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.