Congenital aplasia of the semicircular canals

OBJECTIVE

To describe the underrecognized inner ear malformation characterized by complete aplasia of the labyrinthine semicircular canals associated with a relatively well-formed cochlea, to investigate its relationship with known syndromic forms of hearing loss, and to hypothesize regarding the potential embryopathogenesis of this anomaly.

STUDY DESIGN

A retrospective case review consisting of cases of sensorineural hearing loss with radiographic evidence demonstrating agenesis of the semicircular canals associated with a cochlea that was either morphologically normal or sufficiently well developed to accommodate the full insertion of a cochlear implant electrode. Cases were identified by computerized tomography findings that identified the anomaly under study.

SETTING

Departments of otolaryngology and radiology in a tertiary referral center, with a large cochlear implant program serving over 800 patients, more than half of whom are children.

PATIENTS

Fifteen patients with the anomaly under study were identified.

INTERVENTIONS

Each patient underwent a complete otologic examination, audiometric studies, and high resolution computerized tomography of the temporal bone in axial and coronal planes.

MAIN OUTCOME MEASURES

The bony morphology of the cochlea, round and oval windows, vestibule, semicircular canals, and vestibular aqueduct, and the course of the facial nerve were examined. Auditory findings and otologic treatment are presented.

RESULTS

Of the 15 identified patients, 4 were nonsyndromic, 9 had CHARGE association (Coloboma of the eye, congenital Heart defects, choanal Atresia, mental and/or growth Retardation, Genital hypoplasia, and Ear anomalies and/or deafness), 1 met criteria for Noonan's syndrome, and one had features of both these syndromes. Although the cochlea was present in all cases, the cochlear morphology was usually abnormal in the CHARGE association patients. Of the 20 ears in the CHARGE subjects, only 3 ears (15%) were seen to have completely normal development of the cochlea in both the basal and upper turns. The others showed either mild hypoplasia of the upper turns (13 ears, 65%) or an incomplete partition typical of the classic Mondini deformity (4 ears, 20%). In the 4 nonsyndromic cases, one subject had bilateral Mondini dysplasia and the other three had normal cochleae. In the entire group, abnormalities of oval window development were common (20 of 30 ears, 67%), especially in the syndromic cases (18/22, 81%), but the round window was normal in the majority of cases (73%). Seven patients in the CHARGE association group had an anomalous course of the facial nerve, which was particularly severe in three. Four patients had congenital unilateral facial paralysis, although two of these children had normal radiographic anatomy of the facial nerve. One patient had bilateral facial weakness.

CONCLUSIONS

Syndromic and nonsyndromic cases of isolated semicircular canal aplasia were identified. Except for mild to moderate cochlear dysplasia, and the anomalous course of the facial nerve in some CHARGE association patients, both groups of patients were generally suitable for cochlear implantation if indicated. A high incidence of oval window aplasia with normal round window development may help to explain the embryopathogenesis of this anomaly, considering the sequence of inner ear development.

[Two cases of hypertrophic cranial pachymeningitis associated with infection in the external auditory canal and paranasal sinus]

We here present two cases of hypertrophic cranial pachymeningitis exhibiting unique multiple cranial neuropathies, both of which were associated with otic and paranasal infections. Case 1: A 76-year-old woman developed headache after undergoing surgical dilatation of the external auditory canal, with subsequent development of a bacterial infection. Neurological examination reveled only bilateral hearing disturbance. MRI and CT scans demonstrated thickening of the dura mater and inflammatory granulation around the left cerebellar tentorium. Based on a diagnosis of hypertrophic pachymeningitis associated with previous infection, antibiotics were administered, followed by oral prednisolone therapy. This treatment relieved the headache and improved the MRI findings. However, 2 months later, the headache became worse and impaired movement of the soft palate, atrophy of the left side of the tongue, and atrophy of the sternocleidomastoideus muscle were noted. MRI revealed aggravated inflammatory changes around the left cerebellar tentorium and their expansion into the jugular foramen. Occlusive changes in the transverse and sigmoid sinuses were also seen. Case 2: A 78-year-old man developed bilateral visual loss, right frontal headache, and bilateral restriction of eye movement. He had been treated for phemphigus with prednisolone and azathioprine. MRI showed hypertrophic dura mater spreading continuously from the frontal base and ethmoid and frontal sinuses to the falx and right frontal lobe. Since Pseudomonas aeruginosa was cultivated in biopsy specimens from the dura mater, antibiotic agents were administered. The clinical symptoms resolved and MRI findings gradually improved.

Autoimmune inner ear disease: diagnostic and therapeutic approaches in a multidisciplinary setting

Autoimmune Inner Ear Disease (AIED) is a clinical syndrome of uncertain pathogenesis. It is associated with bilateral rapidly progressive hearing loss. The hearing loss may be associated with vestibular symptoms. Autoimmunity has been proposed as the pathogenesis of this sort of hearing loss, although the mechanism of the disease is poorly understood. It is well accepted that the endolymphatic sac is an immunocompetent organ and circulating autoantibodies against inner ear antigens have been reported, as have viral antigens in the endolymph, although the sensitivity, specificity, and roles of those antibodies in a disease process are poorly defined. We will describe the clinical aspects of the disease, the histopathology, the immunologic indicators, the types of presentation, both from the audiologic and vestibular point of view, clinical trials for treatment and the follow-up. One of our conclusions is that many of these patients respond favorably to the treatment Methotrexate.

Mucoepidermoid carcinoma arising from the eustachian tube and middle ear

We report a case of mucoepidermoid carcinoma (MEC) originating from the eustachian tube and middle ear. A 31-year-old male who presented with otorrhoea and methicillin-resistant Staphylococcus aureus (MRSA) in the right ear was admitted to hospital due to cerebral infarction and deep vein thrombosis. After recovery, biopsies from a granulomatous mass found in the middle ear during operation for chronic otitis media revealed intermediate-grade MEC and a nasopharyngeal mass identified after surgery also revealed the same result. He received combined radiation therapy and chemotherapy and no residual or recurrent tumour was detected after two years of follow-up.

Choristomatous polyps of the aural and pharyngeal regions: first simultaneous case

The first known case of embryological development of a salivary gland choristoma of the middle ear and a hairy teratoid (choristomatous) mass of the pharynx arising in the same patient is reported. On the day after the patient, a female, was born, a posterior pharyngeal mass was discovered, resected, and diagnosed histopathologically as a hairy teratoid (choristomatous) polyp. At 10 months of age, the patient underwent myringotomy and tympanostomy tube placement, and another mass was found in the left middle ear. This mass was diagnosed as a salivary gland choristoma. Our review of the literature showed that, consistent with our case, choristomas are more prevalent in females, and those in the middle ear almost always occur on the left side. Both types of polyps are rare and are thought to be due to errors in development of the second and first branchial arches.

Otolaryngological manifestations of ligneous conjunctivitis

Ligneous conjunctivitis is a rare condition that can involve the mucous membranes of the upper and lower airways and temporal bone extensively. This can lead to life threatening airway obstruction. Involvement of the middle ear and mastoid may cause significant conductive hearing loss. This is the first reported case with temporal bone sections of ligneous conjunctivitis, and awareness of the associated obstructive hydrocephalus may prevent death in this condition. Evidence suggests that plasminogen deficiency may be a causative factor in ligneous conjunctivitis, and this finding may offer new prospects for management.

Allergic disease and associated concurrent medical illnesses

This retrospective study examined the pattern of medical illnesses, surgical procedures, and medication usage among 249 patients with allergic rhinitis contrasted with a comparison group of 253 patients with cerumen impaction. Results revealed that allergic patients experienced more frequent nasal and abdominal surgery, a higher prevalence of pulmonary and gastrointestinal disease, and used nasal sprays, antihistamines, and psychoactive medications more often than the comparison group. Implications for otolaryngology nursing practice are discussed.

Hamartoma in the internal auditory canal

An 11 year old girl presented with hearing loss in her left ear and left trigeminal and facial nerve palsy. Radiological examinations revealed an enlargement of the left internal acoustic canal and the existence of a mass protruding from the canal into the cerebellopontine angle. The partial resection of the mass by a suboccipital craniectomy resulted in ceasing the progression of her symptoms. Histological diagnosis was hamartoma with cerebellar heterotopia. The concurrence of heterotopic cerebellar tissue could help to understand the pathogenesis of hamartomas.

Type III tympanoplasties: the Sherbrooke experience

OBJECTIVES

To review short- and longer-term results of type III tympanoplasties as performed by the senior author and to compare these results with those reported in the literature.

METHOD

Retrospective review of 96 type III tympanoplasties, with and without mastoidectomy, performed between April 1996 and August 2000.

RESULTS

At a mean of 384 days postoperatively, 57.3% of patients had an air-bone gap of less than 20 dB. The average postoperative gap is 21.4 dB. Gap closure is best at 2000 Hz, with an average drop of 51% from initial value, compared with 34%, 39%, and 18% at 500, 1000, and 4000 Hz, respectively.

CONCLUSION

Our results are similar to those published previously. We emphasize the improvement at 2000 Hz, which is an important frequency for speech discrimination. It would be interesting to see if it correlates with an improvement in quality of life.

Comparison of head thrust test with head autorotation test reveals that the vestibulo-ocular reflex is enhanced during voluntary head movements

OBJECTIVES

To compare 2 clinical tests of vestibular function, the head autorotation test (HART) and the head thrust test (HTT), and to determine why they give disparate results in patients with known unilateral vestibular deficiency (UVD) due to labyrinthectomy.

METHODS

We used scleral coils to measure the horizontal (yaw) vestibulo-ocular reflex (VOR) in 5 healthy human subjects and in 11 patients who underwent labyrinthectomy. We used 2 paradigms. Using HART, subjects visually fixated a target during self-generated, swept-frequency, sinusoidal, horizontal head rotations. Using HTT, patients fixated the target during horizontal head thrusts delivered randomly in direction and time.

RESULTS

In subjects without UVD, eye movements were almost perfectly compensatory for both paradigms. In subjects with UVD, VOR gain for ipsilesional head thrusts was low for both paradigms, but significantly (P<.001) higher (less abnormal) for HART (0.60 +/- 0.13) than for HTT (0.14 +/- 0.13). Contralesional gain was reduced for both, to 0.64 +/- 0.20 for HART and to 0.57 +/- 0.17 for HTT. Because ipsilesional and contralesional gains were not statistically different for HART (P =.69), comparison of VOR gains for half-cycle responses to the HART stimulus could not reliably identify the side of the known lesion. In contrast, HTT consistently identified the side of the lesion for all subjects with UVD. To investigate whether preprogramming contributes to the boost in VOR as measured by HART, we compared the gain and response delay of eye movements during actively self-generated and passively received head thrusts. For subjects without UVD, response delays were shorter for active (6 +/- 1 milliseconds) than for passive (12 +/- 1 milliseconds) HTT. For ipsilesional rotations of subjects with UVD, active HTT yielded a significantly higher gain (0.44 +/- 0.20) (P<.001) and a shorter delay (15 +/- 6 milliseconds) (P<.001) than did passive HTT (0.14 +/- 0.13 and 37 +/- 15 milliseconds, respectively). Contralesional test results revealed a similar performance boost for active head movements. Data are given as mean +/- SD.

CONCLUSION

When comparison of half-cycle gains is used to identify the lesion side, self-generated predictable head movement paradigms, such as HART and active HTT, are less accurate than passive HTT in the characterization of UVD, in part because preprogramming can augment the VOR during voluntary head movements.

Otological disorders in Down's Syndrome

OBJECTIVE

To assess if children with Down's Syndrome have a higher prevalence of otological abnormality compared to their normal counterparts in Malaysia.

METHODOLOGY

Thirty children with Down's Syndrome and normal children underwent otoscopic ear examination and Impedance test in the ENT outpatients clinic in University Hospital, Kuala Lumpur, Malaysia.

RESULTS

The study showed that children with Down's Syndrome had higher otological disorders. Forty four percent had impacted wax compared to 14.4% in normal children. Twenty one percent of ears in the study group had retracted drums compared to 6.6% of control. Fifteen percent of ears in the study group had middle ear effusion compared to 3.4% in controls, 55% had a type B tympanogram compared to 8.3% in controls and 73.4% had auditory canal stenosis compared to 14.4% in controls.

CONCLUSION

Children with Down's Syndrome, thus have a higher incidence of otological disorders.

[The value of exploratory anterior tympanotomy in differentiating causes of conductive hearing loss and assessment of their treatment results]

The aim of examination was value of exploratory anterior tympanotomy in differentiation causes of conductives hearing loss and assessment of results treatment. Materials of examinations determined 34 patients aged 15-66 years, treated in 1995-2000 years, who qualified to exploratory anterior tympanotomy in aim decision of cause of conductives hearing loss. Among of examined were 14 patients with suspicion of otosclerosis (41.2%), 12 patients with unclear etiology of hypoacusis (35.3) and 8 patients with deterioration of hearing after stapedectomy (23.5%). Preoperative diagnostic embraced: a history, otolaryngologic examination, full audiologic examination and chosen cases of radiologic assessment of temporal bone by computer tomography. After perioperative decision cause of conductive hypoacousis were performed of operations of improved hearing and comprised of average hearing loss by CPT and PTA pre- and postoperative treatment. After performed of exploratory tympanotomy there vere stated following causes of conductive hypoacusis: otosclerosis (61.8%), separated of prosthesis after stapedectomy (14.7%) synechia of prosthesis with tympanic membrane (8.8%) and in singles causes of ossicular synechia in tympanic cavum (5.9%), tympanosclerosis (5.9%) and vitium of middle ear (2.9%). The best of hearing improvement after repairment operations of conductive system were obtained in cases of stapedectomy, exchange of prosthesis after stapedectomy, reconstruction of system by TORP prosthesis, however smaller improvement after operations of synechias of stapes prosthesis with surroundings and postoperation of tympanosclerosis.

The natural history of congenital cholesteatoma

OBJECTIVES

To describe the natural history of congenital cholesteatoma (CC) and to determine whether such a description provides clues about the origins and end points of these lesions.

DESIGN

A retrospective qualitative analysis of intraoperative illustrations of 34 consecutive patients with 35 CCs (1 bilateral).

SETTING

Two tertiary care children's hospitals.

PATIENTS

Thirty-four children with CC, mean age, 5.6 years (range, 2-13 years).

RESULTS

Congenital cholesteatoma originates generally, but not universally, in the anterior superior quadrant. The progression of growth is toward the posterior superior quadrant and attic and then into the mastoid. Contact with the ossicular chain generally results in loss of ossicular continuity and in conductive hearing loss.

CONCLUSIONS

Congenital cholesteatoma appears to have a predictable trajectory of growth, starting as a small pearl in the middle ear, eventually growing to involve the ossicles and mastoid, and causing varying degrees of destruction and functional impairment. The clinical picture of a young child with otorrhea, conductive hearing loss, tympanic membrane perforation in a nontraditional location, and a mastoid filled with cholesteatoma may represent the end point in the natural history of CC, despite the fact that this type of lesion is outside the accepted definition of CC.

Spontaneous CSF rhinorrhoea from separate defects of the anterior and middle cranial fossa

Multiple congenital dehiscence of the skull base is rare and can give rise to spontaneous CSF rhinorrhoea. A search of the world literature revealed only five reports of CSF leak with more than one concomitant skull base defect. When treating a patient with spontaneous CSF rhinorrhoea the possibility of its originating from the middle ear and eustachian tube should be considered. An intrathecal injection of fluorescein is useful in establishing the site of a CSF leak especially when a computed tomography scan (CT) or magnetic resonance image (MRI) has not localized the site. We discuss a case of a 72-year-old lady presenting with CSF rhinorrhoea, who had an anterior skull base defect localized with the help of intrathecal fluorescein and repaired surgically. Subsequent to this she had a further episode of CSF rhinorrhoea that originated from a middle-ear meningocele that was then repaired.

Ear involvement in ligneous conjunctivitis: a rarity or an under-diagnosed condition?

Conjunctivitis lignosa, a rare affliction of the conjunctiva, is sometimes associated with other disturbances. We present two children with concurrent conjunctivitis lignosa and ear involvement. In these two cases, there were histopathologically verified ligneous changes of the middle ears. Routine haematoxylin and eosin, van Gieson, periodic acid-Schiff (PAS) and alcian blue staining of specimens from the eyes and middle ears revealed findings typical for ligneous conjunctivitis. In addition, new histochemical and immunohistochemical studies for glycosaminoglycans on specimens from the eyes and middle ears showed that the accumulations of the amorphous, cell-deficient material stained strongly but heterogeneously for hyaluronic acid and weakly but uniformly for keratin sulphate. The staining for other glycosaminoglycans, e.g. chondroitin-4-sulphate and dermatan sulphate was confined to vessels and areas rich in collagen fibres and fibroblasts. In patients with conjunctivitis lignosa, the ear involvement may remain undiagnosed due to its resemblance to secretory otitis media with effusion. Since isolated ear involvement may occur, we advocate biopsies for routine haematoxylin and eosin, and specific staining for hyaluronic acid and keratin sulphate, also in children with protracted, refractory otitis media with atypical effusion.

Tympanoplasty results in patients with cleft palate: an age- and procedure-matched comparison of preliminary results with patients without cleft palate

OBJECTIVE

Because of continued eustachian tube abnormalities, the presence of a cleft palate repair has been thought to be associated with poor outcomes after tympanoplastic surgery. However, little published data exist regarding the results of major otologic surgery in patients with cleft palate. The objective of this study was to review our results of otologic surgery in these patients and compare results with those of age- and procedure-matched controls.

METHODS

Our otologic database was used to identify patients with a repaired cleft palate who underwent otologic surgery between March 1994 and December 1999. Two control patients were identified for each cleft palate patient. Results of hearing, graft take, and need for postoperative pressure-equalizing tubes were compared.

RESULTS

No significant difference existed between patients with a repaired cleft palate and control patients with regard to postoperative air-bone gap (P = 0.6805), graft survival rate (P = 1.00), and need for postoperative intubation (P = 0.457).

CONCLUSION

Results in patients with cleft palate appear to be similar to those in patients without cleft palate.

Combined autoimmune disease in a patient with AIDS

Immune dysregulation in HIV-infected patients, along with the new medications for treatment of AIDS that possess immunomodulating potential, may lead to an increased incidence of autoimmune diseases in this patient population. However, the presence of combined autoimmune diseases in an AIDS patient is rare. Relapsing polychondritis (RP) is an uncommon inflammatory disease manifested by recurrent attacks of auricular chondritis. The presence of type II and IX collagen antibodies, and their association with HLA-DR4 and other autoimmune diseases, suggests that antiself reactions may be present. Sarcoidosis is a granulomatous disease manifested by inflammation of the lungs, eyes and joints. In the peripheral blood there is depressed cellular immunity and enhanced humoral immunity. We here describe a case of coexisting RP and sarcoidosis in an AIDS patient.

Red ear syndrome and migraine: report of eight cases

We describe eight idiopathic cases of red ear syndrome in seven children and one adult. All were migraineurs with a history of paroxysmally painful and red ear, unilateral or alternating, in isolation or associated with migraine attacks. The reported duration of these episodes varied from 30 minutes to 1 hour. Neurologic examination, brain MRI and CT scans, and x-rays of the cervical spine were normal. The close temporal relationship between the "red ear episodes" and migraine attacks suggests an association between the two conditions.

Psychogenic hearing loss with panic anxiety attack after the onset of acute inner ear disorder

A very rare case of a 50-year-old female showing psychogenic hearing loss with a panic anxiety attack that complicated an acute organic sensorineural hearing loss is reported. At the first visit to our clinic, the patient showed left sensorineural hearing loss with an inner ear disorder pattern. Five days after the onset, her left hearing threshold markedly increased without any subjective signs. On the next day, she suddenly experienced a severe panic attack with anxiety. After the attack, she felt mildly anxious and depressed. A combined therapy using primary corticosteroid therapy for the acute inner ear disorder, psychiatric counseling based on cognitive therapy and the administration of a minor tranquilizer was performed. Her left hearing threshold recovered to within normal ranges except in the high-frequency ranges immediately after the treatment. This case was considered very rare because: (1) the panic anxiety attack occurred in the conversion disorder as psychogenic hearing loss and (2) the psychogenic hearing loss complicated the primary sudden deafness. We suggest that otorhinolaryngologists should have psychiatric knowledge and be able to treat psychogenic hearing loss as a primary care.

Large vessel arteritis in relapsing polychondritis

A healthy 58-year-old woman presented with recurrent swelling and pain of the nose and both auricules. Bruits were heard over both carotid arteries. Magnetic resonance angiography revealed stenosis of both internal carotid arteries. Relapsing polychondritis was diagnosed. These symptoms improved after treatment with prednisolone and azathioprine. Although relapsing polychondritis is sometimes associated with systemic vasculitis, large vessel arteritis is rare and can negatively affect prognosis. We conclude that the detection of systemic vascular lesions, including those involving the central nervous system, can play an important role in the diagnosis of relapsing polychondritis and that early treatment is essential for a good outcome.

False-positive magnetic resonance image in the diagnosis of small acoustic neuroma

A patient presented with sudden hearing loss on her first visit to our department. Gadolinium-DTPA-enhanced magnetic resonance imaging (MRI) of the posterior cranial fossa portrayed an intracanalicular tumour image (2-3 mm), and the pure tone average (PTA) and speech discrimination score (SDS) values were 65 dB and 60 per cent, respectively. Surgical intervention to remove the suspected tumour was scheduled by the translabyrinthine approach. Intracanalicular observations by the retrolabyrinthine approach revealed limited oedema on the inferior vestibular nerve with vascular dilation. The tumour image disappeared two years after the operation. Surgical findings and the post-operative course advocate that gadolinium-DTPA-enriched MRI image of an intracanalicular lesion such as arachnoiditis might produce a false-positive result.

[Melorheostosis associated with arteriovenous malformation of the ear]

BACKGROUND

Melorheostosis is a rare bone dystrophy that may be associated with various vascular malformations. We report a case of arteriovenous fistulae of the ear associated with melorheostosis limited to the same side of the body.

CASE REPORT

A 13 year-old boy presented a congenital port-wine nevus of the right side of the head complicated by an arteriovenous fistulae and angiomatous nodules of the ear. He was treated by laser, surgery of the nodules, arterial embolisations and sclerotherapy. In 1999, he had a benign trauma of the right hand. The X-ray showed hyperostosis resembling wax flowing down a candle reaching the carpus and some of the metacarpals and the phalanges of the right hand, typical of melorheostosis. The complete radiographic check-up showed the same characteristic appearance on the right side of the skull and the long bones of the right upper limb. Except a deformation of the right fingers, there were no others symptoms.

DISCUSSION

Melorheostosis is a rare, sporadic and benign bone dysplasia that may be localized to a single limb or disseminated. The diagnosis is usually made in late childhood. Pain, stiffness, deformation of a limb are the main clinical manifestations. The skin may be erythematous and sclerotic. The radiographic appearance is characteristic with hyperostosis on one side of the bone resembling wax flowing down a candle. A vascular abnormality is present in 17 p. 100 of cases (hemangiomas, aneurysms, renal artery stenosis.). In these cases, melorheostosis is usually limited to the same side of the vascular lesion. We report the first case of arteriovenous fistulae of the ear associated with melorheostosis, on the same side of the body. The physiopathology of melorheostosis is still unknown but the association with a homolateral vascular abnormality suggests a localized defect in embryogenesis of the vascular and skeletal systems.

Extraesophageal manifestations of reflux disease: myths and reality

Because of the anatomic proximity of the esophagus and the upper respiratory tract, it is not surprising that, in some patients with GERD, symptoms attributable to the respiratory and upper aerodigestive tract may occur. The prevalence of respiratory or other extraesophageal manifestations of GERD remains unknown, however, primarily because in any given patient it is often difficult to determine whether GERD is causing the extraesophageal condition or whether the two conditions are coexisting independently. Acid can reflux into the hypopharynx or trachea in some patients with GERD, thereby causing a variety of respiratory tract symptoms. Additionally, vagovagal reflexes triggered by acid that comes in contact with the esophageal or tracheal mucosa may contribute to the pathogenesis of GERD-related respiratory symptoms, particularly wheezing and coughing. The clinician should be particularly suspicious of underlying GERD in patients with unexplained dental caries, posterior laryngitis, chronic unexplained cough, and intrinsic asthma that does not respond to (or worsens with) bronchodilator therapy. Intensive medical antireflux therapy should be instituted in patients with a suspected extraesophageal manifestation of GERD. Failure to respond to this should not lead automatically to antireflux surgery; the clinician should use 24-hour pH monitoring to document the relationship between GERD and extraesophageal complications and to demonstrate that intensive medical therapy has indeed failed to eliminate acid reflux.

Eighth nerve aplasia and hypoplasia in cochlear implant candidates: the clinical perspective

OBJECTIVE

To identify the clinical and radiologic characteristics of aplasia and hypoplasia of the eighth nerve.

STUDY DESIGN

Retrospective case-note review.

SETTING

Cochlear implant program.

PATIENTS

All children at the authors' institution in whom the cochlear implant assessment failed because of absence or hypoplasia of the eighth nerve.

INTERVENTION

Computed tomography of petrous bones and magnetic resonance imaging of the brain.

MAIN OUTCOME MEASURES

Presence or absence of eighth nerve and other radiologic factors contraindicating implantation.

RESULTS

Of 143 cochlear implant candidates, 237 were judged ineligible for cochlear implantation. The preimplant assessment failed in 10 candidates of 143 because of bilateral aplasia or hypoplasia of the eighth nerve (7 cases) or unilateral aplasia or hypoplasia of the eighth nerve and a contraindication to operation on the other side (3 cases). The aplasia or hypoplasia of the eighth nerve was confirmed by magnetic resonance imaging in seven cases (5%): six were syndromic (3 CHARGE, 1 VATER-RAPADILLINO, 1 Möbius, 1 Okihiro), and one was nonsyndromic autosomal-recessive. All seven children had delayed motor milestones and absence of auditory brainstem responses.

CONCLUSION

Aplasia and hypoplasia of the eighth nerve are not uncommon in pediatric cochlear implant candidates, particularly in the presence of a syndrome such as CHARGE. Magnetic resonance imaging of the brain is mandatory before implantation because it can identify the presence or absence of the eighth nerve. Parents of children with profound hearing loss, delayed motor milestones, absence of auditory brainstem responses, and a syndromic diagnosis, should be made aware of this possible abnormality.

Hyperacusis: Review and Clinical Guidelines

OBJECTIVE

To review the current known causes of hyperacusis and the different hypotheses concerning its etiology, and to suggest clinical guidelines.

DATA SOURCE

A review of the literature with the aid of the MEDLINE database, using the following key words: hyperacusis, intolerance to sound, loudness discomfort level, and phonophobia.

DATA EXTRACTION

The data collected included clinical studies, case reports and laboratory studies.

CONCLUSION

Hyperacusis was shown to be caused by pathologic conditions of the peripheral auditory system, diseases of the central nervous system diseases, and hormonal and infectious diseases. In some cases there was no known cause. The pathophysiology of hyperacusis probably involves a central mechanism rather than a peripheral one. Suggested clinical guidelines and treatment are discussed.

[Combined drug therapy in patients with chronic otitis media and mucositis]

The data of the authors own studies using conservative therapy in patients with chronic otitis media (COM) and mucositis are presented. The efficiency of treatment of these patients is shown depending on the method of treatment (the highest efficiency being noted in the main group of patients in whom the altered middle ear mucosa was concurrently exposed to autoserum (AS) and magnetic laser therapy (MLT). The efficiency of this or that conservative treatment was found to be related to the magnitude of altered middle ear mucosal changes: the more marked the signs of mucositis are, the more difficult it is to achieve a positive result. The results of treatment were assessed visually (under an operating microscope), bacteriologically, cytologically, and crystallographically. There was a correlation between the visual assessment of obtained treatment results and crystallographic findings. The high efficiency of the proposed treatment in patients with COM and mucositis is determined by the concurrent combined AS and MLT exposure of the entire thickness of the changed mucosa and by the stimulating action of MLT on AS. This conservative therapy can pretend to be the method of choice in treating patients with COM and mucositis.

Pediatric fluctuating sensorineural hearing loss: problems in medical management

OBJECTIVES

To discuss the diagnosis and management of children with fluctuating sensorineural hearing loss, especially focusing on those problems dealing with autoimmune inner ear disease.

STUDY DESIGN

A retrospective chart review of a large pediatric otolaryngology practice. A series of 40 children with progressive hearing losses was identified. Of that group, 22 children, aged 1.5 to 12.2 years at first audiogram, were considered to have fluctuating sensorineural hearing loss (FSNHL). Criteria for inclusion in the FSNHL group were threshold variations of 15 dB or more in at least one ear at two or more of the standard audiometric frequencies on at least 2 testing days.

METHODS

Charts were reviewed for age, sex, otologic history, laboratory evaluations, medical or surgical treatments, significant medical history, and family medical history.

RESULTS

Twenty-two children met the criteria for fluctuating sensorineural hearing loss. Of those with fluctuating hearing loss, 15 were idiopathic, 3 had positive lymphocyte transformation tests (LTT) suggestive of autoimmune inner ear disease (AIED), and 4 had fistula on middle ear exploration. Average fluctuation for all groups was 29.1 dB. Average duration of fluctuations was 4.95 years.

CONCLUSIONS

The majority of pediatric FSNHL cases (15 of 22) were idiopathic in nature. Of those FSNHL children with positive LTTs, only one was treated with steroid therapy. In the other patients with positive LTTs, parents or other physicians were often reluctant to treat, or the patient was lost to follow-up. Mean fluctuations varied substantially across all standard audiometric frequencies for all groups.

Glossal palpation of the eustachian tube cushion: an unusual cause of globus sensation

Globus sensation, the sensation of a lump in the throat, is a common symptom which, in its chronic form, accounts for 4% of first-patient visits to ENT clinics. We describe a rare cause of globus sensation and stress the importance of thorough investigation to exclude any possible organic causes.

[Anesthetic management of a patient with May-Hegglin anomaly]

The May-Hegglin anomaly is a rare hereditary disorder characterized by the presence of giant platelets and platelet deficiency. This report presents a successful management of a patient with May-Hegglin anomaly. A 5-year-old girl with May-Hegglin anomaly was scheduled for closure of fistulae of her ears. Although preoperative physical examination revealed platelet count of 8,000 mm-3, she had no bleeding tendency. No premedication was given. Anesthesia was induced with inhalational agents of a mixture of sevoflurane, nitrous oxide and oxygen. Neuromuscular blockade was achieved with vecuronium 0.1 mg.kg-1 and the trachea was gently intubated. Anesthesia was maintained with sevoflurane, nitrous oxide and oxygen. Five units of platelet were transfused during the operation. No bleeding tendency was observed perioperatively. It is important to plan the management of anesthesia for a patient with bleeding tendency.

Sudden hearing loss and autoimmune inner ear disease

This case report describes the audiologic and medical diagnostic evaluations, results, and treatment options in a patient with a classic presentation of immune-mediated sensorineural hearing loss, commonly called autoimmune inner ear disease (AIED). It reviews findings of the basic battery, immittance audiometry, transient otoacoustic emissions, and auditory brainstem response measures and medical findings over more than 2 years. AIED generally causes asymmetric bilateral sensorineural hearing loss with atypical configuration. Although hearing loss is generally fluctuant, the overall pattern is usually rapid progression, particularly in the absence of early medical intervention. Word recognition is usually disproportionately poor. In our case, otoacoustic emissions and auditory brainstem responses suggest both cochlear and retrocochlear involvement and may initially appear to be inconsistent with pure-tone thresholds. Audiologists must be familiar with AIED because early identification is critical. Additionally, an immunologic basis may be a factor in other disorders, including many cases of Meniere's disease.

The prevalence of allergy in young children with an acquired cholesteatoma

STUDY OBJECTIVE

To determine whether allergic sensitisation occurs more frequently in young children with an acquired cholesteatoma in comparison with young children without ear diseases.

DESIGN

In this retrospective case-control study the allergic sensitisation of 43 children (age 0-10 years) who were operated for an acquired cholesteatoma was compared with the allergic sensitisation of children without ear pathology.

SETTING

Otology department of the ORL clinic of the Academic Medical Centre of University of Amsterdam in the Netherlands.

MEASUREMENTS

From all subjects a complete history examination was performed and stored in a database. To assess for the presence of allergic sensitisation in patients who underwent radical ear surgery because of an acquired cholesteatoma, and the control group a multiantgen radioallergosorbent test (RAST) was performed. The GraphPad Prism v 2.0. statistical software was used to perform the analyses.

RESULTS

Eighteen subjects (41.8%) demonstrated sensitivity to allergens and this is statistically significant (P < 0.0047) higher than the control group and expected for the general paediatric population. 80% of the patients with a positive multiantgen radioallergosorbent test were boys. In all positive cases an allergy for the house dust mite was determined.

CONCLUSION

Allergy is statistically frequently present in paediatric patients with an acquired cholesteatoma. The house dust mite seems to be the most important allergen when allergy is involved with an acquired cholesteatoma. Cholesteatoma with an positive allergy test occurs much more often in boys than girls. This could mean that young boys with a series of inflammatory middle ear diseases and allergic sensitisation are probably more at risk to develop an acquired cholesteatoma in childhood.

What inner ear diseases cause benign paroxysmal positional vertigo?

Benign paroxysmal positional vertigo (BPPV) originating from the posterior semicircular canal (pSCC) is a common vestibular disorder that is easy to diagnose and usually easy to treat. The majority of patients with BPPV have no known inner ear disease; they have "primary" or "idiopathic" BPPV. However, a minority does have objective evidence of an inner ear disease on the same side as the BPPV and this group has "secondary" or "symptomatic" BPPV. Previous publications differ on the prevalence of secondary BPPV and about the types of inner ear diseases capable of causing it. In order to determine what proportion of patients have secondary as opposed to primary BPPV and which inner ear diseases are capable of causing secondary BPPV, we searched our database for the 10-year period from 1988 to 1997 and found a total of 2847 patients with BPPV. Of these, 81 (3%) had definite pSCC-BPPV secondary to an ipsilateral inner ear disease. Sixteen had Menière's disease, 24 had an acute unilateral peripheral vestibulopathy, 12 had a chronic unilateral peripheral vestibulopathy, 21 had chronic bilateral peripheral vestibulopathy and 8 had unilateral sensorineural hearing loss. It seems that any inner ear disease that detaches otoconia and yet does not totally destroy pSCC function can cause BPPV and that a case can be made for audiometry and caloric testing in all patients with BPPV.

[Determination of plasma ciprofloxacin levels in children treated with 0.2% topical ciprofloxacin for tympanic perforation]

Topical drug use can produce locally adverse effects by direct action or systemic effects as a result of drug absorption. Local tolerance of topically-administered ciprofloxacin (ear drops) and serum antibiotic levels after 7-10 days of treatment were evaluated in 30 children with tympanic membrane perforation and suppuration. There were no signs of local intolerance or ototoxicity and significant serum ciprofloxacin levels were not detected. We conclude that ciprofloxacin ear drops can be safely used in children with suppurative otitis media and tympanic perforation.

Otologic and audiologic evaluation of human immunodeficiency virus-infected patients

PURPOSE

To quantify the incidence of ear disease in patients infected with human immunodeficiency virus (HIV).

MATERIALS AND METHODS

This is a descriptive case series of HIV-positive patients, with data collected using an otologic questionnaire. otologic examination, audiologic evaluation, and chart review. The study was performed at an urban University Hospital's outpatient Infectious Disease and Otolaryngology clinics. A consecutive sample of 50 HIV-infected patients volunteered for this study. Ten subjects refused. Almost all patients received public assistance for medical care. Descriptive results were tabulated. Audiometric data were analyzed for ear, Centers for Disease Control (CDC) group, otologic complaint, and age effects. Data were compared with established norms.

RESULTS

Twenty-three men and 27 women with a mean age of 40 years and mean duration of HIV disease of 3.5 years were studied. Eighteen percent of patients were in category CDC-A, 38% in CDC-B, and 44% in CDC-C. Otologic complaints were more prevalent than expected: 34% of patients reported aural fullness, 32% dizziness, 29% hearing loss, 26% tinnitus, 23% otalgia, and 5% otorrhea. Results of the neuro-otologic examination were abnormal in 33%. Tympanometric examination was abnormal in 21%. A significant degree of high-frequency sensorineural hearing loss was observed. CDC-B and CDC-C patients had worse hearing than CDC-A patients at 3 frequencies. Patients who complained of hearing loss had significantly worse otoacoustic emission results and hearing results than patients who did not, at all frequencies except 1,000 Hz. Patients in their 30s had better hearing in the speech frequencies than did all other patients.

CONCLUSIONS

Ear disease affects up to 33% of HIV-infected patients. Otitis media is a frequent finding. Sensorineural hearing loss is more severe in patients with more severe HIV infection. Patients with ear complaints have demonstrable otopathology. Continuation of this preliminary descriptive work is necessary.