[Two cases of hearing disorder following general anesthesia]

Hearing impairment is not often considered as a potential complication of general anesthesia, despite several reports of post-operative sensorineural hearing loss. These disorders have occurred after otological as well as cardiobypass surgery. We experienced two patients both of whom had undergone orthopedic surgery. In both cases the patients experienced bilateral reversible hearing impairment after general anesthesia with nitrous oxide. It is likely that a change in the middle ear pressure as a result of Eustachian tube dysfunction may have caused transient conductive hearing loss added to sensorineural hearing disorder. After these cases we interviewed a series of 115 patients who had undergone general anesthesia to assess the extent of this problem. Contrary to our expectation, 7 patients complained of ear fullness or autophony after inhalation of nitrous oxide, although these symptons diminished within 24 hours. It is important to be aware of the possibility of hearing impairment when nitrous oxide is used especially if the patient has a history of a previous middle ear disease.

Early ear problems and developmental problems at school age

Retrospective history of middle ear disease was compared with developmental diagnosis in 507 consecutively referred school-age children. History of major ear problems was positively associated with discrepancies between the performance and verbal IQ on the WISC-R. History of major ear problems was positively associated with the presence of articulation disorders for children in the low social class, hyperactivity in the middle social class, and language problems in the high social class. A history of significant middle ear disease in early childhood should raise concerns for articulation difficulties and possible language problems in children presenting to clinicians with school problems.

Cochlear implants and electrical brainstem stimulation in sensorineural hearing loss

Cochlear implants and multichannel auditory brainstem implants enable patients with bilateral total or profound hearing loss to receive at least acoustic information. Both types of prosthesis are based on electrical stimulation of the auditory pathway. Different speech coding strategies and the number of electrodes used may influence the postoperative results. The preoperative evaluation of patients is of utmost importance. The cochlear implant is suitable for patients with hearing loss due to inner ear disorders, but who have functioning hearing nerve. Patients with a defect of the hearing nerve can be provided with an auditory brainstem implant.

Tinnitus. Current evaluation and management

Evaluation and management of tinnitus presents a significant challenge to the internist and the otolaryngologist. Tinnitus may be divided into two basic categories: subjective and objective. The importance of a thorough history and physical examination is emphasized in this article. The steps in a complete evaluation and the rationale for referral to an otolaryngologist are outlined. Multidisciplinary care of the tinnitus patient is best coordinated by the otolaryngologist.

Evaluation of the dizzy patient: experience from a multidisciplinary neurotology clinic

In 1993 a multidisciplinary neurotology clinic was established at the Toronto Hospital, University of Toronto, where patients with symptoms of dizziness were assessed by both otolaryngologists and neurologists. The results from the first 400 patients seen in consultation are described. The disease pathologies identified in this patient population with dizziness showed some significant differences from other published series, which we believe reflects the specialized tertiary nature of referrals to this clinic. A model for the collaborative investigation of the dizzy patient is provided consistent with the current trend towards multidisciplinary approaches in medicine.

Spontaneous otogenic pneumocephalus. Case report and review of the literature

Pneumocephalus is commonly seen in clinical neurosurgical practice. Typical causes include trauma, tumor, and infection. Pneumocephalus may also occur iatrogenically at the time of intracranial surgery; it is not pathological and may be seen routinely on postoperative neuroimaging. Pneumocephalus is rarely encountered in the absence of the aforementioned entities. The authors report on an elderly woman in whom spontaneous intraventricular pneumocephalus occurred because of a congenital defect in the left tegmen tympani. Eustachian tube closure and middle ear exclusion were used to obliterate the fistulous connection. This case illustrates both an unusual cause and a unique treatment for spontaneous otogenic pneumocephalus.

[Fixed mallear head syndrome]

Fixed head malleus syndrome is a rare anatomoclinical entity first described by Goodhill in 1966. We present a series of 9 patients who underwent surgery between 1991 and 1997 and discuss the technical procedures used and functional outcome. Ossicular mobility can be re-established with two surgical methods. The more simple method consists in a classical incus transposition with malleus neck section. The more physiological method consists in drilling the synostosis fixing the malleus without disrupting the ossicular chain; stapedotomy is associated in certain cases (Type III).

A personal history of stapedectomy

Aristotle has said the essential ingredient of tragedy is first hubris. Fame leads to the hubris that offends the gods, who send great punishment. This is so true in the history of stapedectomy. The three distinct eras of surgery for otosclerosis teach us a lot about what happens in science and in life. The first stapes era began in Europe, ahead of its time, and in those halcyon days before the turn of the century, the Belle Epoch, proceeded, uncorrected to its tragic extreme, and then was stopped suddenly, quite rightly, by the establishment. The fenestration era proceeded to an extreme, when its technical master Julius Lempert would allow no criticism or improvement in "his" one-stage endaural technique, however good, nor would he accept the new mobilization and stapedectomy operations, and he and it ended badly. The fact that Jenkins and Holmgren would make an opening in the lateral semicircular canal and then close it in the epitympanum, not open to the ear canal, to expect to improve hearing is amazing. Until Sourdille went to Stockholm and saw one closed fenestration operation performed by Holmgren and devised his "open to the ear canal technique," the closed fenestration operation was not reasonable. Then Sourdille came to New York City, and Lempert heard him speak and read and reread his publication and greatly improved on his operation. It was Lempert's one-stage endaural open operation that gave the fenestration operation the worldwide acceptance it gained. The second stapedectomy era began before the fenestration era ended with the accidental and originally unrecognized mobilization of the stapes by Rosen and my resurrection of stapedectomy. I realized in reading the literature of the past that stapedectomy was not necessarily fatal to the ear or the patient as was generally believed, and what was needed was to seal the oval window with a living elastic membrane and reconstruct the sound-conducting mechanism of the middle ear with a biocompatible implant prosthesis to make it successful. But for me, in 1955-1956, the "Zeitgeist" was finally right. I realized the stapes could be removed and covered the oval window with a vein graft, and Harry Treace made me a biocompatible implant prosthesis out of the newly discovered Teflon. For a new technology to be accepted, it must be much better than what it replaces, and stapedectomy was much better than fenestration. In the new microsurgical era of otology that began, improvements in the stapedectomy operation came from everywhere and were readily accepted. Stapedectomy has now become so successful, like many treatments in medicine, the problem has now largely disappeared. If the measles virus is the cause of the growth of the otosclerotic focus, as it seems to be, then vaccination against measles eventually will eliminate the hearing loss of otosclerosis completely. What the history of stapedectomy reveals is the truth of the quotation from Ecclesiastes, "There is nothing new under the sun." Progress is only made when the Zeitgeist is right, by someone who puts together the truths of the past with the new discoveries of the present.

[MRI in progressive sensorineural hearing loss]

Magnetic resonance contrast imaging using gadolinium-DTPA and performing new high resolution sequences (Fast Spin-Echo, Spoiled Gradient-Echo) or angiographic sequences (Magnetic Resonance Angiography) allows an excellent visualization of the inner ear and the cerebellopontine angle to be obtained. Furthermore, using sequences obtained with the "steady-state" technique (Gradient Recalled At Steady-State-GRASS, Constructive Interference at Steady-State-CISS), a good analysis of the structures of the membranous labyrinth can be achieved. Based on these diagnostic techniques, we have studied the morphological features of the membranous labyrinth in patients with progressive sensorineural hearing loss due to inner ear malformations, labyrinthitis, neuritis of VII and VIII cranial nerves, degenerative entities such as otosclerosis and Ménière's disease, neoplasms of the cerebellopontine angle, of the inner ear and of the middle ear (glomus tumours, acoustic neuromas, meningiomas, epidermoid tumours, arachnoid cysts and malignant neoplasms).

Troy, Mycenae, and the otologic demise of Herr Heinrich Schliemann

Heinrich Schliemann (1822-1890) was a self-made man with a remarkable aptitude for language and an excellent business mind. He was also the founder of Aegean archeology, providing a factual base for the writings of Homer, which until then had been considered merely a collection of mythologic poems. During his life, Schliemann suffered from ear trouble, ultimately dying from an otogenic temporal lobe brain abscess. He consulted many of the most famous 19th century otologists and was eventually operated on by the famous Professor Schwartze. We present the life and death of arguably the most famous man of his day as drawn from a number of biographic sources and speculate on the ear pathology that ultimately lead to his demise.

Cerumen removal--current challenges

Each week in the United States, approximately 150,000 cerumen removals take place. Otologic complications include pain, perforated tympanum, dizziness, bleeding and infection. The prevention and management of such complications are discussed below. Accepted methods of removal should be used and all perforations and other forms of trauma, when they occur, must be evaluated for middle and inner ear pathology. Handicapped patients and those under custodial care represent a group that is underserved at this time. Possible solutions are discussed.

Evaluating facial paralysis. Expensive diagnostic tests are often unnecessary

In most cases, the cause of facial paralysis can be determined on the basis of the clinical evaluation, and expensive diagnostic tests can be avoided. Because Bell's palsy is not always the cause, physicians need to be able to identify critical findings on history and physical examination that indicate an alternative diagnosis. Once identified, these findings can lead to a specific and directed evaluation.

Osteoma with cholesteatoma in the external auditory canal

We report an unusual case of a 13-year-old girl with a benign osteoma associated with a cholesteatoma in the external auditory canal and serous otitis media. The osteoma was located in the antero-inferior wall of the right external auditory canal. A cholesteatoma was present between the osteoma and the tympanic membrane. Computed tomography revealed a soft tissue density within the external auditory canal and in the middle ear cleft. The shadow in the middle ear cleft was considered to represent the serous otitis media. Surgical removal of the osteoma and cholesteatoma proved successful, and no recurrences or complications have occurred in the first year postoperatively.

Bilateral conductive deafness related to erosive lichen planus

A case of bilateral progressive stenosis of both external auditory canals with resultant conductive hearing loss is presented. The stenosis revealed multifocal erosive and synechiant lichen planus. To our knowledge, this is the first reported case of lichen planus involvement of the external ear.

Quantified EEG in patients with vertigo of central or peripheral origin

Computerized EEG frequency analysis was performed in 18 patients with peripheral vestibular dysfunction (PVD), 17 patients with central vestibular dysfunction (CVD) and 22 aged matched controls. Increase in the relative theta activity in the centrotemporal region was found in patients with PVD. The decrease of centroparietal beta activity in both groups of patients, as compared to controls, did not reach statistical significance. We conclude that quantified EEG may be a sensitive method to show changes of cortical electrical activity in patients with vertigo, reflecting the imbalance in afferent vestibular input to the cortex.

Medical management of migraine-related dizziness and vertigo

Historically, review of migraine-related vestibular symptoms has focused on the various clinical presentations that occur and the results of diagnostic studies of vestibular function. Treatment of vestibular symptoms related to migraine has been proposed similar to that used for headache control, but few examples of the effectiveness of this therapy have been published. The purpose of this study is to present the various approaches that can be used to manage vestibular symptoms related to migraine, and to evaluate the overall effectiveness of these treatment approaches. This was a retrospective review of 89 patients diagnosed with migraine-related dizziness and vertigo. The character of vestibular symptoms, pattern of cochlear symptoms, results of auditory and vestibular tests, and comorbidity factors are presented. Treatment was individualized according to symptoms and comorbidity factors, and analyzed regarding effectiveness in control of the major vestibular symptoms of episodic vertigo, positional vertigo, and nonvertiginous dizziness. Medical management included dietary changes, medication, physical therapy, lifestyle adaptations, and acupuncture. Complete or substantial control of vestibular symptoms was achieved in 68 (92%) of 74 patients complaining of episodic vertigo; in 56 (89%) of 63 patients with positional vertigo; and 56 (86%) of 65 patients with non-vertiginous dizziness. Similarly, aural fullness was completely resolved or substantially improved in 34 (85%) of 40 patients; ear pain in 10 (63%) of 16 patients; and phonophobia in 17 (89%) of 19 patients. No patient reported worsened symptoms following medical management. The conflicting concept of a central disorder (migraine) as the cause of cochlear and vestibular dysfunction that often has peripheral features is discussed.

Ototoxicity resulting from intracochlear perfusion of Streptococcus pneumoniae in the guinea pig is modified by cefotaxime or amoxycillin pretreatment

Acute changes in the electrophysiology and ultrastructure of the organ of Corti were studied after microperfusion of c. 5 x 10(6) CFU of serotype 2 Streptococcus pneumoniae D39 or Escherichia coli K-12 directly into the scala tympani of guinea pigs. Hearing loss was assessed by recording the auditory nerve compound action potential response to a 10 kHz tone pip. Mean hearing loss 3 h after pneumococcal perfusion (n = 4) was 44 dB, compared to 6 dB after E. coli perfusion (n = 4) (P<0.001). After pneumococcal perfusion, scanning electron microscopy revealed damage to hair cell stereocilia and cratering of the apical surface of supporting cells. Intraperitoneal injection of 100 mg/kg cefotaxime (n = 4) or 100 mg/kg amoxycillin (n = 4) 30 min before perfusion of pneumococci significantly reduced mean hearing loss to 23 dB (P=0.01) or 20 dB (P=0.01), respectively, and diminished ultrastructural damage. The data suggest that if pneumococci invade the inner ear during meningitis, cochlear deafness may rapidly ensue.

Video otoscopy in audiologic practice

Recent advances in endoscopic optics and miniature video camera technology have made video otoscopy (VO) accessible to audiologists in a practical way. Seven categories of VO applications are presented with clinical examples: (1) general examination of the earcanal and tympanic membrane, (2) physician communication/telemedicine, (3) hearing instrument selection and fitting applications, (4) patient education, (5) scope of practice reinforcement, (6) knowledge base/skill growth, and (7) cerumen management.

Needle placement with transtympanic electrocochleography

Electrocochleography (ECoG) is an objective, electrophysiologic test useful in the clinical diagnosis of endolymphatic hydrops, or Meniere's disease. The purpose of this study was to determine if the position of the needle, using transtympanic methodology, gives a variable SP/AP (summating potential/action potential) response. SP/AP ratios were obtained during routine tympanoplasty procedures. After the tympanic membrane remnant was removed using a lateral graft technique, precise needle placement was obtained at the medial and lateral round window niches, as well as on the promontory. SP/AP ratios were obtained in these three needle positions. There was no significant difference in the SP/AP ratio responses despite the location of needle placement. The use of transtympanic electrocochleography can give very good wave form morphology and consistent results. Therefore, if elevated SP/AP ratios do occur, they are thought to be due to a pathologic process of the ear and not needle placement.

The differential diagnosis of Meniere's disease

The diagnosis of "classic" Meniere's disease is easy to make. Unfortunately, Meniere's disease is a diagnosis of exclusion and many disease entities can mimic Meniere's disease. Thus, it is essential to eliminate other possible etiologic agents for complaints that could be related to Meniere's disease before making this diagnosis. This article evaluates the differential diagnosis in Meniere's disease.

Surgical strategy of cochlear implantation in patients with chronic middle ear disease

We report 10 postlingually deafened adults in whom the electrophysical criteria for cochlear implant were fulfilled, except that they showed the following unfavorable middle ear lesions: otitis media with effusion, chronic perforative otitis media, cholesteatoma and previous radical ear operation. Staged operations for cochlear implant were performed in 8 cases, and 2 patients who had undergone radical ear operation had a single-stage operation. As a first step, one of the following was performed in each patient as surgically indicated: myringoplasty with or without mastoidectomy, mastoidectomy with reconstruction of the posterior wall of the external canal, mastoidectomy with the insertion of a ventilation tube, radical mastoidectomy or surgical cleansing of the radical cavity. From 6 months to 2.5 years after the first operation, the actual cochlear implant was performed in the second or third stage. There was no major complication as a result of electrode insertion into the cochlea and the results of speech perception in these cases were not different from those in patients with normal middle ears. In our experience, it was considered that the staged operations would enable successful cochlear implants in selected patients with pathological middle ear lesions even if they had previously been diagnosed as contraindicated for this procedure. In a case with radical ear cavity a single-stage operation could be performed when there was no cavity problem.

Minute findings of inner ear anomalies by three-dimensional CT scanning

In actual clinical situations, inner ear anomalies must be diagnosed by image diagnosis such as high resolution CT-scanning of the temporal bone before three dimensional (3D) CT-scanning was introduced. In this paper, the usefulness of 3D-CT was investigated in some anomaly cases. It was found that 3D-CT was useful in observing the minute structure of the inner ear in that it could ascertain spatial relationships and minute constrictions and protrusions that could not be detected by 2D analysis. This CT was also capable of assessing the stage of embryological injuries and evaluating anomalies in cochlear turning that are the hidden factors of hearing impairment.

[Immune-mediated inner ear disease: report of clinical cases]

Many clinical and experimental studies have obtained evidence of immune-mediated inner ear disease. Discrepancies between theories of the mechanisms of injury to the inner ear and the laboratory tests that identify it mean that the diagnosis is based on clinical symptoms and a positive response to treatment. We report four cases of immune-mediated inner ear disease characterized by endolymphatic hydrops, fluctuating hearing loss, sudden deafness (first symptom of primary Sjögren's syndrome), and rapidly progressive sensorineural hearing loss.

[Endocranial complications of cholesteatoma: apropos of 8 cases]

The authors present a recent series of 8 cases of intracranial complications secondary to cholesteatoma. The series is made up of 3 temporal lobe abscesses, 1 parietal lobe abscess, 1 cerebellar abscess, 1 extradural abscess, one lateral sinus thrombo-phlebitis with subdural abscess and one meningitis on its own. Otological management with removal of the cholesteatoma was by open or closed technique, depending on the local anatomical conditions. It was supplemented by multiple antibiotic therapy, in turn guided by the bacteriological cultures and by any known epidemiological information. It was necessary to needle the abscess by a neurosurgical approach in two cases. The results of bacteriological samples taken for analysis from the intracranial abscesses are often negative, which limits their clinical value. In such cases, the choice of antibiotics rests on epidemiological information. The authors emphasise the progress that has been made towards the early diagnosis of intracranial complications. Appropriate combined medical and surgical treatment leads to complete cure without neurological sequelae in most cases.

Plasmapheresis in autoimmune inner ear disease: long-term follow-up

OBJECTIVE

This study aimed to evaluate the outcome of long-term hearing benefits of plasmapheresis (PMP) in presumed autoimmune inner ear disease (AIED).

STUDY DESIGN

The study was a case series, with retrospective chart review, written questionnaire, telephone interview, and follow-up examination.

SETTING

It was performed in a private practice otology and neurotology referral center.

PATIENTS

Sixteen patients (5 males, 11 females) whose symptoms were compatible with the diagnosis of AIED, who underwent PMP, and who had 2-year or later objective follow-up. Age ranged from 8-62 years, with a mean of 40.9 years. Follow-up ranged from 2-12 years, with a mean of 6.7 years.

INTERVENTION

Plasmapheresis at one or more times during the active phase of disease.

MAIN OUTCOME MEASURE

Stability of hearing, defined according to the American Academy of Otolaryngology-Head and Neck Surgery recommended criteria for reporting hearing results in Meniere's disease, was used as the main outcome measure.

RESULTS

Eight (50%) of 16 patients had improved or stable hearing in 1 or both ears. Eleven (39.3%) of 28 ears with measurable hearing pre-PMP were improved or stable. Only 25% of patients required continued use of immunosuppressive drugs.

CONCLUSION

Plasmapheresis may be beneficial as an adjunctive therapy for maintaining hearing in some patients with AIED. Cost and reimbursement factors are major obstacles in the use of this therapy. The overall success rate and individual patient results warrant further study of PMP in the treatment of AIED.

Retraction of the pars tensa--long-term results of surgical treatment

Severe retraction of the pars tensa usually requires surgical treatment. Long-term follow-up of patients is essential as they may still suffer from eustachian tube dysfunction, resulting in a recurrence of the condition. Seventy-two tympanoplasties for retraction of the pars tensa (32 posterior retraction pockets and 40 completely collapsed tympanic membranes) were followed up for between 3 to 8 years. The long-term outcome of surgery for the posterior retraction pockets was favourable with at least 80% of the patients free of subsequent recurrence of the retraction pocket. The hearing gain and the post-operative hearing results were good. The surgical outcome for the completely collapsed tympanic membranes was disappointing with re-collapse in 50% of patients. Consequently, the postoperative hearing results were poor.

[Polyps of the external auditory canal and cholesteatoma]

A retrospective study of 50 patients with an aural polyp located in the external auditory canal was made. Our main objective was to identify predictive factors for underlying cholesteatoma, as well as to determine our management strategy for aural polyps. We analyzed the most important findings of otological imaging, hearing loss, radiological examination, and medical or surgical treatment. The anatomopathological examination in some cases showed a rare pathology that should be considered in our diagnostic evaluation. The presence of cholesteatoma underlying the polyp in 52% of cases indicates the importance of the polyp location and radiological signs as predictive factors for the diagnosis of cholesteatoma.

Otoneurologic evaluation of child vertigo

In this study 282 children with vertigo are subdivided (according to previous experiences) into three large groups: (1) vertigo and cochlear diseases; (2) vertigo as an isolated symptom; and (3) vertigo and C.S.N. diseases. Due to the difficult etiopathogenetic investigation of the patients from the second group, the authors focused on that group as they are less studied, are without associated symptoms (deafness--first group; CNS diseases--second group) and where vertigo appears as an idiopathic and an isolated symptom. A careful anamnestic, clinical and instrumental analysis leads to the following observations: (1) in decreasing order of frequency we find the third group, followed by the first and finally by the second; (2) in spite of the overall lower incidence of the second group, this latter includes the paroxismal benign vertigo (PBV) which is overall the second most frequent vertiginous form (after vertigo due to cranial trauma). In this group the authors underline the reasonably high incidence of the iatrogenic syndromes, insisting on the need of their accurate prevention of these risks; (3) the authors confirm that, nowadays, a reliable etiopathogenetic cause of the apparently isolated vertigo (except for the ascertained iatrogenic forms) cannot be identified. Moreover, in spite of its frequency, PBV is the less known form of vertigo, of which we cannot give a certain diagnosis and which can be identified only the the exclusion of all the other known forms through instrumental and clinical observations.

Relapsing polychondritis: clinical and immunogenetic analysis of 62 patients

OBJECTIVE

In this study we describe clinical and immunogenetic findings in 62 unselected patients with relapsing polychondritis.

METHODS

In a multicenter study, clinical data of 26 (41.9%) female and 36 (58.1%) male patients were collected. HLA-DR specificities were identified in 60, and the frequencies were compared with those in healthy controls.

RESULTS

The median age at the time of diagnosis was 46.6 years (range 17 to 86). 58 (93.5%) patients had auricular chondritis, 31 (50.0%) ocular symptoms, 35 (56.5%) nasal involvement. Involvement of joints (53.2%), respiratory system (30.6%), skin (24.2%), cardiovascular system (22.6%), central nervous system (9.7%), and kidneys (6.5%) was found as well. 22 (35.5%) patients had associated diseases such as systemic lupus erythematosus or rheumatoid arthritis. Susceptibility to relapsing polychondritis was significantly associated with HLA-DR4 (p < 0.001). There was no difference in the frequency or distribution of DRB1*04 subtype alleles between patients and healthy controls. The extent of organ involvement was negatively associated with HLA-DR6 (p < 0.011).

CONCLUSION

Immunogenetic findings as well as similarities and overlapping clinical symptoms with other autoimmune or rheumatic diseases suggest that immunological mechanisms play a major role in the pathogenesis of relapsing polychondritis.

Prevalence and mechanisms of hearing loss in patients with resistance to thyroid hormone

Hearing impairment was anecdotally reported in resistance to thyroid hormone (RTH), a condition caused by mutations in the beta-thyroid hormone receptor (beta TR) gene. Because of its ontogenic distribution in the cochlea, the beta TR may have a pivotal role in the development of auditory function. To assess the prevalence and mechanisms of hearing impairment in RTH, 82 RTH-positive (RTH+) patients and 55 unaffected relatives (RTH-) underwent systematic audiological examination, including puretone and speech reception thresholds, and tests studying middle ear (tympanometry and acoustic reflexes), cochlear (otoacoustic emissions), and retrocochlear integrity (brain stem auditory evoked potentials). Significant hearing loss was present in 21% of RTH+ patients vs. none in RTH- patients. More RTH+ patients had abnormal tympanometry (34% vs. 12%) and abnormal acoustic reflexes (39% vs. 19%). Isolated conductive deficit was found in 7 of 17 RTH+ patients with hearing loss, isolated sensorineural deficit in 7 cases, and mixed deficit in 3 cases. Cochlear dysfunction was found in 50% of all RTH+ patients, with or without hearing loss. Retrocochlear function was normal. No morphological cochlear abnormalities were detected on computed tomography of the temporal bone. In conclusion, hearing loss is a significant problem in RTH, with an equal frequency of conductive (probably related to the frequent ear infections) and sensorineural deficits. Abnormal otoacoustic emissions suggest that the mutant beta TR has a specific negative impact on cochlear function.

Mondini dysplasia with recurrent meningitis

Mondini dysplasia is a congenital malformation of the inner ear, commonly associated with hearing impairment, cerebrospinal fluid otorrhea/rhinorrhea and recurrent meningitis. Two such cases are described, with hearing impairment, cerebrospinal fluid rhinorrhea, and several episodes of meningitis. Diagnosis was confirmed by high-resolution computed tomography. After surgical correction of the malformation, there was no recurrent episode of meningitis at subsequent follow-up. To avoid the suffering and the sequelae of recurrent meningitis, an early diagnosis and prompt surgical intervention are crucial for such patients.

Dizziness and vertigo in a department of emergency medicine

Dizziness is a common and vexing diagnostic problem in emergency departments. The term is rather undefinite and often misused, but can in practice be classified into four categories: fainting, disequilibrium, vertigo and miscellaneous syndromes. Vertigo is the most common category of dizziness. Classification of vertigo can be based either on chronological criteria (acute, recurrent or chronic vertigo) or on topographical criteria (peripheral or central vertigo). Physicians working in emergency departments must be able to rapidly identify patients with potentially serious forms of vertigo, which could cause death or disability, and patients with mild conditions, that can be effectively treated. Previous studies and the experience of the authors have shown that reliable diagnostic hypotheses can be generated by taking a proper clinical history (focused on the onset and duration of the disease, the circumstances causing the vertigo and associated otological or neurological symptoms) and performing an accurate physical examination (evaluation of neurological defects and spontaneous or provoked nystagmus), supplemented by few laboratory tests and diagnostic procedures. Therapy of vertigo in emergency settings is mainly symptomatic and based on sedation and use of vestibulosuppressant drugs (antihistamines, phenothiazines).

Application of split-thickness skin grafts for acquired diseases of the external auditory canal

Over the past 10 years a variety of acquired external auditory canal pathologies have been treated at the University of Virginia. Surgical intervention has been required in 16 patients (18 ears). The most common diagnosis in this group was canal stenosis. Split-thickness skin grafts have been used for epithelial coverage. Depending on the size and location of the canal defect, one of three graft types was used: island, segmental, or circumferential. Surgical techniques are discussed and illustrative cases presented. Long-term graft results have been excellent, with no patient requiring a second graft for coverage. In those patients with preoperative conductive losses, the average improvement in hearing threshold was 27 decibels.

Evidence of cellular supplies to the endolymphatic sac from the systemic circulation

Donor T lymphocytes injected into the host systemic circulation were observed to infiltrate into the host endolymphatic sac in mice. These findings suggest that the endolymphatic sac, a major immune organ in the inner ear, is supplied with immunocompetent cells from the systemic circulation. This concept is consistent with clinical reports that inner ear disorders accompany certain systemic autoimmune diseases. Bone marrow transplantation to replace autoreactive immunocompetent cells with normal cells should be considered as a potential therapy for inner ear autoimmune diseases and an alternative to conventional treatments.

Ear disease and schizophrenia: a case-control study

The rates of middle ear disease in 70 patients with schizophrenia from a defined catchment population were compared with the rates in 359 nonpsychiatric controls who were matched for age, sex and general practice. A relative risk (odds ratio) of middle ear disease in schizophrenia of 1.92 was found. This was raised to 2.29 when ear disease occurring after the onset of schizophrenia was excluded. Excluding aetiological factors such as brain damage or family history raised the odds ratio further to 2.50 and 2.71 respectively. The implications of these results are discussed, and it is suggested that middle ear disease may be an aetiological factor in some cases of schizophrenia.

[Tympanosclerosis--clinical and pathological investigation]

Fifty-nine cases of tympanosclerosis were investigated clinically and pathologically, and the following results were obtained: 1) The male to female ratio was about 1:1.8 2) Calcification in the tympanic membrane was most common in the upper quadrants of the pars tensa, and never seen in the pars flaccida. 3) Calcification in the middle ear cavity was most common around the malleus. 4) Chronic otitis media was the most common complication of tympanosclerosis. 5) Preoperative audiometry revealed a stiffness curve with elevated bone conduction thresholds. 6) 54% of the patient had chronic otitis media in the contralateral ear. 7) Microscopic examination revealed calcification in the submucosa of the middle ear. 8) Postoperative hearing was improved in 49 ears (79.7%). Because there was no difference in the average postoperative hearing gain after type I and type III tympanoplasty, type III tympanoplasty is recommended to remove sclerotic masses completely.

[Patulous eustachian tube]

Patulous eustachian tube is a pathological condition which exists more often than we make a diagnosis, and a patient is not often aware of his disease. This disease can be manifested with various symptoms: respiratory synchrony noises in the ear, because of the penetration of the air current through the eustachian tube and with the movement of the eardrum outwards and inside, with autophony, reduction of the hearing, the buzzing, dizziness and disturbance of the balance. Two patients are presented. The first one was sick for many years from various chronics exhausted diseases: Jackson's epilepsy, temporary vascular brain disturbances, tuberculosis of lung, stomach ulcer, heart diseases, the patient is from low class, on one side, and also suffers from some local diseases: a paralysis of soft palate and palatal arcs, a chronic catarrhal rhinitis and sinusitis, a deviation of nasal dividing wall and hindered breathing through the nose, on the other side. Many years the patient didn't know for patological condition in the ears and in the eustachian tubes. After improving the hygienic conditions, the physical condition and local therapy, the patient felt much better. The second patient, with considerable shorter evolution of the disease and mild symptomatology, showed the amplified symptoms of the disease of the Eustachian tube in the course of the acute otitis. It is attained a satisfying calming of the manifestative symptoms by remedy therapie. Man must thing about possibility of the appearance of this pathology condition in various disease or conditions, which can take to the fast lost of the weight and physical and moral exhaustion of the patient, i.e. an adult, first as the protection of the appearance of the disease (condition) and afterwards, eventually early and regulary treatment in order to prevent various possible, above mentioned complications.