration or ossification, 4) it is suitable for very young children, where the mastoid has not yet been sufficiently developed, 5) it is suitable for revision cases and 6) makes cochlear implantation simple and safe for the hands of the average ear surgeon.

Abstract Otology 2000 C13-6

Claus Jansen Dr.med.

Honorary Member ENT Clinic D-Gummersbach

Video endoscopy of the Inner Ear was started at the beginning of the nineties using flexible endoscopes of the caliber 300 and 200 micron. Several video films demonstrated the procedure in detail including a study of Neodyn-Yag laser application using a new side firing system. Aim of the study is to find out its effects onto the cochlea structures. After some years micro endoscopy of the vestibule was started. First of all a micromanipulator has been constructed in order to avoid irritations of the inner ear system. Further details of the procedure are shown in the second part of the video film.

Abstract Otology 2000 C13-7

Douglas E. Mattox MD

Department of Otolaryngology Head and Neck Surgery Emory University School of Med USA-Atlanta, GA

Traditional otologic surgery is limited by the line-of-sight visualization imposed by the operating microscope. Line-of-sight visualization of lesions deep in the temporal bone can require mobilization or destruction of vital structures. In particular, lesions of the petrous apex can require mobilization of the facial nerve and carotid artery and excision of the cochlea. This presentation will describe five cases (three cholesterol granulomas and two cholesteatomas) that were managed with angled telescopes that allowed visualization and surgical manipulation of these lesions. Endoscopic visualization of cholesterol cysts in three patients (two infracochlear and one transphenoidal approach) allowed lysis of adhesions and removal of inspissated debris within the cyst that could not be seen without enlarging the opening into the cyst and risking damage to adjacent structures. The fourth patient had a question of recurrent cholesteatoma in the supralabyrinthine cells one year after removal of a large middle ear and mastoid cholesteatoma. The ear was re-explored and an endoscope passed through the arch of the superior semicircular canal allowing visualization of the supralabyrinthine cells and the of the internal auditory canal passing through them. The last patient was an elderly woman with a massive petrous apex cholesteatoma and temporal lobe abscess. Endoscopic excision of the cholesteatoma through the infracochlear and retrofacial cells allowed removal of the cholesteatoma without mobilization of the carotid, facial nerve or destruction of the cochlea. Our experience is that endoscopy is an important adjunct to neurotology providing access to structures that cannot be approached with traditional line-of-sight techniques.

Abstract Otology 2000 C14-1

Bernhard Schick MD (1), Dominik Brors MD (1), Gabriele Kahle MD (2), Wolfgang Draf MD, PhD, FRCS (1)

(1) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda
(2) Institute of Radiology Academic Teaching Hospital D-Fulda

Objectives: Radiological follow-up after surgical treatment in extended jugulotympanic paragangliomas (JTP) is still a challenge. Small residual tumors may escape detection in early radiological follow-up leading to the false assumption of complete tumor resection. The study analysis the effectiveness of complete tumor resection in extended JTP and highlights on the value of computertomography, magnetic resonance imaging and angiography for follow-up. Methods: Retrospective study of 34 extended JTP treated from 01.01.1981 to 31.12.1998 at a tertiary care facility. The study group included 23 paragangliomas at level C and 11 paragangliomas at level D according to the classification proposed by Fisch. The medical reports and radiological follow-up investigations were analysed. Results: 10 of the 34 paragangliomas had already been surgically treated before at the time of first presentation. Twice additional radiation had been performed. In 14 out of 34 JTP the tumor resection in our department was found to be incomplete in radiological follow-up. In two cases only angiography had proved 18 months and three years after surgery a small residual tumor, even magnetic resonance imaging was found to be inconspicuous at the same time. Residual tumor was mainly found at two sides: vertical part of the internal carotid artery and jugular foramen/cerebellopontine angle. Retroclival tumor location and residual tumor lateral to the bony canal of the hypoglossal nerve were single findings. Conclusion: Residual tumor after surgical treatment of extended JTP (level C and D) is not uncommon, but can be highly difficult to visualize. Computertomography and magnetic resonance imaging can fail to detect residual tumor, especially in early follow-up. Small residual tumors may only be recognized in angiography. In order to evaluate the long-term results in paraganglioma treatment a precise follow-up over decades has to be provided.

Abstract Otology 2000 C14-2

Nemesio Gómez Estancona MD, C. Gorostiza MD, A. Mugica MD, J. Elorduy MD, C. Iriarte MD, L. Urruticoechea MD, L. Muñiz MD, A.G. Tena MD

Hospital de Cruces (Vizcaya) E-Bilbao

A 61-year-old man with right ear pain and hearing loss was diagnosed with a glomus jugulare tumor for which he received radiation therapy and after embolization of the tumor total petrosectomy by infratemporal approach without injury to the cranial nerves. One year later labile hypertension and five tumors at the abdominal cavity with surgical excision, excess of catecholamines. One year later develops a pathological hip fracture with tumor metastatic to the sacrum and pelvis.

Abstract Otology 2000 C14-3

Takashi Nakagawa MD, PhD, Yoshihiko Kumamoto MD, Masahiro Iwamoto MD, PhD, Jun-ichi Fukushima MD, Yoshiro Natori MD, PhD, Jun Shinokuma MD, PhD, Shizuo Komune MD, PhD, Sohtaro Komiyama MD, PhD

Department of Otorhinolaryngology Faculty of Medicine Kyushu Univ. J-Fukuoka

Malignant tumor in a peripheral auditory system is not common. Especially, adenocarcinoma in the middle ear is very rare. Previously reported cases of a middle ear adenocarcinoma are originated from an endolymphatic sac. In these cases, the tumor lies between the middle ear and the posterior cranial fossa, because the endolymphatic sac exists anterior to Trautmann*s triangle within the dura in the posterior cranial fossa. We have experienced a slowly progressive middle ear tumor which finally extended into the middle cranial fossa. A patient was a 50-year-old female. The lesion caused her right facial palsy two times in *87 and *96. At both times, the tumor and surrounding granulation were surgically removed in order to decompress the facial nerve. An atypical cell was observed by a pathological study, but it did not suggest enough evidences to be a malignant tumor. However, the MR image in October *97 showed the mass in the middle ear extending into the middle cranial fossa with enhancing the attached dura which suggested an intracranial invasion. Since the malignancy was strongly indicated from the clinical course, we decided to dissect her middle ear mass with a combination of transotic and supralabyrinthine approaches. We have removed the whole mass with a partial resection of the temporal bone and the middle cranial fossa dura. Her facial nerve was sacrificed by this procedure. An adenocarcinoma was finally diagnosed from the specimens by the operation.

Abstract Otology 2000 C14-4

Ming Zhang MD, PhD (1), Ugo Fisch MD (2)

(1) House Ear Institute USA-Los Angeles CA
(2) ORL-Klinik Universitätsspital CH-Zürich

Six temporal bones (3 in large and 3 in small head size) were dissected to study the anatomic landmarks of supralabyrinthine and extended middle fossa approaches, the space gain through the supralabyrinthine approach, the special relationship between the superior semicircular canal and internal auditory canal. The space gain was obtained by removing bones above the tegmen tympani and supralabyrinthine region. The space gain at valley between the labyrinthine segment of the facial nerve and superior ampulla are essential to reduce the dural elevation compared to other approaches. The space to reach the singular nerve and jugular bulb is limited by endolymphatic duct in the extended approach. The variation of the structures situated posterior to internal auditory canal is much less than those anterior to it. Our data confirm that the superior semicircular canal is a reliable landmark to locate the internal auditory canal. Head size and age determine the anatomical variation of the area anterior to internal auditory canal. A new method using lengths to determine the angle in presence of narrow and complicated topographic space between superior semicircular canal and internal auditory canal is proposed.

Abstract Otology 2000 C15-1

Caglar Batman MD, Selcuk Inanlý MD, Alper Tutkun MD, Mehmet Ali Pehitoglu MD

ENT Department Marmara University Hospital KBB Klinigi TR-Marmara-Altunizade

Deposition of fibrous or osseous tissue within the fluid spaces of the cochlea is encountered during the operation of some cochlear implant candidates. Imaging techniques such as computed tomography (CT) scanning and magnetic resonance imaging (MRI) give valuable information to detect any abnormality within the cochlea and this influences the applicability, feasibility and success of cochlear implantation. However, on some cochleas no signs of obliteration can be identified with preoparative imaging especially if there are partial fibrous or raw osseous tissues within the cochlea. Fibrosis may represent itself as a liquid nature although the canal was not patent. Four cases were experienced and managed like these unexpected situations. CT and MRI findings are neverthless merely one element in the implantation and intraoperative experiences can modify the procedure.

Abstract Otology 2000 C15-2

Michio Isono MD, Kiyotaka Murata MD, Meiho Nakayama Dr.med., Hiroaki Miyashita MD, Kei Saito MD, Masahiro Ishikawa MD

ENT Department Kinki University School of Medicine J-Osaka

Even though inner ear anomalies may cause deafness in many cases, in clinical situations, conditions such as, recurrent meningitis or inner ear anomalies that cause sensorinural hearing impairment (fluctuating hearing) are sought. Especially, since recurrent meningitis sometimes causes death, the significance of image diagnosis is extremely high. So far, inner ear anomalies must be diagnosed by image diagnosis such as two-dimensional high resolution CT-scanning of the temporal bone before three-dimensional CT was introduced. It was found that three-dimensional CT was useful in observing the minute findings of the anomalous inner ear. We have applied three-dimensional CT (helical CT scanning of Xvigor, Toshiba) for 5 cases of inner ear anomalies, and observe the inner ear from several directions to find any small morphologic changes. The three-dimensional images revealed very small changes in the labyrinthine capsule. Even with a two-dimensional CT, such features as poor cochlear turning, hypoplasia of the semicircular canals and an enlarged vestibule in the bony labyrinthine capsule could be seen. However, the realistic images provided by three-dimensional CT scanning provided superior clarity and detail, even of slight structural differences. Furthermore, this CT was also capable of assessing the stage of embryological injuries and evaluating anomalies in cochlear turning that are the hidden factors of hearing impairment.

Abstract Otology 2000 C15-3

Vel Nandapalan F.R.C.S, Athina Pangalu MD, Ugo Fisch MD

ENT Department University Hospital CH-Zürich

Background: Subtotal petrosectomy is a complete exenteration of all pneumatic cell tracts of the temporal bone. The eustachian tube also obliterated at isthmus. If the otic capsule is preserved a few remnants of the suprameatal and apical air cells medial to the otic capsule will not be exenterated. The middle ear cavity thus created is usually obliterated by free abdominal fat and temporalis muscle rotation flap. There is no study has been performed to show, the fate of the air cells that have been left behind in the petrous bone when the otic capsule is preserved and similarly formation of any new air cells once the air cell tracts have been completely removed. Further, the long term survival of the free fat that is used is debatable. Fat atrophy can lead to CSF leak even several years after the surgery. Aims: To evaluate: 1.Fate of air cells in patients where the otic capsule has been preserved. 2.Whether there is formation of new air cell tracts in patients where all cell tracts have been removed. 3.Whether there is significant atrophy of the free fat used in obliteration. Methods: In this ongoing study so far, 30 patients with subtotal petrosectomy between15 to 5 years ago at the Otolaryngology department, University Hospital, Zurich, have been recruited. Their pre-operative and serial post-operative CT/MRI scans were evaluated. Results: In the preliminary stage, our study shows there is evidence of fat tissue shrinkage after 5 years. This leads to concomitant inward displacement of the pinna. Before 5 years there is no change in the size of the fat tissue. There is so far no evidence of new aircell tract formation when the aircell tracts are totally exenterated and there appears to be no changes in the aircell tracts that were left behind.

Abstract Otology 2000 C15-4

Tuncay Ulug Prof.Dr.

ENT Department Istanbul University Istanbul Medical Faculty TR-Besiktas, Istanbul

Objective: To demonstrate that the anatomical sturucture, the processus cochleariformis with its intimate and constant relationship to inner ear stuructures, can be used as a reliable landmark in middle cranial fossa surgery alone, or in conjunction with other landmarks. Another objective is to give an indication of the anatomy and relationship of the inner ear and allied stuructures within the intact bone during middle cranial fossa surgery. Study Design: An anatomical prospective study using cadavaric temporal bones to define six reproducible measurements that relate the processus cochleariformis to inner ear structures, which are encountered during middle cranial fossa surgery and 14 other measurements that relate inner ear structures to adjacent structures within the intact bone Method: Using ten cadaver specimens, twenty reproducible measurements were defined. The first six of these measurements define the relation of the processus cochleariformis to inner ear structures in middle cranial fossa surgery. The other measurements give an impression of the inner ear structures and adjacent structures within the intact bone. Using the processus cochleariformis alone, or in combination with other landmarks, the reliability of this landmark in middle cranial fossa surgery was established in four clinical cases. Results: The vertical crest lies at a 20 degree angle from the processus cochleariformis to the coronal plane, and at a distance of 5 to 6 mm from the processus cochleariformis. The point where the medial margin of the basal turn of the cochlea crosses the labyrinthine segment of the facial nerve, is at a 0 degree angle from the processus cochleariformis to the coronal plane, and at a distance of 6.5 to 7.5 mm from the processus cochleariformis. The superior semicircular canal is at a 45 degree angle from the processus cochleariformis to the coronal plane. The medial wall of the vestibulum is 6-7mm from the processus cochleariformis in the same direction. With other measurements important clues about the position of greater superficial petrosal nerve, cochlea, vestibulum and labyrinhine segment of the facial nerve are defined. Conclusions: Middle cranial fossa surgery is a technically demanding procedure, partly due to the lack of easily identifiable landmarks and partly due to limited exposure. If the classical landmarks are indiscernible, then the processus cochleariformis with its intimate and constant relationship to the inner ear structures is a safe and reproducible landmark.

Abstract Otology 2000 C15-5

Boris Kitanoski MD, B. Ristic MD, V. Savanovic MD, Miodrag Dinic MD, MA, N Milanovic MD, Bozidar Jakovljevic MD

ENT Department Military Medical Academy YU-Belgrad

The authors have examined 40 patients with various complaints after low degree closed head injuries, and found pathological value of Auditory Evoked Responses (BERA) in 42.5% of them. All the patients had normal findings of a Computerised Tomography (CT) of the brain. The pathological values of Auditory Evoked Responses were evaluated, that includes prolonging of the interwaves latencies and normal wave amplitude V: I, as well as reduction of the relative wave amplitude V:I. The patients in whom brain tissue changes were not found by neuroradiological examination, they have relatively large percentage of pathological findings of BERA. The authors conclude that in such a cases BERA can confirm a functional changes in the brainstem , which can explain subjective complaints such as headache, memory loss, poor concentration, irritability etc., that besides the importance in diagnosis and therapy has a significance in medical legislation.

Abstract Otology 2000 C16-1

Konrad Schwager MD, L. Pfreundner MD, M. Flentje MD, Jan Helms MD

ENT Dept Univ of Würzburg D-Würzburg

Between 1978 and 1997, 30 patients (17 female, 13 male) were treated atthe departments of otolaryngoloy and radiation oncology for carcinoma of the outer ear canal and middle ear. The patients age at time of diagnosis was 60 years mean (range 26-85 years). 27 patients came for initial treatment, 3 patients with recurrent disease after primary treatment at an other institution. Most tumors were squamous cell carcinomas (n=23), 5 were adenoid cystic, 1 was a mucoepidermoid carcinoma and 1 a papillary adenocarcinoma. At time of diagnosis 6 patients showed dural tumor infiltration, in 2 patients the temporal lobe was invaded by tumor. 5 patients (17%) had lymph node metastases. These were located intraparotideal (n=3), infraparotideal (n=1) and retropharyngeal (n=1). Distant (pulmonary) metastases were found in 1 patient with dura infiltration 5 months after diagnosis. According to the Pittsburgh staging system 7 patients were stage I, 1 patient stage II, 10 patients stage III, and 12 patients stage IV. Therapy included surgical procedures (external auditory canal resection, partial temporal bone resection, subtotal temporal bone resection) followed by external beam radiation therapy (EBRT) of median 70 Gy. In cases of recurrent or residual tumor after surgery and EBRT a 192-Iridium HDR (high dose rate) brachytherapy was administered. The overall survival rate was 61% at 3 years and 53% at 5 years. 48% of all patients were free of disease at 5 years, the 5 year disease free survival rate for in-sano resected patients was 100%.

Abstract Otology 2000 C16-2

Yurij A. Soushko MD, PhD, Oleg Borissenko MD, Rustem M. Trosh MD, PhD, Victor V. Gudkov MD, Ilona A. Srebnjak MD

Otolaryngology Research Institute UKR-Kyiv

Eighteen patients with skull base tumors treated at the Kyiv Otolaryngology Research Institute between 1995 and 1998 were submitted to present retrospective study. The patients were treated surgically with combined transmastoid-transcervical approach, modified according to the individual tumor growth. In ten patients performed infratemporal fossa approach of Fisch and Mattox with obliteration of middle ear spaces. There were 13 women and 5 men. Ages ranged at the time of surgery from 20 to 50, with a median age of 38,4. The average duration of symptoms was 5,6 years. Three patients suffered neuroma of the facial nerve, one had a meningioma in the jugular foramen area, 11 had a glomus tumor and 3 were with malignant tumors. The tumor sizes up to 2 cm was found in 5 patients, up to 3 cm in 2 patients, up to 4 cm in 5 patients and more than 4 cm in 6 patients. The tumor was removed completely in ten patients. In a further 8 patients the tumor was resected subtotally and these patients received postoperative radiotherapy. The reasons for incomplete tumor resection were interruption of the surgery because of severe hemorrhage and spreading of a tumor on ICA. The facial nerve was not damaged by a tumor in 7 patients, during the operation we saved its integrity. For one patient with the facial neuroma after removal of a tumor the VII-XI anastomosis was made; 6 patients underwent the VII-XII anastomosis. It was impossible to make anastomosis for 4 patients because of the nerves-donors damage. Follow-up intervals were from 12 to 45 months (average 28,2). The patients with malignant tumors died in terms from 6 to 10 months after surgery. The dysphagy is marked in 3 patients, 2 had the hoarseness. The function of a facial nerve is saved or restored completely in 8 patients, 4 patients have a facial paralyses House grade II, 2 patients grade III and 4 patients grade VI. The hearing remained unchanged in 7 patients. In our opinion the combined transmastoid-transcervical approach is the most suitable access to the skull base tumors, which allows to remove a tumor and save integrity of a facial nerve or to make its neurorrhaphy.

Abstract Otology 2000 C16-3

Vesna Ciric MD, Milan Stankovic MD, PhD

University ENT Clinic YU-Nis

Temporal bone carcinoma is a rare disease, but it has very aggressive course and bad prognosis. Clinical presentation of temporal bone tumor is usually insufficiently specific, and when it is obvious the disease is advanced with rapid progression and limited therapeutic success. Different surgical techniques for temporal bone resection are developed, but their success is difficult to access. The aim of this study was to analyze the clinical characteristics, surgical results of twelwe patients who underwent surgical therapy for secondary temporal bone tumor. We divided them in stages according to Arriaga et al. (1990). Partial temporal bone resection, subtotal resection (petrosectomy) or total temporal bone resections were surgical methods of treatment. Postoperative irradiation with 6 000 cGy during 6 weeks in 30 fractions was applied in all the patients. Secondary affection of bony external meatus and middle ear was the result of local invasiveness of planocellular (58%) or basocellular carcinoma (42%). For secondary tumor involvement five years survival rate amounted 75%, 66%, and 0%, depending on the stage of disease. It can be concluded that prognosis of temporal bone carcinoma directly depends on the propagation of tumour. Computerised tomography is a reliable method for determination of the propagation and for planning the treatment. Temporal bone resection with postoperative irradiation is the method of choice of temporal bone carcinoma.

Abstract Otology 2000 C16-4

Thomas P. Nikolopoulos MD, PhD, Gerald M. O'Donoghue M.Ch FRCS

E.N.T Department Nottingham University Hospital GB-Nottingham

Introduction: The outcome of skull base surgery has been evaluated extensively by surgeons throughout the world. However, the patients' perspective has recently become of increasing importance in the assessment of surgical outcomes1,2. Material and methods: 52 patients were randomly selected following skull base surgery (removal of acoustic neuromas or meningiomas). One, at least, year after surgery, the patients were asked to assess the outcome of the operation. Results: 45 out of 52 patients (87%) reported that the operation was partially or fully successful and 47 out of 50 (94%) reported that their family/friends believe that the outcome of surgery was the same successful. A degree of disappointment was expressed by 12 out of 52 patients (23%). With regard to the effect of the adverse results of surgery on their overall life, 22 out of 52 patients (42%) reported that it was moderately or greatly affected. However, only 3 out of 52 patients (6%) reported that they would not recommend the same operation to a member of their family or a close friend in case he/she had a similar tumour. Conclusion: The majority of patients considered and reported partially or fully successful the outcome of surgery for the removal of skull base tumours. Only a small minority considered the operation as failure, although over 40% of patients experienced adverse results of the operation that had moderately or greatly affected their overall life. References 1) Irving RM, Beynon GJ, Viani L., Hardy DG, Baguley DM, Moffat DA. The patient's perpective after vestibular schwannoma removal: quality of life and implications for management. Am J Otol 1995; 16 (3): 331-337. 2) Nikolopoulos T., I. Johnson, G. O'Donoghue. Quality of Life After Acoustic Neuroma Surgery. Laryngoscope 1998; 108(9): 1382-1385.

Abstract Otology 2000 C16-5

Janez Zupancic MD, Saba Battelino MD, Miha Zargi MD, PhD

Department of ENT and CFS University Medical Centre SLO-Ljubljana

In the last 15 years we treated 14 patients with malignant tumours of EAEC and the MEC, primarily surgically with following radiotherapy. In 12 cases we did the classical LTBD with no obliteration of the entrance of EAEC. In these cases, during and after radiotherapy, we had a lot of difficulties with inflammations and discharge from operative cavity, as well as the osteomielitis. In two cases we performed the LTBD (one modified), where we removed all the EAEC, the ear drum and the ossicules. In one case we left open the tuba Eustachii for the ventilation of the remanding mucosa. In the second case, we performed also the mastoidectomy and removed the mucosa of MEC. In both cases we closed the entrance of the EAEC with the skin of the tragus. In these two cases we had no complications during and after radiotherapy with 61,9 Gy. Both patients are now 3 and 12 years after therapy, with no loco-regional recurrence of primary disease and with no late complications after surgery or radiotherapy. We think the LTBD with occlusion of the entrance of EAEC and radiotherapy is a therapy of choice for malignant tumours of EAEC and MEC in early stages. The obliteration of the entrance into the EAEC reduces the complications during and after the radiotherapy, but on the other hand, makes the eventual recidiv or residuum later discovered. According to the very bad prognosis in such cases we still speak in favour of obliteration of the entrance of EAEC.

Abstract Otology 2000 C17-1

Athanasios Katsarkas M.D., M.Sc.

Department of Otolaryngology McGill University Royal Victoria Hospital, #E4.4 CDN-Montréal, Québec

Between October 1973 and May 1997, 15,000 patients were seen in our Dizziness Clinic. All patients were evaluated and followed up by the author. There were 5,628 men (mean age: 52±16) and 9,372 women (mean age: 51±16). Patients were investigated by: a) a clinical neurootologic assessment; b) a neurologist (N=4,830); c) electronystagmographic (ENG) recordings (N=8,698); d) detailed audiologic tests (N=6,240); e) imaging techniques if necessary. In 3,363 patients, no definite diagnosis was established. These patients, however, suffered from remote or mild transient dizziness, or vague chronic symptoms. In 3,811 patients there was a convincing history of benign paroxysmal positional vertigo (BPPV). In other 2,473 patients, BPPV was confirmed by the clinical examination. Thus 5,836 (38.9%) patients were suspected or proved to suffer from BPPV. Other causes of dizziness were: 1) Meniere's disease (N=909); 2) vascular disease (N=349); 3) vestibular neuronitis (N=370); 4) tumors (N=246); 5) functional disturbances (>15%). In the latter group, there were occasionally other various types of organic dizziness, exaggerated by the functional background. Other interesting diagnoses, around fifty, in smaller groups of patients are discussed in this paper. Four main points emerged from this study: a) the higher prevalence of dizziness, as a symptom, among women than men; b) the high prevalence of BPPV; c) the low prevalence of dizziness induced by vascular disease; d) the low prevalence of functional dizziness. One wonders whether the diagnosis of functional dizziness is occasionally an undiagnosed organic syndrome.

Abstract Otology 2000 C17-2

Saumil N. Merchant MD, Luis Velazquez-Villasenor M.D., Kojiro Tsuji M.D., Conrad Wall III Ph.D., Steven Rauch M.D.

Department of Otolaryngology and Eaton Peabody Lab. of Aud.Physiol. Mass. Eye and Ear Infirmary USA-Boston MA

Quantitative studies of the vestibular system using celloidin embedded, H&E stained and serially sectioned human temporal bones have been limited because it has been generally difficult to reliably differentiate hair cells from supporting cells, and type I from type II hair cells. A new method was developed using Nomarski (differential interference contrast) microscopy to overcome the above limitations. The method enables visualization of the cuticular plate and Stereociliary bundle, thus allowing unambiguous identification of hair cells. The method is reliable, valid and repeatable. The densities of type I, type II and total numbers of hair cells in each of the five vestibular sense organs were determined in 67 normal bones from birth through 100 years. Scarpa's ganglion cell counts were also made on these bones. Mathematical models were developed to predict the various hair cell and ganglion cell counts using age and sex parameters. These counts and models will serve as normative databases to compare counts from pathologic cases. Quantitative studies were performed on 20 bones with aminoglycoside ototoxicity and 30 bones with Meniere's disease. A number of new findings were noted, the significance of which will be discussed. The new method, which can provide insight into the pathology and pathophysiology of many vestibular disorders, has several advantages compared to alternative techniques such as surface preparations. The method is applicable to archival bones, permits simultaneous evaluation of the rest of the labyrinth, is relatively inexpensive, and does not preclude other techniques of study (e.g., PCR, immunostaining).

Abstract Otology 2000 C17-3

Kohichiro Shigeno MD, Hidetaka Kumagami MD, Toshimitsu Kobayashi MD, PhD

Otolaryngology Nagasaki University J-Nagasaki

The direction-changing positional nystagmus (DCPN) of geotropic and apogeotropic types have been commonly recognized as neurotologic findings which indicate a lesion of a central origin. But the possibility exits that many cases of DCPN might be caused by a peripheral lesion. Eleven cases of geotropic DCPN and seven cases of apogeotropic DCPN which seemed to be of peripheral origin were examined. This study was conducted to identify further the clinical features of DCPN and to measure the slow phase velocity of nystagmus when the head position was changed 30 degrees and 60 (90) degrees in any direction from the sitting position. The following results were obtained : Caloric tests and hearing tests indicated an inner ear disturbance in half of the cases. A gaze nystagmus test, OKN, ETT, and suppression of nystagmus with fixation and MR(CT), did not indicate abnormal findings. The slow phases of DCPN were found to be regulated at a certain base plane in which the direction of cupula in lateral semicircular canal (LSC) of one side should coincide with the direction of gravity. In conclusion, we believe that the theory of cupulolithiasis is not sufficient to fully explain DCPN of geotropic type or apogeotropic type. As positional nystagmus did not disappear in anterior-flexion of 30 degrees in which the LSC was near the horizontal position, we find the theory that proposes change of specific gravity in the endolymph to also be insufficient. We propose that change of cupular density in LSC provokes DCPN of the peripheral origin.

Abstract Otology 2000 C17-4

Mohamed Ibrahim Shabana MD, PhD

Audiology Department Cairo University Hospital ET-Cairo

Otosclerosis is confirmed to the otic capsule and with a few other conditions give rise to deafness and vestibular symptoms (Beales, 1987). In this study, our aim is to study the vestibular system pre and post stapedectomy. In postoperative period, the vestibular system was studied immediately postoperatively and after one month. Twenty patients were studied and the results of posturoraphy and electronystagmography were evaluated and its relation to the audological findings. References: Beales, P.H. (1987). Otosclerosis.In: Vein, A.G ed.scoh. Brown's. Otolaryngology, vol 3: Otology. Sthed. London: Buttenworths.

Abstract Otology 2000 C17-5

Mohamed Ibrahim Shabana MD, PhD

Audiology Department Cairo University Hospital ET-Cairo

Neonatal hyperbilirubinimia is a very common problem of newborn infants and can lead to serious neurological sequalae. The ABR test is currently used technique to assess newborn auditory sensitivity and pathway integrity. This study has included 50 newborns suffering from neonatal hyperbilirubinemia and subjected to laboratory and ABR tests before and after treatment. 24 cases attended their follow up examination after 6 months. The study showed that wave I is the parameter that was mostly affected by treatment. Other risk factors were also discussed like sepsis, effect of exchange transfusion on ABR test.

Abstract Otology 2000 C19-1

Nikolaos Marangos MD, Antje Aschendorff MD

HNO-Klinik Albert-Ludwigs-Universität Freiburg D-Freiburg

Since children with congenital deafness have been considered Cochlear Implant candidates, high resolution computed tomography (CT) of their temporal bones has been performed routinely to evaluate cochlear abnormalities prior to Cochlear Implant (CI) surgery. Thus, several types of malformations of the bony cochlea and labyrinth are revealed by CT scans which were unknown previously, as CT was not performed on every congenital deafness. Many malformations were wrongly referred to as Mondini-dysplasia. Jackler proposed a radiologic classification of inner ear deformities based on the embryogenesis: those with abnormal or absent cochlea representing an interruption of embryogenesis in various stages and those with normal cochlea that are inde-pendent from embryonic development. Since 1986 more that 700 children with con-genital deafness, considered for CI, have been evaluated by high resolution CT. As many deformities observed cannot be assigned to this classification but they are of interest regarding cochlear implantation, they will be presented in this paper.

Abstract Otology 2000 C19-2

Bernhard Schick MD (1), Dominik Brors MD (1), Andreas Prescher MD, PhD (2)

(1) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery Academic Teaching Hospital D-Fulda
(2) Institute of Anatomy University Aachen D-Aachen

Objectives: Conductive hearing loss caused by congenital ear abnormalities is a rather rare finding. Beside stapes ankylosis fixation of the malleus can cause congenital conductive hearing loss. This study highlights on the embryological aspects of congenital malleus fixation. Methods: Embryological and comparative anatomical study. Results: The malleus derives from the posterior part of Meckel's cartilage. A part of this cartilage remains attached to the malleus to form the processus anterior mallei. The major part of this process usually recedes to form the ligamentum mallei anterius. The processus anterior mallei, which can be up to 10mm in neonates, remains in the adult malleus only as a small prominence. A lack of bony involution can keep the malleus fixed at the fissura petrotympanica. In comparative studies of animals (marsupials, carnivores) this theory of congenital anterior fixation of the malleus in the epitympanon was proved. Conclusion: As the malleus development is related to the Meckel's cartilage congenital malleus fixation represents a second branchial arch anomaly. Anterior bony fixation of the malleus in the epitympanon can be understood as atavism of the processus anterior mallei.

Abstract Otology 2000 C19-3

Bernard Fraysse MD (1), Young Shin MD (1), Didier Soulié MD (1), Bernard Escude MD (2), Corinne Berges MD (1), Oliver Deguine MD (1)

(1) Service ORL CHU Purpan F-Toulouse Cedex
(2) Radiology Department Clinique Pasteur F-Toulouse Cedex

The authors report their CT Scan experience in otosclerosis. On the one hand, in the positive diagnosis concerning a range of 485 CT scan asked in a context of transmission deafness with a normal ear-drum, 431 (89%) present a positive focus and 54 (11 %) had a negative CT Scan. In these last cases, 3 diagnosis have been found : - infra radiological form of otosclerosis (4 %) - minor malformation of the ossicular chain (4,5 %) - inner ear transmission deafness (2,5 %) On the other hand, the authors discuss of a CT Scan interest in the lesions topographic localisation (round window, cavitation, inner ear auditory canal, ossicular chain). At last, the authors describe the CT Scan interest before revision surgery concerning 31 cases and discuss the problem of intra vestibular penetration.

Abstract Otology 2000 C19-4

Dominik Brors MD (1), Maria Schäfers MD (2), Bernhard Schick MD (1), Wolfgang Draf MD, PhD, FRCS (1)

(1) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery D-Fulda
(2) Department of Neurology University Hospital Würzburg D-Würzburg

Objectives: Langerhans cell histiocytosis is a rare and enigmatic proliferative disorder, which usually occurs in children. It is characterized by localized granulomas (Hand-Schueller-Christian disease, eosinopilic granuloma) or by an extensive involvement of multiple organs as in Letterer-Sive disease. The etiology of this disease is probably a dysfunction of the immune system. The lesions are localized in allmost all bones, but the mandible, the skull, the ribs and the femur are most frequently involved. In single cases temporal bone affection can cause the first symptoms. Surgery, radiotherapy and chemotherapy are the different therapeutic options. Case presentation: A 12year old boy presented in 1979 with recurrent painful tumors of the skull, multiple bone lesions (femur, tibia) and skin affections. Between 1983 and 1994 different therapies (local radiotherapy 5 times, chemotherapy 2 times and surgery 2 times) were performed to treat bone and skin lesions. Already in 1986 x-ray indicated temporal bone affection on the right side. Acute vestibular symptoms gave rise in 1996 to perform computertomography and MRI evaluation. Both temporal bones were affected by granulomatous lesions and erosion of the lateral semicircular canal on the left site was detected. Conclusion: Vestibular symptoms present a rare finding in Langerhans cell histiocytosis. As localized and multiple sites of manifestation as well as a wide range of acute fulminant to waxing, chronic courses with possible spontaneous regression, individual therapy based on precise radiological diagnosis and long term observation is demanded.

Abstract Otology 2000 C19-5

Viktor Chrobok MD, PhD, Eva Simakova MD

ENT Department General Hospital CZ-Pardubice

A total of 37 temporal bones were examined from 22 fetuses. Five fetuses had renal agenesis, six polycystosis, two nonserious kidney pathology and nine had no pathology in the renal/urinary tract. During the histological study of temporal bones we found abnormalities of the stapes in three temporal bones of two fetuses. There were missing crura of stapes. Dilatation of the eustachian tube was seen in one case with Potter's sequence. Mondini's dysplasia was seen in the inner ears in the same three temporal bones with pathology of the stapes. Second part of study, we measured the volume of mesenchymal tissue in the middle ear cavity. We used the method of picture analysis by PC computer [Lucia]. The group without any pathology of the renal/urinary tract demonstrated that mesenchyme had decreased during the life of fetus. But the fetus with renal agenesis or polycystosis had much more mesenchyme than normal group. We demonstrated these results in graphs and statistic analysis. Such mesenchymal remnants may play a role in the development of otitis media, hearing loss or cholesteatoma can arise from this tissue. This problem is discussed in the literature.

Abstract Otology 2000 C19-6

Andreas Prescher MD, PhD (1), Dominik Brors MD (2), Björn Loewenhardt MD (3), Bernhard Schick MD (1)

(1) Institute of Anatomy University Aachen D-Aachen
(2) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery D-Fulda
(3) Institute of Radiology Academic Teaching Hospita D-Fulda

Capybara, the largest of all living rodents, is native in the inaccessible forests, rivers and swamps of Venezuela and Brazil. As the subcutaneous fatty tissue of this animal is iodiferous, it is used to produce different drugs. The crown-rump-length of this animal measures 100-130cm, the bodyhigh lies about 50cm. The capybara shows a short-stubby snoout with cleft superior lip and small, rounded ears. The anatomical description of capybara is still fragmentary. The architecture of the temporal bone was investigated by Hyrtel (1845) and Denker (1899) by use of corrosion casts and sections. Both authors reported already interesting specific anatomical features (e.g. dehiscence in the anterio-inferior part of the bony external auditory meatus, very enlarged epitympanic recess communicating with the tympanic cavity by a special foramen, 4 2/3 or more turns of the cochlea, a thickwalled promontorium in contrast to other rodents and a special anatomy of the internal auditory meatus). Therefore it can be assumed that the temporal bone of the capybara has an exceptional position within the rodent. 3 adult and one juvenile capybara skulls were studied by means of conventional x-ray, computertomography including 3-D-reconstructions and anatomical dissections. Additionally to the studies of Hyrtel and Denker the presented findings give an overview about the temporal bone anatomy of this rare and conspicious animal.

Abstract Otology 2000 C21-1

Michael Gleeson MD (1), Ugo Fisch MD (2), Antonio Mazzoni MD (3), Bernard K.H. Pauw MD (4)

(1) Otolaryngol. & Skull Base Surg Guy's Hospital GB-London Bridge
(2) ORL-Klinik Universitätsspital CH-Zürich
(3) Divisione ORL Ospedale Riuniti I-Bergamo
(4) ENT Dept Academisch Ziekenhuis Dijkzigt NL-Rotterdam GD

Lateral skull base surgery deals with the management of the facial nerve, internal carotid artery, otic capsula, dura, sigmoid sinus and jugular bulb, and the lower cranial nerves pathology. The surgical techniques, important anatomical landmarks, tips and pitfalls will be discussed on carefully prepared specimens.

Abstract Otology 2000 C22-1

Gerald M. O'Donoghue M.Ch FRCS (2), Per Möller MD (3), F. Erwin Offeciers MD (4), William H. Slattery MD (5)

(2) ENT Department University Hospital Queen's Medical Centre GB-Nottingham
(3) ENT Department Haukeland Sykehus N-Bergen
(4) Univ. Dept. of Otolaryngology St. Augustinus Hospital B-Wilrijk
(5) House Ear Clinic USA-Los Angeles, CA

The indications and results for stapes surgery will be discussed during the Round Table A04 (Controversies in Stapes Surgery) discussion. This instructional course will focus on the surgical techniques presented by three distinguished surgeons. Surgical tips and pitfalls will be presented and each panelist will briefly show their technique, preferred prosthesis and surgical instruments. (A similar course will be held on Monday during Session A21)

Abstract Otology 2000 C23-1

Heinz Stammberger MD (1), Daniel Simmen MD (2)

(1) Med. Fak., HNO-Klinik Karl-Franzens-Universität A-Graz
(2) ORL-Klinik Universitätsspital CH-Zürich

This session will present all systems available with the help of the companies and hands on navigation will be demonstrated. The positive and negative aspects of different systems can be discussed with the faculty during this session.

Abstract Otology 2000 C24-1

Herman Kingma MD (1), Peter M. Ott MD (2), J.C. Andrews MD (3), Daniele Nuti MD (4), Lorne S. Parnes MD (5), Dominik Straumann MD (6)

(1) ENT Department Univ. Hosp. Maastricht NL-Maastricht
(2) ORL-Klinik Universitätsspital CH-Zürich
(3) U.C.L.A. Center for Health Science USA-Los Angeles CA
(4) Dep. of ORL Università di Siena I-Siena
(5) Dept. of Otolaryngology Univ of Hospital of Western Ontario London Health Sciences Centre CDN-London Ontario
(6) Neurology University Hospital CH-Zürich

Benign paroxysmal positional vertigo of the semicircular canal can be treated with high success using canalith repositioning manoeuvers. How to achieve complete symptom relieve and what to do with treatment failures will be discussed by experts in this field. Other variations of positional vertigo will be described with conservative treatment options.

Abstract Otology 2000 D01-1

Philippe Lefèbvre MD

Human Physiology and Pathophys. University of Liege, Dep. of ENT B-Liège

Most hearing loss result from lesions of the sensory cells and/or of the neurons of the auditory part of the inner ear. There is currently no treatment able to stop the progression of a hearing loss or to restore a lost auditory function. In this presentation, we review the progress which has been made with respect to the regeneration and the protection of the hair cells and of the auditory neurons in the cochlea. In particular, we emphasize the control by growth factors of the protection/repair mechanisms of the neurosensory structures within the inner ear, in the prospect of the possible clinical use of these molecules. Finally, we discuss the different approaches which can be used to deliver these therapeutic agents to the inner ear.

Abstract Otology 2000 D02-1

Gerald M. O'Donoghue M.Ch FRCS (1), Norbert Dillier Ph.D. (2), Jona Kronenberg MD (3), Thomas Lenarz MD (4), F. Erwin Offeciers MD (5), Alain Uziel MD (6)

(1) ENT Department University Hospital Queen's Medical Centre GB-Nottingham
(2) Labor für Experimentelle Audiologie ORL-Klinik Universitätsspital CH-Zürich
(3) ENT-Department Sheba Medical Center University of Tel Aviv IL-Tel Hashomer
(4) HNO-Klinik Medizinische Hochschule Hannover D-Hannover
(5) Univ. Dept. of Otolaryngology St. Augustinus Hospital B-Wilrijk
(6) Service d'ORL Hôpital Saint-Charles F-Montpellier Cedex 5

This round table session will be organized as a spirited and informative discussion on the best scientific evidence regarding cochlear implantation. The following topics will be covered: Neuronal Survival and Histopathology, aetiology of deafness, ossified cochlea. Audiological selection criteria for adults and children Evaluation of communication, language and speech perception abilities in the very young children Diagnostic imaging Pre-implant electrophysiological testing Choice of Implant System Surgery - the routine case and the special case Intra-operative objective measures Postoperative care, programming adults and children, rehabilitation programme, maintenance Outcomes and outcome measures, health economics The future

Abstract Otology 2000 D03-1

Alan F. Ryan MD (1), Elmar Oestreicher MD (2), Yehoash Raphael PhD (3), Jukka Ylikoski MD (4), Justin Weir MD (5)

(1) Div. of Otolaryngology UCSD School of Medicine USA-La Jolla CA
(2) ENT Department Technical University of Munich D-München
(3) Kresge Hearing Research Institute The Univ.of Michigan Medical School MSRB III Room-9303 USA-Ann Arbor, MI
(4) Department of Otorhinolaryngology Helsinki University CentralHospital SF-Helsinki
(5) Physiology University of Bristol GB-Bristol

Sensorineural hearing loss consists of damage to the hair cells and neurons of the cochlea. Until recently, the mechanisms responsible for such damage were unknown. Moreover, options for the prevention and treatment of sensorineural hearing loss and peripheral vestibular disorders were limited. Recently, application of the techniques of cellular and molecular biology to the inner ear have begun to provide new information on these topics. Molecular signals which control the development of inner ear hair cells and neurons are being discovered, and could be applied to the regeneration of sensory structures. Intracellular events that lead to cell damage and death in the inner ear, and pharmacological mechanisms for prevention, have been identified. Using the tools and findings of molecular biology, methods for the application of gene therapy to the inner ear have been explored. Techniques for transplantation of sensory cells are also being developed. The participants in the round table will review recent developments, and discuss the potential for future application to patients.

Abstract Otology 2000 D03-2

Elmar Oestreicher MD, Wolfgang Arnold MD, Dominik Felix MD

ENT Department Technical University of Munich D-München

The cochlear inner hair cells (IHC) are connected to afferent type I auditory neurons and use probably L-glutamate as a neurotransmitter. This inner hair cell synapse receives efferent input from the lateral part of the efferent olivo-cochlear system with neurons originating in the brainstem and terminating below IHC synapsing with the afferent type I dendrites. A number of substances have been proposed to function as neurotransmitter or neuromodulator in the lateral efferent system: acetylcholine, GABA, dopamine, enkephaline and dynorphine. With the aid of microiontophoretic techniques we studied several transmitter candidates and characterized their receptor subtypes as well as their function on spontaneous or evoked activity of afferent dendrites. The results showed that the glutamatergic transmission of IHC is facilitated by all types of glutamate receptors: ionotropic glutamate receptors of the NMDA and AMPA type as well as group I and II metabotropic glutamate receptors. This excitatory glutamatergic transmission is under inhibitory control of GABA (mediated by GABA A receptors) and dopamine (mediated by D1 and D2 receptors). In contrast, acetylcholine was able to excite afferent dendrites via muscarinic receptors. These results demonstrate that the lateral efferent system has modulatory function on the glutamatergic neurotransmission of IHC. Excitation of afferent dendrites by glutamate released from IHC can thus be tuned in different physiologic or pathophysiologic conditions. During over-excitation of IHC like in noise, a possible therapy based on the neurochemical data would be a) glutamate release inhibitors b) glutamate antagonists c) dopamine agonists d) GABA agonists or a combination from a,b and c,d.

Abstract Otology 2000 D04-1

J.C. Andrews MD (1), Herman Kingma MD (2), Jan W.C.M. Jansen Ph.D. (3), Daniele Nuti MD (4), Peter M. Ott MD (5), Lorne S. Parnes MD (6), P. Vannucchi MD (7)

(1) U.C.L.A. Center for Health Science USA-Los Angeles CA
(2) ENT Department Univ. Hosp. Maastricht NL-Maastricht
(3) Assistant Professor NL-DA Weesp
(4) Dep. of ORL Università di Siena I-Siena
(5) ORL-Klinik Universitätsspital CH-Zürich
(6) Dept. of Otolaryngology Univ of Hospital of Western Ontario London Health Sciences Centre CDN-London Ontario
(7) Service of Audiology University of Florence I-Firenze

no abstract

Abstract Otology 2000 D04-3

Jan W.C.M. Jansen Ph.D.

Assistant Professor NL-DA Weesp

Betahistine is an orally active compound for the treatment of Ménière's disease and vertigo. The beneficial effect of Betahistine in Ménière's disease is assumed to be caused by increasing inner ear blood flow leading to normalization of the increased osmotic pressure of the endolymph. Animal data support this statement showing increased microcirculation in the inner ear caused by Betahistine administration: Kubicek et al. (1967) measured increased flow changes in labyrinthine arteries in the dog, Suga and Snow (1969) measured an increased blood flow in the cochlea of the guinea pig and Laurikanen et al. (1993) confirmed these phenomena in the rat using laser doppler flowmetry. The H1-agonistic (partial) and the H3-antagonistic properties of Betahistine explain these phenomena. Clear indications are also present that Betahistine affects neuronal activity: Betahistine induces an inhibitory effect on the polysynaptic neurons in the vestibular nuclei. Modulation of the excitability of MVN neurons by the histaminergic system is probably an endogenous mechanism during abnormal vestibular stimulation. Under pathological conditions Betahistine stimulates this mechanism leading to vestibular compensation and conditional improvement : Tighilet et al. (1995) showed that Betahistine treatment strongly accelerated the recovery process of unilateral vestibular neurectomized cats. The H3-antagonistic activity of Betahistine is responsible for this beneficial effect. The observations make clear that 1/ histamine and histamine-receptors play a key role in vestibular processes; 2/ Betahistine affects the vestibular system at different levels: increase of cochlear blood flow and inhibition of vestibular neuronal cell activity leading to accelerated vestibular compensation; 3/ these properties make Betahistine an efficient agent leading to improvement of vestibular dysfunction. Sponsored by: Solvay Pharmaceuticals

Abstract Otology 2000 D05-1

Cor W.R.J. Cremers MD (1), Steven J.H. Bom MD (1), Bill Kimberling MD (2), Alessandro Martini MD (3), Thomas Spillmann MD (4), Guy Van Camp MD (5)

(1) ENT-Deptmt. Academisch Ziekenhuis Nijmegen Postbus 9101 NL-Nijmegen
(2) Cent. for Hered.Comm.Disord. Boys Town Nat. Research Hosp. USA-Omaha Nebraska
(3) Servizio di Audiologia Clinica ORL Università degli studi I-Ferrara
(4) Dept. Otolaryng. and Head & Neck S. University Hospital CH-Zürich
(5) Centrum Medische Genetica Univ. Ziekenhuis Antwerper B-Wilrijk

Since the early nineties molecular genetic technology has become sufficiently strong to localise and identify genes for non-syndromic autosomal dominant (DFNA-21), autosomal recessive (DFNB1-26) and X-linked (DFN1-8) genetic hearing impairment. In Europe "The Work Group on the Genetics of Hearing impairment" was supported by a Biomed grant and has stimulated this research by organising workshops and by editing a newsletter. In this short time about 50 new genetic types of non-syndromic genetic hearing impairment have been identified. Almost 20 genes have been identified. Many of them proved to be molecular cornerstones of the inner ear like Potassium and chloride channels. Based on the different genotypes the audiometric phenotype has been studied in large affected families. The audiometric pattern for autosomal dominant inherited hearing impairments (DFNA1-21) will be presented. Most of the genetic deaf-blindness is the result of Usher syndrome (USHI A-F, USHII A-B, USHIII). This panel will present the state of the art in this field research.

Abstract Otology 2000 D06-1

Alan G. Kerr MD (1), Stephan Schmid MD (2), Cor W.R.J. Cremers MD (3), Gordon B. Hughes MD (4), Jacques Magnan Prof.Dr.med. (5), Per Möller MD (6)

(1) Eye and Ear Clinic Victoria H IRL-Belfast
(2) ORL-Klinik Universitätsspital CH-Zürich
(3) ENT-Deptmt. Academisch Ziekenhuis Nijmegen Postbus 9101 NL-Nijmegen
(4) Otolaryngology The Cleveland Clinic Foundation USA-Cleveland OH
(5) Dept. ORL Hôpital Nord F-Marseille Cedex 20
(6) ENT Department Haukeland Sykehus N-Bergen

In this final panel the highlights and the "take home messages" will be reviewed and dicussed by experts of the Politzer Society. the idea is to give a summary of the important points we learned during this congress. There will also be an outlook of the next Politzer meeting and the new frontiers of otology an the otological skull base surgery.

Abstract Otology 2000 D06-2

Albert Mudry MD

ENT Department University Hospital CHUV CH-Lausanne

Objective: To study and understand the role of Adam Politzer to 20th century otology and analyse his place in the history of otology. Method: Study his four reference works, some of his publications in medical journals and diverse publications written about him. Results: All areas of otology have been studied, compiled and improved through his varied publications, notably his atlas of otoscopy published in 1865, the first work of its kind, expanded and re-edited in 1896; his ten anatomical drawings emended in 1873; his work based on otology which was first published in two volumes in 1878 and 1882, then re-edited four times as one volume, the last time being in 1908; his anatomy and histology book published in 1889; and his book on the history of otology which, up to now, is the most complete tome existing on the subject, edited in two volumes in 1907 and 1913. No other has been as prolific as he. He invented, in particular, a revolutionary method of making the Eustachian tube permeable, a method which made him famous and carries his name. He also developed an acoumeter to measure hearing and was the first to describe histologically, certain pathologies of which otosclerosis is one. Conclusion: Politzer is certainly the greatest otologist of the 19th century and probably one of the greatest of all time. His influence during fifty years of otology has never been equalled. He deserves a double mention in the history of otology, as an otologist and as a historian.

Abstract Otology 2000 D10-1

Thomas P. Nikolopoulos MD, PhD, Gerald M. O'Donoghue M.Ch FRCS, Kevin P. Gibbin

E.N.T Department Nottingham University Hospital GB-Nottingham

Introduction: Increased surgical experience, anatomical and histological data, and accumulating evidence that early implantation is of great importance1,2, led clinicians to reevaluate the lower limit for implantation (2 years of age - US FDA). Material and methods: In a total number of 210 children implanted in Nottingham University Hospital, 8 were younger than 2 years old (the youngest being 1 year and three months old). The aetiology of deafness was meningitis for 5 children (62.5%) and congenital deafness for 3 children (37.5%). Results: All 8 cases under 2 years of age were successfully implanted using an extended endaural surgical approach. The facial nerve was not exposed and chorda tympani was preserved in all cases. Through a separate cochleostomy, the basal cochlear turn was found patent in 5 children (62.5%), partially obliterated in 2 cases (25%), and fully obliterated with soft tissue in one case (12.5%). In the 3 latter cases scala tympani drill-out was required (3-5 mm). In 7 cases (87.5%) 22 electrodes were inserted and in 1 case (the fully obliterated) 18 electrodes were inserted. The time of operation varied between 2.5 and 3.5 hours and did not differ from the average duration of surgery in the other 208 older children implanted in our center. Conclusion: Cochlear implantation, in experienced centers, as a surgical procedure does not differ in children under 2 years of age in comparison with older children. Moreover, in cases with early post-meningitic obliteration, implantation in very young age is strongly indicated. References 1. Waltzman SB, Cohen NL, Gomolin RH, Green JE, Shapiro WH, Hoffman RA, Roland JT-Jr. Open-set speech perception in congenitally deaf children using cochlear implants. Am J Otol 1997; 18: 342-349. 2. T. Nikolopoulos, G. O'Donoghue, S. Archbold. Age at implantation: Its importance in paediatric cochlear implantation. Laryngoscope 1999; 109: 595-599.

Abstract Otology 2000 D10-2

Jan Kiefer MD, Christoph Von Ilberg Prof.Dr., Volker Gall Prof.Dr., Gottfried Diller Prof.Dr.phil., K. Neumann Dr.med.

Universitätsklinik ZHNO Klinikum der J.W. Goethe-Univ. D-Frankfurt a.M.

Long term results after cochlear implantation in 88 prelingually deaf children with five different cochlear implants are presented and compared to 35 children wearing hearing aids. Children were tested at regular intervalls with speech tests, presented from PC. Everyday auditory and verbal behavior were asessed with the MUSS and MAIS-questionaires. Results showed a continuous increase of results over time, extending beyond the third year. The benefit after cochlear implantation was calculated as the difference between the actual performance with CI and the predicted performance with hearing aids for each individual child. Children performed significantly better than they would have with hearing aids. Implanted below the age of 6, they obtained results equal to children with hearing aids and Pure Tone Averages (250-4000 Hz) of 70-85 dB HL. A statistically significant positive correlation between PTA and benefit was found. From the regression line, a break even point of 86 dB was found, i.e. children with PTA>86 dB HL were likely to profit from implantation. Based on these results, a borderline of 95 dB PTA for indication to cochlear implantation is proposed. The time after implantation, the age at time of testing and the age at implantation were the most important predictive factors. Children implanted below the age of 6 were performing significantly better and improving at a faster range than children implanted at an older range. Furthermore, the effects of preoperative hearing levels, different speech coding strategies, etiology of hearing loss and other factors will be discussed.

Abstract Otology 2000 D10-3

Zdenek Kabelka MD, Vladimíra Boleslavská MD, Eva Vymlátilová PhD, Jaroslava Prihodova MD

ENT Department 2nd Medical School Charles University CZ-Praha

There were 75 children operated on in the Cochlear implant centre for children in Prague, Czech Republic from the year 1993. We used cochlear implant system Nucleus (36 Nucleus 22, 13 Nucleus 20 + 2, 26 Nucleus 24). From surgical point of view we prefer Lehnhardt's soft surgery (40 children) and round window insertion (34 children). Total insertion (22 electrodes) was possible in all except of 5 children - (11, 11, 14, 17 and 18 electrodes). Obliteration of the basal turn was diagnosed in 4 children; removal of the new formated bone enabled total insertion. Cause of deafness in our set : congenital 42, meningitis 25, other 6, unknown 2 children. Average age was 5,5 years ( from 1 year and 10 months to 17 years). In the last years an increased amount of research has addressed the benefit size from cochlear implant in children and predictive factors significance. 30 Czech children who have been using the Nucleus cochlear implant for more than 2 years were thoroughly assessed in our CI centre. Their achievements and auditory skills were statistically correlated to the results of preoperative psychological examinations and other predictive factors. Cognitive skills of the implanted children were found to be one of the most important factors influencing the degree of benefit from cochlear implantation. Absence of symptoms of minimal brain dysfunction seems to be of equal importance.

Abstract Otology 2000 D10-4

Thomas L. Eby M.D., T.E. Borton M.D., B. Champion MD, M. Springfield M.D.

Div. of Otolaryngology/Head & Neck Department of Surgery University of Alabama USA-Birmingham AL

Despite the increase in cochlear implantation in children in recent years, little has been published about the performance of prelingually deaf adolescents after implantation. Reports suggest slow progress or lack of significant progress in open set speech recognition and speech intelligibility. Some have discouraged cochlear implants in older children. We reviewed the outcome of cochlear implantation in six pre-adolescent children. All had prelingual deafness and were implanted with the Nucleus 22 cochlear implant with Spectra coding strategy. The age at implantation ranged from 9 to 17 years and follow up time was 1 to 5 years. The educational environment of these children varied with 2 in auditory verbal programs and four in total communication programs, one of whom is in a residential school for the deaf. The post implantation assessment of speech recognition, speech intelligibility, as well as, patient and family satisfaction are reviewed. Modest improvement on speech recognition measures and variable results on speech intelligibility were seen. However, several of the implanted children showed dramatic improvement in overall school performance including standardized testing of verbal and reading ability. Although other factors for this improved performance cannot be absolutely excluded, both patients and their parents attributed it to benefit from the cochlear implant. We conclude that while scores on standardized tests of speech perception are important tools for evaluation of the benefits of cochlear implantation, they should not be the sole determiners of success for implanted patients.

Abstract Otology 2000 D10-5

Marianna Küstel MD, PhD, Otto Ribari MD, DSc., Katalin Speer , Agnes Szirmai MD

Clinic of Otorhinolaryngology, Head and Neck Surgery Semmelweis Univ. Med. School H-Budapest

Since the beginning of our cochlear implant program in 1985 ninety cochlear implantations have been performed. Over the last 7 years contralateral hearing improvement has been observed in several patients. This phenomenon was usually demonstrated 6 months after the operation. In comparison with the preoperative hearing threshold at least 10 dB improvement could be observed on two or more frequencies in the contralateral ear. On the basis of Prof. Ilberg¢s new theory of hearing improvement on the implanted ear we report our experience applying both hearing aid and cochlear implant on the same ear. Also vestibular function of cochlear implant patients were checked routinely pre- and postoperatively and changes in vestibular responsiveness were observed. In most patients the vestibular function was unchanged after implantation, but in some cases significant improvement of the vestibular responsiveness was noted. It seems, that chronic electrical stimulation on one side effects both ears and results, to a certain degree, in regeneration of the auditory pathways. The considerably more frequent occurrence of the regenerating effects of cochlear implantation on the hearing and vestibular function of both ears might be due to the newer generation of implants with more effective stimulation.

Abstract Otology 2000 D10-6

Christoph Von Ilberg Prof.Dr., Jan Kiefer MD, Jochen Tillein MD, Thomas Pfennigdorff MD, Rainer Hartmann Dr.-Ing., Rainer Klinke Prof.Dr.

Zentrum f. HNO Klinikum der J.W.Goethe-Univ. D-Frankfurt a.M.

Cochlear implantation has proved to be highly effective in patients with bilateral deafness or residual hearing. On the other hand acoustic stimulation of the hearing system by conventional hearing aids in patients with severe or profound hearing loss is of limited value, especially in cases with deficits in the high frequency range. For these patients, an additional electrostimulation of the high frequency fibers of the auditory nerve might improve their hearing. The question of our ongoing studies is: Does a simultaneous electrical stimulation interfere with the physiological discharge pattern of the auditory nerve in response to acoustic stimulation? In animal experiments, single fibre recordings of primary auditory afferents in 7 normal hearing cats were performed with concomitant extracochlear stimulation. Tuning curves and characteristic frequencies of the nerve fibers were determined for acoustic stimulation alone. Then electrical thresholds were determined for sinusoidal stimuli at 125 Hz and the tuning curves and CF was measured again for simultaneous electrical and acoustical stimulation. We could demonstrate, that the electrical stimulation does not mask the response to acoustic stimulation. The effect of chronic electrostimulation on acoustic hearing is currently evaluated in guinea-pigs. Our findings are considered to be the first steps towards the possibility of a combined electro-acoustic stimulation (EAS) in cases with severe or profound high frequency hearing loss. First clinical results in patients show, that combined EAS can increase the performance over acoustic or electric stimulation alone.

Abstract Otology 2000 D10-7

Monika Lehnhardt Dr.

Cochlear AG CH-Basel

Entering a new millenium means to pause and reflect, "where do we come from?", "where do we stand now?" and "where do we go from here?". Many people expect revolutionary rather than evolutionary developments just because of the fascination of the round number 2000. Whether this high level of expectation will be met is rather questionable. Realistically, the speed of changes and hopefully progress will continue growing, the amount of data and information will be accumulated much faster and be made more easily accessible. This should be a sound basis to draw conclusions and make strategic decisions that lead the way into the future. The presentation will review the history of Cochlear Implant as a concept to replace the function of the inner ear. The current state of the art will be described by explaining the various features and benefits of the NUCLEUS system, e.g. the flexibility of various speech coding strategies (SPEAK, CIS, ACE), the choice between a body-worn SPRINT and a Behind-the-Ear ESPrit speech processor and the availability of Neural Response Telemetry as a development that will hopefully provide a tool to predict which coding strategy is best for very young children in the future. An outlook into new developments with the goal to improve the quality of life of C.I. users, i.e. cosmetic aspects as well as higher levels of performance in speech understanding and appreciation of music will be given. Other factors influencing the "success" of C.I. will be described, e.g. physiological and psychological aspects, post-operative care and various rehabilitation methods. Potential limiting factors such as economical considerations that may decide upon patient selection will be mentioned and studies how to overcome monetary obstacles will be suggested.

Abstract Otology 2000 D11-1

Alan F. Ryan MD, K. Pak MD, A. Battaglia MD, Stefan Dazert MD, D. Dulon MD

Div. of Otolaryngology UCSD School of Medicine USA-La Jolla CA

Damage to hair cells is a leading cause of hearing and balance disorders. New strategies for the prevention and treatment of hair cell damage have emerged from the growing fields of molecular and pharmacological otology. The intracellular pathways involved in hair cell damage and death are being elucidated. In addition, receptors that promote cell survival have recently been discovered on hair cells. This information has provided new opportunities for pharmacological intervention to prevent hair cell loss. For example, we have found that inhibitors of G-protein signaling and apoptosis will protect hair cells from damage due to ototoxicity. Also, activation of cell surface receptors by FGF-2 and TGFa is protective of hair cells. Another source of potential new treatments has emerged from molecular genetic studies. Genes that produce inherited forms of hearing loss are being identified at an accelerating rate. Understanding of these molecular defects allows genetic counseling and provides additional potential modes of therapy. Manipulation of the genetic response of air cells using gene therapy is an additional avenue for treatment. For example, we have found that incorporation of a bacterial antibiotic resistance gene into hair cells protects them from aminoglycoside ototoxicity. Finally, molecular biological techniques have been developed with which to pursue new avenues of research. They permit the separation of events involved in hair cell death, such as loss of the stereociliary array and death of the cell body. They also allow the study of transfer of cells between sensory epithelia. (Supported by grant DC00139 from the NIH/NIDCD and by the Research Service of the VA.)

Abstract Otology 2000 D11-2

Timo Stöver Dr.med., Masao Yagi Dr.med., Thomas Lenarz MD, Yehoash Raphael PhD

Department of Otolaryngology Kresge Hearing Research Institute The University of Michigan USA-Ann Arbor, MI

In vivo intracochlear gene transfer has been shown to be a feasible tool for inner ear gene therapy in the guinea pig. By transfecting cochlear cells with gene sequences that encode neurotrophic factors and thereby inducing the expression of neurotrophic factors in cochlear tissue, viral-mediated gene transfer provides an alternative to direct drug application (Yagi et al., 1999). Interestingly, we observed protective transgene effects in both ears, following viral vector inoculation via a cochleostomy into one ear. Local cochlear drug delivery, via osmotic pumps, has also been described to cause drug related effects in the contralateral ear (LePrell et al., 1999). The mechanism of the contralateral effect is unclear. Hypotheses to explain the contralateral cochlear effects following local cochlear manipulation included blood mediated transport, bone marrow mediated diffusion or brain fluid mediated transfer into the untreated cochlea (Lalwani et al., 1998). To directly test these hypotheses, we used adenoviral vectors containing the reporter gene b-galactosidase. We determined that inoculation of 15-25 microliters or more in guinea pig ears results in reproducible contralateral transfection with the reporter gene. Preliminary data indicate that the contralateral effect is based on transport via the perilymph and CSF. This work was supported by NIH NIDCD Grant P01 DC00078. TS is a scholar of the Alexander-von Humboldt-Foundation.

Abstract Otology 2000 D11-3

Yehoash Raphael PhD

Kresge Hearing Research Institute The Univ.of Michigan Medical School MSRB III Room-9303 USA-Ann Arbor, MI

Approaching the last year of this millenium, treatment for genetic and environmentally induced inner ear (IE) disease is rapidly advancing. Since loss of hair cells (HCs) in mammals is irreversible, their protection and rescue are of clinical importance. Neurotrophic factors (NFs) have been shown to protect the structure and function of cochlear and vestibular epithelia from trauma. We have used an adenoviral vector expressing the human GDNF gene in guinea pig IEs for protection and rescue of HCs and cochlear function. The viral vector was inoculated into the scala tympani of the left cochlea through the round window. Controls included the unoperated (right) ears, and additional operated ears, inoculated with a lacZ-expressing vector or artificial perilymph. ABRs were measured to assess function, before experiments begun, and at sacrifice. Four days post injection, animals were traumatized with noise (4 kHz octave band noise, 115 dB SPL, 5 hours) or aminoglycosides and sacrificed 7 days later. In both noise and drug groups, GDNF over-expression protected HCs and cochlear function. Inoculation with control solutions alone demonstrated that gene transfer by itself is not toxic to the IE. These data demonstrate the feasibility for gene therapy for protection and rescue of HCs after noise and drug trauma. Current experiments are aimed at extending gene-based therapy to treating genetic IE disease. Supported by Amgen Inc. and NIH NIDCD Grants P01 DC00078 and RO1 DC 01634.

Abstract Otology 2000 D11-4

Thomas J. McDonald M.D., M.S., F.A.C.S.

Department of Otolaryngology Head and Neck Surgery Mayo Clinic & Mayo Foundation USA-Rochester, MN

Bilateral fluctuating sensorineural hearing loss or fluctuating hearing loss in the only hearing ear are two situations that truly constitute a medical emergency. Eighteen patients having either of these problems are presented in the preliminary report and the early results of treatment with Methotrexate are reviewed. Criteria for inclusion in the study were patients having truly idiopathic hearing loss which had responded to corticosteroids. All patients received the following studies: ophthalmologic examination, CBC, SGOT, creatinine levels, FTA-ABS, head imaging, sedimentation rates, and antiphospholipid antibody titers (aPL). Each patient was started on 7.5 mg. of Methotrexate weekly and monitored monthly for evidence of liver toxicity. The dose of corticosteroids was tapered and ultimately discontinued in each patient. Hearing results were very encouraging. There were no side effects. The rationale for using Methotrexate as an alternate treatment to corticosteroids in patients with autoimmune disease is presented and the possibility of this disease being a complication of aPL are discussed.

Abstract Otology 2000 D11-5

Run Sheng Ruan MD, Seng Kee Leong MD, Kian Hian Yeoh MD

Department of Otolaryngology National University of Singapore SGP-Singapur

The aim of this study is to determine whether neurotrophic factors, like brain derived neurotrophic factor (BDNF) and neurotrophin 3 (NT-3) would protect auditory hair cells from ototoxicity of aminoglycoside antibiotic. Twenty seven Wistar guinea pigs were divided into 3 groups of 9 animals each. BDNF, NT-3 at a concentration of 100 µg/ml were delivered into the right scala tympani of guinea pig cochlea through a cannula-osmotic pump device. Artificial perilymph (AP) was used as control. Right after implantation of the device, each animal was given 5 successive doses of kanamycin at 400 mg/kg body weight. At 15, 30 and 60 days after infusion, surviving inner and outer hair cells were counted at each turn of every cochlea with a Philips 515 scanning electron microscope. Multiple comparison tests were carried out among the groups, using ANOVA and Dunnett T3 /Tukey HSD. Protective effects of NT-3 on hair cells were observed at 30 and 60 days after kanamycin injection. BDNF had no protective effect on hair cells at 15 and 60 days, but some at 30 days. This study suggests that NT-3 and BDNF may protect against cochlea hair cell damage caused by kanamycin treatment. Possible mechanisms for the otoprotective effects were discussed. No single mechanism postulated can explain fully the results seen in this study. It is possible that the mechanisms act in concert to produce the observed effects, or there are as yet undiscovered mechanisms or secondary messengers responsible for the otoprotective effects.

Abstract Otology 2000 D11-6

Steven J.H. Bom MD, M.H. Kemperman MD, Y.J.M. De Kok MD, P.L.M. Huygen MD, W.I.M. Verhagen PD, F.P.M. Cremers MD, Cor W.R.J. Cremers MD

ORL Department University Hospital Nijmegen NL-Nijmegen

We examined auditory and vestibulo-ocular functions in a Dutch family with hereditary sensorineural hearing impairment (SNHI), caused by a 208C>T mutation in the COCH gene located in chromosome 14q12-q13 (DFNA9), which showed an autosomal dominant pattern of inheritance with full penetrance. We were able to evaluate fifteen of the sixteen genetically affected persons. They all developed hearing and vestibular impairment symptoms in the fourth to fifth decade and, in many cases, also cardiovascular disease. We derived the gross characteristics for the hearing impairment in this trait from linear regression analysis of individual longitudinal data (n=11) of age corrected hearing thresholds and scatterplots of all data available. At the low frequencies (0.25-2 kHz), it started at the age of about 40 and showed an average annual progression of approximately 3 dB. In two exceptional cases, annual progression attained levels of up to 24 dB. At the high frequencies (4-8 kHz), the average threshold increased from about 50 dB at the age of 35 to about 120 dB at the age of 75 (which amounts to 1.8 dB annual threshold increase). All affected individuals tested showed normal ocular motor functions. The patients aged over 46 years showed absence and in one case severe impairment of the vestibulo-ocular reflex and enhancement of the cervico-ocular reflex, whereas those aged 40-46 years showed either severe bilateral vestibular hyporeflexia or unilateral caloric areflexia. These findings suggest a gradual development of vestibular areflexia.

Abstract Otology 2000 D11-7

A.M. Meyer zum Gottesberge MD, Heidi Felix Ph.D., H. Weiher PhD

Department of Otorhinolaryngology University of Duesseldorf D-Düsseldorf

The Mpv17 transgenic mouse strain, generated by insertion of defective retrovirus into the germline, is characterized by early onset focal segmental glomerulosclerosis, concomitant hypertension and impairment of the inner ear function. In an effort to identify the role of the Mpv17 proteine in the inner ear, a comparative study was performed using histological, immunohistological, histochemical, and electron microscopical approaches. Time dependent degeneration of the stria vascularis and of the spiral ligament, the organ of Corti, and cochlear neurons were revealed. The changes in the stria vascularis range from thickening and splitting of the basement membrane of the capillary wall to the complete desintegration of strial epithelium and its atrophy. Morphological studies of kidneys and inner ears in transgenic MPV17-negative mice reveled similar histopathologic findings to patients with clinical Alport syndome, an inherited disorder characterized by progressive nephritis and neurosensory deafness. Our results indicate that beside primary mutations of several type IV collagens known for Alport syndrome, also the loss of Mpv17 gene function is somehow responsible for the renal- and otopathology. The primary cause of the disease in mutants is a loss of function of Mpv17 protein, a peroxisomal gene product, involved in reactive oxygenmetabolism. As recently found, Mpv17 gene play a crucial role in the regulation of matrix metalloproteinase-2 (MMP-2) a member of large subfamily of proteinases which has a major role in physiological control of extracellular matrix components. Both locations of pathology the inner ear and the kidney, show increased MMP-2 expression in the absence of the Mpv17 gene product. Thus, it seems conceivable, that MMP-2mediates the molecular mechanisms involved in the pathology of both organs. (supported by DFG ME 890-1, 890-2)

Abstract Otology 2000 D12-1

Christiane I. Messias Dr.med., Carlos A. Oliveira Prof.Dr.

Department of Otolaryngology Brasília University Medical School Campus Univ. Darcy Ribeiro BR-Brasília- D.F.

In 1992 we described a patient with classic Ménière's syndrome. His four daughters and three of his four sons also had the syndrome. The proband's incapacitating vertigo and drop attacks were much improved after an endolymphatic sac enhancement procedure. Headache was present in all affected siblings. In 1997 we described a similar family. This time the associated headache was characterized as migraine in most patients. For the last two years (1997-1998) we selected from our outpatient department all patients displaying classic Ménière's syndrome and carefully searched for other family members affected by the symptoms. We collected 8 patients with the classic Ménière's syndrome (episodic vertigo, tinnitus, fluctuant hearing loss, pressure in the ear). Three had enough siblings affected by the syndrome to characterize an autosomal dominant genetic transmission, 2 had other family members affected but not enough to characterize the mode of transmission and 3 had no other family members affected. Migraine was present in all three families and in 2 sporadic cases. Audiometry and ENG were performed on all affected siblings. Although we see a large number of dizzy patients typical Ménière's syndrome is uncommon in Brasília. Indeed in the last 22 years only 15 endolymphatic sac procedures were performed in our clinic. Among 8 patients with the classic syndrome seen in 2 years 38% had an autosomal dominant pattern of genetic transmission and 25% had other family members affected. We believe a strong case can be made for a genetic etiology in idiopathic Ménière's syndrome (Ménière's disease).

Abstract Otology 2000 D12-2

Levent Sennaroglu MD, Gonca Sennaroglu MD, Bulent Gursel MD

Department of Otolaryngology Head and Neck Surgery Hacettepe University TR-Ankara

Intractable vertigo in Ménière's Disease still presents a challenging situation for the otolaryngologist. In the presence of serviceable hearing, treatment options include intratympanic steroids, intratympanic gentamicin, vestibular nerve section, and endolymphatic sac decompression. As there is no established treatment which is universally agreed upon, the debate is still going on. In this investigation intratympanic dexametasone, gentamicin and endolymphatic sac decompression are compared in intractable vertigo. All patients were given medical treatment (salt and caffeine restriction, vasodilator (betahistine hydrochloride BetasercR), diuretic (acetazolamide, DiamoxR and encouragement to eliminate nicotine) for at least six months and only those who did not benefit from this regimen and still had disabling vertigo attacks were included in this study. Dexametasone was applied through ventilation tube in 24 patients, intratympanic gentamicin to 16 patients, while 25 patients underwent endolymphatic sac surgery. Satisfactory control of vertigo was 72%, 50% and 52% respectively for the three modality. Two patients in the gentamicine group had total hearing loss. In the dexametasone group hearing level remained the same in 46% of the patients with 16% increase and 38 % decrease (30% 10dB and 8% 20 dB). To conclude we believe that strict adherence to the medical treatment at least six months improves the vestibular symptoms in the vast majority of the patients and they do not need further procedures. If the vertiginous symptoms still persist after six months intratympanic steroids can be started. After three months if there is no further improvement, patients with profound sensorineural hearing loss undergo intratympanic gentamicin. ESD is reserved for patients with good hearing. If ESD also fails patients with good hearing may undergo vestibular nerve section while patients with nonservicable hearing become candidates for labyrinthectomy.

Abstract Otology 2000 D12-3

Sertac Yetiser MD, Mustafa Kertmen Prof.Dr.med., Yalcin Ozkaptan Prof.Dr.med., Ahmet Dundar Prof.Dr.med.

Dept. of ORL & HNS Gulhane Medical School TR-Etlik, Ankara

The ideal treatment which prevents the progress in Ménière's disease has not been developed yet. For patients with incapacitating unilateral Ménière's disease who are resistant to medical therapy, chemical ablation of vestibular function with intratympanic gentamicin has been recommended recently since it can be done easily as an outpatient procedure without the risk of cochlear damage due to adjusted dosing. However, central compensation after ablation of unilateral vestibular function varies in each patient and is the major concern since it may result with result with prolonged inability to work and restricted social life. This study presents a long-term folow-up of 17 patients who were treated with an application of intratympanic gentamicin since 1995. The compensation process was followed by clinically and by periodic ENG recording. 1ml of 30mg/cc pH adjusted gentamisin solution was injected into the middle ear through the tympanic membrane for 3 consecutive days if the patient's hearing level is better than 40dB and SD score is greater than 60%. However, 1ml of 40mg/cc gentamicin was given if the patient has hearing threshold worse than 40 dB and SD score less than 60%. Their hearing level was followed by audiogram on daily basis during the therapy. After completion of therapy, patients were encouraged to come to interview for clinical and electrophysiological evaluation twice a month. Their response to therapy was noted according to their sex, age, hearing level, presence of bilateral occurence, their occupation, visual ability, the severity and the duration of symptoms. It was found that it lasted more than 10 months in 1 patient who is 65 years old and it took almost one and a half year in another one who is 77 years old. Additionally, even minimal involvement in the counterlateral ear is a considerable factor which delays the balance improvement. On the other hand, two patients ho have unilateral loss of vision never developed compensation for 16 and 18 months. It was found that dosing, the severity of symptoms (tinnitus, hearing level, previous form of vertigo) and sex have no role in compensatory period but the age and the quality of vision. This result may propose a rationale for patient selection to ablative therapy or initiation of vestibular adaptation tests prior to gentamicin application.

Abstract Otology 2000 D12-4

Sertac Yetiser MD, Mustafa Kertmen Prof.Dr.med., Yalcin Ozkaptan Prof.Dr.med., Ahmet Dundar Prof.Dr.med.

Dept. of ORL & HNS Gulhane Medical School TR-Etlik, Ankara

Detection of hydrops in patients with Ménière's disease having normal or near to normal hearing and presenting unpredictable symptoms with great variability of severity, periodicity and duration is the major concern in reaching the accurate diagnosis and assessment of any particular treatment. Diverging results after repeated recordings of EcocG bring some questions on reliability of this test. In order to investigate the level of vestibular hydrops, electronystagmographic evaluation of patients with Ménière's disease before and after Furosemide application which is administered intravenously as a potent natriuretic agent has been reviewed. The relation between the improvement in caloric response and the periodicity of vertigo, duration of disease, age and sex of patients has been systematically documented. 40 subjects (20 patients with Ménière's disease [13 definite with vestibular symptoms, 7 possible Ménière; 2 cochlear with mild hearing loss, 5 vestibular with 2 attacks] and 20 adults with no symptom as control group) have participated in this study. Before and 30 min. after administration of 20 mgr Furosemide, both ears were tested with air caloric ENG given at +52°C for 9sec with a flow rate of 15lt/min. Slow phase velocity of each recording was particularly analyzed. The test was accepted as positive after injection if the slow phase velocity of maximum nystagmus was found to be elevated more than 9.4%. No correlation between the active status of the disease and the level of positive response on the test has been found. There is also no correlation between the duration of the disease and the results. However, the level of canal paresis is greater and if the beginning of the disease is more than a year and the involved ear gives better improvement on ENG after Furosemide injection if the disease is less than 6 months. It has been concluded that this test may only be used for a particular group of Ménière patients.

Abstract Otology 2000 D12-5

David W. White MD

Eastern Oklahoma Hearing and Balance Center USA-Tulsa OK

Retrolabyrinthine/retrosigmoid vestibular neurectomy (RL/RSIG VN) has been widely used for the treatment of severe vertigo. Out of the series of RL/RSIG vestibular neurectomies performed at our center, there have been a series of special situations which occurred both while planning and during surgery. Failure to address these situations could have resulted in complications, altered outcomes or even termination of the planned procedure. These unique situations will be presented. The steps used in evaluation and management of each situation will be discussed. Actual case photographs, diagrams and CT scans will be used to demonstrate the specific situation and the technique used in solving the problem.

Abstract Otology 2000 D12-6

Olivera Miskovska MD, Ilija Filipce MD, R. Sundovski MD, Sandre Gjorsevski MD

ENT Department Medical Center Bitola MAZ-Bitola

Every otorinolaryngologist is confronted by the problem of therapy for Ménière's disease. Although the classic triad of symptoms of episodic vertigo, tinnitus, and fluctuating sensorineural hearing loss are well recognized an effective method for relief from these disabling attacks is not known. Medical and surgical treatment of Ménière's disease are controversial. This paper discusses the current options for the treatment of disabling vertigo. Medical therapy is effective in controlling symptoms in the majority of patients. Surgical treatment is reserved for those patients who continue to have disabling vertigo despite medical treatment. Several of the surgical procedures discussed also have aplication for dizinness of other aetiologies such as post-traumatic vertigo, post-surgical vertigo, and persistence of disabling symptoms folowing an episode of vestibular neuronitis. The surgical treatment of benign positional vertigo, vascular loops, and perylymphatic fistula is also briefly discussed.

Abstract Otology 2000 D12-7

Alan G. Kerr MD (1), Joseph G. Toner MD (2)

(1) Eye and Ear Clinic Victoria H IRL-Belfast
(2) ENT Opd Belfast City Hospital IRL-Belfast

Over the years we have often been surprised at how many patients have been free from dizziness between the date of surgery being planned and the date of admission. We started a prospective study in May 1994 in those who had prolonged incapacitating episodic vertigo. We offered surgery but not without a waiting period of 6 to 8 weeks. We reassured the patients that they would not have to continue indefintely with the problems of their vertigo. We then saw them 6-8 weeks later. This survery has now run for over five years. During that time we saw 23 patients with incapacitating vertigo whom we thought should be offered surgery. Six to eight weeks later, 12 had had a dramatic improvement in vertigo, most not having had any further attacks. Eleven of these have continued to be free from incapacitating vertigo. Two who had not settled by the first review have subsequently done so. What is happening? Maybe the indications for surgery are too low, but we don't think so. Maybe the incidence of attacks of vertigo in Meniere's disease reaches a crescendo just before going into remission and we are catching that point. Maybe something physical happens within the inner ear. Are we simply looking at the natural history of the disease and is this what is happening with the so called conservative operations? Continued follow up is required to find out how this group will do in the long term.

Abstract Otology 2000 D13-1

Olivier Sterkers MD, A. Rey MD, M. Kalamarides MD, D. Bouccara MD

Service d'ORL, Hôpital Beaujon Faculté Xavier Bichat Université Paris 7 F-Clichy

The management of small vestibular schwannomas (VS), either intracanalar (stage I) or with a small extension of less than 2 cm in CPA (stage II) is still under debate including surgery, observation and stereotactic irradiation. From 1987 to 1997, among 343 VS referred to our department, 202 were small VS (79 stage I and 123 stage II). Initially, 72 patients were observed mainly because of the age of the patients (more than 60 y), 127 patients were operated on, and 3 were irradiated for medical reasons. Among observed patients (72 patients) tumor growth was noticed in 15 cases who were operated on in 14 cases and irradiated in 1 case for medical reasons. This concerned 7 and 8 among 55 stage I and 17 stage II, respectivelly. Thus 57 untreated VS (28 %) and 4 irradiated ones (2 %) are still under yearly MRI follow up, and 142 VS (70 %) were operated on. VS (142 cases)were operated through transpetrosal approaches : (64 % translabyrinthine, 21 % middle fossa (MFa), 15 % retrosigmoid (RSa). These was no mortality. Post-operative complications include 11 CSF leakages with reoperation (5 %). Post-operative facial function was good (Gr. I and II, HB) in 93 % of either stage I or stage II tumors. Hearing preservation was attempted in 51 selected cases (PTA < 50 dB, SDS 100 %) with a success rate of 55 % (53 % and 57 % through MFa and RSa, respectively). In conclusion, surgery is indicated for small VS, except for intracanalar tumors in elderly.

Abstract Otology 2000 D13-2

Dominik Brors MD (1), Bernhard Schick MD (1), Oliver Koch (1), Maria Schäfers MD (2), Gabriele Kahle MD (3), Wolfgang Draf MD, PhD, FRCS (1)

(1) Department of ENT-Diseases, Head, Neck and Facial Plastic Surgery D-Fulda
(2) Department of Neurology University Hospital Würzburg D-Würzburg
(3) Institute of Radiology Academic Teaching Hospital D-Fulda

Objectives: In acoustic neuroma diagnosis and postoperative follow-up MRI represents the radiological technique of choice. The value of MRI in diagnosis of acoustic neuromas is well-established, but the various MRI findings in postoperative follow-up were only cursoryly considered in literature. Differentiation of normal postoperative changes and graft materials (e.g. abdominal fat, muscle) in opposite to findings suggesting residual tumor or complications are still diagnostic problems. Material and Methods: In a retrospective study of 86 cases the postoperative MRI findings of 70 patients (mean age 54,1 years), who had undergone surgery for acoustic neuroma between 1987 and 1998 via a transtemporal (48) and translabyrinthine (22) approach by the use of fat-graft were reviewed. The signal intensity of the fat-grafts were subdivided into 4 levels: I. 0-25%, II. 25-50%, III 50-75% and 75-100% in order to describe the changes over the time. Additionally, manifestation of postsurgical temporal lobe gliosis was evaluated. Results: In 7 out 70 patients residual tumors were detected by MRI. In further 23 cases with localized enhancement in the internal auditory meatus residual tumor could be excluded only by decreased enhancement over the time. After transtemporal tumor resection MRI depicted 15 cases of different degree temporal lobe gliosis. During the first year of follow-up the signal intensity of the abdominal fat grafts decreased from level 4 to level 1 or 2 in most cases. Conclusion: Differentiation between residual tumor and granulation tissue may only be achieved over a long observation period. Thus, follow-up examinations at the same institution are highly desirable in order to provide best facilities in early diagnosis of residual tumor. Even abdominal fat has been proved clinically to support prevention of CSF-leakage, the study indicates graft fibrosis. Detection of temporal lobe gliosis requires analysis of the individual surgical technique to improve outcome in transtemporal surgery.

Abstract Otology 2000 D13-3

V.B. Pothula F.R.C.S, Vel Nandapalan F.R.C.S, Tristram H.J. Lesser MD, C. Mallucci F.R.C.S, P. May F.R.C.S, F.R.C.P, P. Foy F.R.C.S

University Hospital GB-Liverpool

Sporadic unilateral acoustic neuromas are very rare in childhood. We report three children under 16 years of age bringing the in the world literature to 39. These tumours are more common in boys and they tend to present late with raised intracranial pressure, cerebellar symptoms or multiple cranial nerve palsies. These surprisingly are often large tumours. Eventhough, none of the three children in our series presented with otological symptoms the literature review showed only 59% of the children had deafness and tinnitus as presenting symptoms. These tumours can be vascular, difficult to remove and are associated with significant postoerative neurological deficits. It should be borne in mind that acoustic neuroma may be the first manifestation of neurofibromatosis type 2 and we recommend follow up with serial Magnetic Resonance Imaging (MRI) to detect the appearance of other lesions.

Abstract Otology 2000 D13-4

Derald E. Brackmann MD, Jose N. Fayad MD, William Hitselberger MD

House Ear Clinic Inc. USA-Los Angeles CA

Introduction: The management of patients with neurofibromatosis type II (NF2) has always posed a challenging problem for neurosurgeons and neurotologists. Guidelines for appropriate management of this devastating disease are controversial. Methods: A retrospective study of 24 patients with neurofibromatosis type II who underwent 34 middle fossa craniotomies for excision of their acoustic tumors is reported. Ten patients underwent bilateral procedures. The study focused on hearing preservation and facial nerve results in this group of patients. Results: There were 13 males and 11 females. Age at the time of surgery ranged between 10 and 70 years. The size of the tumor ranged between 0.5 cm and 2.5 cm with the majority of the tumors being between 1 and 2 cm. The hearing was preserved in 24 ears (77.42%), lost in 7 ears (22.58%). Three recently operated patients did not have a follow-up at this time. In the immediate postoperative period 28 cases (82.35%) had a grade I House-Brackmann. Three cases had a grade II (8.82%). One case had a grade III. One case had a grade V, and one had a grade VI. Long-term facial nerve results will be reported. Discussion and Conclusions: Based upon these data, we conclude that early surgical treatment of acoustic tumors in NF2 patients is the treatment of choice.

Abstract Otology 2000 D13-5

Daqing Li MD (1), Ugo Fisch MD (2)

(1) ORL - Head & Neck Surgery Univ. of Maryland School of Medicin USA-Baltimore
(2) ORL-Klinik Universitätsspital CH-Zürich

The transotic approach developed by senior author (U.F.) provides extensive lateral exposure of cerebellopintine angle (CPA) and is ideally suited for the removal of large tumor (up to 2.5 cm in medial-lateral diameter) extending from the CPA. The purpose of this study is to present a strategy of using transotic approach for 1-stage removal of cochlear-involved intracanalicular and cerebellopontine angle tumors. Two typical cases are described in the present study. One case was with multicentric acoustic tumor arising separately from the left cochlea and internal auditory canal whereas another one had an intracanalicular meningioma with intracochlear involvement. In both cases, tumors were completely removed in 1-stage and facial nerve function remained in normal condition. In addtion, there was no postoperative cerebrospinal fluid leak. The patients are being followed routinely and, when last seen 3 years after there initial surgery, were free of the tumor. The present study indicates that transotic approach can be well-applied not only in large CPA tumors but also in cochlear-involved intracanalicular and CPA tumors.

Abstract Otology 2000 D13-6

Sudhakar B. Ogale MD, N.S. Gaidward MD, K.B. Sandu MD

Dept. of Otolaryngology K.E.M. Hospital Parel IND-Bombay

Hemifacial spasms - HFS -(Syn: Clonic Facial Spasms) is a cosmetically disabling, socially embarrassing disorder with an erratic behavior. At our institution we have treated 21 cases of idiopathic HFS after investigating them by a battery of audiological, vestibular and electrophylogical tests. The age group variies between 26-55 years and females were predominant. Our standard procedure of transtympanic facial nerve needling was performed on all these patients. Out of 21 patients, 18 had 100% relief of spasms, 2 patients had 60% improvement and only one patient had no relief at all. The 3 unrelieved patients were subjected to transmastoid needling to obtain 100% relief of spasms. Results of the above procedure were very enterprising. 3 patients had a recurrence of spasms after a period of 12-36 months. A repeated needling of the facial nerve proved beneficial in 2 patients, one of them was lost of follow up.

Abstract Otology 2000 D13-7

Vel Nandapalan F.R.C.S, V.B. Pothula F.R.C.S, Tristram H.J. Lesser MD

University Hospital Aintree GB-Liverpool

For many years vestibular testing has relied on measurements of the vestibulo-ocular reflex. Recently quantified assessment of balance using fixed or moving force platforms and magnetometry have been applied to clinical research. These are objective attempts to quantify the vestibulo-spinal reflex. This study evaluates whether the Sway Weigh, a simple device which measures lateral body sway can provide an objective assessment of balance dysfunction. 35 patients with peripheral vestibular balance disorder and 33 age matched subjects with normal balance were tested with eyes opened and eyes closed whilst they were standing on a flat surface and then on air bed to reduce the limb proprioception. The lateral sway in patients with a balance disorder was compared to that in the normal subjects and highly significant differences (p<0.0001) were observed. The Sway Weigh balance platform is a simple, portable, economical and user friendly device which objectively measures balance dysfunction.

Abstract Otology 2000 D14-1

Jan Helms MD, Joachim Müller MD, F. Schön MD, Wafaa E. Shehata-Dieler MD, PhD, H. Kühn-Inacker Prof.Dr.

HNO-Klinik Julius-Maximilians-Universität D-Würzburg

The cochlea implantation is accepted as the therapy of choice in bilaterally deaf patients. The improvement of life quality with successful implantation cannot be over-estimated. The best results are obviously obtained with implants using the CIS strategy with fast stimulation of more than 1200 or 1500 Hz per electrode. In order to improve the obtained results better stimulation techniques and new speech coding strategies may be developed. In addition the bilateral implantation with the optimal CIS stimulation strategy offers chances. 16 patients, adults and pre-lingual deaf children were bilaterally implanted. Two of them received their implants in a one stage surgery. In all cases, as far as postoperative speech perception could be analyzed or hearing could be estimated by behavioural controlling, the bilateral implant was advantageous to the patients.

Abstract Otology 2000 D14-2

Frank Rattay PhD, Petra Lutter PhD, Heidi Felix Ph.D.

Inst.f.Analysis, Techn. Mathem Techn. Universitaet Wien A-Wien

Our understanding of the spiking generation mechanisms in cochlear implant patients is generally derived from material based on animal data. There are, however, essential differences between the cochlear neurons in humans and the animals (cat, guinea pig and chinchilla). In contrast to the animals, the majority of cell bodies of the human cochlear afferents are unmyelinated and encapsulated by one to a few sheaths of satellite cells, i.e. they are not insulated by myelin layers. As a consequence, human somatic capacitance is significantly higher, which results in a larger somatic delay for spikes on their way from the peripheral to the central nerve processes. During electrical stimulation spikes are generated in the peripheral as well as in the central process, both in humans and animals. Our compartment model of the human cochlear neuron indicates that peripherally initiated spikes arrive with a time delay greater than 300 µs compared to spikes already generated in the central process, which is in agreement with recent neural response telemetry data. Many cochlear implant patients have a remarkable reduction of peripheral nerve processes: our computer simulations demonstrate that in contrast to animals human thresholds increase significantly, and often stimulation is possible with one stimulus polarity only.

Abstract Otology 2000 D14-3

George Psillas MD, Alex Fitzgerald O'Connor M.B. Ch. B. F.R.C.S

Audiology Department Guy's & St. Thomas' Hospital Trust GB-London

The Clarion positioner has been developed to optimize the position of the electrode within the cochlea. Six patients, five male and one female, ages 2y to 59y (mean 13,25y) were implanted using the Clarion positioner system. Intraoperatively evoked acoustic reflex threshold (IEEART) and impedances were measured before and after insertion of positioner. Assuming the total penetration of the electrode array into tympanic scala, all the patients IEEART were found to be lower with positioner than without. This was valuable for the apical, middle and basal turns, except in three subjects, where only the last one or two basal channels have shown higher IEEART. Impedance values varied randomly, indicating no clinical correlation. The IEEART results demonstrate that the electrode array was placed closer to the modiulus, near the spiral ganglion cells, with the assistance of the positioner. On the contrary, impedance values were not related to the positioner effect. Moreover, it has been shown that IEEART provides a reliable estimate of maximum confortable implant patients, is valuable and may increase overall confidence in the reliability at an estimated program map.

Abstract Otology 2000 D14-4

Cecile Schwarz Ph.D., Erika Gruner Dipl.Klin.Log.

ENT Department University Hospital CH- Zürich

With our 37 CDs and 22 textbooks we were able to create a new kind of systematic etude-like supplementary training programme (SENFT) for Cochlear Implant-patients (CI-patients). The SENFT aims at programming and connecting speech-specific areas (such as WERNICKE's- and BROCA's area) responsible for the recognition and production of phonemes in connection with language comprehension and speaking. The SENFT was developped by C.Schwarz after recognizing that in numerous CI-patients the programming of the Speech-Processor and the perfect adjustment of the electrodes alone were not sufficient to guarantee good speaking and language comprehension without lipreading. The author understood that those patients also have to have a precise phonematic stimulation and programming of the speech-specific cortical areas. Babies with normal hearing acquire their cortical elementary phonematic programming mainly during the extensive periods of crying and babbling. This enables them among other factors to develop and improve individual speech. In contrast to that the prelingual deaf babies acquire no or very little programming because of their poor babbling-phase. The SENFT can be considered as an "artificial substitute to the natural babbling programme" as it consists in innumerable variations of memorizing, repeating aloud, reading and writing all of the different phonemes and phoneme-combinations. This is presented and explained in our collection of CDs and textbooks. The accurate execution of the SENFT-technique according to our instructions is essential to bring about marked improvement of language comprehension without lipreading and of speech quality in CI-patients.

Abstract Otology 2000 D14-5

Erwin Löhle Prof.Dr., Sabine Frischmuth MD, Marianne Holm MD

Phoniatrie & Pädaudiologie HNO-Klin.d.Albert-Ludwigs-Universi D-Freiburg i.Br.

We studied the prosodic structure of utterances produced by children who received a cochlear implant between the ages of 2 and 11 years. We were especially interested in the influence of age on implantation and the ability to structure utterances in rhythmically and melodically. Our results indicate that from a certain age, the acquisition of prosodic features is no longer possible. Three different groups of children with congenitally profound hearing loss were compared: children implanted from 2 to 4 years (group 1), children implanted from 5 to 9 years (group 2) and children implanted after the age of 9 (group 3). Spectrographic analysis of spontaneous utterances showed that only children belonging to group 1 were able to develop a natural and vivid prosody, whereas children in group 2 and 3 were unable to develop prosody, so that their voices remainded monotonous.

Abstract Otology 2000 D14-6

Nikola Sprem MD, PhD, Srecko Branica MD, PhD, Krsto Dawidowsky MD

ORL Zagreb Clinical Hospital & Univers. CRO-Zagreb

A total of 21 patients were operated on one ear with a combined technique: intratympanic installation of a ventilation tube and gentamycin intratympanic installation. The reason for this approach was that in the case of failure we could repeat gentamycin treatment through ventilation tube. We treated in this manner a total of 21 patients. All patients were female and the age was between 21 to 62 years, glycerol negative.

Abstract Otology 2000 D14-7

Timo P. Hirvonen MD, PhD, M. Peltomaa MD, Jukka Ylikoski MD

Department of Otorhinolaryngology Helsinki University CentralHospital SF-Helsinki

Purpose: Intratympanic and simultaneous systemic dexamethasone treatment of Ménière's disease (MD) was evaluated in a prospective study. Methods: Seventeen patients (6 men and 11 women) with verified MD (5 right-sided, 11 left-sided and one bilateral) were treated with 0.2-0.4 mL intratympanic dexamethasone hyaluronate (16 mg/mL) injections three times during a week and a initial intramuscular dexamethasone injection of 15 mg. Their mean age was 48 (range 29-77) years and mean duration of the MD was 5.3 (range 0.8-23) years. Pure tone and speech audiometry and symptom scale of the patients were followed up to 1 year after treatment. Results: Symptoms of MD patients did not improve significantly; although a tendency to better control of vertigo attacks was found. The mean hearing level showed no significant improvement. Tinnitus and aural fullness levels remained unchanged. Conclusion: Intratympanic dexamethasone has been introduced as an alternative to treat intractable MD patients. In our preliminary study, patients of mainly late stage of MD did not benefit significantly from simultaneous intratympanic and systemic dexamethasone treatment. Thus the clinical use of dexamethasone in MD needs further evidence.

Abstract Otology 2000 D14-8

Lidija Dubrovska MD, Elena Bogeska MD, Marina Cakar MD, Gordana Mladenovska MD

ENT Department University Hospital MAZ-Skopje

Antihistamines for long time have been used for treatment of vertigo due to diseases of the vestibular system. These antihistamines have excellent efficacy but because of their side effects have had limited chronic use. Loratidine, non-sedating antihistamine has been shown to effectively reduce dizziness in our study of 10 patients with Meniere's desease and 10 patients with vestibulopathies.

Abstract Otology 2000 D14-9

Chul-Ho Jang MD, Seung T. Park MD

Dept. of ENT Wonkwang Medical School ROK-ChunBuk

In order to examine the toxic effect of oxygen radicals, the cytotoxic effects were done on cultured mouse Schwann cells facial nerve which were treated with various concentrations of xanthine oxidase(XO) and hypoxanthine(HX) for 4 hours, and also the neuroprotective effect of antioxidants on oxidant-induced neurotoxicity were also examined. The results were as follows: Cell viability of cultured mouse Schwann cells treated with XO/HX was markedly decreased in a dose-dependent manner. MTT50 value was at a concentration of 20mU/ml XO and 0.1mM HX. Cultured mouse Schwann cells exposed to 50µM STZ for 24 hours showed degenerative changes such as the decrease of cell number and process. Pretreatment of 80uM tetrakis(2-ridylmethyl)ethylenediamine(TPEN) for 2 hours increased remarkably the cell viability of cultured Schwann cells exposed to 20mU/ml XO/0.1mM HX. From these results, it is suggested that oxygen radicals induce toxic effect on cultured mouse Schwann cells, and selective antioxidant such as TPEN is very effective in blocking the oxidant-induced neurotoxicity.