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Zebbakh H, Sidki K, Laamrani FZ, Jroundi L, Aoufir OE. Minor's syndrome: Dehiscence of the superior semicircular canal. A case report. Radiol Case Rep 2024; 19:3321-3323. [PMID: 38860269 PMCID: PMC11163144 DOI: 10.1016/j.radcr.2024.04.075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 04/22/2024] [Accepted: 04/24/2024] [Indexed: 06/12/2024] Open
Abstract
Superior semicircular canal (SSC) dehiscence syndrome, also known as Minor syndrome, is a rare condition characterized by vestibular and cochlear symptoms linked to a defect in the bony roof of the SSC. The prevalence is estimated at 0.5%, with a male predominance. Dehiscence may result from abnormal bone development, becoming symptomatic due to minimal trauma or pressure changes. Clinical presentation varies based on dehiscence size and location, with dizziness and oscillatory movements triggered by pressure changes or loud sounds being common symptoms. Other manifestations include conductive hearing loss due to the formation of a ``third window'' in the inner ear. Diagnosis typically involves computed tomography, distinguishing SSCDS from otosclerosis. Surgical treatment is reserved for cases of disabling vestibular pathology, often involving sealing the dehiscence through various approaches.
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Affiliation(s)
- Hajar Zebbakh
- Emergency radiology department, Ibn Sina University Hospital, Rabat, Maroc
| | - Kenza Sidki
- Emergency radiology department, Ibn Sina University Hospital, Rabat, Maroc
| | | | - Laila Jroundi
- Emergency radiology department, Ibn Sina University Hospital, Rabat, Maroc
| | - Omar El Aoufir
- Emergency radiology department, Ibn Sina University Hospital, Rabat, Maroc
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Castellucci A, Dumas G, Abuzaid SM, Armato E, Martellucci S, Malara P, Alfarghal M, Ruberto RR, Brizzi P, Ghidini A, Comacchio F, Schmerber S. Posterior Semicircular Canal Dehiscence with Vestibulo-Ocular Reflex Reduction for the Affected Canal at the Video-Head Impulse Test: Considerations to Pathomechanisms. Audiol Res 2024; 14:317-332. [PMID: 38666899 PMCID: PMC11047701 DOI: 10.3390/audiolres14020028] [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: 12/22/2023] [Revised: 03/10/2024] [Accepted: 03/21/2024] [Indexed: 04/29/2024] Open
Abstract
Posterior semicircular canal dehiscence (PSCD) has been demonstrated to result in a third mobile window mechanism (TMWM) in the inner ear similar to superior semicircular canal dehiscence (SSCD). Typical clinical and instrumental features of TMWM, including low-frequency conductive hearing loss (CHL), autophony, pulsatile tinnitus, sound/pressure-induced vertigo and enhanced vestibular-evoked myogenic potentials, have been widely described in cases with PSCD. Nevertheless, video-head impulse test (vHIT) results have been poorly investigated. Here, we present six patients with PSCD presenting with a clinical scenario consistent with a TMWM and an impaired vestibulo-ocular reflex (VOR) for the affected canal on vHIT. In two cases, an additional dehiscence between the facial nerve and the horizontal semicircular canal (HSC) was detected, leading to a concurrent VOR impairment for the HSC. While in SSCD, a VOR gain reduction could be ascribed to a spontaneous "auto-plugging" process due to a dural prolapse into the canal, the same pathomechanism is difficult to conceive in PSCD due to a different anatomical position, making a dural herniation less likely. Alternative putative pathomechanisms are discussed, including an endolymphatic flow dissipation during head impulses as already hypothesized in SSCD. The association of symptoms/signs consistent with TMWM and a reduced VOR gain for the posterior canal might address the diagnosis toward PSCD.
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Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Georges Dumas
- EA 3450 DevAH–Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, 54500 Nancy, France;
| | - Sawsan M. Abuzaid
- Otorhinolaryngology Department, Royal Medical Services, Amman 11855, Jordan;
| | - Enrico Armato
- Ph.D. Program in Development, Adaptation and Handicap, Faculty of Medicine, University of Lorraine, 54500 Vandoeuvre-lès-Nancy, France;
| | | | - Pasquale Malara
- Audiology & Vestibology Service, Centromedico, 6500 Bellinzona, Switzerland;
| | - Mohamad Alfarghal
- Otorhinolaryngology—Head and Neck Section, Surgery Department, King Abdulaziz Medical City, Jeddah 21556, Saudi Arabia;
| | - Rosanna Rita Ruberto
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Pasquale Brizzi
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Francesco Comacchio
- ENT Unit, Regional Vertigo Specialized Center, University Hospital of Padova, Sant’Antonio Hospital, 35039 Padova, Italy;
| | - Sébastien Schmerber
- Department of Oto-Rhino-Laryngology, Head and Neck Surgery, University Hospital, 38043 Grenoble, France;
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Tozzi A, Castellucci A, Ferrulli G, Brandolini C, Piras G, Martellucci S, Malara P, Ferri GG, Ghidini A, Marchioni D, Presutti L. Audiovestibular Findings in Patients with Concurrent Superior Canal Dehiscence and Vestibular Schwannoma. Otol Neurotol 2024; 45:299-310. [PMID: 38291792 DOI: 10.1097/mao.0000000000004117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
OBJECTIVE To describe the clinical-instrumental findings in case of concurrent superior canal dehiscence (SCD) and ipsilateral vestibular schwannoma (VS), aiming to highlight the importance of an extensive instrumental assessment to achieve a correct diagnosis. STUDY DESIGN Retrospective case review. SETTING Tertiary referral center. PATIENTS Five patients with concurrent SCD and VS. INTERVENTION Clinical-instrumental assessment and imaging. MAIN OUTCOME MEASURE Clinical presentation, audiovestibular findings, and imaging. RESULTS The chief complaints were hearing loss (HL) and unsteadiness (80%). Other main symptoms included tinnitus (60%) and pressure-induced vertigo (40%). Mixed-HL was identified in three patients and pure sensorineural-HL in 1, including a roll-over curve in speech-audiometry in two cases. Vibration-induced nystagmus was elicited in all cases, whereas vestibular-evoked myogenic potentials showed reduced thresholds and enhanced amplitudes on the affected side in three patients. Ipsilesional weakness on caloric testing was detected in three patients and a bilateral hyporeflexia in one. A global canal impairment was detected by the video-head impulse test in one case, whereas the rest of the cohort exhibited a reduced function for the affected superior canal, together with ipsilateral posterior canal impairment in two cases. All patients performed both temporal bones HRCT scan and brain-MRI showing unilateral SCD and ipsilateral VS, respectively. All patients were submitted to a wait-and-scan approach, requiring VS removal only in one case. CONCLUSION Simultaneous SCD and VS might result in subtle clinical presentation with puzzling lesion patterns. When unclear symptoms and signs occur, a complete audiovestibular assessment plays a key role to address imaging and diagnosis.
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Affiliation(s)
- Andrea Tozzi
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Modena, Italy
| | - Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Giuseppe Ferrulli
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Modena, Italy
| | - Cristina Brandolini
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Casa Di Cura Privata "Piacenza" S.P.A., Gruppo Otologico, Piacenza-Rome, Italy
| | | | - Pasquale Malara
- Audiology & Vestibology Service, Centromedico, Bellinzona, Switzerland
| | - Gian Gaetano Ferri
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Daniele Marchioni
- Otorhinolaryngology-Head and Neck Surgery Department, University Hospital of Modena, Modena, Italy
| | - Livio Presutti
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, Bologna, Italy
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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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Eberhard KE, West NC, Cayé-Thomasen P. Transmastoid Surgery for Superior Canal Dehiscence: Prospective Longitudinal Objective and Patient-Reported Audiovestibular Outcomes. Otol Neurotol 2024; 45:184-194. [PMID: 38206067 DOI: 10.1097/mao.0000000000004078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2024]
Abstract
OBJECTIVE We assess symptom control, reversal and stability of objective third-window indicators, and hearing and balance function after transmastoid superior canal dehiscence plugging. To do this, we combine patient self-assessment questionnaires with auditory and vestibular test data collected at a preoperative and multiple postoperative visits. STUDY DESIGN Prospective cohort study. SETTING Tertiary referral center. PATIENTS Patients who underwent transmastoid plugging for superior canal dehiscence from 2012 to 2020. INTERVENTIONS Plugging of the superior semicircular canal using the transmastoid approach. MAIN OUTCOME MEASURES Patients were evaluated preoperatively, 3-month postoperative, and at yearly follow-ups (up to 8 yr postoperative). Self-assessment questionnaires included Autophony Index, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, and Hearing Handicap Inventory. Objective tests included audiometry, cervical vestibular evoked myogenic potential, ocular vestibular evoked myogenic potential, and video head impulse test. RESULTS There was a statistically significant improvement in Autophony Index and Hearing Handicap Inventory total scores from the preoperative evaluation to 1 year postoperative. Dizziness Handicap Inventory and Tinnitus Handicap Inventory total scores also improved but statistically insignificant. Cervical and ocular vestibular evoked myogenic potential amplitudes and low-frequency air-bone gap showed statically significant reversal of the third-window effect preoperative versus 1 year postoperative. Video head impulse test of the superior semicircular canal revealed cases of pathological function preoperative with postoperative recovery. Results were stable over time. CONCLUSIONS Superior canal dehiscence repair resolves symptoms of autophony and improves hearing disability. Objective third-window indicators reverse and show long-term stability. Auditory and vestibular function is preserved postoperative, even superior semicircular canal function may be normal. Data suggest that surgical outcomes should not be evaluated until 1 year postoperative.
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Affiliation(s)
- Kristine Elisabeth Eberhard
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet
| | - Niels Cramer West
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery and Audiology, Copenhagen University Hospital-Rigshospitalet
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Shaul C, Weder S, Dragovic A, Gerard JM, Briggs RJS. Trans-mastoid plugging of superior semicircular canal dehiscence: long-term follow-up. Eur Arch Otorhinolaryngol 2024; 281:67-74. [PMID: 37378725 DOI: 10.1007/s00405-023-08079-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 06/14/2023] [Indexed: 06/29/2023]
Abstract
OBJECTIVE To evaluate the long-term outcomes of trans-mastoid plugging of superior semicircular canal dehiscence (SSCD), focusing on complicated cases. METHODS In this cohort study, we included all patients who underwent trans-mastoid plugging of SSCD between 2009 and 2019. We evaluated the symptoms (autophony, sound-/pressure-induced vertigo, disequilibrium, aural fullness and pulsatile tinnitus) before and 1 year after surgery in the medical records. We systematically assessed the current symptoms 6.2 ± 3 years postoperative (range 2.2-12.3 years) using questionnaires sent by post and validated by telephone interviews. We also documented any complications and the need for further procedures. We compared pure tone and speech audiometry before and 1 year after surgery. Finally, the degree of mastoid pneumatisation and mastoid tegmen anatomy were reviewed on preoperative CT scans. RESULTS We included 24 ears in 23 patients. No complications were recorded, and none required a second procedure for SSCD. Following surgery, oscillopsia and Tullio phenomena resolved in all patients. Hyperacusis, autophony, and aural fullness were also settled in all patients except one. Balance impairment persisted to some degree in 35% of patients. No deterioration over the years was reported regarding the above symptoms. On average, bone conduction pure tone average pre- and 1 year postoperative were 13.7 ± 17 and 20.5 ± 18 dB, respectively (P = 0.002). Air bone gaps were reduced from 12.7 ± 8 to 5.9 ± 6 (P = 0.001). Two patients had a significant sclerotic mastoid, three had a prominent low-lying mastoid tegmen, and two had both. Anatomy had no effect on outcome. CONCLUSION Trans-mastoid plugging of SSCD is a reliable and effective technique which achieves long-lasting symptom control, even in cases with sclerotic mastoid or low-lying mastoid tegmen.
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Affiliation(s)
- Chanan Shaul
- The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia.
- Department of Otolaryngology and Head and Neck Surgery, Shaare-Zedek Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Stefan Weder
- The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
- Department of ENT, Head and Neck Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adrian Dragovic
- The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
| | - Jean-Marc Gerard
- The Royal Victorian Eye and Ear Hospital, East Melbourne, Australia
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Castellucci A, Malara P, Martellucci S, Alfarghal M, Brandolini C, Piras G, Armato E, Ruberto RR, Brizzi P, Presutti L, Ghidini A. Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation? Audiol Res 2023; 13:802-820. [PMID: 37887852 PMCID: PMC10604197 DOI: 10.3390/audiolres13050071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 10/06/2023] [Accepted: 10/17/2023] [Indexed: 10/28/2023] Open
Abstract
Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.
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Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
| | - Pasquale Malara
- Audiology & Vestibology Service, Centromedico, 6500 Bellinzona, Switzerland;
| | | | - Mohamad Alfarghal
- Otorhinolaryngology—Head and Neck Section, Surgery Department, King Abdulaziz Medical City, Jeddah 21556, Saudi Arabia;
| | - Cristina Brandolini
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (L.P.)
| | - Gianluca Piras
- Department of Otology and Skull Base Surgery, Gruppo Otologico, Casa Di Cura Privata “Piacenza” S.P.A., 29121 Piacenza, Italy;
| | - Enrico Armato
- Faculty of Medicine, University of Lorraine, 54000 Vandoeuvre-lès-Nancy, France;
| | - Rosanna Rita Ruberto
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Pasquale Brizzi
- Audiology and Ear Surgery Unit, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy; (R.R.R.); (P.B.)
| | - Livio Presutti
- Otorhinolaryngology and Audiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Policlinico S. Orsola-Malpighi, 40138 Bologna, Italy; (C.B.); (L.P.)
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL—IRCCS di Reggio Emilia, 42123 Reggio Emilia, Italy;
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Kontorinis G, Tailor H, Tikka T, Slim MAM. Six-canal video head impulse test in patients with labyrinthine and retrolabyrinthine pathology: detecting vestibulo-ocular reflex deficits. J Laryngol Otol 2023; 137:398-403. [PMID: 35570664 DOI: 10.1017/s0022215122001153] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
BACKGROUND Abnormal gains in six-canal video head impulse test are attributed to semi-circular canal deficits. However, as video head impulse test responses are linked to the vestibulo-ocular reflex, it was hypothesised that abnormal gains can be caused by vestibulo-ocular reflex pathway deficits. METHODS This study compared video head impulse test gains in 20 patients with superior semi-circular canal dehiscence (labyrinthine cause) and 20 side- and gender-matched patients with vestibular schwannomas (retrolabyrinthine cause), and investigated correlations between them (Mann-Kendall trend test). RESULTS Vestibular schwannoma but not superior semi-circular canal dehiscence was significantly associated with abnormal lateral (odds ratio = 9.00 (95 per cent confidence interval = 1.638-49.44), p = 0.011) and posterior (odds ratio = 9.00 (95 per cent confidence interval = 2.151-37.659), p = 0.003) canal status. In vestibular schwannoma patients, there was a statistically significant degree of dependence between all ipsilesional canal video head impulse test gains; such dependence was not observed in superior semi-circular canal dehiscence. CONCLUSION Vestibulo-ocular reflex gains differ in patients with labyrinthine and retrolabyrinthine disease; this suggests that abnormal gains can indicate deficits not only in the semi-circular canals but also elsewhere along the vestibulo-ocular reflex pathway.
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Affiliation(s)
- G Kontorinis
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - H Tailor
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - T Tikka
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
| | - M A M Slim
- Department of Otolaryngology, Head and Neck Surgery, Queen Elizabeth University Hospital, Glasgow, Scotland, UK
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Altamami N, Khoury M, Saliba I. Manual neuronavigation for superior semicircular canal dehiscence surgery. Front Neurol 2023; 14:1105869. [PMID: 37064194 PMCID: PMC10098155 DOI: 10.3389/fneur.2023.1105869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 02/28/2023] [Indexed: 04/01/2023] Open
Abstract
BackgroundIntraoperative identification of a superior semicircular canal (SSC) dehiscence via the middle cranial fossa approach (MCFA) remains a difficult endeavor without a neuronavigation system. To address these challenges, we propose a technique to localize the SSC dehiscence intraoperatively using certain anatomical landmarks.MethodThree anatomical landmarks should be identified on preoperative radiological images: the distance from the squamous part of the temporal bone to the dehiscent SSC, the lower limit of the craniotomy, and the exact location of the craniotomy in relation to the bony external auditory canal. The use of these landmarks intraoperatively can allow the surgeon to correctly identify the position of the SSC. Two instructional videos explaining this technique are presented.ConclusionThe proposed manual neuronavigation technique seems to be an accurate, safe, and cost-effective alternative technique for use in SSC dehiscence surgery.
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Affiliation(s)
- Nasser Altamami
- Division of Otorhinolaryngology and Head & Neck Surgery, University of Montreal, Montreal, QC, Canada
- Otology and Neurotology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Michel Khoury
- Division of Otorhinolaryngology and Head & Neck Surgery, University of Montreal, Montreal, QC, Canada
- Otology and Neurotology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Issam Saliba
- Division of Otorhinolaryngology and Head & Neck Surgery, University of Montreal, Montreal, QC, Canada
- Otology and Neurotology, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
- *Correspondence: Issam Saliba
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Renteria AE, Elblidi A, Altamami N, Alhabib S, Saliba I. Video Head Impulse Test Demonstrates a Residual Function after Plugging of Dehiscent Superior Semicircular Canal. Otol Neurotol 2023; 44:252-259. [PMID: 36728463 DOI: 10.1097/mao.0000000000003794] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Plugging a symptomatic dehiscent superior semicircular canal (SSCC) often leads to a nonfunctional postoperative canal. However, in some instances, a residual function has been described. This study attempts to describe what factors may lead to such residual function. STUDY DESIGN Retrospective study. SETTING Tertiary referral center. PATIENTS Thirty-five patients with confirmed SSCC dehiscence. INTERVENTION Video head impulse test was conducted pre- and postoperatively to assess any difference in the function of the SSCC. MAIN OUTCOME MEASURES Mean gain and pathological saccades were recorded according to well-established thresholds along with dehiscence length and location to evaluate any associations to residual canal function. RESULTS When comparing preoperative to postoperative SSCC abnormal gains, a significant increase was observed after plugging ( p = 0.023). This also held true when abnormal gain and pathologic saccades were taken together ( p < 0.001). Interestingly, 55.3% of patients were observed to remain with a residual SSCC function 4 months postoperatively even with a clinical improvement. Of these, 47.6% had normal gain with pathologic saccades, 38.1% had an abnormal gain without pathologic saccades, and 14.3% had normal gain without pathologic saccades (normal function). Preoperatively, SSCC abnormal gain was associated with a larger dehiscence length mean ( p = 0.002). Anterosuperior located dehiscences were also associated with a larger dehiscence length mean ( p = 0.037). A residual SSCC function after plugging was associated with a shorter dehiscence length regardless of location ( p = 0.058). CONCLUSION Dehiscence length and location may be useful in predicting disease symptomatology preoperatively and canals function recovery after plugging. These factors could be used as indicators for preoperative counseling and long-term management.
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Affiliation(s)
| | - Ahlem Elblidi
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Nasser Altamami
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
| | - Salman Alhabib
- †Division of Otolaryngology-Head and Neck Surgery, University of Montreal Hospital Center (CHUM), Montreal, QC, Canada
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Shen LL, Andresen NS, Chari DA, Pogson JM, Lauer AM, Rabbitt RD, Carey JP, Santos F, Ward BK. Otolith Membrane Herniation, not Semicircular Canal Duct Dilation, Is Associated with Decreased Caloric Responses in Ménière's Disease. J Assoc Res Otolaryngol 2023; 24:95-106. [PMID: 36539657 PMCID: PMC9971415 DOI: 10.1007/s10162-022-00883-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022] Open
Abstract
Ménière's disease (MD) is a debilitating disorder with unclear pathophysiology whose diagnosis often relies on clinical judgment rather than objective testing. To complicate matters further, a dissociation has emerged between two vestibular function tests commonly used in patients with MD to examine the same end-organ (the semicircular canals): the caloric test and video head impulse testing (vHIT). Caloric responses are often abnormal, while vHIT results remain normal. Explaining this dissociation could reveal novel insights into MD pathophysiology. Here, we conduct a histopathological study using temporal bone specimens (N = 58, 21 MD-affected ears and 37 age-matched controls) and their clinical testing data to examine current hypotheses aimed at this dissociation. We find otolith membrane herniation into the horizontal semicircular canal in 69% of MD ears, with 90% of these ears demonstrating a diminished caloric response. No ears with a normal response had this herniation. Moreover, we evaluated the semicircular canals for endolymphatic hydrops, which had been hypothesized to contribute to the dissociation, and found no evidence of duct dilation/hydrops. We did, however, note a potentially novel morphologic finding-smaller bony labyrinth cross-sectional diameters/areas in some MD ear canals compared to controls, suggesting relative size of the membranous duct to the bony canal rather than absolute size may be of importance. Taken together, this study refines hypotheses on the vestibular test dissociation in MD, holding diagnostic implications and expanding our understanding of the mechanisms underlying this enigmatic disease.
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Affiliation(s)
- Leo L Shen
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Nicholas S Andresen
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Divya A Chari
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Jacob M Pogson
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Neurology Department, Royal Prince Alfred Hospital, Camperdown, NSW, 2050, Australia
| | - Amanda M Lauer
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Solomon H. Snyder Department of Neuroscience, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Richard D Rabbitt
- Department of Biomedical Engineering, University of Utah, Salt Lake City, Utah, USA
| | - John P Carey
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Felipe Santos
- Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, MA, USA
| | - Bryan K Ward
- Department of Otolaryngology-Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
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12
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Hyperacusis: Loudness Intolerance, Fear, Annoyance and Pain. Hear Res 2022; 426:108648. [DOI: 10.1016/j.heares.2022.108648] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/02/2022] [Accepted: 11/07/2022] [Indexed: 11/10/2022]
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13
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Unidirectional Vertical Vestibuloocular Reflex Adaptation in Humans Using 1D and 2D Scenes. Otol Neurotol 2022; 43:e1039-e1044. [PMID: 36075099 DOI: 10.1097/mao.0000000000003684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
HYPOTHESIS The vertical vestibuloocular reflex (VOR) in response to pitch head impulses can be optimally trained to increase in one direction using a two-dimensional (2D) visual training target with minimal effect on the horizontal VOR. BACKGROUND We modified the incremental VOR adaptation (IVA) technique, shown to increase the horizontal VOR in patients with vestibular hypofunction, to drive vertical VOR adaptation in healthy control subjects. METHODS We measured the horizontal and vertical active (self-generated) and passive (imposed) head impulse VOR gains (eye velocity/head velocity) before and after 15 minutes of unidirectional downward IVA training. IVA training consisted of two sessions, one using a single-dot one-dimensional (1D) target, the other a grid-of-dots 2D target. RESULTS The downward head impulse VOR gain significantly increased because of training by 13.3%, whereas the upward VOR gain did not change. The addition of extraretinal (2D) feedback did not result in greater adaptation, i.e., 1D and 2D gain increases were 15.5% and 10.6%, respectively. The vertical VOR gain increase resulted in a 3.2% decrease in horizontal VOR gain. CONCLUSION This preliminary study is the first to show that physiologically relevant (high frequency) unidirectional increases in vertical VOR gain are possible with just 15 minutes of training. This study sets the basis for future clinical trials examining vertical IVA training in patients, which may provide the first practical rehabilitation treatment to functionally improve the vertical VOR.
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A Once-Daily High Dose of Intraperitoneal Ascorbate Improves Vestibulo-ocular Reflex Compensation After Unilateral Labyrinthectomy in the Mouse. J Assoc Res Otolaryngol 2022; 23:27-34. [PMID: 34981264 PMCID: PMC8782995 DOI: 10.1007/s10162-021-00831-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 12/15/2021] [Indexed: 02/03/2023] Open
Abstract
Ascorbate potentiates the response of nicotinic-acetylcholine-receptors containing α9 and α10 subunits found predominantly in the efferent systems of the inner ear, such as the efferent vestibular system (EVS). Prior mouse studies have shown that an attenuated EVS results in reduced vestibulo-ocular reflex (VOR) gain (=eye_velocity/head_velocity) plasticity in intact (VOR adaptation) and surgically-lesioned (VOR compensation) mice. We sought to determine whether ascorbate-treatment could improve VOR recovery after vestibular organ injury, possibly through potentiation of the EVS pathway. We tested 10 cba129 mice, 5 received ascorbate-treatment and 5 did not, but otherwise experienced the same conditions. Ascorbate-treatment comprised a once-daily intraperitoneal injection of L-form reduced ascorbate (4 g/kg) in 0.2 ml saline starting 1 week before, and ending 4 weeks after, unilateral labyrinthectomy surgery. These were deliberately high doses to determine the ascorbate effects on recovery. Baseline, acute, and chronic sinusoidal VOR gains (frequency and velocity ranges: 0.2-10 Hz, 20-100 deg/s) were measured 3-5 days before, 3-5 days after, and 28-31 days after labyrinthectomy. Mice treated with ascorbate had acute ipsilesional VOR gains 12 % higher compared to control mice (+45.2 ± 14.9 % from baseline versus +33.7 ± 15.4 %, P < 0.001). Similarly, chronic ipsilesional and contralesional VOR gains were respectively 16 % (+74.3 ± 16.3 % from baseline versus +58.1 ± 15.8 %, P < 0.001) and 13 % (+78.6 ± 16.0 % versus +65.6 ± 10.9 %, P < 0.001) higher compared to control mice. These data suggest ascorbate-treatment had a prophylactic effect reducing acute loss, and helped recovery during acute to chronic stages of compensation. One possible mechanism is that an ascorbate-enhanced EVS drives an increase in the number and sensitivity of irregular-discharging primary vestibular afferents, important for VOR plasticity.
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15
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Auditory Outcomes Following Transmastoid and Middle Cranial Fossa Approaches for Superior Semicircular Canal Dehiscence Repair. Otol Neurotol 2021; 42:1544-1552. [PMID: 34608000 DOI: 10.1097/mao.0000000000003323] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe postoperative hearing outcomes following transmastoid (TM) and middle cranial fossa (MCF) approaches for semicircular canal dehiscence (SSCD) repair. STUDY DESIGN Retrospective review. SETTING Academic, tertiary referral center. PATIENTS Adults with SSCD who underwent repair between 2005 and 2019. INTERVENTIONS Pure tone audiometry pre- and postoperatively after SSCD repair. MAIN OUTCOME MEASURES Change in air-bone gap (ABG) at 250 and 500 Hz, pure tone average (PTA), bone conduction (BC), and air conduction (AC) thresholds at 500, 1000, 2000, and 4000 Hz for patients undergoing TM and MCF approaches for SSCD repair. RESULTS The average change in BC PTA for patients undergoing TM (n = 26) and MCF (n = 24) SSCD repair was not significantly different between the two groups. The first and final postoperative PTAs were recorded an average of 1.7 (range 0.30-3.0) and 29.1 (range 3.5-154) months postoperatively. For patients who underwent MCF repair, the average BC PTAs increased (+) by 2.2 dB HL (p 0.43) and 0.57 dB HL (p 0.88) at the first and final audiograms respectively compared to +1.27 dB HL (p 0.53) and a decrease (-) of 0.57 dB HL (p 0.63) for the TM group. The average changes in low frequency ABG for patients undergoing MCF repair were -4.7 dB (p 0.08) and -6.9 dB (p 0.15) at first and final audiograms respectively compared to -4.9 dB (p 0.06) and -4.1 dB (p 0.36) for patients who underwent TM repair. There was a high frequency hearing loss noted at 8000 Hz for the MCF (30.0 dB ± 18.7 preop; 41.7 dB ± 21.7 postop; p 0.01) and TM (32.1 dB ± 23.2 preop; 44.3 dB ± 29.6 postop; p 0.001) groups which persisted on long term follow up. CONCLUSIONS Both TM and MCF approaches to SSCD repair can be performed with long-term preservation of hearing. ABGs were reduced in each treatment group but did not reach significance. A high frequency hearing loss (8000 Hz) may be expected with either approach.
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Peusner KD, Bell NM, Hirsch JC, Beraneck M, Popratiloff A. Understanding the Pathophysiology of Congenital Vestibular Disorders: Current Challenges and Future Directions. Front Neurol 2021; 12:708395. [PMID: 34589045 PMCID: PMC8475631 DOI: 10.3389/fneur.2021.708395] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/13/2021] [Indexed: 12/13/2022] Open
Abstract
In congenital vestibular disorders (CVDs), children develop an abnormal inner ear before birth and face postnatal challenges to maintain posture, balance, walking, eye-hand coordination, eye tracking, or reading. Only limited information on inner ear pathology is acquired from clinical imaging of the temporal bone or studying histological slides of the temporal bone. A more comprehensive and precise assessment and determination of the underlying mechanisms necessitate analyses of the disorders at the cellular level, which can be achieved using animal models. Two main criteria for a suitable animal model are first, a pathology that mirrors the human disorder, and second, a reproducible experimental outcome leading to statistical power. With over 40 genes that affect inner ear development, the phenotypic abnormalities resulting from congenital vestibular disorders (CVDs) are highly variable. Nonetheless, there is a large subset of CVDs that form a common phenotype of a sac-like inner ear with the semicircular canals missing or dysplastic, and discrete abnormalities in the vestibular sensory organs. We have focused the review on this subset, but to advance research on CVDs we have added other CVDs not forming a sac-like inner ear. We have included examples of animal models used to study these CVDs. Presently, little is known about the central pathology resulting from CVDs at the cellular level in the central vestibular neural network, except for preliminary studies on a chick model that show significant loss of second-order, vestibular reflex projection neurons.
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Affiliation(s)
- Kenna D Peusner
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Nina M Bell
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - June C Hirsch
- Department of Neurology, The George Washington University School of Medicine and Health Sciences, Washington, DC, United States
| | - Mathieu Beraneck
- Université de Paris, Integrative Neuroscience and Cognition Center, CNRS UMR 8002, Paris, France
| | - Anastas Popratiloff
- The George Washington University Nanofabrication and Imaging Center, Washington, DC, United States
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17
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Totten DJ, Smetak MR, Manzoor NF, Perkins EL, Cass ND, Hatton K, Santapuram P, O'Malley MR, Haynes DS, Bennett ML, Rivas A. Endoscope-Assisted Superior Semicircular Canal Dehiscence Repair: Single Institution Outcomes. Ann Otol Rhinol Laryngol 2021; 131:743-748. [PMID: 34459286 DOI: 10.1177/00034894211041223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To compare outcomes of endoscope-assisted middle cranial fossa MCF) repair of superior semicircular canal dehiscence (SSCD) compared to microscopic MCF repair. STUDY DESIGN Retrospective cohort. SETTING Tertiary medical center neurotology practice. METHODS Retrospective chart review and cohort study of patients who underwent surgical repair of SSCD via MCF approach from 2010 to 2019 at our institution. Patients were categorized according to use of endoscope intraoperatively. Pre- and post-operative symptom number was calculated from 8 patient-reported symptoms. Pre- and post-operative changes in symptom number were assessed using paired t-tests. Single-predictor binary logistic regression was used to compare final reported symptoms between cohorts. Linear regression was performed to assess air-bone gap (ABG) changes postoperatively between cohorts. RESULTS Forty-six patients received surgical management for SSCD. Of these, 27 (59%) were male and 19 (41%) were female. Bilateral SSCD was present in 14 cases (29%), of which 3 underwent surgical management bilaterally, for a total of 49 surgical ears. Surgery was performed on the right ear in 19 cases (39%) and on the left in 30 cases (61%). Forty ears (82%) underwent microscopic repair while 9 (18%) underwent endoscope-assisted repair. Microscopic and endoscope-assisted MCF repair both demonstrated significantly improved symptom number postoperatively (P < .001 for each). There was no significant difference in change in ABG between the 2 cohorts. On average, patient-reported symptoms and audiometrically-tested hearing improved postoperatively in both groups. CONCLUSION While endoscopic-assisted MCF repair has the potential to provide better visualization of medial and downslope defects, repair via this technique yields similar results and is equivalent to MCF repair utilizing the microscope alone.
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Affiliation(s)
| | | | | | | | - Nathan D Cass
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kelsey Hatton
- Vanderbilt University Medical Center, Nashville, TN, USA
| | | | | | - David S Haynes
- Vanderbilt University Medical Center, Nashville, TN, USA
| | - Marc L Bennett
- Vanderbilt University Medical Center, Nashville, TN, USA
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18
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Stultiens JJA, Guinand N, Van Rompaey V, Pérez Fornos A, Kunst HPM, Kingma H, van de Berg R. The resilience of the inner ear-vestibular and audiometric impact of transmastoid semicircular canal plugging. J Neurol 2021; 269:5229-5238. [PMID: 34374862 PMCID: PMC9467949 DOI: 10.1007/s00415-021-10693-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Revised: 04/18/2021] [Accepted: 06/28/2021] [Indexed: 11/30/2022]
Abstract
Background Certain cases of superior semicircular canal dehiscence or benign paroxysmal positional vertigo can be treated by plugging of the affected semicircular canal. However, the extent of the impact on vestibular function and hearing during postoperative follow-up is not known. Objective To evaluate the evolution of vestibular function and hearing after plugging of a semicircular canal. Methods Six patients underwent testing before and 1 week, 2 months, and 6 months after plugging of the superior or posterior semicircular canal. Testing included caloric irrigation test, video Head Impulse Test (vHIT), cervical and ocular Vestibular Evoked Myogenic Potentials (VEMPs) and audiometry. Results Initially, ipsilateral caloric response decreased in all patients and vHIT vestibulo-ocular reflex (VOR) gain of each ipsilateral semicircular canal decreased in 4/6 patients. In 4/6 patients, postoperative caloric response recovered to > 60% of the preoperative value. In 5/6 patients, vHIT VOR gain was restored to > 85% of the preoperative value for both ipsilateral non-plugged semicircular canals. In the plugged semicircular canal, this gain decreased in 4/5 patients and recovered to > 50% of the preoperative value. Four patients preserved cervical and ocular VEMP responses. Bone conduction hearing deteriorated in 3/6 patients, but recovered within 6 months postoperatively, although one patient had a persistent loss of 15 dB at 8 kHz. Conclusion Plugging of a semicircular canal can affect both vestibular function and hearing. After initial deterioration, most patients show recovery during follow-up. However, a vestibular function loss or high-frequency hearing loss can persist. This stresses the importance of adequate counseling of patients considering plugging of a semicircular canal. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10693-5.
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Affiliation(s)
- Joost J A Stultiens
- Department of Otorhinolaryngology & Head and Neck Surgery, Faculty of Health Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands.
| | - Nils Guinand
- Division of Otorhinolaryngology and Head-and-Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Vincent Van Rompaey
- Department of Otorhinolaryngology and Head & Neck Surgery, Faculty of Medicine and Health Sciences, Antwerp University Hospital, University of Antwerp, Antwerp, Belgium
| | - Angélica Pérez Fornos
- Division of Otorhinolaryngology and Head-and-Neck Surgery, Department of Clinical Neurosciences, Geneva University Hospitals, Geneva, Switzerland
| | - Henricus P M Kunst
- Department of Otorhinolaryngology & Head and Neck Surgery, Faculty of Health Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hermanus Kingma
- Department of Otorhinolaryngology & Head and Neck Surgery, Faculty of Health Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Raymond van de Berg
- Department of Otorhinolaryngology & Head and Neck Surgery, Faculty of Health Medicine and Life Sciences, School for Mental Health and Neuroscience, Maastricht University Medical Center, Maastricht, The Netherlands
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Castellucci A, Martellucci S, Malara P, Botti C, Del Vecchio V, Brandolini C, Ferri GG, Ghidini A, Armato E. Possible pathomechanisms accounting for both sound/pressure-induced eye movements and video head impulse test data in superior canal dehiscence. Acta Otolaryngol 2021; 141:749-753. [PMID: 34236943 DOI: 10.1080/00016489.2021.1944664] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Andrea Castellucci
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | | | - Pasquale Malara
- Audiology and Vestibology Service, Centromedico, Bellinzona, Switzerland
| | - Cecilia Botti
- PhD Program in Clinical and Experimental Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Valeria Del Vecchio
- UOC Audiology and Vestibology, University Hospital Federico II, Naples, Italy
| | - Cristina Brandolini
- ENT and Audiology Unit, DIMES, S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Gian Gaetano Ferri
- ENT and Audiology Unit, DIMES, S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL - IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Enrico Armato
- ENT Unit, SS Giovanni e Paolo Hospital, Venice, Italy
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Eberhard KE, Chari DA, Nakajima HH, Klokker M, Cayé-Thomasen P, Lee DJ. Current Trends, Controversies, and Future Directions in the Evaluation and Management of Superior Canal Dehiscence Syndrome. Front Neurol 2021; 12:638574. [PMID: 33889125 PMCID: PMC8055857 DOI: 10.3389/fneur.2021.638574] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 02/08/2021] [Indexed: 01/14/2023] Open
Abstract
Patients with superior canal dehiscence syndrome (SCDS) can present with a range of auditory and/or vestibular signs and symptoms that are associated with a bony defect of the superior semicircular canal (SSC). Over the past two decades, advances in diagnostic techniques have raised the awareness of SCDS and treatment approaches have been refined to improve patient outcomes. However, a number of challenges remain. First, there is currently no standardized clinical testing algorithm for quantifying the effects of superior canal dehiscence (SCD). SCDS mimics a number of common otologic disorders and established metrics such as supranormal bone conduction thresholds and vestibular evoked myogenic potential (VEMP) measurements; although useful in certain cases, have diagnostic limitations. Second, while high-resolution computed tomography (CT) is the gold standard for the detection of SCD, a bony defect does not always result in signs and symptoms. Third, even when SCD repair is indicated, there is a lack of consensus about nomenclature to describe the SCD, ideal surgical approach, specific repair techniques, and type of materials used. Finally, there is no established algorithm in evaluation of SCDS patients who fail primary repair and may be candidates for revision surgery. Herein, we will discuss both contemporary and emerging diagnostic approaches for patients with SCDS and highlight challenges and controversies in the management of this unique patient cohort.
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Affiliation(s)
- Kristine Elisabeth Eberhard
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
| | - Divya A. Chari
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Hideko Heidi Nakajima
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
| | - Mads Klokker
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Per Cayé-Thomasen
- Copenhagen Hearing and Balance Centre, Department of Otorhinolaryngology, Head and Neck Surgery & Audiology, Copenhagen University Hospital – Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Daniel J. Lee
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, United States
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Barbara M, Margani V, Voltattorni A, Monini S, Covelli E. Concomitant Dehiscences of the Temporal Bone: A Case-Based Study. EAR, NOSE & THROAT JOURNAL 2020; 101:NP324-NP328. [PMID: 33175590 DOI: 10.1177/0145561320973782] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Otic capsule dehiscences create a pathological third window in the inner ear that results in a dissipation of the acoustic energy consequent to the lowered impedance. Superior semicircular canal dehiscence (SSCD) was identified by Minor et al in 1998 as a syndrome leading to vertigo and inner ear conductive hearing loss. The authors also reported the relation between the dehiscence and pressure- or sound-induced vertigo (Tullio's phenomenon). Prevalence rates of SSCD in anatomical studies range from 0.4% to 0.7% with a majority of patients being asymptomatic. The observed association with other temporal bone dehiscences, as well as the propensity toward a bilateral or contralateral "near dehiscence," raises the question of whether a specific local bone demineralization or systemic mechanisms could be considered. The present report regard a case of a patient with a previous episode of meningitis, with a concomitant bilateral SSCD and tegmen tympani dehiscence from the side of meningitis. The patient was affected by dizziness, left moderate conductive hearing loss, and pressure/sound-induced vertigo. Because of disabling vestibular symptoms, the patient underwent surgical treatment. A middle cranial fossa approach allowed to reach both dehiscences on the symptomatic side, where bone wax and fascia were used for repair. At 6 months from the procedure, hearing was preserved, and the vestibular symptoms disappeared.
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Affiliation(s)
- Maurizio Barbara
- NESMOS Department, ENT Clinic, Sant'Andrea University Hospital, 9311Sapienza University, Rome, Italy
| | - Valerio Margani
- NESMOS Department, ENT Clinic, Sant'Andrea University Hospital, 9311Sapienza University, Rome, Italy
| | - Anna Voltattorni
- NESMOS Department, ENT Clinic, Sant'Andrea University Hospital, 9311Sapienza University, Rome, Italy
| | - Simonetta Monini
- NESMOS Department, ENT Clinic, Sant'Andrea University Hospital, 9311Sapienza University, Rome, Italy
| | - Edoardo Covelli
- NESMOS Department, ENT Clinic, Sant'Andrea University Hospital, 9311Sapienza University, Rome, Italy
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Abstract
Third window syndrome describes a set of vestibular and auditory symptoms that arise when a pathological third mobile window is present in the bony labyrinth of the inner ear. The pathological mobile window (or windows) adds to the oval and round windows, disrupting normal auditory and vestibular function by altering biomechanics of the inner ear. The most commonly occurring third window syndrome arises from superior semicircular canal dehiscence (SSCD), where a section of bone overlying the superior semicircular canal is absent or thinned (near-dehiscence). The presentation of SSCD syndrome is well characterized by clinical audiological and vestibular tests. In this review, we describe how the third compliant window introduced by a SSCD alters the biomechanics of the inner ear and thereby leads to vestibular and auditory symptoms. Understanding the biomechanical origins of SSCD further provides insight into other third window syndromes and the potential of restoring function or reducing symptoms through surgical repair.
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Affiliation(s)
- Marta M. Iversen
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
| | - Richard D. Rabbitt
- Department of Biomedical Engineering, University of Utah, Salt Lake City, UT, United States
- Department of Otolaryngology, University of Utah, Salt Lake City, UT, United States
- Neuroscience Program, University of Utah, Salt Lake City, UT, United States
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Lee SY, Bae YJ, Kim M, Song JJ, Choi BY, Koo JW. Changes in Vestibulo-Ocular Reflex Gain After Surgical Plugging of Superior Semicircular Canal Dehiscence. Front Neurol 2020; 11:694. [PMID: 32849185 PMCID: PMC7385253 DOI: 10.3389/fneur.2020.00694] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 06/09/2020] [Indexed: 11/13/2022] Open
Abstract
Superior semicircular canal dehiscence (SCD), which is characterized by a “third mobile window” in the inner ear, causes various vestibular and auditory symptoms and signs. Surgical plugging of the superior semicircular canal (SC) can eliminate the symptoms associated with increased perilymph mobility due to the presence of the third window. However, the natural course of vestibular function after surgical plugging remains unknown. Therefore, we explored longitudinal vestibular function after surgery in 11 subjects with SCD who underwent SC plugging using the middle cranial fossa approach. Changes in vestibulo-ocular reflex (VOR) gain in all planes were measured over 1 year with the video head impulse test. We also evaluated surgical outcomes, including changes in symptoms, audiometric results, and electrophysiological tests, to assess whether plugging eliminated third mobile window effects. The mean VOR gain for the plugged SC decreased from 0.81 ± 0.05 before surgery to 0.65 ± 0.08 on examinations performed within 1 week after surgery but normalized thereafter. Four of seven subjects who were able to perform both VOR tests before surgery and immediately after surgery had pathologic values (SC VOR gain < 0.70). Conversely, the mean VOR gain in the other canals remained unchanged over 1 year. The majority of symptoms and signs were absent or markedly decreased at the last follow-up evaluation, and no complications associated with the surgery were reported. Surgical plugging significantly attenuated the air-bone gap, in particular at low frequencies, because of increased bone conduction thresholds and deceased air conduction thresholds. Moreover, surgical plugging significantly increased vestibular-evoked myogenic potential thresholds and decreased the ratio of summating potential to action potential in plugged ears. Postoperative heavily T2-weighted images were available for two subjects and showed complete obliteration of the T2-bright signal intensity in the patent SC lumen in preoperative imaging based on filling defect at the site of plugging. Our results suggest that successful plugging of dehiscent SCs is closely associated with a transient, rather than persistent, disturbance of labyrinthine activity exclusively involved in plugged SCs, which may have clinical implications for timely and individualized vestibular rehabilitation.
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Affiliation(s)
- Sang-Yeon Lee
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Yun Jung Bae
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Minju Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae-Jin Song
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung Yoon Choi
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Ja-Won Koo
- Department of Otorhinolaryngology-Head and Neck Surgery, Seoul National University Bundang Hospital, Seongnam, South Korea.,Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seoul, South Korea
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Castellucci A, Piras G, Del Vecchio V, Crocetta FM, Maiolo V, Ferri GG, Ghidini A, Brandolini C. The effect of superior canal dehiscence size and location on audiometric measurements, vestibular-evoked myogenic potentials and video-head impulse testing. Eur Arch Otorhinolaryngol 2020; 278:997-1015. [PMID: 32592013 DOI: 10.1007/s00405-020-06169-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 06/23/2020] [Indexed: 02/07/2023]
Abstract
PURPOSE To correlate objective measures of audio-vestibular function with superior canal dehiscence (SCD) size and location in ears with SCD and compare results with literature. METHODS We retrospectively evaluated 242 patients exhibiting SCD and/or extremely thinned bone overlying superior canals (SC) on CT scans and selected 73 SCD patients (95 ears with SCD). Data concerning audiometry, impedance audiometry, video-head impulse test (vHIT), cervical vestibular-evoked myogenic potentials (cVEMPs) and ocular VEMPs (oVEMPs) to air- (AC) and bone-conducted (BC) stimuli were collected for each pathologic ear and correlated with dehiscence size and location. RESULTS AC pure-tone average (PTA) (p = 0.013), low-frequency air-bone gap (ABG) (p < 0.001), AC cVEMPs amplitude (p = 0.002), BC cVEMPs amplitude (p < 0.001) and both AC and BC oVEMPs amplitude (p < 0.001) positively correlated with increasing SCD size. An inverse relationship between dehiscence length and both AC cVEMPs and oVEMPs thresholds (p < 0.001) and SC vestibulo-ocular reflex (VOR) gain (p < 0.001) was observed. Dehiscences at the arcuate eminence (AE) exhibited lower SC VOR gains compared to SCD along the ampullary arm (p = 0.008) and less impaired BC thresholds than dehiscences at the superior petrosal sinus (p = 0.04). CONCLUSION We confirmed that SCD size affects AC PTA, ABG and both amplitudes and thresholds of cVEMPs and oVEMPs. We also described a tendency for SC function to impair with increasing SCD size and when dehiscence is located at the AE. The latter data may be explained either by a spontaneous canal plugging exerted by middle fossa dura or by a dissipation through the dehiscence of mechanical energy conveyed to the endolymph during high-frequency impulses.
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Affiliation(s)
- Andrea Castellucci
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy. .,ENT Unit, Department of Surgery, Azienda USL - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy.
| | - Gianluca Piras
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy.,Department of Otology and Skull Base Surgery, Casa Di Cura Privata ''Piacenza'' S.P.A Gruppo Otologico, Piacenza, Rome, Italy
| | - Valeria Del Vecchio
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy.,UOC Audiology & Vestibology, University Hospital Federico II, Naples, Italy
| | - Francesco Maria Crocetta
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy.,ENT Unit, Department of Surgery, Azienda USL - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Vincenzo Maiolo
- Radiology Department, S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Gian Gaetano Ferri
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy
| | - Angelo Ghidini
- ENT Unit, Department of Surgery, Azienda USL - IRCCS, Viale Risorgimento 80, 42123, Reggio Emilia, Italy
| | - Cristina Brandolini
- ENT & Audiology Unit, Department of Diagnostic, Experimal and Specialty Medicine (DIMES), S.Orsola - Malpighi University Hospital, Bologna, Italy
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Cozart AC, Kennedy JT, Seidman MD. A Basis for Standardizing Superior Semicircular Canal Dehiscence Management. EAR, NOSE & THROAT JOURNAL 2020; 100:NP444-NP453. [PMID: 32436400 DOI: 10.1177/0145561320927941] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES (1) To determine how otologic/neurotologic surgeons counsel patients with superior semicircular canal dehiscence (SSCD). (2) To understand the plethora of presenting symptoms associated with SSCD and appropriate management. (3) To suggest appropriate management; oftentimes avoiding surgery. METHODS This was a survey study of both community and academic physicians. A 23-question survey was distributed to all members of the American Neurotological (ANS) and American Otologic Societies (AOS) via email in the Fall of 2018. A total of 54 responses were received from a possible pool of 279 for a response rate of 19.4%. Inferences were made about the population through sample proportions and confidence intervals. RESULTS All respondents use computed tomography (CT) in diagnosing SSCD and 11.1% use CT exclusively. Cervical vestibular evoked myogenic potential (VEMP; 77.8%) are used more often than ocular VEMPs (38.9%). Magnetic resonance imaging (7.4%) is used infrequently; 96.3% of surgeons surveyed have seen patients with SSCD on imaging that are asymptomatic. Following surgical treatment, respondents reported balance issues and mild-to-moderate high-frequency sensorineural hearing loss (88.4%); 32.6% reported that the majority (>50%) of their patients needed further intervention after surgery, typically aggressive vestibular rehabilitation. CONCLUSIONS There is a discrepancy in the systematic approach to SSCD between both the surgeons and the published literature. Patients with SSCD on ultra-high-resolution CT may have myriad symptoms while others are asymptomatic, and surgery may lead to additional complications. We will present a methodical recommendation to assist in the management of patients with SSCD depending upon their symptoms. This may improve patient selection, counseling, and outcomes.
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Affiliation(s)
- Ashley C Cozart
- University of Central Florida (UCF) College of Medicine, Orlando, FL, USA
| | - John T Kennedy
- University of Central Florida (UCF) College of Medicine, Orlando, FL, USA
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Reducing Radiation Dose for High-resolution Flat-panel CT Imaging of Superior Semicircular Canal Dehiscence. Otol Neurotol 2019; 39:e683-e690. [PMID: 30113564 DOI: 10.1097/mao.0000000000001927] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE High-resolution flat panel computed tomography (FPCT) is useful for the evaluation of temporal bone pathologies. While radiation exposure remains a concern, efforts have been devoted to reduce dose, while maintaining image quality. We hypothesize that removing the antiscatter grid (ASG) results in decreased radiation exposure, while maintaining diagnostic image quality for the evaluation of superior semicircular canal dehiscence (SSCD). METHODS Ten patients with clinical suspicion for SSCD participated in this prospective study. Two sequential collimated 20-second FPCT acquisitions were performed (first: grid in; second: grid removed) in all patients. Secondary reconstructions were created by manually generating the volume of interest to include the middle ear using a voxel size of 0.1 mm and 512 × 512 matrix. Radiation dose parameters (air kerma (Ka,r) in mGy and dose area product (DAP) in μGym) were recorded. Three reviewers analyzed images for the ability to diagnose SSCD, to identify the stapes crurae, and to determine if an ASG was present. RESULTS The average Ka,r and DAP for the grid-in acquisitions were 246.7 mGy (SD 47.9) and 2838.0 μGym (SD 862.8), versus 160.2 mGy (SD 33.2) and 2026.3 μGym (SD 644.8) for the grid-out acquisitions, respectively (p<0.001 for both Ka,r and DAP). Radiation exposure was reduced by approximately 30% solely by removing the ASG. All reviewers correctly identified all patients with SSCD (confirmed at surgery), with mean AUC of 0.99 (κ = 0.90). CONCLUSION Removing the antiscatter grid during FPCT imaging of the temporal bones is a simple and effective way to reduce radiation exposure while maintaining diagnostic image quality for the evaluation of SSCD.
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Gauging the effectiveness of canal occlusion surgery: how I do it. The Journal of Laryngology & Otology 2019; 133:1012-1016. [PMID: 31668162 DOI: 10.1017/s0022215119002032] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Transmastoid occlusion of the posterior or superior semicircular canal is an effective and safe management option in patients with refractory benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence. A method of quantifying successful canal occlusion surgery is described. METHODS This paper presents representative patients with intractable benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence, who underwent transmastoid occlusion of the posterior or superior semicircular canal respectively. Vestibular function was assessed pre- and post-operatively. The video head impulse test was included as a measure of semicircular canal and vestibulo-ocular reflex functions. RESULTS Post-operative video head impulse testing showed reduced vestibulo-ocular reflex gain in occluded canals. Gain remained normal in the non-operated canals. Post-operative audiometry demonstrated no change in hearing in the benign paroxysmal positional vertigo patient and slight hearing improvement in the superior semicircular canal dehiscence syndrome patient. CONCLUSION Transmastoid occlusion of the posterior or superior semicircular canal is effective and safe for treating troublesome benign paroxysmal positional vertigo or symptomatic superior semicircular canal dehiscence. Post-operative video head impulse testing demonstrating a reduction in vestibulo-ocular reflex gain can reliably confirm successful occlusion of the canal and is a useful adjunct in post-operative evaluation.
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Pressure Transmission to the Inner Ear by Mastoid Palpation After Transmastoid Surgery for Superior Canal Dehiscence. Otol Neurotol 2019; 40:e925-e927. [DOI: 10.1097/mao.0000000000002372] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Nguyen T, Sheppard JP, Duong C, Ding K, Dejam D, Alkhalid Y, Romiyo P, Azzam D, Prashant G, Gopen Q, Yang I. Age and gender considerations on the symptomology in patients with superior semicircular canal dehiscence: A systematic review and case illustration. J Clin Neurosci 2019; 65:112-120. [DOI: 10.1016/j.jocn.2019.04.006] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 03/11/2019] [Accepted: 04/12/2019] [Indexed: 12/16/2022]
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Different Materials for Plugging a Dehiscent Superior Semicircular Canal: A Comparative Histologic Study Using a Gerbil Model. Otol Neurotol 2019; 40:e532-e541. [DOI: 10.1097/mao.0000000000002205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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31
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Dasgupta S, Ratnayake SAB. Functional and Objective Audiovestibular Evaluation of Children With Apparent Semicircular Canal Dehiscence-A Case Series in a Pediatric Vestibular Center. Front Neurol 2019; 10:306. [PMID: 31001191 PMCID: PMC6454049 DOI: 10.3389/fneur.2019.00306] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 03/11/2019] [Indexed: 11/28/2022] Open
Abstract
Semicircular canal dehiscence is a bony abnormality in the otic capsule especially involving the superior semicircular canal. Since its identification in 1998, there is significant research regarding the pathology in the adult population. This condition generates a third window effect that is well–described in the literature. However, the entity is rare in the pediatric population with limited research. Difficulties encountered in children are obtaining a direct history that is essential for the diagnosis followed by neurovestibular tests that may be difficult to perform. This study presents observations regarding different clinical and diagnostic aspects of semicircular canal dehiscences in children as a retrospective audit in a tertiary pediatric vestibular center. Of 580 children assessed in a 30 months period undergoing comprehensive functional and objective audiovestibular assessment, 13 children (2.2%) were detected to possess radiological semicircular canal dehiscences (high resolution computed tomography scans at 0.625 mm slices reformatted in the axial, coronal and sagittal planes). The right superior semicircular canal was most commonly affected (66.6%). There were 4 bilateral semicircular canal dehiscences. Clinical suspicion of the condition was raised with reliable surrogate history from carers or from older children (100%), a mixed or conductive hearing loss (80% of hearing losses) in the presence of normal impedance audiometry (92.3%), normal transient otoacoustic emissions (84.6%) on the side of the dehiscence and the presence of replicable pathological saccades in the video head impulse test (76.9%). Disequilibrium symptoms and typical third window symptoms were absent or difficult to elicit in children (46.15 and 30.76% respectively). Only 3 (0.5%) fulfilled the adult criteria of a superior semicircular canal dehiscence syndrome. The abnormal video head impulse test characterized by pathological saccades may affect other non-dehisced ipsilateral canals. Semicircular canal dehiscences are rare in children but may be considered as an etiology for hearing losses and imbalance. Children with semicircular canal dehiscence may present differently from the classical superior semicircular canal dehiscence syndrome found in adults.
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Affiliation(s)
- Soumit Dasgupta
- Department of Paediatric Audiology and Audiovestibular Medicine, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
| | - Sudhira Asanka Bandara Ratnayake
- Department of Paediatric Audiology and Audiovestibular Medicine, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
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Causes of Persistent Positional Vertigo Following Posterior Semicircular Canal Occlusion for Benign Paroxysmal Positional Vertigo. Otol Neurotol 2018; 39:e1078-e1083. [PMID: 30239433 DOI: 10.1097/mao.0000000000001990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To report causes of persistent recalcitrant positional vertigo (PRPV) after posterior semicircular canal occlusion (PSCO) for benign paroxysmal positional vertigo (BPPV). STUDY DESIGN Retrospective chart review. SETTING Single high-volume otology practice. PATIENTS Patients diagnosed with BPPV from 2007 to 2017. INTERVENTION PSCO and follow-up care including diagnostic and particle repositioning maneuvers for recurrent BPPV. MAIN OUTCOME MEASURES PRPV, defined as recalcitrant positional vertigo for any reason following PSCO. RESULTS Twenty seven PSCO operations were performed in 26 patients. Twenty five patients (96.2%) had resolution of the Dix-Hallpike test in the operated ear. Eleven patients (42.3%) developed BPPV postoperatively, three (11.5%) in the operated ear and eight (30.8%) in the contralateral ear. Five of eight patients (62.5%) who developed contralateral BPPV had unilateral BPPV preoperatively. Eight patients (30.8%) developed BPPV at least twice after surgery or did not resolve, qualifying as PRPV, and all but one of these events occurred in the nonsurgical ear. No instances of cerebrospinal fluid leak, postoperative infection, facial palsy, clinically significant hearing loss, or death occurred. CONCLUSIONS PSCO is a safe and effective option for recalcitrant BPPV. However, 30.8% of patients, including patients with initially unilateral BPPV, had recalcitrant positional vertigo postoperatively, usually due to contralateral BPPV. Patients considering PSCO should be counseled regarding this risk to ensure realistic expectations.
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Öhman J, Forssén A, Sörlin A, Tano K. Patients’ experiences of living with superior canal dehiscence syndrome. Int J Audiol 2018; 57:825-830. [DOI: 10.1080/14992027.2018.1487086] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Affiliation(s)
- Jenny Öhman
- Department of Clinical Science, Unit of Otorhinolaryngology, Umeå University, Umeå, Sweden
| | - Annika Forssén
- Department of Public Health and Clinical Medicine, Family Medicine, Umeå University, Umeå, Sweden
| | - Anette Sörlin
- Department of Clinical Science, Unit of Otorhinolaryngology, Umeå University, Umeå, Sweden
| | - Krister Tano
- Department of Clinical Science, Unit of Otorhinolaryngology, Umeå University, Umeå, Sweden
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Nguyen T, Lagman C, Sheppard JP, Romiyo P, Duong C, Prashant GN, Gopen Q, Yang I. Middle cranial fossa approach for the repair of superior semicircular canal dehiscence is associated with greater symptom resolution compared to transmastoid approach. Acta Neurochir (Wien) 2018; 160:1219-1224. [PMID: 29022108 DOI: 10.1007/s00701-017-3346-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 09/29/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Superior semicircular canal dehiscence (SSCD) is a disorder of the skull base that is gaining increasing recognition among neurosurgeons. Traditionally, the middle cranial fossa (MCF) approach has been used for the surgical repair of SSCD. However, the transmastoid (TM) approach is an alternative strategy that has demonstrated promising results. METHODS We performed independent searches of a popular database to identify studies that described outcomes following the surgical repair of SSCD through MCF and TM approaches. The primary outcome was symptom resolution. RESULTS Our analysis included 24 studies that described 230 patients that underwent either an MCF (n = 148, 64%) approach or a TM (n = 82, 36%) approach for primary surgical repair of SSCD. A greater percentage of patients in the MCF group experienced resolution of auditory symptoms (72% vs 59%, p = 0.012), aural fullness (83% vs 55%, p = 0.049), hearing loss (57% vs 31%, p = 0.026), and disequilibrium (75% vs 44%, p = 0.001) when compared to the TM group. The MCF approach was also associated with higher odds of symptom resolution for auditory symptoms (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.14-2.82), aural fullness (OR 4.02, 95% CI 1.04-15.53), hearing loss (OR 2.91, 95% CI 1.14-7.42), and disequilibrium (OR 3.94, 95% CI 1.78-8.73). The mean follow-up was 9 months. CONCLUSIONS The literature suggests that the MCF approach for the repair of SSCD is associated with greater symptom resolution when compared to the TM approach. This information could help facilitate patient discussions.
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Affiliation(s)
- Thien Nguyen
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Carlito Lagman
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - John P Sheppard
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
- Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, USA
| | - Prasanth Romiyo
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Courtney Duong
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Giyarpuram N Prashant
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Quinton Gopen
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, CA, USA
| | - Isaac Yang
- Department of Neurosurgery, University of California, Los Angeles, Los Angeles, CA, USA.
- David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA.
- Los Angeles Biomedical Research Institute (LA BioMed), Harbor-UCLA Medical Center, Torrance, CA, USA.
- Department of Head and Neck Surgery, University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Radiation Oncology, University of California, Los Angeles, Los Angeles, CA, USA.
- Jonsson Comprehensive Cancer Center, Ronald Reagan UCLA Medical Center, University of California, Los Angeles, Los Angeles, CA, USA.
- Department of Neurosurgery, Harbor-UCLA Medical Center, Torrance, CA, USA.
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35
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Banakis Hartl RM, Cass SP. Effectiveness of Transmastoid Plugging for Semicircular Canal Dehiscence Syndrome. Otolaryngol Head Neck Surg 2018; 158:534-540. [PMID: 29313443 PMCID: PMC6154498 DOI: 10.1177/0194599817751092] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2017] [Accepted: 12/08/2017] [Indexed: 12/19/2022]
Abstract
Objectives (1) Evaluate changes in subjective symptoms in patients following transmastoid canal plugging for superior semicircular canal dehiscence (SSCD) syndrome. (2) Quantify changes in hearing in patients who have undergone transmastoid canal plugging for SSCD syndrome. Study Design Case series with chart review. Setting Single tertiary care institution. Subjects and Methods We retrospectively reviewed patients with SSCD who underwent repair with canal plugging via a transmastoid approach between January 2012 and January 2017. Symptom severity was assessed prospectively (autophony, sound/pressure-induced vertigo, disequilibrium, aural fullness, and pulsatile tinnitus) and after surgery. Pure-tone and speech audiometry were measured before and after surgery. Two-sided Wilcoxon rank-sum tests were used to evaluate changes in subjective symptoms and audiometric outcomes. Results Seventeen patients (19 ears) met inclusion criteria. The superior canal was successfully plugged via the transmastoid approach in all cases. Patients reported a statistically significant improvement in autophony, vertigo, aural fullness, and pulsatile tinnitus ( P < .01), without significant improvement in disequilibrium rating ( P = .06). There were no changes noted in pure-tone average or word recognition score; however, there was a statistically significant improvement in air-bone gap at 250 Hz of 10.9 dB ( P = .04) with 12.9-dB improvement in air conduction thresholds ( P = .02) and no difference (0.9 dB, P = .9) in bone conduction thresholds. Conclusion In our study, patients with SSCD demonstrated excellent hearing outcomes and resolution of most otologic symptoms after surgical repair. Transmastoid canal plugging, which has been described to date only in smaller case series, is a safe and effective alternative to the traditional middle cranial fossa approach.
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Affiliation(s)
| | - Stephen P. Cass
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, CO
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36
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Superior semicircular canal dehiscence: Diagnosis and management. J Clin Neurosci 2018; 48:58-65. [DOI: 10.1016/j.jocn.2017.11.019] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2017] [Accepted: 11/15/2017] [Indexed: 11/21/2022]
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37
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Volkenstein S, Dazert S. Recent surgical options for vestibular vertigo. GMS CURRENT TOPICS IN OTORHINOLARYNGOLOGY, HEAD AND NECK SURGERY 2017; 16:Doc01. [PMID: 29279721 PMCID: PMC5738932 DOI: 10.3205/cto000140] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Vertigo is not a well-defined disease but a symptom that can occur in heterogeneous entities diagnosed and treated mainly by otolaryngologists, neurologists, internal medicine, and primary care physicians. Most vertigo syndromes have a good prognosis and management is predominantly conservative, whereas the need for surgical therapy is rare, but for a subset of patients often the only remaining option. In this paper, we describe and discuss different surgical therapy options for hydropic inner ear diseases, Menière's disease, dehiscence syndromes, perilymph fistulas, and benign paroxysmal positional vertigo. At the end, we shortly introduce the most recent developments in regard to vestibular implants. Surgical therapy is still indicated for vestibular disease in selected patients nowadays when conservative options did not reduce symptoms and patients are still suffering. Success depends on the correct diagnosis and choosing among different procedures the ones going along with an adequate patient selection. With regard to the invasiveness and the possible risks due to surgery, in depth individual counseling is absolutely necessary. Ablative and destructive surgical procedures usually achieve a successful vertigo control, but are associated with a high risk for hearing loss. Therefore, residual hearing has to be included in the decision making process for surgical therapy.
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Affiliation(s)
- Stefan Volkenstein
- Department of Otolaryngology, Head & Neck Surgery, Ruhr-University of Bochum at the St. Elisabeth Hospital of Bochum, Germany
| | - Stefan Dazert
- Department of Otolaryngology, Head & Neck Surgery, Ruhr-University of Bochum at the St. Elisabeth Hospital of Bochum, Germany
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Carender WJ, Grzesiak M. Vestibular rehabilitation following surgical repair for Superior Canal Dehiscence Syndrome: A complicated case report. Physiother Theory Pract 2017; 34:146-156. [PMID: 28891720 DOI: 10.1080/09593985.2017.1374491] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Superior Canal Dehiscence Syndrome (SCDS) causes auditory and vestibular symptoms. Following surgical repair of the dehiscence, patients often experience dizziness and imbalance. This case report describes a postoperative vestibular exercise program, focusing on the principles of central compensation and habituation, and how it was modified for a patient with delayed progress secondary to strabismus and visual vertigo. A 63-year-old male with history of strabismus eye surgery, right hearing loss, aural fullness, and sensitivity to loud sounds was referred for vestibular rehabilitation (VR). He was seen for one preoperative and six postoperative PT visits over eight months. Outcome measures two weeks postoperative were as follows: Dizziness Handicap Inventory (DHI) 38/100; Timed Up & Go (TUG) 9.92 seconds; Dynamic Gait Index (DGI) 16/24; and a 3-line difference in Dynamic Visual Acuity (DVA). Improved outcomes at discharge included: DHI 18/100; TUG 6.87 seconds; DGI 23/24; and 1-line difference in DVA. He was able to return to work and previously enjoyed recreational activities. Postoperative vestibular rehabilitation programs are functionally and symptomatically beneficial following surgical repair for SCDS. Deviations from expected recovery should be addressed to achieve optimal outcomes as demonstrated in this complicated case report.
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Affiliation(s)
- Wendy J Carender
- a Department of Otolaryngology-Head and Neck Surgery , University of Michigan , Ann Arbor , MI , USA
| | - Melissa Grzesiak
- a Department of Otolaryngology-Head and Neck Surgery , University of Michigan , Ann Arbor , MI , USA
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Ziylan F, Kinaci A, Beynon AJ, Kunst HPM. A Comparison of Surgical Treatments for Superior Semicircular Canal Dehiscence: A Systematic Review. Otol Neurotol 2017; 38:1-10. [PMID: 27861193 DOI: 10.1097/mao.0000000000001277] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE We investigate the postoperative subjective and objective outcomes of different surgical treatments for superior semicircular canal dehiscence (SSCD): vestibular signs, auditory signs, vestibular evoked myogenic potential test, pure tone audiogram, speech audiogram, or video-nystagmography. DATA SOURCES An electronic search performed in the PubMed, Cochrane Library, and EMBASE databases on 15th of September 2015. A systematic search was conducted. Articles were included if written in English, Dutch, German, or French language. STUDY SELECTION Original studies reporting on the pre and postoperative subjective and/or objective outcomes of surgical treatments for superior semicircular canal dehiscence were included. DATA EXTRACTION The methodological quality of the studies was independently assessed by two reviewers using a constructed critical appraisal, to assess the directness of evidence and the risk of bias. The results of the pre and postoperative subjective and/or objective outcomes were extracted. DATA SYNTHESIS Comparative study was conducted. CONCLUSION Surgical treatment for SSCD is particularly effective for vestibular symptoms and there is no evidence for improvement of hearing loss after surgical treatment. Since plugging using transmastoid approach had a lower complication rate, lower revision rate, and a shorter hospital stay, this treatment is recommended in high disabled SSCD patients.
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Affiliation(s)
- Fuat Ziylan
- *Department of Otorhinolaryngology and Head and Neck Surgery †Vestibular & Auditory Evoked Potential Lab, Donders Institute for Brain, Cognition & Behaviour, Centre for Neuroscience, Radboud University Medical Centre, Nijmegen, The Netherlands
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Ossen ME, Stokroos R, Kingma H, van Tongeren J, Van Rompaey V, Temel Y, van de Berg R. Heterogeneity in Reported Outcome Measures after Surgery in Superior Canal Dehiscence Syndrome-A Systematic Literature Review. Front Neurol 2017; 8:347. [PMID: 28790965 PMCID: PMC5523725 DOI: 10.3389/fneur.2017.00347] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 07/03/2017] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Superior canal dehiscence syndrome (SCDS) can be treated surgically in patients with incapacitating symptoms. However, the ideal treatment has not been determined. OBJECTIVES This systematic literature review aims to assess available evidence on the comparative effectiveness and risks of different surgical treatments regarding: (1) symptom improvement; (2) objectively measurable auditory and vestibular function; (3) adverse effects, and (4) length of hospitalization. SEARCH METHOD AND DATA SOURCES A systematic database search according to PRISMA statement was conducted on Pubmed, Embase, and Cochrane library. In addition, reference lists were searched. No correspondence with the authors was established. The last search was conducted on June 9, 2017. STUDY ELIGIBILITY CRITERIA Retrospective and prospective cohort studies were held applicable under the condition that they investigated the association between a surgical treatment method and the relief of vestibular and/or auditory symptoms. Only studies including quantitative assessment of the pre- to postoperative success rate of a surgical treatment method were included. Case reports, reviews, meta-analysis, and studies not published in English, Dutch, or German were excluded. DATA COLLECTION AND ANALYSIS The first author searched literature and extracted data; the first and last analyzed the data. MAIN RESULTS Seventeen studies (354 participants, 367 dehiscences) met the eligibility criteria and were grouped according to surgical approach. Seven combinations of surgical approaches and methods for addressing the dehiscence were identified: plugging, resurfacing, or a combination of both through the middle fossa (middle fossa approach); plugging, resurfacing, or a combination of both through the mastoid (transmastoid approach); round window reinforcement through the ear canal (transcanal approach). Several studies showed high internal validity, but quality was often downgraded due to study design (1). Outcome measures and timing of postsurgical assessment varied among studies, making it unfeasible to pool data to perform a meta-analysis. CONCLUSION A standardized protocol including outcome measures and timeframes is needed to compare the effectiveness and safety SCDS treatments. It should include symptom severity assessments and changes in vestibular and auditory function before and after treatment.
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Affiliation(s)
- Mira E Ossen
- Faculty of Medicine, Maastricht University, Maastricht, Netherlands
| | - Robert Stokroos
- Department of Otorhinolaryngology and Head & Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Herman Kingma
- Department of Otorhinolaryngology and Head & Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands.,Faculty of Physics, Tomsk State University, Tomsk Russian Federation, Tomsk, Russia
| | - Joost van Tongeren
- Department of Otorhinolaryngology and Head & Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Vincent Van Rompaey
- Faculty of Medicine and Health Sciences, University of Antwerp, Antwerp, Belgium.,Department of Otorhinolaryngology and Head & Neck Surgery, Antwerp University Hospital, Edegem, Belgium
| | - Yasin Temel
- Department of Neurosurgery, Maastricht University Medical Center, Maastricht, Netherlands
| | - Raymond van de Berg
- Department of Otorhinolaryngology and Head & Neck Surgery, Maastricht University Medical Center, Maastricht, Netherlands.,Faculty of Physics, Tomsk State University, Tomsk Russian Federation, Tomsk, Russia
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Xie Y, Sharon JD, Pross SE, Abt NB, Varma S, Della Santina CC, Minor LB, Carey JP. Surgical Complications from Superior Canal Dehiscence Syndrome Repair: Two Decades of Experience. Otolaryngol Head Neck Surg 2017; 157:273-280. [DOI: 10.1177/0194599817706491] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective To determine the incidence of surgical complications associated with superior canal dehiscence syndrome (SCDS) repair and identify the demographic, medical, and intraoperative risk factors that are associated with SCDS complications. Study Design Cases series with chart review, including patients who underwent SCDS repair between 1996 and 2015. Setting A tertiary care academic medical center. Subjects and Methods Data were collected from 220 patients, including demographic information, medical comorbidities, prior otologic surgical history, surgical approach, intraoperative findings, and postoperative complications. Relative risk analysis and multivariable logistic regression evaluated the associations between perioperative risk factors and SCDS complications. Results A total of 242 consecutive cases were performed: 95.5% middle fossa and 4.5% transmastoid approach (mean age: 47.8 ± 10.6 years; 54.5% female). Surgical complications were reported in 27 (11.2%) cases; 20 (8.3%) had Clavien-Dindo grade I complications, most commonly benign paroxysmal positional vertigo (n = 11, 4.5%) and profound sensorineural hearing loss (n = 6, 2.5%). Two cases (0.8%) had grade II; 4 cases (1.7%), grade III; and 1 case (0.4%), grade IV complications. In the analysis of comorbidities, only preoperative coagulopathy was significantly associated with increased risk of complications (relative risk = 6.4, P < .01). Following multivariate logistic regression adjusting for demographic covariates, coagulopathy was still associated with increased odds of complications (odds ratio = 15.7, P = .03). There were no significant associations between other risk factors and complications. Conclusion SCDS repair has low rates of adverse events. We observed an incidence of 11.2% complications, most commonly postoperative benign paroxysmal positional vertigo. The risk of nonotologic intracranial complications (1.7%) is low.
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Affiliation(s)
- Yanjun Xie
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jeffrey D. Sharon
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Seth E. Pross
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nicholas B. Abt
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sanskriti Varma
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charley C. Della Santina
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Lloyd B. Minor
- Department of Otolaryngology–Head and Neck Surgery, Stanford University School of Medicine, Stanford, California, USA
| | - John P. Carey
- Department of Otolaryngology–Head and Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Ward BK, Wenzel A, Ritzl EK, Carey JP. Electrocochleography summating potential seen on auditory brainstem response in a case of superior semicircular canal dehiscence. Surg Neurol Int 2017; 8:90. [PMID: 28607824 PMCID: PMC5461570 DOI: 10.4103/sni.sni_442_15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 03/04/2017] [Indexed: 12/02/2022] Open
Abstract
Background: Superior canal dehiscence syndrome (SCDS) is a condition in which an abnormal communication between the superior semicircular canal and the middle cranial fossa causes patients to hear internal noises transmitted loudly to their affected ear as well as to experience vertigo with pressure changes or loud sounds. Patients with SCDS can have an elevated ratio of summating potential (SP) to action potential (AP) as measured by electrocochleography (ECochG). Changes in this ratio have been observed during surgical intervention to correct this abnormal communication. Case Description: We present a case of SCDS along with history, physical examination, vestibular function testing, and computed tomography imaging. Due to the disabling symptoms, the patient elected to undergo surgery for plugging of the superior semicircular canal by middle cranial fossa approach. Simultaneous intraoperative ECochG and auditory brainstem response (ABR) were performed. Changes in SP/AP ratio, SP amplitude, and ABR wave I latency were observed during surgery, with a large ECochG SP amplitude generating a new wave, identifiable on the ABR and preceding the traditional wave I. The patient's symptoms resolved after surgery, and no long-term detriment to hearing was observed. Conclusions: This case demonstrates the intraoperative changes in ECochG during surgery for repair of a SCDS. The substantial intraoperative changes in the summating potential can create a novel wave on intraoperative ABR.
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Affiliation(s)
- Bryan K Ward
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Angela Wenzel
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Eva K Ritzl
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - John P Carey
- Department of Otolaryngology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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43
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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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44
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Superior semicircular canal dehiscence syndrome: a new aetiology. The Journal of Laryngology & Otology 2017; 122:741-4. [DOI: 10.1017/s0022215108001965] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
AbstractObjective:We report what we believe to be a unique aetiology of the superior semicircular canal dehiscence syndrome, a recently described condition in which vestibular imbalance and/or hearing loss results from the loss of continuity of the bone overlying the superior semicircular canals.Case report:A 58-year-old woman presented with autophony in the right ear and momentary imbalance when shouting (Tullio phenomenon). Temporal bone computed tomography revealed a defect of the right superior semicircular canal caused by an enlarged superior petrosal sinus receiving drainage from a large cerebellar developmental venous anomaly.Conclusions:We review superior semicircular canal dehiscence syndrome and its management, and we discuss common aetiologies, contrasting these with the unusual aetiology presented here. We conclude that superior semicircular canal dehiscence syndrome may present with a solely developmental aetiology, despite presenting late in life.
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45
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Bi WL, Brewster R, Poe D, Vernick D, Lee DJ, Eduardo Corrales C, Dunn IF. Superior semicircular canal dehiscence syndrome. J Neurosurg 2017; 127:1268-1276. [PMID: 28084916 DOI: 10.3171/2016.9.jns16503] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Superior semicircular canal dehiscence (SSCD) syndrome is an increasingly recognized cause of vestibular and/or auditory symptoms in both adults and children. These symptoms are believed to result from the presence of a pathological mobile "third window" into the labyrinth due to deficiency in the osseous shell, leading to inadvertent hydroacoustic transmissions through the cochlea and labyrinth. The most common bony defect of the superior canal is found over the arcuate eminence, with rare cases involving the posteromedial limb of the superior canal associated with the superior petrosal sinus. Operative intervention is indicated for intractable or debilitating symptoms that persist despite conservative management and vestibular sedation. Surgical repair can be accomplished by reconstruction or plugging of the bony defect or reinforcement of the round window through a variety of operative approaches. The authors review the etiology, pathophysiology, presentation, diagnosis, surgical options, and outcomes in the treatment of this entity, with a focus on potential pitfalls that may be encountered during clinical management.
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Affiliation(s)
- Wenya Linda Bi
- 1Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital
| | - Ryan Brewster
- 1Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital
| | - Dennis Poe
- 2Department of Otolaryngology and Communication Enhancement, Boston Children's Hospital.,3Department of Otolaryngology, Harvard Medical School
| | - David Vernick
- 3Department of Otolaryngology, Harvard Medical School
| | - Daniel J Lee
- 3Department of Otolaryngology, Harvard Medical School.,4Department of Otolaryngology, Massachusetts Eye and Ear Infirmary; and.,5Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts
| | - C Eduardo Corrales
- 3Department of Otolaryngology, Harvard Medical School.,5Division of Otolaryngology, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ian F Dunn
- 1Center for Skull Base and Pituitary Surgery, Department of Neurosurgery, Brigham and Women's Hospital
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Mantokoudis G, Saber Tehrani AS, Wong AL, Agrawal Y, Wenzel A, Carey JP. Adaptation and Compensation of Vestibular Responses Following Superior Canal Dehiscence Surgery. Otol Neurotol 2016; 37:1399-405. [PMID: 27556420 PMCID: PMC5025376 DOI: 10.1097/mao.0000000000001196] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe vestibulo-ocular function and compensatory mechanisms in the immediate postoperative period after superior canal dehiscence surgery. STUDY DESIGN Prospective longitudinal study. SETTING Tertiary medical center. PATIENTS Five patients who underwent plugging of superior semicircular canal via middle cranial fossa approach. INTERVENTIONS Bedside quantitative video head impulse testing (vHIT). MAIN OUTCOME MEASURES Dynamic measures of vestibulo-ocular reflex (VOR) function including VOR gain and compensatory saccades during vHIT. RESULTS Mean VOR gain of the ipsilateral superior semicircular canal (SC) decreased from 0.71 ± 0.1 preoperatively to 0.28 ± 0.07 on postoperative day (POD) 2-4 (p = 0.0031), consistent with plugging. There was also a significant immediate postoperative decrease of VOR gain for the other ipsilateral canals (posterior canal (PC) from gain 0.91 ± 0.33 down to 0.55 ± 0.14, p = 0.040; horizontal canal (HC) from 0.81 ± 0.08 down to 0.54 ± 0.19, p = 0.038). On PODs 1-2, compensatory saccades after testing the plugged SC occurred exclusively after the head stopped moving (overt) with latency of 186.2 ms ± 19.9 ms. By POD 7 saccade latency decreased to 141.0 ± 17.5 ms (p = 0.032), and saccades were occurring during the vertical head rotation (covert saccades). Follow-up >40 days was consistent with previous findings in that mean SC gain remained low. HC gain recovered fully, but some cases did not have full recovery of PC gain. CONCLUSION When the SC is plugged surgically, early quantitative vHIT demonstrates significantly reduced VOR gain for all of the ipsilateral canals. Possible mechanisms include labyrinthine inflammation and loss of perilymph at the time of surgery. Full recovery is typical for the horizontal canal but not always for the PC. Evidence of central compensation occurred by the elicitation of compensatory saccades and by reducing their latencies within the first week after surgery.
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Affiliation(s)
- Georgios Mantokoudis
- Department of Otorhinolaryngology, Head and Neck Surgery, Inselspital Bern, University of Bern, Switzerland
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Ali S. Saber Tehrani
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Aaron L Wong
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Yuri Agrawal
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Angela Wenzel
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - John P. Carey
- Department of Otolaryngology-Head & Neck Surgery, Johns Hopkins University School of Medicine, Baltimore, USA
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Newlands SD, Wei M, Morgan D, Luan H. Responses of non-eye-movement central vestibular neurons to sinusoidal yaw rotation in compensated macaques after unilateral semicircular canal plugging. J Neurophysiol 2016; 116:1871-1884. [PMID: 27489364 DOI: 10.1152/jn.00212.2016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/27/2016] [Indexed: 01/24/2023] Open
Abstract
After vestibular labyrinth injury, behavioral measures of vestibular performance recover to variable degrees (vestibular compensation). Central neuronal responses after unilateral labyrinthectomy (UL), which eliminates both afferent resting activity and sensitivity to movement, have been well-studied. However, unilateral semicircular canal plugging (UCP), which attenuates angular-velocity detection while leaving afferent resting activity intact, has not been extensively studied. The current study reports response properties of yaw-sensitive non-eye-movement rhesus macaque vestibular neurons after compensation from UCP. The responses at a series of frequencies (0.1-2 Hz) and peak velocities (15-210°/s) were compared between neurons recorded before and at least 6 wk after UCP. The gain (sp/s/°/s) of central type I neurons (responding to ipsilateral yaw rotation) on the side of UCP was reduced relative to normal controls at 0.5 Hz, ±60°/s [0.48 ± 0.30 (SD) normal, 0.32 ± 0.15 ipsilesion; 0.44 ± 0.2 contralesion]. Type II neurons (responding to contralateral yaw rotation) after UCP have reduced gain (0.40 ± 0.27 normal, 0.35 ± 0.25 ipsilesion; 0.25 ± 0.18 contralesion). The difference between responses after UCP and after UL is primarily the distribution of type I and type II neurons in the vestibular nuclei (type I neurons comprise 66% in vestibular nuclei normally; 51% ipsilesion UCP; 59% contralesion UCP; 38% ipsilesion UL; 65% contralesion UL) and the magnitude of the responses of type II neurons ipsilateral to the lesion. These differences suggest that the need to compensate for unilateral loss of resting vestibular nerve activity after UL necessitates a different strategy for recovery of dynamic vestibular responses compared to after UCP.
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Affiliation(s)
- Shawn D Newlands
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
| | - Min Wei
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
| | - David Morgan
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
| | - Hongge Luan
- Department of Otolaryngology, University of Rochester Medical Center, Rochester, New York
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48
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Cheng YS, Kozin ED, Remenschneider AK, Nakajima HH, Lee DJ. Characteristics of Wax Occlusion in the Surgical Repair of Superior Canal Dehiscence in Human Temporal Bone Specimens. Otol Neurotol 2016; 37:83-8. [PMID: 26649609 DOI: 10.1097/mao.0000000000000916] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
HYPOTHESIS Superior canal dehiscence (SCD) repair using surgical bone wax may result in variable outcomes if large wax volumes are applied. BACKGROUND SCD is a disorder characterized by a pathologic defect in the bony labyrinth of the superior semicircular canal (SSC), resulting in vestibular and/or auditory symptoms. Repair of SCD using bone wax can provide symptomatic relief, but surgical outcomes are variable. These observations may be associated with the inconsistency in the position and extension of intralabyrinthine bone wax during surgical repair. METHODS A pathological model of SCD was created using cadaveric human temporal bones and a microdrill. Defects in the arcuate eminence 0.5 to 3.5 mm in length were repaired by surgical occlusion with bone wax. The volume of wax used in the repair was quantified. The position of bone wax was evaluated by direct visualization and imaging (computed tomography [CT]). To visualize wax on CT, specimens were repaired using radiopaque wax. RESULTS Exceedingly small volumes of bone wax (3.0-5.0 mm2) reliably occluded the canal lumen. Multiple wax applications resulted in extension into the common crus and ampulla. The length of this extension was related to the number of applications. CONCLUSIONS Repair of SCD with bone wax occludes the bony defect completely in most patients. Wax can extend along the lumen of the superior canal beyond the limits of the dehiscence to reach the sensory neuroepithelium of the vestibular end organs. Limiting the number of wax applications is essential to avoid inadvertent injury to the delicate neurosensory systems.
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Affiliation(s)
- Yew Song Cheng
- *Department of Otology and Laryngology, Harvard Medical School†Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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Hirvonen T, Aalto H, Jutila T. Labyrinthine function after semicircular canal surgery on seventeen patients with cholesteatoma. Clin Otolaryngol 2016; 41:76-9. [DOI: 10.1111/coa.12453] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/26/2015] [Indexed: 11/28/2022]
Affiliation(s)
- T.P. Hirvonen
- Department of Otolaryngology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - H. Aalto
- Department of Otolaryngology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
| | - T. Jutila
- Department of Otolaryngology; University of Helsinki and Helsinki University Hospital; Helsinki Finland
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50
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Barber SR, Cheng YS, Owoc M, Lin BM, Remenschneider AK, Kozin ED, Lee DJ. Benign paroxysmal positional vertigo commonly occurs following repair of superior canal dehiscence. Laryngoscope 2015; 126:2092-7. [PMID: 26666775 DOI: 10.1002/lary.25797] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2015] [Revised: 10/29/2015] [Accepted: 11/02/2015] [Indexed: 11/07/2022]
Abstract
OBJECTIVES/HYPOTHESIS Repair of superior canal dehiscence (SCD) often results in the resolution of preoperative auditory and vestibular symptoms; however, many patients experience dizziness in the postoperative period. Postoperative dizziness may be the result of new-onset benign paroxysmal positional vertigo (BPPV). This study aims to investigate the prevalence of BPPV before and following SCD repair. STUDY DESIGN Retrospective chart review at a tertiary care center. METHODS Electronic medical records were reviewed for patients with a diagnosis of SCD syndrome (SCDS) between January 2002 and May 2015. Collected information included demographic data, incidence of BPPV diagnosed by Dix-Hallpike maneuver before and following surgery, operative technique, repair material, and the duration of time to BPPV onset. RESULTS A total of 180 patients with a diagnosis of SCDS were identified: 84 patients underwent surgery (operated subjects) and 96 were observed (nonoperated, control group). In operated subjects, 20 of 84 (23.8%) developed BPPV following SCD repair versus 6.2% of nonoperated (P < 0.005). Benign paroxysmal positional vertigo lateralized to the operated side in all but one subject whose laterality was unknown (P < 0.0001). There were no associations of BPPV with surgical approach (P = 0.50) or repair material (P = 0.33). The majority of subjects (58%) were diagnosed with BPPV within 3 months of surgery. CONCLUSION New-onset BPPV occurs commonly after SCD repair and may be the result of mobilized otoliths from inner ear pressure changes. Although the exact etiology of post-SCD repair BPPV remains unknown, postoperative dizziness is important to discuss with patients during preoperative counseling. LEVEL OF EVIDENCE 4. Laryngoscope, 126:2092-2097, 2016.
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Affiliation(s)
- Samuel R Barber
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Yew Song Cheng
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Maryanna Owoc
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Brian M Lin
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Aaron K Remenschneider
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Elliott D Kozin
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
| | - Daniel J Lee
- Department of Otology and Laryngology, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology-Head and Neck Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, U.S.A
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