Biomedical subjects
Publications and source records attributed to R A Goldenberg.
This article discusses the design of a composite prosthesis developed from a desire to combine the advantages of two synthetic materials. Hydroxyapatite can be used directly against the tympanic membrane, and Plastipore can be easily trimmed intraoperatively. The need for any human tissue can be eliminated; hearing results and extrusion rates appear comparable to other implants commonly used.
Pneumocystis carinii is the opportunistic pathogen frequently causing pneumonitis in the acquired immunodeficiency syndrome. Extrapulmonic manifestation of P carinii is unusual and is commonly associated with severe systemic illness, other immune deficiency status, malignancy, or immune suppression. We describe a case of acquired immunodeficiency syndrome with manifestations of P carinii otitis media with severe otalgia and conductive hearing loss.
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Between 1987 and 1991, I have used 215 hydroxylapatite middle ear implants, in various styles, for hearing reconstruction. The first such implants were composed entirely of hydroxylapatite. Because of intraoperative difficulties in shaping and trimming these prostheses, hybrid prostheses using Plasti-Pore were developed. For each of four implant designs (incus, incus-stapes, PORP, and TORP), the head is constructed from hydroxylapatite and the shaft from Plasti-Pore. Extrusion rate for the hybrid prostheses is low (4.3%). Hearing results from 47 patients with the hybrid hydroxylapatite prostheses, 140 patients with total hydroxylapatite prostheses, and 75 control group patients with homograft bone or Plasti-Pore prostheses were compared. A "successful" hearing result was achieved in 51.1%, 51.4%, and 60.0% of the three groups, respectively. Surgical technique for use of the new hybrid hydroxylapatite prostheses is described.
The use of hydroxylapatite for ossicular chain reconstruction is increasing. In this study, hearing results and extrusion rate for 157 consecutive patients receiving hydroxylapatite prostheses were evaluated. Results were compared to those of a control group of patients who had received either homograft bone or Plasti-Pore prostheses. Four (2.6%) cases of extrusion have occurred. Hearing success was defined as a postoperative puretone average air-bone gap of < or = 15 dB for incus prostheses and partial ossicular replacement prostheses (PORPs) or < or = 25 dB for incus-stapes prostheses and total ossicular reconstruction prostheses (TORPs). Overall success rate in the hydroxylapatite group was 51.4% for the 140 patients with postoperative data (mean follow-up, 11.5 months) and 46.7% for 90 patients who were followed for more than 6 months (mean follow-up, 16 months). PORP results were significantly poorer than those of the other prostheses. The success rate for the control group was 58.6% for 58 patients. The difference between hydroxylapatite and control group success rates appears to be due to the poorer results of the hydroxylapatite PORP.
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In 1983, results of a 5-year study using the endolymphatic mastoid shunt for treatment of Menière's disease were reported. Forty-eight patients were followed for between 1 and 5 years postoperatively, and 81% obtained satisfactory relief of vertigo. In the present analysis, 24 of these patients responded to a questionnaire, participated in a direct interview, and completed audiometric evaluations at 7 to 11 years after surgery. Eighty-three percent of these patients reported satisfactory relief of their vertigo. Results for hearing, tinnitus, and limitation of activities also varied little between the initial study and this longer-term follow-up. Studies with shorter follow-up appear valid in predicting longer-term results. These findings support the American Academy of Otolaryngology-Head and Neck Surgery's recommendation of a 2-year follow-up period for reporting results of therapy for Menière's disease.
Hearing results and extrusion rate for 89 consecutive patients receiving hydroxylapatite prostheses for hearing reconstruction were evaluated and compared to a control group of 75 patients who had received homograft bone or Plasti-Pore prostheses. At the 3-month follow-up, there were no cases of extrusion of the hydroxylapatite prostheses. Hearing success was defined as a postoperative air-bone gap of less than or equal to 15 dB for incus prostheses and partial ossicular replacement prostheses or less than or equal to 25 dB for incus-stapes prostheses and total ossicular replacement prostheses. There was a statistically significant difference in the distribution-of-success rate by prosthesis type for the hydroxylapatite. Incus, incus-stapes, and total ossicular replacement prosthesis results were similar, but partial ossicular replacement prosthesis results were poorer. The overall success rate in the hydroxylapatite group was 51.2%; in the control group, it was 60%. Hearing results tended to be better with the hydroxylapatite incus prosthesis than with the homograft bone incus, but poorer with the hydroxylapatite partial ossicular replacement prosthesis than with the Plasti-Pore. Several technical modifications of the prosthesis that may improve results with the hydroxylapatite partial ossicular replacement prosthesis are suggested. Hydroxylapatite middle ear prostheses appear to be a reasonable alternative to other more commonly used prostheses, which carry disadvantages related to the use of human tissue.
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Although it is rarely seen now, lateral sinus thrombosis may occur in either its septic or aseptic form. Septic lateral sinus thrombosis is a potentially fatal condition in which early diagnosis may be difficult because of previous antibiotic therapy. Once diagnosis is made, combined antibiotic and surgical treatment is necessary to keep the mortality rate at 25%. Aseptic lateral sinus thrombosis is a condition that is rarely fatal but that leads to symptoms of severe headache and visual impairment. The increased intracranial pressure is associated with a blockage of the dominant sinus (usually the right one). The decision to use medical treatment alone or to combine it with surgical treatment must depend on the clinical features of each case.
This paper presents the surgical anatomy of the skull base and infratemporal fossa. The information has been derived from the author's own experience in surgical and cadaver dissection, standard anatomical references, and selected experience of other skull base surgeons. Because the lateral approach has become the utilitarian method of exposure, the intricate detailed anatomy is demonstrated from this view at five levels of dissection, so the surgeon may gain a practical understanding of the surgical relationship of critical structures. Consistent anatomical landmarks can be used by the surgeon in the location of these critical structures. The styloid process, sphenoidal spine, and middle meningeal artery identify the internal carotid artery as it enters the carotid canal. The bony or fibrous septum that divides the jugular foramen into neural and vascular compartments may be used to better identify nerves IX, X, and XI. The zygomatic root is useful for location of the middle fossa dura. The lateral pterygoid plate leads directly to the foramen ovale. The increased precision of dissection permitted by use of the microscope requires an increased level of knowledge of anatomical structures in this area. It is hoped that the information presented in this paper will assist surgeons in the meticulous and thorough removal of skull base tumors and in the preservation of neural and vascular structures that are presently being sacrificed.
Meniere's disease is the classic triad of fluctuating hearing loss, episodic vertigo, and severe tinnitus. It usually occurs unilaterally, although about 15% to 20% of patients may have bilateral disease. The disease involves a series of acute exacerbations followed by a period of remission; it progresses until the ear has essentially "burned itself out," causing symptoms to subside. Treatment of Meniere's disease should be tailored to the severity of symptoms and the patient's life-style. Initial treatment involves conservative medical management and psychologic support. If this fails, endolymphatic shunt surgery is effective in alleviating symptom in the majority of patients.
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The endolymphatic mastoid shunt seems to be an effective treatment for those patients whose Meniere's disease is refractory to medical and/or supportive treatment. This series is composed of 48 patients who were followed for up to 5 years postoperatively, with 1 year being the minimum follow-up period; 81% of these patients obtained a satisfactory relief of their vertigo. The morbidity of the procedure is low with no severe or total hearing loss reported in this series. Surgery should not be recommended until the symptoms have caused severe incapacitation; however, this delay must be tempered by the desire to operate while the hearing is still fluctuating. One of the most important factors in the surgical success may be the exact identification and exposure of the sac at the time of surgery, regardless of the specific shunt technique used. Shorter duration of symptoms and lack of fluctuant hearing loss may be preoperative factors which predict a less satisfactory surgical result. While the endolymphatic shunt procedure is effective in the majority of cases, the patient should be prepared for a secondary procedure if necessary.
We report the sixth known case of a pleomorphic adenoma of the external auditory canal. It manifested as an aural polyp, and the diagnosis was made only after microscopic pathologic examination. Complete removal was accomplished after a total parotidectomy (with preservation of the facial nerve) provided access to the parapharyngeal space surrounding the internal carotid artery, where it is postulated that the tumor originated. A thorough knowledge of the developmental anatomy of this area greatly enhances operative success.
The purpose of this paper is to present a technique of preparing a homograft ossicular prosthesis in the most efficient and precise manner for use in ossicular reconstruction. While there are other techniques of reconstruction, this technique will benefit those surgeons who utilize homograft ossicles for hearing reconstruction. There are two major advantages of this technique. First, operating time is decreased because of preparations of the prostheses in advance. Second, the prostheses may be more precisely shaped than by other methods. The technique of preparation is not difficult and may be done by ancillary surgical personnel readily trained in this simple method.