Biomedical subjects
A W Langman
Publications and source records attributed to A W Langman.
Sensorineural hearing loss with delayed onset of vertigo.
Sensorineural hearing loss with delayed onset of vertigo is a syndrome in which episodic vertigo arises in a person who has preexisting unilateral severe-to-profound sensorineural hearing loss. This syndrome has an ipsilateral form in which the vertigo arises from the poorer hearing ear and a contralateral form in which the aural symptoms arise from the better hearing ear. The existence of this syndrome has only been noted within the past two decades. This report details our clinical experience with 17 persons with the ipsilateral form of this disorder. The onset of the vertigo after the occurrence of the hearing loss was quite variable. It ranged from 1 to 60 years after the development of the hearing loss. The hearing loss occurred for several reasons. Most patients had hearing loss due to an unknown cause. The development of the vertigo and the timing of the onset of the vertigo were not related to the cause of the hearing loss. Bithermal caloric testing identified the offending labyrinth in most patients who underwent ablative vestibular surgery. Ablative vestibular surgery was performed in 13 of the 17 persons in this study because of disabling symptoms. In all 13 cases, the episodic vertigo was eliminated. Surgical treatment for sensorineural hearing loss with delayed-onset vertigo, as with all surgery for vertigo, should be based on the severity of the afflicted person's symptoms.
Use of botulinum toxin to prevent facial nerve stimulation following cochlear implantation.
Facial nerve stimulation can develop because of the electric fields generated from an activated cochlear implant. This problem can usually be ameliorated by reducing or eliminating the current through the electrodes causing the undesirable stimulation. Occasionally there may be numerous electrodes that have to be deactivated in order to eliminate the facial nerve stimulation, and this may result in a marked reduction of auditory benefit to the cochlear implant user. Botulinum toxin causes transient neuromuscular blockade and has been shown to be effective in reducing or eliminating facial nerve hyperactivity due to a variety of causes. This report details the use of botulinum toxin in a patient with a cochlear implant who developed excessive facial nerve stimulation that necessitated the deactivation of 15 of the implant's 22 electrodes. After treatment with botulinum toxin, twice as many electrodes could be comfortably activated without causing facial nerve stimulation. The dynamic range was increased in 4 of the remaining 6 electrodes that were activated prior to treatment. The patient reported a marked improvement in sound quality and understanding of speech without lipreading as compared to her pretreatment performance. Treatment with botulinum toxin appears to be useful for patients who have excessive facial nerve stimulation after cochlear implantation.
Cochlear implants in children.
Cochlear implants are no longer considered new or experimental technology. Difficulty in evaluating the degree of hearing loss and response to traditional forms of amplification in young children makes pediatric cochlear implant candidacy a complex issue. Cochlear implantation and, in particular, pediatric cochlear implantation, requires a team commitment with contributions from surgeons, audiologists, speech pathologists, psychologists, and special educators. Elements discussed include assessment and candidacy issues, surgical technique, elements of a cochlear implant team, outcome assessment, and potential complications. The decision to perform pediatric cochlear implantation should not be undertaken without serious consideration to the enormous commitment required in both financial and personnel terms.
Surgery for vertigo in the nonserviceable hearing ear: transmastoid labyrinthectomy or translabyrinthine vestibular nerve section.
Two of the surgical options that exist for the treatment of disabling vertigo arising from an ear with nonserviceable hearing are a transmastoid labyrinthectomy (TL) and a translabyrinthine vestibular nerve section (TLVNS). The major difference between the two operations is a section of the vestibular nerves with the TLVNS which removes all preganglionic vestibular tissue from the diseased inner ear. It has been inferred that a TLVNS should be the procedure of choice if hearing is not to be spared, because a TL results in an incomplete removal of preganglionic vestibular tissue, and that this remaining tissue might have continued or recurrent physiologic function resulting in further vertigo. The clinical outcome of 58 patients who had either TL or TLVNS for disabling vertigo arising from a nonserviceable hearing ear was investigated with respect to the control of vertigo and the development of postoperative balance dysfunction. The control of vertigo in the TLVNS and TL groups was 100% and 95.3%, respectively. This difference was not statistically significant. There was a tendency for postoperative dysequilibrium to be more frequent in the TLVNS group, but this finding did not reach statistical significance. A TL appears to offer the same benefit as TLVNS in the control of intractable episodic vertigo without the additional risks of TLVNS.
Tissue-integrated prostheses in the rehabilitation of auricular defects: results with percutaneous mastoid implants.
Functional and cosmetic rehabilitation of the severely atretic auricle poses a formidable challenge. Conventional autologous grafts for auricular reconstruction may produce inconsistent results, and revision of failed grafts is often unsatisfactory. Osseointegrated implant systems to retain auricular prostheses provide an alternative approach in rehabilitating patients with severe auricular defects. Fourteen patients were implanted with 30 osseointegrating implants for rehabilitating major auricular defects and were followed for 1 to 3.5 years, yielding 143 implant observations. Symptomatic skin reactions to the percutaneous implant were noted in 3.5 percent of the observations. Implant extrusion did not occur. This evaluation of tissue-integrated prosthetic systems suggests this approach to be an extremely reliable alternative for selected patients with major auricular defects. The technique of implanting the retention unit is readily adapted to atresia repair.
Operative management of acoustic neuromas: the priority of neurologic function over complete resection.
The objective of surgical management of acoustic tumors is to remove them entirely and preserve facial nerve function and hearing when possible. A dilemma arises when it is not possible to remove the entire tumor without incurring additional neurologic deficits. Twenty patients who underwent intentional incomplete surgical removal of an acoustic neuroma to avoid further neurologic deficit were retrospectively reviewed. They were divided into a subtotal group (resection of less than 95% of tumor) and a near-total group (resection of 95% or more of tumor) and were followed yearly with either computed tomography or magnetic resonance imaging. The subtotal group was planned and consisted of elderly patients (mean age, 68.5 years) with large tumors (mean, 3.1 cm). The near-total group consisted of younger patients (mean age, 45.8 years) and smaller tumors (mean, 2.3 cm). The mean length of followup for all patients was 5.0 years. Ninety percent of patients had House grade I or II facial function post-operatively. Radiologically detectable tumor regrowth occurred in only one patient, who was in the subtotal resection group. Near-total resection of acoustic tumor was not associated with radiologic evidence of regrowth of tumor for the period of observation. Within the limits of the follow-up period of this study, subtotal resection of acoustic neuroma in elderly patients was not associated with clinically significant recurrence in most patients and produced highly satisfactory rates of facial preservation with low surgical morbidity.
Retrolabyrinthine vestibular nerve section: efficacy in disorders other than Menière's disease.
The retrolabyrinthine vestibular nerve section has evolved as an effective treatment for intractable vertigo of peripheral vestibular origin when hearing preservation is desired. This report studies the efficacy of retrolabyrinthine vestibular nerve section for control of vertigo due to causes other than Meniere's disease. This report details our experience with 42 patients with a wide variety of diagnoses. The reduced success rate of retrolabyrinthine vestibular nerve section in these patients is difficult to evaluate, as very few patients have been analyzed with respect to their specific diagnoses. Of patients who underwent retrolabyrinthine vestibular nerve section for control of vertigo, 23 patients had uncompensated vestibular neuritis and 19 others had a wide range of other diagnoses. For patients with uncompensated vestibular neuritis (n = 23), the physician record noted that 39% of patients were cured and 30% improved. This compares to our series of patients with Meniere's disease (n = 48), where 94% were cured and 2% improved. The true vestibular abnormality may be less reliably identified in patients with uncompensated vestibular neuritis, contributing to the less effective results. Since the development of a vestibular rehabilitation program, retrolabyrinthine vestibular nerve section for uncompensated vestibular neuritis has been all but abandoned. Retrolabyrinthine vestibular nerve section appears to achieve a high cure rate in patients with sensorineural hearing loss associated with their vestibular abnormalities. While retrolabyrinthine vestibular nerve section is helpful for control of vertigo in some diagnoses, a substantial incidence of persistent postoperative dysequilibrium was noted.
Stapedectomy: long-term hearing results.
The initial improvement in hearing following stapedectomy usually deteriorates with the passage of time. We studied the long-term results of stapedectomies performed on 42 patients (49 ears) between 1959 and 1969 who had a minimum follow-up of 18 years. Both air conduction (AC) and bone conduction (BC) thresholds progressively deteriorated over the long term. The degree of BC loss paralleled that expected from presbycusis alone. A greater deterioration was noted in the AC levels, producing a recurrent conductive hearing loss in the speech frequencies. Age at the time of surgery had no effect on the long-term outcome. Comparison of the average preoperative speech discrimination scores (SDS) to the 1-year postoperative SDS and the long-term SDS revealed a 1.1% and 16.7% drop, respectively. The improvement in the average speech reception threshold (SRT) obtained 1 year postoperatively deteriorated by less than 1 dB per year over the long term. Patients with a higher SDS (more than 95%) preoperatively fared better in the maintenance of speech discrimination than those with a lower SDS (less than 95%). The preoperative SRT level was predictive of the timing for the requirement of hearing amplification. The postoperative SRT level was predictive of the timing for the requirement of hearing amplification. The caused by presbycusis, combined with a recurrent conductive loss in the speech frequencies rather than cochlear otosclerosis. Although the decline in hearing following stapedectomy exceeds the rate of hearing loss due to presbycusis, many individuals, after successful stapes surgery, are able to delay the need for hearing amplification for longer periods than had been previously reported.
Titration streptomycin therapy for bilateral Meniére's disease. Follow-up report.
Initial reports of the use of parenteral streptomycin for bilateral Meniere's disease (MD) have demonstrated success in reducing the vestibular symptoms and, in some patients, stabilizing hearing. The long-term follow-up (mean, 5.1 years) of 19 patients treated with intramuscular streptomycin for bilateral MD is presented. The amount of streptomycin administered (5 to 50 g) was determined by clinical symptoms and by serial testing of the reduction in the slow-phase velocity on electronystagmography. Episodic vertigo was totally relieved in 12 patients and improved in severity and frequency in an additional 4 patients. Permanent posttreatment dysequilibrium occurred in 47% of the patients treated. The changes in hearing (speech reception threshold) were independent of the therapeutic effect of streptomycin on the vestibular system. The overall results suggest that the intramuscular titration of streptomycin should continue to be considered as one of the therapeutic options in patients with disabling vertigo due to bilateral MD.
Meningioma of the internal auditory canal.
The great majority of tumors that arise in the internal auditory canal are schwannomas of the eighth cranial nerve (acoustic neuromas). Meningiomas constitute the second largest group of posterior fossa tumors. Meningiomas arise from arachnoid villae, the apparatus responsible for cerebrospinal fluid absorption, in proximity to a major vein or dural sinus in most cases. Arachnoid villae are also present along neural foramena at the base of the skull. They have been observed histologically in the internal auditory canal (IAC), and are the probable site of origin of meningiomas in this location. Larger cerebellopontine angle meningiomas occasionally possess a significant intracanalicular component; however, these lesions usually originate from the meningeal lining of the posterior petrous face adjacent to the sigmoid, superior petrosal, or inferior petrosal sinuses and prolapse into the IAC. Two meningiomas have recently been observed that extensively involved the IAC, one of which arose from the lining of the IAC. The clinical manifestations of these meningiomas mimicked those of acoustic neuromas. Preoperative radiographic studies, including magnetic resonance imaging, were unable to differentiate these from acoustic neuromas. Meningiomas have a higher rate of recurrence than acoustic neuromas and should be excised with surrounding dura and several millimeters of subjacent bone. Meningiomas that extensively involve the IAC have a tendency to invade the inner ear and the deeper portions of the temporal bone. In meningiomas that involve the lateral portion of the IAC, consideration should be given to exenteration of the cochlea and semicircular canals.
Malignant carotid artery invasion: sonographic detection.
To assess the reliability of sonography in the detection of absence of invasion of the carotid artery by tumor, high-resolution ultrasound, surgical, and pathologic findings were prospectively evaluated in 24 patients with disease metastatic to the neck. Sonography performed with 5- and 10-MHz transducers had a sensitivity of 100% for the demonstration of absence of carotid invasion. Stringent criteria were used to eliminate false-negative studies. There were only five false-positive studies, for a positive predictive rate of 44.4%. Specific criteria for diagnosis of carotid invasion included visualization of an obvious break in the carotid wall with an offset in two planes and sonographic demonstration of gross tumor within the lumen. False-positive interpretations are more likely if there is inability to image the vessel at a perpendicular interface, if the abnormality cannot be seen in two planes, or if the neoplastic mass adjacent to the carotid considerably attenuates the acoustic beam.
Ewing's sarcoma of the mandible.
Cure rates of Ewing's sarcoma have improved from 10% to 75% with the use of a combination of local therapy and aggressive multi-drug chemotherapy, to decrease both the incidence of local disease recurrence and the development of pulmonary and skeletal metastases. In Ewing's sarcoma of the mandible, complete surgical resection is preferred to irradiation for local control in those instances when surgery can be performed with minimal loss of function and disfigurement.
The endoscopic Teflon keel for posterior and total glottic stenosis.
Most cases of posterior commissure stenosis today result from endotracheal intubation. The problem has been very difficult to repair. Posterior commissure stenosis has been treated by repeated dilations, which do not work, and reconstructive measures by means of laryngofissure to excise the scar followed by the placement of round stents alone or round stents in combination with mucosal or skin grafts. This treatment also fails frequently. Some, but not all, cases have been cured with laser surgery via microdirect laryngoscopy. An endoscopically placed Teflon keel has been useful in the treatment of posterior glottic and total glottic stenosis when laser surgery is not feasible. Nine patients with posterior glottic stenosis, two of whom initially had total glottic stenosis, have undergone placement of the posterior commissure Teflon keel. Six patients had resolution of the stenosis and were decannulated. One required an arytenoidectomy for a fixed cricoarytenoid joint before successful decannulation. Two patients had marked improvement of their laryngeal airway with this approach, but have not yet been decannulated because of fixed cricoarytenoid joints.
Hodgkin's disease and tonsillectomy.
We have reviewed the evidence associating tonsillectomy and Hodgkin's disease. Hodgkin's disease and tonsillectomy may share certain epidemiologic features, such as higher socioeconomic status. Does tonsillectomy lead to Hodgkin's disease? There is no evidence for this, nor is there any plausible reason to suspect it on the basis of the experimental evidence to date.
Radiologic assessment of tumor and the carotid artery: correlation of magnetic resonance imaging, ultrasound, and computed tomography with surgical findings.
Carotid artery fixation is an extremely poor prognostic sign in squamous cell carcinoma of the head and neck. Methods more precise than physical exam are necessary to determine whether a neck dissection is sufficient, to exclude patients from surgery, or to plan a carotid artery resection. Thirty-three patients with a suspicion of carotid wall attachment by physical examination or computed tomography (CT) were further evaluated by magnetic resonance imaging (MRI) and ultrasound (US). The criterion for possible carotid involvement on CT was effacement of greater than 25% of the circumference of the artery. On MRI, the criterion that we proposed was any loss of the fascial plane around the internal or common carotid artery. This was considered effacement of the carotid artery wall. For US, the criterion we used was the loss of the echogeneity along the carotid wall. Histopathological correlation was available in 23 patients (24 necks) who either underwent surgery or necropsy (1 patient); 11 patients were felt not to be surgical candidates or declined surgery, though 1 of these 11 patients did undergo surgical resection after radiotherapy. MRI accurately predicted an uninvolved carotid artery in 13 of 15 cases; US accurately predicted an uninvolved carotid artery in 15 of 20 cases. Demonstration by either MRI or US that the carotid artery is free of tumor had a high degree of reliability. Both US and MRI appear superior to CT and physical examination in assessing the carotid wall in suspicious cases. Individually and in combination, MRI and US offer advantages in selecting patients for possible surgery when the issue of carotid artery fixation is raised.