Methods and apparatus are provided for renal neuromodulation using a pulsed electric field to effectuate electroporation or electrofusion. It is expected that renal neuromodulation (e.g., denervation) may, among other things, reduce expansion of an acute myocardial infarction, reduce or prevent the onset of morphological changes that are affiliated with congestive heart failure, and/or be efficacious in the treatment of end stage renal disease. Embodiments of the present invention are configured for percutaneous intravascular delivery of pulsed electric fields to achieve such neuromodulation.

Methods and apparatus for renal neuromodulation

Objective. Sudden hearing loss (SHL) is a frightening symptom that often prompts an urgent or emergent visit to a physician. This guideline provides evidence-based recommendations for the diagnosis...

/pdf/clinical-practice-guideline-sudden-hearing-loss-8acwe9fo8a.pdf

Clinical practice guideline: sudden hearing loss.

A method and apparatus for treatment of heart failure, hypertension and renal failure by stimulating the renal nerve. The goal of therapy is to reduce sympathetic activity of the renal nerve. Therapy is accomplished by at least partially blocking the nerve with drug infusion or electrostimulation. Apparatus can be permanently implanted or catheter based.

Renal nerve stimulation method and apparatus for treatment of patients

OBJECTIVE : To identify the actual benefits and persisting problems in treating vestibular schwannomas by the suboccipital approach, the results and complications in a consecutive series of 1000 tumors surgically treated by the senior author were analyzed and compared with experiences involving other treatment modalities. METHODS : Pre- and postoperative clinical statuses were determined and radiological and surgical findings were collected and evaluated in a large database for 962 patients undergoing 1000 vestibular schwannoma operations at Nordstadt's neurosurgical department from 1978 to 1993. RESULTS : By the suboccipital transmeatal approach, 979 tumors were completely removed ; in 21 cases, deliberate partial removal was performed either in severely ill patients for decompression of the brain stem or in an attempt to preserve hearing in the last hearing ear. Anatomic preservation of the facial nerve was achieved in 93% of the patients and of the cochlear nerve in 68%. Major neurological complications included 1 case of tetraparesis, 10 cases of hemiparesis, and caudal cranial nerve palsies in 5.5% of the cases. Surgical complications included hematomas in 2.2% of the cases, cerebrospinal fluid fistulas in 9.2%, hydrocephalus in 2.3%, bacterial meningitis in 1.2%, and wound revisions in 1.1%. There were 11 deaths occurring at 2 to 69 days postoperatively (1.1%). The techniques that were developed for avoidance of complications are reported. The analysis identifies preexisting severe general and/or neurological morbidity, cystic tumor formation, and major caudal cranial nerve deficits as relevant risk factors. CONCLUSION : The current treatment options of complete tumor resection with ongoing reduction of morbidity are well fulfilled by the suboccipital approach. By careful patient selection, the mortality rate should be further reduced to below 1%.

Management of 1000 vestibular schwannomas (acoustic neuromas): surgical management and results with an emphasis on complications and how to avoid them.

Methods and apparatus are provided for thermally-induced renal neuromodulation. Thermally-induced renal neuromodulation may be achieved via direct and/or via indirect application of thermal energy to heat or cool neural fibers that contribute to renal function, or of vascular structures that feed or perfuse the neural fibers. In some embodiments, parameters of the neural fibers, of non-target tissue, or of the thermal energy delivery element, may be monitored via one or more sensors for controlling the thermally-induced neuromodulation. In some embodiments, protective elements may be provided to reduce a degree of thermal damage induced in the non-target tissues. In some embodiments, thermally-induced renal neuromodulation is achieved via delivery of a pulsed thermal therapy.

Methods and apparatus for thermally-induced renal neuromodulation

Paragangliomas of the head and neck

Background Vagal paragangliomas (VPs) arise from paraganglia associated with the vagus nerve. Approximately 200 cases have been reported in the medical literature. Because of their rarity, most information regarding these tumors has arisen from case reports and small clinical series. Objective To detail the clinicopathologic features of 46 patients with VP with an emphasis on the role of a multidisciplinary skull base team in both the successful extirpation and rehabilitation. Design Retrospective review of 46 patients with VP managed by a single skull base team. Setting An academic tertiary medical center. Results Forty-six patients were treated over a 20-year period (1978-1998). Ten (22%) demonstrated intracranial extension. There was a history of familial paragangliomas in 9 (20%) of the patients. The incidence of multicentric paragangliomas was 78% in patients with familial paragangliomas vs 23% in patients with nonfamilial paragangliomas. Management of this group of 46 patients consisted of surgery (n=40), radiation therapy (n=4), and observation (n=2). The operative approach consisted of a transcervical excision often combined with a transtemporal or lateral skull base approach as dictated by the tumor extent. Postoperative cranial nerve deficits were common, and, as such, aggressive rehabilitation was a vital component in the management of these tumors. Conclusions The management of VP and its associated cranial nerve deficits remains a difficult clinical problem. Options for treatment include surgical resection, radiation therapy, and, in selected cases, observation. Surgical extirpation requires a multidisciplinary skull base team to achieve complete tumor resection. Radiation therapy is reserved for elderly patients and patients at risk for bilateral cranial nerve deficits. Rehabilitation of cranial nerve deficits is an integral part of the management of VP.

https://jamanetwork.com/journals/jamaotolaryngology/articlepdf/221108/ooa8213.pdf

Vagal paraganglioma: a review of 46 patients treated during a 20-year period.

The patient presenting with a red mass behind the eardrum and a pulsating tinnitus may well have a vascular tumor. One must be ever mindful, however, that the mass may represent a congential vascular anomaly. The most common one seen is the uncovered jugular bulb in which the vessel extends superiorly into the middle ear to or above the incudostapedial joint. More rare is the uncovered and posteriorly displaced carotid artery.

The purpose of this paper is to review the literature on the subject of vascular anomalies of the middle ear and temporal bone and to discuss the diagnosis and management of these lesions. Illustrative case reports with color photographs are presented as well.

Vascular anomalies of the middle ear

Contemporary otomicrosurgical techniques have made total removal of acoustic tumor with preservation of the seventh and sometimes the eighth cranial nerves possible The four approaches currently used in acoustic tumor surgery are the middle cranial fossa, the translabyrinthine, the suboccipital, and the combined translabyrinthine-suboccipital This review examines the surgical results in the removal of more than 600 acoustic tumors and outlines a rationale for the choice of approach Tumor size on computed tomographic scan and auditory reserve establish the parameters used in planning the surgical procedure The translabyrinthine exposure is used most frequently followed by the combined translabyrinthine-suboccipital The middle fossa and suboccipital approaches are used when preservation of hearing is attempted Total removal of tumor was accomplished in more than 99% of patients with a mortality rate of less than 1% Anatomic preservation of the facial nerve, which is directly related to tumor size, was achieved in more than 80% of patients Preservation of hearing is unlikely when the tumor is larger than 2 cm; anatomic preservation of the cochlear nerve was successful in 73% of hearing preservation procedures

A systematic approach to the surgical management of acoustic neuroma.

The authors review 1,939 chronic ear surgeries in which 1,556 underwent some form of tympanic membrane grafting. The overall take rate was 93%. There was no selection of cases with regard to presence of infection, cholesteatoma, polyps, or granulation tissue at the time of surgery. There appeared to be no difference in the take rate based upon age of the patient, presence of infection, or cholesteatoma. Autogenous and homograft fascia performed well and there was no significant difference in take rate. Complications were minimal and were related more to the disease process than the grafting technique per se.



In addition to reviewing the long-term follow-up of the original technique the authors present a method of dealing with tympanic membrane retraction pockets. Called a cartilage tympanoplasty this procedure incorporates a large piece of full thickness tragal cartilage with attached perichondrium into the substance of the tympanic membrane.



With 2 years follow-up at this writing, this procedure has markedly reduced postoperative retraction pockets and recurrent cholesteatoma.

C. Gary Jackson

Papers

Paragangliomas of the head and neck

Vagal paraganglioma: a review of 46 patients treated during a 20-year period.

Vascular anomalies of the middle ear

A systematic approach to the surgical management of acoustic neuroma.

Postauricular undersurface tympanic membrane grafting: A follow-up report†‡