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Duyan Yüksel H, Soydan Çabuk D, Coşgunarslan A. The evaluation of superior semicircular canal in patients with unilateral cleft lip and palate using CBCT. Oral Radiol 2024; 40:269-276. [PMID: 38184496 DOI: 10.1007/s11282-023-00733-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 12/04/2023] [Indexed: 01/08/2024]
Abstract
OBJECTIVES The present study aims to evaluate the thickness and radiological patterns of the superior semicircular canal (SSC) in patients with unilateral cleft lip and palate (CL/P). METHODS Cone beam computed tomography (CBCT) images of the patients were evaluated in axial and Pöschl planes. CBCT images of 84 patients with unilateral CL/P and 168 healthy individual controls were included in the study. Three study groups were established: the CS-CL/P group (cleft side temporal bones of the CL/P patients), NCS-CL/P (non-cleft side temporal bones of the CL/P patients) and the control group. The radiological patterns of SSCs were categorized as dehiscence, papyraceous, normal, pneumatised and thick. The minimum bone thickness of SSC was measured. RESULTS It was found that the CS-CL/P group had a higher prevalence for SSCD compared to both the NCS-CL/P group and the control group. CS-CL/P group had a higher prevalence of dehiscence type and papyraceous type compared to the control group. The SSC thickness on the CS-CL/P patients was thinner than the NCS-CL/P patients and the control group sides (p = 0.033 and p < 0.001, respectively). CONCLUSIONS The mean thickness of SSC was found significantly lower in the CS-CL/P group compared to both the NCS-CL/P group and the control group. The elevated prevalence of dehiscence and papyraceous types in the CS-C/LP group compared to the control group implies that the presence of a cleft may be a predisposing factor for these types.
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Affiliation(s)
- Hazal Duyan Yüksel
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Çukurova University, Adana, Türkiye.
| | - Damla Soydan Çabuk
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Çukurova University, Adana, Türkiye
| | - Aykağan Coşgunarslan
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Erciyes University, Kayseri, Türkiye
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Benchetrit L, Shave S, Garcia A, Chung JJ, Suresh K, Lee DJ. Predictors of non-primary auditory and vestibular symptom persistence following surgical repair of superior canal dehiscence syndrome. Front Neurol 2024; 15:1336627. [PMID: 38469592 PMCID: PMC10925929 DOI: 10.3389/fneur.2024.1336627] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/06/2024] [Indexed: 03/13/2024] Open
Abstract
Objective Patients with superior canal dehiscence syndrome (SCDS) can present with a plethora of auditory and/or vestibular symptoms associated with a bony defect of the superior semicircular canal. While surgical repair is a reasonable option for patients with significant localizing symptoms, the degree of clinical improvement will vary among patients and poses challenges in outcome prediction. This study aims to assess the relationship between preoperative and postoperative symptoms and identify predictors of symptom persistence following repair. Study design Retrospective chart review. Setting Tertiary neurotology single-institution care center. Main outcome measures The primary outcome was to determine the proportion of resolved and persistent primary (most bothersome) and non-primary audiologic and vestibular symptoms following SCD repair. Secondary outcomes included comparison of patient, operative and radiologic characteristics between patients with resolved vs. persistent symptoms. Standardized patient questionnaires including 11 auditory and 8 vestibular symptoms were administered to patients at their preoperative and follow-up visits. Patient pre- vs. postoperative survey results, demographic and clinical characteristics, operative characteristics, audiometric data and cervical vestibular evoked myogenic potential (cVEMP) thresholds were compared via univariate χ2 and multivariate binary logistic regression analyses between those patients reporting full postoperative resolution of symptoms and persistence of one or more symptoms. Radiologic computed tomography (CT) measurements of superior canal dehiscence (SCD) defect size, location, and laterality were also compared between these two groups. Results Of 126 patients (132 ears) included in our study, 119 patients (90.2%) reported postoperative resolution (n = 82, 62.1%) or improvement (n = 37, 28.0%) of primary (most bothersome) symptoms, while 13 patients (9.8%) reported persistence of primary symptoms. The median (interquartile range) and range between surgery and questionnaire completion were 9 (4-28), 1-124 months, respectively. Analyzing all symptoms (primary and non-primary) 69 (52.3%) and 68 (51.1%) patients reported complete postoperative auditory and vestibular symptom resolution, respectively. The most likely persistent symptoms included imbalance (33/65/67, 50.8%), positional dizziness (7/20, 35.0%) and oscillopsia (44/15, 26.7%). Factors associated with persistent auditory symptoms included history of seizures (0% vs. 7.6%, p = 0.023), auditory chief complaint (50.0% vs. 70.5%), higher PTA (mean 19.6 vs. 25.1 dB, p = 0.043) and higher cervical vestibular evoked myogenic potential (cVEMP) thresholds at 1000 Hz (mean 66.5 vs. 71.4, p = 0.033). A migraine diagnosis (14.0% vs. 41.9% p < 0.010), bilateral radiologic SCD (17.5% vs. 38.1%, p = 0.034) and revision cases (0.0% vs. 14.0%, p = 0.002) were associated with persistent vestibular symptoms. Neither SCD defect size nor location were significantly associated with symptom persistence (P > 0.05). Conclusions Surgical repair for SCDS offers meaningful reduction in the majority of auditory and vestibular symptoms. However, the persistence of certain, mostly non-primary, symptoms and the identification of potential associated factors including migraines, PTA thresholds, cVEMP threshold, bilateral SCD, and revision cases emphasize the importance of individualized patient counseling and management strategies.
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Affiliation(s)
- Liliya Benchetrit
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Department of Otolaryngology-Head, and Neck Surgery, Boston University, Boston, MA, United States
| | - Samantha Shave
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, United States
| | - Alejandro Garcia
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
- Department of Otolaryngology-Head, and Neck Surgery, University of Iowa, Iowa City, IA, United States
| | - Janice J Chung
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Krish Suresh
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
| | - Daniel J Lee
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear and Harvard Medical School, Boston, MA, United States
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Usefulness of Cervical Vestibular-Evoked Myogenic Potentials for Diagnosing Patients With Superior Canal Dehiscence Syndrome: A Meta-Analysis. Otol Neurotol 2021; 43:146-152. [PMID: 34855686 DOI: 10.1097/mao.0000000000003430] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To compare the diagnostic accuracy of cervical vestibular-evoked myogenic potential (cVEMP) for detecting superior canal dehiscence (SCD) syndrome to that of computed tomography (CT) and surgical findings. DATABASES REVIEWED PubMed, SCOPUS, Embase, Web of Science, and the Cochrane database. METHODS Databases were searched up to July 2021. True positives, true negatives, false positives, and false negatives were extracted. Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies 2 tool. RESULTS Our search yielded nine studies with 721 patients. Including all cVEMP thresholds, the diagnostic odds ratio (DOR) was 32.8483 (95% confidence interval [CI]: 19.6577, 54.8900; I2 = 49.9%). The area under the summary receiver operating characteristic curve (AUC) was 0.879. Sensitivity and specificity were 0.8278 (95% CI: 0.7517, 0.8842; I2 = 76.4%) and 0.8824 (95% CI: 0.7859, 0.9387; I2 = 92.8%), respectively. However, there was a high degree of heterogeneity (I2 ≥ 70%) due to the different VEMP threshold values used among the studies. In subgroup analysis, higher cVEMP threshold values showed higher sensitivity (threshold ≤ 85: 0.9568; threshold ≤ 65: 0.7691) but lower specificity (threshold ≤ 85: 0.5879; threshold ≤ 65: 0.8913). The threshold ≤75 subgroup showed moderate sensitivity of 0.7455, high specificity of 0.9526, and the highest DOR of 38.9062. The AUC of this subgroup was 0.894. CONCLUSIONS cVEMP is a reliable adjunctive tool for the clinical diagnosis of SCD. Taking the balance between sensitivity and specificity into consideration, a cVEMP threshold value of 75 showed good diagnostic accuracy.
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Evlice B, Çabuk DS, Duyan H. The evaluation of superior semicircular canal bone thickness and radiological patterns in relation to age and gender. Surg Radiol Anat 2021; 43:1839-1844. [PMID: 34241668 DOI: 10.1007/s00276-021-02797-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/05/2021] [Indexed: 12/01/2022]
Abstract
PURPOSE The present study aims to evaluate the superior semicircular canal (SSC) bone thickness and radiological patterns in relation to age and gender in a Turkish population using cone beam computed tomography (CBCT). METHODS A total of 450 temporal bones were evaluated in the study by two examiners. The radiological patterns of SSC were categorized as follows: dehiscent, papyraceous, normal, thick and pneumatised patterns. The bone thickness of SSCs were measured. RESULTS The mean bone thickness of the SSC for females was 1.079 ± 0.8 mm. For males, the mean bone thickness was 0.952 ± 0.6 mm. There was no significant difference between males and females for the mean bone thickness of the SSC. (p > 0.05) The normal pattern was found in 258 temporal bones (57.3%). Seventy-two cases (16%) were defined as "papyraceous pattern"; 23 cases (5.1%) were defined as "thick pattern" and 42 cases (9.3%) were defined as "pneumatised pattern". SSC dehiscence was determined in 55 cases (12.2%). There was no significant difference between radiological patterns for age groups and gender (p > 0.05). CONCLUSION There was no significant relationship between SSC bone thickness with age and gender. The radiological patterns of SSC were not associated with age and gender. Radiologists evaluating the head and neck region for various reasons should be aware of these structures and report not only the SSC dehiscence but also the papyraceous pattern.
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Affiliation(s)
- Burcu Evlice
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Çukurova University, Adana, Turkey
| | - Damla Soydan Çabuk
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Çukurova University, Adana, Turkey.
| | - Hazal Duyan
- Department of Oral and Maxillofacial Radiology, Faculty of Dentistry, Çukurova University, Adana, Turkey
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Dlugaiczyk J. Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing. Laryngorhinootologie 2021; 100:S1-S40. [PMID: 34352900 PMCID: PMC8363216 DOI: 10.1055/a-1349-7475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.
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Affiliation(s)
- Julia Dlugaiczyk
- Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie
& Interdisziplinäres Zentrum für Schwindel und
neurologische Sehstörungen, Universitätsspital Zürich
(USZ), Universität Zürich (UZH), Zürich,
Schweiz
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Swain S, Mohanty S, Sahu M. Superior semicircular canal dehiscence syndrome: Often a missing clinical entity in vertigo management. APOLLO MEDICINE 2020. [DOI: 10.4103/am.am_41_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Kastrinidis N, Kleinjung T. [Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy]. PRAXIS 2019; 108:329-334. [PMID: 30940040 DOI: 10.1024/1661-8157/a003204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Blocked Nose, Nosebleeds, Ringing in the Ear: ENT Diseases During Pregnancy Abstract. In this overview the clinical pictures of ear, nose and throat diseases and their symptoms, which occur frequently but also particularly during pregnancy, are presented. In addition, the respective therapy options in this partially vulnerable phase of mother and child are discussed. The primary principle is 'as much as necessary, but as little as possible'. Even if the complaints often disappear with the birth of the child, there may be considerable suffering of the pregnant woman and therapy may be necessary. Moreover, an adequate therapy should be applied with all ENT diseases, even for those not specifically associated with pregnancy.
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Affiliation(s)
- Nikos Kastrinidis
- 1 Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich
| | - Tobias Kleinjung
- 1 Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie, Universitätsspital Zürich
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8
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Naert L, Berg R, Heyning P, Bisdorff A, Sharon JD, Ward BK, Rompaey V. Aggregating the symptoms of superior semicircular canal dehiscence syndrome. Laryngoscope 2017; 128:1932-1938. [DOI: 10.1002/lary.27062] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 11/20/2017] [Accepted: 11/22/2017] [Indexed: 11/09/2022]
Affiliation(s)
- Laura Naert
- Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerp Belgium
| | - Raymond Berg
- Department of Otorhinolaryngology–Head and Neck SurgeryMaastricht University Medical CenterMaastricht the Netherlands
- Faculty of PhysicsTomsk State Research UniversityTomsk Russia
| | - Paul Heyning
- Faculty of Medicine and Health SciencesUniversity of AntwerpAntwerp Belgium
- Department of Otorhinolaryngology–Head and Neck SurgeryAntwerp University Hospital
| | - Alexandre Bisdorff
- Department of NeurologyCentre Hospitalier Emile MayrischEsch‐Alzette Luxemburg
| | - Jeffrey D. Sharon
- Department of Otolaryngology–Head and Neck SurgeryUniversity of CaliforniaSan Francisco, San Francisco California U.S.A
| | - Bryan K. Ward
- Department of Otolaryngology–Head and Neck SurgeryJohns Hopkins University School of MedicineBaltimore Maryland U.S.A
| | - Vincent Rompaey
- Department of Otorhinolaryngology–Head and Neck SurgeryAntwerp University Hospital
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9
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Zhang BY, Young YH. Sudden Deafness during Antepartum versus Postpartum Periods. ORL J Otorhinolaryngol Relat Spec 2017; 79:274-281. [DOI: 10.1159/000478936] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Accepted: 06/21/2017] [Indexed: 12/12/2022]
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10
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Ward BK, Carey JP, Minor LB. Superior Canal Dehiscence Syndrome: Lessons from the First 20 Years. Front Neurol 2017; 8:177. [PMID: 28503164 PMCID: PMC5408023 DOI: 10.3389/fneur.2017.00177] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2017] [Accepted: 04/13/2017] [Indexed: 11/13/2022] Open
Abstract
Superior semicircular canal dehiscence syndrome was first reported by Lloyd Minor and colleagues in 1998. Patients with a dehiscence in the bone overlying the superior semicircular canal experience symptoms of pressure or sound-induced vertigo, bone conduction hyperacusis, and pulsatile tinnitus. The initial series of patients were diagnosed based on common symptoms, a physical examination finding of eye movements in the plane of the superior semicircular canal when ear canal pressure or loud tones were applied to the ear, and high-resolution computed tomography imaging demonstrating a dehiscence in the bone over the superior semicircular canal. Research productivity directed at understanding better methods for diagnosing and treating this condition has substantially increased over the last two decades. We now have a sound understanding of the pathophysiology of third mobile window syndromes, higher resolution imaging protocols, and several sensitive and specific diagnostic tests. Furthermore, we have a treatment (surgical occlusion of the superior semicircular canal) that has demonstrated efficacy. This review will highlight some of the fundamental insights gained in SCDS, propose diagnostic criteria, and discuss future research directions.
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Affiliation(s)
- Bryan K. Ward
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John P. Carey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lloyd B. Minor
- Department of Otolaryngology-Head and Neck Surgery, Stanford University School of Medicine, Stanford, CA, USA
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Trieu V, Pelargos PE, Spasic M, Chung LK, Voth B, Ung N, Gopen Q, Yang I. Minimally Invasive Middle Fossa Keyhole Craniectomy for Repair of Superior Semicircular Canal Dehiscence. Oper Neurosurg (Hagerstown) 2017; 13:317-323. [DOI: 10.1093/ons/opw046] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2016] [Accepted: 01/11/2017] [Indexed: 11/13/2022] Open
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12
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Chung LK, Ung N, Spasic M, Nagasawa DT, Pelargos PE, Thill K, Voth B, Hirt D, Gopen Q, Yang I. Clinical outcomes of middle fossa craniotomy for superior semicircular canal dehiscence repair. J Neurosurg 2016; 125:1187-1193. [PMID: 26871374 DOI: 10.3171/2015.8.jns15391] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Superior semicircular canal dehiscence (SSCD) is a rare disorder characterized by the formation of a third opening in the inner ear between the superior semicircular canal and the middle cranial fossa. Aberrant communication through this opening causes a syndrome of hearing loss, pulsatile tinnitus, disequilibrium, and autophony. This study analyzed the clinical outcomes of a single-institution series of patients with SSCD undergoing surgical repair by the same otolaryngologist and neurosurgeon. METHODS All patients who underwent SSCD repair at the University of California, Los Angeles, between March 2011 and November 2014 were included. All patients had their SSCD repaired via middle fossa craniotomy by the same otolaryngologist and neurosurgeon. Outcomes were analyzed with Fisher's exact test. RESULTS A total of 18 patients with a mean age of 56.2 years (range 27-84 years) and an average follow-up of 5.0 months (range 0.2-21.8 months) underwent 21 cases of SSCD repair. Following treatment, all patients (100%) reported resolution in ≥ 1 symptom associated with SSCD. Autophony (p = 0.0005), tinnitus (p = 0.0059), and sound- and/or pressure-induced dizziness (p = 0.0437) showed significant symptomatic resolution. Following treatment, 29% (2/7) of patients developed imbalance, 20% (1/5) of patients developed sound- and/or pressure-induced dizziness, and 18% (2/11) of patients developed aural fullness. Among patients with improved symptoms following surgical repair, none reported recurrence of symptoms at subsequent follow-up visits. CONCLUSIONS SSCD remains an underdiagnosed and undertreated condition. Surgical repair of SSCD using a middle fossa craniotomy is associated with a high rate of symptom resolution. Continued investigation using a larger patient cohort and longer-term follow-up could further demonstrate the effectiveness of using middle fossa craniotomy for SSCD repair.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | - Isaac Yang
- Department of Neurosurgery.,Jonsson Comprehensive Cancer Center, University of California, Los Angeles, California
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Klopp-Dutote N, Kolski C, Biet A, Strunski V, Page C. A radiologic and anatomic study of the superior semicircular canal. Eur Ann Otorhinolaryngol Head Neck Dis 2015; 133:91-4. [PMID: 26671715 DOI: 10.1016/j.anorl.2015.11.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES The present study sought to determine whether there is a correlation between the prevalence of superior semicircular canal (SSC) dehiscence (SSCD) on temporal CT and population age. The secondary objective was to identify anatomic factors for SSCD by studying SSC diameter and its protrusion into the middle cranial fossa. The aim was to determine the acquired or congenital origin of SSCD (Minor's syndrome). MATERIAL AND METHOD A single-center retrospective radiological and anatomic study included 180 CT scans of 354 petrous parts of the temporal bone taken between January and December 2011 in a university hospital center. Bone thickness above the SSC was measured and classified in 4 grades: grade 1, >2.5mm; grade 2, <2.5mm: grade 3, predehiscent; grade 4, dehiscent. SSC diameter was also measured, as was the height of SSC protrusion into the middle cranial fossa. RESULTS SSCD was found in 0.8% of cases and predehiscence in 12%. Patients with dehiscence were older; patients with grade 3 or 4 were significantly older than those free of dehiscence (P<0.05). There was no significant difference in SSC diameter according to grade. In grade 1, protrusion was greater than in other subjects, with a significant correlation between age and reduced protrusion (P<0.05). CONCLUSION The study demonstrated a correlation between aging and SSCD prevalence. Reduced SSC roof height with age suggests that SSCD may be an acquired phenomenon, related in some way to aging of the base of the skull.
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Affiliation(s)
- N Klopp-Dutote
- Service d'ORL et de chirurgie de la face et du cou, hôpital Nord, CHU, place Victor-Pauchet, 80054 Amiens cedex, France
| | - C Kolski
- Service d'ORL et de chirurgie de la face et du cou, hôpital Nord, CHU, place Victor-Pauchet, 80054 Amiens cedex, France
| | - A Biet
- Service d'ORL et de chirurgie de la face et du cou, hôpital Nord, CHU, place Victor-Pauchet, 80054 Amiens cedex, France
| | - V Strunski
- Service d'ORL et de chirurgie de la face et du cou, hôpital Nord, CHU, place Victor-Pauchet, 80054 Amiens cedex, France
| | - C Page
- Service d'ORL et de chirurgie de la face et du cou, hôpital Nord, CHU, place Victor-Pauchet, 80054 Amiens cedex, France.
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14
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Gioacchini FM, Alicandri-Ciufelli M, Kaleci S, Scarpa A, Cassandro E, Re M. Outcomes and complications in superior semicircular canal dehiscence surgery: A systematic review. Laryngoscope 2015; 126:1218-24. [DOI: 10.1002/lary.25662] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2015] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - Shaniko Kaleci
- Department of Diagnostic Medicine; Clinical and Public Health University Hospital of Modena; Modena Italy
| | - Alfonso Scarpa
- Department of Medicine and Surgery; University of Salerno; Salerno Italy
| | - Ettore Cassandro
- Department of Medicine and Surgery; University of Salerno; Salerno Italy
| | - Massimo Re
- Otolaryngology Department; Marche Polytechnic University; Ancona Italy
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15
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Temporal bone fracture causing superior semicircular canal dehiscence. Case Rep Otolaryngol 2014; 2014:817291. [PMID: 25295207 PMCID: PMC4176638 DOI: 10.1155/2014/817291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Accepted: 08/09/2014] [Indexed: 12/02/2022] Open
Abstract
Importance. Superior semicircular canal dehiscence (SCD) is a third window lesion of the inner ear causing symptoms of vertigo, autophony, tinnitus, and hearing loss. A “two-hit” hypothesis has traditionally been proposed, whereby thinly developed bone overlying the superior canal is disrupted by a sudden change in intracranial pressure. Although the symptoms of SCD may be precipitated by head injury, no previous reports have described a temporal bone fracture directly causing SCD. Observations.
Two patients sustained temporal bone fractures after closed head trauma, and developed unilateral otologic symptoms consistent with SCD. In each instance, computed tomography imaging revealed fractures extending through the bony roof of the superior semicircular canal. Conclusions and Relevance. Temporal bone fractures, which are largely treated nonoperatively, have not previously been reported to cause SCD. As it is a potentially treatable entity, SCD resulting from temporal bone fracture must be recognized as a possibility and diagnosed promptly if present.
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Niesten MEF, Hamberg LM, Silverman JB, Lou KV, McCall AA, Windsor A, Curtin HD, Herrmann BS, Grolman W, Nakajima HH, Lee DJ. Superior canal dehiscence length and location influences clinical presentation and audiometric and cervical vestibular-evoked myogenic potential testing. Audiol Neurootol 2014; 19:97-105. [PMID: 24434937 DOI: 10.1159/000353920] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 06/19/2013] [Indexed: 11/19/2022] Open
Abstract
Superior canal dehiscence (SCD) is caused by an absence of bony covering of the arcuate eminence or posteromedial aspect of the superior semicircular canal. However, the clinical presentation of SCD syndrome varies considerably, as some SCD patients are asymptomatic and others have auditory and/or vestibular complaints. In order to determine the basis for these observations, we examined the association between SCD length and location with: (1) auditory and vestibular signs and symptoms; (2) air conduction (AC) loss and air-bone gap (ABG) measured by pure-tone audiometric testing, and (3) cervical vestibular-evoked myogenic potential (cVEMP) thresholds. 104 patients (147 ears) underwent SCD length and location measurements using a novel method of measuring bone density along 0.2-mm radial CT sections. We found that patients with auditory symptoms have a larger dehiscence (median length: 4.5 vs. 2.7 mm) with a beginning closer to the ampulla (median location: 4.8 vs. 6.4 mm from ampulla) than patients with no auditory symptoms (only vestibular symptoms). An increase in AC threshold was found as the SCD length increased at 250 Hz (95% CI: 1.7-4.7), 500 Hz (95% CI: 0.7-3.5) and 1,000 Hz (95% CI: 0.0-2.5), and an increase in ABG as the SCD length increased at 250 Hz (95% CI: 2.0-5.3), 500 Hz (95% CI: 1.6-4.6) and 1,000 Hz (95% CI: 1.3-3.3) was also seen. Finally, a larger dehiscence was associated with lowered cVEMP thresholds at 250 Hz (95% CI: -4.4 to -0.3), 500 Hz (95% CI: -4.1 to -1.0), 750 Hz (95% CI: -4.2 to -0.7) and 1,000 Hz (95% CI: -3.6 to -0.5) and a starting location closer to the ampulla at 250 Hz (95% CI: 1.3-5.1), 750 Hz (95% CI: 0.2-3.3) and 1,000 Hz (95% CI: 0.6-3.5). These findings may help to explain the variation of signs and symptoms seen in patients with SCD syndrome.
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Affiliation(s)
- Marlien E F Niesten
- Department of Otorhinolaryngology - Head and Neck Surgery, University Medical Center, Utrecht, The Netherlands
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McEvoy TP, Mikulec AA, Armbrecht ES, Lowe ME. Quantification of hearing loss associated with superior semi-circular canal dehiscence. Am J Otolaryngol 2013; 34:345-9. [PMID: 23398728 DOI: 10.1016/j.amjoto.2013.01.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2012] [Accepted: 01/08/2013] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Superior semi-circular canal dehiscence (SSCD) is a known cause of hearing loss. This study quantifies hearing loss in SSCD ears in a frequency-specific fashion. METHODS A meta-analysis of English language literature pertaining to SSCD was performed, with extraction and evaluation of available human audiometric data. Our own institution's case series of SSCD patients was also similarly analysed. Hearing loss in SSCD ears was compared to same patient control ears and to age-matched normative audiometric data. RESULTS Ears with SSCD had statistically significant worse hearing as compared to both normative data and to own normal ear controls at 2000 Hz and below. The effect appears to diminish with increasing frequency. DISCUSSION The presence of statistically significant conductive hearing loss in the low frequencies was confirmed for SSCD ears. SSCD may also predispose ears to high frequency sensorineural hearing loss.
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Dehiscence of the superior semicircular canal: a review of the literature on its possible pathogenic explanations. Eur Arch Otorhinolaryngol 2013; 271:435-7. [DOI: 10.1007/s00405-013-2497-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 04/11/2013] [Indexed: 10/27/2022]
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19
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Clinical factors associated with prolonged recovery after superior canal dehiscence surgery. Otol Neurotol 2012; 33:824-31. [PMID: 22664897 DOI: 10.1097/mao.0b013e3182544c9e] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To identify clinical factors associated with prolonged recovery after superior canal dehiscence surgery. STUDY DESIGN Retrospective review. SETTING Tertiary care academic medical center. PATIENTS Thirty-three patients that underwent surgery for SCDS were identified from a database of 140 patients diagnosed with SCD (2000-2010) at the Massachusetts Eye and Ear Infirmary (U.S.A.). The diagnosis of SCDS was based on clinical signs and symptoms, audiometric and vestibular testing and high-resolution temporal bone computed tomography. INTERVENTION For the primary repair, the superior canal was plugged in 31 patients through a middle fossa craniotomy approach and in 1 patient through a transmastoid approach. In 1 patient, the SCD was resurfaced through a middle fossa craniotomy approach. MAIN OUTCOME MEASURES Postoperative clinical signs and symptoms and factors that may influence duration of disequilibrium after surgery. RESULTS Thirty-three patients (15-71 yr; mean, 43 yr) underwent surgery for SCDS on 35 ears (2 bilateral). Mean follow-up was 28.7 months (range, 3 mo to 10 yr); 33 of 33 (100%) patients experienced initial improvement of the chief complaint. Three patients required revision surgery, improving symptoms in 2 patients. Six patients had dizziness lasting more than 4 months postoperatively, and all had bilateral SCD, migraines, and a dehiscence of 3 mm or greater. CONCLUSION Surgical plugging of SCD is an effective management option to provide long-term improvement of the chief complaint in SCDS patients. Patients with bilateral SCD, a history of migraines, and larger defects may be at risk of prolonged recovery and should be appropriately counseled.
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Radiological patterns of the bony roof of the superior semicircular canal. Surg Radiol Anat 2012; 35:61-5. [DOI: 10.1007/s00276-012-1019-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 09/03/2012] [Indexed: 10/27/2022]
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Takahashi N, Tsunoda A, Shirakura S, Kitamura K. Anatomical feature of the middle cranial fossa in fetal periods: possible etiology of superior canal dehiscence syndrome. Acta Otolaryngol 2012; 132:385-90. [PMID: 22201523 DOI: 10.3109/00016489.2011.637234] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
CONCLUSION Different from adults, the superior semicircular canal (SSC) protrudes into the cranium during the fetal period. This might cause adhesion of the membranous labyrinth to dura as the bony labyrinth develops much later than the membranous labyrinth. This adhesion interferes with ossification and leads to a bony defect in the SSC. OBJECTIVES The purpose of this study was to investigate a possible etiology of superior canal dehiscence syndrome (SCDS) from a view point of ontogeny. METHODS Forty-two adult cadavers and 4 fetal cadavers were used for macroscopic observation of the middle cranial fossa (MCF). In addition, six fetuses underwent computed tomography (CT) examinations. The volume data of the CT obtained from four adults were also used for comparison. Using these CT data, we investigated the anatomic relationship between the MCF and SSC. RESULTS The SSC and the cochlea in fetuses protruded into the cranium in macroscopic anatomy and CT examination. On the other hand, the SSC of all adults was completely or mostly buried in the temporal bone.
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Affiliation(s)
- Naoto Takahashi
- Department of Otolaryngology, Tokyo Medical and Dental University, Japan
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Superior Canal Dehiscence Syndrome Associated With the Superior Petrosal Sinus in Pediatric and Adult Patients. Otol Neurotol 2011; 32:1312-9. [DOI: 10.1097/mao.0b013e31822e5b0a] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kanaan AA, Raad RA, Hourani RG, Zaytoun GM. Bilateral superior semicircular canal dehiscence in a child with sensorineural hearing loss and without vestibular symptoms. Int J Pediatr Otorhinolaryngol 2011; 75:877-9. [PMID: 21524803 DOI: 10.1016/j.ijporl.2011.03.019] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2010] [Revised: 03/18/2011] [Accepted: 03/24/2011] [Indexed: 11/28/2022]
Abstract
To report a rare case of bilateral superior semicircular canal dehiscence (SCCD) in a child. Case report, 11-year-old female patient. Descriptive case report. Audiological findings of bilateral symmetrical low frequency sensorineural hearing loss with ascending curves and bilateral superior semicircular canal dehiscence on a high resolution computed tomography (CAT) scan. The young child presented with bilateral fluctuating hearing loss with no vestibular symptoms. She was found to have bilateral superior semicircular canal dehiscence. We hereby present a rare case of bilateral semicircular canal dehiscence found incidentally on high resolution CAT scan in a young child during work up for bilateral sensorineural hearing loss.
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Affiliation(s)
- Alyssa A Kanaan
- Department of Otolaryngology, Head and Neck surgery, American University of Beirut Medical Center, Beirut, Lebanon.
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Kumar R, Hayhurst KL, Robson AK. Ear, Nose, and Throat Manifestations during Pregnancy. Otolaryngol Head Neck Surg 2011; 145:188-98. [DOI: 10.1177/0194599811407572] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective. The objective of this clinical review is to highlight the otolaryngological symptoms that occur in pregnancy. Where available, the authors discuss the current evidence of the etiology and management of the various presentations. While it is appreciated that many of these complaints are transient, their impact on the maternal quality of life can be significant, and therefore, medical practitioners should be aware of what to expect in order to provide reassurance to patients and also to safely manage such symptoms. Data Sources. MEDLINE and EMBASE databases were searched for publications related to otolaryngology and pregnancy. Review Methods. All literature was searched for and reviewed by 2 authors independently. Search results were then cross-examined, and any differences were settled by consensus. Results. Pregnancy leads to circulatory changes and increased susceptibility to viral reactivation, and along with the exertion of parturition, it can lead to tinnitus, facial palsies, and deafness. Rising levels of sex hormones and heightened sensitivity to allergens may influence the nasal mucosa, precipitating epistaxis and rhinitis. Increased progesterone and the increased intra-abdominal pressure of the growing fetus can lead to symptoms and sequelae of laryngopharyngeal reflux. Evidence for the treatment of pregnancy-induced symptoms is principally restricted to case reports and retrospective studies. Conclusion. Recognition and understanding of pregnancy-related ear, nose, and throat complaints will allow otolaryngologists to reassure and manage these patients, improving their experience of the gestational period. High-quality evidence for their management is limited, with further research required.
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Affiliation(s)
| | - Kathryn L. Hayhurst
- Department of Obstetrics and Gynaecology, University Hospital of South Manchester, Manchester, UK
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Whyte Orozco J, Martínez C, Cisneros A, Obón J, Gracia-Tello B, Angel Crovetto M. Defecto de cobertura del canal semicircular superior y su implicación clínica. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2011; 62:199-204. [DOI: 10.1016/j.otorri.2010.11.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2010] [Revised: 11/18/2010] [Accepted: 11/20/2010] [Indexed: 10/18/2022]
Affiliation(s)
- Jaime Whyte Orozco
- Departamento de Anatomía e Histología Humanas, Facultad de Medicina, Universidad de Zaragoza, España.
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Defect of the Bony Roof in the Superior Semicircular Canal and Its Clinical Implications. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2011. [DOI: 10.1016/j.otoeng.2010.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Variety of Audiologic Manifestations in Patients With Superior Semicircular Canal Dehiscence. Otol Neurotol 2010; 31:2-10. [DOI: 10.1097/mao.0b013e3181bc35ce] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Roditi RE, Eppsteiner RW, Sauter TB, Lee DJ. Cervical vestibular evoked myogenic potentials (cVEMPs) in patients with superior canal dehiscence syndrome (SCDS). Otolaryngol Head Neck Surg 2009; 141:24-8. [DOI: 10.1016/j.otohns.2009.03.012] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2008] [Revised: 02/02/2009] [Accepted: 03/12/2009] [Indexed: 11/15/2022]
Abstract
Objective: To determine the usefulness of both amplitude and threshold data from tone-burst cervical vestibular evoked myogenic potential (cVEMP) testing for the evaluation of superior canal dehiscence syndrome (SCDS). Study Design: Case series with chart review. Subjects and Methods: Sixty-seven patients underwent cVEMP testing. We correlated mean tone burst cVEMP amplitude and threshold data with temporal bone CT findings. Patients were excluded for Ménière's disease, middle ear disease, or otologic surgery. Results: Superior canal dehiscence patients had higher mean cVEMP amplitudes (SCDS 173.8 μV vs non-SCDS 69.7 μV, P = 0.031) and lower mean thresholds (SCDS 72.8 dB nHL vs non-SCDS 80.9 dB nHL) at 500 Hz. Conclusion: Patients with SCDS have larger amplitudes and lower thresholds on cVEMP testing at 500 Hz. This study supports the utility of tone burst cVEMPs for the evaluation of SCDS and is one of few large single-center studies to establish normative data.
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Affiliation(s)
- Rachel E. Roditi
- Department of Otolaryngology, University of Massachusetts Medical School, Worcester, MA
| | - Robert W. Eppsteiner
- Department of Otolaryngology, University of Massachusetts Medical School, Worcester, MA
| | - Todd B. Sauter
- Department of Otolaryngology, University of Massachusetts Medical School, Worcester, MA
- Department of Audiology, UMass Memorial Medical Center, Worcester, MA
| | - Daniel J. Lee
- Department of Otology and Laryngology, Harvard Medical School, Boston, MA
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Boston, MA
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Vlastarakos PV, Proikas K, Tavoulari E, Kikidis D, Maragoudakis P, Nikolopoulos TP. Efficacy assessment and complications of surgical management for superior semicircular canal dehiscence: a meta-analysis of published interventional studies. Eur Arch Otorhinolaryngol 2008; 266:177-86. [DOI: 10.1007/s00405-008-0840-4] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Accepted: 10/04/2008] [Indexed: 11/29/2022]
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Abstract
OBJECTIVE The traditional surgical repair for superior semicircular canal dehiscence (SSCD) involves either canal plugging or resurfacing via the middle cranial fossa approach. We describe a novel transmastoid occlusion technique. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Three patients with symptomatic computed tomography-proven SSCD. INTERVENTION Transmastoid superior semicircular canal occlusion using bone pate in 2 fenestrations, with 1 placed on either side of the dehiscence. MAIN OUTCOME MEASURES Hearing and vestibular symptoms. RESULTS Two patients were primary cases of SSCD, and a third patient had failed a previous middle fossa occlusion using fascia at an outside institution. In all 3 cases, the 2 sides of the superior semicircular canal adjacent to the dehiscence were occluded using bone pate, formed from a mix of bone dust and fibrin sealant. This allowed for a permanent bony partition to be achieved between the dehiscence and the remainder of the labyrinth. In all cases, hearing was either preserved or improved, and the procedure was successful in controlling vestibular symptoms. CONCLUSION Transmastoid superior semicircular canal occlusion is a viable alternative to the customary middle fossa approach for superior canal dehiscence. Meticulous technique and the use of bone pate may help maximize auditory and vestibular results. Advantages of this technique include obviating a craniotomy, preclusion of temporal lobe retraction, familiarity of the approach for experienced otologists, and the ability to occlude the canal without manipulating the defect. The transmastoid approach for superior canal occlusion may not be possible when the dura is low hanging or when there is extensive cranial base dehiscence requiring reconstruction.
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Zhou G, Gopen Q, Poe DS. Clinical and Diagnostic Characterization of Canal Dehiscence Syndrome. Otol Neurotol 2007; 28:920-926. [PMID: 17704722 DOI: 10.1097/mao.0b013e31814b25f2] [Citation(s) in RCA: 141] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE:: To identify otologic and audiologic characteristics of superior (and posterior) semicircular canal dehiscence (SCD). STUDY DESIGN:: Retrospective case review. SETTING:: Tertiary referral center. PATIENTS:: Sixty-five adult patients were evaluated for SCD; 26 of 65 (35 ears) had dehiscence. INTERVENTION(S):: Otologic examination, high-resolution computerized tomography (CT), air and bone audiometry, tympanometry, acoustic reflex, and vestibular evoked myogenic potential (VEMP). MAIN OUTCOME MEASURE(S):: Imaging demonstrating canal dehiscence, preferentially including Poschel and Stenvers reconstructions. Audiologic findings of pseudoconductive loss, intact ipsilateral stapedial reflex, and abnormally low VEMP thresholds. RESULTS:: The most common presenting complaints were autophony of voice and a "blocked ear" (94%), mimicking patulous eustachian tube, including relief with Valsalva or supine position (50%), but without autophony of nasal breathing. Pseudoconductive loss was found in 86% of dehiscence ears, and 60% (21 of 35) of these ears had better than 0-dB-hearing-loss bone conduction thresholds at 250 and/or 500 Hz. Acoustic reflex was present in 89%. Assuming CT as the criterion standard, VEMP resulted in 91.4% sensitivity and 95.8% specificity. One false-positive CT, with abnormal VEMP, resulted in surgical explorations negative for superior SCD but positive for posterior SCD. CONCLUSION:: Semicircular canal dehiscence may present with various symptoms such as autophony, ear blockage, and dizziness/vertigo. A combination of high-resolution CT and audiologic testing is recommended for diagnosis. Low-frequency conductive loss with better than 0 dB hearing level (HL) bone conduction threshold and normal tympanometry, with intact acoustic reflexes, are audiologic signs of SCD. Vestibular evoked myogenic potential is highly sensitive and specific for SCD, possibly better than CT.
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Affiliation(s)
- Guangwei Zhou
- *Department of Otolaryngology and Communication Disorders, Children's Hospital Boston; and †Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A
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