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Wang K, Gjini EK, Kooper-Johnson S, Cooper MI, Gallant C, Noonan KY. Cochlear Implant Outcomes in Patients with Intralabyrinthine Schwannoma: A Scoping Review. Laryngoscope 2024; 134:3910-3920. [PMID: 38554009 DOI: 10.1002/lary.31422] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 02/28/2024] [Accepted: 03/04/2024] [Indexed: 08/09/2024]
Abstract
OBJECTIVE To evaluate the literature and summarize cochlear implantation (CI) outcomes after intralabyrinthine schwannoma (ILS) excision and tumor observation with CI. DATA SOURCES OVID Medline, Embase, Web of Science; conception to 2024. REVIEW METHODS A literature review was performed using subject headings, MeSH terms, and keywords. Abstracts and full texts were reviewed by two independent reviewers and adjudicated by a third. Inclusion criteria included studies with ILS and CI with reported audiologic outcomes. Subjects were analyzed into two groups, ILS resection with CI and in situ ILS with CI. Patients with NF2 were included. The main outcome of interest was CI audiometric performance level, with secondary outcomes of CI user status and open-set speech attainment. RESULTS There were 29 articles with a total of 93 patients who met inclusion criteria. The resection group had 17% low performers, 44% intermediate performers, and 38% high performers. The in situ group had 40% low performers, 32% intermediate performers, 27% high performers. The resection group had 69 patients with 97% maintaining user status and 92% with open-set speech recognition. The observation group had 24 patients, with 87% user rate and 86% achieving open-set speech recognition. There was a greater percentage of NF2 diagnosis seen in the in situ group. CONCLUSION There is a paucity of literature on CI and ILS. Patients are managed with both resection of tumor and implantation in situ. Early data are limited, with improvement in hearing outcomes and high user rates in both populations. LEVEL OF EVIDENCE N/A Laryngoscope, 134:3910-3920, 2024.
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Affiliation(s)
- Katherine Wang
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Emily K Gjini
- Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | | | - Michael I Cooper
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
| | - Collyn Gallant
- Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts, U.S.A
| | - Kathryn Y Noonan
- Tufts University School of Medicine, Boston, Massachusetts, U.S.A
- Department of Otolaryngology, Tufts Medical Center, Boston, Massachusetts, U.S.A
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Iannacone FP, Rahne T, Zanoletti E, Plontke SK. Cochlear implantation in patients with inner ear schwannomas: a systematic review and meta-analysis of audiological outcomes. Eur Arch Otorhinolaryngol 2024:10.1007/s00405-024-08818-3. [PMID: 38992191 DOI: 10.1007/s00405-024-08818-3] [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: 02/21/2024] [Accepted: 07/01/2024] [Indexed: 07/13/2024]
Abstract
PURPOSE In patients with inner ear schwannomas (IES), reports on hearing rehabilitation with cochlear implants (CI) have increased over the past decade, most of which are case reports or small case series. The aim of this study is to systematically review the reported hearing results with CI in patients with IES considering the different audiologic outcome measures used in different countries. METHODS According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline, a search of published literature was conducted. We included patients with IES (primary or with secondary extension from the internal auditory canal (IAC) to the inner ear, sporadic or NF2 related) undergoing cochlear implantation with or without tumour removal. The audiological results were divided into the categories "monosyllables", "disyllables", "multisyllabic words or numbers", and "sentences". RESULTS Predefined audiological outcome measures were available from 110 patients and 111 ears in 27 reports. The mean recognition scores for monosyllabic words with CI were 55% (SD: 24), for bisyllabic words 61% (SD: 36), for multisyllabic words and numbers 87% (SD: 25), and 71% (SD: 30) for sentences. Results from for multisyllabic words and numbers in general showed a tendency towards a ceiling effect. Possible risk factors for performance below average were higher complexity tumours (inner ear plus IAC/CPA), NF2, CI without tumour removal ("CI through tumour"), and sequential cochlear implantation after tumour removal (staged surgery). CONCLUSION Hearing loss in patients with inner ear schwannomas can be successfully rehabilitated with CI with above average speech performance in most cases. Cochlear implantation thus represents a valuable option for hearing rehabilitation also in patients with IES while at the same time maintaining the possibility of MRI follow-up. Further studies should investigate possible risk factors for poor performance. Audiological tests and outcome parameters should be reported in detail and ideally be harmonized to allow better comparison between languages.
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Affiliation(s)
- Francesco P Iannacone
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padua, Italy
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Torsten Rahne
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany
| | - Elisabetta Zanoletti
- Department of Neuroscience DNS, Otolaryngology Section, University of Padova, Padua, Italy
| | - Stefan K Plontke
- Department of Otorhinolaryngology, Head and Neck Surgery, University Medicine Halle, Martin Luther University Halle-Wittenberg, Ernst-Grube-Str. 40, 06120, Halle (Saale), Germany.
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Pfeiffer CJ, Riemann C, Kim R, Scholtz LU, Schürmann M, Todt I. First Clinical Experience with a New Device for the Removal of Cochlear Schwannomas. J Clin Med 2024; 13:3300. [PMID: 38893011 PMCID: PMC11172928 DOI: 10.3390/jcm13113300] [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: 04/11/2024] [Revised: 05/26/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024] Open
Abstract
Background: In most cases, intralabyrinthine schwannoma (ILS) occurs in patients with unilateral hearing deterioration or neurofibromatosis type II (NF II). The pattern of localization of these tumors varies but mostly affects the cochlea. Extirpation of the cochlear schwannoma, if hidden by the cochlea modiolus, is difficult under the aspect of complete removal. Therefore, a tissue removal device (TRD) was designed and tested in temporal bones. The principle of handling the new device is a pushing and pipe cleaner handling inside the cochlea. This present study aimed to describe the first in vivo experience with the newly developed TRD for removing cochlear intralabyrinthine schwannomas. Methods: In three patients, the TRD was used for the tumor removal of cochlear schwannomas. In two patients with a cochlear schwannoma in combination with a cochlea implantation and one patient suffering from NF II, a cochlear schwannoma was removed with the TRD. The access was performed with a posterior tympanotomy, an enlarged round window approach and an additional second turn access. The device was inserted and extracted gradually from the second turn access until the rings were visible in the second turn access. By pushing and pipe cleaner handling, the tumors were removed. An MRI control was performed on the day postoperatively with a T1 GAD sequence. Results: Tumor removal with the TRD was performed in a 15-min procedure without any complications. An MRI control confirmed complete removal on the postoperative day in all cases. Conclusions: In vivo handling of the device confirmed straightforward handling for the tumor removal. MRI scanning showed complete removal of the tumor by the TRD.
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Affiliation(s)
| | | | | | | | | | - Ingo Todt
- Department of Otolaryngology, Head and Neck Surgery, Medical School OWL, Bielefeld University, Campus Mitte, Klinikum Bielefeld, 33604 Bielefeld, Germany; (C.J.P.); (C.R.); (R.K.); (L.-U.S.); (M.S.)
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Dornhoffer JR, Haller T, Lohse CM, Driscoll CLW, Neff BA, Saoji A, Link MJ, Carlson ML. Cochlear Implant Outcomes between Patients with Sporadic and Neurofibromatosis Type 2-Associated Vestibular Schwannoma. Otol Neurotol 2023; 44:791-797. [PMID: 37464449 DOI: 10.1097/mao.0000000000003963] [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: 07/20/2023]
Abstract
OBJECTIVE Compare cochlear implant (CI) performance between patients with ipsilateral sporadic vestibular schwannoma (VS) and NF2-related schwannomatosis (NF2). Compare CI performance according to VS management modality. STUDY DESIGN Historical cohort. SETTING Tertiary academic center. PATIENTS Forty-nine patients (52 ears) undergoing cochlear implantation in the setting of ipsilateral sporadic (n = 21) or NF2-associated VS (n = 28). INTERVENTIONS CI ipsilateral to VS. MAIN OUTCOME MEASURES Auditory thresholds, consonant-nucleus-consonant (CNC) word scores, and AzBio sentences in quiet scores. RESULTS Among all patients, median post-CI pure tone average was 28 dB HL (interquartile range [IQR], 21-38), CNC word score was 39% (IQR, 6-62), and AzBio sentences in quiet score was 60% (IQR, 11-83) at a median of 12.5 months postimplantation. Despite the NF2 cohort having larger tumors, when comparing patients with sporadic versus NF2-associated VS, there were no statistically significant differences in CNC word (49% [30-70] vs. 31% [0-52]) or AzBio sentences in quiet (66% [28-80] vs. 57% [5-83]) scores. Regardless of NF2 status, all patients managed with observation, and radiosurgery achieved open-set speech. In patients who underwent microsurgery, 6 (46%) of 13 with NF2 achieved open-set speech recognition compared with 4 (67%) of 6 with sporadic disease. CONCLUSION Select patients with VS achieve successful hearing rehabilitation with a CI. In this cohort, tumor management strategy significantly influenced CI performance, whereas differences in NF2 status exhibited less effect. Specifically, all patients managed with observation or radiosurgery achieved open-set speech perception, whereas approximately half of people with NF2-related VS and two-thirds of people with sporadic VS achieved this outcome after tumor microsurgery. When disease permits, observation and radiosurgery should be considered in patients who may later pursue a CI.
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Affiliation(s)
- James R Dornhoffer
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Travis Haller
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
| | - Christine M Lohse
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | | | | | - Aniket Saoji
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic, Rochester, MN
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Holger S, Conrad R, Rayoung K, Scholtz LU, Pfeiffer CJ, Peter G, Ingo T. A new device for the removal of cochlear schwannoma: A temporal bone study. Front Surg 2023; 10:1077407. [PMID: 36816011 PMCID: PMC9928970 DOI: 10.3389/fsurg.2023.1077407] [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: 10/22/2022] [Accepted: 01/09/2023] [Indexed: 02/04/2023] Open
Abstract
Background Intralabyrinthine schwannoma (ILS) is a rare, mostly unilateral disease that causes deafness. Different intralabyrinthine sites of ILS can occur and can be removed by different surgical approaches. Cochlear ILSs are frequently partially hidden by the modiolus and therefore difficult to extirpate. Surgical techniques can be traumatic, offer limited surgical control during removal, and are time-consuming. The aim of this present study was to demonstrate the performance and handling of a newly developed device for the removal of cochlear intralabyrinthine schwannoma in the temporal bone. Methods In a temporal bone study with a prepared posterior tympanotomy, an enlarged round window approach, and additional second turn access, a stiffened device with silicone rings was inserted and extracted gradually from the second turn access until the rings were visible in the second turn access. Results Insertion and extraction of the second cochlear access were easily performed. Pulling and pushing the silicone rings through the modiolus and hidden parts of the basal turn was possible and worked like a pipe cleaner. Conclusion This newly developed tissue removal device in combination with the proposed surgical handling offers a new and less traumatic way to remove cochlear ILS.
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Thompson HL, Blanton A, Franklin B, Merker VL, Franck KH, Welling DB. Patient Report of Hearing in Neurofibromatosis Type 2: Recommendations for Clinical Trials. Neurology 2021; 97:S64-S72. [PMID: 34230203 PMCID: PMC8594003 DOI: 10.1212/wnl.0000000000012424] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 05/03/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To systematically evaluate published patient-reported outcome measures for the assessment of hearing function and hearing-related quality of life (QoL) and recommend measures selected by the Response Evaluation in Neurofibromatosis and Schwannomatosis International Collaboration (REiNS) as endpoints for clinical trials in neurofibromatosis type 2 (NF2). METHODS The REiNS Patient-Reported Outcomes Working Group systematically evaluated published patient-reported outcome measures of (1) hearing function and (2) hearing-related QoL for individuals with hearing loss of various etiologies using previously published REiNS rating procedures. Ten measures of hearing functioning and 11 measures of hearing-related QoL were reviewed. Measures were numerically scored and compared primarily on their participant characteristics (including participant age range and availability of normative data), item content, psychometric properties, and feasibility for use in clinical trials. RESULTS The Self-Assessment of Communication and the Self-Assessment of Communication-Adolescent were identified as most useful for adult and pediatric populations with NF2, respectively, for the measurement of both hearing function and hearing-related QoL. Measures were selected for their strengths in participant characteristics, item content, psychometric properties, and feasibility for use in clinical trials. CONCLUSIONS REiNS recommends the Self-Assessment of Communication adult and adolescent forms for the assessment of patient-reported hearing function and hearing-related QoL for NF2 clinical trials. Further work is needed to demonstrate the utility of these measures in evaluating pharmacologic or behavioral interventions.
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Affiliation(s)
- Heather L Thompson
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston.
| | - Ann Blanton
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Barbara Franklin
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Vanessa L Merker
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - Kevin H Franck
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
| | - D Bradley Welling
- From the Department of Communication Sciences and Disorders (H.L.T.), California State University, Sacramento; Department of Communication Disorders and Sciences (A.B.), SUNY Cortland, NY; REiNS Patient Representative for NF2 (B.F.); Department of Neurology and Cancer Center, Massachusetts General Hospital, Boston (V.L.M.); Center for Healthcare Organization and Implementation Research (CHOIR) (V.L.M.), Edith Nourse Rogers Memorial Veterans Hospital, Bedford; and Departments of Audiology (K.H.F.) and Otolaryngology and Head and Neck Surgery (D.B.W.), Massachusetts Eye and Ear Hospital and Massachusetts General Hospital, Boston
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Butler MJ, Wick CC, Shew MA, Chicoine MR, Ortmann AJ, Vance J, Buchman CA. Intraoperative Cochlear Nerve Monitoring for Vestibular Schwannoma Resection and Simultaneous Cochlear Implantation in Neurofibromatosis Type 2: A Case Series. Oper Neurosurg (Hagerstown) 2021; 21:324-331. [PMID: 34332508 DOI: 10.1093/ons/opab274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 06/06/2021] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Neurofibromatosis type 2 (NF2) often results in profound hearing loss and cochlear implantation is an emerging hearing rehabilitation option. However, cochlear implant (CI) outcomes in this population vary, and intraoperative monitoring to predict cochlear nerve viability and subsequent outcomes is not well-established. OBJECTIVE To review the use of intraoperative electrically evoked cochlear nerve monitoring in patients with NF2 simultaneous translabyrinthine (TL) vestibular schwannoma (VS) resection and cochlear implantation. METHODS A retrospective review was performed of 3 patients with NF2 that underwent simultaneous TL VS resection and cochlear implantation with electrical auditory brainstem response (eABR) measured throughout tumor resection. Patient demographics, preoperative assessments, surgical procedures, and outcomes were reviewed. RESULTS Patients 1 and 3 had a reliable eABR throughout tumor removal. Patient 2 had eABR pretumor removal, but post-tumor removal eABR presence could not be reliably determined because of electrical artifact interference. All patients achieved auditory percepts upon CI activation. Patients 1 and 2 experienced a decline in CI performance after 1 yr and after 3 mo, respectively. Patient 3 continues to perform well at 9 mo. Patients 2 and 3 are daily users of their CI. CONCLUSION Cochlear implantation is attainable in cases of NF2-associated VS resection. Intraoperative eABR may facilitate cochlear nerve preservation during tumor removal, though more data and long-term outcomes are needed to refine eABR methodology and predictive value for this population.
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Affiliation(s)
- Margaret J Butler
- Program in Audiology and Communication Sciences, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Cameron C Wick
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Matthew A Shew
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Michael R Chicoine
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Amanda J Ortmann
- Program in Audiology and Communication Sciences, Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA.,Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Janet Vance
- Saint Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Craig A Buchman
- Department of Otolaryngology - Head and Neck Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
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Dlugaiczyk J. Rare Disorders of the Vestibular Labyrinth: of Zebras, Chameleons and Wolves in Sheep's Clothing. Laryngorhinootologie 2021; 100:S1-S40. [PMID: 34352900 PMCID: PMC8363216 DOI: 10.1055/a-1349-7475] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
The differential diagnosis of vertigo syndromes is a challenging issue, as many - and in particular - rare disorders of the vestibular labyrinth can hide behind the very common symptoms of "vertigo" and "dizziness". The following article presents an overview of those rare disorders of the balance organ that are of special interest for the otorhinolaryngologist dealing with vertigo disorders. For a better orientation, these disorders are categorized as acute (AVS), episodic (EVS) and chronic vestibular syndromes (CVS) according to their clinical presentation. The main focus lies on EVS sorted by their duration and the presence/absence of triggering factors (seconds, no triggers: vestibular paroxysmia, Tumarkin attacks; seconds, sound and pressure induced: "third window" syndromes; seconds to minutes, positional: rare variants and differential diagnoses of benign paroxysmal positional vertigo; hours to days, spontaneous: intralabyrinthine schwannomas, endolymphatic sac tumors, autoimmune disorders of the inner ear). Furthermore, rare causes of AVS (inferior vestibular neuritis, otolith organ specific dysfunction, vascular labyrinthine disorders, acute bilateral vestibulopathy) and CVS (chronic bilateral vestibulopathy) are covered. In each case, special emphasis is laid on the decisive diagnostic test for the identification of the rare disease and "red flags" for potentially dangerous disorders (e. g. labyrinthine infarction/hemorrhage). Thus, this chapter may serve as a clinical companion for the otorhinolaryngologist aiding in the efficient diagnosis and treatment of rare disorders of the vestibular labyrinth.
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Affiliation(s)
- Julia Dlugaiczyk
- Klinik für Ohren-, Nasen-, Hals- und Gesichtschirurgie
& Interdisziplinäres Zentrum für Schwindel und
neurologische Sehstörungen, Universitätsspital Zürich
(USZ), Universität Zürich (UZH), Zürich,
Schweiz
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