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TRANSACTIONS AMERICAN OTOLOGICAL SOCIETY, INC. 2002 VOLUME 90 ONE HUNDRED THIRTY FIFTH ANNUAL MEETING BOCA RATON RESORT&CLUB BOCA RATON, FL MAY 10-11 2002 Legend for Photo AOS 2002 First Row: Left to Right D. Tucci, K. Doyle, S. Wetmore, L. Parnes, G. Lesinsky, R. Chole, M. Paparella, J. Gulya, H. Konrad, S. Kinney, L.Okdvist, J. Neely, B. Wellimg, C. Shelton. 2nd. Row: Left to Right T. Haberkamp, S. Levine, J. Hough, R. Ruggles, B. Gantz, W. Moretz, M. McGee, R. Bellucci, W. Montgomery, B. Hirsch, B. Lonsbury-Martin, J. Dickens, J. Nedzelski. 3rd. Row: Left to Right T. Murphy, W. Adkins, H. Silverstein, J. Harris, G. Matz, T. VanDewater, R. Amedee, A. Eviatar, J. Farrior, L. Duckert, F. Rizer, W. Lippy. 4th. Row: Left to Right D. Weider, G. Singleton, R. Kohut, J. Grote, M. Arriaga, C. Beatty, Friedman, T. Eby, E. Chiossone, A. Shuring, N. Wendell-Todd. R. 5th. Row: Left to Right H. Brodie, A. Sismanis, J. Farmer, P. Antonelli, A. Lalwani,H. Jenkins, D. Kamerer, P. Weber, J. McElveen, D. Pappas, , D. Lim, O. Black, C. Luetje, J. Pulec. 6th. Row: Left to Right from center J. Niparko, N. Coker, A. Kumar, P. Hammerschlag, E. Monsell, J. Rubinstein, M. Hannley, G. Spector, G. Hughes, G. Gates, A. Arts. Award of Merit Presentation to Gregory J. Matz By C. Gary Jackson The most senior past president of the Society views the Award of Merit process with some level of ambivalence. On the one hand, it is his or her last official executive act and therefore constitutes his exit from the Council. My service to the Society on the Council has clearly represented the capstone of my professional life. It is an experience that I will always cherish. I would like to express my sincerest gratitude for your support and significant cooperative spirit during my tenure. But, on the other hand, in this era of hate, terror and terrorism, it is indeed fortifying to recognize and honor merit and all that this term inspires. The Award of Merit Committee, I think, has selected a worthy recipient with whom you will be justly pleased. At this time, I would like to acknowledge the Award of Merit Committee and express my gratitude for all their deliberative effort. So let's get to it! Our story begins in March of 1937 in Chicago. Born premature, our recipient's mother, an RN cared for him in what had to be the city's first neonatal ICU. Born into the inner city, in an area known as Bucktown, this was a predominantly hardworking, Polish enclave of the city of Chicago. Now gentrified, at the time people were very anxious to leave. Most spoke the Polish language, a language he never learned, but I have it on excellent authority that our recipient learned and knew, very well, all of the swear words. It has been claimed that he's never had grass around his house until the age of 26! Ma and pa owned a grocery store and lived in a "3-flat". The business was on the first floor, grandmother occupied Floor 2, and the family Floor-3 .His whole family lived within two blocks of this location. He was significantly, therefore, mentored and couldn't get away with much. Even at parochial school it was tow the line! I assure you, having to deal with one of these, sister, oh no you don't at 5-feet, and 225-pounds having a bad day will incentivise you to be successful like no other force in nature. This ensured a virtually angelic youth. Our Awardee had sartorial integrity. There were early standards as depicted here in a photograph with his dapper father. These standards were clearly maintained as we see in this photograph with his brother at about age 12. Born premature, there were some visual color-blind issues. To this day he is known to appear with different color socks, mismatching ties, etc. But, being the boss, very few people brought this to his attention. I also have it on good authority that while in the Air Force, in the late 1960's at Brooks Air Force Base, he was the only Major, in his dress blues who would be seen regularly in his penny loafers. He has also been known to have color coordinated trip suitcases. His wife would pre-label all items of clothing and, therefore, coordinate them. This seemed to work quite well until one day getting out of a taxi cab his suitcase fell open discharging the labels to the will of the wind and confounding his fashion sense. This is clearly a territorial animal, a creature of the city of Chicago. He lived for baseball, street ball and to this day, and I venture to say to the day he dies, can be counted amongst those dyspeptic and morose Chicagoans known as Cub fans. He is a creature of the city and of his high school which demonstrated and meant a great deal of territorial integrity to him. To this day, every applicant or acquaintance he meets, they appear to be disarmed by the question, "Where did you go to high school". He soon began to flirt with independence. His family never had or could afford a car. Every transportation he either made by bicycle or the "El". As a matter of fact, all his educational choices were based upon location and travel distance by bus or "El". Witness his alma mater of DePaul, Loyola, and the University of Chicago, all only one bus or train ride away. His independence began, however, to blur into the confines of responsibility .His father died when he was 16. Mom sold the store and returned to her duties and profession as a nurse. The boys had to fend for themselves and I again have it on good authority that he and his brother led an "adventuresome" life. His brother died prematurely at age 33 leaving a wife with a small child. He finally owned a car in residency, but all the independence was just too much! In June he opened the trunk of his car to find one-hundred addressed Christmas cards stamped from the previous year. He was said to have fallen to his knees to clutching his head in both hands claiming, "1 need help". After a complicated courtship, he eventually proposed to a woman to whom he referred as "GU': Geographically undesirable. She lived in the suburbs! The rest is history. His career as a mentor and teacher at the University of Chicago and later as the Chair at Loyola for eighteen years constituted the concept of merit. His service to this Society is virtually unparalleled. All of this was achieved with his partner in life, his wife Judy. He was always a serious student of his profession. His advice and decisions were always secure, seldom wrong, but never in doubt! Now recently retired from the Chair at Loyola University, the passions of his life include his family, particularly those newest members of the family, his grandchildren. He is an avid sailor and spends as much time on his boat as possible. And, oh yes, there's Chicago, I feel his passion forever. Ladies and gentlemen, I introduce to you this year's recipient of the Award of Merit of the American Otological Society, Dr. Gregory Matz. 2002 PRESIDENTIAL ADDRESS RICHARD A. CHOLE, MD PhD One of the prerogatives of the President is to give a short Presidential Address and I had debated about what I should say at this address being focused as a physician scientist on the science under-girding the specialty. I thought that would be my focus but there are other pressing issues facing otology and otolaryngology. I just thought I would give you some of my comments about the movement in audiology that is occurring as most of you probably heard about this morning from Dr. Fabrey. I’d like to talk to you about the future of audiology, some perspectives on the new AUD movement and what it means generally, what kind of a movement it is and what it means to us. This is from the AAA about their answer as to why have an AUD. The scope of practice of audiology has expanded substantially since the 1960’s when a master’s degree rather than a bachelor’s degree was required for entry into practice. It has become necessary to increase the academic and clinical training requirements from a master’s degree to a professional doctorate for entry into the profession. Professional organizations have indicated that professional doctorate; the AUD will be the entry-level degree by 2012. This is basically the marching order and the march has begun. A few things about the AUD from the AAA and other professional sources: The AUD is not an academic degree; it’s a clinical professional degree like those in the fields of medicine and dentistry. Students go to the best schools because those graduates will flourish in the doctoring world. The AUD is here to stay. I’d like to point out a couple of factors here. The AUD is a clinical degree and there is some concern on my part and many people’s part as to where do the academic development come in a clinical training program like this. Will perspective PHD researchers in the audiology field choose the AUD instead of choosing a research degree, which the AUD is not? The other point is the statement that this is a doctoring profession and a doctoring degree. This is the difference between current master’s level training and the AUD. The length of training is lengthened from two to three or sometimes four years. Credits are about the same. The scope of information is roughly the same with the addition of emphasis on cochlear implant rehabilitation and some neuro-monitoring and neurophysiology as well as vestibular testing being integrated into the programs, not only vestibular testing but vestibular rehabilitation as well. So, the scope of the AUD has expanded beyond the MS slightly. These programs started only a few years ago but this is from a recent website 39 and counting. These are programs that are either in place or are going to be in place and these are not by small and insignificant University but many which you represent here who are participants in this movement. This is from one of their websites as to what will the AUD do for me for the audiologist? And this is what the promise of the AUD is. First, autonomy graduates will be able to provide hearing services independently. Flexibility, the graduates will have flexibility to provide services to an entire range of patients. That is a different focus than the prior focus. Higher incomes, individuals who hold doctoral degrees can expect higher incomes and public recognition and serving the public. So the AUD movement has certain expectations which are well described. A number of these programs currently, probably most of the programs are run with a distance learning paradigm, that is you can get the degree and accumulate credits and actually be awarded the degree without ever really attending a University or a School. Here some of the schools that are offering distance learning for an AUD and I’d like to show you some details on one of them just as an example so you get a feel for this. The Pennsylvania College of Optometry has a School of Audiology. This is from their website “Welcome to the Pennsylvania College of Optometry, School of Audiology AUD’s distance education website. AUD on line is a bridge program that allows audiologists to earn an AUD degree without leaving their practices. AUD online is reasonably priced and offered 100% on the internet.” Here’s an example of some of the courses of AUD online: anatomy and physiology and the ECOG, anatomy and physiology ENG, otoscopy and cerumen management, business management, vestibular rehabilitation and medical surgical treatment of the ear. I’m not sure how they teach medical and surgical treatment of the ear online but that’s what’s happening. Here are expectations of the AUD movement, principally the independent practice potential. Independent practices in hearing evaluation and hearing aids. There’s a lot of interest among the AUD’s and the AUD schools that routine testing may not really be done by AUD’s but rather by technicians that the AUD's will employ or train. I’ll get back to that in a minute. Clearly this is a doctoring profession that they will be addressed as doctor. Balance disorders are being incorporated into the realm of the AUD including diagnostic testing, diagnosis and treatment in rehabilitation in balance disorders. Neuro-monitoring is also within the scope and the expectation of higher compensation. So really one of the big questions here is once the AUD movement has been full-blown and I guarantee to you that it will be and the master’s degree level will vanish within the next few years, whose going to fill the gap of doing diagnostic audiology and hearing testing? There are needs for otolaryngologists to have someone working in their offices. There are needs for schools to have audiologists and AUD’s themselves are going to want to hire somebody to do hearing testing so these are some of the proposals. The oto-tech proposal that technicians can be trained and a technician course something like the Academy is proposing, an associates degree that would be given in an institution of higher learning where someone would earn an AA for learning basic hearing testing, maybe a continuation of the master’s degree audiologist. The way that the snowball is going, it’s my feeling that those will really disappear. Another suggestion that we are going to make is the idea of a bachelor of science in Audiology be resurrected and that quality training programs and basic audiology be offered on a bachelors science level so that well trained individuals will be able to do the gamete of diagnostic audiology was done before the master’s degree gathered momentum. This is a topic of discussion. We can’t really be complacent about this particular issue because the train has left the station. So what can we do? Well here are a few thoughts about our response to this movement. First of all I think we should support the training and development of another level of audiologists. This might be an oto-tech, an audiology technician or maybe go back to training bachelors of Science audiologists in addition to the AUD. I think it’s imperative that we improve training in our residency programs in audiology. Speaking as a member of the American Board of Otolaryngology, its appalling the level of training that an average otolaryngology resident has when he or she comes to take the boards. This must change. I think that can change by challenging the residency review committees to really require audiology training in the residency programs as it was when I was a resident when there was a much bigger core of audiology training than what we have now. Also challenge the AB OTO to increase emphasis on audiology and hearing aids and audiometric testing in both the certifying examination and the maintenance of certification. Then I would also challenge the University’s and challenge you at your University’s to resist the idea of distance learning and the idea of unearned degrees. These degrees are being grandfathered as well as and I think that’s an extremely bad trend. The AUD is here to stay and I think if it’s done in a responsible and professional manner, these individuals will be well trained and served well. I think we also have a mandate to indeed do this properly and we all need to step up to the plate and do our role in audiometric training. Thank you. GUEST OF HONOR PRESENTATION DAVID A. LIM PRESIDENTIAL CITATION MICHAEL M. PAPARELLA Scientific Session May 10, 2002 Acoustic Neuroma Vestibular Schwannomas Growth Rates in NF2 Natural History Consortium Patients William H. Slattery, MD, Mark L. Oppenheimer, MS Laurel M. Fisher, PhD Objective: To examine the growth patterns of vestibular schwannomas (VS) in NF2 patients. Study design: Retrospective case review. Setting: Multiple tertiary centers across the world (US, England, Germany, and Japan) participating in NF2 Natural History Consortium. Patients: 291 retrospective MRI exams from 88 NF2 patients were examined, resulting in a total of 579 data points for 175 VS. Short-term analyses were restricted to those VS with: 1) at least two data points in time, 2) at least 3 months follow-up, 3) no VS surgery prior to end of follow-up. After these exclusions, 343 data points for 94 VS (from 58 NF2 patients) remained. Long-term analyses had the additional restrictions of: 4) at least 4 data points, 5) at least 18 months of follow-up. 165 data points for 27 VS (from 21 NF2 patients) remained for long-term analyses. Intervention(s): None Main Outcome Measure(s): The primary outcome measure was greatest anterior posterior dimension. In addition, changes in greatest medial lateral and greatest diameter were analyzed. Results: For short-term analyses (n=94 VS), VS at earliest MRI had a mean anterior posterior measurement of 1.1cm (sd=0.8), while the mean at last MRI was 1.3cm (sd=0.9). For long-term analyses (n=27 VS), VS at earliest MRI had a mean anterior posterior measurement of 1.0cm (sd=0.5), while the mean at last MRI was 1.3cm (sd=0.7). Further analyses will be reported, including results stratified by tumor size at earliest MRI. Conclusions: In general, VS from NF2 patients were stable during this analysis. Prospective standardized studies are needed to determine accurate growth rates William H. Slattery, M.D. House Ear Institute 2100 West 3rd St. Los Angeles, CA 91011 The Efficacy of Corticosteroids in Restoring Hearing Loss in Patients with Acoustic Neuromas Anna Aronzon, MD, Douglas C. Bigelow, MD Michael J. Ruckenstein, MD, MSc, FRCSC Objective: To evaluate the role of corticosteroids in restoring hearing loss in patients undergoing conservative management of acoustic neuromas. Study design: Prospective cohort. Setting: Tertiary referral center. Patients: Seven patents who presented with acute hearing loss secondary to an acoustic neuroma. Intervention: Oral Prednisone (1 mg/kg x 1-2 weeks) within a week of onset of hearing loss. Main outcome measures: Audiometric assessment at the time of presentation and after corticosteroid therapy. Results: All seven patients had pure tone reception threshold improvements ranging from 10 to 50 dB in at least two frequencies or more. Speech discrimination thresholds improved after therapy in all seven patients with gain of 4 to 38 percentage points. Conclusions: 1. Patients with acoustic neuromas who are being managed with a "watchful waiting" approach should receive corticosteroid treatment at the first signs of hearing deterioration. 2. A retrocochlear work-up is mandated in patients presenting with sudden hearing loss even if it responds to steroid treatment. 3. Older data documenting the efficacy of corticosteroids in the treatment of sudden hearing loss may need to be reevaluated, as many of these studies were conducted prior to the advent of MRI scanning. 4. These data are the first to document the efficacy of corticosteroid treatment in reversing acute hearing loss caused by acoustic neuromas. Michael J. Ruckenstein, M.D. Dept. of Otorhino Hospital of the University of Pennsylvania 3400 Spruce Street, 5 Ravdin laryngology Philadelphia, PA 19104 CSF Leakage after Acoustic Neuroma Surgery: A Comparison of the Translabyrinthine, Middle Fossa, and Retrosigmoid Approaches Samuel S. Becker, BA, Robert K. Jackler, MD Lawrence H. Pitts, MD Objective: To determine whether or not the choice of surgical approach affects the rate of postoperative cerebrospinal fluid (CSF) leakage in patients who underwent surgical resection of acoustic neuroma. Study Design: Retrospective chart review. Setting: Tertiary referral center. Patients: 300 patients who underwent surgery for acoustic neuromas were selected by consecutive medical record number until 100 resections via each surgical approach (translabyrinthine (TL), middle fossa (MF), retrosigmoid (RS)) had been gathered. Main Outcome Measures: Surgical approach utilized, CSF leak incidence, tumor size, patient age. Results: Post-operative CSF leak of any severity was found in 13% of TL, 10% of MF, and 10% of RS patients. These difference in the rate of CSF leakage were not statistically significant (p=0.72). The majority of leaks were managed conservatively with fluid and activity restriction often accompanied by a period of lumbar subarachnoid drainage. There was a need to return to the operating room for a definitive procedure in 5% of TL, 2% of MF, and 4% RS patients; again not statistically different among the approaches (p=0.51). Tumor size was not correlated with CSF leak rate (p=0.13). Patient age, for patients older than 50 years, was suggestive of increased odds of CSF leak (p=0.07). Conclusion: Neither surgical approach nor tumor size affects the rate of post-operative CSF leakage or the necessity of managing a leak with a return to the operating room. The odds of incurring post-operative CSF leaks may increase with age beyond 50 years. Samuel S. Becker, B.A. 144 Hugo Street #3 San Francisco, CA 94122 DISCUSSION SESSION #1, Papers 1-3. DR. RICHARD CHOLE: These papers, the Presidential Address and the Guest of Honor Address are up for discussion, so are there any comments or questions? DR. DAVID EISENMAN, WASHINGTON DC: On the last paper, did the patients and different approaches have different postop treatment dosage or duration of steroid administration? DR. SAMUEL BECKER: We don’t routinely use steroids except for very large leaks. DR. ARUN GADRE, GALVESTON,TX: You spoke about diffensins. My understanding was that diffensins have very little effect against gram negatives in general and in pseudomonas in particular. Have you looked at that? DR. RICHARD CHOLE: David, did you get the question? The question about diffensins and their activity against gram negatives? DR. DAVID LIM: That is not true our data shows that it is not as strongly active against gram positive but they are quite comparable. DR. ARUN GADRE, GALVESTON, TX: Because there’s a lot in the literature with regards to bovine mastitis and looking at different organisms particularly with respect to diffensins, there’s a huge body of literature that you are aware of. My understanding was that for pseudomonas it’s not very good. DR. DAVID LIM: We have not tested pseudomonas but we are largely interested in pseudo-pathogens that I described and the dramatic one was against the moroxilla, then streptococcus pneumonia, and hemophilus. This maybe has to do with the way that the human better diffensins are prepared, so I think from one study to the other when it’s right to compare it, you have to know exactly what the preparation is. DR. RICHARD CHOLE: Thank you, other questions or comments? Okay I would like to remind the members that the AOS photograph will be taken this afternoon just after the end of these sessions and it will be in the Spanish patio, that’s where all the birds are over as you walk through and we will remind you again of that. I’d like to encourage you to see the exhibitors across the way and we will reconvene here at 3:15 for the next session on Implantable Devices. Thank you. Implantable Devices Rehabilitation of Unilateral Deafness: Comparison of the BAHA Implantable Hearing Device with CROS Amplification John K. Niparko, MD, Lawrence R. Lustig, MD Kenneth M. Cox, MA, CCC-A Objective: Hearing in only one ear imposes constraints under many listening conditions. We compared the speech recognition effects of a semi-implantable bone-conductor (the Entific BAHA device) with conventional contralateral routing of signal (CROS) amplification in adults with unilateral deafness. Design: Prospective trials of subjects with unilateral deafness using hearing-in-noise (HINT) and source identification (SAINT) testing. Setting: Tertiary referral center; outpatient surgical and audiological services. Patients: Adults with unilateral deafness (SRT>90dB; S.D.<20%) after acoustic neuroma excision (n=7) or sudden SNHL (n=3). Entry criteria included normal hearing in the contralateral ear (SRT<25dB; S.D.>80%). Intervention: Subjects were fitted with CROS amplification devices for one month and tested with CROS before (mastoid) implantation of the deaf ear, fitting, and testing for BAHA. Outcome measures: 1) Subject assessment of experience with their devices and patterns of use; 2) speech discrimination in quiet and in noise under conditions of noise-front, noise-to-normal-ear, and noise-to-deaf-ear using HINT protocols; and 3) source localization tests with SAINT. Results: There was consistent satisfaction with BAHA implantation and amplification, and poor acceptance of CROS amplification. Relative to baseline, CROS and BAHA produced significantly better speech recognition in noise under most conditions. BAHA enabled significantly better speech recognition than CROS in the noise-todeaf-ear condition. Sound localization was poor at baseline, and with both BAHA and CROS. Conclusions: Preliminary data indicate that the BAHA overcomes head shadow effects in unilateral deafness. BAHA improves speech recognition in noise based on filtering characteristics of the device and interaural signal transfer. BAHA offers advantages over CROS by avoiding occlusion of the normal hearing ear canal, thereby averting interference of speech signals. BAHA provides a superior approach to CROS in the auditory rehabilitation of unilateral deafness as revealed by initial patient experience and performance. Supported by the Dexter F. and Dorothy H. Baker Foundation, equipment support provided by Entific Medical Systems. John K. Niparko, ,M.D. Johns Hopkins Hospital JHOC-6223 601 N. Caroline St. Baltimore, MD 21287-0910 The Use of Full-Thickness Skin Grafts for the Skin-Abutment Interface Around Bone-Anchored Hearing Aids Mary C. Snyder, MD, Gary F. Moore, MD Perry J. Johnson, MD Objective: To review the complication rate encountered with the use of full-thickness skin grafts to obtain a viable skin-abutment interface around bone-anchored hearing aid (BAHA) implants. Study Design: Retrospective chart review Setting: Tertiary referral center Patients: Fifteen patients who underwent BAHA placement over a four-year period. Intervention: Each percutaneous titanium implant and abutment was placed into the temporal bone the standard Branemark technique. Eight of these procedures were performed in two stages, and seven were done as single stage procedures. In all cases, the skin-abutment interface was established by use of a full-thickness skin graft inset around the implant. Main Outcome Measure: Complications associated with the skin grafts were noted, as well as any additional procedures needed for revision of the skin-abutment interface. Results: Seven patients (46.7%) experienced loss of the full thickness skin graft around the abutment. Three of these seven had complicating medical factors associated with impaired wound healing: two with diabetes mellitus, one of whom was also a smoker, and a third patient who was receiving inhaled steroids for treatment of asthma. Of the seven patients who lost skin grafts, two healed by secondary intention, two underwent repeated full thickness skin grafting, and three underwent galeal rotation flaps with split-thickness skin grafting. No patient experienced loss of the implant. Conclusion: The use of full-thickness skin grafts for establishment of the skin-abutment interface around BAHA implants is associated with a high rate of graft loss. Alternative methods of establishing the skin-abutment interface should be considered, especially in high-risk patients. Mary C. Snyder, M.D. 981225 Nebraska Medical Center Omaha, NE 68198-1225 Long-term Results in the First 100 U.S. Recipients of the Vibrant Soundbridge Implantable Middle Ear Device Thomas J. Balkany, MD, Charles Luetje, MD The Vibrant Soundbridge Clinical Investigators Group Objective: Implantable middle ear devices have been available since August 2000 for treatment of mild-to-severe sensorineural hearing loss. The objective of this study was to evaluate long-term (12-48 months postoperative) safety and performance in the first 100 recipients in theUnited States. Study design: This was a multicenter, prospective, single-subject, repeated measures study. Setting: The study was completed at 14 tertiary care hospital and outpatient facilities. Patients: 100 adults with mild-to-severe sensorineural hearing loss were given a battery of tests including otologic examination, audiometric testing, and self-assessment, prior to implantation with the VSB, and then at postoperative intervals up to 48 months. Intervention: Subjects were implanted with a Vibrant Soundbridge (VSB). Main Outcome Measures: Air, bone, speech and admittance testing measured hearing improvement over time. Patient satisfaction was measured with a validated self-assessment metric, Profile of Hearing Aid Performance (PHAP) and complications were analyzed from review of a computerized data base. Results: Patients maintained statistically significant increases in functional gain compared to their hearing aids over time. Speech recognition scores were similar to those with hearing aids. Self-assessment of satisfaction and benefit in different listening situations (PHAP) indicated sustained improvement over time. No clinically significant decrease in residual hearing or other major complications were caused by the intervention. Conclusions: This study demonstrates safety and efficacy of the VSB over a period of 12-48 months. Thomas J. Balkany, M.D., FACS Dept. of Otolaryngology University of Miami School of Medicine Box 016960 (D-48) Miami, FL 33101 Second Language Capabilities in Children with Cochlear Implants Susan Waltz man, PhD, Noel Cohen, MD, Amy Robbins, MS Janet Green, MS, Yael Bat-Chava, PhD Objective: The development of oral language in children using cochlear implants is dependent on factors including age at implantation, speech perception abilities and intervention approach. Although baseline achievements have been established, ceiling attainment levels of this group have yet to be explored. One indicator of a higher capability level would be the ability of implanted children to learn to communicate orally using a second language. The purpose of this research was to 1) explore the feasibility of children with cochlear implants developing oral fluency in a language in addition to English and 2) categorize the levels of speech perception and linguistic competence necessary for children to learn a second language. Study design: Prospective study of children fulfilling the inclusion criteria. Setting: University Medical Center. Patients: 20 profoundly hearing impaired children who were exposed to a spoken language in addition to English. Interventions: Cochlear implantation at age 3 or younger. Main Outcome Measures: The subjects were evaluated preoperatively and at regular intervals postoperatively using standard speech perception and receptive and expressive language measures. Results: Results indicate that some children using cochlear implants are able to achieve fluency in a second language. Statistically significant correlations exist between level of auditory skills, linguistic competence in English and the ability to learn a second language. Conclusions: High levels of achievement including the learning of a second spoken language are possible following cochlear implantation. Variables include the existence of handicapping conditions, type of therapeutic intervention and educational placement. Susan B. Waltzman, Ph.D. NYU Cochlear Implant Center 660 First Avenue New York, NY 10016 Telephone Use and Understanding in Patients with Cochlear Implants Jeffrey S. Adams, MD, Gregory W. Pippin, MD M. Suzanne Hasenstab, PhD, FAAA, Aristides Sismanis, MD Objective: To determine the number of cochlear implant patients who use the telephone independently, require some form of assistance, or do not use the telephone. To assess telephone understanding by patients who use the telephone independently, and determine characteristics that contribute to successful telephone communication. Study design: Retrospective clinical study. Setting: Tertiary referral center. Patients: Ninety-five adult and pediatric patients (born in or before 1991) at our institution using cochlear implants for at least 6 months. Intervention(s): A mailed survey assessing telephone communication was used to group subjects according to telephone use. Response frequencies were compared between groups for questions regarding patient demographics, clinical and audiologic data, cochlear implant device characteristics, and telephone use. Independent telephone users were eligible for testing with open-set sentences presented via telephone. Statistical analysis was used to correlate performance with patient characteristics and device factors. Main outcome measure(s): Results of the completed survey and the CID Telephone Sentences Test. Results: A 91% (N=86) survey response rate was achieved. Forty-two percent of respondents indicated independent telephone use, 14% reported adapter or code-assisted telephone use, and 44% had no telephone use. Of the independent users, 94% (N=34) participated in the telephone testing task. The average performance score was 67%. Variables associated with independent telephone use and proficient telephone understanding is presented. Conclusions: Results suggest that many cochlear implant patients use the telephone for daily activities without assistive devices or relay services. Patient characteristics and factors related to cochlear implants can impact successful telephone use and understanding. IRB Approval Number: 1677 Jeffrey S. Adams, M.D. VCU - MCV Campus P. O. Box 980146 Richmond, VA 23298 Electrical Suppression of Tinnitus Jay T. Rubinstein, MD, PhD, Richard S. Tyler, PhD Carolyn J. Brown, PhD, Abigail Johnson, MA Cynthia Bergen, BA Objective: Tinnitus is a widespread clinical problem with multiple treatments but no cure. A cure for tinnitus would restore the perception of silence. One plausible hypothesis for the origin of tinnitus associated with sensorineural hearing loss is that it is due to loss or alteration of the normal spontaneous activity in the deafferented regions of the cochlea. Electrical stimulation of the cochlea with high-rate pulse trains has been demonstrated to produce spontaneous-like patterns of spike activity in the auditory nerve. We hypothesize that such stimuli might represent an effective treatment for tinnitus. Study design: Single-blind trial using each subject as their own control. Setting: Outpatient clinic in tertiary referral center. Patients: Eleven volunteer human subjects with bothersome tinnitus and high-frequency sensorineural haring loss. Interventions: Myringotomy and temporary placement of a round window electrode was performed. High-rate pulse train stimuli were presented at various stimulus intensities. Main outcome measures: Tinnitus and stimulus perception were scaled by the subject without feedback of the stimulus condition. Results: Five of eleven subjects showed substantial or complete tinnitus suppression with either no perception or only a transient perception of the stimulus. Three showed tinnitus suppression only in association with the perception of the stimulus. Three showed no effects on tinnitus. Conclusions: The results are promising and support further research to develop a clinically useful intervention for tinnitus associated with high-frequency sensorineural hearing loss. Supported by Braintronics, Inc. and the Tinnitus Research Consortium. IRB#199810088 Jay T. Rubinstein, M.D., Ph.D. Dept. of Otolaryngology 200 Hawkins Drive Iowa City, IA 52242 Discussion Session Papers 4-9 DR> RICHARD CHOLE We have some time for some questions and answers. If you come up with a question, please state your name and address the paper you want to discuss, go ahead. DR. MICHAEL RUCKENSTEIN, PHILADELPHIA: Dr. Rubenstein can you describe the differences in your stimulus parameters as those defined by the old Aran data done in the 70’s using electrical stimulation for tinnitus suppression? DR. JAY RUBENSTEIN: In one word, rate. The idea here is that we know these high rates of stimuli, specifically this particular range of three to five thousand pulses per second, produces spontaneous-like activity in the differentiated auditory nerve. If the loss of spontaneous activity is one mechanism for tinnitus, then in people who have that, you would expect to be able to suppress their tinnitus with those sorts of stimuli. DR . CHARLES LUETJE, KANSAS CITY : For Dr. Rubenstein. In the mid-1980’s we did some acute studies that is unpublished data where we put a 3M House device electrode against the round window through a tympanotomy and then for a series of minutes, hours, I’ve forgotten what it was, with 3M equipment put square waves, round waves, circular waves, sine waves. Four of those thirteen patients had some alteration of their tinnitus. My question to you is how might that rate varied from what you are doing here? DR. RUBENSTEIN: I can answer that by saying when I first presented the idea of doing this at the neuroprosthesis workshop a few years ago, Terry Ambrecht’s response was “Gee that’s sounding an awful lot like a fifteen kilohertz carrier”. Part of what motivated this work is a long history of using high rate, high frequency sinusoidal stimuli in attempts to suppress tinnitus with variable results. So the goal here was to try, knowing that this particular range of frequency produces a physiologic pattern of activity where there are good reasons to think this is associated with certain kinds of tinnitus, to find out whether it really does. DR. STEVEN CHEUNG, SAN FRANCISCO, CA Question for John Niparko. John, a question for you about the directional hearing capacity of patients with BAHA. The question is: was the condition where you would occlude the only hearing ear and test the directional hearing capability of patients with BAHA only input used in your study? DR JOHN NIPARKO: I didn’t catch the last phrase. DR. STEVEN CHUNG, SAN FRANCISCO, CA Was the condition where the better hearing ear is occluded and the task is to identify the sound source through the BAHA, the only condition used? DR.NIPARKO : Through the BAHA only, no we didn’t look at that condition. In fact this is a rather rigorous test because everything is posterior to the patient. There is likely going to be localization tests that are less stringent where the patients may in fact function better. When you talk to these individuals, you get the sense that is likely to be the case, because they feel they have some localization we were not able to show with the tests. DR. STEVEN CHUNG, SAN FRANCISCO, CA It might be interesting to see if there is some systematic distortion in terms of localization of sounds in space with BAHA only and it might be a problem where you have divergence of representation of space in these two modes of hearing. DR. NIPARKO: It’s entirely likely. The hypothesis that you have raised is that because there are low pass filter characteristics of the skull base that there is going to be a distortion in terms of timing and frequency cues. That’s going to interfere with precise localization although some degree of localization may be still possible. DR. RICHARD CHOLE Are there any other questions? DR. RICHARD CHOLE. A question for Dr. Balkany. Could you comment on device failures or redo complications in the series? DR. TOM BALKANY: In the series there were four non-users. There were also four patients whose hearing results were substandard and who received middle ear explorations. In that group, working transtympanically, there was an attempt made to recrimp the device on the incus and that was successful on improving the hearing results in two. There was one patient who was explanted because of a feeling of fullness or stuffiness as well. That was probably due to some bone dust, which was left in the area of the facial recess in which formed a little cast around the FMT. DR. RICHARD CHOLE. Were there no device failures? DR. TOM BALKANY: The data that I presented was with the second generation device and there were no device failures in that group. At the three-month data, those of you who follow this may recall there were some device failures at the stress relief point similar to what we saw with earlier cochlear implants. That was reinforced and since that time there were no device failures. Thanks. DR. RICHARD CHOLE. Are there any other questions? DR. RICHARD CHOLE. A question for Dr. Jeffrey Adams. The left-sided results being better than the right caught my interest and I’m sure many others. Is that just a selection process or a handedness problem, can you explain? DR. JEFFREY ADAMS, DAYTON, OH I don’t know exactly what to make of it. Obviously there was a lot of selection bias in the study. I don’t know if Dr. Sismanis has a theory on it. DR. ARISTIDES SISMANIS, RICHMOND, VA I don’t know that it’s significant, to be honest with you. DR. CHOLE: Any other additional questions? We are slightly ahead of time. Could I remind you all to get your photographs? You have to pick up a number, sign your name next to that same number. The photographs will be out where the birds are. If you all remember where the parrots and parakeets are out there, that is where we are going to have the photograph. Also I think we can go ahead with the next session. LABYRINTHINE ANOMALIES: Dehiscence of Bone Overlying the Superior Semicircular Canal as a Cause of Apparent Conductive Hearing Loss Lloyd B. Minor, MD, John P. Carey, MD Phillip D. Cremer, MD, PhD, Sven-Olrik Streubel, MD Objective: To identify superior canal dehiscence in patients with apparent conductive hearing loss and to define the cause of the air-bone gap. Study design: Prospective study of patients with superior canal dehiscence. Setting: Tertiary referral center. IRB Approval #99-06-29-02. Patients: Vestibular signs and/or symptoms of superior canal dehiscence and findings on high-resolution CT scans of the temporal bone. Interventions: Vestibular-evoked myogenic potential (VEMP responses), three-dimensional eye movement recordings. Outcome measure: Association of superior canal dehiscence with air-bone gap and intact VEMP responses. Results: Three patients with dehiscence of bone overlying the superior canal were noted to have air-bone gaps in the affected ear measuring 25-40 dB for frequencies of 250 - 2000 Hz. Prior to identification of superior canal dehiscence, each of these patients had undergone stapedectomy for correction of presumed impairment of stapes mobility. The air-bone gap was unchanged postoperatively. Each patient had an intact VEMP response from the affected ear, a finding that would not have been expected based upon a middle ear cause of the conductive hearing loss. One patient underwent resurfacing of the superior canal through a middle fossa approach. Postoperatively, his vestibular symptoms were relieved and his air conduction thresholds were improved by 20 dB. Conclusions: Superior canal dehiscence can result in apparent conductive hearing loss. The 'third mobile window' created by the dehiscent superior canal results in dissipation of acoustic energy and is a cause of 'inner ear conductive hearing loss'. Lloyd B. Minor, M.D. Dept. of Otolaryngology Johns Hopkins Outpatient Center 601 N. Caroline St., Rm. 6253 Baltimore, MD 21287-0910 A Novel Stapes Ankylosis Syndrome is Caused by Mutations in the NOG Gene David J. Brown MD, Theresa B. Kim BA, Elizabeth M. Petty MD, Catherine A. Downs MS, Donna M. Martin MD PhD, Peter J. Strouse MD Sayoko E. Moroi MD PhD, Stephen S. Gebarski MD, Marci M. Lesperance MD Hypothesis: An autosomal dominant syndrome of stapes ankylosis, hyperopia and skeletal abnormalities is caused by a mutation in a single gene, hypothesized to be the NOG gene. Background: We studied a family with bilateral congenital stapes ankylosis associated with hyperopia, broad dysmorphic thumbs and great toes, joint abnormalities, and syndactyly, without symphalangism or features of osteogenesis imperfecta. Mutations in the NOG gene are known to underlie similar but distinct stapes ankylosis syndromes. Methods: DNA sequencing of the NOG gene was performed for 8 affected individuals, 3 unaffected relatives, and 100 controls. Clinical and genetic data were correlated. Results: A novel NOG mutation, 1139C>T, Q110X, was found in all affected individuals but not in unaffected family members or controls. The Q110X mutation creates a premature stop codon that truncates the protein from 232 to 110 amino acids. Conclusions: While the presumptive diagnosis was initially otosclerosis, further investigation identified subtle skeletal features comprising a congenital stapes ankylosis syndrome. The Q110X mutation causes milder effects than those reported for other NOG mutations. NOG encodes a secreted protein, noggin, that interacts with bone morphogenic proteins (BMPs) in the extracellular matrix and is essential for normal bone and joint development. The mutant protein may disrupt the BMP pathway or it may be degraded, resulting in insufficient amounts of normal protein. Identifying the genetic cause of a congenital stapes ankylosis syndrome may help identify targets for future therapeutic intervention. Supported by the AOS Research Fund and the General Clinical Research Center #M01-RR00042. IRB #1996-597 Marci M. Lesperance, M.D. F6905 Mott 1500 E. Medical Center Dr. Ann Arbor, MI 48109-0241 Enlarged Vestibular Aqueduct Syndrome in the Pediatric Population Colm Madden, MB FRCSI, Corning Benton, MD FACR John Greinwald, MD, Daniel Choo, MD Objective: To correlate clinical and audiometric findings with the radiological appearance in patients with enlarged vestibular aqueducts (EVA). Design: A retrospective review of a Pediatric hearing loss database of over 820 patients. Setting: A tertiary Pediatric referral center. Patients: Subjects were included for study with a radiographic diagnosis of EVA in at least one ear by a neuroradiologist. Intervention: N/A. Outcome Measures: Audiometric performance and vestibular aqueduct width. Results: Forty-six patients (76 ears) were identified with an EVA with a M:F ratio of nearly 1:1. Patients were followed for a mean of 46 months (range 2 - 205 months). Hearing loss was bilateral in 65% of cases. Associated inner ear pathologies were visualized on 25% of the CT scans. Vertigo was present in only 4 (9%) of the patients and was associated with a sudden drop in hearing after mild head trauma. Borderline enlargement of the vestibular aqueduct was associated with varying degrees of SNHL. 40% of ears had the characteristic low frequency conductive or mixed loss seen in this condition, despite a normal middle ear. Overall, the audiogram remained stable in 57% of ears, fluctuated in 18% and progressively worsened in 25%. Treatment included hearing aids (58%), FM systems (43%), preferential seating (33%) and cochlear implantation (7%). Conclusions: Audiometric thresholds remained surprisingly stable. Sudden deterioration of hearing following head trauma was seen in four male patients, prompting speculation that males are more likely to encounter head trauma and thus are at higher risk of sudden hearing loss. Cochlear implantation was of significant benefit to those children selected for implantation. Colm Madden, M.B., FRCSI Dept. of Pediatric Otolaryngology Children's Hospital Medical Center 3333 Burnet Ave. Cincinnati, OH 45229 Discussion Period Papers 10-12 DR. RICK CHOLE: This paper will be open for discussion in just a minute but let me remind the members of two things. One to pick up a little card like this at the desk outside and sign your name. That’s going to be for the photograph. The photograph will be held immediately after the discussion section out on the Spanish terrace there which is where the parrots and birds are. So please make it there promptly and we can get this done quickly. These papers are now open for discussion. DR, THOMAS VAN DE WATER, MIAMI, FL I had a question for Dr. Brown about the NOG mutation. As you probably know from work that was also done at the University of Michigan in birds by Kate Beraldin and Margaret Lomax, noggin is associated with malformations of the semicircular canal and yet I don’t think you saw any of that in any of the patients, which is very interesting. What do you think is going on there? DR. DAVID BROWN, ANN ARBOR, MI Yes I do know Dr. Beraldin and Dr. Lomax, I worked with them as well. It is true there is no vertigo, no dizziness in this family and there were no anomalies found on the computer tomography scans. In those experiments, if I remember correctly, they put beads in the semicircular canals with and without noggin and they showed that they can inhibit semicircular canal formation. In this family it seems like there’s a gradient type of thing in which there is a certain amount of noggin that is available to inhibit the bone morphogenetic proteins. So, it might be more of a gradient thing. DR. RICHARD CHOLE My question is did you say that other noggin mutations have different phenol types and if so how do you explain that? Is there splice variance with the noggin gene or what is the mechanism of that? DR. DAVID BROWN: Well the NOG gene is a single gene and there are different mutations causing different types of frame-ships. Ours is one of the two that I know that actually has a stop code on and some others might just have a change in a base pair but each of them has a slightly different phenotype and there are a lot of consistencies that are conserved and we are not sure. There are not many functional studies have been done and were not sure how each of the mutations actually change the confirmation of the noggin and how that affects the interaction with other proteins so there is a spectrum with the extreme being more the bony changes which was not present in our family and hyperopia which is far sighted vision and the reason why we suspect that is because noggin was first found in the central nervous system development where brain dorsal ventralization and central nervous system so were not sure how each of the mutations affects the confirmation of the noggin protein. DR. JOHN SHEA, MEMPHIS: I’d like to comment on Dr. Minor’s paper for several reasons, one of which it’s one of the papers I can sort of understand this afternoon. The rest of the program was wonderful but this business of this so-called internal conductive hearing loss is an old and big problem. When I was working with Howard House way back in 1953 and we were doing fenestrations, he was aware of this syndrome and first called it to my attention and I tried to understand it but there’s one additional fact Lloyd that you may or may not know and I don’t think I heard you say it. When you open the middle ear of a person with conductive hearing loss, you of course ought to see if there’s some otosclerosis present, but you also ought to test whether the round window reflex is present because in these people with this so-called internal conductive hearing loss that John House wrote this paper about, they don’t have a round window reflex and that tends to add to your idea. That is, a loss of the acoustic or hydraulic motion of the fluid in the middle ear. But it’s a fascinating group of patients and maybe this superior semicircular canal defect is the cause. I must say I have never seen a patient with this syndrome but you have seen thirteen of them so I must have missed some of them. Thank you. DR. LLOYD MINOR, BALTIMORE, MD Just a brief comment to Dr. Shea and thank you very much. The other entity to keep in mind is enlarged vestibular aqueduct syndrome that Dr. Madden so eloquently described. There was a paper in American Journal of Otology two years ago describing abnormal vestibular myogenic potentials in patients with enlarged vestibular aqueduct syndrome and the pattern of vamp abnormality is similar to that in superior canal dehiscence and it makes sense because enlarged vestibular aqueduct syndrome can act as well as the third mobile window so that may also account for some of the cases of inner ear conductive hearing loss. Of course the temporal bone CT scan these days will identify either problem. DR. SAUMIL MERCHANT, BOSTON, MA, Lloyd I enjoyed your paper and I have a question for you. At our place we have seen three our four patients with the exact same clinical presentation that you described. A relatively large air bone gap, no abnormality in the middle ear when you explore them and a dehiscent canal and some have a vestibular problems and some do not. But one thing we have noticed is that the bone conduction thresholds in all of the individuals that we have seen with this problem are better than normal in the lower frequencies minus five minus ten and we think that John who is here with me, one of our auditory scientist, we think it may be that bone conduction thresholds are slightly improved because of the abnormal mechanics due to the dehiscence. My question to you is have you noticed that in your patients? The other comment is that when audiologists do audiograms, when they reach a bone threshold of zero, they just stop and they don’t find the absolute bone threshold. I think we need to tell our audiologists to look for this problem because I think the bone conduction audiometry can be a clue to diagnosing this and not exploring these patients unnecessarily. DR. LLOYD MINOR, Yes we have also seen that when we use an audiometry calibrated down to minus ten minus fifteen DBHL that often times the bone conduction thresholds are supra normal and that fits also with the fact that I think in every patient I’ve seen with superior canal dehiscence syndrome the Weber has lateralized to the affected ear even when the ear conduction thresholds are completely in the normal range. So there is a conductive hyperacusis I think due to this canal dehiscence. In the patients that I talked about today, three of them had prior stapes surgery so that point in the bone conduction thresholds may be more difficult to interpret but in the group of superior canal dehiscence canal patients in general that’s been a common feature is that the bone conduction features are better than zero DBHL. DR. CHARLES LUETJE, KANSAS CITY, MO Lloyd in the absence of any ossicular change fixation and you saw pulsation of the round window membrane window on exploration synchronous with a heartbeat, would you expect there to be any problems with the semicircular canal or dehiscence? DR. LLOYD MINOR: So this is someone who had an air bone gap on the audiogram preop and you are exploring the ear and the stapes moves fine and the chain looks fine but you see the round window membrane pulsating? DR. CHARLES LUETJE, KANSAS CITY, MO, Yes, correct. DR. MINOR: I think that would be a suspicion that there is another mobile window someplace leading to that pulsation. DR. JJIM SAUNDERS, OKLAHOMA CITY, OK I have a question for Dr. Madden. I was curious by your numbers for progressive hearing loss and also the association with head trauma. I was wondering how that compares with your overall group of 1200 children with sensorineural hearing loss. Are those significantly different from the group at large? DR. COLM MADDEN, CINCINNATI, OH The group with progressive loss was smaller than has been reported in other studies. We have a reduced number of people who have come to us with a history of sudden sensorineural hearing loss following head trauma. Most studies have shown much larger numbers. Perhaps one of those reasons is the now common observation that is passed on to the parents of these children to avoid head trauma. Interestingly enough in the three children that had dips in their hearing following head trauma, all were male, which may predispose males more than females to head trauma in that pediatric age group. DR. JIM SAUNDERS, OKLAHOMA CITY, OK So you haven’t actually looked at the larger group to see whether there were any in that group that had dips with head trauma? In a sensorineural group at large, in other words not the enlargements to their aqueduct? DR. COLM MADDEN, CINCINNATI, OH No, I haven’t analyzed the whole sensorineural group. DR. JIM SAUNDERS, OKLAHOMA CITY, OK And was there any difference in those associated with known syndromes in the Pendrods or the BOR’s? Did you notice any difference in those? DR. COLM MADDEN, CINCINNATI, OH No not specifically no. Thank you. DR. CHOLE: Any further questions? We have another announcement for the members and guests. The banquet location for tomorrow night has been changed to the Estate Ballroom in the Meisner Center. So we will announce that again tomorrow. This session is now closed. Thank you and we will see you tomorrow. . SCIENTIFIC PROGRAM Saturday, May 11, 2002 Cochlea Presumptive Cochlear Hemorrhage as the Source of Sudden Sensorineural Hearing Loss in Five Patients Mark D. Packer, MD, Brian P. Perry, MD Clinical Study Objective: To propose cochlear hemorrhage as an identifiable mechanism of sudden sensorineural hearing loss. Study Design: Case series Background: Five patients with sudden sensorineural hearing loss noted to have intracochlear hemorrhage by MRI. Setting: Tertiary care hospital Results: Five patients with sudden sensorineural hearing loss attributed to cochlear hemorrhage. Conclusion: Cochlear hemorrhage can account for some cases of sudden sensorineural hearing loss, may be related to coumadin treatment, and can be identified by MRI. Routine MR imaging for sudden sensorineural hearing loss (SSNHL) has been shown to increase the diagnostic success for this commonly “idiopathic” disease. It will identify the 10% of vestibular schwannoma cases, and the 5% of multiple sclerosis cases that present with SSNHL. It can also help document ischemia, infectious labyrinthitis, vascular malformations and several other disease processes. Presented here are five cases of SSNHL, two bilateral, with MR sequences suggestive of intracochlear hemorrhage by their pre-contrast, high T1 signal intensity. The high signal intensity corresponds to the increase in methemaglobin levels of subacute and chronic bleeds. Three of these patients were taking coumadin, and one had Ehrler-Danlos syndrome. Although treated with steroids and antiviral medications, only one patient showed significant improvement in hearing post treatment. Cochlear hemorrhage should be considered when evaluating patients with sudden sensorineural hearing loss when precontrast T1 images by MR show high signal intensity. Mark D. Packer, M.D. 8414 Blackcastle Dr. San Antonio, TX 78250 Etanercept-Suppressed Inflammation in Mouse KLH Induced Labyrinthitis Hitoshi Satoh, MD, PhD, Elizabeth M. Keithley, PhD, Gary S. Firestein, MD Peter Billings, PhD, Jeffrey P. Harris, MD, PhD Hypothesis: TNF-a plays an important role in initiation of cochlear secondary immune response, and a recombinant human TNF receptor Fc fusion protein (Etanercept) can reduce the inflammation. Background: The inner ear is capable of rapidly mounting an immune response that can ultimately lead to cochlear degeneration and permanent hearing loss. Blocking the response should prevent these damaging sequelae. The identification of preinflammatory cytokines (IL-1, IL-6 and TNF-a) within the inner ear should lead to rational therapeutic strategies. Methods and Results: A secondary inner ear immune response to keyhole limpet hemocyanin was created in the mouse cochlea. The animals were sacrificed 3-48 hrs and 7 days following initiation of the immune response. The cochleas were assayed for the expression of the preinflammatory cytokines, IL-1b, TNF-a and IL-6, by immunocytochemistry. IL-1b and TNF-a were expressed by infiltrated cells shortly after KLH injection. IL-1b was also expressed by the type I fibrocytes of the spiral ligament. IL-6 is expressed in normal cochleas, but did not show much change during the immune response. Surgical controls showed IL-1b, but not TNF-a, and intrathecal injection, which can eliminate the surgical effect, showed TNF-a expression. Additionally, systemic injection of Etanercept reduced cochlear infiltrating cell number and cochlear fibrosis evaluated 7 days after KLH injection. Conclusions: It is concluded that IL-1b expression is a general cochlear response to trauma and that TNF-a is responsible for amplification of the secondary immune response that leads to pathology. Treatment by Etanercept can reduce the cochlear damaging sequelae induced by the cochlear immune response. Jeffrey P. Harris, M.D., Ph.D. 200 W. Arbor Drive, #8895 San Diego, CA 92103 Discussion Period 4 Papers 13-15 DR. AZIZ BEAL, ALEXANDER EGYPT: I would like to comment on Dr. Packer’s paper. I feel that persistent high signal that was seen four years after the cochlear hemorrhage was not due to the hemorrhage itself but rather to a new bone formation inside the cochlea. We feel the same, that is not persistence of clot or hemorrhage necessarily to account for the persistent high signal but their feeling is that it is more consistent with protein presenting sclerosis within the cochlear labyrinth itself. It would be interesting to have the CT imaging on these patients and that may show if there’s further new bone formation. DR. MARK PACKER, SAN ANTONIO, TX, Yes. In discussion with our neuroradiologist DR. CHOLE: As I mentioned the second paper has been withdrawn. The next paper for presentation is by Hitoshi Sato and colleagues - Eternocept suppressed inflammation in mouse KLH induced Labryinthitis.. DR. JACK PULEC, LOS ANGELES, My question is directed to Dr. Satoh. It seemed a little ironic to be speaking about etanercept after the loss of our member, Jean- Bernard Causse. Would you explain or tell us the source of the Enteracept. DR. HITOSHI SATOH, SAN DIEGO, CA Etanercept antibody is all in the system in Minneapolis, is that okay? We bought the antibody from the LMD systems in Minneapolis, USA. DR. RICHARD CHOLE I had a question for Dr. Packer. If I understand correctly the evidence you presented that it’s a hemorrhage, is that the T1 signal was low the first day and then became high in the days after that. Is that correct, is that the evidence for it actually being hemorrhage? DR. MARK PACKER, SAN ANTONIO, TX that’s part of the evidence. We had two patients that initial negative MR imaging and that follows the progression as shown with intracerebral hemorrhaging. Further evidence we don’t have direct definitive knowledge that this is hemorrhage but the imaging is consistent.. With the past research the things that account for the high T1 signal there have been retrosigmoid resections of acoustics and the postop hemorrhaging shows hyperintensity of the T1 signal. Other conditions that show high protein have not also shown the high T1 signal. DR. ROBERT CEUVA, SAN DIEGO, CA, Also for Dr. Packer, I was going to address that same issue as Dr. Chole. In my experience fortunately in working with neurosurgeons over several years, I have seen a lot of patients with intracranial hemorrhage. We have a routine neuroradiology conference at the institution at which I work and it has been my impression that the delay, the methemoglobin is much brighter than the images that you portrayed. The cochlea looked pretty much isointense with brain where his methemoglobin is very bright on T1 on contrast almost to the intensity of fat. Did your neuroradiologist do measurements in terms of the signal intensity of the specific areas and correlate them with other patients with known hemorrhage? That might be a way to help you to see is that hemorrhage or does it match up with another tissue type? DR. MARK PACKER, SAN DIEGO, CA, Interesting thought. Yes, we did not do those specific imaging techniques however they have theorized that the difference between the inter-cochlear oxygen content and the more anaerobic environment of brain bleeds may account for some of that difference. Acoustic Neuroma Panel DR. RICHARD CHOLE, I’d like to invite the panel members to come on to the podium. I have asked a few neurotologists who are active in acoustic neuroma treatment in surgery to respond to some treatment questions about acoustic neuroma. I was thinking about this and this is a panel we probably could have put on every Otological Society since the treatment parameters and management parameters for acoustic neuromas seem to be changing every year. The panelists are Joel Goebel who is a Professor at Washington University, Bruce Gantz, Department Head at Iowa, John Niparko Professor at Johns Hopkins and Rick Friedman from the House Ear Institute. Phil Wackym unfortunately couldn’t be here. Phil was playing soccer with his eight year old, fell down and broke his clavicle in four places and several ribs so we are currently screening him for osteogenesis imperfecta but he had open surgery on his clavicle and couldn’t be here. Phil is doing gamma knife treatment of acoustic neuroma so we are going to miss him on this panel but I’m sure that the rest of our panelist will represent him very well. I chose to present a few cases and we are going to have some kind of open discussion about management of these cases. I will just get started. The first case is a 12-year old girl who really has had no symptoms. She and her grandmother have neurofibromatosis, her mother recently diagnosed. Her mother has hearing loss in one ear and her grandmother is completely deaf due to eighth nerve tumors. So in her evaluation, audiograms were done and her hearing is really perfectly normal. I’m hoping the panelists are going to be able to see the films okay, they were given to them earlier. This is her MRI. This is an enhanced scan with gadolinium and you can see small tumors in both internal and auditory canals. So we now have a 12-year-old girl pretty well documented with neurofibromatosis II and the parents and child are asking for treatment and recommendations. I will give it to the panel and ask for comments. Maybe I could start with Rick. DR. RICK FRIEDMAN: This is obviously a difficult problem with a young girl. We have just recently published our series in our philosophy on the management of NF2. Obviously all of the options would be discussed with this family and child. The options would include as we al know observation, radiotherapy or microsugery. It’s been our philosophy to manage these patients early when tumors are small and function is good. So in a case like this my recommendation, assuming the child was healthy would be middle fossa removal of the smallest tumor on the right since the hearing is equivalent, maybe some more data like ABR or ENG. Although we did look at ENG and it didn’t really in our series affect hearing outcome. I may look at ABR because these are both relatively small tumors and maybe select the side that was causing less of a problem with the auditory nerve. But in general we would manage this I believe with a middle fossa. PANEL MEMBER NOT IDENTIFIED: I think that is right given the lateral location of these tumors, a retrosigmoid approach which is more commonly used in our institution, would not be in this little girl’s best interest. As we all know these are difficult cases particularly with the relatively few symptoms experienced by the child and there may be a great resistance on the part of the child themselves and extensive counseling is needed for these cases. I would add backing up what Rick said about early intervention. In fact we have had similar size lesions in NF2 patients that turned out to be facial neuromas and in two cases were able to excise those neuromas with nearly normal facial function postoperatively. It’s a rare manifestation of NF2 but if either of these signals represents a facial neuroma, she’s best served with early intervention. PANEL MEMBER NOT IDENTIFIED: Well I have had this situation in a set of twins at fourteen years of age and I can tell you that we did remove the smaller tumor in both children. In one child we were able to save the hearing and the person is now in college and doing well. His brother, we were not able to save the hearing and then the larger tumor continued to grow and in June we are going to have to take out that tumor and put in an ABI. These are extremely difficult cases but if you can have a winner and I have six patients that I have operated on with the smaller tumor and have been able to save hearing in four but it’s a crapshoot. You are not guaranteed that you are going to be able to save the hearing but this is the best chance when it’s small. PANEL MEMBER NOT IDENTIFIED: Yeah I think that makes sense that it almost has a parallel in stapes surgery when you talk to patients about bilateral otosclerosis. These tumors can do individually what they want. They can have individual growth rates and like Bruce said if you hit a home run on one side you are in a good position and if you don’t then you are in a real sticky wicket so I would agree with going after it aggressively because you have the best chance of managing this when the tumors are small. PANEL MEMBER NOT IDENTIFIED: I know Bill Slattery presented it last year and that is for the unfortunate case where you loose hearing despite early intervention, middle fossa decompression has really shown to give fairly long-term in many of the patients reviewed, hearing preservation in the only hearing ear with the tumor remaining so that’s also something included and discussed thoroughly with the patients and family. DR. CHOLE: No one is suggesting watchful waiting or radiation? PANEL MEMBER NOT IDENTIFIED: I think she’s much too young for interval scanning. I don’t think that is a wise approach at all. I do want to say having recently dealt with two similar cases, there are radiation therapists in our region that would radiate in such cases and there are some who are very steadfastly opposed to radiation in these cases. I think its incumbent on us to get to know our radiation therapists as best as you can. I would submit to this audience that there’s a lot of internet play that is really quite disingenuous when it comes to radiation of a benign tumor and we I think are placed in the position of sorting that out for our patients. DR. CHOLE: Okay, let me go to the next case. This is a case of a 54-year-old healthy audiology researcher actually who noticed tinnitus in his left ear in the preceding few months. He did an audiogram on himself and found a mild high frequency hearing loss in one ear. Excellent word discrimination score but was worried about this and an MRI scan was performed. This is his scan. You can see that there’s a small enhancing lesion in the mid -part of the internal auditory canal. So 54-years-old, healthy and having very few symptoms. Let me start with John this time. DR. JOHN NIPARKO: Quite lateral signal. I think the differential has to be opened up on this a little bit and you do have to make sure you aren’t looking at an inflammatory lesion there that could be related to sarcoid or lyme disease or something like that. Assuming Rick that you are not trying to trick us at all and that we have follow up and this is indeed a schwannoma in a 54-year old gentleman, he’s going to be very tempted to have this radiated. I personally would believe that if he’s got relatively few symptoms at this point and a very mild hearing loss that I would probably coach him to consider an interval scan in three to six months, careful audiometry as well. The risk of that of course is that you may loose your option for hearing preservation. PANEL MEMBER NOT IDENTIFIED: Well if this person came to you and was concerned and you found this lesion you have to discuss it with the patient and find out what the patient would like to do. Some people are interested in interval scans but someone like this is probably not if he’s interested in trying to preserve his hearing and I would pursue middle fossa with this person if they were interested in surgical excision. DR. GOEBEL: The hallmark of the radiotherapy literature is not the disappearance of the lesion but the arrest of the lesion and you would never know if he chose radiotherapy for this lesion because its small and you have no idea of growth at all. I think radiotherapy would not be an issue at this point. I think you would be between what Bruce said as either your best chance of taking this out and preserving hearing versus an interval scan and that would depend on the mind set of the patient. These are all very savvy people. They know about serial observation MR, they know about radiotherapy and they know about surgery so you really would have to dig into his head, no pun intended to find out between observation and taking the tumor out DR. CHOLE: Let me get down to the actuality of this here. He’s sitting in your office and your talking to him about these options and certainly a case like this you might consider all three options. Would you send him to the radiotherapist for consultation and opinion or right then and there recommend treatment? Joel? DR. GOEBEL: Every institution has their availability of radiotherapy, either its right there set up or its not. In Washington University every one of our patients if they are sent for the neurosurgical opinion they are automatically sent for the radiotherapy opinion, it’s coupled. I think even though you wouldn’t necessarily recommend it as his treating physician in this case, I think you are behooved for them to hear the argument. The important point is that they come back to touch base to you so that you can wrap it up for them. You have to emphasize to them you are their treating physician; you are going to let them hear the options. So in our institution if you involved neurosurgery at all they would automatically be sent for an opinion. DR. CHOLE: That will get some blood pressure up, let me get some opinions. Go ahead John. DR. NIPARKO: Rick you have submitted to us this sophisticated individual and I would submit to you that a sophisticated individual would want to look at the quality of the evidence and the literature. I would call your attention to a recent publication from the British Society’s of Neurosurgery and Otolaryngology that did an exhaustive evaluation of the literature on radiation therapy for acoustic tumors. In fact they rated the publications from Grade 1 which is the highest level of prospective trial dated down to Grade 4 which is basically inadequately assessed case series and conflicting evidence. The vast majority of publications in fact are Grade 4 in terms of their quality. There are few Grade 3, no Grades1 or 2 publications on the Affect of Radiation Therapy for AcousticTumors. It’s really quite impressive. Rob Jackler, John McElveen, Bruce Gantz and others have reviewed that document. It’s a white sheet that I think is going to be quite important for us to distribute for our patients. DR. CHOLE: You have a comment Rick? DR. FRIEDMAN: I think I agree with every single comment here at the table. I mean a person like this obvious is individualized. A 54-year-old is probably going to have to deal with this at some point in his or her life and the philosophy I think for most of us and certainly at the House Ear Clinic has always been to intervene early, to enhance your postoperative outcomes. So I agree with Bruce. This person is probably going to want to save hearing and I think you have to educate a lot of these patients. You may not have one as sophisticated as this. The radiosurgical literature really focuses on preservation of function but the philosophy and treatment is for cure. If you’re going to treat a tumor, your treating it so that the tumor is over and there is no long-term data to show that. If you look back to what John was saying about the quality of publications…if you look at the Pittsburgh series, I think it was in 2000 or 2001 that Flickinger reported on their five year actuarial control which is even of itself I think an oxymoron. I’m not sure you can look at actuarial control in benign disease but anyway if you look closely at the fine print, there was 30 months of median follow up. At the 30 month mark there had already been 3-5% of patients who required surgery and if you looked at the other criteria they were describing for failure which they downplay on their discussion and that was radiographic evidence of change. If you look at the arrow bars it could be as high as 15% at thirty months. Those are orders of magnitude greater than most microsurgical series so I think the patients really have to understand that the issue is not saving your hearing, the issue is doing this one time and being finished with it and doing it the best way you can to preserve function. DR. CHOLE: Next case is an interesting case of a 15-year-old boy who presented with episodes of vertigo, sudden onset and lasted about two hours, very Meniere’s like. They occurred about once a month and he recently noticed some hearing loss in his left ear. This is his audiogram, which shows normal hearing in the right ear but a mixed hearing loss in his left ear. Because of the mixed hearing loss and discrimination score of 76%, he had an MRI scan. This scan was read as normal by the University neuroradiologists and I would like to point this out for any of the residents or younger members in the audience except radiologists reports. There’s probably not a person in the room that accepts a radiologists report but this was the report by a qualified neuroradiologist. Actually, embarrassingly, I had written a paper with this man once about a similar issue and this was the scan. Could I ask the individuals on the panel to take a look at the scan. I sent them a power point of this before so you would have a little bit of a chance to look at it. It’s kind of hard to see from here. Let me start with Rick . DR. FRIEDMAN: I don’t want to embarrass myself. I didn’t stare at the power point. If I’m seeing it correctly, does this look like an intra-labyrinthine neuroma? Seeing it from this angle? DR. CHOLE: This is an enhanced scan, gadolinium scan with a signal in the labyrinth. DR. FRIEDMAN: I just saw one of these last week. It’s a complicated issue obviously, there’s no such thing as preservation of hearing in cases like this DR. CHOLE: What about the audiogram in comparison to this? How would you compare his audiogram? DR. FRIEDMAN: That’s a good question. Obviously the high frequency sensorineural loss is from the schwannoma in the vestibule and in the cochlea. The conductive component, there’s a mass affect in the inner ear that could be “a cochlear conductive phenomenon”. I don’t see anything protruding out of the labyrinth into the middle ear. I have seen that once actually a schwannoma in the middle ear. Obviously that patient had no hearing it had blown through the footplate of the stapes but I would guess this is similar to the X-linked deafness, mixed deafness patients who have rather than tumors CSF pressure coming through an absent modiolis causing again “a cochlear conductive loss” so I guess its probably the mass affect assuming no other middle ear disease. DR. CHOLE: Let’s ask the panelists about diagnosis here. I may have another scan here to clarify this just a little bit. This is a T-2 scan and if you look carefully here you can see right in the vestibule a negative image right here in the signal of the fluid compared to the other side so you can see a mass affect right in the vestibule there. This is the magnified view of the T-2. Other panelists, comments about it, Joel? DR. GOEBEL: I had a patient and have a colleague in the audience who helped with this because he had bounced around a bit that really carried a diagnosis of Meniere’s disease. He had all of the characteristics and he had a positive ECOG and negative ABR . He had attacks and it responded to diuretic and low salt diet and looked just like Meniere’s and he turned out eventually when he was scanned to have a very tiny intra-labyrinthine schwannoma so it was almost exactly this picture. Your right, you cant’ save hearing on an issue like this, so it’s not a matter of offering him a surgical approach to save hearing. In an instance like this I would probably watch him until his hearing dropped or the lesion looked like it was growing and then you’d have to deal with it at that point. DR. FRIEDMAN: I agree with that and we have had this situation and some of them don’t grow. You watch them and rescan them on a yearly basis. I think I had one that did grow and it destroyed the hearing and it was growing so we decided to do a labyrinthectomy and take care of the problem because we thought we would put the facial nerve at risk over a long period of time so that’s why we removed the tumor. But you are not going to save hearing and watchful waiting is probably the best approach for a patient like this and just explain to them there’s nothing you can do to stop that. PANEL MEMBER NOT IDENTIFIED: Yes Rick just mentioned that the problem is the symptoms and the abruptness of the symptoms. My experience in just a couple of these cases is that in fact they do have very severe symptoms that can come on without warning so if they do a lot of driving, if they are aviators that sort of thing this can be a greater risk for them. DR. CHOLE: He has had some vertigo spells but they have not really worsened and the option I pretty much gave him we were watching for the moment. The thing that is a little disturbing to me is that he’s 15-years-old and I’m diagnosing a schwannoma on him. Are there other possibilities that I should maybe worry about, any chance of malignancy or anything that needs more urgent treatment of a tumor like this? PANEL MEMBER NOT IDENTIFIED: The obvious risk for this child is the subsequent development of NF2 or the existence of NF2 but its manifestations in the opposite nerves or other cranial nerves. So I think it’s obvious that the child needs follow up for a fair number of years to observe the opposite side to observe the other cranial nerves at the skull base. As far as malignancy goes with the severity of the symptoms for such a small size lesion, I don’t believe so. DR. CHOLE: Let me ask you another question. Would you screen this child genetically for NF2? It’s an expensive proposition usually not covered by insurance but it’s available? PANEL MEMBER NOT IDENTIFIED: I’ll comment to that. I personally don’t think I would. I think we’ve got a good diagnostic modality with MR and there are a number of false negatives in NF2 screening. I see Brad here so I don’t want him to kick me for saying anything wrong but I guess a lot of NF2 tumors show no mutation and coding regions of the NF2 gene. A negative screen certainly doesn’t mean the child is out of the woods. I think MR would be the best way to go. DR. CHOLE: The parents are very sophisticated and they did do NF2 testing which was negative and then understood the problems with it. The next case is a 28-year-old healthy man who has noticed hearing loss and ringing in his left ear over the past several months. He’s had no imbalance or vertigo. He’s a professional person who works with the public and is very concerned about his hearing and balance. This is his audiogram showing a mild to moderate high frequency hearing loss, word discrimination score on the affected ear is 84% and here is the scan of his tumor medium size coming out of the internal auditory canal into the cerebellar pontine angle. What do you do? We will start this time with Bruce. DR. GANTZ: This is more of a medial placed tumor. People that do a lot of retrosigmoid tumor removal would most likely approach it from that perspective. In my hands when these tumors touch the brainstem like that the chances of saving hearing are not really great. I mean you can’t say that in this tumor you have a 50% chance of saving hearing. I think it drops quite significantly. It’s a little big for a middle fossa but we have done some middle fossa’s on tumors that size and I guess I would talk to him about those kinds of things. I’ve had a situation where I’ve done a retrosigmoid and the MRI scan didn’t tell me the truth because there was tumor going way out lateral. So I think you have to be concerned about that and if you have a good neurosurgeon that you can work with and do a retrosigmoid, that might be the best approach. I would probably do a combination of a retrosigmoid retrolab and see if I could get it out. If I couldn’t I would just do a translab. DR. CHOLE: Joel, could you comment. Since this is actually your case let me have you comment on that. DR. GOEBEL: This has a lot of confounding factors because of who he is. Rick said he’s interested in his hearing and balance; he’s very interested in his face. Even a Grade 2 facial weakness to this fellow who is a young strapping looking stockbroker that is the part that really pulled him back. Even the outside chance of facial weakness just absolutely floored him. So we had this discussion with him about all three modalities and told him observation is probably not smart. So his options are to have this tumor removed which we could not deny the chance of temporary weakness and the possibility of mild weakness with the outside possibility of even worse. He was sent to my neurosurgical colleague who evaluated him and went through the same surgical spiel but like I said sent him also to the gamma knife which is run by one of the neurosurgeons in conjunction with the radiotherapist. Do you want me to go to the end of the story? DR. CHOLE: Well let me ask about that possibility. We went through this discussion. He’s very anti-surgery oriented. What are the issues about doing radiation in a 28-year-old, what are some of the issues about that? RICK FRIEDMAN: I put up some slides at Rick’s suggestion. I presented it at last year’s Academy. Unfortunately or fortunately for those involved in microsurgery the numbers keep climbing for the number of radiation failures that we have treated at the House Clinic. It’s now 30 and I think with somebody like this you are going to have to treat them with kid gloves and absolutely honor their concerns. If you look very closely at the literature for gamma knife for fractionated stereotactic radiosurgery and microsurgery for tumors of this size which is going to be very difficult for anybody to do because it’s not presented that way, the risk of facial nerve paralysis is not very different. I think the patients have to understand that. There may be a slightly greater risk of facial paresis with the current dosing schemes compared to microsurgery transient facial paresis or maybe even a grade 2 but facial paralysis for a tumor this size in well trained hands the data is very similar. So I think this 28-year-old has to understand the unknown and that is the risk of long-term failure. Again I can show you a few of those slides. I would just explain thoroughly understanding the patients concerns but explain thoroughly that radiotherapy despite what may be being said is an unknown in the long term and for a 28-year-old it’s potentially dangerous. The outcomes after gamma knife for fractionated for microsurgery, the facial nerve outcomes are not good. DR. NIPARKO: I would agree. I think the unknown long-term particularly for a patient this young is the density of arachnoid adhesions and cerebellar pontine angle post radiation. We agree that you are likely to have a good facial nerve result even after radiation therapy but the odds of that go way down in our experience from about a 10% chance of long-term disability to something exceeding 3040%. I would also like to add in our personal experience that at Hopkins we don’t have 30 radiation failures, we now have seven but a year ago we had zero. I would submit that we are probably seeing the dawn of a new era for acoustic neuroma surgery. DR.GANTZ: I would just comment that we have not seen any radiation failures yet because we don’t do a lot of radiation in our area so we are fortunate, but I think that’s the issue that you have to really impress upon this person that if they are worried about their facial nerve, then you have to go to some person or group that has lots of experience and whether you do it retrosig or translab or middle fossa, it depends on the experience of the team more than it does the approach. I just don’t think the hearing is that important to this guy as the facial nerve so if it's the most important then you would probably do a translab. DR. CHOLE: Let’s look at the next case. You’ll see some similarities here. The patient is a 62-year-old diabetic man who has noticed ringing in his left ear with mild hearing loss. He has chronic imbalance he has noticed since recovering from a myocardial infarction two years previously, so kind of a different type of person. Here’s a rather severe hearing loss with no word discrimination on the affected side and surprisingly his scan looks very similar to the last one. So the same tumor, how would you treat this tumor? Let me start with Bruce. DR. GANTZ: Well again you have a lot of issues medically on this patient, diabetic. You can give that patient the option of watching and waiting. It is relatively small, it’s just touching the brainstem and you can see if it’s going to grow over the next months. If it doesn’t then you might want to go another year but it most likely will grow and if it does grow then a translabyrinthine approach would be in my hands the best approach for this patient DR. GOEBEL: I have five or six watchful waiting sick people just like this and of the five or six that I have none of them to date have grown and I have one guy who is eight years out. He’s very ill. He’s a great surgical risk and he’s also a risk even though these fields are collimated so well. He still has a dose to surrounding tissues including some of the temporal bone and if developed a deep skull base osteitis after radiation he would absolutely be a mess to take care of. So if I had him under those parameters, I would say sir I’ll see you back in six months and we will rescan you and we will only treat you and operate on you if our hand is forced. DR. FRIEDMAN: This is another interesting case and I guess to show my open mindedness again this is a patient that needs education because certainly in our community we have seen that patients will be gamma knifed on one scan. I had a 91-year-old gentleman who presented with ear pain. An otolaryngologist in the community got an MR because he also had an asymmetric hearing loss and there was an eight millimeter tumor that was immediately gamma knifed and the poor man is devastatingly dizzy and didn’t respond to a labyrinthectomy. So first of all this patient has to be informed that given the option for gamma knife immediately without a follow up scan would be a mistake as well. But I do think that based a lot on the data in the literature it’s not going to grow and based on the gentleman’s health observation and then potentially gamma knife may be all that he would need in his life time. I think I feel reasonably comfortable that gamma knife might hold back most tumors for 5-10 years so I certainly put that into my equation when I have an elderly patient and infirm patient who I don’t think is going to out-live the potential gamma knife failure. DR.CHOLE: Let me ask you a specific question. Our time is getting short here, maybe more pertinent to the younger patients than the older. What are the long-term risks of malignancy due to radiation either fractionated stereotactic radiation or gamma knife in acoustic neuromas? What is your experience or opinions? PANEL MEMBER NOT IDENTIFIED: Well I’d like to comment that we have looked at this on very careful literature search. There are some legends out there that there are pockets across the world where there are dozens of patients who have developed malignancy after gamma knife, fractionated stereotactic radiation. I think in many cases those are very poorly documented and when you actually call the individuals who made comments at international meetings you can’t get good back up data. On the other hand there are at least eight well- documented cases where this has occurred. They all fit criteria for malignant degeneration in the radiation field. I guess the most troubling aspect of those cases that have been reported is that they have occurred anywhere between 5 and 8 years after radiation therapy. If you go back to the experience and other body sites where radiation therapy has been used for benign disease, in fact that latency period appears to be at least 12-15 years. There may be something about the way radiation therapy has been used at least in the first half of the 90’s that may increase the risk somewhat. I think that is a significant concern for the longterm that is starting to manifest itself earlier than it would have been predicted. DR. CHOLE: Going along with that comment, do you inform your patients as you are referring them for consultation of the malignancy risk? PANEL MEMBER NOT IDENTIFIED: To answer your question , yes I think when you get into these debates with the radiotherapist they say we overplay that and I certainly don’t think it’s a good idea to overplay it, I mean eight cases with the number that have been treated isn’t huge but I think something John said is very true. There’s an article in the 80’s by Breen Flickinger’s and it was an article looking at stereotactic radiosurgeyr for another benign lesion at the skull base and that’s pituitary adenoma. It took them 20-30 years of follow up to see. I think it was 37 and almost 50% failure, but the key to that and if you speak to most radiotherapist and as John said, if you look at the literature at all sites and included in this paper they had a 3% incidence of malignancy in the field . I encourage you all to look at it because I think it’s a valuable paper for patients to know about and so I don’t think you need to over emphasize the risk but I think you certainly need to emphasize that there is a risk of carcinoma. If you look at the literature also, Derrald Brackmann brings this point up and it’s a great one, that the mortality rate for microsurgery versus radiosurgery is no different. There’s an equivalent mortality rate if you look at the literature. DR. CHOLE: Other comments about this issue. Joel? DR. GOEBEL: I think you also need to be well informed on the radiosurgical literature to tell the difference between stereotactic surgical approaches that are done in 2002 and radiosurgical approaches or radiotherapy which seems to get lumped all together. So you need to know if you are going to make an argument to the patient because they will be presented to them by the radiotherapist that well we do things differently in 2002 and all this data is based on our techniques going back in the 80’s and 90’s. So you have to know that data in order to combat it. PANEL MEMBER NOT IDENTIFIED: I was just going to quickly say that most likely the larger problem is going to be regrowth because the radiotherapists have changed their dosage. They are not using as much radiation at this point as they were ten years ago because of the problems they were having and now when you have the regrowth you are seeing the problems that the House group and John has had in removing them with the facial nerve. You tell the patient that and I think that’s a bigger issue to them than the malignancy. PANEL MEMBER NOT IDENTIFIED: One last comment is the biology of radiotherapy and this has been done totally empirically. There’s no science behind it and if you speak to them at great length which I have about what they think the radiotherapeutic affects are there’s no doubt that there’s initial cell death to some of the tumor cells. The rest of it is based on DNA damage and so the cells have two choices. They either go into apthtotic pathway, they die or they remain in what’s called cell cycle arrest and anybody who has seen a post gamma knife MR knows that there’s plenty of those cells that are alive and in “cell cycle arrest” because there’s an enhancing lesion. It’s not scar tissue, it’s the tumor enhancing. Those cells have two choices from now until the patient dies, either to die or to go on dividing, they do not remain in indefinite cell cycle arrest to my knowledge and I have a background in molecular biology not in cell cycle but the people at the institute that are in cell cycle say there’s no such thing as permanent cell cycle arrest. So they either mutate another gene that allows them to continue growing or in these eight reported cases the mutated gene again that allows them to grow out of control. So it’s something that’s going to take a number of years and decades to resolve. DR. CHOLE: I’d like to thank the panelist on some very good remarks, we appreciate it. Thank you. Middle Ear/ Mastoid The Artificial Tympanic Membrane (1840-1910) From Brilliant Innovation to Quack Device Eugene A. Chu, BS, Robert K. Jackler, MD Objective: To utilize the rich and checkered history of the artificial eardrum, a widely utilized device in the 19 th century, to illustrate the behavior of otologists in response to the introduction of a promising new technology. Data Sources: Over 40 published books and articles spanning the years of 1821 to 1909 in English, German, and French. Device descriptions: A wide variety of devices were utilized to improve hearing and, purportedly, to reduce aural discharge. The most popular devices were made of gutta percha attached to a silver wire stem (Toynbee) and cotton balls with extraction cords (Yearsley). Other membranes included India rubber, lint, tin or silver foil, and even the vitelline membrane of an egg. Adhesion to the drum remnant was with saliva water, Vaseline, or glycerine. Some were applied by the physician, while others were inserted daily by the patient much like contact lenses are today. Conclusions: In several cases, the method of positioning an object over the drum remnant was actually invented by clever patients and then later adopted by practitioners. Once introduced, great optimism flowed about the “miraculous” value of this deafness cure. Petty jealousy among early inventors led to very public (and unprofessional) quibbles over the primacy of invention and bickering about whose device was superior. Over the subsequent decades, as more experience demonstrated the device’s limited value, enthusiasm waned until otologists largely abandoned these devices around the turn of the century. In the first two decades of the 20 th century, artificial eardrums reached their peak of fame among the public when they were enthusiastically (and dishonestly) marketed by a slew of quacks through newspaper ads as a universal cure of all forms of deafness. Only with the coming of the FDA did ads for $10 mail order, medicated eardrums disappear from popular newspapers and magazines. Robert K. Jackler, M.D. Department of Otolaryngology University of California, San Francisco 400 Parnassus Ave, A-730 San Francisco, CA 94143-0342 Bioactive Glass Ceramic Particles as an Alternative for Mastoid Obliteration – Results in an Animal Model Bryan D. Leatherman, MD, John L. Dornhoffer, MD Hypothesis: This study was conducted to evaluate the use of NovaBone – C/M Bioglass® (Porex Corporation, College Park, GA) as a graft material for mastoid cavity obliteration in an animal model. Background: Canal wall down procedures in otologic surgery may result in a problematic mastoid cavity. Mastoid cavity obliteration can potentially prevent or correct this problem. Many techniques and implant materials have been utilized for mastoid obliteration, yet no single graft material has proven to be ideal. Methods: Mongolian gerbils received tympanic bulla obliteration utilizing the NovaBone Bioglass particulate. Nine weeks post-implant, the animals were sacrificed, and histologic sections were prepared. Histologic evaluation was performed to evaluate new bone formation within the implant. Results: Wound healing occurred without complication. Mature trabecular bone was found throughout the entire thickness of the implant material. There was no histologic evidence of inflammatory reaction or short-term resorption. Conclusions: The high level of bone formation obtained using NovaBone in this study makes this material a potential alternative resource as a graft material for mastoid obliteration in the future. Bryan D. Leatherman, M.D. Department of Otolaryngology-HNS University of Arkansas for Medical Sciences 4301 West Markham, Slot 543 Little Rock, AR 72205-7199 Mastoid Obliteration: Autogenous Cranial Bone (Paté) Reconstruction Joseph B. Roberson, MD, Katrina R. Stidham, MD Theodore P. Mason, MD Objective: To review outcome in patients with problematic mastoid cavities who have undergone primary complete epitympanic and mastoid bowl obliteration over a 60-month period Study Design: Retrospective review Setting: Tertiary referral center Patients: 68 sequential patients undergoing mastoid obliteration over a 60 month time period with major indications including recalcitrant drainage and debris trapping in the canal wall down cavity, intolerance of water exposure, vertigo that is calorically induced in the existing cavity, and inability to wear a hearing device. 34 patients undergoing second stage surgery for ossicular reconstruction during the same time period are also reviewed. Intervention: Transplanted autogenous cranial bone is used to induce osteoneogenesis resulting in complete obliteration of the epitympanic and mastoid spaces while maintaining a mesotympanic space. Main Outcome Measures: Success of obliteration, incidence of symptoms prompting intervention, hearing outcome, incidence of recurrent cholesteatoma, incidence of eustachian tube dysfunction necessitating treatment and need for revision surgical procedures. Results: Complete take of the bony obliteration occurs in over 95% of cases. Over 90% of treated patients enjoy complete absence of original symptoms. To date, no patient has required revision surgical intervention. Conclusions: Mastoid obliteration with autogenous cranial bone is a safe and effective option for patients with problematic canal wall down mastoid cavities. Surgical techniques that include sterile harvest of the cranial bone graft mixed with antibiotic, revision of the cavity to expose viable native bone, and complete coverage of the (Paté) with autogenous fascia have proven critical to successful outcome. Joseph B. Roberson, M.D. 801 Welch Road Palo Alto, CA 94304 Ionomeric Cement Reconstruction of Incus Erosion Moises A. Arriaga, MD, Douglas A. Chen, MD Objective: This study describes the technique and short-term hearing results of fast-setting ionomeric cement (Serano-Cem) for managing incus erosion in revision stapedectomy and ossiculoplasty. Study Design: Observational and retrospective chart review. Setting: Patients were operated on an ambulatory basis in a tertiary referral center. Patients: Consecutive patients undergoing ionomeric cement incus reconstruction during revision stapedectomy and ossiculoplasty surgery. Intervention: Therapeutic - Incus reconstruction with ionomeric cement. Main Outcome Measures: 1. Technical details and recommendations for handling this new material. 2. Six-week hearing outcomes comparing preoperative and postoperative air conduction and bone conduction thresholds. Results: 1. A small amount of ionomeric cement on the tip of otologic picks applied to the incus remnant successfully reconstitutes the original length of the incus. In revision stapedectomy, a crimp-on prosthesis may be placed on the cement-lengthened incus. In mobile stapes situations, the cement reconstruction directly bridges the ossicular discontinuity produced by incus erosion. 2. Six-week postoperative audiograms demonstrate significant closure of the air-bone gap in operated cases. Conclusions: 1. Ionomeric cement permits direct reconstruction of a pathologically shortened incus in revision stapedectomy and ossiculoplasty. 2. Surgeons must be aware of precautions and limitations of this material. 3. Preliminary results indicate significant hearing improvement with this technique. Moises A. Arriaga, M.D., FACS 420 East North Avenue, Ste. 402 Pittsburgh, PA 15212 Preliminary Experience with a New, Lightweight, Titanium Prosthesis for Ossicular Chain Reconstruction J. Douglas Green, Jr, MD, Clough Shelton, MD John McElveen, MD Objective: European studies have cited improvement in high frequency hearing results using a new, lightweight titanium prosthesis. The effectiveness of this prosthesis in achieving this goal along with other traditional measures of efficacy was assessed. Ease of handling, visualization and tendency for extrusion was also reviewed. Study Design: Retrospective review of clinical cases. Setting: Multicenter study (3 sites) involving academic and private practice tertiary care centers for otologic surgery. Patients: 166 consecutive patients undergoing otologic surgery requiring reconstruction of the middle ear sound conduction mechanism across the 3 practice sites. Intervention: Ossicular chain reconstruction both with and without mastoidectomy and tympanic membrane reconstruction using a titanium total ossicular chain replacement prosthesis (T-TORP) and a titanium partial ossicular chain replacement prosthesis (P-PORP). Cartilage was interposed between the tympanic membrane and the prosthesis. Main Outcome Measures: Audiometric data preoperatively and at 3 months, 12 months and last available audiogram including pure-tone average, speech discrimination scores, and air-bone gap measures. Extrusion rate, drop in sensorineural reserve and high frequency hearing were also studied. Results: Postoperative air-bone gap of < 20 dB was obtained in 64% of patients having undergone placement of the T-PORP. A postoperative air-bone gap of < 30 dB was obtained in 67% of patients with the T-TORP. Results were stable over time in patients with long-term follow-up available. All three surgeons felt that the titanium prostheses were easier to work with than other conventional prostheses, allowing visualization through the head of the prosthesis, and all three now use these prostheses routinely. There have been no extrusions to date with a mean follow-up of 9 months and a maximum of 27 months. High frequency hearing results were somewhat better than the results presented above and were comparable to results from one of the European studies. Conclusions: Initial experience with a new, lightweight titanium prosthesis demonstrated hearing results comparable to other previous reports with improved ease of handling and visualization. Extrusion rates to date have been acceptable. Improved high frequency hearing results over other traditional middle ear prosthesis is supported by the present study. J. Douglas Green, Jr., M.D. Jacksonville Hearing & Balance Institute 836 Prudential Dr., Ste. 1405 Jacksonville, FL32207 Discussion Period 5, Papers 16 - 20 DR. CHOLE: Thank you very much. These papers are now open for discussion, the panel discussion through the other four papers of this session. DR. JOHN MCELVEEN, RALEIGH DURHAM, NC, First a comment. I’m really pleased to see people starting to use the bone cement. We have been using the Otosom actually for what I call a conservation cholesteatoma surgery where we are taking out the posterior canal wall, taking out the cholesteatoma and preserving the ossicular chain and then using the cement to rebuild the posterior canal wall. We’ve tried other techniques but now with the cement I think it makes it very useful. We always focus on conservation hearing with acoustic neuromas. I think we need to start looking at conservation of the ossicular chain with cholesteatoma surgery. The question I have for Dr. Ariaga is related to the incus to stapes junction with this Ionameric cement. Do you make a solid connection to the capitulum or do you try to recreate a little bit of the synovial joint and may this explain some of the problems were having with that particular reconstruction: DR. MOSIES ARRIAGA, PITTSBURG, PA I guess two issues John, first with regard to the canal wall reconstruction. The Europeans actually were using that as well as you know, Geiger, Helms and I think the one caution, more of the facial nerve is exposed and being particularly cautious about that. With regard to the incus reconstruction we are making a solid reconstruction and especially as we are learning more about what happens to this material particularly early on with moisture. I don’t think the problems with the incus reconstruction issues are related to a solid versus a synovial joint. I think the issue is of eustachian tube problems and drum retraction in those cases. I think theoretically that’s interesting. I know that in Tubegin they are doing it that way but I think we just need to emphasize right now that with this material, dry is really important. DR. JENNIFER MAW, SAN JOSE, CA, Comment and caution for Dr. Leatherman and Dornhoffer. I commented at last year’s COSM about some failures of mastoid obliteration with some of the new bone reconstruction materials from Livinger. I just want to elaborate that I have seen a lot more failures and I will be presenting that paper next year but I’m up to a 70% failure rate using those types of reconstruction materials in the mastoid covering it with the traditional fascia graft as described by Dr. Roberson . So just go very slow with your clinical trial because I think the glass products are even less likely to be accepted in the mastoid and my failures have been very late, eighteen months to two years so go very cautiously with your clinical trials with this. Thank you. DR. JAN GROTE, THE NETHERLANDS: I have the same problem and I have remarked to the presentations of Leatherman and Roberson. Most dealing with new bone formation. Now the problem of course is how to get a reliable scaffold in order to promote new bone formation. At the end of the 70’s I published a lot of papers on that. Both materials presented are bioactive so that’s alright. The problem however is different for both materials as already mentioned. For the bone pate it looks like good material but the porosity is too high. We know exactly what kind of porosity you need, in order to have a reliable new bone formation before it’s resolved because you don’t want to end up with holes. That is why I introduced hydroxlappetite and developed it. In 83 I finally agreed that it came into the clinic. With the bioglass, the problem we already know is that the outer surface is the calcium phosphate iron, which will get new bone formation . This center is still a foreign body bioglass so in the long run it will resolve and that’s why Cerventol was taken from the market. Now my question to Leatherman, he didn’t see any inflammation but did he look at the microphage reactions in his experiments because that will indicate that there will be a resorption. As already mentioned by the question before that there will be resorption in the long run. Microphage reaction will continue to beat out the bioglass, that’s why I ask this question as to whether you have seen that or not? DR. BRYAN LEATHERMAN, LITTLE ROCK, AR Yes sir, no we didn’t particularly look at the macrophage reaction. The reason being is the particles all reabsorb part of the process. The bone forms on the outside and works towards the middle. There’s been histological studies of this material carried all the way out to no crystals left. There’s no crystals exposed for microphages to come so even if there’s crystals in the middle ear there’s no exposure for macrophages to come in contact with them. In previous studies we didn’t look at that because it’s been looked at and eventually all the material does get reabsorbed and its supposed to as the bone gets formed around it. DR. EDWARD BRANDON, SYRACUSE, NY Yes, I enjoyed the papers on mastoid obliteration but a word of caution. There’s an incidence of recurrent cholesteatoma beneath the obliteration flap. It’s alright to obliterate a relatively stable old mastoid cavity but in the face of active cholesteatoma disease you probably better not attempt this. A few years back Beels from England poled over a thousand otologists concerning the results of pedicle flap obliteration and he found an incidence of 5% cholesteatoma recurrence under the flap. He also found three cases of brain abscess secondary to the obliteration. DR. ILMARI PYYKKO, STOCKHOLM, SWEEDEN, I have a question for Dr. Roberson about the use of bone pate in the mastoid obliteration. We have been using that, as many of you, in Europe on just using the bone pate. My first question in closing the fistula is causing long-term bacterial phenomena for the patient because it’s not forming the solid bone in these cases and we have to change the technique and use bone chips for that. The same holds for long-term results. If we look for ten years follow up for these patients for the canal reconstruction. It seems that in significant parts of the cases there is continuous absorption of the canal so therefore we use additionally bone chips for the canal which are more stable. I would like your comments on these two topics. DR. JOSEPH ROBERSON, PALO ALTO, CA Thank you for your comments and questions. In terms of the fistulas what we have done is placed fascia over the top of the fistula and then placed a large amount of bone to fill the mastoid cavity. To date those patients have experienced a mild disequilibrium for a few weeks after surgery but following that they have been in good shape. They do not have any sort of vertigo induced either with pressure in the canal and it seems to have worked nicely. Your comment regarding I think really a synopsis is the size of the bone that has moved into place either small pieces of bone taken with the drill like bone pate or bone chips. We have done some work with ear canal, actually my partner Dr. Rodney Perkins had done some work early with reconstruction of the ear canal and his findings were similar. Our switch in the last several years has caused our bone pate to be more coarse and my clinical impression although I can’t show this is that does seem to be a more stable compound if that’s right. We have switched from a low speed to a high speed drill. The flutes of the drill bits are more aggressive and the chips are larger so there may be something to that. DR. ANTONIO DE LACRUZ, LOS ANGELES, CA I have a question about the panel. In the first case that you presented and I don’t know if John Niparko was here, the comment on the bilateral acoustic NF2 in a child. Was this the two cases facial function in those cases. That was the impression I got. He resected the tumor from the nerve and preserved facial function. DR. ANTONIO DE LACRUZ: We have looked at the histopathology of NF2, that is very hard to do. DR. CHOLE: I agree. DR. JOHN HOUSE:, LOS ANGELES, CA, I would like to first of all make a comment on Eugene Chu’s talk and Bob Jackler. That was very enjoyable, you did a great job presenting it and I enjoyed it very much. Of course I always like history; I think its always interesting to look back on what’s been done in the past. A comment and question for Joe Roberson. Joe, as you know we have been doing the bone pate for many, many years and I think Rod started it even before that so it’s been a long time. I was curious what are you using to collect the pate, using the Sheehy pate collector and the second question is that I find it helpful to swing a little Palva flap down to get a little more soft tissue over the bone pate. I am wondering if you do that? that he had that were facial nerve neuromas and did he resect them and save the hearing? It kind of concerned me a little bit because most of us would have to open the internal canal realizing that it was a facial nerve neuroma not resect, leave it on and let the patient have normal facial function for as long as they could. So I was just wondering if he resected and grafted the facial nerve right off the bat and that was my question to him. DR. ROBERSON: Yes, we do use the Sheehy bone pate collector although in hospitals where we don’t have that we have collected the pate with the tongue blade and with a burr rotating into that the old fashioned way. Your second question was regarding the Palva flap. I have not done that. I think the reason I like the way we do it better now is that the fascia is a thickness that is uniform and there’s not the variability of how much soft tissue reabsorption there is. It’s also less traumatic to the ear if not to move so much tissue around. We do retain and these slides didn’t do it justice, flaps of skin anteriorly and posteriorly. We reflect those onto the anterior canal wall and leave them there, obliterate the mastoid and then cover the fascia with that but have not used tissue over the top of it. DR. HERBERT SILVERSTEIN, SARASOTA, FL, I would like to comment on the paper the Ionomeric cement reconstruction. I just wanted to caution the audience. We just had experience using this cement on a very simple case with incus necrosis connecting the incus to the stapes and we waited for the cement to dry and then did a tympanoplasty to reconstruct the eardrum putting gel foam and Vasociden in the middle ear. The patient developed a severe sensorineural hearing loss right after the surgery. We placed the patient on a high dose of steroids and the sensorineural loss improved to the point where the patient has about a 50 -decibel loss and about a70% discrimination. I reported this to the company. They are doing research on this cement and it is quite toxic and they are recommending even waiting 20 minutes before doing any other kind of work with the cement. We imagine that what happened was that there must have been some reaction with the cement and the Vasociden going down to the round window. When we took the pictures and the video we could see it was all connected together and it looked like the toxic substance went into the inner ear to cause the sensorineural loss so I caution people using this cement. DR. JIM SAUNDERS, OKLAHOMA CITY, OK Joe, I wanted to make a comment really not so much a question but in your response to Dr. House. I share your concerns about the palva flap have had some valuable reabsorption of that. What I have been doing with my canal wall reconstruction is actually just taking the periostium on the undersurface of the palva flap which swings into the ear very nicely and gives you a nice vascular coverage without that really big thick flap which you sort of end up with a lot of thick tissue laterally at the meatus and not much deep so it might be something you can consider trying. DR. CONRAD PROCTOR, DETROIT, MI, I followed about 5000 cases of my late father and I did over 25 years using the open cavity technique and our results are very good. Only about 1% of these have needed revision and only about 1% have recurrent drainage so I’d like to just put in a word for the old technique. Probably the secret was the way the mastoidectomy was done. My father taught anatomy and I learned a lot from him and at the University of Michigan and if the mastoidectomy is done properly, results are fantastic I would say. DR. CHOLE: Thank you Dr. Proctor. One last word from Dr. Grote.. DR. IAN GROTE, THE NETHERLANDS, A remark on the periosteal flap. I used the cranial base periosteal flap and not the Palva flap. The reason for that is that with the Palva flap you put it outside of the flap on top of the new bone formation and the inside of the flap is the bone inducing part. So you really enhance the new bone formation if you take the underside of the periosteal flap on top of new bone formation. That’s why I use the cranial base. DR. CHOLE: Thank you. Thank you all for your excellent discussion. Middle Ear/Mastoid Diagnostic Utility of Laser Doppler Vibrometry in Conductive Hearing Loss with Intact Tympanic Membranes John J. Rosowski, PhD, Barbara S. Herrmann, PhD Ritvik P. Mehta, MD, Saumil N. Merchant, MD Hypothesis: Laser Doppler Vibrometry can help the diagnosis of conductive hearing loss. Background: The identification of pathologies responsible for conductive hearing loss with intact tympanic membranes is a continuing challenge. While history, audiometry and tympanometry are helpful, the precise diagnosis is often made only during surgical exploration. The dependence on surgery for proper diagnosis increases the difficulty of pre-surgical counseling and planning. The present study investigates the utility of laser vibrometry in conductive diagnoses. Methods: Pre-surgical laser vibrometry was used to determine the sound-induced vibration of the umbo in 16 cases with conductive hearing loss, intact tympanic membranes and aseptic middle ears. Sound was delivered to the ears via a glassbacked speculum that allowed us to visualize and focus the laser on the umbo. The difference between the measured vibration and the vibration in normals was compared to the surgical diagnosis. The surgeon was blinded to the laser results. Post surgical umbo vibration measurements were also made when a stapedotomy was performed. Results: Three cases with ossicular interruptions had significantly larger than normal pre-surgical umbo vibrations at low frequencies. Thirteen cases with ossicular fixations had smaller than normal umbo vibrations. The umbo vibrations measured post stapedotomy where similar to the measurements made with ossicular interruptions. Conclusions: The results show differences in sound-induced umbo vibration between cases of ossicular interruption and fixation that may be useful in the differential diagnosis of these conditions. Post-stapedotomy measurements suggest successful stapes surgery produces a more mobile middle ear than normal. [Supported by NIDCD; IRB Approval 00-09-041]. John J. Rosowski, Ph.D. Eaton-Peabody Laboratory Massachusetts Eye & Ear Infirmary 243 Charles St. Boston. MA 02114 Middle-Ear Mechanics of Type III Tympanoplasty: Basic and Clinical Studies Ritvik P. Mehta, MD, Michael E. Ravicz, MS John J. Rosowski, PhD, Saumil N. Merchant, MD Objective: To investigate mechanics of type III tympanoplasty. Background: In the classical type III-stapes columella tympanoplasty (graft placed directly onto stapes), postoperative air-bone gaps vary from 10-60 dB. The structural features responsible for the wide range in results are not well understood. Methods and Results: (1) Experimental study: Canal wall-down type III procedures were performed in 10 cadaveric temporal bones. Acoustic stimuli were presented in the ear canal, and round window velocity VRW (used as an index of hearing) was measured, while systematically varying stapes mobility, graft material and graft-to-stapes coupling. VRW after a type III was 20-25 dB lower than in normal ears. Stapes fixation markedly reduced VRW. There was little effect of varying the graft material or varying the tightness of coupling between the graft and stapes. Interposing a thin cartilage disc between the graft and stapes improved VRW by 5-15 dB. (2) Clinical study: Post-operative air-bone gaps were determined in 40 ears after type III tympanoplasty with temporalis fascia graft onto the stapes head. Air-bone gaps of 20-25 dB occurred with a mobile stapes and aerated ear (N=26), which corresponds well with the temporal bone results. Large air-bone gaps of 40-60 dB occurred with stapes fixation (N=4) or non-aerated ears (N=10). Conclusions: A mobile stapes and aerated middle ear are essential for a successful type III tympanoplasty. There is little effect of varying graft materials or graft-to-stapes coupling. Improved results may be achieved by interposing a thin cartilage disc between the graft and stapes head; we hypothesize that the disc improves the "effective" vibrating graft area. Supported by NIDCD R01 DC04798; IRB approval #00-09-041. Saumil N. Merchant, M.D. Department of Otolaryngology Massachusetts Eye & Ear Infirmary 243 Charles Street Boston, MA 02114 Prolonged Middle Ear Ventilation with the Cartilage Shield T-Tube Tympanoplasty Larry G. Duckert, M.D., Ph.D., Kathleen H. Makielski, M.D., Jan Helms, M.D Abstract: In 1994, the favorable experience with composite cartilage “shield” tympanoplasty was reported to the Society. On that occasion, the technical question regarding the concomitant placement of a ventilating tube was posed. In response, the authors proposed that the tympanostomy tube be incorporated in the cartilage graft. Moreover, they proposed that this marriage, when used to reverse atelectasis repneumatize the middle ear, should offer the advantage of both procedures while reducing the incidence of tube extrusion and other complications of prolonged intubation. While attractive in theory, this supposition could only be validated after a prolonged period of follow-up, reported here. Objective: 1. To describe an effective means to secure prolonged middle ear ventilation in a patient population prone to atelectasis and chronic middle ear effusion; and 2. To establish the incidence of favorable and unfavorable outcomes after six years of observation. Study design: A retrospective case series. Setting: A tertiary referral center. Patients: 40 patients (28 adults and 12 children) who underwent tympanic membrane reconstruction with a composite cartilage shield T-tube unit. Results: 1. Overall retention rate was 62.5% over 6 years; 2. 65% of retained tubes were maintained a minimum of 4 years in adult patients; and 3. Extrusion and permanent perforation rates were 0%. Conclusion: The cartilage shield T-tube tympanoplasty can effectively reverse atelectasis and provide prolonged middle-ear ventilation. The technique can be used safely and minimizes the risk of tympanic membrane perforation and other complications associated with prolonged middle ear intubation. Larry G. Duckert, M.D., Ph.D. Otolaryngology-HNS University of Washington Box 357923 Seattle, WA 98195-7923 Laser Eustachian Tuboplasty (LET) Oskar B. Kujawski, MD, Dennis S. Poe, MD Objective: Surgery on the eustachian tube (ET) for chronic eustachian tube dysfunction (ETD) has been previously directed toward the bony isthmus and failed to produce lasting results. Dynamic video analysis demonstrates pathophysiology in the tubal cartilaginous portion. This study investigated a new endoluminal procedure that focused on the cartilaginous ET. Study Design: Prospective surgical trial. Setting: Tertiary care private practice and outpatient surgi-center. Patients: 108 ETs with intractable ETD (middle ear atelectasis or effusion) in 56 patients underwent LET by first author OBK since 1997. Intervention: Dynamic video analyses of ET function were done peri-operatively. LETs were performed unilaterally or bilaterally under general anesthesia through a combined endoscopic nasal and trans-oral approach to the ET nasopharyngeal orifice. CO2 or 980nm diode laser vaporization of mucosa and cartilage from the lumenal posterior wall was accomplished until adequately dilated and the tube was packed. Main outcome measures: Opening of tubal aperature on dynamic video. Normalization of mucosal edema, impedance tympanometry, and tympanic membrane. Results: 74 (69%) tubes achieved normal ET function at 1 year, 70(71%) at 2 years, and 60(65%) at 3years. There were no intraoperative complications. Post-operative complications were limited to minimal peritubal synechiae in 9 (8.3%)tubes and epistaxis in 1 (0.9%) tube. 7(6.5%) tubes failed treatment and required tympanostomy tubes. Conclusions: LET is a new procedure that has demonstrated early promise in correcting intractable ETD with little complications. Further studies will be necessary to reproduce the results and establish the role of LET in the management of chronic intractable ETD. Oskar B. Kujawski, M.D. 3, rue du Conseil-General 1205 Geneva, Switzerland Photoacoustic Effects of Carbon Dioxide Lasers in Stapes Surgery: Quantification in a Temporal Bone Model Edward K. Gardner, MD, John L. Dornhoffer, MD Scott Ferguson, ALET Hypothesis: The carbon dioxide (CO2) laser in stapes surgery creates sound waves that could damage hearing. Background: Application of a laser to any medium causes absorption, reflection, transmission, and thermal effects. To date, research on the safety of CO2 laser stapedotomy has focused on the thermal effects. However, its absorption also presents some risk to the inner ear as the absorbed energy elicits photoacoustic or photochemical effects. Our goal was to measure the photoacoustic effects (sounds) produced by the CO2 laser in simulated stapes surgery. Methods: Using a variety of settings, a Sharplan 150 XJ Laser and a Contour Erbium:YAG laser were applied to the oval window of human temporal bones fixed in a normal saline bath to simulate perilymph. Photoacoustic waves were measured by a hydrophone located 2 mm beneath the oval window. Measurements were made with and without a simulated tissue seal over the window. Results: No detectable sounds were created below 4 Watts (continuous mode) or 60 mJ (superpulse mode). Above these settings, intensities greater than 90 dB were detected when the laser was applied directly to the perilymph. With the tissue seal in place, no detectable sounds were identified. The accuracy of our model was confirmed by comparing our results with previously published results using the Erbium:YAG laser. Conclusions: Below 4 Watts in continuous-wave mode and below 60 mJ in superpulse mode, any sound generated by the laser is negligible. Above these thresholds, however, impact sounds are produced that could result in threshold shifts with repeated applications. Edward K. Gardner, M.D. 4001 West Capitol Little Rock, Arkansas 72205 Physiologically Optimal Placement of Malleus-to-Footplate Prosthesis Larisa D. Kunda, MD, Sunil Puria, PhD Joseph B Roberson, Jr., MD, Rodney C. Perkins, MD Hypothesis: To physiologically optimize malleus-to-footplate prosthesis (MFP) reconstructed ears. Background: The positioning of MFP on the malleus remains a controversial subject. In the past, the acoustic properties of the MFP have been studied using a laser Doppler vibrometer system. Recently, it has been shown that hearing threshold is better correlated to cochlear pressure. We measure cochlear pressure to study human cadaveric ears reconstructed with hydroxylapatite MFP. Methods: The ear-canal pressure (Pe) and vestibule pressure (Pv) are measured in four temporal bones with additional measurements planned. In each bone, measurements were performed (1) with intact incus, (2) removed incus, and (3) with MFP at three positions on the malleus (head, mid-manubrium, and umbo) and center of footplate with intact and removed stapes-superstructure (SS). The incus gain (Gi), is defined as the ratio of Pv before and after removing the incus. Similarly, the MFP gain (Gmfp) is defined as the ratio of Pv with reconstructed MFP and removed incus. Results: Gmfp reached 37-38 dB with MFP at the neck and with the SS intact and after removal. The range of Gmfp at the mid-manibrium and umbo, with SS intact and after removal, was 23-26 dB. For reference Gi was 42 dB for all ears. All of these averaged peak gains were in the 1.1 to 1.3 kHz region. Conclusions: With MFP reconstructed middle ears there is a 11-15 dB improvement in pressure gain with the prosthesis beneath the neck of the malleus than at other locations. Larisa D. Kunda, M.D. 738 Channing Avenue Palo Alto, CA 94301 Discussion Period, Papers 21 -26 DR. GULYA: Okay, these papers are now open for discussion. Dr. Mansfield Smith. DR. MANSFIELD SMITH, DAVIS, CA, I would like to comment on the excellent paper on Photoacoustic Effects of Carbon Dioxide Lasers in Stapes Surgery. We developed a number of years ago a CO2 laser delivery system with Reliant Laser, which used a mirror reflection system, which did two things. One, it allowed the laser, using CO2 because of all the reasons given,and it brought the laser aiming beam and the laser so they are exactly the same. Two, that the laser beam could be reduced to a tenth of a millimeter accurately which makes it a much more effective instrument. It reduces the energy delivered particularly noise and with the absorption of it less than a tenth of a millimeter into perilymph it made it extremely safe. I’ve used that for years and I’m glad to see this work further collaborate that effort. Thank you . DR. GEORGE LESINSKY, CINCINNATI, OH, I would again like to congratulate John on a wonderful paper but I need to point out several important facts. One is the laser company’s deceived us when we got to pulsing CO2 lasers by settings called “average power”. Milligules are terribly important when we are pulsing the laser and the milligule is defined as the watts times the milliseconds that the pip of the micropulse is on. A micropulse might be on for a tenth of a second but it might have ten pips that are only a tenth of a millisecond. Our work shows that anything over 25 milligules per pip is dangerous because we get flaring. We had recommended in our work with the thermal effects between 10 and 20 milligules per pip. IL Med Laser that was developed specifically for CO2 laser has 16 milligules per pip. The problem is the neurosurgeons and other specialists who are driving this CO2 laser force Sharplin and Coherent to be delivering 500-600 watts of peak power while they were on super pulse so the least you could get was 50 milligules which was much too powerful. It is terribly important when we are revising stapes surgery to open the vestibule. It is the only way I know of to determine the true depth of the footplate where it should have been and also any residual footplate below it and many, many times as I pointed out in a paper last year where we reviewed 289 I believe revisions, the collagen layer contracts and is above the level of the footplate. So palpation of the sealing collagen neomembrane is not valid because we are not near the footplate. It lateralizes up on the promontory and facial ridge and consequently in 18% of the cases we have found intact stapes footplate below the center of the fenestration. In summary milligules per pip is what’s important. The thermal spread is dependent on how long the power is on the target tissue and if we use continuous wave for a tenth of a second or were using super pulse, the difference is the super pulse pip is on for a tenth of a millisecond, 1000 times less than a continuous pulse. In revision surgery if you do revision under local like I do that is important if we raise the temperature of the vestibular perilymph and ultimately endolymph more than one degree centigrade we can begin to get vertigo. In summary super pulse mode is the best mode for stapedotomy and stapedectomy revision, calculate the milligules per pip on super pulse mode by multiplying the on time for the super pulse mode each pip times the peak power and keep between 10 and 20 milligules. DR. ELIAS MICHAELIDES, DETROIT, MI, A question for Doctor Dornhoffer. You noted that at lower power settings you got no decibels and as you raised up the power levels you did get a response. Could you explain how you were getting absolutely no sound levels at the lower power settings and were you seeing any tissue effect at those power levels? DR. DORNHOFFER: It has to do with energy. I mean the photoacoustic effect is probably created by a small bubble of vaporized medium and it’s just less energy. I think that’s just the best way to express it. It may be simplistic but I think it didn’t produce detectable sounds also which means that it doesn’t necessarily mean it produced no sound, it just means that we weren’t able to detect them with our current setup if that answers your question.. DR. JENNIFER MAW, SAN JOSE, CA: I enjoyed the papers on the eustachian tube problems very much despite all the neurotology training, I’m still humbled it seems just by simple eustachian tube dysfunction. I’m wondering if Dr. Duckert could give us some words of wisdom about keeping the tubes open after surgery because that’s been a problem for me. and if Dr. Kujawsky could comment in a chronic sinusitis patient is pus in the nasal pharynx a contraindication to doing a procedure? DR. OSKAR KUJAWSKY, GENEVA, SWITZERLAND, First your question is very important. I mentioned before we consider that with any surgery all factors that can lead to obstruction of eustachian tube has to be removed or try to be treated. What you mentioned evidently is one so the first cases I’ve done with a careful selection. They were divers and they just wanted to be better, I said okay we will try so of course we have to resolve all pathologies known before. I won’t say it’s a contradiction but if you don’t treat it before or consider the correct way to approach this very new early surgery. DR. LARRY DUCKERT, SEATLE, WA, Thank you for the question regarding patency of the tube. That is a problem technically speaking. At the time of surgery the less amount of gel foam that you put in the middle ear which has a less tendency to obstruct the tube more acutely. Later on passage of very small suction tips can facilitate or increase or maintain the patency of the tube. That’s a problem we have in children. I think that probably contributes to the increased failure rate in children because they don’t tolerate the tubule maintenance and manipulation of the tube. They have a greater incidence in those situations where the tube has to be removed but keeping it clean with a suction tip does seem to help DR. ILMARI PYYKKO, STOCKHOLM, SWEEDEN, I have one question for Dr. Kujawaski.. I think this new approach is really promising but when we are doing endoscopy of the eustachian tube we see a different kind of pathology like mucosal pathology which you can easily access with your laser surgery. In some rare cases there may be ankylosis of the cartilage prohibiting it from rotation. The third pathology which seems to be present is the muscular pathology. My question is do you think that those cases which were not responding for later surgery were belonging to muscular pathology of the eustachian tube or what is your opinion on that? DR. OSKAR KUJAWSKI, I didn’t want to mention in this study old data base that I’ve taken to consider patients. Slow motion video helped me before to overall see if there is a functional, a more obstructive permanent problem. There are some first results but I prefer just Dr. Poe who has more focus now on this dysfunction or obstruction of eustachian tube, which is a crucial problem of course. We have some enhancement with the function of the obstruction that maybe we can say is an obstruction problem to delay the eustachian tube, maybe this is a correct word so those data are really evident, they are the first. The criteria is very easy, very simple. There is quite a good data base but we need much, much more data and before we analyze the results we have really to discard old data. I had to learn a lot before I imagined the surgery. So the discussion is very open. DR. ARVAND KUMAR, CHICAGO, IL, The question is for Dr. Kunda. Did you measure the angle between the handle of the malleus and the center of the footplate because that would influence how the system works: DR. LARISA KUNDA, PALO ALTO, CA, Unfortunately we did not come up with any good measurement devices for that but we do plan to do it in the future. Vestibular Efficacy of a Falls Prevention Clinic: A Pilot Study Utilizing Quality of Life Assessments Priya Krishna, MD, Manali Amin, MD, Marian Girardi, MA Sandra Lin, MD, Horst R. Konrad, MD, Larry F. Hughes, PhD Objective: To determine whether evaluation at and intervention from a Falls Prevention Clinic improves balance, reduces falls risk, and affects quality of life for elderly patients. Study Design: Retrospective chart review Setting: Tertiary referral center Patients: Urban/rural Midwestern elderly population referred to a Falls Prevention Clinic. Intervention: Rehabilitative Outcome Measures: Dizziness Handicap Inventory and Investigator-Designed Survey. Results: Thirty-six patients who were evaluated and treated at the Falls Prevention Clinic were asked to participate in this pilot study. 100% of these individuals had fallen at least once prior to visiting the clinic, and their mean number of falls was 3.36. All were given specific customized therapeutic balance exercises to perform. A large majority of patients performed the exercises. Approximately two years after their initial evaluation and treatment at the Clinic, these individuals completed Dizziness Handicap Inventory (DHI) forms and investigator-designed surveys. The mean age of the patients was 80.4 years. In the two years since their visit to the clinic, only 23.1% of the respondents reported falling and no serious fall-related injuries were described. DHI's completed post-treatment demonstrated a statistically significant improvement to DHI's completed pre-treatment (p=0.026). In addition, the satisfaction level with treatment was very high, with almost all patients stating they would recommend this Clinic to other individuals with similar balance, dizziness, and falling problems. Conclusion: Elderly patients who received therapy at a Falls Prevention Clinic were satisfied with their experience, demonstrated both objective and subjective improvement in their symptoms of dizziness and imbalance, showed a decrease in falls, and reported an improvement in their quality of life. Marian Girardi, M.A. Division of Otolarlyngology SIU School of Medicine P. O. Box 19662 Springfield, IL 62794-9662 Anatomic Differences in the Vestibular Canals and their Implications in Vestibular Neuritis Gerard J. Gianoli, MD, Joel A. Goebel, MD, Sarah Mowry, BS, Paul Pooms, BS Hypothesis: Anatomic differences may render the superior division of the vestibular nerve more susceptible to injury during vestibular neuritis. Background: Neural degeneration has been identified in temporal bone studies of vestibular neuritis. Previous studies of vestibular neuritis have demonstrated that the superior division of the vestibular nerve is preferentially affected, with sparing of the inferior division. A preliminary temporal bone study has implicated neural entrapment as a possible cause for this preferential injury. Methods: Two independent observers performed histologic analysis of 184 normal temporal bones from our temporal bone library. Measurements of the medial, lateral and midpoints of the superior vestibular, inferior vestibular and the singular nerves and canals were made. These measurements included the length, width and percent of the canals occupied by bony spicules. Results: The lengths of the bony channels of the singular nerve (0.598 mm) and the inferior vestibular nerve (0.277 mm) were significantly shorter than the average length of the superior vestibular canal (1.944 mm; p<0.0001). The total percent of the canal occupied by bone at the canal midpoint was significantly greater for the superior vestibular canal (28%) compared to either the singular canal (0%) or the inferior vestibular canal (18%) (p<0.0001). Conclusion: The bony canal of the superior vestibular nerve is seven times longer than the inferior vestibular canal and four times longer than the singular canal. There are a larger percentage of bony spicules occupying the superior vestibular canal compared to the inferior vestibular or singular canals. This anatomic arrangement of a longer canal with more interspersed bony spicules would make the superior vestibular nerve more susceptible to entrapment and ischemia. Gerard Gianoli, M.D. 17050 Medical Center Drive, Ste. #315 Baton Rouge, LA 70816 Meniett Therapy for Meniere’s Disease George A. Gates, MD, J. Douglas Green, MD, Richard J. Wiet, MD Educational Objective: At the end of this presentation, the participants should be able to describe the short-term benefits of Meniett therapy for people with medically unresponsive unilateral cochleovestibular Ménière’s disease. Objectives: To evaluate the use of the Meniett device for treatment of people with unilateral cochleovestibular Ménière’s disease who have failed medical therapy. Study Design: Descriptive preliminary analysis Methods: Intermittent transtympanic micropressure therapy using the Meniett device was self-administered for 5 minutes 3 times a day. The Meniett generates complex pressure pulses with a total amplitude of 12 cm. H 20 and a duration of 0.6 sec. The micropulses reach the round window via an indwelling tympanostomy tube. Results: Eleven consecutive patients with classic unilateral Ménière’s disease received Meniett therapy. Ten cases were judged as responders. Cessation of vertigo and relief of pressure symptoms occurred within 2 weeks in 5 and within 2 months for a sixth. The remaining patients estimated reductions in vertigo frequency and intensity of 50%. One patient failed to respond in three weeks and underwent endolymphatic sac surgery. Improvement in hearing was confined to the low tones and was modest. The treatment was well tolerated and no complications were observed. Conclusions: This preliminary experience indicates that the Meniett is a reasonable option for people with classic unilateral Ménière’s disease who have failed medical therapy. J. Douglas Green, Jr., M.D. Jacksonville Hearing & Balance Institute 836 Prudential Dr., Ste. 1405 Jacksonville, FL 32207 Discussion Period, Papers 27-29 DR. ALLEN RUBIN, TOLEDO OH, I just wanted to address my question to George Gates on the Meniett device. Have you noticed any difference in the outcomes based on the duration of the patients who have had Meniere’s? That’s my first question, the second question any difference in the age, do the younger patients do better than the older patients and the third question is do you think there will be a difference if you use something like a T-tube with a larger boar than the smaller tubes? DR. GEORGE GATES: Thank you Allen. We don’t have enough people to analyze and answer the question about age and duration. The preliminary feeling is that people with shorter duration Meniere’s disease whose hearing fluctuates in between attacks will do the best. The type of tube I think is going to be very important. We are using a larger bore gromet. Dr. Densert did not recommend T-tubes but I think that’s going to be an option in the future. DR. LOREN PARNES, LONDON, CANADA: This is also for Dr. Gates. I know that in one of the European studies it was noted that patient’s attacks lessened after the insertion of the tube and there was no subsequent improvement once they started using the pressure device, the Meniett device. I was wondering if you noted that in your group of patients? DR. GEORGE GATES: Thank you. We have not noticed improvement with the tube but we haven’t looked at it specifically. We will in the clinical trial. Dr. Oldquists group had a interval between tube insertion and use of the placebo and control device and there was no effect of tube insertion on these patients symptoms. So we believe it’s the device and not the tube. DR. JOHN HOUSE, LOS ANGELES, CA, George one more question for you. A question about the tube, you said that you shouldn’t do it without the tube being in place and how do you know if the tube does come out because in my experience of one case the tube did in fact come out. He continued to use it. They came back because the symptoms sort of returned but you implied that there’s a contraindication to use it with an intact tympanic membrane . DR. GEORGE GATES: Yes thank you. We have to teach the patients how to valsalva and clear their tube and we ask them to check that they can feel air coming out before every use. Barbara Densert who is one of the inventors of the device notes that when the tube is blocked and people use it, it can make them worse. I don’t know why it makes them worse. The theory is that the pressure application is going to the round window and not through the ossicular chain. There’s a lot to learn on this yet. DR. LARS OKAVIST, SWEDEN, I was referred to and I have to make a few comments. Once you take a Meniere’s patient into your service you really have to treat the patient all the way until for example you do the nerve sectioning or the gentamycin and you have at last treated the patient for the final solution. Concerning the function of the tube. We have a certain number of patients in this two week study that was mentioned and also in the ongoing study with two months of treatment and half of the patients for the placebo.. There are about 10% of these people who get rid of their attacks by tube treatment alone. As we know from the publications by Tumarkin in the 60’s already so there is an effect in some patients. Also in these studies we don’t accept the patients who get well on the tube alone so those are excluded. DR. FRED TELESHI, MIAMI, FL, Why can’t patients generate the same effect with simple autoinflation? DR. GEORGE GATES: That’s a good question. When I was talking to Jack Hough about this he reminded me that when he was a resident eustachian tube inflation with a cannula was a useful therapy and widely used to abort impending Meniere’s attacks. This may be an alternative but not all people can do that and it hasn’t been studied in a way that is scientific. One of the points that have been made is that static pressure does not change the fluid distribution in the ear very much and the Densert’s did a number of studies on this. It’s the alternating pressure so I suppose if you can pop and push and pop and push you might get some therapy but that appears to be a key element. DR. GEORGE HICKS, INDIANAPOIS,IN, Doctor Gates one of my associates late yesterday afternoon was at the Medtronix desk here and was told that the company is going public for all physicians to have access to the device. I don’t know if that’s true or not and if so the ramifications could be not desirable. What is your opinion and is this a true fact? DR. GATES: Well the device has been cleared by the US FDA for sale and I understand that the Swedish company Pascol Medical was purchased by Medtronix Xomed and that once the manufacturing gets up to speed in the United States it will be available for any physician on a prescription. I think that the use of this will be limited to a otolaryngologists and otologistss who know how to put tubes in the ears, diagnose Meniere’s disease and monitor and care for these people. These are high maintenance patients and it takes a lot of your time and effort to counsel with them and walk through this to check that the machine is working because the patients get panicked when the machine stops working and the emails and phone calls come back and forth. So there is a substantial physician overhead on this. DR. FIRAS HAMDAN, PERRY, FL, Last question to follow up on the autoinflation, the flip side of it. Would you advise the use of this device on a patient with patulous eustachian tube or would you skip it and go along for other options? DR. GATES: I don’t think the patulous eustachian tube would affect it but I don’t know that. DR. JOHN LI, JUPITER, FL, What is the science behind the one second on and four seconds off or is there science behind that and how much pressure and all of that kind of stuff? DR. GATES: Well if you read Dr. Densert’s articles over the past twenty years, there are a number of carefully done animal experiments to examine various combination of pressure pulsed with intensity. I would refer you to those articles for an answer to your question. This is the result of those investigations. DR. STEPHANIE MOODY, LOS ANGELES, CA It’s interesting the effect on the dizziness but do you have any insight whether the device is altering the pathophysiology of the disease such as the hearing loss that progresses over time? DR. GATES: In some cases it appears to alter the pathophysiology as the hearing improves and the vertigo disappears. Some of our patients have stopped using the device three times a day and then go down to two and then down to one and then their vertigo recurs and they get back on the device. There are a number of mysteries involved in this and that’s why I refer to the black box and I think that continued research will help answer a lot of these questions. The main point at this time is there is an effect from the device; it appears to be a continuing effect as long as it’s used and the device seems to be safe and reasonably effective. DR. GULYA: With that I would like to thank the speakers for staying to their allotted time limits and I’ll turn this back over to Dr. Chole. DR. CHOLE: As we wrap up this morning a couple of reminders, please fill out your continuing education forms and a comment form and I would like to remind all the members and guests about the banquet this evening. It’s going to be in the Estate Ballroom and bring your tickets to the banquet and pick them up if you do not already have them. So as my last act professionally as President of the Society I would like to announce your next President, Dr. Ron Conrad, next President of the American Otological Society. DR. CONRAD: I need your attention for just another minute yet. Dr. Richard Chole has been our President for this year and will continue to be so until July 1, 2002. He has been an outstanding leader. The program as you know has been excellent, the organization has been wonderful and he accomplished some very important jobs this year. I’d like to present him with this plaque and also the President’s pin. Thank you very much on behalf of this Society. The only other thing is be sure to mark on your calendar the next meeting will be in Opry Land in Nashville, Tennessee, May 2nd and 3rd and I hope to see you all there and I beg that you submit excellent abstracts. Thank you very much. IN MEMORIAM Jean-Bernard Causse, MD Jean Bernard Causse, MD May 13, 1944- December 13, 2001 He was born May, 13, 1944. Jean Bernard attended The Strasbourg Faculty of Medicine and won first prize from the faculty there. He was intelligent, enthusiastic, happy, and emotional. He had great difficulty speaking negatively about anyone or anything, and he always made you feel like you were his best friend. Jean-Bernard was a member of many organizations, received many honors and wrote 150 publications. His personal affiliations included, the American Otological Society, Otosclerosis Study Group, American Academy of Otolaryngology, Paris Hospitals ENT Society, New York Academy of Sciences, National Council for Noise Pollution, Politzer Society, Prosper Meniere Society, and he was an Honorary member of the Society of Ear Research Foundation Fellows. In 1998 he was made a member of the Marquis Who’s Who in the World. He was presented with the French Legion of Honor in1999. He received the Certificate of honor from the American Academy of Otolaryngology. In 2000, he was awarded the New Century Award by Barons 500 Who’s Who (USA) which includes those people who have been cited as leaders for the new century. He was made an Honorary Citizen of Memphis, Tenn. His academic appointments included Faculty Member of the University of Nijmegen, an Assistant at the University of Montpellier ENT Department, and Surgeon at the University of Montpellier, France. He was often the Guest of Honor at meetings around the globe, the guest of princes and kings and government officials. He performed surgery in China and was a guest of the Chinese Communist Government. All admired him. His charm and charisma could sway even the top officials of world organizations and certainly honored everyone with whom he came to know. He loved the phase,” If we can see far it is because of those who have come before us. We are merely dwarfs riding on the shoulders of giants”. He believed in the “intelligence of the heart,” and he treated all people and patients as equals. His sense of humor kept him strong. He loved telling jokes, he was always spinning a good yarn, and best of all, he was always ready to make fun of himself first, and his friends second. He was a master surgeon and loved to entertain people in his clinic. Everyone around the world admired his great surgical skills and his patients came from everywhere. He was the only surgeon I know who made 2 videotapes of his surgery – 1 for the referring physician and 1 for the patient’s family. Over 350 doctors would visit him in his clinic during the course of a year, and he also traveled and lectured extensively. Jean Bernard was surgically booked for 2 years in advance. He was a master at stapes surgery and correction of congenital middle ear defects; He performed about 25,000 stapes surgeries which is more than anyone else in the world, and developed 54 different prostheses to make surgery even more efficient with better hearing results. He could do things surgically that some of us could not even dream of duplicating. Perhaps the most difficult time for him was when he sold his new clinic in Colombiers. Because he trusted everyone, he did not realize the consequences of selling the clinic without the advice of an attorney. The result was disastrous and it hurt him deeply. Perhaps the stress of this entire transaction began his illness. Strong to the core, he began a new clinic in Beziers in 1998 and his patients faithfully followed him there. He struck up again, performing 5 cases a day, until he really began to get ill in March. His father, Jean-Rene Causse,MD., was a prominent otologist and started a large Clinic in Beziers, France and performed 22,600 stapedectomies. He passed away 3 days before Jean Bernard at age 93. Jean Bernard spoke about retiring at the age of 60 to become a professional photographer, but that was not in his cards. Many of his pictures won prizes. He fought very hard to stay alive for nearly a year and with the help and support of his family and friends maintained as cheerful an outlook as was possible. Primary Amyloidosis is a horrible disease with no known cure. His son Jerome learned as much as possible about the disease so he could help find new treatments and better inform people. He tried to obtain the experimental agent human Interleukin6 from Japan, which may one day help treat this disease, but the drug came too late. At first, Jean Bernard tried to keep his illness a secret, but eventually he let me spread the word to his American friends. His wife, Isabel, son Jerome, and daughter Annabel stayed close and took care of him during his illness. He was very happy to have the support of his family during this difficult time. The funeral was held in a 12th century Cathedral in Beziers, France. He loved this place and used to take friends through its hallowed halls showing off the beautiful art inside. An estimated 700 people came to pay their respects to this great man and 2 priests gave a magnificent mass. One of the young priests compared Jean Bernard to John the Baptist. He was sent to earth to do his special work, and when that time was done, God called him home. Jean Bernard was at peace when he passed. Although he suffered physically more than anyone should, his mind was clear and his sense of humor never left. He is survived by his wife Isabel and his children, Jerome and Annabel. John Emmett poignantly said, “If this were the 16th century, he would surely be a Knight.” But, in my book, Jean Bernard was a King among men. With that note, I wish him good night, and God’s speed. He will forever reign in my heart as one of the greatest men on earth and my best friend. Dr. Causse became a Corresponding Member of the American Otological Society in 1995. Written by Herbert Silverstein, MD Ralph J. Caparosa, MD Sketch drawn by Mark Caparosa Ralph J. Caparosa, MD was born in Clairton, PA on February 8, 1924. He graduated from St. Vincent College and Long Island College of Medicine. He completed his internship and residency programs at Mercy Hospital in Pittsburg and served as a Captain in the U.S. Army. Dr. Caparosa was board certified in Otolaryngology. He later limited his practice to the subspecialty of Otology and Neurotology. He was a Clinical Professor of Otolaryngology at the University Of Pittsburg School Of Medicine and served on the staff at Pittsburg Eye and Ear Hospital. He also was on the staff at the Vetrans Adminstration Hospital, Mercy Hospital, Divine Providence Hospital, Braddock Hospital, Montefiore Hospital and South Side Hospital. He was a member of numerous professional organizations. He was recognized for his distinguished work as a medical educator as well as his 42 year commitment to Otology and Neurotology as a physician and surgeon. Dr. Caparosa was a kind and generous man who spent endless hours devoted to teaching and patient care. He received numerous teaching awards nationally and internationally for his work in 3-D presentations of surgical anatomy of the temporal bone. He was honored for distinguished service in educational programs by the American Academy of Otolaryngology. Dr. Caparosa died on May 9, 2001 at Forbes Hospice in Pittsburg, PA from complications following a cerebral hemorrhage. He is survived by his six children and 11 grandchildren. Ralph J. Caparosa, MD became and Active member of the American Otologic Society in 1972 and a Senior Member in 1992. This memorial was kindly supplied by Rosemary Caparosa Siegfried NEW MEMBERS Active Moises A. Arriaga, MD M. Jennifer Derebery, MD Karen J. Doyle, MD Joseph G. Feghali, MD Michael McGee, MD Terrence P. Murphy, MD Steven M. Parnes, MD Jay T. Rubinstein, MD Fred F. Telischi, MD Peter C. Weber, MD Corresponding Member Johannes J. Grote, MD Honorary Member Graeme M. Clark, MD