Traumatic perilymphatic fistulas in children: etiology, diagnosis and management

FLUCTUATING HEARING LOSS AS A SYMPTOM OF ACQUIRED PERILYMPHATIC FISTULA (PLF) UNDER EXTERNAL INJURIES FACTOR

OBJECTIVE

The aim: To evaluate the effectiveness of treatment patients with spontaneous PLF and labyrinthine window ruptures by studying the clinical and audiological results.

PATIENTS AND METHODS

Materials and methods: 52 patients after exposure to traumatic factors in the anamnesis were evaluated. The perilymphatic fistula was diagnosed in 18 patients after the complex examination. All patients with PLF underwent surgical treatment.

RESULTS

Results: Vestibular disorders and hearing loss were the predominant symptoms. The fistula test was positive in 11 (61%) patients. Fluctuating hearing loss was determined in 9 (50%) patients. Labyrinthine window ruptures were detected in 16 (88%) patients: oval window membrane rupture was identified in 6 patients, and in another 10 patients round window membrane rupture was found and was detected on CT scan. The surgical treatment included minimally invasive tympanotomy with combined microscopic and endoscopic visualization and sealing techniques. Results were evaluated in 6 months after surgical treatment, patients had a decrease in bone and air conduction thresholds at all evaluated frequencies and a significant decrease in the level of the air-bone interval.

CONCLUSION

Conclusions: Fluctuating hearing loss is considered one of the key symptoms, which suggests the presence of PLF. Determination of PLF and its surgical treatment, by using minimally invasive tympanotomy with sealing technique using optimal combined visualization, allows obtaining a stable functional result, with hearing improvement and vestibular symptoms reducing.

Case Report of a Patient With Posttraumatic Perilymphatic Fistula

On a perilymphatic fistula, there is an extravasation of the perilymph fluid into the middle ear cavity. Cross-sectional imaging techniques have very important role in evaluation of inner and middle ear structures and temporal bone. While thin section CT scans can show successfully pneumolabyrinth and temporal bone fracture, high-resolution 3D volumetric MRI sequences can help to demonstrate posttraumatic ear effusion and cerebrospinal fluid fistula into inner ear or middle ear.

Vertigo in children; a narrative review of the various causes and their management

Vertigo is a not an uncommon symptom in children, but often the treating doctors are unsure of the diagnosis and the management of these cases. This narrative review of the literature discusses the brief etiopathology, the clinical manifestations and the management algorithm of most of the conditions causing vertigo in children. The relevant information has been condensed into a table for the perusal of the readers, which would assist in the appropriate management of these children.

A nationwide multicenter study of the Cochlin tomo-protein detection test: clinical characteristics of perilymphatic fistula cases

OBJECTIVE

To investigate the positive rate for the Cochlin tomo-protein (CTP: an inner ear-specific protein) detection test among patients with inner ear-related clinical manifestations and evaluate the clinical characteristics of definite perilymphatic fistula (PLF).

METHODS

We have performed an ELISA-based CTP detection test using middle ear lavage (MEL) samples from 497 cases of suspected PLF enrolled from 70 clinical centers nationwide between 2014 and 2015. In addition to the CTP-positive rate, audio-vestibular symptoms were compared between CTP-positive and -negative cases.

RESULTS

8-50% of patients in category 1 (trauma, middle and inner ear disease cases), and about 20% of those in categories 2, 3 and 4 (external origin antecedent events, internal origin antecedent events, and without antecedent event, respectively) were positive for CTP. In category 1 cases, the earlier tested samples showed a higher CTP-positive rate, whereas no differences were observed in categories 2, 3 or 4. The characteristic clinical features in the earlier tested cases were nystagmus and fistula sign in CTP test-positive cases in category 1, and streaming water-like tinnitus in those in categories 2, 3 and 4.

CONCLUSION

The present study clarified that CTP detection test-positive patients exist at considerable rates among patients with inner ear-related manifestations.

Vestibular disorders following different types of head and neck trauma

This review focuses on the published literature on vestibular disorders following different types of head and neck trauma. Current knowledge of the different causes and underlying mechanisms of vestibular disorders, as well as the sites of organic damage, is presented. Non-organic mechanisms are also surveyed. The frequency of occurrence of vestibular symptoms, and of other accompanying subjective complaints, associated with different types of trauma is presented and related to the specific causes. Hypotheses about the pathogenesis of traumatic vestibular disorders are presented, and the knowledge derived from animal experiments is also discussed. We believe this to be a very important topic, since vestibular complaints in traumatic patients often remain undiagnosed or underestimated in clinical practice. This review article aims to suggest directions for additional research and to provide guidance to both the scientific and clinical practice communities.

[Trauma of the temporal bone]

Temporal bone fractures are mostly due to high-energy head trauma with high rates of concurrent intracranial and cervical spine injuries and belong to the wider spectrum of lateral skull base trauma. Given that the temporal bone represents the most complex bone structure in the human body, containing a multitude of vital neurovascular structures, variable clinical presentations may arise from such fractures, ranging from asymptomatic courses to serious consequences, such as conductive and/or sensorineural hearing loss, vascular and/or cranial nerve injury as well as cerebrospinal fluid leakage. The present paper presents typical clinical sequelae and provides a detailed illustration of characteristic imaging findings related to temporal bone injury. Last but not least, in the final section of the manuscript the focus is placed on distinct anatomic structures which may mimic fracture lines and, thus, entail a high potential for misclassification as temporal bone fractures.

Treatment of traumatic stapediovestibular luxation: case report with the introduction of a new technique and review of literature

OBJECTIVE

Stapediovestibular luxations are rare lesions that are most commonly caused by direct, penetrating trauma to the external ear canal. In this type of ossicular dislocation, disruption of the annular ligament or footplate fracture may lead to a perilymphatic fistula (PLF) presenting with cochleovestibular symptoms including (progressive) sensorineural hearing loss, tinnitus, and vestibular symptoms. The objective of this article is to define the optimal treatment of stapediovestibular luxations and review the literature on this topic.

PATIENT

We present a case of internal stapediovestibular dislocation and pneumolabyrinth after penetrating trauma with predominantly conductive hearing loss and incapacitating vertigo.

INTERVENTION

Middle ear inspection with removal of the luxated incus, repositioning of the stapes with a "stapedial strut" and closure of the tympanic membrane.

MAIN OUTCOME MEASURES

Hearing outcome and vestibular symptoms of this patient are presented, and all comparable cases in the literature are reviewed.

RESULTS

Complete resolution of the vestibular symptoms and stabilization of the bone conduction thresholds.

CONCLUSION

In patients with pneumolabyrinth after middle ear trauma with mild symptoms, we recommend initial conservative treatment with close monitoring of hearing. In patients with severe, persisting, or progressive vestibulocochlear symptoms, exploratory tympanotomy should be performed to check for and treat PLF. Oval window fistula repair is reported to have variable hearing outcomes but offers complete resolution of vestibular symptoms in most cases. The stapedial strut is one of the possible surgical techniques in case of an internally luxated stapes.

Perilymphatic fistula of the round window after whiplash injury: another cause of inner ear conductive hearing loss

Perilymphatic fistula is usually associated with sudden or fluctuating sensorineural hearing loss. We present a case of whiplash injury in a patient who showed conductive hearing loss at low frequencies due to a perilymphatic fistula occurring in the round window. Although no middle ear pathology was found, the symptoms and laboratory findings were mimicking the so called "third mobile window" phenomenon, but without the presence of inner ear dehiscence. Following early surgical exploration with patching of the round window the hearing was restored and the patient was free of symptoms.

Prevalence and diagnosis of vestibular disorders in children: a review

OBJECTIVES

To systematically review and discuss the main pathologies associated with vertigo and dizziness in children, paying particular attention to recent advances in diagnosis and therapy.

METHODS

One appropriate string was run on PubMed to retrieve articles dealing with the topics mentioned above. A cross-check was performed on citations and full-text articles found using the selected inclusion and exclusion criteria. A non-comparative meta-analysis concerning the rate of singular vertiginous forms was performed.

RESULTS

Ten articles were identified comprising a total of 724 subjects. Overall, the articles we analyzed indicated benign paroxysmal vertigo of childhood (18.7%) and migraine-associated vertigo (17.6%) as the two main entities connected with vertigo and dizziness in children. Head trauma (14%) was the third most common cause of vertigo. The mean (95% CI) rate of every vertiginous form was also calculated in relation to the nine studies analyzed with vestibular migraine (27.82%), benign paroxysmal vertigo (15.68%) and vestibular neuritis (9.81%) being the three most common forms. There appeared to be a paucity of recent literature concerning the development of new diagnostic methods and therapies.

CONCLUSIONS

On the basis of the literature study, when evaluating a young patient with vertigo and dizziness, the otolaryngologist should be aware that, in children, these symptoms are often connected to different pathologies in comparison to the entities observed in the adult population.

Miracle still happens: a rare case of self-inflicted penetrating injury of ear

Though foreign bodies of ear are quite commonly encountered in our day-to-day practice, self-inflicted penetrating injury of ear is not common. One such case of selfinflicted penetrating injury of ear with giant sized nail is presented here. In this patient the nail had traversed the whole thickness of skull and the pointed end of the nail could be traced at opposite temporal area. Extraction of the nail was posed with great difficulties as it was deeply impacted inside the dense bone of skull base. Miraculously, post-operative morbidity was very minimal in this case both in terms of intracranial tissue damage and hearing impairment.

Temporal bone fractures

Temporal bone injury is frequently associated with severe brain injury which limits the clinical evaluation and detracts from the clinical signs of temporal bone fracture such as sensorineural hearing loss, conductive hearing loss, and facial nerve paralysis. Radiologists are often the first to note the presence of temporal bone fractures and should be familiar with common types of injuries and their clinical implications. We review the traditional classification systems of temporal bone fractures with respect to clinical findings and management and suggest that radiologists should be familiar with the classification systems and, more importantly, focus their attention to identifying all critical temporal bone structures and describing their status of involvement to better the individual care.