The goals of this retrospective case review were to analyze the long-term results of surgery for petrous temporal bone cholesteatomas and to propose a new classification system for these lesions. Patients with a surgically confirmed petrous temporal bone cholesteatoma were treated at Addenbrooke's Hospital, a tertiary referral center. Postoperative facial function, hearing, residual/recurrent cholesteatoma, and other complications were assessed in relation to preoperative signs, intraoperative findings, and surgical approach. Between 1983 and 2004, 43 patients were treated. There were no perioperative deaths. There was no long-term recurrence in 95.4% of the patients, possibly because of meticulous surgical technique, bipolar diathermy, and use of the laser to denature the cholesteatoma matrix that was adherent to the dura. At presentation, 95% of the patients had no socially useful hearing in the affected ear. Facial nerve function, however, was usually preserved. Both direct anastomosis and nerve grafting can improve facial nerve function from House-Brackmann grade VI to grade III if the palsy is not longstanding. Four patients had cerebrospinal fluid leakage; other complications were rare. The proposed classification facilitates surgical planning and predicts the postoperative outcome with regards to hearing.

The initial presentation of macroprolactinoma with visual field impairment, especially in males, is well recognized. Successful treatment with dopamine agonist therapy is characterized by a reduction in hyperprolactinaemia and often rapid and progressive resolution of the visual impairment. A small proportion of patients may subsequently develop a secondary deterioration in both their visual fields and visual acuities despite normalization of prolactin levels and tumour shrinkage. When pituitary apoplexy can be excluded this may result from traction on the optic chiasm which is pulled down into the now partially empty sella. We report a series of seven patients in whom chiasmal traction is believed to be the cause of their secondary deterioration in visual acuity occurring after dopamine agonist therapy for macroprolactinoma. The clinical history of two patients both of whom had rapid resolution of field defect with bromocriptine therapy but subsequently developed a recurrence of their bitemporal hemianopia is detailed. In both patients MRI scanning showed not only tumour involution but also marked optic chiasm herniation into the pituitary fossa. Surgical treatment was considered too risky; but on reduction of bromocriptine dosage the field defect improved in both cases; there was a modest elevation of prolactin and a degree of tumour re-expansion. The latter is believed to have released tethering of the optic chiasm and/or its vascular supply and thus obviated the need for surgery. Regular monitoring of visual fields in patients with macroprolactinoma receiving medical treatment is therefore important. Early recognition of secondary field loss due to chiasmal herniation enables correction of the visual field loss by manipulation of the medical therapy.

Both cognitive behavioural therapy and tinnitus retraining therapy are effective for tinnitus, with neither therapy being demonstrably superior. Further research using standardised, validated questionnaires is needed so that objective comparisons can be made.

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BackgroundBalloon Eustachian tuboplasty is a surgical management option for Eustachian tube dysfunction; it has shown promising results in studies worldwide, but has had limited uptake in the UK. This study reports long-term outcomes for patients offered balloon Eustachian tuboplasty for chronic dilatory and baro-challenge-induced Eustachian tube dysfunction, and describes practical experience gained from its implementation.MethodsBalloon Eustachian tuboplasty was conducted in 25 patients (36 ears) with Eustachian tube dysfunction over three years. Information on presenting symptoms and signs, audiometric findings, tympanometry, and Eustachian Tube Dysfunction Questionnaire-7 scores were recorded pre- and post-operatively with a minimum follow up of one year.ResultsSixteen (64 per cent) of the 25 patients demonstrated symptom resolution after balloon Eustachian tuboplasty according to the Eustachian Tube Dysfunction Questionnaire-7. Fourteen (64 per cent) of the 22 patients with a type B or C tympanogram pre-operatively, had a type A trace post-operatively. Fifteen (75 per cent) of 20 patients with pre-operative conductive hearing loss showed improvement post-operatively, and 11 (50 per cent) of 22 patients with pre-operative middle-ear effusion or tympanic membrane retraction showed resolution.ConclusionBalloon Eustachian tuboplasty can improve subjective and objective measures of Eustachian tube dysfunction, and provide longer-term resolution.