Biomedical subjects
Publications and source records attributed to J L Pulec.
The authors report two cases of the microscopic total removal of meningiomas in the region of the cerebellopontine angle using the translabyrinthine approach. Although both tumors were larger than 4 cm, the only resulting neurological deficit was ipsilateral hearing loss. The translabyrinthine approach may be an alternative measure in dealing with these difficult lesions.
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An idiopathic basal ganglion calcification occurring in a 35-year-old man was first observed as a speech deficit. The literature is reviewed, the condition of patients with this disease is evaluated, and a prognosis is given. To our knowledge, the prolongation of visual-evoked potentials by this abnormality is reported herein for the first time.
This report describes a series of 18 patients, deaf in one ear, upon whom an endolymphatic subarachnoid shunt procedure was performed on the remaining hearing ear affected by Ménière's disease. As with other patients with Ménière's disease, those whose problem involves their only hearing ear can have differing priorities and etiologies requiring variations in diagnosis and management. The preservation of hearing is of major consideration as is the need for thorough study and careful diagnosis in the determination of when to operate. Special surgical techniques that help minimize the risks from surgery are employed resulting in no patient's hearing being made worse by the surgery. Study results lead to the conclusion that the use of the endolymphatic subarachnoid shunt procedure early in the course of Ménière's disease in an only hearing ear can significantly reduce the risk of permanent hearing loss and disability.
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The utricular otoconia of four patients, which were removed during surgical procedures (one for an eighth nerve section operation and three for removal of acoustic neuromas) with the use of the translabyrinthine approach, were observed with the scanning electron microscope. The otoconia of these patients showed some abnormal features. In three of the four patients, a number of otoconia were found to have cracked lines. One of these patients was a 14-year-old boy; the other patients were more than 40 years old. In the remaining case, the otoconial facet surfaces were rough, and a few otoconia were unusually shaped.
Congenital malformation of the ear has a complex origin and the possibility of hereditary, viral and toxic etiologies. The authors require audiometric evaluation, using the objective brain stem evoked response in young children, and polytomography of the middle and inner ears in all patients with atretic external auditory canals. Unilaterally atretic ear canals can be repaired electively at the discretion of the family and the patient, while in bilateral cases reconstruction is ideally done at approximately age four years. Regular follow-up is recommended to be certain that no cholesteatoma develops medial to an atretic external ear canal. The authors propose a working classification for congenital malformation of the ear. In the author's series of 35 operations for the repair of congenital ear abnormalities, 55% were improved to adequate levels of hearing without the use of a hearing aid. Eight exemplary cases and comments are presented.
Experience gained from the treatment of 41 patients with 42 operations for the relief of Vth nerve pain over the past 5 years is reported. For the selective section of the posterior root of the trigeminal nerve 28 retrolabyrinthine procedures were performed for typical tic douloureux with complete lasting relief in 25; 1 was relieved with the addition of aspirin; and 2 were relieved by Tegratol even though it was ineffective before surgery. There were no deaths and no serious complications. None had facial paralysis or anesthesia dolorosa. The retrolabyrinthine approach to the posterior root of the trigeminal nerve is ideally suited for those patients with refractory tic douloureux or patients with facial pain secondary to other causes such as tumor. Because of its effectiveness and low morbidity, this procedure offers advantages over other surgical techniques.
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Ménière's disease has been shown to have multiple causes, each of which requires a specific treatment. Patients who do not respond to medical treatment often are allowed to suffer prolonged disability from their symptoms or develop permanent hearing loss without the benefit of surgery. The physician's uncertainty regarding which patient will ultimately respond to medical treatment or have spontaneous remission of symptoms can cause a delay in what would otherwise have been definitive surgical treatment which would have allowed the patient to return to a happy and productive life. A careful analysis of 120 patients studied intensively for five years has shown that patients who exhibit specific characteristics and diagnostic findings will ultimately require surgery for control and relief of their symptoms, while others can be expected to recover with medical treatment. Fifty-six of the 120 patients ultimately required surgery to rid them of their symptoms. These patients were almost exclusively of the group considered to be idiopathic, viral, small internal auditory canal syndrome, or caused by physical or acoustic trauma. Those patients who had other causes for their Ménère's disease rarely required surgical treatment and were well controlled by specific medical therapy. These observations would seem to provide us with information which would allow patients who might be reasonably stages of their disease where conservative measures can more often be expected to give complete relief with preservation of hearing. The indications for surgery in patients with Ménière's disease based on this information will be reviewed. The use of this knowledge has significantly reduced the morbiditiy associated with Ménière's disease.
The radical mastoid cavity can be troublesome and odoriferous, may require frequent visits to an otologist, and may interfere with swimming and showering. Three procedures can be used to reconstruct the radical mastoid cavity. Soft tissue obliteration with autograft bone paste is the most versatile and commonly used technique. Reconstruction with homograft external auditory canal bone is useful for extremely large mastoid cavities that are free of infection. Use of these techniques in 35 patients since 1969 has resulted in dry, trouble free ears and improved hearing when reconstruction of the ossicular chain was performed. Use of this technique has helped patients with radical mastoid cavities to return to a normal active life style.
The use of a homograft tympanic membrane with and without attached ossicles, staging the operation, and the use of sculptured homograft or autograft ossicles have improved the results in tympanoplasty. The indications and techniques of homograft tympanoplasty are described, and the results in 99 primary cases and 11 cases with repair of a mastoid cavity are given. The overall graft success rate was 86 per cent. In patients with an intact ossicular chain, the conductive loss was reduced to less than 20 dB. in 88 per cent. A hearing loss less than 20 dB. was obtained in 68 per cent with an intact stapes, in 77 per cent when the stapes superstructure was absent, and in 79 per cent in stapedectomy done at a second stage. The use of homograft material has provided the means for significantly improving the results in our patients who require tympanoplasty.
Pain in the ear is a common complaint for which patients consult their otolaryngologist. A rare cause is geniculate neuralgia, which has also been called tic douloureux of the nervus intermedius. In its most typical form, it is characterized by severe paroxysmal neuralgic pain centered directly in the ear. The pain may also be of gradual onset and of a dull, persistent nature, with occasional sharp, stabbing pain. The diagnostic features and two new surgical techniques for its treatment are described. Afferent sensory facial nerve fibers are shown to pass not only through the nervus intermedius, but also through the main motor trunk of the facial nerve. Excision of the nervus intermedius and/or of the geniculate ganglion by the middle cranial fossa approach without the production of facial paralysis, in any of 15 cases with geniculate neuralgia is reported. Use of these new techniques, sometimes in combination with selective section of the Vth cranial nerve, has been successful in relieving the pain of geniculate neuralgia.
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