Dr. Jackler was raised in Waterville, Maine, attended college and medical school in Boston, and moved west to the University of California, San Francisco for residency in Otolaryngology-Head & Neck Surgery. After taking a Neurotology fellowship at the House Ear Clinic (1985), Dr Jackler joined the faculty at UCSF where he remained until 2003 when he become the Sewall Professor and Chair of the Department at OHNS and professor in the departments of Neurosurgery and Surgery at the Stanford University School of Medicine.

Dr. Jackler is an otologist-neurotologist who specializes in complex ear diseases. He has a special interest in tumors of the lateral and posterior cranial base and has written numerous analytical papers derived from his microsurgical series. A long standing collaboration with medical artist Chirstine Gralapp has produced over 1500 original illustrations of a wide variety of cranial base and ear microsurgical approaches ( For over 25 years Dr Jackler has directed a fellowship program in neurotology & skull base surgery which has trained a number of academic leaders in the field.

Dr Jackler has authored over 150 peer reviewed papers, over 35 textbook chapters, numerous editorials, published three books Neurotology (1994, 2004), Atlas of Neurotology & Skull Base Surgery –(1996, 2008), and Tumors of the Ear and Temporal Bone - 2000). Dr. Jackler leads the Stanford Initiative to Cure Hearing Loss whose mission is to create biological cures for major forms of inner ear hearing loss through a research effort that is sustained, large-scale, multidisciplinary, focused, goal–oriented, and transformational (

In 2007, Dr. Jackler and his wife Laurie founded the interdisciplinary research group SRITA (Stanford Research Into The Impact of Tobacco Advertising). SRITA conducts research the ways the tobacco industry targets teens, women, and African Americans as well as how recently introduced products such as electronic cigarettes are marketed. While the Jackler collection of over 30,000 original tobacco advertisements now resides in the National Museum of American History of the Smithsonian Institution, SRITA maintains an annotated online digital collection of over 28,000 tobacco advertisement for use by scholars ( and offers a traveling museum exhibit.

Clinical Focus

  • Acoustic Neuroma, Cerebellopontine Angle
  • Meningioma
  • Neurofibromatosis 2
  • Glomus Jugulare Tumor
  • Ear Neoplasms
  • Otosclerosis
  • Cholesteatoma
  • Facial Paralysis
  • Facial Nerve Tumor
  • Otolaryngology
  • Otolaryngology - Head & Neck Surgery (Ear, Nose and Throat)

Academic Appointments

Administrative Appointments

  • Associate Dean, Postgraduate Medical Education, School of Medicine (2007 - 2011)
  • Sewall Professor and Chair, Department of Otolaryngology-Head & Neck Surgery (2003 - Present)

Honors & Awards

  • Honorary Fellow, Royal College of Surgeons (London) (2012)
  • Honorary Fellow, Royal College of Surgeons (Edinburgh) (2005)
  • Honorary Member, French Society of ENT (1996)
  • Distinguished Service Award, American Academiy of Otolaryngology- Head & Neck Surgery (1999)

Professional Education

  • Residency:Univ of California San Francisco (1984) CA
  • Internship:Univ of California San Francisco (1980) CA
  • Board Certification: Neurotology, American Board of Otolaryngology (2004)
  • Fellowship:House Ear Institute (1985) CA
  • Board Certification: Otolaryngology, American Board of Otolaryngology (1984)
  • Medical Education:Boston University School of Medicine (1979) MA
  • MD, Boston Univ School of Medicine, Medicine (1979)
  • Residency, Univ California, SF, Otolaryngology - Head/Neck Surg (1984)
  • Fellowship, House Ear Institute, Neurotology (1985)

Research & Scholarship

Current Research and Scholarly Interests

SRITA: Stanford Research into the Impact of Tobacco Advertising

In 2007, I created a research team which studies the impact tobacco advertising, marketing, and promotion. Stanford Research into the Impact of Tobacco Advertising, known as SRITA, is an interdisciplinary collaboration involving faculty and trainees from medicine, history, and anthropology.

Over the last decade, Stanford Research into the Impact of Tobacco Advertising (SRITA) has built an online database of over 30,000 tobacco advertising images ( which over the last few years has had over 380,000 unique users. Our goal is to facilitate research into tobacco advertising and provide a resource to support the work of scholars, regulators, and advocates. As of April 2015, the online collection includes 18,598 tobacco, 10538 electronic cigarette, and 1140 anti-smoking advertisements. SRITA’s YouTube channel contains 178 tobacco and 157 electronic cigarette videos.The entire compendium of over 30,000 tobacco original tobacco advertisement, spanning 1890 through 2015, have been donated to the National Museum of American History at the Smithsonian Institution.

The advertisements have been organized into themes such as health claims (doctors hawking cigarettes, medicinal cigarettes), health reassurance (light, mild, low tar), appealing imagery (glamour, style), association with popular culture (music, art, sports), targeting (eg. youth, women, African Americans), sponsorships (eg. Olympic Games), cultural icons (religious symbols, motorcycles, family pets), reassuring names (True, Merit, Vantage), global village (Latin America, Asian, Europe) and numerous other categories.

The entire tobacco advertising database is searchable by a number of metadata fields. These include manufacturer (eg RJ Reynolds), brand (eg. Camel), campaign (eg. Joe Camel), theme (eg. targeting youth), date, and key words.

SRITA scholarship focuses upon analyzing the channels used in advertising (eg. print, web, point of sale), imagery (eg. glamour, health reassurance), association with popular culture (eg music, art, sports), targeting (eg. youth, women, African Americans), sponsorships (eg. Olympic Games) and how industry practice has adapted regulations intended to constrain its advertising practices.

Pathophysiology of Otological Diseases:

For many years, I have been engaged in the study of the pathophysiology of ear diseases, particularly when commonly held beliefs did not adequately explain the properties and behaviors of the disorder. When inner ear malformations were described by nineteen century eponyms and not considered with any harmonizing themes, I sought to rationalize their appearance by relating these anomalies to the embryology stages of the developing cochlea, semicircular canals, and vestibular & cochlear aqueducts. This system is now widely adopted.

The widely cited pathophysiological mechanism by which cholesterol granuloma of the petrous arise seemed implausible as similarly aggressive, bone-destroying lesions seldom occurred in other pneumatized locations. This led me to propose an exposed marrow theory which postulates that excrescent apical apical bone marrow was the source of ongoing hemorrhage which drives these lesion’s aggressive behavior. A number of other studies have published confirmatory evidence for this mechanism.

Cholesteatoma is a common acquired disease the ear. All existing theories postulate that changes in the squamous epithelium of the tympanic membrane underlie cholesteatoma formation. However, none of these theories satisfactorily explained the behavior of the disease. Seeking in alternative mechanism, I considered the possibility that cholesteatoma was fundamentally a mucosal disease driven by abnormalities in migration of the mucosa and/or its mucous blanket. Along with several colleagues, we undertook animal and epidemiological approaches led support to this postulated mechanism.

Clinical Trials

  • Subtotal Resection of Large Acoustic Neuromas With Possible Stereotactic Radiation Therapy Recruiting

    The investigators study is to investigate safety and efficacy of performing a planned incomplete removal of large acoustic neuroma tumors to decrease surgical morbidity and yet avoid tumor recurrence by post-operative radiation therapy.

    View full details


  • Electronic Cigarette Advertising and its Targeting of Youth, Stanford Research Into the Impact of Tobacco Advertising (9/26/2013 - 12/31/2015)

    We are in the midst a surge electronic cigarettes advertising which has resurrected methods long been prohibited in the marketing of tobacco products. The industry maintains that their primary intent is to recruit present cigarette smokers to convert to electronic cigarettes. However, their advertising content suggests that they also seek to recruit youthful starter smokers, adult non-smokers, and even to reclaim lapsed smokers. We plan to addresses three aims: 1. To systematically examine electronic cigarette advertising to determine the advertising methods used and their apparent targets; 2. To identify antecedent tobacco advertising campaigns which have been emulated in current electronic cigarette advertisements; and 3. To interpret electronic cigarettes advertising in relation fo federal (FTC, FDA) regulatory actions intended to constrain cigarette marketing.


    Stanford University

  • Tobacco Advertising Targeting of African Americans, Stanford Research Into the Impact of Tobacco Advertising (9/26/2013 - 1/31/2015)


    Stanford University

  • Electronic cigarette marketing via social media channels, Stanford University


    801 Welch road, Stanford, CA 94305


2017-18 Courses

Stanford Advisees

Graduate and Fellowship Programs


All Publications

  • In reference to Evidence against the mucosal traction theory in cholesteatoma. The Laryngoscope Jackler, R. K., Santa Maria, P. L., Blevins, N. H. 2018

    View details for DOI 10.1002/lary.27097

    View details for PubMedID 29392724

  • Promotion of tobacco products on Facebook: policy versus practice. Tobacco control Jackler, R. K., Li, V. Y., Cardiff, R. A., Ramamurthi, D. 2018


    Facebook has a comprehensive set of policies intended to inhibit promotion and sales of tobacco products. Their effectiveness has yet to be studied.Leading tobacco brands (388) were identified via Nielsen and Ranker databases and 108 were found to maintain brand-sponsored Facebook pages. Key indicators of alignment with Facebook policy were evaluated.Purchase links (eg, 'shop now' button) on brand-sponsored pages were found for hookah tobaccos (41%), e-cigarettes (74%), smokeless (50%) and cigars (31%). Sales promotions (eg, discount coupons) were present in hookah tobacco (48%), e-cigarette (76%) and cigar (69%) brand-sponsored pages. While conventional cigarettes did not maintain brand-sponsored pages, they were featured in 80% of online tobacco vendors' Facebook pages. The requirement for age gating, to exclude those <18 from viewing tobacco promotion, was absent in hookah tobacco (78%), e-cigarette (62%) and cigar (21%) brand-sponsored pages and for 90% of online tobacco stores which promote leading cigarette brands (eg, Marlboro, Camel). Many of the brand-sponsored tobacco product pages had thousands of 'likes'.It is laudable that Facebook has policies intended to interdict tobacco promotion throughout its platform. Nevertheless, widespread tobacco promotion and sales were found at variance with the company's policies governing advertising, commerce, page content and under age access. Vetting could be improved by automated screening in partnership with human reviewers.

    View details for DOI 10.1136/tobaccocontrol-2017-054175

    View details for PubMedID 29622602

  • Chordomas and Chondrosarcomas of the Skull Base: Transpetrosal Approaches CHORDOMAS AND CHONDROSARCOMAS OF THE SKULL BASE AND SPINE, 2ND EDITION Sevy, A. G., Jackler, R. K., Harsh, G. R., VazGuimaraes, F. 2018: 205–15
  • Chordomas and Chondrosarcomas of the Skull Base: Retrosigmoid Approaches CHORDOMAS AND CHONDROSARCOMAS OF THE SKULL BASE AND SPINE, 2ND EDITION Vaz-Guimaraes, F., Harsh, G. R., Jackler, R. K., Harsh, G. R., VazGuimaraes, F. 2018: 217–20
  • The American Otological Society at its Sesquicentennial: Insights Into the Society's Formative Years. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Jackler, R. K., Alyono, J. C., Mudry, A. C. 2018; 39 (4S Suppl 1): S1–S9


    To elucidate the sequence of events which led to the formation of the American Otological Society (AOS) in 1868 and to examine the lives and contributions of the nine founding members of the Society.Study of primary historical documents, biographical material, and previous histories of the AOS.Earlier treatments of the history of the AOS minimally covered the events and personalities from the Society's formative period. The founders of the AOS were much influenced by recent advances in European Otology and the success of the nascent American Ophthalmological Society which had been founded in 1864. The AOS has long credited Elkanah Williams as its first president of the AOS, although he never actually served in this role and was not a contributor to otological literature. Documents suggest that 30 years old New York physician Daniel Bennett St John Roosa, recently returned from a grand tour of the leading European otological centers, was the principal advocate for the creation of the AOS.The 1860s were a pivotal period in the maturation of American Otology. Previously, most "aurists" were widely considered to be charlatans who practiced unscientifically and often unscrupulously. The AOS founder generation were a group of Ophthalmologists who strove to elevate otology from being a lesser appendage of the mother field to becoming a respected and scientifically based medical specialty in its own right.

    View details for DOI 10.1097/MAO.0000000000001702

    View details for PubMedID 29342043

  • 'Addressed to you not as a smoker… but as a doctor': doctor-targeted cigarette advertisements in JAMA. Addiction (Abingdon, England) Jackler, R. K., Ayoub, N. F. 2018


    During the mid-20th century tobacco companies placed advertisements in medical journals to entice physicians to smoke their brand and, more importantly, to recommend it to their patients. They have been little studied, in part because advertising sections in medical journals are almost universally discarded before binding. This study aimed to define the themes and techniques used in doctor-targeted tobacco advertisements that appeared in American medical journals in the mid-20th century and determine the motivations and tactics of the tobacco industry in engaging the medical profession in this way.Doctor-targeted tobacco advertisements from JAMA and the New York State Medical Journal appearing between 1936 and 1953 were studied. These were obtained from the New York Academy of Medicine and the UCSF Truth database of tobacco industry documents. Content analysis of advertising slogans and imagery was conducted. Using internal tobacco industry documents, we examined the relationship between tobacco advertisers and medical journals.Among the 519 doctor-targeted advertisements, 13 brands were represented, with two (Philip Morris and Camel) accounting for 84%. Correspondence between tobacco advertisers and medical journal editors reveals the potent influence of revenue to the sponsoring society and personal compensation derived from consulting arrangements. Content analysis of the advertisements revealed much flattery of doctors and arguments professing the harmlessness of the company's brand.Analysis of doctor-targeted tobacco advertisements in American medical journals from 1936 to 1953 suggest that tobacco companies targeted physicians as a potential sales force to assuage the public's fear of health risks and to recruit them as allies against negative publicity. Tobacco companies also appeared to try, through the substantial advertising revenue passed by journals to their parent medical societies, to temper any possible opposition by organized medicine.

    View details for DOI 10.1111/add.14151

    View details for PubMedID 29417649

  • Practice of Otology During the First Quarter Century of the American Otological Society (1868-1893). Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Sioshansi, P. C., Jackler, R. K., Alyono, J. C. 2018; 39 (4S Suppl 1): S10–S29


    To describe the practice of otology in America during the first quarter century of the American Otological Society (AOS).Two sources were used to determine the most prevalent disease conditions cared for and surgical procedures undertaken during this era. All articles published in the AOS transactions between 1868 and 1893 were studied as were the otology textbooks published by 6 of the first 10 Presidents of the Society.The primary emphasis of late 19th century American otological scholarship was on chronic ear infection with numerous articles focusing on complications of otitis including frequent descriptions of fatalities. Much emphasis was placed upon the Eustachian tube with catheterization and insufflation a major part of otological practice. Due to limitations in technology, the overwhelming focus was on diseases of the ear canal and middle ear. Understanding of temporal bone anatomy was much superior to that of physiology. Erroneous speculations on the function of the middle and inner ear were common. Surgical interventions were largely limited to myringotomy and mastoidectomy, the latter of which was sometimes life saving during the preantibiotic era.The latter half of the 19th century saw the emergence of otology as a specialty in America and many emerging diagnostic and therapeutic advances were adopted. While capabilities were notably limited during this era, the efforts of a small band of pioneer otologists in the founder generation of the AOS contributed greatly to the progress of the emerging specialty.

    View details for DOI 10.1097/MAO.0000000000001706

    View details for PubMedID 29533373

  • Assessment of Hearing During the Early Years of the American Otological Society. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Fitzgerald, M. B., Jackler, R. K. 2018; 39 (4S Suppl 1): S30–S42


    To describe the manner in which hearing was evaluated in American Otological Practice during the late 19th and early 20th centuries before introduction of the electric audiometer.Primary sources were the Transactions of the American Otological Society and American textbooks, especially those authored by Presidents of the Society.In the era before electric audiometry multiple methods were used for evaluating the thresholds of different frequencies. Tuning forks were important for lower frequencies, whisper, and speech for mid-frequencies, and Galton's whistle and Konig's rod evaluated high frequencies. Hearing threshold was often recorded as in terms of duration of a sound, or distance from the source, rather than intensity. Hearing ability was often recorded a fraction, for example, with the distance a watch tick could be heard over the distance of a normal hearing individual. A variety of devices, such as Politzer's Acoumeter, attempted to deliver sound in a calibrated manner, thus enhancing the accuracy and reproducibility of test results.The early years of the American Otological Society were marked by a number of ingenious efforts to standardize hearing assessment despite the technical limitations. These efforts facilitated the development of the audiometer, and continue to influence clinical practice even today.

    View details for DOI 10.1097/MAO.0000000000001759

    View details for PubMedID 29533374

  • Women of the American Otological Society. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Alyono, J. C., Jackler, R. K., Chandrasekhar, S. S. 2018; 39 (4S Suppl 1): S69–S80


    To describe the history of women in the American Otological Society (AOS).Biographies of the early women of the AOS were compiled through review of the AOS transactions, their published scholarship, newspaper articles, and memorials. Interviews were conducted with the only two women to have led the society and also with former colleagues and family members of pioneering AOS women members who are no longer with us. The evolving gender composition of the society over time was researched from AOS membership lists and compared with data on surgical workforce composition from multiple sources such as the Association of American Medical Colleges, Accreditation Council for Graduate Medical Education, American Medical Association, and the American Academy of Otolaryngology-Head and Neck Surgery.Although American women specialized in otology as far back as 1895, the first woman to be invited to join the AOS as Associate member in 1961 was Dorothy Wolff, PhD. The first female full member was otologic surgeon LaVonne Bergstrom, M.D., who was elected in 1977, 109 years after the foundation of the Society. As of 2017, only two women have served as AOS President. The first was Aina Julianna Gulya, M.D., who took office during the 133rd year in 2001. At the time of the sesquicentennial (2017), 7.5% of AOS members are women including three of eight who serve on the AOS Council. This compares with 15.8% of women among the otolaryngology workforce and a growing 10.9% representation among those who have earned subcertification in neurotology.Gender disparities remain in the AOS, but both participation and scholarly contributions by women in otology have grown substantially since the society's inception 150 years ago, and particularly in the 21st century. Increasing the presence of women in leadership provides role models and mentorship for the future.

    View details for DOI 10.1097/MAO.0000000000001707

    View details for PubMedID 29533377

  • Reflections on the Last 25 Years of the American Otological Society and Thoughts on its Future. Otology & neurotology : official publication of the American Otological Society, American Neurotology Society [and] European Academy of Otology and Neurotology Welling, D. B., Jackler, R. K. 2018; 39 (4S Suppl 1): S81–S94


    To review contributions of the American Otological Society (AOS) over the most recent quarter century (1993-2018) and to comment on possible future evolution of the field during the quarter century to come.Retrospective review of selected topics from the AOS transactions, distinguished lectureships over the past 25 years, and selective reflection by the authors. Speculation on potential advances of the next quarter century derived from emerging topics in the current literature and foreseeable trends in science and technology are also proffered for consideration (and possible future ridicule).Integration of multiple disciplines including bioengineering, medical imaging, genetics, molecular biology, physics, and evidence based medicine have substantially benefitted the practice of otology over the past quarter century. The impact of the contributions of members of the AOS in these developments cannot be over estimated.Further scientific advancement will certainly accelerate change in the practice of otologic surgery and medicine over the coming decade in ways that will be marvelous to behold.

    View details for DOI 10.1097/MAO.0000000000001760

    View details for PubMedID 29533378


    View details for DOI 10.1097/MAO.0000000000001606

    View details for Web of Science ID 000425284200060

    View details for PubMedID 29065092

  • Alcohol-flavoured tobacco products. Tobacco control Jackler, R. K., VanWinkle, C. K., Bumanlag, I. M., Ramamurthi, D. 2017


    In 2009, the Food and Drug Administration (FDA) banned characterising flavours in cigarettes (except for menthol) due to their appeal to teen starter smokers. In August 2016, the agency deemed all tobacco products to be under its authority and a more comprehensive flavour ban is under consideration.To determine the scope and scale of alcohol-flavoured tobacco products among cigars & cigarillos, hookahs and electronic cigarettes (e-cigarettes).Alcohol-flavoured tobacco products were identified by online search of tobacco purveyors' product lines and via Google search cross-referencing the various tobacco product types versus a list of alcoholic beverage flavours (eg, wine, beer, appletini, margarita).48 types of alcohol-flavoured tobacco products marketed by 409 tobacco brands were identified. Alcohol flavours included mixed drinks (n=25), spirits (11), liqueurs (7) and wine/beer (5). Sweet and fruity tropical mixed drink flavours were marketed by the most brands: piña colada (96), mojito (66) and margarita (50). Wine flavours were common with 104 brands. Among the tobacco product categories, brands offering alcohol-flavoured e-cigarettes (280) were most numerous, but alcohol-flavoured products were also marketed by cigars & cigarillos (88) and hookah brands (41). Brands by major tobacco companies (eg, Philip Morris, Imperial Tobacco) were well represented among alcohol-flavoured cigars & cigarillos with five companies offering a total of 17 brands.The widespread availability of alcohol-flavoured tobacco products illustrates the need to regulate characterising flavours on all tobacco products.

    View details for DOI 10.1136/tobaccocontrol-2016-053609

    View details for PubMedID 28592404

  • Benign Temporomandibular Joint Lesions Presenting as Masses in the External Auditory Canal OTOLOGY & NEUROTOLOGY Williams, R. A., Jackler, R. K., Corrales, C. E. 2017; 38 (4): 563-571


    Describe benign lesions arising from the temporomandibular joint (TMJ) that presented as masses in the external auditory canal (EAC).Retrospective case series of two academic medical centers.Six patients with lesions emanating from the TMJ that presented as EAC masses. Lesions included pigmented villonodular synovitis (PVNS), nodular fasciitis, foramen of Huschke herniation with salivary fistula, fibroepithelial polyp, superficial angiomyxoma, and giant cell tumor (GCT).Surgical resection.Tumor control, TMJ function, and hearing.All patients presented with hearing loss, TMJ pain, and otalgia. Three patients with EAC occluding masses developed entrapment cholesteatoma between the mass and tympanic membrane. Following surgical resection, four patients were free of disease. The patient with PVNS has a stable remnant at 3 years follow up and the patient with giant cell tumor is under active surveillance. Hearing improved in three patients, remained stable in one patient, and worsened in two patients. All had resolution of their TMJ and ear pain.EAC masses of uncertain origin should be imaged preoperatively to exclude lesions best not biopsied (e.g., encephalocele, facial nerve schwannoma, paraganglioma). In the differential of EAC masses, lesions emanating from the TMJ need to be considered, especially for those based anteriorly. Understanding the extent of TMJ involvement is crucial for surgical planning which optimizes outcome. Goals for therapy are to control the underlying disease process, restore patency of the EAC, improve hearing, and preserve function of TMJ.

    View details for DOI 10.1097/MAO.0000000000001354

    View details for Web of Science ID 000397773100019

    View details for PubMedID 28288478

  • Leading-Brand Advertisement of Quitting Smoking Benefits for E-Cigarettes. American journal of public health Ramamurthi, D., Gall, P. A., Ayoub, N., Jackler, R. K. 2016; 106 (11): 2057-2063


    To provide regulators and the US Food and Drug Administration with a description of cessation-themed advertising among electronic cigarette (e-cigarette) brands.We performed a content analysis of 6 months (January through June 2015) of advertising by e-cigarette brands on their company-sponsored social media channels and blogs as well as user-generated content (testimonials) appearing within brand-sponsored Web sites. An explicit claim of cessation efficacy unambiguously states that e-cigarettes help in quitting smoking, and implicit claims use euphemisms such as "It works." We selected a cohort of 23 leading e-cigarette brands, either by their rank in advertising spending or their prevalence in Internet searches.Among leading e-cigarette brands, 22 of 23 used cessation-themed advertisements. Overall, 23% of the advertisements contained cessation claims, of which 18% were explicit and 82% were implicit.Among leading e-cigarette advertisers, cessation themes are prevalent with implicit messaging predominating over explicit quit claims.These results can help the Food and Drug Administration clarify whether tobacco products should be regulated as drugs with therapeutic purpose or as recreational products.

    View details for PubMedID 27631743

  • Perpetuation of errors in illustrations of cranial nerve anatomy. Journal of neurosurgery Eduardo Corrales, C., Mudry, A., Jackler, R. K. 2016: 1-7


    For more than 230 years, anatomical illustrations have faithfully reproduced the German medical student Thomas Soemmerring's cranial nerve (CN) arrangement. Virtually all contemporary atlases show the abducens, facial, and vestibulocochlear nerves (CNs VI-VIII) all emerging from the pontomedullary groove, as originally depicted by Soemmerring in 1778. Direct observation at microsurgery of the cerebellopontine angle reveals that CN VII emerges caudal to the CN VIII root from the lower lateral pons rather than the pontomedullary groove. Additionally, the CN VI root lies in the pontomedullary groove caudal to both CN VII and VIII in the vast majority of cases. In this high-resolution 3D MRI study, the exit location of CN VI was caudal to the CN VII/VIII complex in 93% of the cases. Clearly, Soemmerring's rostrocaudal numbering system of CN VI-VII-VIII (abducens-facial-vestibulocochlear CNs) should instead be VIII-VII-VI (vestibulocochlear-facial-abducens CNs). While the inaccuracy of the CN numbering system is of note, what is remarkable is that generations of authors have almost universally chosen to perpetuate this ancient error. No doubt some did this through faithful copying of their predecessors. Others, it could be speculated, chose to depict the CN relationships incorrectly rather than run contrary to long-established dogma. This study is not advocating that a universally recognized numbering scheme be revised, as this would certainly create confusion. The authors do advocate that future depictions of the anatomical arrangements of the brainstem roots of CNs VI, VII, and VIII ought to reflect actual anatomy, rather than be contorted to conform with the classical CN numbering system.

    View details for PubMedID 27791521

  • Unicorns cartoons: marketing sweet and creamy e-juice to youth. Tobacco control Jackler, R. K., Ramamurthi, D. 2016

    View details for DOI 10.1136/tobaccocontrol-2016-053206

    View details for PubMedID 27543562

  • Facial Nerve Outcome and Tumor Control Rate as a Function of Degree of Resection in Treatment of Large Acoustic Neuromas: Preliminary Report of the Acoustic Neuroma Subtotal Resection Study (ANSRS) NEUROSURGERY Monfared, A., Corrales, C. E., Theodosopoulos, P. V., Blevins, N. H., Oghalai, J. S., Selesnick, S. H., Lee, H., Gurgel, R. K., Hansen, M. R., Nelson, R. F., Gantz, B. J., Kutz, J. W., Isaacson, B., Roland, P. S., Amdur, R., Jackler, R. K. 2016; 79 (2): 194-200


    Patients with large vestibular schwannomas are at high risk of poor facial nerve (cranial nerve VII [CNVII]) function after surgery. Subtotal resection potentially offers better outcome, but may lead to higher tumor regrowth.To assess long-term CNVII function and tumor regrowth in patients with large vestibular schwannomas.Prospective multicenter nonrandomized cohort study of patients with vestibular schwannoma ≥2.5 cm who received gross total resection, near total resection, or subtotal resection. Patients received radiation if tumor remnant showed signs of regrowth.Seventy-three patients had adequate follow-up with mean tumor diameter of 3.33 cm. Twelve received gross total resection, 22 near total resection, and 39 subtotal resection. Fourteen (21%) remnant tumors continued to grow, of which 11 received radiation, 1 had repeat surgery, and 2 no treatment. Four of the postradiation remnants (36%) required surgical salvage. Tumor regrowth was related to non-cystic nature, larger residual tumor, and subtotal resection. Regrowth was 3 times as likely with subtotal resection compared to gross total resection and near total resection. Good CNVII function was achieved in 67% immediately and 81% at 1-year. Better immediate nerve function was associated with smaller preoperative tumor size and percentage of tumor left behind on magnetic resonance image. Degree of resection defined by surgeon and preoperative tumor size showed weak trend toward better late CNVII function.Likelihood of tumor regrowth was 3 times higher in subtotal resection compared to gross total resection and near total resection groups. Rate of radiation control of growing remnants was suboptimal. Better immediate but not late CNVII outcome was associated with smaller tumors and larger tumor remnants.CNVII, cranial nerve VIIGTR, gross total resectionHB, House-BrackmannMRI, magnetic resonance imageNTR, near total resectionSTR, subtotal resection.

    View details for DOI 10.1227/NEU.0000000000001162

    View details for Web of Science ID 000382335100019

    View details for PubMedID 26645964

  • Ossicular calisthenics: Pneumomassage of the tympanic membrane LARYNGOSCOPE Mudry, A., Maria, P. S., Jackler, R. K. 2016; 126 (5): 1180-1186


    Throughout the latter portion of the 19th and early 20th centuries, pneumomassage devices were widely used by otologists to treat a variety of ear diseases. The so-called eardrum massagers produced a regular, repetitive, oscillatory movement through modifying the air pressure in the ear canal. The goal of this study was to trace the invention, clinical use, technological diversification, abandonment, and ultimate resurrection of tympanic pneumomassage.Review of the 19th- and early 20th-century medical journals, texts, and trade catalogs concerning the tympanic pneumomassage.In 1884, the Belgian otologist Charles Delstanche introduced what he called a rarefacteur, and 5 years later he introduced the masseur du tympan. This lead to a frenzied development of imaginative mechanical and electrical pneumassagers with a goal to exercise the tympanic membrane and ossicles to overcome contraction and rigidity. Tympanic pneumomassage rose to prominence in mainstream otology as a treatment for otitis media, chronic deafness, and tinnitus. After gradually fading out of the otological practice by the 1930s, pneumomassage was reintroduced in the 1980s after a half century of obscurity, this time as a novel invention notably for the treatment of Menière's disease.The golden era of pneumomassage illustrates the ingenuity of otologists and medical instrument makers in creating a proliferation of clever devices, as well as how highly touted treatment methods may become widely adopted by practitioners despite the lack of efficacy. It also noteworthy that historic therapeutic methods are sometimes reintroduced for purposes not envisioned by their original makers.N/A. Laryngoscope, 2015.

    View details for DOI 10.1002/lary.25556

    View details for Web of Science ID 000374769400036

    View details for PubMedID 26421977

  • Iatrogenic Phenol Injury Causing Facial Paralysis With Tympanic Membrane and Ossicular Necrosis OTOLOGY & NEUROTOLOGY Maria, P. L., Corrales, C. E., Sevy, A. B., Jackler, R. K. 2016; 37 (4): 385-387


    To describe a serious iatrogenic injury and propose means of reducing the risk of its reoccurrence.A 21-year-old man who suffered facial paralysis, complete necrosis of the tympanic membrane, and ossicular discontinuity because of chemical burn from accidental application of copious amounts of topical anesthetic phenol into the ear.Conservative management of facial paralysis and delayed reconstruction of the tympanic membrane and ossicular chain.Gradual recovery to grade 1/6 facial function, successful repair of the tympanic membrane, but persistent 30-dB conductive hearing loss after partial ossicular replacement prosthesis presumably because of scarring.Phenol is a highly toxic chemical, topically to both skin and eyes. Absorbed through the skin it can have lethal cardiotoxicity. It is also potent neurotoxin at concentrations much lower (4-7%) than used for tympanic membrane anesthesia (89%) and has long been used therapeutically to destroy nerves in patients of contractions or intractable pain. Otologists need to have a healthy respect for the dangers of using phenol. As only a minute quantity is needed for tympanic anesthesia, commercially available prepackaged applicators are preferred. Storage of stock bottles of 89% phenol solutions in clinical settings risks injury to both patients and practitioners.

    View details for DOI 10.1097/MAO.0000000000000979

    View details for Web of Science ID 000374881000016

    View details for PubMedID 26927759

  • In response to a new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope Jackler, R. K., Maria, P. L., Varsak, Y. K., Blevins, N. H., Nguyen, A. 2016; 126 (3): E131-?

    View details for DOI 10.1002/lary.25654

    View details for PubMedID 26372503

  • In reference to A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope Jackler, R. K., Santa Maria, P. L., Varsak, Y. K., Blevins, N. H., Nguyen, A. 2016; 126 (1): E50-?

    View details for DOI 10.1002/lary.25542

    View details for PubMedID 26267761

  • New Web-Based Tool for Generating Scattergrams to Report Hearing Results. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Oghalai, J. S., Jackler, R. K. 2016; 154 (6): 981

    View details for DOI 10.1177/0194599816638314

    View details for PubMedID 27251009

  • Testimony by Otolaryngologists in Defense of Tobacco Companies 2009-2014 LARYNGOSCOPE Jackler, R. K. 2015; 125 (12): 2722-2729

    View details for DOI 10.1002/lary.25432

    View details for Web of Science ID 000367187700028

  • Electronic cigarette marketers manipulate antitobacco advertisements to promote vaping. Tobacco control Ramamurthi, D., Fadadu, R. P., Jackler, R. K. 2015

    View details for DOI 10.1136/tobaccocontrol-2015-052661

    View details for PubMedID 26546153

  • Inflammatory Pseudotumors of the Skull Base: Meta-Analysis OTOLOGY & NEUROTOLOGY Alyono, J. C., Shi, Y., Berry, G. J., Recht, L. D., Harsh, G. R., Jackler, R. K., Corrales, C. E. 2015; 36 (8): 1432-1438


    To describe the presentation, treatment, and outcome of inflammatory pseudotumors (IPs) of the skull base.English-language articles in PubMed, Web of Science, and EMBASE from earliest available through April 2014.Articles were identified using a keyword search for "inflammatory pseudotumor," "inflammatory myofibroblastoma," or "plasma cell granuloma," including a keyword localizing to the skull base.One hundred papers with 157 cases met inclusion criteria. History, tumor site, initial and subsequent treatment, outcomes, and complications were extracted. Student t test, z test, and analysis of variance were used to analyze demographics, symptoms, sites involved, and outcomes. Odds ratios for site versus initial treatment were calculated.At diagnosis, average patient age was 41 years. Approximately 70% of lesions primarily involved the anterior skull base, 29% the lateral skull base, and 1.2% the occiput. The most common initial treatments were steroids (44%), surgery (28%), and surgery with steroids (16%). Anterior lesions were 55.8 times more likely than lateral lesions to be treated initially with steroids (CI, 14.7-212). Seventy-six percent of patients had stable or resolved symptoms after a single course of treatment.Diagnosis of skull base IP requires ruling out other aggressive pathologies, such as malignancy and infection, and maintaining a high index of suspicion. Surgery is favored for lesions that can be removed in toto with minimal morbidity, as well as steroids for those sites where anatomy limits complete resection, such as within the orbit, cavernous sinus, or brain. An option for larger lesions involving vital anatomy is debulking, followed by postoperative steroids.

    View details for DOI 10.1097/MAO.0000000000000818

    View details for Web of Science ID 000360488000023

  • A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction. Laryngoscope Jackler, R. K., Santa Maria, P. L., Varsak, Y. K., Nguyen, A., Blevins, N. H. 2015; 125: S1-S14


    Although the migration of its squamous outer surface of the tympanic membrane has been well characterized, there is a paucity of data available concerning the migratory behavior of its medial mucosal surface. Existing theories of primary acquired cholesteatoma pathogenesis do not adequately explain the observed characteristics of the disease. We propose a new hypothesis, based upon a conjecture that mucosal membrane interactions are the driving force in cholesteatoma.A retrospective chart review and a prospective observational cohort study in rats.After developing the new theory, it was tested through both clinical and experimental observations. To evaluate whether impairment of middle ear mucociliary migration would influence cholesteatoma formation, a retrospective chart review evaluating cholesteatoma occurrence in a sizable population of patients with either primary ciliary dyskinesia (PCD) or cystic fibrosis (CF) was performed. To study mucosal migration on the medial aspect of the tympanic membrane, ink tattoos were monitored over time in a rat model.No cholesteatomas were identified in either PCD patients (470) or in CF patients (1,910). In the rat model, mucosa of the posterior pars tensa migrated toward the posterior superior quadrant, whereas the mucosa of the anterior pars tensa migrated radially toward the annulus.Mucosal coupling with traction generated by interaction of migrating opposing surfaces provides the first comprehensive theory that explains the observed characteristics of primary acquired cholesteatoma. The somewhat counterintuitive hypothesis that cholesteatoma is fundamentally a mucosal disease has numerous therapeutic implications.4. Laryngoscope, 125:S1-S14, 2015.

    View details for DOI 10.1002/lary.25261

    View details for PubMedID 26013635

  • A new theory on the pathogenesis of acquired cholesteatoma: Mucosal traction LARYNGOSCOPE Jackler, R. K., Maria, P. L., Varsak, Y. K., Anh Nguyen, A., Blevins, N. H. 2015; 125: S1-S14


    Although the migration of its squamous outer surface of the tympanic membrane has been well characterized, there is a paucity of data available concerning the migratory behavior of its medial mucosal surface. Existing theories of primary acquired cholesteatoma pathogenesis do not adequately explain the observed characteristics of the disease. We propose a new hypothesis, based upon a conjecture that mucosal membrane interactions are the driving force in cholesteatoma.A retrospective chart review and a prospective observational cohort study in rats.After developing the new theory, it was tested through both clinical and experimental observations. To evaluate whether impairment of middle ear mucociliary migration would influence cholesteatoma formation, a retrospective chart review evaluating cholesteatoma occurrence in a sizable population of patients with either primary ciliary dyskinesia (PCD) or cystic fibrosis (CF) was performed. To study mucosal migration on the medial aspect of the tympanic membrane, ink tattoos were monitored over time in a rat model.No cholesteatomas were identified in either PCD patients (470) or in CF patients (1,910). In the rat model, mucosa of the posterior pars tensa migrated toward the posterior superior quadrant, whereas the mucosa of the anterior pars tensa migrated radially toward the annulus.Mucosal coupling with traction generated by interaction of migrating opposing surfaces provides the first comprehensive theory that explains the observed characteristics of primary acquired cholesteatoma. The somewhat counterintuitive hypothesis that cholesteatoma is fundamentally a mucosal disease has numerous therapeutic implications.4. Laryngoscope, 125:S1-S14, 2015.

    View details for DOI 10.1002/lary.25261

    View details for Web of Science ID 000358374200001

  • Imaging Innovations in Temporal Bone Disorders OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Corrales, C. E., Fischbein, N., Jackler, R. K. 2015; 48 (2): 263-?

    View details for DOI 10.1016/j.otc.2014:12.002

    View details for Web of Science ID 000352518300003

    View details for PubMedID 25769351

  • Imaging innovations in temporal bone disorders. Otolaryngologic clinics of North America Corrales, C. E., Fischbein, N., Jackler, R. K. 2015; 48 (2): 263-280


    The development of new imaging techniques coupled with new treatment algorithms has created new possibilities in treating temporal bone diseases. This article provides an overview of recent imaging innovations that can be applied to temporal bone diseases. Topics covered include the role of magnetic resonance (MR) diffusion-weighted imaging in cholesteatomas and skull base epidermoids, whole-body molecular imaging in paragangliomas of the jugular foramen, and MR arterial spin labeling perfusion for dural arteriovenous fistulas and arteriovenous malformations.

    View details for DOI 10.1016/j.otc.2014.12.002

    View details for PubMedID 25769351

  • Testimony by otolaryngologists in defense of tobacco companies 2009-2014. The Laryngoscope Jackler, R. K. 2015


    To examine expert testimony offered by otolaryngologists in defense of the tobacco industry and to assess whether opinions rendered were congruent with evidence in the scientific literature.Data sources include publically available expert witness depositions and trial testimony of board-certified otolaryngologists employed by the tobacco industry in defense of lawsuits brought by smokers suffering from head and neck cancer. The cases, adjudicated in Florida between 2009 and 2014, focused on whether smoking caused the plaintiff's cancer.The study includes nine legal cases of upper aerodigestive tract cancer involving six otolaryngologists serving as expert witnesses for the tobacco industry. Cancer sites included larynx (5), esophagus (2), mouth (1), and lung (1). Five of the six otolaryngologists consistently, over multiple cases, offered opinions that smoking did not cause the plaintiff's cancer. By highlighting an exhaustive list of potential risk factors, such as human papillomavirus (HPV), alcohol, asbestos, diesel fumes, salted fish, mouthwash, and even urban living, they created doubt in the minds of the jurors as to the role of smoking in the plaintiff's cancer. Evidence shows that this testimony, which was remarkably similar across cases, was part of a defense strategy shaped by tobacco's law firms.A small group of otolaryngologists regularly serve as experts on behalf of the tobacco industry. Examination of their opinions in relation to the scientific literature reveals a systematic bias in interpreting the data relating to the role played by smoking in head and neck cancer causation.N/A. Laryngoscope, 2015.

    View details for DOI 10.1002/lary.25432

    View details for PubMedID 26186270

  • 203 Seven-year update of multicenter prospective study of large vestibular schwannomas: acoustic neuroma subtotal resection study. Neurosurgery Monfared, A., Corrales, E., Theodosopoulos, P. V., Blevins, N., Oghali, J. S., Selesnick, S. H., Lee, H., Gurgel, R., Hansen, M., Nelson, R. F., Gantz, B., Kutz, W., Isaacson, B., Roland, P., Amdur, R., Jackler, R. 2014; 61: 228-?


    Patients with large acoustic neuromas are at high risk of poor facial nerve (CNVII) function following surgery. Subtotal resection has the potential for better facial nerve outcome but higher tumor recurrence.Patients with acoustic neuromas = 2.5 cm underwent gross total (GTR), near total (NTR) with remnant tumor no larger than 0.5 cm on postoperative magnetic resonance imaging (MRI) or 2 × 2 × 5 mm residual in surgery, or subtotal (STR) resection defined as any larger remnant. Patients received stereotactic radiation if tumor remnant grew.Of 132 enrolled patients, 73 had at least 1-year follow-up (mean 38 months). Average age was 48.7 years, mean tumor diameter was 3.33 cm, and 34% were cystic. As defined by postoperative MRI, 12 had GTR, 22 NTR, and 39 STR. There were 14 (21%) recurrences, 1 (8%) in GTR, 2 (9%) in NTR, and 11 (28%) in STR groups with average of 35 months to recurrence (4-74 months). The recurrences were treated with SRT in 11 cases, intensity-modulated radiation therapy in 1 case, and surgery in 2 cases due to size and cystic nature of recurrence. Four post-radiation remnants (33%) continued to grow and required surgical salvage. Tumor recurrence was related to longer follow-up, non-cystic tumor, larger residual tumor, and STR resection. Good facial nerve function (House-Brackmann I and II) was achieved in 67% immediately and 81% at 1-year from surgery. Better immediate but not late nerve function was associated with smaller preoperative tumor size and residual tumor left behind.Less-than-total resection of large acoustic neuromas allows for excellent facial nerve outcomes; however, the rate of persistent growth is inversely proportional to the size of residual tumor. Growing tumor remnants may be treated effectively with stereotactic radiation, though about 1/3 of tumors may still require surgical salvage. The NTR group had slightly better CNVII outcome compared to GTR without increased risk of recurrence.

    View details for DOI 10.1227/01.neu.0000452477.59065.43

    View details for PubMedID 25032654

  • Facial nerve schwannomas presenting as occluding external auditory canal masses: a therapeutic dilemma. Otology & neurotology Alyono, J. C., Corrales, C. E., Gurgel, R. K., Blevins, N., Jackler, R. K. 2014; 35 (7): 1284-1289


    To present a series of patients with facial nerve schwannomas (FNSs) presenting as occluding external auditory canal (EAC) masses.Retrospective case series.Four patients were identified with mastoid segment FNSs occluding the EAC. Three patients presented with conductive hearing loss (CHL), and the fourth presented with facial paralysis, later developing CHL.One patient underwent conservative debulking, removing the EAC component only. Two patients were managed nonoperatively with periodic cleaning of entrapped keratin. The fourth patient received radiation therapy.Facial nerve function, canal cholesteatoma formation, and hearing.Among the patients managed with serial cleaning of entrapped keratin, one maintained normal facial function and one worsened to House-Brackmann II/VI. Facial function worsened to House-Brackmann II/VI in the patient who underwent surgical debulking. The fourth patient, who received radiation, developed complete facial paralysis. All patients accumulated keratin medial to the tumor, and all had CHL.When evaluating an EAC tumor, it is important to obtain imaging before biopsy because biopsy of a schwannoma can result in paralysis. EAC occlusion by a schwannoma presents a challenging management issue, particularly when cholesteatoma forms between the tumor and the tympanic membrane. The primary goal is maintaining normal facial function as long as possible and avoiding secondary ear canal complications. The presence of canal occlusion limits the choice of stereotactic radiation because this leads to a month-long period of tumor swelling and cutaneous sloughing. Resection and grafting are indicated when substantial facial weakness or twitch develops.

    View details for DOI 10.1097/MAO.0000000000000398

    View details for PubMedID 24853246

  • Revisiting Max Brödel's 1939 Classic Coronal Illustration of the Ear. Otology & neurotology Jackler, R. K., Gralapp, C. L., Mudry, A. 2014; 35 (3): 555-560


    To create an anatomically more accurate coronal schematic illustration of the ear.Analysis of Max Brödel's 1939 classic coronal depiction of the ear including the story of its creation. Utilization of high-resolution CT images and 3D digital models of the temporal bone to create an updated and more anatomically accurate illustration.For nearly 7 decades, Brödel's beautiful illustration has served as the inspiration for innumerable textbook and article illustrations. In his design, the artist intentionally choose to diverge from literal anatomy in that he distorted some structures (such as the cochlea and posterior semicircular canal) to bring them into greater prominence and clarity and eliminated others (such as the carotid artery) to avoid a cluttered image. Numerous anatomic errors exist such as a 180-degree reversal of the incus and a markedly foreshortened internal auditory canal.Brödel's illustration has been routinely imitated by subsequent illustrators (in collaboration with otologists) and virtually all have faithfully reproduced Brödel's artistic distortions and inadvertent errors in their depictions-often with the assumption that they represented actual anatomy rather than an artistic interpretation. It is hoped that adoption of a more anatomically accurate standard coronal schematic of the ear will enhance the clarity and precision of future illustrations in the otologic literature.

    View details for DOI 10.1097/MAO.0000000000000207

    View details for PubMedID 24509612

  • Otolaryngology: "It's All Greek to Me". Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Jackler, R. K., Mudry, A. 2014; 150 (3): 337-341


    This study explores the origins and evolution of the specialty name for what is now primarily known in the English-speaking world as otolaryngology-head and neck surgery. This appellation is the longest and least pronounceable of all medical specialties. While it is reasonably well understood among medical professionals, surveys show that only a small fraction of health consumers understand its meaning. The ideal medical specialty name should have a meaning recognizable to a large segment of the public, be easily pronounceable, be reasonably short, and serve to communicate the type of illnesses treated. The cumbersomeness of the specialty name has led to nearly universal use of informal substitutes, which do not covey the scope of contemporary practice (eg, ear, nose, and throat) and to abbreviations (eg, ENT, ORL, OHNS). Based on the commercial experience, it is clear that shorter is better. The authors advocate that dialog be opened, guided by the experience from instances of successful corporate rebranding, to consider possible alternatives.

    View details for DOI 10.1177/0194599813514366

    View details for PubMedID 24316790

  • Re: Local versus general anesthesia for stapes surgery. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery Corrales, C. E., Jackler, R. K. 2013; 149 (6): 963-?

    View details for DOI 10.1177/0194599813509216

    View details for PubMedID 24259345

  • Recurrent contralateral hearing loss after 2 craniotomies for vestibular schwannoma: etiologic implications. Otology & neurotology Bliss, M. R., Jackler, R. K., Gurgel, R. K. 2013; 34 (7): 1237-1240


    To describe recurrent sudden sensorineural hearing loss after contralateral vestibular schwannoma resection and re-resection.Clinical capsule report.Tertiary academic referral hospital.A patient who underwent 2 craniotomies for vestibular schwannoma.In 2003, a patient experienced contralateral low-frequency sensorineural hearing loss after undergoing translabyrinthine resection of a vestibular schwannoma. This resolved after a course of oral steroids. Seven years later, in 2010, the patient developed tumor recurrence. After retrosigmoid resection, the patient experienced a similar episode of transient, contralateral, low-frequency predominant sensorineural hearing loss.The recurrence of contralateral hearing loss after craniotomies years apart suggests that patient specific anatomic risk factors predispose an individual to hearing loss after contralateral cerebellopontine angle surgery. Patients with previous history of contralateral hearing loss should be counseled that they may be at increased risk for recurrent loss in the setting of re-resection.

    View details for DOI 10.1097/MAO.0b013e318298dedc

    View details for PubMedID 23921925

  • A New Standardized Format for Reporting Hearing Outcome in Clinical Trials OTOLARYNGOLOGY-HEAD AND NECK SURGERY Gurgel, R. K., Jackler, R. K., Dobie, R. A., Popelka, G. R. 2012; 147 (5): 803-807


    The lack of an adequate standardized method for reporting level of hearing function in clinical trials has hampered the ability of investigators to draw comparisons across studies. Variability in data reported and presentation format inhibits meta-analysis and makes it impossible to accumulate the large patient cohorts needed for statistically significant inference. Recognizing its importance to the field and after a widely inclusive discussion, the Hearing Committee of the American Academy of Otolaryngology-Head and Neck Surgery endorsed a new minimal standard for reporting hearing results in clinical trials, consisting of a scattergram relating average pure-tone threshold to word recognition score. Investigators remain free to publish their hearing data in any format they believe is interesting and informative, as long as they include the minimal data set to facilitate interstudy comparability.

    View details for DOI 10.1177/0194599812458401

    View details for Web of Science ID 000314285800001

    View details for PubMedID 22931898

  • Rehabilitation of Central Facial Paralysis With Hypoglossal-Facial Anastomosis OTOLOGY & NEUROTOLOGY Corrales, C. E., Gurgel, R. K., Jackler, R. K. 2012; 33 (8): 1439-1444


    To evaluate the ability of hypoglossal-facial nerve anastomosis to reanimate the face in patients with complete nuclear (central) facial nerve palsy.Retrospective case series.Tertiary academic medical center.Four patients with complete facial nerve paralysis due to lesions of the facial nucleus in the pons caused by hemorrhage due to arteriovenous or cavernous venous malformations, stroke, or injury after tumor resection.All patients underwent end-to-end hypoglossal-facial nerve anastomosis.Facial nerve function using the House-Brackmann (HB) scale and physical and social/well-being function using the facial disability index.The mean age of the patients was 53.3 years (range, 32-73). There were 3 female and 1 male patients. All patients had preoperative facial function HB VI/VI. With a minimum of 12 months' follow-up after end-to-end hypoglossal-facial anastomosis, 75% of patients regained function to HB grade III/VI, and 25% had HB grade IV/VI. Average facial disability index scores were 61.25 for physical function and 78 for social/well-being, comparable to results from complete hypoglossal-facial anastomosis after peripheral facial nerve palsy after acoustic neuroma resection.Patients with nuclear facial paralysis who undergo end-to-end hypoglossal-facial nerve anastomosis achieve similar degrees of reanimation compared with those with peripheral facial nerve palsies. This raises the intriguing possibility that reinnervation may also be of benefit in patients with the vastly more common facial dysfunction because of cortical stroke or injury.

    View details for DOI 10.1097/MAO.0b013e3182693cd0

    View details for Web of Science ID 000309113900030

    View details for PubMedID 22935815

  • Subtotal/near-total treatment of vestibular schwannomas CURRENT OPINION IN OTOLARYNGOLOGY & HEAD AND NECK SURGERY Gurgel, R. K., Theodosopoulos, P. V., Jackler, R. K. 2012; 20 (5): 380-384


    The review evaluates current literature on subtotal and near-total resection of vestibular schwannomas.Recent findings suggest that subtotal and near-total resection of vestibular schwannomas can be performed to improve facial nerve outcomes. This is particularly true for large tumors. Whereas postoperative facial nerve function is likely improved by partial resection, recurrence rates are higher, although they vary depending on the extent of resection. If a tumor remnant grows following partial resection, the small-volume remnant can be treated with stereotactic radiation with good tumor control rates.Subtotal and near-total resection of vestibular schwannomas is a reasonable surgical paradigm for vestibular schwannomas which cannot be completely removed without injuring the facial nerve. Whereas facial nerve outcomes are more favorable in partial resections, the risk of recurrence increases and is proportional to the volume of residual tumor.

    View details for DOI 10.1097/MOO.0b013e328357b220

    View details for Web of Science ID 000308831500006

    View details for PubMedID 22954813

  • Radiographic Evaluation of the Tegmen in Patients With Superior Semicircular Canal Dehiscence OTOLOGY & NEUROTOLOGY Nadaraja, G. S., Gurgel, R. K., Fischbein, N. J., Anglemyer, A., Monfared, A., Jackler, R. K., Blevins, N. H. 2012; 33 (7): 1245-1250


    To determine a radiographic association between superior semicircular canal dehiscence (SSCD) and tegmen dehiscence (TD).Retrospective case-control series.Tertiary referral center.Patients seen between 2003 and 2010 with radiographic SSCD were compared with cochlear implant recipient controls.The tegmen and superior semicircular canal were evaluated on computed tomographic temporal bone scans.If detected, the widest point of the SSCD was measured. The tegmen was graded on a 5-point scale. After analysis, a radiographic TD was defined as any single area of absent tegmen greater than 5 mm, multiple areas of absent tegmen, or evidence of meningocele. Age, sex, and body mass index were also noted.Thirty-eight patients with SSCD and 41 cochlear implant controls were identified. Seventy-six percent (29/38) of patients with unilateral or bilateral SSCD had a radiographic TD on at least 1 side compared with 22% (9/41) of the comparison group. Ninety-four percent (7/18) of patients with bilateral SSCD had a TD on at least 1 side. Patients with SSCD had a 10.2 times (p < 0.001) higher odds of having radiographic TD in either ear compared to the controls. Among patients with any SSCD, for every millimeter increase in the width of dehiscence, the relative risk for any TD increased more than 2-fold (odds ratio, 2.5; p = 0.019). Age, sex, and a body mass index greater than 30 did not confound the association between SSCD and TD.There is a strong radiologic association between SSCD and TD, suggesting a similar etiologic process. The tegmen should be carefully evaluated in patients with SSCD. We have also proposed a new system for radiographically grading the integrity of the tegmen.

    View details for DOI 10.1097/MAO.0b013e3182634e27

    View details for Web of Science ID 000308092200029

    View details for PubMedID 22872173

  • Is It Valid to Calculate the 3-Kilohertz Threshold by Averaging 2 and 4 Kilohertz? OTOLARYNGOLOGY-HEAD AND NECK SURGERY Gurgel, R. K., Popelka, G. R., Oghalai, J. S., Blevins, N. H., Chang, K. W., Jackler, R. K. 2012; 147 (1): 102-104


    Many guidelines for reporting hearing results use the threshold at 3 kilohertz (kHz), a frequency not measured routinely. This study assessed the validity of estimating the missing 3-kHz threshold by averaging the measured thresholds at 2 and 4 kHz. The estimated threshold was compared to the measured threshold at 3 kHz individually and when used in the pure-tone average (PTA) of 0.5, 1, 2, and 3 kHz in audiometric data from 2170 patients. The difference between the estimated and measured thresholds for 3 kHz was within ± 5 dB in 72% of audiograms, ± 10 dB in 91%, and within ± 20 dB in 99% (correlation coefficient r = 0.965). The difference between the PTA threshold using the estimated threshold compared with using the measured threshold at 3 kHz was within ± 5 dB in 99% of audiograms (r = 0.997). The estimated threshold accurately approximates the measured threshold at 3 kHz, especially when incorporated into the PTA.

    View details for DOI 10.1177/0194599812437156

    View details for Web of Science ID 000314267600018

    View details for PubMedID 22301102

  • A Regenerative Method of Tympanic Membrane Repair Could Be the Greatest Advance in Otology Since the Cochlear Implant OTOLOGY & NEUROTOLOGY Jackler, R. K. 2012; 33 (3): 289-289

    View details for DOI 10.1097/MAO.0b013e318245cb51

    View details for Web of Science ID 000301439300005

    View details for PubMedID 22410728

  • Spontaneous Cerebrospinal Fluid Leak through the Posterior Aspect of the Petrous Bone. Journal of neurological surgery. Part B, Skull base Nadaraja, G. S., Monfared, A., Jackler, R. K. 2012; 73 (1): 71-75


    Spontaneous cerebrospinal fluid (CSF) leak through the posterior fossa (PF) aspect of the petrous bone is exceedingly rare. A case series allows analysis of etiologies and how they may differ from the more common middle fossa (MF) route of leakage. The design was a retrospective case series. The setting was a tertiary care institution. A series of three patients with PF spontaneous CSF leaks was identified. High-resolution imaging (CT and MRI) and intraoperative observations were evaluated. Both in this series and in previously reported cases, patients share the demographics typically found in the MF leak population. In our series, two patterns of PF CSF leak were identified: (1) large unilateral with cerebellar encephalocele and (2) small punctate defects just lateral to the endolymphatic sac. Two presented with simultaneous MF and PF leaks suggesting a shared etiology, at least in some cases, with a role for increased intracranial pressure. In spontaneous CSF leaks, it is important to evaluate the posterior petrous bone along with the tegmen. The concomitant appearance of MF with PF leaks points out the risk that repair via MF craniotomy could fail to identify a leakage site in the vicinity of the endolymphatic sac.

    View details for DOI 10.1055/s-0032-1304560

    View details for PubMedID 23372998

  • The price paid: Manipulation of otolaryngologists by the tobacco industry to obfuscate the emerging truth that smoking causes cancer LARYNGOSCOPE Jackler, R. K., Samji, H. A. 2012; 122 (1): 75-87


    Our objectives were to explore the multifaceted campaign by the tobacco industry to enlist otolaryngologists in support of their efforts to reassure consumers that cigarettes were safe, and to elucidate the incentives that led so many leading otolaryngologists to give testimony denying a causal linkage between tobacco use and head and neck cancer.Historical analyses.Recent litigation has exposed for public viewing a huge trove of internal tobacco industry documents. These documents include correspondence files, internal memoranda, research solicitations, grant agreements, records of payments, marketing plans, and testimony by otolaryngologists on behalf of tobacco interests in court proceedings, before congressional committees, and at U.S. Federal Trade Commission hearings.Evidence shows that marketing divisions of major tobacco companies systematically sought to use the authority and prestige of otolaryngologists to support their promotional efforts. Industry documents reveal widespread collaboration by leaders in the field through conducting research and giving well-compensated testimony favorable to tobacco interests. Invariably, industry-funded research showed tobacco in a favorable light. The industry also sought to influence otolaryngologists with free cigarettes, elegant dinners, and hospitality booths at conventions.In revealing this unfortunate period in our history, we by no means intend to diminish the memory of distinguished leaders whose tobacco involvements were certainly more acceptable by the standards of their own time. Rather, by exposing the pervasive tobacco industry manipulation of scientific research for commercial purposes we seek to encourage vigilance by contemporary researchers who might consider seeking funding from an industry that places the pursuit of profits above the well-being of its customers.

    View details for DOI 10.1002/lary.22358

    View details for Web of Science ID 000298586300016

    View details for PubMedID 22183630

  • Facial and Vestibulocochlear Nerve Avulsion at the Fundus of the Internal Auditory Canal in a Child Without a Temporal Bone Fracture OTOLOGY & NEUROTOLOGY Corrales, C. E., Monfared, A., Jackler, R. K. 2010; 31 (9): 1508-1510


    To describe a case of facial, vestibular, and cochlear nerve avulsion secondary to blunt trauma without an associated temporal bone fracture.Clinical capsule report.University hospital.A 3.5-year-old girl presented with immediate facial nerve paralysis and complete deafness after being struck by an automobile. High-resolution computed tomography demonstrated a depressed occipital bone fracture with no visible fracture of the temporal bone. Magnetic resonance imaging sequence raised the question of VIIth nerve bundle discontinuity at the distal end of the internal auditory canal.The patient underwent a posterior fossa craniotomy via a translabyrinthine approach 9 months after the initial injury, and facial and auditory nerve avulsion at the fundus was confirmed at the time of surgery. The proximal segment of the facial nerve had formed a traumatic neuroma, which was resected, and primarily anastomosed to the rerouted distal segment.Facial nerve function.Patient has regained facial function to Grade III/VI House-Brackmann with no asymmetry at rest.An unusual pattern of injury is described. We suggest that in patients presenting with facial nerve paralysis secondary to blunt trauma, without an associated temporal bone fracture, high-resolution magnetic resonance imaging is recommended to evaluate internal auditory canal discontinuity of the VIIth and VIIIth nerve complexes. A potential mechanism of avulsion is explained.

    View details for DOI 10.1097/MAO.0b013e3181f0c848

    View details for Web of Science ID 000284111700028

    View details for PubMedID 20856161

  • The Fickle Finger of Quackery in Otology: The Saga of Curtis H. Muncie, Osteopath OTOLOGY & NEUROTOLOGY Swamy, R. S., Jackler, R. K. 2010; 31 (5): 846-855


    Throughout history, false and outrageous cures for deafness have been abundant. Most of these false remedies were short lived and did not gain much attention. However, Curtis H. Muncie, a New York osteopathic physician, accrued vast wealth and fame over a half century career (1910-1960) with his proclaimed cure of deafness through reconstruction of the Eustachian tube with his index finger. Through creative marketing, clever manipulation of the press, and outrageous claims of efficacy, he profited handsomely from what was, no doubt, the most egregious and remunerative instance of deafness quackery in 20th century otology.A collection of original pamphlets issued by Curtis H. Muncie between 1921 and 1960 supplemented by articles from the popular press and both osteopathic and medical journals.The evidence that Dr. Muncie used unscientific methods and unscrupulous business practices is overwhelming. Famously, he fraudulently claimed in 1923 and for years thereafter that he had cured a congenitally deaf Spanish Prince (Don Jaime). At the height of the depression, his magical finger earned him over half a million dollars. Even his 1942 prison sentence for tax evasion did not keep him from resuming his flimflam upon his release.The story of Curtis H. Muncie is the quintessential example of how desperate patients can be exploited by an unscrupulous practitioner whose goal is satisfying his own avarice rather than curing illness.

    View details for DOI 10.1097/MAO.0b013e3181d8d881

    View details for Web of Science ID 000279163000022

    View details for PubMedID 20593544

  • The History of Middle Cranial Fossa Approach to the Cerebellopontine Angle OTOLOGY & NEUROTOLOGY Monfared, A., Mudry, A., Jackler, R. 2010; 31 (4): 691-696


    To investigate the historical origins of the current middle fossa (MF) approach to the cerebellopontine angle (CPA).A review of more than 30 original articles from the 1880 s to the early 1960s that document the evolution of the MF approach. Historically important journal articles and book chapters in various languages were supplemented by interviews with surgeons instrumental in the adaptation of this method to modern microsurgical neurotology.The inspiration for the current MF approach could be traced back to the late 19th century extradural subtemporal surgeries for the trigeminal neuralgia performed by Krause and Hartley and the contemporary surgeries performed by Ernst von Bergmenn for treatment of otogenic temporal bone infections. The first case of MF approach to CPA for vestibular nerve section was reported by RH Parry in 1904. In the mid-20th century, otologists found numerous applications for this approach, which gained popularity at the hands of William House. Although his initial MF operations aimed to decompress the internal auditory canal for cochlear otosclerosis, House soon realized the versatility of this approach and performed his first MF acoustic neuroma surgery in 1961.The current MF approach has its roots in operations for trigeminal neuralgia and otologic surgeries for palliation of temporal bone infections performed in the late 19th century. The earliest reported MF approach to the CPA dates back to 1904 and its application to microsurgical exposure of the internal auditory canal to the late 1950s.

    View details for DOI 10.1097/MAO.0b013e3181c0e98e

    View details for Web of Science ID 000278254200025

    View details for PubMedID 19816222

  • Surgical Rehabilitation of Voice and Swallowing After Jugular Foramen Surgery ANNALS OF OTOLOGY RHINOLOGY AND LARYNGOLOGY Oestreicher-Kedem, Y., Agrawal, S., Jackler, R. K., Damrose, E. J. 2010; 119 (3): 192-198


    We sought to determine the patient population that will benefit from surgical rehabilitation of voice and swallowing after jugular foramen tumor (JFT) resection.We performed a retrospective case study of patients with a history of JFT resection. The patients' files were reviewed for data on preoperative and postoperative function of cranial nerves VII and IX through XII, voice and swallowing function, and surgical procedures for voice and swallowing rehabilitation and their timing.Twenty-one patients underwent JFT resection. Thirty-eight percent presented with deficits of cranial nerves VII and IX through XII, and 61% developed new postoperative deficits. Three patients recovered glossopharyngeal nerve function, 2 recovered vagus nerve function, and 1 recovered facial nerve function. Surgical rehabilitation procedures were undertaken in 8 patients. Patients who eventually underwent surgical rehabilitation procedures for voice and swallowing tended to have larger tumors, tumors within the nerve bundle in the jugular foramen, and multiple nerve deficits.Most patients with multiple deficits of cranial nerves VII and IX through XII after JFT resection are unlikely to regain spontaneous nerve function, will experience long-term dysphonia and dysphagia, and will elect to undergo corrective surgery to improve voice and swallowing. Preoperative evaluation and close postoperative follow-up can identify patients who would benefit from early surgical rehabilitation.

    View details for Web of Science ID 000276421300008

    View details for PubMedID 20392033

  • Signed, sealed and delivered: "big tobacco'' in Hollywood, 1927-1951 TOBACCO CONTROL Lum, K. L., Polansky, J. R., Jackler, R. K., Glantz, S. A. 2008; 17 (5): 313-323


    Smoking in movies is associated with adolescent and young adult smoking initiation. Public health efforts to eliminate smoking from films accessible to youth have been countered by defenders of the status quo, who associate tobacco imagery in "classic" movies with artistry and nostalgia. The present work explores the mutually beneficial commercial collaborations between the tobacco companies and major motion picture studios from the late 1920s through the 1940s.Cigarette endorsement contracts with Hollywood stars and movie studios were obtained from internal tobacco industry documents at the University of California, San Francisco (UCSF) Legacy Tobacco Documents Library and the Jackler advertising collection at Stanford.Cigarette advertising campaigns that included Hollywood endorsements appeared from 1927 to 1951, with major activity in 1931-2 and 1937-8 for American Tobacco Company's Lucky Strike, and in the late 1940s for Liggett & Myers' Chesterfield. Endorsement contracts and communication between American Tobacco and movie stars and studios explicitly reveal the cross-promotional value of the campaigns. American Tobacco paid movie stars who endorsed Lucky Strike cigarettes US$218,750 in 1937-8 (equivalent to US$3.2 million in 2008) for their testimonials.Hollywood endorsements in cigarette advertising afforded motion picture studios nationwide publicity supported by the tobacco industry's multimillion US dollar advertising budgets. Cross-promotion was the incentive that led to a synergistic relationship between the US tobacco and motion picture industries, whose artefacts, including "classic" films with smoking and glamorous publicity images with cigarettes, continue to perpetuate public tolerance of onscreen smoking. Market-based disincentives within the film industry may be a solution to decouple the historical association between Hollywood films and cigarettes.

    View details for DOI 10.1136/tc.2008.025445

    View details for Web of Science ID 000259504500015

    View details for PubMedID 18818225

    View details for PubMedCentralID PMC2602591

  • Selection of surgical approach to acoustic neuroma (Reprinted from Otolaryngologic Clinics of NA vol 25, pg 361-388, 1992) NEUROSURGERY CLINICS OF NORTH AMERICA Jackler, R. K., Pitts, L. H. 2008; 19 (2): 217-?


    A variety of surgical approaches are available in the management of acoustic neuroma. Each procedure has certain advantages and disadvantages in terms of surgical exposure, the capability of preserving cranial nerve function, and postoperative morbidity. This article advocates tailoring the operative approach to each acoustic neuroma according to its size, location, and clinical manifestations.

    View details for DOI 10.1016/

    View details for Web of Science ID 000257173200005

    View details for PubMedID 18534336

  • Cranial base approaches to inaccessible intracranial tumors CURRENT OPINION IN NEUROLOGY Monfared, A., Agrawal, S., Jackler, R. K. 2007; 20 (6): 726-731


    Craniotomy created through the base of the skull has improved exposure of many types of extraaxial tumors and thus enhanced both tumor control and preservation of neural function. The purpose of this article is to review recent advances in this emerging field.Use of microscopes and endoscopes has allowed these procedures to become progressively less invasive. Electrophysiological monitoring has enhanced neural identification and preservation. The increasingly documented efficacy of stereotactic radiation for certain tumor types (e.g. meningioma, schwannoma) has permitted nonoperative therapy for some individuals. In large tumors, selective use of less-than-complete microsurgical resection is establishing an increasing role, at times combined with focused radiotherapy of the surgical remnant. The role for transbasal craniotomy is well established in both benign tumors and vascular lesions, but has only limited applicability for high-grade malignant lesions. Today, the vast majority of procedures can be conducted in a single stage by a multidisciplinary team.Operative trajectories created through the cranial base, although technically demanding, have led to substantially improved outcomes for a wide variety of inaccessible intracranial lesions.

    View details for Web of Science ID 000251209300021

    View details for PubMedID 17992097

  • Aggressiveness in cholesterol granuloma of the temporal bone may be determined by the vigor of its blood source OTOLOGY & NEUROTOLOGY Pfister, M. H., Jackler, R. K., Kunda, L. 2007; 28 (2): 232-235


    Recently, it has been proposed that the aggressive behavior of cholesterol granuloma (CG) of the petrous apex is explained by its proximity to the richly vascular marrow of the petroclival junction. Most CGs of the lateral temporal bone are indolent. The purpose of the present study is to examine the factors responsible for atypical aggressive behavior in mastoid CG.Retrospective case series.: Tertiary academic practice.Four patients with atypically aggressive CG of the mastoid.In each case, the CG abutted a rich blood source: the sigmoid sinus, carotid artery, a large dural vein, or a rich deposit of vascular marrow in the mastoid tip.These observations lend further support to the theory that aggressiveness of CG is sustained by a robust source of ongoing hemorrhage.

    View details for Web of Science ID 000243847300015

    View details for PubMedID 17255892

  • The aborted early history of the translabyrinthine approach: A victim of suppression or technical prematurity? OTOLOGY & NEUROTOLOGY Nguyen-Huynh, A. T., Jackler, R. K., Pfister, M., Tseng, J. 2007; 28 (2): 269-277


    To ascertain the reasons translabyrinthine (TL) approach to acoustic neuroma, initially attempted in 1911, became relegated to obscurity for nearly half a century.A scholarly review of more than 40 publications in German and English from the late 19th to the mid-20th century. LITERATURE SUMMARY: Surgeons who first contemplated approaching the cerebellopontine angle recognized that the shortest route from the surface was through the petrous bone. In the late 19th century, otologic surgeons devised numerous procedures to deal with infection in and around the semicircular canals. This familiarity led R. Panse of Dresden to propose (but not actually perform) a TL approach (1904). F.H. Quix of Utrecht performed the first pure TL approach (1911), but others before him had used petrosectomy to augment the suboccipital approach. Subsequent TL attempts by other surgeons met with variable results. Devastating criticism of the method was proffered by leading acoustic neuroma surgeons of the day such as H. Cushing (1921) and W. Dandy (1925). The most important criticisms were that the approach provided only a deep and narrow field of action, was surrounded by major vascular structures, and led to great difficulty with cerebrospinal fluid leakage. HISTORICAL PERSPECTIVE: The literature on this subject is replete with erroneous citations. Panse is often miscited as having performed the first surgery. It has also become traditional to give Quix great credit, even though his procedure failed to remove much of the tumor. Poor outcome and intense criticism led surgeons to abandon the TL approach until W.F. House, armed with operating microscope and high-speed drill, successfully resurrected it in the 1960s. He concisely summarizes the pioneers' efforts: "They had the ideas and desire, but not the technical tools."

    View details for Web of Science ID 000243847300022

    View details for PubMedID 17255895

  • Virtuosity with the mallet and gouge: The brilliant triumph of the "Modern" mastoid operation OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Sunder, S., Jackler, R. K., Blevins, N. H. 2006; 39 (6): 1191-?


    The development of mastoid surgery can be traced through the past 4 centuries. Once used as a means of evacuating a postauricular abscess, it has evolved to become a method for gaining entry into the middle ear for diagnostic purposes, to control chronic ear disease, or for otologic and neuro-otologic procedures. Earlier works led the way to the Wilde postauricular incision, which gave rise to Schwartze mastoidectomy. Stacke's technique of mastoidectomy was practiced for some time before Bondy, Heath, and Bryant introduced the modified radical mastoidectomy. By the 1930s, the mastoidectomy had evolved into a generally accepted otologic procedure. Endowed with a rich history, the future of mastoid surgery promises to be equally momentous.

    View details for DOI 10.1016/j.otc.2006.08.014

    View details for Web of Science ID 000242734700009

    View details for PubMedID 17097441

  • The challenges of revision skull base surgery OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Nguyen-Huynh, A., Blevins, N. H., Jackler, R. K. 2006; 39 (4): 783-?


    Because the skull base is an anatomically complex structure, skull base tumors can hide easily in the crevices that interconnect the intra- and extracranial spaces and intermingle with important neurovascular structures. Often, total surgical resection of these tumors is not possible, and even with postoperative adjuvant radiotherapy, some recurrences after treatment are inevitable. Early detection of recurrent skull base tumors requires clinical vigilance and periodic imaging studies. The management of recurrent skull base tumors presents many challenges beyond those associated with primary procedures. A multidisciplinary setting that includes modern microsurgery and stereotactic radiation therapy provides patients with optimal care.

    View details for DOI 10.1016/j.otc.2006.04.006

    View details for Web of Science ID 000240080900010

    View details for PubMedID 16895785

  • Skull base chondrosarcoma originating from the petroclival junction OTOLOGY & NEUROTOLOGY Oghalai, J. S., Buxbaum, J. L., Jackler, R. K., McDermott, M. W. 2005; 26 (5): 1052-1060


    To define the presentation of patients with skull base chondrosarcoma, to elucidate surgical strategies, and to identify the role of postoperative radiotherapy.Retrospective review.Tertiary referral center.All patients (n = 33) with skull base chondrosarcoma managed at our institution. The average follow-up time was 7.7 years (range, 0-20 years).Tumor location, presenting symptoms, presence of residual or recurrent tumor, and mortality.The most common tumor location was the petroclival junction (n = 29). Common presenting symptoms were diplopia (48%) and headache (45%). Surgical approaches included retrosigmoid, transtemporal, transfacial, and frontotemporal craniotomies. Biopsy only was performed in four patients, subtotal resection in 19 patients, and total resection in nine patients. Most patients received postoperative radiotherapy (82%). Follow-up revealed residual, stable disease in 28% of patients and recurrent disease in 24% of patients. The mean time to recurrence was 3.0 +/- 2.8 years. The lack of postoperative radiation was significantly correlated with an increased risk of recurrence (odds ratio, 28; p = 0.007) but incomplete tumor resection was not (p = 0.6). Life-table analysis revealed that the 5-year survival rate was 85% and the 10-year survival rate was 77%. Five patients died; four of the deaths attributable to recurrent disease.The characteristic growth pattern of skull base chondrosarcoma is tumor eroding the petroclival junction. Current therapeutic strategy is resection through an extradural subtemporal craniotomy with removal of the petrous apex and clivus. Radical resection of uninvolved structures is often not necessary. Nonetheless, gross total removal is often achievable. Postoperative radiotherapy reduces the chance of tumor recurrence.

    View details for Web of Science ID 000231943600037

    View details for PubMedID 16151358

  • The prevalence of "incidental" acoustic neuroma ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Doris, L., Hegarty, J. L., Fischbein, N. J., Jackler, R. K. 2005; 131 (3): 241-244


    To estimate the prevalence of "incidental" acoustic neuromas (ANs) in the population at large.An intracranial magnetic resonance imaging (MRI) database of 46 414 patients presenting to the University of California, San Francisco (UCSF), without known audiovestibular complaints was searched retrospectively from July 1995 to February 2003. Seventy percent of these MRIs included gadolinium, and none was specifically targeted through the internal auditory canal. A medical chart review of 688 patients with acoustic neuromas presenting to UCSF between 1980 and 1999 was searched for sex distribution.Tertiary care university medical center.Eight patients with incidental AN were discovered. This figure suggests that undiagnosed ANs may be present in at least 0.02% of the population. Three patients were found to have audiovestibular symptoms on inquiry after diagnosis. Audiometry revealed asymmetry at 4 kHz in only 3 of 7 patients, with an otherwise symmetric audiogram in the remaining patients. Tumor size in this population ranged from 3 to 28 mm. Incidental ANs were more common in men, but ANs were more common in women overall.The prevalence of incidental AN appears to be roughly 2 in 10,000 people. This figure indicates that AN may be less prevalent than suggested in previously reported temporal bone studies and more prevalent than suggested by epidemiologic studies.

    View details for Web of Science ID 000227446300009

    View details for PubMedID 15781765

  • Intraoperative electrophysiologic identification of the nervus intermedius OTOLOGY & NEUROTOLOGY Ashram, Y. A., Jackler, R. K., Pitts, L. H., Yingling, C. D. 2005; 26 (2): 274-279


    Although enormous attention has been directed to the localization and preservation of the facial nerve in acoustic neuroma surgery, the nervus intermedius has largely been ignored. In this article, we describe a method for intraoperative electrophysiologic identification of the nervus intermedius.Retrospective case review.University hospital (tertiary care center).Thirty-three patients who underwent intraoperative facial nerve monitoring for various cerebellopontine angle procedures. Recording electrodes were placed in the orbicularis oculi and orbicularis oris muscles. A constant-voltage stimulator was used to stimulate both the facial nerve and the nervus intermedius.None.Electrophysiologic response after stimulation of the nervus intermedius.Stimulation of the nervus intermedius produced long-latency, low-amplitude response recorded only on the orbicularis oris channel. The response had a mean threshold 0.4 V, a mean latency of 11.1 ms, and a mean amplitude of 11.1 microV, all significantly different from responses to stimulation the facial nerve.Knowledge of electrophysiologic features of nervus intermedius stimulation can help protect the facial nerve during cerebellopontine angle surgery. The surgeon must recognize that stimulation of the nervus intermedius can cause electromyographic activity in the facial nerve monitoring channels, but the main trunk of the facial nerve may lie in entirely different location in the cerebellopontine angle.

    View details for Web of Science ID 000231411700026

    View details for PubMedID 15793419

  • Combination of aberrant internal carotid artery and persistent stapedial artery OTOLOGY & NEUROTOLOGY Lau, C. C., Oghalai, J. S., Jackler, R. K. 2004; 25 (5): 850-851

    View details for Web of Science ID 000223831600036

    View details for PubMedID 15354022

  • Anatomy involved in the jugular foramen approach for jugulotympanic paraganglioma resection. Neurosurgical focus Inserra, M. M., Pfister, M., Jackler, R. K. 2004; 17 (2): E6-?


    The goal in paraganglioma resection is to allow adequate exposure to remove the lesion while preserving cranial nerve function. Knowledge of the anatomy of the jugular foramen is crucial to this endeavor. In this report the authors describe a jugular foramen approach for the resection of glomus jugulare tumors in cases in which rerouting of the facial nerve can be avoided. This approach provides adequate exposure of the jugular bulb for many jugulotympanic paragangliomas without increased risk of injury to the facial nerve. In addition, special circumstances surrounding intracranial and carotid artery involvement are briefly discussed.

    View details for PubMedID 15329021

  • Transjugular craniotomy for the management of jugular foramen tumors with intracranial extension Annual Meeting of the American-Neurotology-Society/Triological-Society Forum Oghalai, J. S., Leung, M. K., Jackler, T. K., McDermott, M. W. LIPPINCOTT WILLIAMS & WILKINS. 2004: 570–79


    To elucidate indications and outcomes with the transjugular craniotomy for resection of jugular foramen tumors with intracranial extension. The transjugular approach is a lateral craniotomy conducted through a partial petrosectomy traversing the jugular fossa combined with resection of the sigmoid sinus and jugular bulb, which often have been occluded by disease.Retrospective review.University medical center.Twenty-eight patients with intracranial jugular foramen tumors who underwent a total of 30 surgical procedures.Pathologic findings, surgical approach, extent of tumor resection, rate of facial nerve mobilization and ear canal closure, facial and lower cranial nerve outcomes, and hearing preservation.Tumors included schwannoma (37%), meningioma (33%), glomus jugulare (23%), and chordoma (7%). The surgical approaches were tailored to maximize functional preservation, and included the transjugular (53%), translabyrinthine (17%), retrosigmoid (10%), and far lateral (7%) craniotomies. Translabyrinthine (3%) or transcondylarfar lateral (3%) approaches were occasionally used in combination with the trans-jugular approach. Most procedures were managed in a single stage (90%), but three patients with massive tumor in the neck required two stages. Microsurgical gross total and near-total tumor removal (37% each) were commonly achieved, although subtotal resections (27%) were occasionally performed. In only a minority of cases was facial nerve mobilization (7%) or ear canal closure (21%) required. If present preoperatively, Grade I facial nerve function was usually maintained (22 of 24 [92%]) and Hearing Class A or B could always be maintained (9 of 9 [100%]). As expected, new lower cranial nerve dysfunction was common (8 of 30 [27%]), although over half of the patients had complete lower nerve palsy preoperatively (16 of 30 [53%]).Most patients with jugular foramen tumors with intracranial extension can be managed with a single-stage transjugular craniotomy. Facial nerve mobilization or ear canal closure is usually not required, permitting conservation of facial function and hearing, when present preoperatively.

    View details for Web of Science ID 000222614100028

    View details for PubMedID 15241237

  • Chronic pachymeningitis presenting as asymmetric sensorineural hearing loss OTOLOGY & NEUROTOLOGY Oghalai, J. S., RAMIREZ, A. L., Hegarty, J. L., Jackler, R. K. 2004; 25 (4): 616-621


    The objective of this study was to characterize the auditory dysfunction associated with chronic pachymeningitis (inflammation of the dura mater).We conducted a university-based retrospective review.Three patients were identified who were diagnosed with chronic pachymeningitis after being referred for asymmetric sensorineural hearing loss. All patients were found to have other neurologic symptoms and signs during careful neurotologic evaluation. Two varieties of chronic pachymeningitis exist: a hypertrophic mass lesion and a linear dural thickening. Although the hypertrophic variety could be easily detectable by noncontrast magnetic resonance imaging (MRI), the linear form is only visible with the use of gadolinium enhancement.Chronic pachymeningitis is a rare form of sensorineural hearing loss that could portend an underlying disease of greater concern. Extensive evaluation is needed to exclude identifiable causes of chronic pachymeningitis, including infectious, neoplastic, and autoimmune diseases.The clinician should be aware that the evaluation of a patient with asymmetric sensorineural hearing loss involves more than simply ruling out an acoustic neuroma. Fast-spin echo MRI techniques without the use of gadolinium contrast could miss a number of potentially treatable diseases such as chronic pachymeningitis. Patients with asymmetric sensorineural hearing loss should be carefully evaluated for other neurologic findings, and imaging with enhanced MRI is recommended.

    View details for Web of Science ID 000222614100037

    View details for PubMedID 15241244

  • The fate of the tumor remnant after less-than-complete acoustic neuroma resection 106th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Bloch, D. C., Oghalai, J. S., Jackler, R. K., Osofsky, M., Pitts, L. H. MOSBY-ELSEVIER. 2004: 104–12


    We sought to determine the recurrence rate after near-total and subtotal resection of acoustic neuroma. STUDY DESIGN, SETTING, AND PATIENTS: We conducted a retrospective chart review of a total of 79 patients: 50 with near-total resections (remnant < or =25 mm(2) and < or =2 mm thick) and 29 with subtotal resections (any larger remnant). Surgical approach included 5 middle fossa, 17 retrosigmoid, and 57 translabyrinthine.Recurrence was defined as documented tumor growth by serial imaging or the recommendation for further treatment after a single scan. No recurrence was defined as no visible tumor on imaging for a minimum follow-up time of 3 years or tumor remnants that remained unchanged on serial scans (mean, 5-year follow-up).Fifty-two patients were included in the study group. Recurrences were seen in 1 (3%) of 33 patients who had a near-total resection compared with 6 (32%) of 19 patients who had a subtotal resection. After adjustment for follow-up time and large tumor size, the odds ratio for recurrence was 12 times larger for subtotal than for near-total resections (P = 0.033). All recurrences were seen following the translabyrinthine approach in the mid-cerebellopontine angle. None were encountered in the internal auditory canal. The mean time interval from surgery to the detection of a recurrence was 3 years (range, 1 to 5 years).The recurrence rate when performing a near-total resection is low but is substantially higher with a subtotal resection. Recurrences can be detected within the first 5 postoperative years. We recommend near-total resection in any patient if needed to preserve neural integrity. Subtotal resection is best avoided whenever possible; however, adjunctive treatment with stereotactic radiotherapy may be considered.

    View details for DOI 10.1016/S0194-5998(03)01598-5

    View details for Web of Science ID 000188702000013

    View details for PubMedID 14726918

  • Anatomy of the combined retrolabyrinthine-middle fossa craniotomy. Neurosurgical focus Oghalai, J. S., Jackler, R. K. 2003; 14 (6)


    The goal of combined retrolabyrinthine-middle fossa craniotomy is to provide exposure of both the middle and posterior cranial fossae via a partial petrosectomy and division of the tentorium. Its major benefits over others are that hearing and facial nerve function are preserved and only minimal brain retraction is required. The retrolabyrinthine approach involves a presigmoid posterior fossa craniotomy that preserves the structures of the inner ear. Additionally, a middle fossa craniotomy, extending to the zygomatic root, is performed to gain access to the superior aspect of the temporal bone in the middle cranial fossa. This approach works well in cases of lesions involving the petroclival junction, including petroclival meningiomas, trigeminal schwannomas, epidermoids, and large chondrosarcomas or chordomas with intradural components. The authors describe the surgical technique of this approach.

    View details for PubMedID 15669793

  • The effect of age on acoustic neuroma surgery outcomes OTOLOGY & NEUROTOLOGY Oghalai, J. S., Buxbaum, J. L., Pitts, L. H., Jackler, R. K. 2003; 24 (3): 473-477


    To ascertain the effect of age on hearing preservation, facial nerve outcome, and complication rates after acoustic neuroma surgery.Retrospective chart review. Two study arms were used: a comparison of the authors' oldest patients with their youngest patients (extremes of age arm) and an analysis of all middle fossa surgical procedures (middle fossa arm).Tertiary referral centerTotal of 329 patients. For the extremes of age arm, 205 patients were studied in two cohorts with 150 older patients (>60 years) compared with 55 younger patients (<40 years). The approaches included 21 middle fossa (MF), 38 retrosigmoid (RS), and 91 translabyrinthine (TL) procedures in the older group versus 25 MF, 17 RS, and 13 TL in the younger. For the middle fossa arm, there were 170 patients (age range 15-76 years) who underwent the MF approach for an attempt at hearing preservation.Hearing preservation was defined as the maintenance of either class A or class B hearing (AAO-HNS class). Good facial nerve outcome was considered the maintenance of either grade 1 or 2 (House-Brackmann scale). Cerebrospinal fluid leak rates and other postoperative complications were also tabulated.After adjustment for tumor size and surgical approach using multiple logistic regression analysis, the extremes of age study arm demonstrated that there is a lower chance of preserving good hearing in older patients (p = 0.048, odds ratio = 0.30). Age was not associated with a difference in the rate of good facial nerve outcome (p = 0.2). There was a trend toward slightly higher rates of cerebrospinal fluid leak in the older patient group (p = 0.07) but no difference in the rate of other complications (p = 0.9). The middle fossa study arm, after adjustment for tumor size and surgical approach, demonstrated that older patient age is associated with a lower rate of preservation of good hearing (p = 0.01, O.R.=1.044). There was no association between age and good facial outcome (p = 0.7).Older patient age lowers the chance of hearing preservation but does not affect facial outcomes. There is a trend toward a higher rate of cerebrospinal fluid leak in older patients, but no increased risk of other complications.

    View details for Web of Science ID 000183052000021

    View details for PubMedID 12806302

  • Is it worthwhile to attempt hearing preservation in larger acoustic neuromas? OTOLOGY & NEUROTOLOGY Yates, P. D., Jackler, R. K., Satar, B., Pitts, L. H., Oghalai, J. S. 2003; 24 (3): 460-464


    To determine the hearing outcome in patients undergoing surgery via the retrosigmoid approach for acoustic neuromas with a substantial component in the cerebellopontine angle.Retrospective case review.Tertiary referral center.The medical records of all patients undergoing acoustic neuroma removal via the retrosigmoid approach at a tertiary referral center were retrospectively reviewed. Sixty-four patients with both cerebellopontine angle component >or=15 mm and preoperative audiometry of class A or B (American Academy of Otolaryngology-Head and Neck Surgery) were identified.Postoperative average pure tone threshold and word recognition scores, categorized according to the classification of the American Academy of Otolaryngology-Head and Neck Surgery, were used to assess hearing outcome.Overall, only 6.3% (4 of 63) retained good hearing (class A or B) postoperatively. Hearing preservation rate in the smallest (15- to 19-mm) group was 17.6% (3 of 17), which was better than that for the larger groups. No successful hearing preservation was achieved in tumors with >or=25 mm cerebellopontine angle component (0 of 23).Surgeon and patient alike would always choose a hearing preservation technique if there was no potential for increased morbidity in making the attempt. When compared with the non-hearing preservation translabyrinthine approach, the retrosigmoid approach had a higher incidence of persistent headache. In addition, efforts to conserve the auditory nerve prolong operating time, increase the incidence of postoperative vestibular dysfunction, and carry a slightly higher risk of tumor recurrence. Nevertheless, even though the probability of success is disappointingly small, when excellent hearing is present we favor offering the option of a hearing conservation attempt when the patient has been well informed of the pros and cons of the endeavor. Factors weighing against undertaking this effort include larger cerebellopontine angle component (>or=25 mm), deep involvement of the fundus, wide erosion of the porus, and marginal residual hearing.

    View details for Web of Science ID 000183052000018

    View details for PubMedID 12806299

  • The artificial tympanic membrane (1840-1910): From brilliant innovation to quack device OTOLOGY & NEUROTOLOGY Chu, E. A., Jackler, R. K. 2003; 24 (3): 507-518


    To present the rich and checkered history of the artificial eardrum, a widely used device in the 19th century, and to illustrate the behavior of otologists in response to the introduction of a promising new technology.Over 40 published books and articles spanning the years 1821 to 1909 in English, German, and French. DEVICE DESCRIPTIONS: A wide variety of devices were used 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, petroleum jelly (Vaseline), or glycerin. Some were applied by the physician, whereas others were inserted daily by the patient, much as contact lenses are today.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 was generated about the "miraculous" value of this deafness cure. Petty jealousy among early inventors led to very public (and unprofessional) quarrels 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 last century. In the first two decades of the 20th century, artificial eardrums reached their peak of fame among the public when they were enthusiastically (and dishonestly) marketed by numerous quacks through newspaper advertisements as a universal cure for all forms of deafness. Only with the coming of the Food and Drug Administration did advertisements for US dollars 5 mail-order, medicated eardrums disappear from popular newspapers and magazines.

    View details for Web of Science ID 000183052000027

    View details for PubMedID 12806308

  • A 73-year-old man with hearing loss JAMA-JOURNAL OF THE AMERICAN MEDICAL ASSOCIATION Jackler, R. K. 2003; 289 (12): 1557-1565

    View details for Web of Science ID 000181803100034

    View details for PubMedID 12672773

  • A new theory to explain the genesis of petrous apex cholesterol granuloma OTOLOGY & NEUROTOLOGY Jackler, R. K., Cho, M. 2003; 24 (1): 96-106


    To propose a new hypothesis that attempts to explain the pathogenesis of petrous apex cholesterol granuloma (PA CG). CLASSIC OBSTRUCTION-VACUUM HYPOTHESIS: PA CGs form when mucosal swelling blocks the circuitous pneumatic pathways to the apical air cells. Trapped gas resorption results in a vacuum that triggers bleeding, and CG forms through anaerobic breakdown of blood products. PROBLEMS WITH THE CLASSIC (OBSTRUCTION-VACUUM) HYPOTHESIS: Impaired ventilation of mucosa-lined pneumatic tracts in the middle ear, mastoid, paranasal sinuses, and lung are very common, but CG is rare. The extraordinary levels of temporal bone pneumatization typically observed in PA CG cases is indicative of excellent ventilation and freedom from inflammatory mucosal disease. Were under pressure due to gas absorption alone sufficient to trigger hemorrhage, CG ought to be frequent in otitis media with effusion.The opposite PA of 13 patients with PA CG compared with 31 highly pneumatic PAs in patients undergoing imagery for non-otologic reasons.The nature of the bony partition, as seen on computed tomography, between the PA air cell system and the adjacent marrow compartment.4 of 13 PAs with CGs on the opposite side showed deficient septation between air cells and marrow, whereas this was not observed in any of the 31 extensively pneumatized normal ears. NEW HYPOTHESIS (EXPOSED MARROW): As cellular tracts penetrate the apex during young adulthood, budding mucosa invades and replaces hematopoietic marrow. The bony interface becomes deficient, with coaptation of richly vascular marrow and the mucosal air cell lining. Hemorrhage from the exposed marrow coagulates within the mucosal cells and occludes outflow pathways. Sustained hemorrhage from exposed marrow elements provides the engine responsible for the progressive cyst expansion. As the cyst expands, bone erosion increases the surface area of exposed marrow along the cyst wall. This exposed marrow theory explains the unique proclivity of the healthy and well-pneumatized PA to form a CG.

    View details for Web of Science ID 000180314500020

    View details for PubMedID 12544037

  • Cerebrospinal fluid leak after acoustic neuroma surgery: A comparison of the translabyrinthine, middle fossa, and retrosigmoid approaches OTOLOGY & NEUROTOLOGY Becker, S. S., Jackler, R. K., Pitts, L. H. 2003; 24 (1): 107-112


    To determine whether the choice of surgical approach affects the rate of postoperative cerebrospinal fluid leakage in patients who have undergone surgical resection of acoustic neuroma.Retrospective chart review.Tertiary referral center.Three hundred patients who underwent surgery for acoustic neuromas were selected by consecutive medical record number until 100 resections via each surgical approach (translabyrinthine, middle fossa, and retrosigmoid) had been gathered.Surgical approach used, cerebrospinal fluid leak incidence, tumor size, patient age.Postoperative cerebrospinal fluid leak of any severity was observed in 13% of translabyrinthine, 10% of middle fossa, and 10% of retrosigmoid patients. These difference in the rate of cerebrospinal fluid leakage were not statistically significant (p = 0.82). 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 4% of translabyrinthine, 2% of middle fossa, and 3% retrosigmoid patients; again not statistically different among the approaches (p = 0.43). Tumor size was not correlated with cerebrospinal fluid leak rate (p = 0.13). Patient age, for patients older than 50 years, was suggestive of increased odds of cerebrospinal fluid leak (p = 0.06).Neither surgical approach nor tumor size affects the rate of postoperative cerebrospinal fluid leakage or the necessity of managing a leak with a return to the operating room. Cerebrospinal fluid leakage rates have remained stable in recent decades despite numerous innovative attempts to improve dural closure, seal transected air cell tracts, and occlude anatomic pathways. The finding that leak rates were similar among three dissimilar surgical techniques suggests that factors other than techniques of wound closure, such as transient postoperative rises in cerebrospinal fluid pressure, may be responsible for these recalcitrant cases.

    View details for Web of Science ID 000180314500023

    View details for PubMedID 12544038

  • Limitations to mobilizing the intrapetrous carotid artery. The Annals of otology, rhinology, and laryngology Jackler, R. K., Oghalai, J. S. 2002; 111 (9): 860-?

    View details for PubMedID 12296345

  • Risk-benefit analysis of using the middle fossa approach for acoustic neuromas with > 10 mm cerebellopontine angle component LARYNGOSCOPE Satar, B., Jackler, R. K., Oghalai, J., Pitts, L. H., Yates, P. D. 2002; 112 (8): 1500-1506


    To evaluate hearing preservation and facial nerve (FN) outcome in the middle fossa (MF) approach for acoustic neuromas with a cerebellopontine angle (CPA) component >10 mm.Retrospective review of 193 patients.Patients were grouped according to tumor size: intracanalicular tumors (IC; 64), 1 to 9 mm CPA extension (42), and 10 to 18 mm CPA extension (47). Additionally, a group of 40 patients (tumor size 10-18 mm CPA extension) who had undergone a translabyrinthine (TL) approach was studied to assess comparative FN outcome. Hearing and FN function were measured 1 year postoperatively. We defined the success at functional hearing preservation as AAO-HNS class B or better and good FN outcome as House-Brackmann grade II or better.For IC tumors and those with up to 9-mm CPA extension, there was no significant difference in the rate of functional hearing preservation (62.2% vs. 63.1%, P =.931) and good FN outcome (93.7% vs. 97.6%, P =.358). For tumors of 10- to 18-mm CPA extension, the rate of hearing preservation (34%) was lower than the other groups (P =.006 and P =.009). In this group, the rate of good FN outcome was lower compared with the IC and 1- to 9-mm tumors (80.8% vs. 93.7%, P =.037 and 97.6%, P =.012). The rate of good FN outcome following the TL approach in a comparable cohort of patients was 100% (P =.003 in comparison with 10-18 mm tumor resected with the MF approach).When considering surgical options, patients with >10-mm tumors should be advised that choosing the MF approach for hearing preservation carries a somewhat higher risk of persistent FN dysfunction.

    View details for Web of Science ID 000177289300031

    View details for PubMedID 12172269

  • Neurofibromatosis 2 and malignant mesothelioma NEUROLOGY Baser, M. E., De Rienzo, A., Altomare, D., Balsara, B. R., Hedrick, N. M., Gutmann, D. H., Pitts, L. H., Jackler, R. K., Testa, J. R. 2002; 59 (2): 290-291


    Mutations of the neurofibromatosis 2 (NF2) tumor suppressor gene cause the inherited disorder NF2 and are also common in malignant mesothelioma, which is not a characteristic feature of NF2. The authors report an asbestos-exposed person with NF2 and malignant mesothelioma. Immunohistochemical analysis of the mesothelioma confirmed loss of expression of the NF2 protein, and comparative genomic hybridization revealed losses of chromosomes 14, 15, and 22, and gain of 7. The authors propose that a person with a constitutional mutation of an NF2 allele is more susceptible to mesothelioma.

    View details for Web of Science ID 000176875400029

    View details for PubMedID 12136076

  • Distal anterior inferior cerebellar artery syndrome after acoustic neuroma surgery OTOLOGY & NEUROTOLOGY Hegarty, J. L., Jackler, R. K., Rigby, P. L., Pitts, L. H., Cheung, S. W. 2002; 23 (4): 560-571


    To define a clinicopathologic syndrome associated with persistent cerebellar dysfunction after acoustic neuroma (AN) excision.Case series derived from radiographic and clinical chart review.Tertiary referral center.In 12 patients with AN, persistent cerebellar dysfunction developed after AN removal. Each case demonstrated abnormality in the ipsilateral cerebellar peduncle on postoperative magnetic resonance imaging.Cerebellar function and ambulatory status over the first postoperative year.On magnetic resonance imaging scans, the extent of cerebellar peduncle infarcts was variable. It ranged from focal brain injury (<1 cm) involving only one third of the peduncle to diffuse defects (>2 cm) spanning the full thickness of the peduncle. Peduncular infarcts were associated with large tumor size (average 3.8 cm, range 2.0-5.5 cm diameter). The long-term functional outcomes (>1 yr) varied. Dysmetria was unchanged or improved in over half of the patients (6 of 11 patients). Gait recovered to normal or to preoperative levels in 5 patients. In the 6 patients with persistent impaired mobility, 2 had mild gait disturbance, 3 required regular use of a cane, and 1 has been dependent on a walker. One patient had sustained mild motor weakness. Three of 11 patients remained dependent on others for activities of daily living.Peduncle injury most likely stems from interruption of distal branches of the anterior inferior cerebellar artery (AICA). These small vessels are intimately related to the capsule of the tumor and may supply both the neoplasm and the brain parenchyma. It has long been recognized that interruption of the proximal segment of the AICA results in severe injury to the pons, with devastating neurologic sequelae. A limited AICA syndrome caused by loss of its distal ramifications seems a more plausible explanation for peduncular infarction than either venous insufficiency or direct surgical trauma.

    View details for Web of Science ID 000176943300032

    View details for PubMedID 12170162

  • The value of enhanced magnetic resonance imaging in the evaluation of endocochlear disease Meeting of the Western Section of the Triological-Soceity Hegarty, J. L., Patel, S., Fischbein, N., Jackler, R. K., Lalwani, A. K. JOHN WILEY & SONS INC. 2002: 8–17


    Gadolinium-enhanced magnetic resonance imaging (GdMRI) is routinely used in the evaluation and management of suspected retrocochlear pathology such as vestibular schwannoma. However, its value in the evaluation and diagnosis of cochlear pathology associated with sensorineural hearing loss (SNHL) has been less clear.Retrospective review of case histories and imaging studies of patients with SNHL and cochlear enhancement on GdMRI diagnosed between 1998 and 2000.Five patients with SNHL who required gadolinium administration to establish the diagnosis of endocochlear disease were identified. Diagnosed lesions included an intralabyrinthine schwannoma, intracochlear hemorrhage, radiation-induced ischemic change, autoimmune labyrinthitis, and meningogenic labyrinthitis. In these illustrative cases, the GdMRI demonstrated intrinsic high signal or contrast enhancement within the cochlea and labyrinth in the absence of a retrocochlear mass. In one patient with meningogenic labyrinthitis, cochlear enhancement on MRI led to prompt cochlear implantation before the potential development of cochlear ossification.Our experience suggests that GdMRI plays a crucial role in the diagnosis of cochlear pathology associated with sensorineural hearing loss and may directly impact patient management.

    View details for Web of Science ID 000173415300002

    View details for PubMedID 11802031

  • A century of eighth nerve surgery OTOLOGY & NEUROTOLOGY Jackler, R. K., Whinney, D. 2001; 22 (3): 401-416


    A scholarly review of over 70 original papers from the late 19th and early 20th centuries.Although many neurotologists consider vestibular nerve section to be a recent innovation, eighth nerve division dates back to the dawn of intracranial surgery. Although surgery of peripheral nerves (e.g., repair after injury) is ancient, intracranial nerve surgery began in the latter part of the 19th century with fifth nerve division for tic douloureux. By analogy, it was reasoned that hyperactivity of the eighth nerve (initially tinnitus and later vertigo) could be relieved by dividing this nerve. In 1898, Fedor Krause (1856-1937) of Berlin attempted the first eighth nerve section. This patient, as did many during this era, died shortly after the operation. Most of the survivors had facial palsy. These innovative early surgeons used a variety of approaches, including the suboccipital, middle fossa, and transtemporal routes. After an initial burst of excitement during the first decade of the century, poor results led to few procedures being performed through the second and third decades. Throughout this era, there was much debate about the relative merits of labyrinthectomy (introduced by Milligan and Lake in 1904) as opposed to eighth nerve division. In the late 1920s, the prolific Walter E. Dandy (1886-1946) of Baltimore repopularized eighth nerve section and ultimately performed 607 procedures between 1927 and 1946. Although Dandy achieved a high vertigo control rate and reduced the mortality rate to <1%, he had a high rate of facial nerve weakness (9.1% transient, 4.2% permanent). Remarkably, the latter outcome was never published in his numerous papers on the subject, but was first revealed in a 1951 retrospective survey, which appeared some 5 years after his death. Selective division of the vestibular fibers was introduced by Kenneth G. McKenzie (1892-1963) of Toronto in 1931. At least 11 sizable series appeared in the literature before the introduction of microsurgical vestibular nerve section by William F. House (b. 1923) of Los Angeles in 1960.The introduction and progressive refinement of eighth nerve section played a central role in the evolution of operative neurotology. Many of the most vigorous debates of recent years (e.g., the choice of operative route, the optimal site of division, and the relative role of inner ear surgery vs. nerve surgery) have antecedents in the controversies of the distant past.

    View details for Web of Science ID 000168446300024

    View details for PubMedID 11347648

  • A warning on venous ligation for pulsatile tinnitus OTOLOGY & NEUROTOLOGY Jackler, R. K., Brackmann, D. E., Sismanis, A. 2001; 22 (3): 427-428

    View details for Web of Science ID 000168446300028

    View details for PubMedID 11347652

  • MR imaging in two cases of subacute denervation change in the muscles of facial expression AMERICAN JOURNAL OF NEURORADIOLOGY Fischbein, N. J., Kaplan, M. J., Jackler, R. K., Dillon, W. P. 2001; 22 (5): 880-884


    Denervation changes in muscle following damage to cranial and peripheral nerves can be observed on both CT and MR imaging studies. These findings are well described for cranial nerves (CN) V, X, XI, and XII. The CT findings of denervation atrophy due to CN VII dysfunction have been reported. We describe the MR imaging findings in two patients with perineural spread of tumor along CN VII. Both patients showed T2 prolongation and postcontrast enhancement in muscles of facial expression, suggestive of subacute denervation changes.

    View details for Web of Science ID 000168681600017

    View details for PubMedID 11337333

  • Lesions of the internal auditory canal and cerebellopontine angle in an only hearing ear: Is surgery ever advisable? AMERICAN JOURNAL OF OTOLOGY Driscoll, C. L., Jackler, R. K., Pitts, L. H., Brackmann, D. E. 2000; 21 (4): 573-581


    To define the indications for surgery in lesions of the internal auditory canal (IAC) and cerebellopontine angle (CPA) in an only hearing ear.Retrospective case series.Tertiary referral center.Seven patients with lesions of the IAC and CPA who were deaf on the side opposite the lesion. Five patients had vestibular schwannoma (VS), and one each had meningioma and progressive osseous stenosis of the IAC, respectively. The opposite ear was deaf from three different causes: VS (neurofibromatosis type 2 [NF2]), sudden sensorineural hearing loss, idiopathic IAC stenosis.Middle fossa removal of VS in five, retrosigmoid resection of meningioma in one, and middle fossa IAC osseous decompression in one.Hearing as measured on pure-tone and speech audiometry.Preoperative hearing was class A in four patients, class B in two, and class C in one. Postoperative hearing was class A in three patients, class B in one, class C in two, and class D in one.Although the vast majority of neurotologic lesions in an only hearing ear are best managed nonoperatively, in highly selected cases surgical intervention is warranted. Surgical intervention should be considered when one or more of the following circumstances is present: (1) predicted natural history of the disease is relatively rapid loss of the remaining hearing, (2) substantial brainstem compression has evolved (e.g., large acoustic neuroma), and/or (3) operative intervention may result in improvement of hearing or carries relatively low risk of hearing loss (e.g., CPA meningioma).

    View details for Web of Science ID 000166431600022

    View details for PubMedID 10912705

  • Is the entire fundus of the internal auditory canal visible during the middle fossa approach for acoustic neuroma? AMERICAN JOURNAL OF OTOLOGY Driscoll, C. L., Jackler, R. K., Pitts, L. H., Banthia, V. 2000; 21 (3): 382-388


    To determine the degree to which the fundus of the internal auditory canal (IAC) can be visualized during the middle fossa approach (MFA).Conventional wisdom states that the MFA provides excellent access to the IAC from the porus acusticus to the fundus. On the basis of observations derived from a substantial surgical experience, it became obvious that a variable fraction of the fundus lies obscure from the surgeon's line of sight during the MFA because of (1) the overhand of the transverse crest and/or (2) the immobility of the facial nerve at its entry into the fallopian canal.Intraoperative measurements were performed in ten cases to determine the typical angle of view to the fundus of the IAC in the MFA. This angle of view was projected onto coronal computed tomography scans of 40 temporal bones. Measurements of the IAC were made to determine the amount of fundus that could not be directly visualized during a MF exposure.On the basis of a surgical line of sight, the fraction of the inferior compartment of the canal that could not be directly visualized because of overhand of the transverse crest ranged from 14% to 34% (median 25%).Complete resection of IAC tumors involving the fundus via the MFA requires some degree of blind dissection. Specialized tools and techniques are required to minimize the risk of neural injury during this indirect dissection. Inspection of the fundus with either mirror or endoscope is often necessary to exclude the possibility of retained tumor fragments.

    View details for Web of Science ID 000086904000017

    View details for PubMedID 10821552

  • Metastatic spinal ependymoma presenting as a vestibular schwannoma - Case illustration JOURNAL OF NEUROSURGERY Smyth, M. D., Pitts, L., Jackler, R. K., Aldape, K. D. 2000; 92 (2): 247-247

    View details for Web of Science ID 000086273300025

    View details for PubMedID 10763704

  • Neurofibromatosis 2, radiosurgery and malignant nervous system tumours BRITISH JOURNAL OF CANCER Baser, M. E., Evans, D. G., Jackler, R. K., Sujansky, E., Rubenstein, A. 2000; 82 (4): 998-998

    View details for Web of Science ID 000085212500040

    View details for PubMedID 10732777

  • Please don't close the patent office yet AMERICAN JOURNAL OF OTOLOGY Jackler, R. K. 2000; 21 (1): 3-4

    View details for Web of Science ID 000084710400002

    View details for PubMedID 10651426

  • The history of otology through eponyms II: The clinical examination AMERICAN JOURNAL OF OTOLOGY Lustig, L. R., Jackler, R. K. 1999; 20 (4): 535-550

    View details for Web of Science ID 000081351800022

    View details for PubMedID 10431898

  • Endoscope-assisted vestibular neurectomy. Laryngoscope Jackler, R. K. 1999; 109 (6): 1010-1011

    View details for PubMedID 10369299

  • Extradural temporal lobe retraction in the middle fossa approach to the internal auditory canal - Biomechanical analysis American-Neurotology-Society Spring Scientific Session Driscoll, C. L., Jackler, R. K., Pitts, L. H., Banthia, V. LIPPINCOTT WILLIAMS & WILKINS. 1999: 373–80


    The middle fossa (MF) approach is undergoing a marked resurgence in vestibular schwannoma surgery as a hearing conservation technique. It is widely recognized that the extradural temporal lobe retractors used in this procedure, despite their cleverness of design, could be improved.To identify the characteristics of an ideal MF retractor, a systematic analysis of the safety and functionality of four commonly used retractors (House-Urban, Fisch, Garcia-Ibanez, and UCSF) in a human anatomical model was conducted. Intensity of temporal lobe compression, width of exposure, angle of visualization, obstruction to instrument access, ergonomic convenience of use, and adaptability to other subtemporal procedures (e.g. lesions of Meckel's cave and cavernous sinus) were quantified.Because the intracranial portions of the retractors are similar, the force transmitted to the brain differed little among the four retractors. Numerous differences were noted in the ergonomics of use and versatility of the various designs.The optimal MF retractor would incorporate the best features of each of the existing systems: the integral suction of the Garcia-Ibanez, the bone contour-following design of the Fisch retractor base, the unobtrusiveness and adaptability of the UCSF, and the three-plane adjustability of the vintage House-Urban. Evolution of an "ideal" MF retractor requires further technical refinements and the development of an experimental model of extradural brain retraction to assess the optimal strategy for obtaining exposure while minimizing the risk for temporal lobe injury.

    View details for Web of Science ID 000080091600018

    View details for PubMedID 10337981

  • Brave new world ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Jackler, R. K. 1999; 125 (4): 471-472

    View details for Web of Science ID 000079617000017

    View details for PubMedID 10208690

  • Facial nerve dysfunction associated with cystic lesions of the mastoid OTOLARYNGOLOGY-HEAD AND NECK SURGERY Hwang, P. H., Jackler, R. K. 1998; 119 (6): 668-672

    View details for Web of Science ID 000077409400022

    View details for PubMedID 9852546

  • Meningiomas presenting in the temporal bone: The pathways of spread from an intracranial site of origin OTOLARYNGOLOGY-HEAD AND NECK SURGERY Chang, C. Y., Cheung, S. W., Jackler, R. K. 1998; 119 (6): 658-664

    View details for Web of Science ID 000077409400020

    View details for PubMedID 9852544

  • Subcochlear petrous cholesterol granuloma involving the infratemporal fossa OTOLARYNGOLOGY-HEAD AND NECK SURGERY Lustig, L. R., Cheung, S. W., Jackler, R. K. 1998; 119 (6): 685-689

    View details for Web of Science ID 000077409400026

    View details for PubMedID 9852550

  • Treatment of acoustic neuromas NEW ENGLAND JOURNAL OF MEDICINE Pitts, L. H., Jackler, R. K. 1998; 339 (20): 1471-1473

    View details for Web of Science ID 000077051700011

    View details for PubMedID 9811925

  • The perils of decentralized care in otology/neurotology AMERICAN JOURNAL OF OTOLOGY Jackler, R. K. 1998; 19 (6): 691-692

    View details for Web of Science ID 000079245700001

    View details for PubMedID 9831137

  • Lipomas of the internal auditory canal and cerebellopontine angle 101st Annual Meeting of the American-Laryngological-Rhinological-and-Otological-Society Bigelow, D. C., Eisen, M. D., Smith, P. G., Yousem, D. M., Levine, R. S., Jackler, R. K., Kennedy, D. W., Kotapka, M. J. JOHN WILEY & SONS INC. 1998: 1459–69


    To evaluate lipomas of the internal auditory canal (IAC) and cerebellopontine angle (CPA).Retrospective review.Review of a multi-institutional series of 17 lipomas of the IAC/CPA, combined with a Medline review of the 67 cases reported in the world literature.This series of 17 IAC/CPA lipomas is the largest reported series to date, bringing the total number of documented cases to 84. There appears to be a nearly 2:1 male to female predominance. Sixty percent were left-sided lesions, and three were bilateral. Hearing loss, dizziness, and tinnitus were the most common presenting symptoms. Surgical resection was performed in 52 (62%) of these lesions; however, total tumor removal was accomplished in only 17 (33%), which is most likely because of the fact that these tumors tend to have a poorly defined matrix and a dense adherence to neurovascular structures. Sixty-eight percent of patients experienced a new deficit postoperatively, 11% were unchanged, and only 19% improved with no new deficit. Only one documented case of tumor growth was identified; however, the reported follow-up was short (average, less than 3 years).With the magnetic resonance imaging techniques now available, lipomas can be reliably differentiated from other masses within the CPA and IAC, so histopathologic diagnosis is rarely necessary. Because of the potential for significant morbidity with resection of these lesions, we believe that conservative follow-up is the best treatment option for patients with these rare lesions. Surgery is indicated only when significant progressive or disabling symptoms are present.

    View details for Web of Science ID 000076340100008

    View details for PubMedID 9778284

  • Germline screening of the NF-2 gene in families with unilateral vestibular schwannoma 101st Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Bikhazi, P. H., Lalwani, A. K., Kim, E. J., Bikhazi, M., Attaie, L., Slattery, W. H., Jackler, R. K., Brackmann, D. E. SAGE PUBLICATIONS LTD. 1998: 1–6


    Vestibular schwannoma may present clinically in two forms: sporadic unilateral or hereditary bilateral. Familial transmission of vestibular schwannoma is known to occur only in neurofibromatosis type II (NF-2). We have previously described the clinical characteristics of unilateral vestibular schwannoma presenting in families, in the absence of ther criteria necessary for the diagnosis of NF-2. Polymerase chain reaction-single strand chain polymorphism was used to screen for germline NF-2 gene mutations in six families with unilateral vestibular schwannoma. Direct sequencing of DNA from blood was done in affected subjects from three families. No germline mutations were identified. Because NF-2 gene mutations are detected in only 33% of patients with NF-2, hereditary transmission of mutations cannot be entirely excluded. However, in the absence of germline mutations in the NF-2 gene, familial occurrence of unilateral vestibular schwannoma more likely represents either a chance somatic NF-2 gene mutation or originates from a separate genetic loci.

    View details for Web of Science ID 000074822600001

    View details for PubMedID 9674507

  • Further characterization of the DFNA1 audiovestibular phenotype ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Lalwani, A. K., Jackler, R. K., Sweetow, R. W., LYNCH, E. D., Raventos, H., Morrow, J., KING, M. C., Leon, P. E. 1998; 124 (6): 699-702


    Autosomal dominant, nonsyndromic, hereditary hearing impairment in a large Costa Rican kindred is caused by a mutation in the human homolog of the Drosophila diaphanous gene.To further characterize the phenotype of DFNA1 with comprehensive audiovestibular evaluation and computed tomography of the temporal bone.One affected child and 2 affected adults of the Costa Rican kindred who harbor a mutation in the diaphanous gene.Medical Center at the University of California, San Francisco.Otologic and neuro-otologic examination; pure tone audiometry, speech audiometry, and immitance testing; auditory evoked potentials, electrocochleography, and otoacoustic emissions; electronystagmography and vestibular autorotation tests; and computed tomography of the temporal bone.The youngest subject, an 8-year-old boy, had a mild hearing loss, intact stapedial reflexes, otoacoustic emissions at high frequencies, normal auditory evoked potentials, and electrocochleographic findings consistent with endolymphatic hydrops. The two adults had severe to profound bilateral sensorineural hearing impairment. Electronystagmography disclosed normal vestibular function. Computed tomography demonstrated normal external, middle, and inner ear structures.These results suggest that the early low-frequency hearing loss in this family is associated with endolymphatic hydrops. Elucidation of the role of the diaphanous gene in hearing will therefore lead to a better understanding of the mechanism of endolymphatic hydrops.

    View details for Web of Science ID 000074229000014

    View details for PubMedID 9639482

  • The history of otology through its eponyms I: Anatomy AMERICAN JOURNAL OF OTOLOGY Lustig, L. R., Jackler, R. K., Mandelcorn, R. 1998; 19 (3): 371-389

    View details for Web of Science ID 000077356200022

    View details for PubMedID 9596191

  • Hearing preservation in patients undergoing vestibular schwannoma surgery: comparison of middle fossa and retrosigmoid approaches JOURNAL OF NEUROSURGERY Irving, R. M., Jackler, R. K., Pitts, L. H. 1998; 88 (5): 840-845


    The goal of this retrospective study was to evaluate hearing preservation after surgery for vestibular schwannoma in which the middle fossa (MF) or retrosigmoid (RS) approaches were used. Hearing preservation in vestibular schwannoma surgery can be achieved by using either the MR or RS approach. Comparative outcome data between these approaches are lacking, and, as a result, selection has generally been determined by the surgeon's preference.The authors have compared removal of small vestibular schwannomas via MF and RS approaches with regard to hearing preservation and facial nerve function. The study group was composed of consecutively treated patients with vestibular schwannoma, 48 of whom underwent operation via an MF approach and 50 of whom underwent the same number of RS operations. Tumors were divided into size-matched groups. Hearing results were recorded according to the American Academy of Otolaryngology-Head and Neck Surgery criteria, and facial nerve outcome was recorded as the House-Brackmann grade. Overall, 26 (52%) of the patients treated via the MF approach achieved a Class B or better hearing result compared with seven (14%) of the RS group. Some hearing was preserved in 32 (64%) of the patients in the MF group and in 17 (34%) of the RS group. The results obtained by using the MF approach were superior for intracanalicular tumors (p=0.009, t-test), and for tumors with a cerebellopontine angle (CPA) component measuring 0.1 to 1 cm (p=0.006, t-test). For tumors in the CPA that were 1.1 to 2 cm in size, our data were inconclusive because of the small sample size. Facial weakness was seen more frequently after MF surgery in the early postoperative period, but results were equal at 1 year.The results of this study have demonstrated a more favorable hearing outcome for patients with intracanalicular tumors and tumors extending up to 1 cm into the CPA that were removed via the MF when compared with the RS approach.

    View details for Web of Science ID 000073244500007

    View details for PubMedID 9576251

  • Facial nerve surgery in the 19th and early 20th centuries: The evolution from crossover anastomosis to direct nerve repair AMERICAN JOURNAL OF OTOLOGY Shah, S. B., Jackler, R. K. 1998; 19 (2): 236-245


    The historical aspects of facial nerve (FN) anatomy and of Bell's palsy have long been favorite topics of otologic historians. Little attention has been paid, however, to the evolution of FN surgery, a subject with a remarkably rich and engaging history. In the early 13th century, Roland, an Italian surgeon, used a red hot iron to coapt severed nerve endings. In the 17th century, Ferrara, another Italian, sutured injured nerves with tortoise tendon dipped in hot red wine. It was not until the late 19th century that peripheral nerve suture became a subject of serious scientific study. Although it is ironic, the course of events suggests that the evolution of FN repair was greatly stimulated by the development of the modern mastoid operation. Whereas the simple mastoid operation practiced by Wilde (1853) and others carried little risk of FN injury, more adventuresome procedures such as radical mastoidectomy (Kessel, 1885) carried a much greater risk. The abundance of iatrogenic palsies during this era undoubtedly did much to motivate surgeons to seek a better means of restoring facial animation. Most surgeons would be surprised to learn that crossover anastomoses predated direct nerve repair by nearly half a century. In 1879, the German surgeon Drobnik performed the first facial-spinal accessory anastomosis. Over the next two decades, numerous articles were written (most notably by Sir Charles Balance and Harvey Cushing) on crossovers between the FN and cranial nerves IX, X, XI, and XII. Although a few tentative attempts at reapproximating severed FNs took place in the first two decades of this century, it was not until 1925 that an actual suture repair of an intratemporal injury was undertaken. This feat was first accomplished by the famous hand surgeon Sterling Bunnell and shortly thereafter by the otolaryngologist Robert Martin. The evolution of FN surgery in the days predating the operating microscope is a rich tapestry of colorful personalities and clashing egos, which saw promising advances relegated to obscurity and some previously obscure techniques become progressively more promising.

    View details for Web of Science ID 000077356100020

    View details for PubMedID 9520063

  • Acoustic neuromas presenting with normal or symmetrical hearing: Factors associated with diagnosis and outcome Annual Meeting of the American-Otologic-Society Lustig, L. R., Rifkin, S., Jackler, R. K., Pitts, L. H. LIPPINCOTT WILLIAMS & WILKINS. 1998: 212–18


    To evaluate the clinical features leading to diagnosis in patients with acoustic neuroma (AN) who present with normal or symmetrical hearing. Underlying tumor characteristics are also studied to identify a possible explanation for this unique presentation in the AN population.Retrospective case review comprising patients who were identified as having AN that presented with normal audiometry.A tertiary referral center.Patients with AN who met the criteria for normal were included in the report. For this study, abnormal audiometry is defined as an interaural difference of > or =15 dB at a single frequency or > or =10 dB at two or more frequencies, and an interaural speech reception threshold difference of > or =20 dB, or a speech discrimination score of > or =20%.Presenting symptoms and signs, clinical features that led to the diagnosis of AN, auditory brain stem response results, tumor location, size and relationship to temporal bone landmarks, surgical intervention, surgical outcome, and results of hearing preservation attempts were tabulated for each patient.A total of 29 patients (5%) were identified who had normal or symmetrical pure-tone audiograms between 500 and 4,000 Hz. The average difference in speech reception threshold between tumor and nontumor ear was 3.2 dB, and the average difference in speech detection score was 2.6%. The most common presenting symptoms that led to the diagnosis of the AN were dysequilibrium/vertigo (12 cases), cranial nerve V and VII abnormalities (11 cases), routine screening for families with neurofibromatosis type 2 (5 cases), asymmetrical tinnitus (4 cases), headaches (4 cases), unilateral subjective hearing difficulty (4 cases), and incidental finding during evaluation for another problem (4 cases). The average tumor size was 19 mm, with five cases presenting with tumors of size > or =30 mm. Nineteen patients underwent a hearing preservation procedure (middle fossa or retrosigmoid), 11 of whom had useful hearing postoperatively.Despite normal audiometry, patients presenting with imbalance or vertigo, Vth or VIIth cranial nerve deficits, or unilateral hearing complaints may warrant further evaluation to rule out the possibility of AN or other retrocochlear lesion. To seek an explanation for this phenomenon, the incidence of various tumor characteristics (e.g., depth of penetration into the internal auditory canal and degree of porous erosion) is discussed and compared with the entire AN population.

    View details for Web of Science ID 000077356100016

    View details for PubMedID 9520059

  • Comparison of response amplitude versus stimulation threshold in predicting early postoperative facial nerve function after acoustic neuroma resection American-Neurology-Society Annual Meeting Mandpe, A. H., Mikulec, A., Jackler, R. K., Pitts, L. H., Yingling, C. D. LIPPINCOTT WILLIAMS & WILKINS. 1998: 112–17


    This study aimed to better predict the early postoperative facial nerve (FN) function after acoustic neuroma (AN) resection.This study was a prospective series.The surgery was conducted in a tertiary referral center.A total of 44 patients undergoing AN resection with cranial nerve monitoring were observed for at least 1 year after surgery.The predictive value of amplitude of the FN stimulus response on the early postoperative FN function was measured.Cranial nerve monitoring in AN surgery was used to obtain the stimulation threshold and facial electromyograph response amplitudes to FN stimulation proximal and distal to the tumor at 0.2 V above threshold. Thirty-eight of forty-four patients studied had a low postresection threshold (< or = 0.1 V). Of these (10), 26% sustained a postoperative FN dysfunction of House-Brackmann (HB) grades 3-6. In an effort to improve the predictive value from cranial nerve monitoring, the response amplitude to suprathreshold stimulation was compared with the threshold and FN function. Eighty-nine percent of patients with an amplitude of > or =200 microV had a grade 1-2 early postoperative FN function, whereas only 41% of patients with < 200 microV had a grade 1-2 early postoperative FN function (p = 0.00035). Eighty-eight percent of patients with both a low threshold and high amplitude had a grade 1-2 early postoperative FN function, whereas the remaining 12% of patients had a grade 3-6 FN function (p = 0.0032). The false-positive rate of threshold alone in predicting a grade 1-2 FN function was 26% compared to 12% for low threshold and high amplitude combined.The use of FN threshold and amplitude together is superior to threshold alone as a predictor of early postoperative FN function.

    View details for Web of Science ID 000072650000023

    View details for PubMedID 9455959

  • The vulnerability of the vein of Labbe during combined craniotomies of the middle and posterior fossae SKULL BASE SURGERY Lustig, L. R., Jackler, R. K. 1998; 8 (1): 1-9


    During combined middle and posterior cranial fossae ("petrosal") approaches to the skull base, the anastamotic vein of Labbe, which bridges between the inferior surface of the temporal lobe and the transverse sinus is placed at risk. Occlusion of this vein, which may drain a large section of the temporal and parietal lobes, may lead to speech, memory, and/or other cognitive disorders. Labbe may be injured along its course on the inferior aspect of the temporal lobe where it may be laceraed during dural incision or thrombosed due to prolonged or overly vigorous retraction. The anastamotic segment of the vein, which bridges between the temporal lobe and transverse sinus, may be avulsed during elevation of the temporal lobe or injured during tentorial division. Labbé may course in close proximity to the upper surface of the tentorium or even travel within it for a short segment of its course en route to the transverse sinus. This article reviews the anatomy of the vein of Labbé, discusses its clinical significance, and highlights the technical points relevant to the preservation of this important structure.

    View details for Web of Science ID 000079354600001

    View details for PubMedID 17171036

  • Removal of jugular foramen tumors: The fallopian bridge technique OTOLARYNGOLOGY-HEAD AND NECK SURGERY Pensak, M. L., Jackler, R. K. 1997; 117 (6): 586-591


    Despite recent advances in neuroradiographic and electrophysiologic assessment, the surgical extirpation of lesions of the bony skull base remains challenging. Moreover, as surgeons have gained experience in removing tumors from the irregular osteologic confines of the skull base, attention has been directed toward preservation of vital neural and vascular structures traversing the operative field. This report describes the creation of a fallopian bridge with preservation of the facial nerve in removing tumors that arise within or juxtaposed to the jugular fossa. Thirty-five patients are reported herein with analysis of pathology, surgical approach, and outcome. An algorithm for use of the fallopian bridge, as opposed to facial nerve mobilization and rerouting, is presented with particular emphasis on limitation of this selective procedure.

    View details for Web of Science ID 000071083200004

    View details for PubMedID 9419083

  • Are acoustic neuromas encapsulated tumors? 99th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Kuo, T. C., Jackler, R. K., Wong, K. D., Blevins, N. H., Pitts, L. H. SAGE PUBLICATIONS LTD. 1997: 606–9


    In articles and chapters on the subject of acoustic neuroma, it is almost invariably stated that they are well-encapsulated tumors. During surgical procedures, blunt mechanical dissection defines a natural subsurface cleavage plane that leaves intact a several millimeter thick rind of tumor surface. Occasionally, as a concession to neural integrity, less than complete resection is elected, leaving behind this "capsular" remnant. To clarify the nature of the surface of acoustic neuromas and to test whether this long held description is indeed correct, a microscopic analysis of 10 surgical specimens was performed. A wedge was harvested from the free surface of the tumor in the mid cerebellopontine angle that included a large, undisturbed section of the tumor surface. Histologic analysis showed that for most of the tumor surface only an extremely thin (3 to 5 microm) layer of connective tissue envelops the tumor. Neoplastic Schwann cells, which extend essentially to the margin of the tumor, were found to be somewhat flattened and compressed in the vicinity of the surface. Although acoustic neuromas are surrounded by a continuous layer of connective tissue, it is so exceptionally thin (on average less than the diameter of a red blood cell) that its edge cannot be visualized intraoperatively by a surgeon. Because the pathologic definition of a capsule is a thick, enveloping layer of connective tissue that is both micro- and macroscopically evident, it must be concluded that acoustic neuromas are nonencapsulated, at least in the conventional sense of the term. The surface peel observed intraoperatively is surgically produced during tumor debulking by cleaving of the looser central component from the more compressed portion of neoplastic cells that lies immediately beneath the free margin of the lesion.

    View details for Web of Science ID 000071083200007

    View details for PubMedID 9419086

  • Familial occurrence of unilateral vestibular schwannoma 100th Annual Meeting of the American-Laryngological-Rhinological-and-Otological-Society Bikhazi, N. B., Slattery, W. H., Lalwani, A. K., Jackler, R. K., Bikhazi, P. H., Brackmann, D. E. WILEY-BLACKWELL. 1997: 1176–80


    Vestibular schwannoma (VS) may present clinically in one of two forms: sporadic unilateral or hereditary bilateral. Almost all cases of familial transmission have been associated with the diagnosis of neurofibromatosis type II (NF-2). In this report, we describe nine families (18 individuals) presenting with unilateral VS without evidence of NF-2. In four of the nine families, the affected individuals were of parent-offspring relationship, in three families they were cousin-cousin, and in the remaining two families, they were sibling-sibling and aunt-nephew. No other members of the families were diagnosed with NF-2. There was no evidence for gender predilection or genomic imprinting among affected individuals. This study suggests that familial occurrence of unilateral VS may be genetically inherited as it occurs more commonly than would be estimated by chance alone. Future genetic studies will elucidate whether occurrence of unilateral VS in these families represents a variable expression of NF-2, chance occurrence of unilateral VS in families, or a new genetic disorder.

    View details for Web of Science ID A1997XV10400004

    View details for PubMedID 9292599

  • Lodestones, quackery, and science: Electrical stimulation of the ear before cochlear implants AMERICAN JOURNAL OF OTOLOGY Shah, S. B., Chung, J. H., Jackler, R. K. 1997; 18 (5): 665-670

    View details for Web of Science ID A1997XW11700024

    View details for PubMedID 9303167

  • Socioeconomic impact of acoustic neuroma surgery Annual Meeting of the American-Neurotology-Society Chung, J. H., Rigby, P. L., Jackler, R. K., Shah, S. B., COOKE, D. D. LIPPINCOTT WILLIAMS & WILKINS. 1997: 436–43


    This study aimed to assess the impact of acoustic neuroma (AN) surgery on socioeconomic function.This study was a retrospective postal survey.The study was performed at a tertiary referral center.One hundred thirty late postoperative AN patients were surveyed a minimum of 6 months after surgery (average 39 months). The survey response rate was 65% (130 of 200).These included effect of AN surgery on employability, income, activities of daily living, social involvement, and psychological well-being.When comparing preoperative occupational status with latest follow-up, 2 of 125 (1.6%) became unemployed from their usual occupations. An additional 15 of 125 (12%) retired, attributing their retirement to the effects of the tumor itself (3), an aftermath of surgery (2), and causes unrelated to their AN (10). After AN removal, two formerly unemployed patients became employed. Among those remaining employed, there was no significant impact of surgery on either income or work responsibility. Return to normal activity was gradual: < or = 6 weeks, 31%; < or = 3 month, 64%; and < or = 6 months, 84%. Among activities of daily living, the tasks most often impaired (both before and after tumor removal) were ladder climbing and night driving, whereas dressing and bathing were seldom problematic. Overall, patients reported a minor decline in ability to perform routine daily activities after tumor removal. Social function (contact with friends, community involvement, and participation in sports) changed little after surgery. The incidence of both stress and depression decreased slightly after tumor removal.The economic, social, and psychological impact of AN and its surgical management appears to be relatively minor, with few individuals having life altering consequences.

    View details for Web of Science ID A1997XK48400006

    View details for PubMedID 9233482

  • Acoustic neuroma Surgery: Outcome analysis of patient-perceived disability AMERICAN JOURNAL OF OTOLOGY Rigby, P. L., Shah, S. B., Jackler, R. K., Chung, J. H., COOKE, D. D. 1997; 18 (4): 427-435


    Numerous studies have investigated the outcome of acoustic neuroma (AN) treatment using classical medical measures. In an effort to describe the long-term lifestyle consequences of AN removal from the patient's perspective, patients filled out detailed questionnaires concerning their functional status.This was a retrospective survey.This study was performed at a tertiary referral center.A total of 130 late postoperative acoustic neuroma patients were surveyed a minimum of 6 months following surgery (average, 39 months). Survey response rate was 65% (130/200).The main outcome measures were the patient's perception of their hearing, balance, facial expression, and eye function in relation to its impact upon the activities of daily life. A comparison of pretreatment with long-term posttreatment functional levels.When asked to designate their "most significant" symptom, hearing loss was by far most prevalent (61.3%), followed by balance troubles (14.3%) and facial weakness (10.1%). The relatively low incidence of facial weakness as the patient's dominant complaint was somewhat surprising. When considering the incidence of each symptom, women were more likely to complain of facial weakness, dry eye, and headache, whereas men had a marginally higher incidence of hearing loss and imbalance. Patient age had no apparent influence upon either the distribution or severity of symptomatic complaints. Both hearing in the tumor ear and overall auditory function (e.g., the ability to understand in a restaurant) tended to worsen following surgery. One finding, which was both unanticipated and intriguing, was the improvement in sound localization ability reported by 57% of patients following surgery. Although the proportion of patients complaining of frequent tinnitus increased postoperatively, the number of patients who found the tinnitus troublesome decreased markedly. In terms of balance function, only 31% preoperatively and 15% postoperatively described themselves as free of balance difficulties. An aid to ambulation (e.g., cane, walker) was needed in five patients (4%) preoperatively, two of whom regained the ability to walk independently following tumor removal.These functional outcome data provide much useful information to both patient and clinician to consider when contemplating the optimal course of AN management. Although virtually all acoustic neuroma patients have some degree of persistent symptoms over the long-term, the data indicates that most of these are attributable to the tumor itself as opposed to the after effects of its surgical removal. The relatively slight differences between preoperative and late postoperative symptom profiles was a rather unanticipated finding. As the degree of disability tends to increase with larger tumor sizes, these data tend to support a policy of early intervention.

    View details for Web of Science ID A1997XK48400005

    View details for PubMedID 9233481

  • Exophytic brain tumors mimicking primary lesions of the cerebellopontine angle Meeting of the Western Section of the American-Laryngological-Rhinological-and-Otological-Society Ahn, M. S., Jackler, R. K. LIPPINCOTT-RAVEN PUBL. 1997: 466–71


    The vast majority of cerebellopontine angle (CPA) tumors are extraaxial masses arising from either the eighth nerve (acoustic neuroma) or meninges (meningioma). Rarely, a tumor that arises from the brain parenchyma may protrude laterally to present with a clinical and radiographic picture simulating that of the much more common extraaxial lesions. Three individuals with CPA lesions that ultimately proved at operation to be exophytic brain tumors (pontine medulloblastoma, cerebellar astrocytoma, and fourth ventricular ependymoma) are described. The clinical manifestations of these lesions, although not entirely typical, fell well within the possible range of presentation of benign tumors primary to the CPA. In two of these cases the tumor actually penetrated into the internal auditory canal. As the optimal management strategy for treating parenchymal tumors differs substantially from that for extraaxial lesions, it is essential that the surgeon have a preoperative awareness of the lesion's nature before embarking on a surgical endeavor. Critical to arriving at the correct diagnosis is the close examination of preoperative imaging studies. The clinician should be alerted to the possibility that a CPA tumor is of intraaxial origin when the preoperative magnetic resonance imaging scan shows 1) blurring of the margin between the tumor and brainstem or cerebellum; 2) a degree of peritumoral hyperintensity on T2-weighted scans disproportionate to the size of the extraaxial mass; and 3) dilation of the lateral recess of the fourth ventricle.

    View details for Web of Science ID A1997WU27700007

    View details for PubMedID 9111375

  • Radiation-induced tumors of the temporal bone Annual Meeting of the American-Otological-Society Lustig, L. R., Jackler, R. K., LANSER, M. J. LIPPINCOTT-RAVEN PUBL. 1997: 230–35


    To discuss a rare but devastating complication following radiotherapy to the head and neck: radiation-induced malignancies of the temporal bone.A retrospective case review comprising five patients with radiation-induced tumors involving the temporal bone.A tertiary referral center.Patients with tumors involving the temporal bone who have satisfied the criteria for being considered radiation-associated.Initial tumor histology, radiation-induced tumor histology, latency between radiotherapy and diagnosis of the radiation-associated malignancy, amount of radiation received, therapeutic interventions, and survival statistics for each patient.Five cases of radiation-induced tumors of the temporal bone are presented (two osteosarcomas, two fibrosarcomas, and one squamous cell carcinoma). All five temporal bone tumors occurred in individuals that had previously received > 5,000 cGy of radiation. The initial histologic diagnoses included two astrocytomas, a glomus jugulare, a malignant meningioma, and a vestibular schwannoma. There was an average latency period of 15 years (range, 7-23 years) between completion of radiation and diagnosis of the malignancy. Four patients were treated with resection plus chemotherapy, and one decided against therapy. The prognosis was poor, with survival time of 7-14 months after the diagnosis of the radiation-induced tumor. Only one patient survived > 14 months and is currently free of disease, 3 years after diagnosis of the radiation-induced tumor.Although radiation-induced tumors of the temporal bone occur with a very low incidence, their prognosis is extremely poor. The remote possibility of a radiation-associated tumor should be factored in when deciding upon the most appropriate therapeutic modality for individuals with neoplasms of the CNS and head and neck. Such considerations are particularly germane when contemplating radiation therapy for a benign lesion (e.g., glomus jugulare, acoustic neuroma, or meningioma) in an individual with a long predicted lifespan.

    View details for Web of Science ID A1997WQ04200022

    View details for PubMedID 9093681

  • Lipoid meningitis due to aseptic necrosis of a free fat graft placed during neurotologic surgery LARYNGOSCOPE Hwang, P. H., Jackler, R. K. 1996; 106 (12): 1482-1486


    We present two unusual cases of aseptic postoperative lipoid meningitis resulting from necrosis of a free fat graft placed into a skull base craniotomy defect. Two patients underwent translabyrinthine resection of acoustic neuroma and received abdominal fat grafts to ablate the surgical defect. Both patients presented postoperatively with persistent cerebrospinal fluid (CSF) wound leak and severe headache. Computed tomography demonstrated hydrocephalus and widely dispersed intracranial fat droplets throughout the CSF circulation. Both patients ultimately required CSF diversion for management of persistent communicating hydrocephalus. The clinical and radiographic correlates of lipocephalus and lipoid meningitis are presented, and a review of free fat graft physiology is discussed.

    View details for Web of Science ID A1996VX21200007

    View details for PubMedID 8948607

  • Repair of chronic tympanic membrane perforations with fibroblast growth factor 1993 Annual Meeting of the American-Academy-of-Otolaryngology - Head-and-Neck-Surgery Kato, M., Jackler, R. K. MOSBY-YEAR BOOK INC. 1996: 538–47


    A number of angiogenic growth factors have been shown to accelerate wound healing. Previous work has demonstrated that topical application of epidermal growth factor is effective in healing chronic tympanic membrane perforations in an animal model. Theoretically, fibroblast growth factor may result in a superior healed membrane through preferential stimulation of the fibroblasts within the middle layer of the tympanic membrane. To test this hypothesis, the effects of exogenously applied fibroblast growth factor on the chronically perforated tympanic membrane were evaluated. A buffered solution of fibroblast growth factor (25 microliters of fibroblast growth factor, 0.2 mg/ml) was administered to a Gelfoam pledget placed over chronic tympanic membrane perforations in chinchillas. Control ears were treated with Gelfoam and the buffer solution only. Complete closure of the tympanic membrane perforation was observed in 81% (13 of 16) of the fibroblast growth factor-treated ears, but in only 41% (7 of 17) of the controls (p = 0.05). Heading took place gradually, requiring an average of 4 weeks for the fibroblast growth factor-treated and 6.5 weeks for the control ears that healed. The relatively high healing rate for the control group does not imply that the pretreatment perforations were not chronic, rather there appears to be some efficacy to the control protocol of repeated applications of Gelfoam and buffer. A histologic analysis of the fibroblast growth factor-healed eardrums immediately after closure demonstrated hypertrophy of the squamous and fibrous layers of the tympanic membrane. Over time, the eardrum thinned to reach proportions similar to those of the normal tympanic membrane, including the presence of a substantial middle fibrous layer. A screening ototoxicity study revealed no structural damage to the organ of Corti after growth factor treatment. To assess the potential for systemic toxicity, blood and peripheral tissues were analyzed for radioactivity at time points during a 48-hour period after application of 25 microliters of 125I-fibroblast growth factor to the perforated tympanic membrane. More than 78% of the radioactivity remained at the application site. Given the tiny original dosage, the small fraction absorbed systemically is minuscule and highly unlikely to induce adverse effects in light of published toxicity data. On the basis of these promising safety and efficacy data in the chinchilla model, clinical trials of fibroblast growth factor in repair of chronic tympanic membrane perforations in human beings are being initiated.

    View details for Web of Science ID A1996VZ27200008

    View details for PubMedID 8969759

  • The early history of the neurofibromatoses - Evolution of the concept of neurofibromatosis type 2 ARCHIVES OF OTOLARYNGOLOGY-HEAD & NECK SURGERY Ahn, M. S., Jackler, R. K., Lustig, L. R. 1996; 122 (11): 1240-1249


    Although neurofibromatosis (NF) became widely recognized as a pathologic entity in the late 19th century, only relatively recently has a clear distinction been made between its generalized form and the central variety. The latter form is typified by bilateral acoustic neuromas (ANs), which may be accompanied by other intracranial tumors, in particular, meningiomas. Up until almost the current era, confusion regarding the protean manifestations of the 2 types of NF existed in the minds of clinicians and in the literature. In 1987, a consensus panel of the National Institutes of Health differentiated the clinical manifestations associated with classic von Recklinghausen syndrome from those of the predominantly intracranial subtype and they were subsequently deemed NF type 1 (NF-1) and NF type 2 (NF-2), respectively. During the last few years, the genetic flaws that underlie these 2 syndromes have been elucidated, revealing that their origins lie in defects on separate chromosomes. The early literature on the subject included repeated descriptions of patients with manifestations typical of NF-2. The investigators, however, considered the intracranial lesions to be merely 1 facet of the generalized form of the disease. A few prescient individuals, however, demonstrated an appreciation for the distinguishing characteristics between these superficially similar, yet quite different, syndromes. The goals of this article are to trace the evolution of the concept of NF-2 as a distinct clinical entity from NF-1 and to assess the early awareness of and attitudes toward bilateral ANs, familial ANs, and ANs associated with other intracranial tumors.

    View details for Web of Science ID A1996VQ70600015

    View details for PubMedID 8906061

  • Cost-effective screening for acoustic neuroma with unenhanced MR: A clinician's perspective AMERICAN JOURNAL OF NEURORADIOLOGY Jackler, R. K. 1996; 17 (7): 1226-1228

    View details for Web of Science ID A1996VC32900004

    View details for PubMedID 8871703

  • The variable relationship between the lower cranial nerves and jugular foramen tumors: Implications for neural preservation AMERICAN JOURNAL OF OTOLOGY Lustig, L. R., Jackler, R. K. 1996; 17 (4): 658-668


    Tumors involving the jugular foramen (JF) have a variable relationship to the neurovascular structures (jugular vein, cranial nerves IX-XI) that traverse this conduit through the skull base. The surgeon familiar with the site of origin, growth pattern, and geometry of each of the common lesions affecting this region with respect to surrounding nerves and vessels is at a considerable advantage when undertaking a function-sparing procedure. Anatomically, the JF has two vascular compartments that may be affected by tumor: the jugular bulb laterally and a passage for the inferior petrosal sinus medially. Tumors may also penetrate the JF along the fibro-osseous diaphragm, which divides these two vascular channels. The lower cranial nerves lie on either side of this partition, which is connected to the posterior cranial fossa via a curved, funnel-shaped cone of dura. Tumors that arise within or penetrate the JF lateral to this neural plane displace the nerves medially, a position favorable for their preservation during tumor extirpation. By contrast, medially positioned tumors displace the cranial nerves onto the lateral tumor surface, where they interpose between surgeon and tumor-an unfavorable location. Glomus tumors consistently arise in the lateral aspect of the JF, displacing the lower cranial nerves medially. This positioning accounts for the high rate of neural preservation in small and medium-size glomus tumors that have not invaded the foramen's central partition. Meningiomas that arise lateral to the JF (e.g., the posterior petrous surface, sigmoid sinus) favorably displace the lower cranial nerves medially. By contrast, tumors that originate medial to the JF (e.g., clivus, foramen magnum) are unfavorable, laterally displacing the multiple small rootlets that coalesce into cranial nerves IX-XI into a vulnerable location. Schwannomas arise within the neural plane and have a variable geometry that depends, in part, upon the nerve of origin. Theoretically, tumors that arise from the ninth nerve, which is located on the lateral surface of the neural plane, should be more favorable than those originating from the tenth or eleventh nerves, which lie on its deep surface. The propensity of these three tumor types toward thrombosis of the jugulosigmoid complex also carries important surgical implications. Because glomus tumors arise from the jugular bulb, the jugulosigmoid complex is nearly always occluded. In both meningiomas and schwannomas, however, the jugular system may occasionally remain patent. This is important to recognize through angiography and/or magnetic resonance venography, since sacrifice of a patent, dominant system risks intracerebral venous infarction.

    View details for Web of Science ID A1996UZ06700026

    View details for PubMedID 8841718

  • Anterior facial nerve rerouting in cranial base surgery: A comparison of three techniques OTOLARYNGOLOGY-HEAD AND NECK SURGERY VONDOERSTEN, P. G., Jackler, R. K. 1996; 115 (1): 82-88


    Anterior rerouting of the facial nerve is a maneuver designed to enhance exposure of the jugular foramen and carotid canal during resection of cranial base tumors. Our clinical impression is that the degree of additional exposure afforded by moving the facial nerve varies considerably according to both anatomic variations and the technique used. Three possible techniques exist based on the extent of facial nerve mobilization and point of rotation: canal wall up-second genu pivot point (CWU-2G); canal wall down-second genu pivot point (CWD-2G); and canal wall down-first genu pivot point (CWD-IG). We anatomically studied 20 human cadaver heads to establish clinically relevant guidelines for the selective use of these techniques. At the level of the dome of the jugular bulb, the facial nerve mobilized anteriorly a mean of 4.2 mm for CWU-2G, 10 mm for CWD-2G, and 14 mm for CWD-1G. Detailed analysis of numerous measurements and rotation angles suggests that the typical exposure afforded by the various rerouting techniques is as follows: CWU-2G, complete exposure of the jugular bulb; CWD-2G, exposure of the jugular bulb and a mean of 6 mm of the posterior aspect of the carotid artery; and CWD-IG, exposure of the jugular bulb and entire carotid genu. Minimizing the amount of facial nerve manipulation needed to achieve sufficient surgical exposure helps optimize postoperative functional status.

    View details for Web of Science ID A1996VA14100013

    View details for PubMedID 8758635

  • Lasers in surgery for chronic ear disease OTOLARYNGOLOGIC CLINICS OF NORTH AMERICA Saaed, S. R., Jackler, R. K. 1996; 29 (2): 245-?


    This article describes specific situations in which the laser has been found to be useful in surgery for chronic ear disease. In the opinion of the authors, the most important application is the atraumatic removal of cholesteatoma from a mobile stapes. Additional uses include precise and hemostatic removal of diseased tissue (polyps, granulations, adhesions) and manipulations upon an intact ossicular chain without induction of vibrational trauma. Potential complications such as facial nerve and inner ear injury are considered.

    View details for Web of Science ID A1996UH43700003

    View details for PubMedID 8860923

  • Neurofibromatosis type 1 involving the external auditory canal OTOLARYNGOLOGY-HEAD AND NECK SURGERY Lustig, L. R., Jackler, R. K. 1996; 114 (2): 299-307

    View details for Web of Science ID A1996TX01300029

    View details for PubMedID 8637757

  • DELAYED-ONSET FACIAL-NERVE DYSFUNCTION FOLLOWING ACOUSTIC NEUROMA SURGERY Annual Meeting of the American-Neurotology-Society Lalwani, A. K., Butt, F. Y., Jackler, R. K., Pitts, L. H., Yingling, C. D. LIPPINCOTT-RAVEN PUBL. 1995: 758–64


    Delayed onset facial nerve dysfunction following acoustic neuroma surgery is an under-appreciated phenomenon. The authors have recently reviewed long-term (> 1 year) facial nerve outcome in 129 patients who underwent acoustic neuroma removal with the aid of cranial nerve monitoring between 1986 and 1990. The facial nerve was anatomically preserved in 99.2% of the patients, and at one year, 90% of all the patients had House-Brackmann (H-B) grade I or II facial nerve function. Delayed onset worsening of facial nerve function was noted in 38 of 129 (29%) patients, most of which occurred in the first few postoperative days. The incidence increases to 41% (38 of 93) when corrected for those with immediate H-B grade VI weakness, and who therefore could not manifest further deterioration. The facial nerve function either deteriorated from normal to abnormal or increased in severity of weakness. Delayed facial palsy was not related to the size of tumor or the surgical approach. The most common occurrence was that of a patient with H-B grade I or II facial nerve function worsening to H-B grade VI in the postoperative period. The prognosis for recovery of facial nerve function following delayed palsy was excellent. In the majority of cases, the recovery was complete within the first 6 months without specific treatment. Comparable to the patients without delayed palsies, 89% (34 of 38) of the cases had H-B grade I or II and 97% (37 of 38) had H-B grade III or better facial nerve function at 1 year. This review suggests a surprisingly high incidence of delayed facial palsy following acoustic neuroma surgery, which fortunately has an excellent prognosis for spontaneous recovery.

    View details for Web of Science ID A1995TD81500009

    View details for PubMedID 8572138


    View details for Web of Science ID A1995TD81500022

    View details for PubMedID 8572151



    This article is a comprehensive overview of tympanic membrane injury and its healing. Its wound healing process is unique from soft tissue because epithelialization occurs before fibrous tissue advancement. Contemporary and future modalities to improve tympanic membrane repair are also discussed in this article.

    View details for Web of Science ID A1995RY95900007

    View details for PubMedID 8559580



    Tumors of the clivus, such as chordoma and chondrosarcoma, are generally amenable to an anterior surgical approach. However, approaches that traverse the pharynx or paranasal sinuses do not adequately expose tumor posterolateral to the horizontal course of the intrapetrous carotid artery. In addition, when tumor extends into the posterior fossa, supplemental exposure of neurovascular structures is necessary. A combination petrosectomy and subtemporal craniotomy can provide simultaneous access to the entire clivus as well as the lateral aspect of the midbrain, pons, and upper medulla. The extent of petrosectomy performed depends on a number of factors including status of hearing, facial nerve function, and degree of brainstem compression. In our experience with three patients (two chordomas and one chondrosarcoma), using either the retrolabyrinthine-subtemporal or transcochlear-subtemporal approach, excellent resection was achieved with acceptable morbidity considering the extensive nature of the disease.

    View details for Web of Science ID A1995TK18800018

    View details for PubMedID 7666734



    The advent of combined computed tomography (CT) and magnetic resonance imaging (MRI) for the evaluation of petrous apex lesions has improved the otologist's ability to differentiate among many disease processes. Temporal bone CT details osseous anatomy, whereas MRI delineates soft tissue signal characteristics. The employment of these two imaging modalities is often successful in differentiating between cholesterol common entities encountered in the petrous apex. The finding of a smoothly marginated, expansile, bone eroding lesion on CT, coupled with hypointensity on T1-weighted and hyperintensity on T2-weighted images on MRI, is highly suggestive of cholesteatoma. The authors recently encountered two cases of arachnoid cyst involving the petrous apex that shared the same imaging features seen with the more common cholesteatoma. One patient presented with tic douloureux, whereas the other had a spontaneous transotic cerebrospinal fluid leak. The contemporary skull base surgeon should include arachnoid cyst as a rare possibility in the evaluation and treatment of petrous apex lesions.

    View details for Web of Science ID A1995RT23300021

    View details for PubMedID 8588679

  • CONTRALATERAL HEARING-LOSS AFTER NEUROTOLOGIC SURGERY Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Lustig, L. R., Jackler, R. K., Chen, D. A. MOSBY-YEAR BOOK INC. 1995: 276–82

    View details for Web of Science ID A1995RU33500020

    View details for PubMedID 7675490



    Options for the surgical exposure of the internal auditory canal (IAC) include the translabyrinthine, retrosigmoid, and middle fossa approaches. Of the three, the anatomical reference points to the IAC are most subtle when it is exposed from above. The classically described methods for localizing the canal during the middle fossa approach direct the surgeon's attention initially towards the lateral extremity of the canal, a location where the margin for error is at its minimum. The cochlea, semicircular canals, and geniculate ganglion of the facial nerve are all positioned in close proximity to the fundus of the canal. An approach which is initially directed towards the porus acusticus has the advantage of locating the canal away from these vulnerable structures in an area where there is a relatively wide margin of safety. In this medially directed technique, drill excavation is commenced in the petrous apex well anterior to the anticipated location of the porus. Once the medial portion of the IAC has been well defined, dissection can proceed laterally by removal of bone directly over the known course of the canal. This strategy minimizes the risk of injury to the viscera of the petrous bone.

    View details for Web of Science ID A1995RG29900001

    View details for PubMedID 17171178



    Meckel's cave is an avenue for tumor to spread between the posterior and middle cranial fossae. The most common neoplasms that traverse this channel are trigeminal schwannomas and meningiomas. The classic approach to address disease in both cranial fossae involves separate craniotomies. Recent innovations in skull base surgery have made it possible to perform a single opening with simultaneous exposure of the posterior and middle fossae, without undue brain retraction. Tumors with a large middle fossa component and a smaller posterior fossa portion are exposed via subtemporal craniotomy with petrosectomy and tentorium division. However, tumors with a large posterior fossa component and a smaller middle fossa portion in the setting of serviceable hearing are addressed with retrosigmoid craniotomy and petrosectomy. For bilobed tumors with substantial components in both fossae, subtemporal craniotomy combined with varying degrees of transtemporal petrosectomy and tentorium division is employed. The evolution of techniques to address tumors that traverse Meckel's cave is reviewed and a treatment algorithm is proposed.

    View details for Web of Science ID A1995QK48100014

    View details for PubMedID 8572120



    Intradural tumors that are situated anterior to the midbrain, pons, and medulla have historically been among the most inaccessible of all intracranial lesions. The classic approaches to the posterior fossa (e.g., suboccipital, retrosigmoid) provide only limited access to the anterior midline, primarily due to interposition of the cerebellum, brain stem, and numerous cranial nerves between the tumor and the viewpoint of the surgeon. A variety of techniques have been developed in recent years that create a craniotomy by removal of a portion of the lateral skull base. These procedures enhance exposure of the ventral surface of the brain stem while markedly reducing the need for brain retraction. An underlying theme of transbasal craniotomy is judicious removal of a portion of the petrous pyramid. The most radical form of petrosectomy, the extended transcochlear approach, involves removal of the entire petrous pyramid along with the lateral aspect of the clivus. This provides an unimpeded view of the ventral surface of the pons, including the basilar artery, vertebrobasilar junction, and both abducens nerves. Whereas this technique provides splendid exposure along the midsegment of the brain stem, it carries substantial morbidity, including hearing loss and transient facial palsy, which typically recovers incompletely and with synkinesis. Over the past few years transcochlear procedures have been gradually supplanted, at the University of California Medical Center, by techniques that involve creating a simultaneous craniotomy of both the middle and posterior fossae fashioned around a more limited petrosectomy. These versatile procedures, in particular the middle fossa/retrolabyrinthine approach, provide excellent exposure of the region ventral to the midbrain and pons with less morbidity than the transcochlear approach. When tumors extend inferiorly, ventral to the lower medulla and/or upper cervical spinal cord, augmented inferior exposure is required. Approaches to ventrally situated lesions at the craniovertebral junction include the far lateral (transcondylar) approach to the foramen magnum and the transjugular approach, both of which involve removal of the inferior portion of the petrous bone. To efficiently utilize these innovative surgical options the surgeon must decide which of the potential approaches optimizes resection while minimizing morbidity. An analysis of the anatomy of the tumor, the functional integrity of cranial nerves, and the extent of resection planned provides the surgeon with the information needed to arrive at a rational choice.

    View details for Web of Science ID A1995QA48000009

    View details for PubMedID 8579176

  • FACIAL-NERVE OUTCOME AFTER ACOUSTIC NEUROMA SURGERY - A STUDY FROM THE ERA OF CRANIAL NERVE MONITORING 1993 Annual Meeting of the American-Academy-of-Otolaryngology - Head-and-Neck-Surgery Lalwani, A. K., Butt, F. Y., Jackler, R. K., Pitts, L. H., Yingling, C. D. MOSBY-YEAR BOOK INC. 1994: 561–70


    The introduction of intraoperative cranial nerve monitoring in posterior fossa surgery has greatly aided the surgeon in identification and anatomic preservation of cranial nerves. As a result, the long-term function of the facial nerve continues to improve after removal of acoustic neuroma. Herein, we report our long-term (1 year or greater) facial nerve outcome in 129 patients who underwent surgical removal of their acoustic neuromas with the aid of intraoperative neurophysiologic monitoring between 1986 and 1990. The facial nerve was anatomically preserved in 99.2% of the patients, and 90% of all the patients had grade 1 or 2 facial nerve function 1 year after surgery. Long-term facial function was inversely correlated with the size of tumor (chi-squared, p < 0.02) and was not related to the side of tumor, the age and sex of the patient, or the surgical approach. In a comparison among tumor groups matched for size, no statistically significant difference in facial nerve outcome between the translabyrinthine and retrosigmoid approaches was detected. The proximal facial nerve stimulation threshold at the end of surgical removal was predictive of long-term facial nerve function (analysis of variance, p < 0.02). At 1 year, 98% (87 of 89) of the patients with electrical thresholds of 0.2 V or less had grade 1 or 2 facial nerve function compared with only 50% (8 of 16) of those with thresholds between 0.21 and 0.6 V. In the era of cranial nerve monitoring, patients can be better advised about long-term facial nerve outcome after surgical intervention. Preoperatively, the size of the tumor is the most critical factor in predicting long-term facial function. Postoperatively, the proximal seventh nerve stimulation threshold at the end of the surgical procedure can be used as one prognostic measure of long-term facial nerve function.

    View details for Web of Science ID A1994PR79400005

    View details for PubMedID 7970793

  • INDICATIONS FOR CRANIAL NERVE MONITORING DURING OTOLOGIC AND NEUROTOLOGIC SURGERY AMERICAN JOURNAL OF OTOLOGY Jackler, R. K., Brackmann, D. E., Hirsch, B. E., Kartush, J. M., Niparko, J. K., Selesnick, S. H., Silverstein, H. 1994; 15 (5): 611-613

    View details for Web of Science ID A1994PG16700005

    View details for PubMedID 8572060

  • EXPOSURE OF THE LATERAL EXTREMITY OF THE INTERNAL AUDITORY-CANAL THROUGH THE RETROSIGMOID APPROACH - A RADIOANATOMIC STUDY 97th Annual Meeting of the American-Academy-of-Otolaryngology-Head-and-Neck-Surgery Blevins, N. H., Jackler, R. K. MOSBY-YEAR BOOK INC. 1994: 81–90


    The recent trend toward earlier diagnosis of acoustic neuroma has substantially increased the number of candidates suitable for surgery with an attempt at hearing preservation. Although the retrosigmoid approach affords the possibility of saving hearing in selected cases, it is associated with a somewhat greater morbidity that other approaches, in terms of persistent headache, cerebrospinal fluid leakage, and cerebellar dysfunction. For this reason, it is best used selectively, when the probability of success in hearing conservation is high. Only a portion of the internal auditory canal can be exposed through the retrosigmoid approach without violating the inner ear, a maneuver that greatly reduces the chance of preserving residual hearing. Substantial variability exists between individuals as to just how far laterally the internal auditory canal may be opened without compromising labyrinthine integrity. To assess the magnitude of this variability, measurements were obtained from 60 high-resolution temporal bone computed tomography scans with a schema intended to model the surgical angle of view used during the retrosigmoid procedure. Intraoperative measurements in a series of cases established that the actual surgical point of view is situated along a line that passes approximately 1.5 cm behind the sigmoid sinus. In this typical surgical position, these data predict that an average of 3.0 mm (32% of the internal auditory canal length) must be left unexposed to avoid labyrinthine injury, with a range between 1.1 mm and 5.3 mm (9% to 58% of the internal auditory canal). Each additional 1-cm retraction on the cerebellum beyond that customarily used affords approximately 1 mm (10% of the internal auditory canal) further exposure of the canal. When considering the retrosigmoid approach to an acoustic neuroma, the clinician is urged to evaluate each patient individually to estimate the amount of internal auditory canal accessible without the removal of a portion of the inner ear. This can be ascertained from an axially oriented, gadolinium-enhanced magnetic resonance imaging scan in the internal auditory canal plane by drawing a line that originates 1.5 cm behind the posterior margin of the sigmoid sinus and passes tangential to the most medial extent of the labyrinth. If this line intersects the posterior margin of the internal auditory canal at least 2 mm lateral to the deepest point of tumor penetration, then adequate exposure with preservation of the labyrinth is likely an achievable goal.

    View details for Web of Science ID A1994NX93600016

    View details for PubMedID 8028948


    View details for Web of Science ID A1994MP90000025

    View details for PubMedID 8109623

  • SURGICAL APPROACHES TO TUMORS OF THE JUGULAR FORAMEN 1st International Skull Base Congress Pitts, L. H., Jackler, R. K. KARGER. 1994: 1010–1016


    In an earlier study, epidermal growth factor (EGF) was shown to be effective in healing chronic tympanic membrane (TM) perforations in the chinchilla. The original protocol required rimming of the perforation's epithelial edge, application of a paper patch, placement of a Gelfoam pledget, and then administration of EGF solution. To develop a simple outpatient method of healing chronic TM perforations, an attempt was made to simplify the treatment protocol while preserving efficacy. In the modified experimental protocol, a large Gelfoam pledget was placed over the chronic perforation in contact with the residual TM, without mechanical disruption of the perforation edge or use of a paper patch. Then EGF in phosphate buffered saline (PBS) was applied to the Gelfoam pledget (50 microL of 0.5 mg EGF/mL PBS). A series of control ears received Gelfoam pledgets and PBS. Complete closure of the TM perforation was achieved in 80 percent (12/15) of treated ears but in only 20 percent (3/15) of controls (p < 0.01), results similar to those obtained with the original protocol. At long-term follow-up, 4 to 9 months after treatment, EGF-healed TMs were histologically similar to normal TMs, both in their overall thickness and in the relative proportions of the three component layers. In contrast, the few spontaneously healed TMs from the control group were less than half the thickness of normal TMs. To ascertain the optimal EGF concentration for therapeutic effect, a dose ranging study was undertaken.(ABSTRACT TRUNCATED AT 250 WORDS)

    View details for Web of Science ID A1994MP90000006

    View details for PubMedID 8109618



    Irradiation of the central nervous system may cause significant morbidity, including endocrine dysfunction and intellectual impairment. The authors report a case of bilateral temporal bone encephaloceles in a 21-year-old man who had received prophylactic central nervous system irradiation for acute lymphocytic leukemia in early childhood. Endaural encephaloceles are uncommon, and most occur as a complication of mastoid surgery. The etiology, clinical features, radiological diagnosis, and surgical treatment of temporal bone encephaloceles are discussed.

    View details for Web of Science ID A1993LZ62800019

    View details for PubMedID 8410231



    Enlargement of the cochlear aqueduct (CA) is often mentioned in the otologic literature, usually in its purported association with sensory hearing loss, stapes gusher, and transotic cerebrospinal fluid leak. In CT scans of 100 ears, the diameter of the CA medial aperture was found to be highly variable, ranging from 0 to 11 mm, with a mean of 4.5 mm. In contrast, the otic capsule segment was very narrow in every case. It could be visualized in only 56% of cases, none of which exceeded 2 mm in diameter. Several published reports of supposed CA enlargement presented images of a dilated medial aperture that was well within the range of normal variability according to the present study. In a thorough review of the literature on radiology of the CA, we were unable to find a single published image that convincingly demonstrated enlargement of the otic capsule portion. As radiographic CA enlargement has not been convincingly reported to date, it appears to be an exceedingly rare or perhaps even nonexistent malformation. It is important to recognize than even a radiographically normal CA may be hyperpatent. It is theoretically possible for increased fluid flow to result from either deficiencies in intraluminal membrane baffles or subtle canal enlargement beneath the resolution limits of CT scanning. However, as fluid flow through a tube is regulated by its narrowest point, it is extremely improbable that stapes gusher, transotic CSF leak, and vigorous perilymphatic fistula are generated by the CA when CT scans show any portion of it to be very narrow. A substantial body of evidence points to a deficient partition between the internal auditory canal and inner ear as causative in such cases. We propose that the criteria for the diagnosis of CA enlargement on high-resolution CT scan be a diameter exceeding 2 mm throughout its course from the posterior fossa to the vestibule.

    View details for Web of Science ID A1993LP14800004

    View details for PubMedID 8336962



    Preoperative differentiation between acoustic neuroma (AN) and meningioma of the cerebellopontine angle (CPA) is important in selection of the surgical approach, successful tumor removal, and preservation of hearing and facial nerve. We retrospectively reviewed the magnetic resonance imaging (MRI) findings associated with 30 meningiomas involving the CPA (MCPA) encountered between 1987 to 1991 at the University of California, San Francisco. Magnetic resonance imaging was critical in differentiating meningioma from AN in the CPA. Typical findings on MRI associated with MCPA, differentiating them from ANs, include: meningiomas are sessile, possessing a broad base against the petrous face, whereas ANs are globular; they are often extrinsic and eccentric to the internal auditory canal (IAC); when involving the IAC, they usually do not erode the IAC; MCPAs demonstrate hyperostosis of the subjacent bone and possess intratumoral calcification; they involve adjacent intracranial spaces and structures; and meningiomas are characterized by a distinctive dural "tail" extending away from the tumor surface. While any one finding may not be diagnostic by itself, taken together the constellation of these findings is strongly indicative of meningioma. In our experience, MRI with gadolinium enhancement was able to distinguish MCPA from AN in nearly every case.

    View details for Web of Science ID A1993LP14800014

    View details for PubMedID 8336973



    Radiation therapy for temporal bone paragangliomas has been advocated by many authors, but remains controversial. Radiation has little direct effect on the tumor cells, and diminution in tumor size is seldom seen. The main reason radiation therapy is recommended over surgical management of glomus tumors is its purported lower complication rate. We report a case of a lethal radiation-induced fibrosarcoma presenting 15 years following irradiation for a benign glomus jugulare tumor. Radiation-induced malignancies are rare, but are lethal when they occur. In experienced hands, surgical removal of glomus jugulare tumors carries a limited morbidity and virtually no mortality. In our opinion, the possibility of inducing a secondary life-threatening malignancy must be seriously considered when discussing therapeutic options with otherwise healthy individuals who are expected to survive 10 or more years after treatment.

    View details for Web of Science ID A1993LK37100016

    View details for PubMedID 8238279



    The application of magnetic resonance imaging (MRI) scanning in the diagnosis of acoustic neuroma (AN) has increased the relative incidence of smaller tumors and has impacted on the typical clinical presentation of AN patients. The charts of 126 patients treated at the University of California, San Francisco for newly diagnosed AN from 1986 to 1990 were reviewed. Twenty-four percent of tumors fell into the smallest size category (< 1 cm); this was a substantial improvement over earlier series. However, 16% of tumors remained undiagnosed until they achieved large size (> 3 cm). The incidence of hearing loss, dysequilibrium, headache, facial numbness, and diplopia all increased with increasing tumor size, while the incidence of vertigo decreased. Diagnosticians should not overemphasize "typical" symptom complexes, as substantial variability in clinical manifestations exists. An improved awareness by clinicians of the variability of AN presentation will improve diagnostic efficiency and continue the trend toward earlier diagnosis of these lesions.

    View details for Web of Science ID A1993KY18600012

    View details for PubMedID 8459753



    Audiologic data from 126 patients treated at the University of California, San Francisco for newly diagnosed acoustic neuromas (ANs) from 1986 to 1990 were reviewed. Subjectively normal hearing was present in 15% of patients and was most frequent in patients with small (< 1 cm) tumors. Only 4% had objectively normal hearing on the basis of speech reception threshold (SRT), speech discrimination score (SDS), and high-frequency pure-tone loss. This was most frequent in patients with < 1 cm tumors. Abnormal but symmetrical hearing is usually not considered to be indicative of a unilateral AN. In the present series, 7% of patients with ANs possessed symmetrical hearing. High-frequency asymmetry was a more sensitive indicator of the presence of an AN than differences in either SRT or SDS. The clinician must be aware of the relatively high incidence of atypical audiologic findings in acoustic tumor patients.

    View details for Web of Science ID A1993KY18600013

    View details for PubMedID 8459754


    View details for Web of Science ID A1993KG50900025

    View details for PubMedID 8424469



    Perforation of the tympanic membrane (TM) is a frequent cause of conductive hearing loss. Persistent TM perforations often require surgical repair with an autologous tissue graft to restore hearing and prevent recurrent infection. While highly efficacious, this method of closure requires a relatively complex and expensive microsurgical procedure. We have recently developed a chronic TM perforation model in the chinchilla for use in the exploration of novel methods of TM repair.

    View details for Web of Science ID A1992JZ47600009

    View details for PubMedID 1437205



    As a consequence of improved diagnostic imaging modalities, otologists have encountered a steadily increasing number of petrous apex lesions in recent years. Contemporary imaging techniques not only provide precise anatomic localization of the lesion, but also are able to suggest specific tissue diagnoses in the majority of cases. Computed tomography (CT), by virtue of its sensitivity and low false-positive rate, is the screening examination of choice in a patient suspected of having a petrous apex lesion. Once a lesion is identified, it is often necessary to obtain a combination of CT and magnetic resonance imaging (MRI). Computed tomography is important in the detection of osseous erosion as well as in the evaluation of the extent of pneumatization and marrow formation. It also provides important details about potential surgical routes to this relatively inaccessible region. Magnetic resonance imaging provides information about the composition of the lesion that cannot be readily discerned on CT scans. In the great majority of cases, it is capable of differentiating between petrous apicitis, cholesterol granuloma, osteomyelitis, cholesteatoma, and neoplasms such as schwannoma, meningioma, chondroma, and chordoma. In the interpretation of MRI scans, a familiarity with the typical appearance of the lesions that affect the petrous apex on T1-weighted, T2-weighted, and gadolinium-enhanced images is essential. A combination of MRI and CT scanning is also necessary to evaluate normal anatomic variations, such as giant air cells and asymmetric bone marrow, which may at times, on MRI alone, simulate pathologic conditions.

    View details for Web of Science ID A1992JX16600015

    View details for PubMedID 1449185



    The neurofibromatosis type 2 (NF2) gene has been hypothesized to be a recessive tumor suppressor, with mutations at the same locus on chromosome 22 that lead to NF2 also leading to sporadic tumors of the types seen in NF2. Flanking markers for this gene have previously been defined as D22S1 centromeric and D22S28 telomeric. Identification of subregions of this interval that are consistently rearranged in the NF2-related tumors would aid in better defining the disease locus. To this end, we have compared tumor and constitutional DNAs, isolated from 39 unrelated patients with sporadic and NF2-associated acoustic neuromas, meningiomas, schwannomas, and ependymomas, at eight polymorphic loci on chromosome 22. Two of the tumors studied revealed loss-of-heterozygosity patterns, which is consistent with the presence of chromosome 22 terminal deletions. By using additional polymorphic markers, the terminal deletion breakpoint found in one of the tumors, an acoustic neuroma from an NF2 patient, was mapped within the previously defined NF2 region. The breakpoint occurred between the haplotyped markers D22S41/D22S46 and D22S56. This finding redefines the proximal flanking marker and localizes the NF2 gene between markers D22S41/D22S46 and D22S28. In addition, we identified a sporadic acoustic neuroma that reveals a loss-of-heterozygosity pattern consistent with mitotic recombination or deletion and reduplication, which are mechanisms not previously seen in studies of these tumors. This finding, while inconsistent with models of tumorigenesis that invoke single deletions and their gene-dosage effects, lends further support to the recessive tumor-suppressor model.

    View details for Web of Science ID A1992JJ82800004

    View details for PubMedID 1496981


    View details for Web of Science ID A1992JP59200027

    View details for PubMedID 1408241



    If an AN is suspected, a detailed patient history and a thorough otologic and neurotologic physical examination should be carried out. The first echelon of diagnostic testing begins with a pure tone audiogram, speech reception threshold, speech discrimination testing, and acoustic reflex testing. If the clinician is even moderately suspicious of the presence of an AN, the patient should undergo a Gd-MRI scan. If suspicion is low, an ABR should be performed, and if negative, the patient should be reevaluated periodically.

    View details for Web of Science ID A1992HW29800003

    View details for PubMedID 1625864



    A variety of surgical approaches are available in the management of acoustic neuroma. Each procedure has certain advantages and disadvantages in terms of surgical exposure, the capability of preserving cranial nerve function, and postoperative morbidity. This article advocates tailoring the operative approach to each acoustic neuroma according to its size, location, and clinical manifestations.

    View details for Web of Science ID A1992HM52600007

    View details for PubMedID 1630834



    On rare occasions, facial paralysis associated with a parotid tumor need not denote malignancy. We present two cases in which, contrary to appropriate conventional wisdom, facial paralysis resulted from benign mixed tumors. Each patient presented over 8 years following primary surgical excision. In neither patient was a mass palpable, and facial paralysis was the sole sign of recurrent disease. Each patient had been followed up for several months with a presumptive diagnosis of Bell's palsy prior to discovery of recurrent tumor by radiologic imaging. In each case, at operation the tumor was found to infiltrate the temporal bone via the stylomastoid foramen. Facial paralysis presumably resulted from extrinsic compression of the facial nerve. These two cases add to the few previous reports of facial paralysis due to benign parotid gland tumors.

    View details for Web of Science ID A1992HN29900015

    View details for PubMedID 1313249


    View details for Web of Science ID A1992HJ15500021

    View details for PubMedID 1589224



    This study explored the effects of relaxation and imagery procedures on the voluntary self-regulation of immune responses. Immune studies of 19 adults were made before and after a 45 minute intervention consisting of relaxation with imagery aimed at enhancing immune activity. A self-report measure of psychological distress was completed before each blood sample. Results indicate that the seven blood measures of immune functioning were measured with adequate reliability and consisted of two sets of immune parameters. A statistically significant increase in one of the mitogen measures and a marginally significant increase in one of the blood count measures was found following the relaxation/imagery procedure. Age, hypnotizability, and their interaction significantly predicted change on the set of blood count measures but not on the set of mitogen measures. As expected, level of subjective psychological distress generally decreased following the intervention. The methodological limitations of this study included limited sample size and absence of a control group.

    View details for Web of Science ID A1992HT92900012

    View details for PubMedID 1304560



    Previous investigations into the healing and reconstruction of tympanic membrane (TM) perforations have involved animal models with acute TM perforations. A problem with the acute TM perforation model is that most acute TM perforations will heal spontaneously, both in animals and human beings. A second inadequacy of acute perforation models is that they are not analogous to the salient problem in human beings: long-standing TM perforation. The ideal animal model must have a TM perforation that is permanent, well-epithelialized, and free from infection. The perforation must also be subtotal to preserve a rim of membrane for experimental manipulations. In the chinchilla, we have identified a hardy animal with a short, wide ear canal and relatively large tympanic membranes. Thermal myringectomy, followed by medial infolding of TM microflaps, has resulted in permanent, subtotal chronic TM perforations in the chinchilla animal model. Of the 19 chinchillas (38 TMs) perforated, chronic subtotal perforations were created in 32 ears, 6 to 8 weeks after the initial procedure (84% success). Persistent infection or TM regeneration despite reperforation was recorded in 6 ears (16%) failure). This model is currently being used to assess various biomembrane scaffolds impregnated with growth-promoting substances in the regeneration of a physiologically sound TM, initially in our animal model and then in human beings. We envision the development of a biomembrane disc impregnated with biorecombinant growth factors that may provide a simple office technique for the repair of chronic, non-infected TM perforations.

    View details for Web of Science ID A1992GZ50800022

    View details for PubMedID 1734366



    Idiopathic or spontaneous hemotympanum (SH) is an uncommon disorder characterized by a black-blue tympanic membrane discoloration as a result of recurrent hemorrhage in the middle ear or mastoid in the presence of eustachian tube obstruction. Initial evaluation of a blue middle ear mass includes an audiogram and computed tomography (CT) scan with intravenous contrast. CT may identify congenital vascular malformation or bone erosion due to chronic otitis media or tumors. A magnetic resonance imaging (MRI) scan is useful in distinguishing hemotympanum from a vascular tumor and avoiding angiography, which is associated with significant morbidity. Evidence suggests that secretory otitis media and SH are different phases of the same disease process.

    View details for Web of Science ID A1991GQ42300012

    View details for PubMedID 1805639


    View details for Web of Science ID A1991GL06500014

    View details for PubMedID 1762798

  • STAPEDECTOMY - LONG-TERM HEARING RESULTS LARYNGOSCOPE Langman, A. W., Jackler, R. K., SOOY, F. A. 1991; 101 (8): 810-814


    The initial improvement in hearing following stapedectomy usually deteriorates with the passage of time. We studied the long-term results of stapedectomies performed on 42 patients (49 ears) between 1959 and 1969 who had a minimum follow-up of 18 years. Both air conduction (AC) and bone conduction (BC) thresholds progressively deteriorated over the long term. The degree of BC loss paralleled that expected from presbycusis alone. A greater deterioration was noted in the AC levels, producing a recurrent conductive hearing loss in the speech frequencies. Age at the time of surgery had no effect on the long-term outcome. Comparison of the average preoperative speech discrimination scores (SDS) to the 1-year postoperative SDS and the long-term SDS revealed a 1.1% and 16.7% drop, respectively. The improvement in the average speech reception threshold (SRT) obtained 1 year postoperatively deteriorated by less than 1 dB per year over the long term. Patients with a higher SDS (more than 95%) preoperatively fared better in the maintenance of speech discrimination than those with a lower SDS (less than 95%). The preoperative SRT level was predictive of the timing for the requirement of hearing amplification. The postoperative SRT level was predictive of the timing for the requirement of hearing amplification. The caused by presbycusis, combined with a recurrent conductive loss in the speech frequencies rather than cochlear otosclerosis. Although the decline in hearing following stapedectomy exceeds the rate of hearing loss due to presbycusis, many individuals, after successful stapes surgery, are able to delay the need for hearing amplification for longer periods than had been previously reported.

    View details for Web of Science ID A1991GU62300002

    View details for PubMedID 1865727

  • A comparison of facial nerve monitoring systems in cerebellopontine angle surgery. American journal of otology Jackler, R. K. 1991; 12 (4): 312-?

    View details for PubMedID 1928310


    View details for Web of Science ID A1991FR47900012

    View details for PubMedID 1877209


    View details for Web of Science ID A1991FQ30100019

    View details for PubMedID 1908984



    Prolonged (several days or repeated) exposure to nitrous oxide (N2O) can cause injury or death. To assess whether relatively prolonged anesthesia with N2O in normal patients might similarly cause untoward effects, we investigated whether the addition of N2O to isoflurane anesthesia caused injury to patients having surgical resection of acoustic neuroma lasting approximately 10 h. Twenty-six patients undergoing surgical resection of acoustic neuroma were randomly assigned to a regimen that included or excluded N2O (50%-60%) during isoflurane anesthesia plus intravenous adjuvants. On average, slightly less isoflurane (0.24%) was used during anesthesia with N2O. We measured standard clinical variables (blood pressure, heart rate), oxygen saturation, neurologic status, pain, and the incidence and type of morbid outcomes. Exposure to N2O did not increase the incidence of morbid outcomes (including hepatic injury, infection, or hypoxemia), prolong hospitalization, or increase common postoperative complaints such as nausea, vomiting, coughing, or headache. Patients anesthetized with either regimen were equally satisfied with their anesthetic.

    View details for Web of Science ID A1990EK58200002

    View details for PubMedID 2240628


    View details for Web of Science ID A1990EH94600017

    View details for PubMedID 2260296



    Contrast-enhanced MR images (at 1.5 T) were obtained in 11 patients with facial palsy. The group included five people with acute idiopathic facial (Bell's) palsy, three with chronic idiopathic facial palsy, and one each with acute facial palsy after local radiation therapy, acute facial palsy resulting from herpes zoster virus infection, and facial palsy caused by facial neuroma. Eight of the 11 patients demonstrated marked enhancement of the affected facial nerve from the labyrinthine portion through the descending canal. Three patients also demonstrated mild enhancement of the distal canalicular portion of the facial nerve, simulating small distal acoustic neuromas. No difference in the pattern of enhancement between the acute or chronic Bell's palsy patients was seen. Radiographic resolution appeared to lag behind clinical resolution. The facial neuroma appeared distinct from the other lesions as a focally enhancing mass. The enhancement pattern in the Bell's group correlated with the histopathologic features of Bell's palsy and is consistent with the viral hypothesis of the syndrome. Thin-section contrast-enhanced MR scans are recommended for individuals with atypical presentation of facial paralysis. In the proper clinical setting, contrast-enhanced MR imaging may permit a positive radiographic diagnosis of Bell's palsy, which has previously been a diagnosis of exclusion.

    View details for Web of Science ID A1990DU95000025

    View details for PubMedID 2117359



    Contrast-enhanced MR images (at 1.5 T) were obtained in 11 patients with facial palsy. The group included five people with acute idiopathic facial (Bell's) palsy, three with chronic idiopathic facial palsy, and one each with acute facial palsy after local radiation therapy, acute facial palsy resulting from herpes zoster virus infection, and facial palsy caused by facial neuroma. Eight of the 11 patients demonstrated marked enhancement of the affected facial nerve from the labyrinthine portion through the descending canal. Three patients also demonstrated mild enhancement of the distal canalicular portion of the facial nerve, simulating small distal acoustic neuromas. No difference in the pattern of enhancement between the acute or chronic Bell's palsy patients was seen. Radiographic resolution appeared to lag behind clinical resolution. The facial neuroma appeared distinct from the other lesions as a focally enhancing mass. The enhancement pattern in the Bell's group correlated with the histopathologic features of Bell's palsy and is consistent with the viral hypothesis of the syndrome. Thin-section contrast-enhanced MR scans are recommended for individuals with atypical presentation of facial paralysis. In the proper clinical setting, contrast-enhanced MR imaging may permit a positive radiographic diagnosis of Bell's palsy, which has previously been a diagnosis of exclusion.

    View details for Web of Science ID A1990DL90400029

    View details for PubMedID 2114760



    Gadolinium-DTPA (Gd-DTPA) is a paramagnetic contrast agent that increases the intensity of acoustic neuromas (AN) on T1-weighted magnetic resonance imaging (MRI) scans. Over a 9-month period we have reviewed Gd-DTPA-enhanced MRI scans on 32 consecutive cases (35 tumors) involving the internal auditory canal (IAC) and cerebellopontine angle (CPA). The majority of patients (84%) were imaged on latest generation 1.5 Tesla scanners. Every tumor studied showed marked enhancement after Gd-DTPA administration. This improved contrast permitted identification of three small tumors that were not evident on unenhanced scans. Gd-DTPA appears to be particularly useful in the evaluation of recurrent or residual AN. In three patients with known residual tumor after planned subtotal excisions, the remaining tumor could only be differentiated from surrounding scar, cerebral spinal fluid (CSF), and brain parenchyma after contrast enhancement. In one of these, a small rim of tumor capsule left on the facial nerve was evident only on Gd-DTPA-enhanced T1 images. Gd-DTPA also provides a more reliable estimate of the depth of tumor penetration in the IAC. This information is useful in selecting candidates suitable for a hearing conservation approach.

    View details for Web of Science ID A1990DN84700008

    View details for PubMedID 2115653



    The great majority of tumors that arise in the internal auditory canal are schwannomas of the eighth cranial nerve (acoustic neuromas). Meningiomas constitute the second largest group of posterior fossa tumors. Meningiomas arise from arachnoid villae, the apparatus responsible for cerebrospinal fluid absorption, in proximity to a major vein or dural sinus in most cases. Arachnoid villae are also present along neural foramena at the base of the skull. They have been observed histologically in the internal auditory canal (IAC), and are the probable site of origin of meningiomas in this location. Larger cerebellopontine angle meningiomas occasionally possess a significant intracanalicular component; however, these lesions usually originate from the meningeal lining of the posterior petrous face adjacent to the sigmoid, superior petrosal, or inferior petrosal sinuses and prolapse into the IAC. Two meningiomas have recently been observed that extensively involved the IAC, one of which arose from the lining of the IAC. The clinical manifestations of these meningiomas mimicked those of acoustic neuromas. Preoperative radiographic studies, including magnetic resonance imaging, were unable to differentiate these from acoustic neuromas. Meningiomas have a higher rate of recurrence than acoustic neuromas and should be excised with surrounding dura and several millimeters of subjacent bone. Meningiomas that extensively involve the IAC have a tendency to invade the inner ear and the deeper portions of the temporal bone. In meningiomas that involve the lateral portion of the IAC, consideration should be given to exenteration of the cochlea and semicircular canals.

    View details for Web of Science ID A1990DL16000011

    View details for PubMedID 2343905


    View details for Web of Science ID A1990CU20200015

    View details for PubMedID 2108420

  • Acoustic neuroma. Neurosurgery clinics of North America Jackler, R. K., Pitts, L. H. 1990; 1 (1): 199-223


    Acoustic neuromas are benign schwannomas that arise from the vestibular portion of the eighth cranial nerve. Small tumors confined to the internal auditory canal may be removed via an extradural subtemporal approach. Tumors that involve the cerebellopontine angle require posterior fossa craniotomy utilizing either the suboccipital or translabyrinthine technique. The choice of surgical approach depends primarily on the size of the tumor, its location, and the status of hearing in the involved ear. Operative mortality is very low. The most common sources of morbidity are hearing loss and facial nerve dysfunction.

    View details for PubMedID 2135969

  • THE LARGE VESTIBULAR AQUEDUCT SYNDROME LARYNGOSCOPE Jackler, R. K., Delacruz, A. 1989; 99 (12): 1238-1243


    It has long been known that abnormally large vestibular aqueducts may accompany congenital malformations of the cochlea and semicircular canals. Recently, enlargement of the vestibular aqueducts as the sole radiographically detectable inner ear anomaly has been recognized as a distinct pattern of congenital inner ear malformation. Pathogenesis of the large vestibular aqueduct syndrome probably stems from an early derangement in the embryogenesis of the endolymphatic duct. This anomaly appears to be relatively common in children with sensorineural hearing loss and is probably significantly underdiagnosed. Hearing loss is typically bilateral and progressive, with stepwise rather than fluctuant hearing decrements often triggered by relatively minor head trauma. A review of 17 patients (33 ears) revealed an average hearing level at presentation of 57 dB with a speech discrimination score of 66%. Considerable variability exists in hearing level among affected ears, ranging from normal hearing (4%) to profound deafness (39%). In 12 patients (23 ears) with an average long-term follow-up of 7.3 years, the hearing loss progressed by an average of 25 dB, with a drop of 29% in speech discrimination over the period of observation. An endolymphatic to subarachnoid shunt was performed on seven ears in an effort to stabilize hearing. Four of these ears had a substantial immediate postoperative drop in hearing. For this reason, endolymphatic sac surgery is not recommended for patients with this deformity.

    View details for Web of Science ID A1989CE17700006

    View details for PubMedID 2601537


    View details for Web of Science ID A1989CD66900011

    View details for PubMedID 2512557



    The majority of cholesteatomas assume typical growth patterns that are dictated by their site of origin and related anatomic structures. These routes of penetration tend to develop along vestigial planes that were created during the embryogenesis of the middle ear and mastoid. Knowledge of the relevant surgical anatomy allows the surgeon to recognize and remedy pathologic changes and avoid complications.

    View details for Web of Science ID A1989AQ56100005

    View details for PubMedID 2694067



    The removal of an indwelling cochlear implant electrode followed by reinsertion of a new device has been a maneuver of uncertain consequences to the cochlea and its surviving neural population. The present study was conducted in an attempt to elucidate the factors that determine whether a reimplantation procedure will be successful. Cochlear implantation followed by explantation and subsequent reimplantation was performed in eight adult cats. Evaluation of cochlear histopathology suggested a significant increase in electrode insertion trauma when there was proliferation of granulation tissue in the round window area and scala tympani. In other cases, atraumatic reinsertion was achieved without apparent injury to the cochlea. The results of a survey of cochlear implant manufacturers and surgeons indicate that electrode replacement can usually be accomplished without adverse effects. Difficulties have been encountered, however, in removing implants with protuberant electrodes and when reimplantation was attempted on a delayed basis following explantation.

    View details for Web of Science ID A1989AV33900011

    View details for PubMedID 2802465



    Accommodation for head growth presents one of several challenges unique to pediatric cochlear implantation. Given contemporary cochlear implant device designs, an electrode cable implanted at the age of 2 years must extend 2 to 3 cm as the head grows during childhood. In an initial study we found that model lead wires with redundant loops extended effectively when they were maintained within air-containing spaces such as the mastoid cavity or middle ear space. However, when looped leads traversed soft tissues overlying the parietal bone, they became embedded in fibrous tissue and did not extend. The present study evaluated three different configurations of expansile devices that were enclosed in polytetrafluoroethylene (PTFE) envelopes to deter fibrous ingrowth. This simple strategy was designed to ensure effective cable extension over cable pathlengths by protecting the redundant leads from any mechanically significant connective tissue ingrowth. Twelve such devices were implanted across the calvaria of four newly weaned piglets. Skull growth and changes in electrode dimensions were documented by sequential computed tomographic scans. At 3 months of age, cranial circumferences had increased substantially. Animals were then killed, the model cable extension appliances examined physically, and their implantation sites examined histologically. For all experimental devices, extension of redundant lead wires was satisfactory, and there was no mechanically significant invasion of fibrous connective tissue into the PTFE envelope. This indicates that enclosure of excess lead wire within a PTFE envelope may be an effective means of inhibiting fibrous ingrowth. This strategy should prove useful for ensuring effective electrode cable extension in cochlear implants applied in young children.

    View details for Web of Science ID A1989AF99300008

    View details for PubMedID 2502762

  • NEUROMAS OF THE FACIAL-NERVE AMERICAN JOURNAL OF OTOLOGY ODONOGHUE, G. M., Brackmann, D. E., House, J. W., Jackler, R. K. 1989; 10 (1): 49-54


    Forty-eight patients with facial nerve neuromas were treated at the Otologic Medical Group Inc. between 1974 and 1985. The most common presenting symptoms were hearing loss and tinnitus. Facial paralysis occurred in 22 patients (46%). A mass behind the tympanic membrane was seen on otoscopy in 14 patients (29%). These tumors typically involved more than one segment of the nerve and eroded otic capsule bone in 14 patients (29%). High resolution computed tomography (CT) was highly accurate in determining the extent and location of these tumors. Restoration of the continuity of the nerve was undertaken at the time of tumor removal. The major determinant of the ultimate status of facial nerve function was the duration of preoperative paralysis.

    View details for Web of Science ID A1989U285100010

    View details for PubMedID 2719087



    Hemophiliacs are well known to be among the high-risk groups for acquiring acquired immunodeficiency syndrome due to their frequent exposure to pooled blood products. We reviewed our recent experience involving hemophiliacs undergoing a variety of otolaryngologic surgical procedures. A protocol was developed to minimize the risks of hemorrhage through the judicious use of preoperative and post-operative coagulation replacement products. Modern hemostatic techniques, such as the use of the surgical laser, also had a role in lessening the incidence of bleeding problems. The relative risks of the various hemostatic products with regard to the transmission of communicable diseases such as acquired immunodeficiency syndrome and hepatitis were evaluated. Recent data suggest that heat treatment of factors VIII and IX concentrates eliminates the risk of acquired immunodeficiency syndrome transmission, and these heated concentrates should be used in preference to older products. Hepatitis remains a problem, but this risk may be reduced to some degree through immunization with hepatitis B vaccines that have recently been proved safe and effective.

    View details for Web of Science ID A1988R136800029

    View details for PubMedID 3142497



    The majority of temporal bone radiographic studies are obtained either for middle ear and mastoid disease or in the evaluation of retrocochlear pathology. With recent technologic advances, diagnostic imaging of the inner ear has developed an increasing role in the evaluation and management of diseases that affect the cochlea, semicircular canals, and the vestibular and cochlear aqueducts. High-resolution computed tomography (CT) provides excellent detail of the osseous labyrinth, whereas magnetic resonance imaging (MRI) generates images derived from the membranous labyrinth and its associated neural elements. Optimal techniques for obtaining high quality CT and MRI images of the normal and diseased inner ear are presented. CT has proved useful in the evaluation of inner ear malformations, cochlear otosclerosis, labyrinthine fistulization from cholesteatoma, translabyrinthine fractures, otic capsule osteodystrophies, in the assessment of cochlear patency before cochlear implantation, and in the localization of prosthetic devices such as stapes wires and cochlear implants. While MRI produces discernible images of the soft tissue and fluid components of the inner ear, it has yet to demonstrate any unique advantages in the evaluation of inner ear disease. However, MRI produces excellent and highly useful images of the audiovestibular and facial nerves, cerebellopontine angle, and brain.

    View details for Web of Science ID A1988Q961800008

    View details for PubMedID 3147443

  • ENDOLYMPHATIC SAC SURGERY IN CONGENITAL-MALFORMATIONS OF THE INNER-EAR LARYNGOSCOPE Jackler, R. K., Luxford, W. M., Brackmann, D. E., Monsell, E. M. 1988; 98 (7): 698-704


    A retrospective analysis of 40 patients (49 ears) with congenital progressive sensorineural hearing loss who underwent endolymphatic sac surgery was performed. The inner ears were radiographically abnormal in 57% of operated ears. In the remaining cases, subtle malformations beyond the resolving power of radiographic studies were suspected. Early postsurgical hearing loss (defined as a loss greater than 10 dB in three-tone average or greater than 15% in speech discrimination score) was found in 29% of operated ears (14/49). However, only two of these patients lost all of their residual hearing postoperatively (2/49 or 4%). An enlarged endolymphatic sac was noted at surgery in 50% of those with significant postoperative hearing losses. Longer-term stability of hearing was assessed in 22 patients with bilateral inner-ear pathology who underwent surgery on one side only. A comparison of the hearing fate of the operated and nonoperated ears suggested no benefit from the surgical intervention when compared to the natural history of the disease. Based upon this experience, endolymphatic sac surgery for the purpose of hearing stabilization in patients with congenital malformations of the inner ear is no longer recommended.

    View details for Web of Science ID A1988P157200002

    View details for PubMedID 3386372



    Computed tomography (CT) and magnetic resonance imaging (MRI) have become the radiographic investigations of choice for the vast majority of ear and temporal bone disorders. CT provides excellent images of bone and is indicated where osseous changes are of greatest diagnostic importance. MRI is superior in the evaluation of the eighth nerve complex and the central nervous system. Anticipated future advances include the production of three-dimensional images, more rapid scan times permitting dynamic (cine) studies, and the imaging of labeled chemical markers with insights into physiologic derangements.

    View details for Web of Science ID A1988P676500010

    View details for PubMedID 3052096



    Epitympanic cholesteatoma may involve the facial nerve at several anatomic locations resulting in functional impairment. The most common site of nerve compression is the middle-ear segment where the nerve is frequently devoid of bony covering. In five patients with facial palsy due to epitympanic cholesteatoma, a characteristic pattern of growth was recognized in which the cholesteatoma traversed the anterior epitympanum rather than taking the more common posterior route. Extension anteromedial to the head of the malleus leads to compression of the facial nerve in the region of the geniculate ganglion at the level of the middle cranial fossa floor. The most probable pathogenesis of this lesion is extension of disease along the embryologic course of either the saccus anticus or the anterior saccule of the saccus medius. Management of these lesions is surgical and may require, in addition to mastoidectomy with anterior and/or posterior atticotomy, middle fossa craniotomy and/or partial removal of the labyrinth for complete excision.

    View details for Web of Science ID A1988M344700007

    View details for PubMedID 3343877

  • COCHLEAR PATENCY PROBLEMS IN COCHLEAR IMPLANTATION LARYNGOSCOPE Jackler, R. K., Luxford, W. M., Schindler, R. A., McKerrow, W. S. 1987; 97 (7): 801-805


    Sensory deafness may be associated with partial or total obliteration of the cochlear scalae. Before undertaking cochlear implant surgery, a preoperative assessment of cochlear patency with high-resolution computed tomography (CT) is indicated. To determine the accuracy of pre-implant CT, a review of the radiographic and surgical findings in 36 implanted ears was performed. An abnormal CT scan was found to be a reliable predictor of compromised cochlear patency at operation. These findings help the surgeon to select the side most favorable for implantation and to anticipate problems that may be encountered during device insertion. A normal pre-implant CT scan, however, does not exclude the possibility of compromised cochlear patency. A 46% false negative rate was encountered, presumably because subtle degrees of osseous or fibrous obliteration of the cochlea are beyond the resolution by current generation CT scanners. In our opinion, the radiographic finding of cochlear ossification is not a contraindication to an attempt at cochlear implantation. The only assured way of determining the extent of cochlear patency is by performing an "exploratory cochleostomy" with fenestration of the basal cochlear turn. Drilling anteriorly through an ossified basal scala tympani will often expose an adequate lumen and permit insertion of even a long multichannel electrode into a partially ossified cochlea. Nevertheless, it is essential that the implant team be prepared with devices appropriate for whatever existing or surgically created lumen may be available.

    View details for Web of Science ID A1987J137500004

    View details for PubMedID 3110517



    Approximately 20% of patients with congenital sensorineural hearing loss have radiographic abnormalities of the inner ear. A broad spectrum of anomalous patterns have been described, most of which have been lumped together under the term "Mondini's dysplasia." We feel that this grouping of many dissimilar entities under a single umbrella term is unwarranted. Based on a review of 63 patients with 98 congenitally malformed ears, we have been able to recognize a number of distinct anatomic patterns from their radiographic appearance. A remarkable similarity between these morphologies and the appearance of the inner ear at various stages of embryogenesis was found. This led us to propose a classification system based upon the theory that these deformities result from an arrest of development during varying stages of inner ear organogenesis.

    View details for Web of Science ID A1987G399900001

    View details for PubMedID 3821363



    Xanthomata are soft tissue tumors composed of lipid-laden "foamy" histiocytes associated with cholesterol clefts and inflammation. They are considered to be specialized granuloma rather than true neoplasms and are usually associated with disorders of lipid metabolism, most commonly one of the hyperlipoproteinemia syndrome. A rare case of a xanthoma involving the temporal bone and causing extensive destruction of the skull base is presented. Otalgia and infection are the most common presenting symptoms of this disorder, with multiple cranial nerve palsies resulting in some cases. Treatment includes conservative surgical debulking, dietary restriction of fat and cholesterol, and pharmacologic reduction of serum lipids.

    View details for Web of Science ID A1987H111200007

    View details for PubMedID 3591917



    To determine if the cochlear implant can enable sound detection in children with a congenitally deformed cochlea, we reviewed warble-tone thresholds in five ears of four children in the implant clinical trials program. Of the five ears, there were two common cavity deformities, two cochlear hypoplasias, and one incomplete partition. Four of the five ears had an auditory response to stimulation by the implant at the same level as ears deafened by other disorders. One ear that had an auditory response to stimulation also produced facial stimulation that precluded use of the implant. The one ear that did not stimulate was the incomplete partition. This ear had a very narrow internal auditory canal. Three patients are now using the implant in three ears to detect sound. Results show that a cochlear implant may enable sound detection in a patient with a malformed cochlea but that a very narrow internal auditory canal (less than 1.5 mm) detected preoperatively on radiographs may contraindicate an implant. Such anatomy suggests only a rudimentary audiovestibular nerve or no such nerve and only a facial nerve.

    View details for Web of Science ID A1987G399900002

    View details for PubMedID 3821361



    The histopathologic findings in five temporal bones from three patients with congenital malformation of the inner ear are described. The external contour of the cochlea was deformed in two temporal bones, while the internal architecture was abnormal in all five temporal bones. Intracochlear abnormalities included defects in the interscalar septum, deficiencies in the modiolus, and a paucity of neural elements. Spiral ganglion cell populations varied, but were substantially diminished in all five temporal bones. Enlargement of the vestibule and semicircular canals (lateral and posterior) was seen in two temporal bones. A large vestibular aqueduct and saccular hydrops were found in one temporal bone each. An attempt was made to relate the histologic patterns of deformity to the proposed clinical classification of inner ear malformations. Radiographic abnormality of the cochlea would have been detectable in two bones (incomplete partition pattern), while two other bones would have appeared as vestibule-semicircular canal syndromes. One bone would have been radiographically normal.

    View details for Web of Science ID A1987G399900003

    View details for PubMedID 3821362

  • SURGICAL CONSIDERATIONS AND HEARING RESULTS WITH THE UCSF STORZ COCHLEAR IMPLANT LARYNGOSCOPE Schindler, R. A., Kessler, D. K., Jackler, R. K., Rebscher, S. J., Merzenich, M. M. 1987; 97 (1): 50-56


    Sixteen patients have been implanted with the UCSF/Storz multichannel implant, 11 of whom have been fitted with their external speech processors and transmitters and administered postoperative audiological evaluations. Both the surgical procedures used and the hearing results for these patients are presented. The potential medical/surgical complications of implant surgery and the future direction of research and development within the UCSF/Storz implant program are discussed.

    View details for Web of Science ID A1987F595300012

    View details for PubMedID 3796176



    Cochlear implants in children must be designed to allow for a child's growth and maturation. An experimental animal study was performed to document the influence of head growth on a prototype expansile electrode system. Seven kittens were implanted with a stimulated electrode which had been coiled to allow for a two-to-one expansion in length. Head growth was monitored both by direct skull measurements and by serial radiography. The animals were sacrificed when they had reached maturity and the implanted devices were studied. When implanted in subcutaneous tissue, the coils became encased in fibrous tissue, while within air-containing spaces, such as the bulla, they distended freely. This suggested that a route which maximized the amount of air-containing space traversed by an electrode should be the preferred route for a cochlear implant in children.

    View details for Web of Science ID A1986D014100001

    View details for PubMedID 3755562

  • THE UCSF STORZ MULTICHANNEL COCHLEAR IMPLANT - PATIENT RESULTS LARYNGOSCOPE Schindler, R. A., Kessler, D. K., YANDA, J. L., Rebscher, S. J., Jackler, R. K. 1986; 96 (6): 597-603


    Using the four channel cochlear implant system with a vocoder-based processor developed at UCSF over an extensive period of research, clinical trials of the UCSF/Storz device were initiated in February 1985, under the sponsorship of Storz Instrument Company. To date, 13 patients have been implanted with this device, nine of whom have been fitted with their external processor and transmitter and have received at least their initial postoperative evaluation. Patient results have been extremely promising, with eight of the nine patients obtaining some open-set auditory only speech understanding. Most patients have demonstrated improvement over time and all patients have attained an enhancement in lipreading ability with the use of the UCSF/Storz device.

    View details for Web of Science ID A1986C666000001

    View details for PubMedID 3754921



    Magnetic resonance imaging (MRI) is capable of providing excellent images of the contents of the internal auditory canal and cerebellopontine angle. In order to determine whether MRI is comparable to air contrast computed tomography in the diagnosis of small acoustic neuromas, 44 patients with suspected retrocochlear disease were studied with both CT and MRI. Twenty-one lesions were identified successfully with MRI and CT. The size of the tumors ranged from 4 mm to 5 cm. In twenty-three nontumor patients the normal audiovestibular nerve bundles were well visualized. Air contrast CT, on the other hand, was falsely positive in two cases. The results of this study indicate that MRI is suitable as the primary anatomic investigation in patients suspected of having retrocochlear lesions. It has the advantages of being highly reliable as well as free of ionizing radiation and the need for invasive procedures. The expense of MRI compares favorably with that of combined intravenous and gas contrast CT.

    View details for Web of Science ID A1986A168000004

    View details for PubMedID 3946998



    Successful implantation in children requires that provision be made for later head growth. The timing and magnitude of this growth was determined by measurements made from high-resolution computerized tomographic images of developing temporal bones. The temporal bone scans of 103 children of varying ages were studied. The development of the petrous and squamous portion of the temporal bone was at its greatest in the first 2 years of life. The order of magnitude of growth varied with the different axes measured.

    View details for Web of Science ID A1986AYY9200013

    View details for PubMedID 3081861



    A cochlear implant for use in children must take into account the high incidence of middle ear infection in this age group. A scala tympani electrode that traverses the middle ear and round window will likely act as a conduit by which infection can spread to the inner ear and potentially to the CNS. In this study an attempt was made to reestablish a separation of the cochlea from the middle ear by developing a seal around the implant at the level of the round window. A series of cats were implanted with simulated cochlear prostheses consisting of either a plain Silastic cylinder, a Silastic cylinder wrapped with autogenous fascia, or a Silastic cylinder with a cuff of bioactive ceramic. Middle ear infection was induced, followed by histologic examination. Bioactive ceramic appears to have some merit as a round window sealing material, while fascia was shown to be of no value. Intracochlear infection, when it did occur, was limited to the basal regions of the cochlea.

    View details for Web of Science ID A1986A168000013

    View details for PubMedID 3753835

  • Experimental evidence against middle ear oxygen absorption. Laryngoscope Jackler, R. K. 1985; 95 (10): 1281-1282

    View details for PubMedID 4046721



    Forty-two patients with chronic otitis media underwent preoperative CT scanning followed by surgical exploration of the middle ear and mastoid. The CT finding of abnormal soft tissue density associated with bone erosion was highly correlated with the surgical finding of cholesteatoma. By contrast, the total absence of abnormal soft tissue on CT essentially excluded cholesteatoma. However, 50% of all patients had abnormal soft tissue on CT scan not accompanied by bone erosion. In this largest group of patients it was not possible to diagnose or exclude cholesteatoma on the basis of CT findings alone. Also, CT occasionally gave the erroneous impression of lateral semicircular canal fistulization, tegmen tympani erosion, and facial nerve involvement due to volume averaging of these structures with adjacent soft tissues. CT scan has a role in the evaluation of selected patients with chronic otitis media, but must be interpreted cautiously in view of its limitations and numerous pitfalls.

    View details for Web of Science ID A1984SV78000004

    View details for PubMedID 6727511



    Otologists have long debated the importance of the mastoid in determining the success or failure of tympanic membrane reconstruction. The pneumatic spaces within the mastoid represent an "air reservoir" which can be drawn upon during periods of eustachian tube dysfunction and buffer the middle ear against the development of detrimental negative pressures. Mastoid inflammatory disease, if untreated, may result in recurrent suppuration and graft failure. Small mastoid volume, aside from its well known association with chronic infectious middle ear disease, has been shown to effect adversely graft survival following myringoplasty. In 48 patients undergoing myringoplasty with simple mastoidectomy, neither small mastoid size nor inflammatory mastoid disease significantly decreased the rate of graft healing. This suggests that simple mastoidectomy is an effective means of repneumatizing the mastoid and eradicating mastoid sources of infection. The successful surgical creation of a pneumatized mastoid cavity in communication with the middle ear was confirmed by postoperative computerized tomographic (CT) scans. In failed cases, CT scanning predictably identified residual mastoid disease. Simple mastoidectomy is considered to be a safe and useful adjunct to myringoplasty in selected cases of chronic otitis media with perforation.

    View details for Web of Science ID A1984SM05100012

    View details for PubMedID 6708693



    Eighty-two patients underwent myringoplasty combined with simple mastoidectomy when preoperative indicators suggested an increased risk of failure with myringoplasty alone. Indications for mastoid exploration included (1) chronic aural discharge, (2) suspicion of cholesteatoma, (3) previous failed myringoplasty, and (4) small sclerotic mastoid. Healing of perforations was successful in 71 patients (86.6%), and the air-bone gap was closed to within 20 dB in 85%. No mastoidectomy-related complications occurred, nor was there a tendency to form postoperative cholesteatoma. Simple mastoidectomy is considered to be a safe and effective adjunct to myringoplasty in selected cases of chronic otitis media with perforation.

    View details for Web of Science ID A1983QD63500003

    View details for PubMedID 6405343



    From 1976 to 1982, 109 patients with recurrent laryngeal papillomas were treated with a total of 548 CO2 laser excisions followed by podophyllum painting. There was high incidence of multiple sites of involvement, especially the tracheobronchial tree (18.3%) and palate (8.3%). Four patients had pulmonary parenchymal involvement. Patients were treated at 2-month intervals until they entered remission. Thereafter, microdirect laryngoscopies were advised at longer intervals. Remission was achieved in 41%; it occurred at all ages although it was most common during adolescence and rarest in the very young and very old. Many patients obtained remission with the CO2 laser after multiple prior cup forceps removals had not achieved remission. Only two tracheotomies (1.8%) were required and no deaths occurred. When compared with mechanical methods of papilloma removal, CO2 laser excision with podophyllum painting represents a clear advance in terms of preservation of laryngeal physiology and avoidance of life-threatening complications.

    View details for Web of Science ID A1982PE33200018

    View details for PubMedID 7114726