A perilymph fistula is an abnormal communication between the fluids surrounding the membranous labyrinth and the middle ear space. Because of the potential hazards of meningitis, permanent hearing loss, and occasionally incapacitating vestibular symptoms, early recognition and prompt repair of the perilymph leak is important. One hundred thirty three cases of perilymph fistulas are presented, stressing the clinical characteristics, evaluation, and management of patients with this otologic entity. The historical and contemporary literature on this subject is reviewed. A pathophysiological basis for perilymph fistula formation is presented, based upon certain anatomic, physiologic and mechanical principles involving the temporal bone and surrounding structures. For the purpose of publication, the Materials and Methods and Evaluation sections of the paper have been omitted. These are available from the author upon request in mimeographed form. The interested reader may wish to refer to items 80 and 133 in the Bibliography, previous publications by the author in which the bulk of the data used in the omitted sections can be found.
Review of a series of 2,307 stapedectomy procedures revealed five cases of delayed facial paralysis. The paralysis was clinically complete in three and incomplete in two cases. Onset of weakness occurred from five to 13 days postoperatively. Complete recovery occurred in all cases within eight weeks and surgical intervention was unnecessary. The cause of this uncommon complication is felt to be retrograde edema of the chorda tympani nerve into the facial trunk, or edema of a dehiscent facial nerve in the postoperative period. This phenomenon has not been stressed in the otologic literature to date. Careful evaluation of the patient, close follow‐up with nerve excitability testing in cases of complete paralysis, and steroid and vasodilator therapy is the recommended mode of management. Exploration and decompression of the facial nerve should be strongly considered if the nerve excitability threshold exceeds that of the normal side by 3.5 ma. or more, or should the stimulus threshold be lost altogether. With preservation of nerve excitability thresholds, the outlook for return of function is good, according to this small series.
Sodium fluoride ( NaFl) has the effect of changing active foci of otosclerosis to quiescence. Strontium86 (Sr86) was used to determine the rocess of calcium deposition in normal canal wall bone and in the foo lates of patients withtilateral otosclerosis before and Fragments from oval window bone initially showed up to 34 times as much radioactivity as fragments from canal wall bone. The patients then took 25 mg of NaFl daily for six months.None failed to close and maintain gap closure within 11 dB for five months. The same evaluation was done on the bone of the footplate after surgery on the second ear. There was little or no more radioactivity in the footplate bone than in the ear canal wall bone used as a control, indicating cessation or diminution of activity at the otosclerotic focus. Prior to initiating this study, other patients with familial, progressive, purely sensorineural loss showed little or no hearing loss progression after undergoing fluoride thera y. W e now recommend 25 mg daily for individuals with progressive hereditary sensorineuraf hearing loss and evidence of otosclerosis by polytomography.after the administration of NaFl. The 2 r st surgery was performed on the poorer hearing ear.
A technique for repairing small to medium-sized defects in the osseous posterior superior canal resulting from pathologic or iatrogenic causes is described. Bone pâte is harvested from the mastoid cortex by means of a simple collection technique. A sandwich graft composed of autologous temporalis fascia lined with bone pâte is used to fill in the canal wall defect. This technique has been used successfully in 27 of 28 cases, with follow-up as long as 8 years. When fully healed, the bone graft has attained the texture and consistency of the normal osseous canal and, if necessary, can be curetted or drilled for reshaping during planned second-stage tympanomastoid surgery. The temporalis fascia/bone pâte graft technique is simple, easy to learn, and has proven to be a reliable method for repairing the defects described.
Clinicians have been aware of the problem of post-stapedectomy perilymph fistulas for some time. The existence of non-surgical oval and round window fistulas has been known and was first described in detail by Fee in 1968. This paper concerns a small series of patients with spontaneous and traumatic perilymph fistulas. Five oval window fistulas and one round window fistula are reported. Clinical features, audiometric, radiographic and vestibular findings are discussed. The etiology of traumatic and spontaneous fistulas is not well understood, but seems to bear a relationship to sudden increased in intracranial pressure transmitted to the inner ear through the cochlear aqueduct. Middle ear pressure changes, as seen in acoustic or barotrauma, may also cause these leaks. Indications for surgery and techniques of perilymph fistula identification and repair are discussed in the paper. Surgical correction led to relief of vertigo in 80 percent of patients in this series, and significant hearing improvements were seen in 50 percent of the patients. In evaluating patients with sudden sensori-neural hearing loss, or persistent vestibular symptoms following head or ear trauma, the otologist should keep in mind the possibility of a perilymph fistula and actively investigate these patients. Evidence presented in this paper and in the literature suggest that identification and correction of spontaneous and traumatic perilymph fistulas can lead to resolution of vestibular symptoms and improved hearing in a significant number of patients with these lesions.
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