A detailed preoperative and postoperative examination of the olfactory function of 111 patients with chronic polypoid ethmoiditis was carried out. Eighty-seven patients required a complete endoscopic endonasal sphenoethmoidectomy. In 24 patients an endoscopic partial resection of the ethmoidal cell system was performed. Before surgery a normosmia was ascertained in 39 patients (35%). Thirty-four patients (31%) were hyposmic, and 38 patients (34%) suffered from anosmia. In the postoperative olfactory function test 89 patients (80%) had a normal sense of smell; 13 patients (12%) showed hyposmia, and nine patients (8%) experienced anosmia. Seventy-eight percent of the patients with impaired olfactory function had marked improvement after the operation. Patients who had previously undergone a polypectomy had a less favorable prognosis. None of the preoperatively normosmic patients became hyposmic or even anosmic after endoscopic sinus surgery. The sense of smell of only two of the 34 patients with preexisting hyposmia worsened after surgery. The postoperative size of the middle nasal turbinate did not correlate with the ability to smell. More important was the accessibility of the olfactory cleft.

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Recently, the usefulness of preservation of hearing in acoustic neurinoma surgery has been a controversial subject. The value of preserving severely impaired function must be balanced between the surgical priorities of complete tumor removal and preservation of good facial nerve function.In an attempt to combine the goals of complete tumor ablation and controlled facial nerve dissection with predictable preservation of hearing, a new technique'-3 has been developed for the exposure of the cerebellopontine angle (CPA). Our search for better methods was stimulated by our observation of a remarkable rate of hearing preservation in our material. One has to take into account that not only "serviceable hearing" of the affected ear (as defined by 60 dB HL in the averaged pure-tone audiogram) is worth preserving but that still worse hearing ability may contribute to the capability of sound localization. From this observation,4 it can be inferred that also for the discrimination of speech in a free sound field, hearing losses of more than 60 dB in the operated ear may sometimes be valuable for the unaffected contralateral ear just by contribution to directional hearing. Patients with nonuseful hearing function of their operated ear have also emphasized a better acoustic orientation than when it is occluded by ear plugs.With regard to these experiences and in order to retain options for future application of hearing aids or implants, the translabyrinthine removal of acoustic neurinomas was canceled in our department since 1983 in favor of the enlarged middle fossa approach (EMFA). TECHNIQUEAfter the formation of a caudally pedicled skin flap over the sleeve with the root of the zygomatic arch in its center and after a Y-shaped transection of the temporalis muscle, a bone flap of 4 by 5 cm is excised from the temporal squama. The floor of the middle cranial fossa is exposed to the middle meningeal artery (anteriorly), the sigmoid sinus (posteriorly), and the superior petrosal crest (medially). Cautery and transection of the meningeal artery with packing of the foramen spinosum by Oxycel and sharp dissection of the petrosal nerves from the dura helps to mobilize the dura from the bone. Further space for a broad exposure of the CPA can be gained by the resection of the superior petrosal sinus. This maneuver comprises an anterior and a posterior closure by packing the incised sinus with Surgicel (Tabotamp), and the subsequent highfrequency cautery ofthe isolated segment of the sinus. The direction of the internal auditory canal (IAC) is easily found by bisectioning the angle that is formed by the greater petrosal nerve and by the "gray line" of the superior semicircular canal. The most important step of the procedure consists of an ample bone resection in front of and behind the IAC (hatched area in the sketch of Figure 1) 183

With the aim of preserving hearing, 20 acoustic neurinomas in 17 patients with neurofibromatosis 2 were intentionally submitted to an incomplete (80%) tumour removal. In 12 cases this was an operation on the last hearing ear with total deafness of the contralateral ear. If an auditus existed in both ears the better hearing ear was selected for the primary intervention. Early audiological controls evidenced residual hearing in 19 of the 20 cases operated on by the enlarged middle fossa approach, which was utilized inspite of the tumour diameters being between 1 and 6 cm in the cerebello-pontine angle. The oncologic and functional follow-up over 1 to 7 years showed different patterns of slow progression of hearing loss and of persistent auditory function over 2 to 7 years. Facial nerve function was excellent in 16 of the 18 controlled cases. Continued CT or MRT imaging revealed no signaling in 2 cases, constant tumour sizes in 10 cases and slow progression in 3 cases. With regard to the importance of an auditory communication in the younger adult, the described treatment modality appears to be the first choice method.

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