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Biomedical subjects

H Silverstein

Publications and source records attributed to H Silverstein.

At least 19 recordsLinked to original sources
PubMed1992

Vestibular neurectomy in the United States--1990.

During the last decade, vestibular neurectomy has become a more frequently performed procedure to cure symptoms of inner ear vertigo while preserving hearing. In an effort to determine the results of vestibular neurectomy across the country, a questionnaire was prepared and sent to the 350 members of the American Otologic Society and the American Neurotology Society. Results of that survey indicated that 2,820 vestibular neurectomy procedures were performed by 58 surgeons. Ninety-two percent (2,590 cases) were performed through the posterior fossa approach. Of these, 1149 cases (44%) were through the retrolabyrinthine approach, 940 cases (36%) were through the retrosigmoid approach, 307 cases (12%) were through the combined retrolabyrinthine-retrosigmoid approach, and 194 cases (8%) were unspecified as to which posterior fossa approach was used. The remaining 230 cases (8%) were through the middle fossa approach. Sectioning of the vestibular nerve was done by the otologist in 58 percent of cases, by the neurosurgeon in 12 percent, and by either surgeon in 30 percent. Classic Meniere's disease, the most common indication for vestibular neurectomy, resulted in the best cure rate of 91 percent. Other inner ear diseases such as traumatic labyrinthitis and vestibular neuronitis had a lower cure rate of 74 to 81 percent. Hearing was preserved to within 20 dB of the preoperative pure-tone thresholds in 87 percent. There were no deaths, 11 cases of meningitis and 16 cases of facial paralysis, 15 of which occurred after middle fossa surgery, representing a 7 percent incidence of facial paralysis after middle fossa surgery. Eleven of the 15 cases resulted in permanent paralysis and four in temporary paralysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Humans↗
PubMed1991

Rapid protein test for perilymph fistula.

The existence of a perilymph fistula may be difficult to prove preoperatively or at surgery, except in obvious cases in which perilymph can be seen coming out of the inner ear around the stapes footplate or round window niche. Some surgeons doubt the common occurrence of spontaneous perilymph fistula. Most surgeons believe that a perilymph fistula is rare and is produced by some type of trauma and pressure change to the inner ear fluids. Analysis of fluid collected from the oval window area and round window niche may be a great help in confirming or disproving the diagnosis of perilymph fistula. After a myringotomy or tympanotomy, fluid collected in micropipets from the oval window or round window area is analyzed for protein concentration, using rapid protein indicator paper. The original technique was developed in the 1960's to analyze the inner ear fluid as a diagnostic procedure (i.e., diagnostic labyrinthotomy) in acoustic neuroma suspects. Normal perilymph has a protein content of approximately 200 mg %, which turns the indicator paper light green, whereas serum or transudate has a protein content of approximately 7000 mg %, which turns the indicator paper dark green. The protein concentration is determined by comparing the color of the indicator paper with the color developed by known protein standards. A middle ear tap may help avoid negative middle ear exploration for perilymph fistula and helps document the presence or absence of perilymph after the exploration.

Cochlear Diseases↗
PubMed1991

Intraoperative facial nerve monitoring.

Facial nerve monitoring is one of the most exciting innovations in otologic surgery in the past decade. Intraoperative monitoring has been shown to reduce the probability of iatrogenic injury to the facial nerve during surgery. It saves surgical time and reduces the anxiety level of both patients and surgeons. There are several reasons to use facial nerve monitoring: The surgeon nerve knows when it will be needed in a particular case, the operating room personnel become familiar with the equipment, and the surgeon learns how to interpret the sounds produced by the monitor and how to correlate them with surgical manipulations around the facial nerve. Facial nerve monitoring has added another dimension of safety to otologic and neurotologic surgery and has reduced the incidence of facial weakness or paralysis in the authors' surgical practice.

Facial Nerve↗
PubMed1991

Bilateral Menière's disease in surgical versus nonsurgical patients.

In patients with Menière's disease, the possibility of developing Menière's disease in the uninvolved ear is of great concern. In this study, the incidence of bilateral Menière's disease (BMD) in medically treated patients was found to be 17 percent, while in surgically treated patients it was significantly lower, 5.9 percent (p less than 0.01). The incidence of BMD for each surgical procedure was as follows: 9 percent after endolymphatic subarachnoid shunt (n = 101), 7 percent after cochleovestibular neurectomy (n = 100), 6 percent after cochleosacculotomy (n = 18), and 0 percent after vestibular nerve section (n = 73). The average duration of disease prior to surgery was 6.3 years. Seventy-two percent of the patients who developed BMD did so within 5 years of the onset of their symptoms. Proper patient selection is the most likely explanation for the low incidence of BMD among surgically treated patients.

Adolescent↗
PubMed1990

An evolution of approach in vestibular neurectomy.

Since introducing the retrolabyrinthine vestibular neurectomy in 1978, we have performed 78 procedures with good results. In 1985 we introduced the retrosigmoid-IAC vestibular neurectomy, which allows a more complete transection of the vestibular nerves within the internal auditory canal (IAC). Vertigo control has been excellent; however, in 75% of patients, postoperative headaches have been a significant problem. In 1987, the best aspects of the two procedures were incorporated and the combined retrolab-retrosigmoid vestibular neurectomy was developed. The procedure is similar to the RVN in that all bone covering the lateral venous sinus is removed. It differs from the RVN in that a limited mastoidectomy is performed and the dura is opened just behind the LVS. The LVS is retracted forward, exposing the cerebellopontine angle. This allows the surgeon the option to section the vestibular nerve in either the CP angle or the IAC, depending upon the presence or absence of a cochieovestibular cleavage plane in the CP angle. The results have been good and the incidence of headache has been reduced to 10%. The technique, results, and complications are reported here.

Ear, Inner↗
PubMed1990

Adaptor for continuous stimulation (SACS) with the WR-S8 monitor-stimulator.

An adaptor for continuous stimulation of the facial nerve (SACS) to be used with the WR-S8 Monitor/Stimulator during otologic surgery has been developed. This device allows the surgeon to use the electrified air drill and microsurgical instruments instead of a probe-tip during dissection. The SACS saves surgical time, is easy and convenient to use, and is safe. Routine monitoring of facial nerve function using SACS has helped prevent iatrogenic facial nerve injuries and has improved our ability to save the facial nerve during otologic and neurotologic surgery.

Ear↗
PubMed1990

Wide surgical exposure for singular neurectomy in the treatment of benign positional vertigo.

Since 1972, singular neurectomy has been performed on 58 patients who had classical benign positional vertigo. The procedure is done under general anesthesia; a wide postauricular exposure is made and the external auditory canal is maximally enlarged until the vertical portion of the facial nerve is identified. This gives an excellent view of the round window niche. Our results indicate vertigo was completely cured in 80% of the cases and improved in 17%. There has been no incidence of total hearing loss in the last 49 cases and only 3 of 49 patients (6%) had sensorineural loss. Although singular neurectomy can be mastered, it will remain a procedure done by few surgeons. The wide exposure technique is safer for preservation of cochlear function and the posterior ampullary nerve is easier to find than using the transmeatal approach as described by Gacek.

Adult↗
PubMed1990

The resurrection of vestibular neurectomy: a 10-year experience with 115 cases.

Between 1925 and 1945, Walter Dandy and Kenneth McKenzie performed more than 700 posterior fossa eighth nerve sections and vestibular neurectomies to treat the intractable vertigo accompanying Ménière's disease. During the past 10 years, with the aid of microsurgical techniques and the approach to the posterior fossa through the temporal bone, vestibular neurectomy has undergone a resurgence of popularity. When hearing is to be preserved, vestibular neurectomy is the surgical treatment of choice for patients who fail to undergo a remission of the vertigo attacks of Ménière's disease. This report reviews 115 consecutive vestibular neurectomies performed from 1978 to 1988 for the treatment of Ménière's disease. In 1978, retrolabyrinthine vestibular neurectomy (RVN), a procedure in which the posterior fossa is entered anterior to the sigmoid sinus and behind the labyrinth, was introduced. During the last 3 years, the approach to the posterior fossa has been a small dural opening behind the sigmoid sinus; this approach is known as the combined retrolabyrinthine retrosigmoid approach. There have been no cases of facial paralysis and no serious complications connected with this technique. A high incidence of headache (50%) resulted when the posterior wall of the internal auditory canal was drilled away for better exposure. Transient cerebrospinal fluid (CSF) leaking occurred in 7% of the patients undergoing RVN; however, no CSF leaks occurred when the combined retrolabyrinthine retrosigmoid approach was used. In the RVN series, wound infection occurred in 20% of the cases until perioperative antibiotics reduced the rate to 3%. The results in terms of curing or improving vertigo have been excellent (94%), and hearing has been preserved to within 20 dB preoperative levels in 76% of the cases. Until a cure for Ménière's disease is found, microsurgical posterior fossa vestibular neurectomy remains the best treatment.

Cochlear Nerve↗
PubMed1989

Natural history vs. surgery for Menière's disease.

Menière's disease has an episodic course, and certain patients undergo spontaneous remission of their vertigo. A retrospective study of patients treated from 1974 to 1983 was undertaken to evaluate the long-term outcome of patients with Menière's disease for whom surgery was recommended, comparing those who had a surgical procedure with a similar group of patients who declined surgery. The surgical procedures performed were endolymphatic subarachnoid shunt (ELS), retrolabyrinthine vestibular neurectomy (RVN), middle fossa vestibular neurectomy (MFVN), and transmeatal cochleo-vestibular neurectomy (CVN). We used a questionnaire, made up according to the 1985 American Academy of Otolaryngology (AAO) criteria, for reporting results for Menière's disease treatment, and compared patients who were offered surgery but declined (N = 50) with those who underwent surgery (N = 83). The data were analyzed statistically. Initial evaluation, which included air and bone conduction audiometry, speech discrimination, electronystagmography (ENG), frequency of vertigo attacks per month, and disability, showed both groups to be comparable at the outset. Of the non-operated group 57% had complete control of vertigo at 2 years; 71% had complete control after an average of 8.3 years. After an ELS, 40% of patients had complete control of vertigo after 2 years; 70% had complete control after an average of 8.7 years. After a neurectomy (RVN or CVN), 93% had complete control of vertigo (average followup, 4.4 years). These results indicate statistically that the ELS procedure does not alter the long-term natural course of vertigo control in Menière's disease, whereas both the RVN and CVN significantly improve the patient's chance of being permanently free of vertigo attacks.

Aged↗
PubMed1989

Long-term results of transmeatal cochleovestibular neurectomy: an analysis of 100 cases.

One hundred patients have been treated over a 13-year period with a transmeatal approach to the internal auditory canal for cochleovestibular neurectomy. Ninety-one of these patients have followup of more than 3 months (average, 4.67 years). The most common indication for the procedure was Meniere's disease (71%). Chronic labyrinthitis, usually following stapes, middle ear, or mastoid surgery, was the next most common indication. Patients with the preoperative diagnosis of Meniere's disease had better results in the curing of vertigo (89%) than those having chronic labyrinthitis (68%). Overall, vertigo was cured in 84% of patients and markedly improved in another 15.1%. Tinnitus was relieved or improved in 65% of all patients and in 67% of patients with Meniere's disease. Mild unsteadiness was commonly noticed postoperatively, but only 11% described this as severe. Eighty percent of these latter patients reported unsteadiness preoperatively. Complications were uncommon and temporary: one case of delayed facial paresis that recovered completely, one CSF leak, and one wound infection. There were no cases of permanent facial paralysis or meningitis. The advantages of the transmeatal approach to the IAC for CVN over labyrinthectomy without CVN are assurance of complete labyrinthine denervation, increased likelihood of improved tinnitus, practice at sectioning the posterior ampullary nerve (PAN), and the ability to inspect the internal auditory canal for a small tumor or other pathology. We recommend this procedure for treatment of unilateral vestibular dysfunction in patients with no serviceable hearing.

Adult↗
PubMed1989

Small fenestra stapedotomies with and without KTP laser: a comparison.

The results of 33 small fenestra stapedotomies performed using conventional techniques were compared with the results of 33 stapedotomies performed using the argon or KTP laser. The ossicular chain was reconstructed using a Teflon wire piston of 0.6 mm diameter, and follow-up was at least 1 year. Over-closure of the air-bone gap or closure to within 10 dB was accomplished in 91% of the laser-treated group versus 72% of the conventionally treated group (p less than 0.10). The hearing results were statistically better in the laser group (p less than 0.05). Transient delayed vestibular symptoms, lasting from 1 to 3 weeks, were present in 39% of the laser-treated group and in 12% of the patients treated by conventional techniques (p less than 0.05). The KTP laser stapedotomy, using a micromanipulator mounted on the microscope, is a safe, efficient technique that reduces some of the technical difficulties associated with conventional stapes surgery. The main advantage of the laser is that it enables the surgeon to make an atraumatic, bloodless opening in a fixed or mobile stapes footplate without mechanical manipulation of the stapes. Using a lower wattage to vaporize the footplate and waiting several seconds between laser bursts may decrease the incidence of postoperative vestibular symptoms. The use of the KTP laser in stapes surgery represents a major advance in surgery for otosclerosis.

Fenestration, Labyrinth↗
PubMed1989

Combined retrolab-retrosigmoid vestibular neurectomy. An evolution in approach.

Since introducing the retrolabyrinthine vestibular neurectomy (RVN) in 1978, we have performed 78 procedures with good results. In 1985, we introduced the retrosigmoid-internal auditory canal vestibular neurectomy (RSG-IAC), which allowed a more complete transection of the vestibular nerves in the IAC. Vertigo control has been excellent. However, in 50% of cases postoperative headaches have been a significant problem. In 1987, we combined these two approaches into one procedure, the combined retrolab-retrosigmoid vestibular neurectomy (RSG-RVN). The procedure is similar to a RVN, in that all bone covering the lateral venous sinus (LVS) is removed. It differs from the RVN in that the dura is opened just behind the LVS. The LVS is retracted forward, thereby exposing the cerebellopontine (CP) angle. This allows the surgeon the option to sever the vestibular nerve either in the CP angle or in the IAC, depending on the presence or absence of a cochleovestibular (CV) cleavage plane in the CP angle. The technique, results, and complications will be reported in this article.

Cerebellopontine Angle↗
PubMed1988

The singular canal: a valuable landmark in surgery of the internal auditory canal.

The singular canal transmits the posterior ampullary nerve between the inferior part of the internal auditory canal (IAC) and ampulla of the posterior semicircular canal. The anatomy of the singular canal was studied in temporal bone dissections, in surgical dissections, and in high-resolution computerized tomography scans. Measurements were taken for distances between the origin of the singular canal in the IAC, the porus acousticus, the vestibule, and posterior canal ampulla. The location and importance of the singular canal are demonstrated for retrosigmoid-IAC vestibular neurectomy, retrosigmoid acoustic neuroma surgery, and transcochlear cochleovestibular neurectomy. The main purpose for the use of the retrosigmoid approach to the internal auditory canal during vestibular neurectomy and excision of acoustic neuromas is preservation of hearing. A major concern when the contents of the internal auditory canal are exposed through this approach is fenestration of the labyrinth, which results in sensorineural hearing loss. In the retrosigmoid approach, the singular canal has been found to be a vital landmark in prevention of fenestration during surgery of the internal auditory canal.

Dissection↗