Cochlear implantation in patients with Cogan syndrome: long-term results

Cochlear implantation in otosclerosis: surgical and audiological outcomes between ossified and non-ossified cochlea

AIM

To evaluate (1) Audiological and surgical outcomes in patients with otosclerosis following cochlear implantation. (2) surgical difficulties and outcomes between both groups. (3) Audiological outcomes between both groups.

STUDY DESIGN AND SETTING

Retrospective study conducted at Otology and Skull Base Surgery Center.

SUBJECTS AND METHODS

Data were analyzed from 111 patients with otosclerosis (114 ears) who underwent cochlear implant surgery using the cochlear implant database. Demographic characteristics (age, sex, and operated ear), auditory outcomes, and operative details (extent of cochlear ossification, surgical approach [posterior tympanotomy or subtotal petrosectomy], electrode insertion [partial/complete, scala tympani or vestibuli], and complications) were analyzed Auditory outcomes were assessed over at least one year follow-up period using pure tone audiometry and speech discrimination scores. Patients were divided into two groups (with and without cochlear ossification) to compare auditory outcomes and surgical outcomes.

RESULTS

The mean age of patients with ossified and non-ossified cochlea was 60.04 and 62.22 years respectively. Sixty-five of 114 ears had cochlear ossification, with complete round window involvement in 75.4% of these patients, while the rest had partial or complete basal turn ossification. Subtotal petrosectomy was performed in 63.1% and 28.6% of ossified and non-ossified cochlea respectively while the rest underwent cochlear implantation through posterior tympanotomy. Only one case had scala vestibuli insertion and four had incomplete electrode insertion. Six patients underwent re-implantation due to infection, device failure, and erosion of the posterior canal wall. Auditory outcomes among patients with ossified otosclerosis were slightly better than those without ossification but this difference was not statistically significant.

CONCLUSION

Cochlear implantation for otosclerosis yields excellent auditory outcomes with a low rate of surgical complications, despite the high incidence of cochlear ossification.

Cochlear Implantation by Veria Technique in Abnormal Cochlea: Our Experience

This study describes the clinical profile, operative findings, surgical technique, type of implant and complications encountered in implantation of abnormal cochlea by the transcanal (veria) technique in a tertiary care centre. This is a retrospective study done amongst 337 patients who underwent cochlear implantation by veria technique between January 2013 to August 2023. Based on pre-operative imaging with high-resolution computed tomography and magnetic resonance imaging the cochleovestibular malformations in this study were classified according to Sennaroglu classification and the cochlear ossification was graded from I to IV. Amongst the 337 patients who underwent cochlear implantation during the study period there were 79 cases (23.4%) with abnormalities of cochlea. This included 45 patients (13.4%) with congenital malformations, 20 patients (5.9%) with cochlear fibrosis and 14 patients (4.2%) with cochlear ossification. The commonest cochlear malformation was Incomplete Partition 2 which was present in 21 patients (46.7%). The other common malformations were cochlear hypoplasia (31.1%), Incomplete Partition 1(13.3%) and common cavity (8.9%). Out of the 20 patients with cochlear fibrosis, 17 patients had fibrosis only in the basal turn. Out of the 14 patients with cochlear ossification 8 patients (57.1%) had a grade 1 ossification, 2 patients (14.3%) had a grade 2 ossification and 4 patients (28.6%) had a grade 3 ossification. One of the patients required re-exploration for correcting the placement of electrode. The type of implant were chosen depending on individual malformation or length of ossification and fibrosis. In the past, inner ear anomalies were considered as a contraindication for cochlear implantation however it is now possible to implant most of these abnormal cochlea by careful planning, a modification of the surgical technique and the type of electrode used.

Paediatric Cogan Syndrome masquerading as IgA vasculitis

Paediatric Cogan Syndrome is a rare and underrecognised autoimmune vasculitis characterised by ocular inflammation and sensorineural hearing loss. Its etiopathogenesis, diagnosis, and management are not well defined. We report a 12-year-old girl who initially presented with symptoms of IgA vasculitis formerly called Henoch Schoenlein Purpura (HSP) and eventually developed anterior uveitis and bilateral sensorineural hearing loss leading to the diagnosis of atypical Cogan Syndrome. The workup for infectious etiologies and other systemic rheumatologic disorders was negative. The management was multidisciplinary involving Rheumatology, Ophthalmology, Otorhinolaryngology, and Audiology. The anterior uveitis responded well to systemic glucocorticoids and Methotrexate, but the hearing loss was grossly progressive warranting a cochlear implant. We are not aware of Paediatric Cogan Syndrome being reported as a mimicker of IgA vasculitis previously in the literature. It is an important finding as IgA vasculitis is prevalent in the paediatric age group and new-onset ocular or vestibular symptoms after IgA vasculitis should alert the clinician to the possibility of Cogan Syndrome. In the absence of well-defined diagnostic criteria, it is crucial to recognise the clinical symptoms of Paediatric Cogan Syndrome for early diagnosis and treatment since the delay in diagnosis can lead to permanent disability.

Cogan Syndrome: A Case Study and Review of the Literature

Cogan syndrome is an autoimmune disease characterized by vestibular symptoms, bilateral sensorineural hearing loss, and inflammatory ocular manifestations, which may be accompanied by systemic vasculitis. We herein present the case of a patient with bilateral sensorineural hearing loss who presented with pain over her cochlear implantation incision site. She was later found to have evidence of ocular disease and underlying vasculitis leading to a diagnosis of Cogan syndrome.

Speech reception after cochlear implantation for Cogan's syndrome: Case series following CARE guidelines

INTRODUCTION

Cogan's syndrome is a rare form of vasculitis mainly affecting young subjects of whatever gender, associating cochleovestibular and ophthalmological damage. Despite medical treatment, auditory prognosis is uncertain, with 50-60% of patients showing irreversible severe to profound hearing loss, thus being candidates for cochlear implantation. Following CARE guidelines, we report 10 cases of cochlear implantation in Cogan's syndrome, with assessment of speech reception threshold and maximum intelligibility after a minimum 1 year's experience with the implant.

CASE SERIES

Ten patients from 4 centers received cochlear implants (14 implants) for Cogan's syndrome between 2005 and 2020. After 1 year's experience, there was significant improvement in speech reception threshold (P=0.0002) and maximum intelligibility (P=0.0002).

CONCLUSION-DISCUSSION

Audiovestibular signs associated with ophthalmological manifestations should suggest Cogan's syndrome. Hearing impairment is usually irreversible. Cochlear implantation may be necessary and improves hearing performance.

Case report: Cochlear implantation was effective for progressive bilateral severe hearing loss associated with Kawasaki disease

Sensorineural hearing loss associated with Kawasaki disease has been increasingly reported, but its etiology remains unclear. Most reported cases of sensorineural hearing loss associated with Kawasaki disease have been mild and reversible during acute or subacute phases. However, bilateral severe hearing loss as a complication of Kawasaki disease can cause delays in cognitive and speech development. A 4-year-old Japanese boy treated for Kawasaki disease had right-side moderate and left-side profound sensorineural hearing loss on the 141st day after onset of Kawasaki disease. Despite systemic steroid pulse treatment, hearing loss remained in both sides. After the recurrence of Kawasaki disease, hearing on the right side progressively worsened, meaning there was now severe hearing loss on both sides. Left cochlear implantation performed on the 1065th day after the onset of Kawasaki disease improved the patient's hearing and his ability to communicate. Sensorineural hearing loss associated with Kawasaki disease may progress over a long period and cause bilateral severe hearing loss, although past reports showed occurrence during acute or subacute phases. The clinical course of our patient suggests that intense inflammation caused by Kawasaki disease could be related to prolonged hearing loss. Cochlear implantation seems to be effective for sensorineural hearing loss associated with Kawasaki disease.

Paediatric Cogan´s syndrome - review of literature, case report and practical approach to diagnosis and management

BACKGROUND

Cogan´s syndrome is a rare, presumed autoimmune vasculitis of various vessels characterized by interstitial keratitis and vestibular impairment accompanied by sensorineural hearing loss. Due to the rarity of Cogan´s syndrome in children, therapeutic decision making may be challenging. Therefore, a literature search was performed to collect all published paediatric Cogan´s syndrome cases with their clinical characteristics, disease course, treatment modalities used and their outcome. The cohort was supplemented with our own patient.

MAIN TEXT

Altogether, 55 paediatric Cogan´s syndrome patients aged median 12 years have been reported so far. These were identified in PubMed with the keywords "Cogan´s syndrome" and "children" or "childhood". All patients suffered from inflammatory ocular and vestibulo-auditory symptoms. In addition, 32/55 (58%) manifested systemic symptoms with musculoskeletal involvement being the most common with a prevalence of 45%, followed by neurological and skin manifestations. Aortitis was detected in 9/55 (16%). Regarding prognosis, remission in ocular symptoms was attained in 69%, whereas only 32% achieved a significant improvement in auditory function. Mortality was 2/55. Our patient was an 8 year old girl who presented with bilateral uveitis and a history of long standing hearing deficit. She also complained of intermittent vertigo, subfebrile temperatures, abdominal pain with diarrhoea, fatigue and recurrent epistaxis. The diagnosis was supported by bilateral labyrinthitis seen on contrast-enhanced magnetic resonance imaging. Treatment with topical and systemic steroids was started immediately. As the effect on auditory function was only transient, infliximab was added early in the disease course. This led to a remission of ocular and systemic symptoms and a normalization of hearing in the right ear. Her left ear remained deaf and the girl is currently evaluated for a unilateral cochlear implantation.

CONCLUSIONS

This study presents an analysis of the largest cohort of paediatric Cogan´s syndrome patients. Based on the collected data, the first practical guide to a diagnostic work-up and treatment in children with Cogan´s syndrome is provided.

Cochlear implantation in systemic autoimmune disease

PURPOSE OF REVIEW

Autoimmune inner ear disease (AIED) is a rare, but likely underrecognized cause of hearing loss. However, hearing loss is common in systemic autoimmune disease and it is important for the clinician to be familiar with the spectrum of disease. In this article, we will review the developments in diagnosis and management of AIED, with a focus on the outcomes and potential pitfalls of cochlear implantation.

RECENT FINDINGS

Hearing loss in AIED tends to be progressive and bilateral, but up to 40% can present as sudden hearing loss and one-third can present unilaterally. HSP-70 serology may help with diagnosis and may predict steroid response. Cochlear implantation provides excellent hearing and quality of life outcomes in patients deafened by AIED. Intracochlear fibrosis/ossification is found intraoperatively in the majority (54%) of patients undergoing cochlear implantation. A large percentage (32%) of patients has fluctuating impedances postimplantation, which may interfere with implant performance and mapping.

SUMMARY

Diagnosis of AIED is largely clinical, and a strong index of suspicion is required. Multidisciplinary care is crucial for optimal management. Cochlear implant outcomes are generally excellent, but the clinician needs to be cognizant of the pitfalls of encountering intracochlear fibrosis intraoperatively and likelihood of implant performance fluctuation related to ongoing inflammation in the cochlea.

Auditory and speech outcomes of cochlear implantation in post-meningitis deafness

PURPOSE

This study aims to identify the auditory, speech, and surgical outcomes of cochlear implantation in patients with profound SNHL following bacterial meningitis.

METHODS

Subjects with bilateral severe to profound SNHL who underwent unilateral cochlear implantation from 2003 to 2020 were included in this historical cohort study. The main outcomes were assessed using Categories of Auditory Performance (CAP) and Speech Intelligibility Ratings (SIR) scores. The CAP and SIR outcomes were collected as three-time points after surgery: 6, 12, and 24 months. In order to achieve the strength of the relationship and for computing the Risk Ratio (RR) by log-binominal regression method, we used two binary categorizations of CAP and SIR in our analyses.

RESULTS

The mean of age at implantation of the study and control group were 144.30 (156.90) and 121.10 (133.70) months, respectively. In the study group, 19 of 35 (54.3%) patients were male, and 16 (45.7%) were female. In the control group, 34 of 81 (42.0%) patients were male and 47 (58.0%) were female. The mean scores of CAP and SIR in our study improved significantly during the time in both groups. All p-values (p) were significant in both groups (T2 vs T1, T3 vs T1, and T3 vs T2). Our analysis by log-binomial regression and computing the RR based on the first and second categorization of CAP and SIR showed moderate to strong relationships between the presence of a history of meningitis and inappropriate CAP and SIR outcomes in these patients.

CONCLUSIONS

Although subjects who were deafened due to meningitis benefit significantly from cochlear implantation, we found moderate to strong relationships between the history of meningitis and inappropriate CAP and SIR outcomes in these patients.

Hearing loss in inner ear and systemic autoimmune disease: A systematic review of post-cochlear implantation outcomes

OBJECTIVES

To assess outcomes following cochlear implantation (CI) in patients with hearing loss secondary to primary or secondary autoimmune inner ear disease (AIED).

METHODS

A systematic review and narrative synthesis was completed according to PRISMA guidelines. Databases searched included MEDLINE, PubMed, EMBASE, Web of Science, Cochrane Collection, and ClinicalTrials.gov. No limits were placed on year of publication or language.

RESULTS

A total of 551 studies were identified, of which 29 were included after removal of duplicates, and screening the title, abstract, and full text. All except one study were OCEBM grade IV. 114 of 115 patients displayed improvement in hearing following cochlear implantation. With implant use, roughly a third of these patients had hearing that improved over time, a third improved and plateaued, and a third remained stable. There was no additional risk of perioperative complications found in AIED patients compared what is generally accepted in general cochlear implantation, although two episodes of device failure after 6 months were noted, and four patients with secondary AIED displayed poor initial audiological outcomes.

CONCLUSION

CI in both primary and secondary AIED provides marked improvement in hearing. Early CI may be a valid management option, provide long-lasting hearing in patients and reduce the side effects of long-term systemic immunosuppressants. However, patients should be counseled residual hearing may be lost if there is cochlear ossification or fibrosis which may make implant insertion more traumatic.

LEVEL OF EVIDENCE

NA.

Scoping review of cochlear implantation in Susac's syndrome

Objective

Scoping review of published literature to establish clinical characteristics and audiologic outcomes in patients diagnosed with Susac’s Syndrome(SS) who have undergone cochlear implantation (CI).

Data sources

All published studies of CI in SS and contribution of two of our own patients who have not been reported previously.

Methods

A comprehensive search of MEDLINE (via PubMed) was carried out in March 2020 using the following keywords and related entry terms: Susac’s Syndrome, Cochlear Implantation.

Results

Our search identified a total of five case reports of CI in SS. With the addition of our two patients reported here, we analyzed characteristics and outcomes in seven patients. Mean age at implantation was 30 years old (range 19–46), with six women and one man implanted. Mean time from onset of hearing loss to implantation was 17 months (range three months to four years). Best reported postoperative speech understanding was reported via different metrics, with six of seven patients achieving open set speech scores of 90% or better, and one subject performing at 68%. Vestibular symptoms were present preoperatively in four of seven patients (57%), with vestibular testing reported in two patients, and showing vestibulopathy in one patient. No complications were reported following cochlear implantation.

Conclusion

Cochlear implantation is a viable option for hearing rehabilitation in patients with SS, with levels of attainment of open set speech comparable to other populations of CI candidates.

An unusual case of post-cochlear implant performance degradation in a patient with suspected Cogan's syndrome

Cogan's Syndrome is an autoimmune disorder that can affect the ear, eye and other organs. Although rare, Cogan's Syndrome is particularly relevant to the cochlear implant surgeon because the resulting hearing loss is often bilateral and the majority of cases progresses to profound levels where cochlear implantation may be indicated. There are many issues relating to this condition that concern the cochlear implant surgeon. Its rarity, lack of specific laboratory diagnostic tests and variability in the onset and types of manifestation relating to the ear, eye and other organs often pose diagnostic difficulties. Pre-operatively, the cochlear implant surgeon must anticipate and exclude the possibility of cochlear luminal obliteration and ossification. Although the post-implant hearing results are expected to be generally good in Cogan's Syndrome, the possibility of adverse hearing outcomes cannot be ruled out whether in the initial or subsequent post-operative period. The possible side effects of long-term immuno-suppressive therapy on the well-being of the cochlear implant are to be appreciated and managed. A case which posed much difficulty in management is presented and discussed to highlight some of these challenges.

Cochlear Ossification in a Patient with Cogan's Syndrome Undergoing Bilateral Cochlear Implantation

We present the case of a young female patient diagnosed with Cogan's syndrome after the rapid onset of profond hearing and vestibular loss with concomitant eye symptoms. After appropriate medical treatment, her hearing did not respond and she underwent bilateral simultaneous cochlear implantation with findings of extensive cochlear ossification in both ears. The case and outcome are described in the body of the paper.

The Role of Autoimmunity in the Pathogenesis of Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSHL) is a clinically common acute symptom in otolaryngology. Although the incidence of SSHL has increased around the world in recent years, the etiology of the disease is still unclear. It has been reported that infections, ototoxic drugs, membrane labyrinth rupture, carcinomas, circulatory system diseases, autoimmune diseases, brain lesions, mental diseases, congenital or inherited diseases, and so on, are all risk factors for SSHL. Here, we discuss the autoimmune mechanisms behind SSHL, which might be induced by type II–IV allergic reactions. We also introduce the main immunosuppressive medications that have been used to treat SSHL, which will help us to identify potential targets for immune therapy.

Hearing loss in autoimmune disorders: Prevalence and therapeutic options

The objective of this study was to review our current knowledge relative to the correlation between sensorineural hearing loss (SNHL) and autoimmune diseases, focusing on the prevalence of hearing loss in different pathologies and possible therapeutic approaches. A review of the literature on hearing loss in different forms of autoimmune disease has been carried out, with emphasis on incidence and prevalence of SNHL. Therapeutic protocols have been assessed including both conservative medical and rehabilitative methods. Cochlear implant outcomes have been investigated. The prevalence of hearing loss in autoimmune and immune-mediated inner ear diseases, as referred by case reports or single-center statistics, is widely variable. More difficult is the evaluation of severe/profound SNHL, usually reported in relation to cochlear implantation. Though these patients represent ideal candidates for cochlear implantation, as they become deaf after years of hearing; the associated systemic disease, the specific damage on inner ear structures and the medication taken may influence the result of cochlear implantation. The main problem is the cochlear fibrosis or ossification that has been found to affect 50% of implanted ears in patients suffering from autoimmune and immune-mediated SNHL. Hence, in the presence of severe/profound SNHL earlier implantation may be indicated before post-inflammatory obliterative changes to the cochlea.

Comparative Impacts of Scala Vestibuli Versus Scala Tympani Cochlear Implantation on Auditory Performances and Programming Parameters in Partially Ossified Cochleae

OBJECTIVE

To compare scala vestibuli versus scala tympani cochlear implantation in terms of postoperative auditory performances and programming parameters in patients with severe scala tympani ossification.

STUDY DESIGN

Retrospective case-control study.

SETTING

Tertiary referral center.

PATIENTS

One hundred three pediatric and adult patients who underwent cochlear implant surgery between 2000 and 2016. Three groups were formed: a scala vestibuli group, a scala tympani with ossification group, and a scala tympani without ossification group. Patients were matched based on their age, sex, duration of deafness, and side of implantation (ratio of 1:2:2).

INTERVENTIONS

Postoperative evaluation of auditory performances and programming parameters following intensive functional rehabilitation program completion.

MAIN OUTCOME MEASURES

Multimedia adaptive test (MAT), hearing in noise test (HINT SNR +10 dB, HINT SNR +5 dB, and HINT SNR +0 dB), impedances, neural response telemetry thresholds (NRT), neural response imaging thresholds (NRI), comfortable levels (C-levels), and threshold levels (T-levels) were compared between groups.

RESULTS

Twenty-one patients underwent scala vestibuli cochlear implantation: 19 adults and two children. Auditory performances were similar between groups, although sentence recognition in a noisy environment was slightly higher in the scala vestibuli group. Impedance values were also higher in the scala vestibuli group, but all other programming parameters were similar between groups.

CONCLUSIONS

We present the largest series of patients with scala vestibuli cochlear implantation. This approach provides at least comparable auditory performances without having any deleterious effects on programming parameters. This viable and useful insertion route might be the primary surgical alternative when facing partial cochlear ossification.

Autoimmune Inner Ear Disease: Immune Biomarkers, Audiovestibular Aspects, and Therapeutic Modalities of Cogan's Syndrome

Cogan's syndrome (CS) is a rare autoimmune disorder characterized by audiovestibular dysfunction and ocular inflammation. Currently, there is no specific serum autoantibody used in the diagnostic workup of CS. Treatment is based on immunosuppressive agents, mainly corticosteroids as first-line choice. Recently, novel therapeutic modalities in CS have emerged. These include tumor necrosis factor-α inhibitors and other biologicals. Despite medical treatment, hearing loss may progress to irreversible bilateral profound SNHL in approximately half of CS patients resulting in candidacy for cochlear implantation (CI). Due to the inflammatory nature of the disease that is causing endosteal reaction with partial obliteration or complete neoossification of the intracochlear ducts, early CI is recommended. CI provides excellent and stable hearing rehabilitation with high score of word and sentence recognition. In this review, we will discuss different aspects of CS including clinical presentation, diagnosis, treatment, and future directives.

Optimal management of Cogan's syndrome: a multidisciplinary approach

Cogan's syndrome (CS) is a rare disorder characterized by nonsyphilitic interstitial keratitis (IK) and audio-vestibular symptoms. CS affects mainly young Caucasian adults, mostly during their first three decades of age, and may develop into typical and atypical variants. Typical CS manifests primarily with IK and hearing loss, whereas atypical CS usually presents with inflammatory ocular manifestations in association with audio-vestibular symptoms but mostly different Ménière-like symptoms and, more frequently, with systemic inflammation (70%), of which vasculitis is the pathogenic mechanism. CS is considered as an autoimmune- or immune-mediated disease supported mainly by the beneficial response to corticosteroids. Using well-developed assays, antibodies to inner ear antigens, anti-Hsp70, and antineutrophil cytoplasmic antibodies were found to be associated with CS. Corticosteroids represent the first line of treatment, and multiple immunosuppressive drugs have been tried with variable degrees of success. Tumor necrosis factor-alpha blockers and other biological agents are a recent novel therapeutic option in CS. Cochlear implantation is a valuable rescue surgical strategy in cases with severe sensorineural hearing loss unresponsive to intensive and/or innovative immunosuppressive regimens.

Histopathology of the Human Inner Ear in the Cogan Syndrome with Cochlear Implantation

The Cogan syndrome is a rare disorder characterized by nonsyphilitic interstitial keratitis and audiovestibular symptoms. Profound sensorineural hearing loss has been reported in approximately half of the patients with the Cogan syndrome resulting in candidacy for cochlear implantation in some patients. The current study is the first histopathologic report on the temporal bones of a patient with the Cogan syndrome who during life underwent bilateral cochlear implantation. Preoperative MRI revealed tissue with high density in the basal turns of both cochleae and both vestibular systems consistent with fibrous tissue due to labyrinthitis. Histopathology demonstrated fibrous tissue and new bone formation within the cochlea and vestibular apparatus, worse on the right. Severe degeneration of the vestibular end organs and new bone formation in the labyrinth were seen more on the right than on the left. Although severe bilateral degeneration of the spiral ganglion neurons was seen, especially on the right, the postoperative word discrimination score was between 50 and 60% bilaterally. Impedance measures were generally higher in the right ear, possibly related to more fibrous tissue and new bone found in the scala tympani on the right side.

The experience of bilateral cochlear implantation in a child with LEOPARD syndrome

We present a 3-year old boy with Leopard syndrome. His clinical manifestations included a congenital bilateral sensorineural hearing loss. He underwent cochlear implantation on the right side at age 1 year and on the left side at age 1.5 years. The patient is doing very well and mainstreamed in a regular pre-school program with a teacher of the deaf and home based speech therapy. Bilateral cochlear implantation in the case of a child with Leopard syndrome can be successful.

Otologic disorders causing dizziness, including surgery for vestibular disorders

This chapter will focus on vertigo/dizziness due to inner-ear malformations, labyrinthine fistula, otosclerosis, infectious processes, and autoimmune inner-ear disorders. Inner-ear malformation due to dehiscence of the superior semicircular canal is the most recently described inner-ear malformation. Vertigo/dizziness is typically induced by sound and pressure stimuli and can be associated with auditory symptoms (conductive or mixed hearing loss). Labyrinthine fistula, except after surgery for otosclerosis, in the context of trauma or chronic otitis media with cholesteatoma, still remains a challenging disorder due to multiple uncertainties regarding diagnostic and management strategies. Otosclerosis typically manifests with auditory symptoms and conductive or mixed hearing loss on audiometry. Vertigo/dizziness is rare in nonoperated otosclerosis and should draw clinical attention to an inner-ear malformation. Computed tomography scan confirms otosclerosis in most cases and should rule out an inner-ear malformation, avoiding needless middle-ear surgical exploration. Labyrinth involvement after an infectious process is unilateral when it complicates a middle-ear infection but can be bilateral after meningitis. Labyrinth involvement due to an inflammatory disease is a challenging issue, particularly when restricted to the inner ear. The diagnosis relies on the bilateral and rapid aggravation of audiovestibular symptoms that will not respond to conventional therapy but to immunosuppressive drugs.