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Shi S, Li W, Wang D, Ren T, Wang W. Characteristics of clinical details and endolymphatic hydrops in unilateral and bilateral Ménière's disease in a single Asian group. Front Neurol 2022; 13:964217. [PMID: 36176561 PMCID: PMC9513353 DOI: 10.3389/fneur.2022.964217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 07/25/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesTo elucidate the characteristics of the clinical details and endolymphatic hydrops (EH) in bilateral Ménière's disease (BMD).MethodsA total of 545 patients with definite MD were enrolled. Demographic variables; the age of onset; disease course; inner ear function; the coexistence of related disorders such as migraine, delayed MD, drop attacks, and autoimmune diseases; familial history; and characteristics of EH were analyzed.ResultsIn the study population, the prevalence of BMD was 15.4%. The disease duration of BMD (84.0 ± 89.6 months) was significantly longer than that of unilateral MD (UMD, 60.1 ± 94.0 months) (P = 0.001). As evaluated by hearing thresholds and cervical and ocular vestibular evoked myogenic potentials, inner ear functions were more deteriorated in BMD (P < 0.05) than in UMD. The proportions of delayed MD and a family history of vertigo were significantly larger in BMD (P < 0.05). EH was observed in 100% of cases on the clinically affected side and 6.1% of cases on the unaffected side.ConclusionA low prevalence of BMD, longer disease duration, higher frequencies of delayed MD, and family history of vertigo in patients with BMD were significant findings observed in the present study. All affected ears presented with EH, and a low percentage of unaffected sides presented with EH.
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Affiliation(s)
- Suming Shi
- ENT Institute and Otorhinolaryngology Department, Eye & ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, China
| | - Wenquan Li
- Department of Otolaryngology, The Second Affiliated Hospital of Soochow University, Soochow, China
| | - Dan Wang
- ENT Institute and Otorhinolaryngology Department, Eye & ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, China
| | - Tongli Ren
- ENT Institute and Otorhinolaryngology Department, Eye & ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, China
| | - Wuqing Wang
- ENT Institute and Otorhinolaryngology Department, Eye & ENT Hospital of Fudan University, Shanghai, China
- NHC Key Laboratory of Hearing Medicine, Fudan University, Shanghai, China
- *Correspondence: Wuqing Wang
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Selleck AM, Dillon M, Perkins E, Brown KD. Cochlear Implantation in the Setting of Menière's Disease After Labyrinthectomy: A Meta-Analysis. Otol Neurotol 2021; 42:e973-e979. [PMID: 34049331 DOI: 10.1097/mao.0000000000003200] [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] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Characterize the speech recognition and sound source localization of patients with unilateral Menière's disease who undergo labyrinthectomy for vertigo control with simultaneous or sequential cochlear implantation. DATABASES REVIEWED PubMed, Embase, and Cochrane databases. METHODS The search was performed on May 6, 2020. The keywords utilized included: "Menière's disease AND cochlear implant;" "cochlear implant AND single sided deafness;" "cochlear implant AND vestibular;" and "labyrinthectomy AND cochlear implant." Manuscripts published in English with a publication date after 1995 that assessed adult subjects (≥18 years of age) were included for review. Subjects must have been diagnosed with Menière's disease unilaterally and underwent labyrinthectomy with simultaneous or sequential cochlear implantation. Reported outcomes with cochlear implant (CI) use included speech recognition as measured with the consonant-nucleus-consonant (CNC) word test and/or sound source localization reported in root-mean squared (RMS) error. The method of data collection and study type were recorded to assess level of evidence. Statistical analysis was performed with Wilcoxon signed ranks test. RESULTS Data from 14 CI recipients met the criteria for inclusion. Word recognition comparisons between the preoperative interval and a postactivation interval demonstrated a significant improvement with the CI (p = 0.014), with an average improvement of 23% (range -16 to 50%). Sound source localization postoperatively with the CI demonstrated an average RMS error of 26° (SD 6.8, range 18.7-43.1°) compared to the 42° (SD 19.1, range 18-85°) in the preoperative or CI off condition, these two conditions were not statistically different (p = 0.148). CONCLUSION Cochlear implantation and labyrinthectomy in adult patients with Menière's disease can support improvements in speech recognition and sound source localization for some CI users, though observed performance may be poorer than traditional CI candidates.
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Affiliation(s)
- Anne Morgan Selleck
- Department of Otolaryngology, Head and Neck Surgery, University of North Carolina at Chapel Hill, North Carolina
| | - Margaret Dillon
- Department of Otolaryngology, Head and Neck Surgery, University of North Carolina at Chapel Hill, North Carolina
| | - Elizabeth Perkins
- Department of Otolaryngology, Head and Neck Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin D Brown
- Department of Otolaryngology, Head and Neck Surgery, University of North Carolina at Chapel Hill, North Carolina
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Bächinger D, Schuknecht B, Dlugaiczyk J, Eckhard AH. Radiological Configuration of the Vestibular Aqueduct Predicts Bilateral Progression in Meniere's Disease. Front Neurol 2021; 12:674170. [PMID: 34168610 PMCID: PMC8217812 DOI: 10.3389/fneur.2021.674170] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2021] [Accepted: 04/13/2021] [Indexed: 11/18/2022] Open
Abstract
Objective: Meniere's disease (MD) progresses from unilateral to bilateral disease in up to 50% of patients, often chronically and severely impairing balance and hearing functions. According to previous studies, 91% of bilateral MD patients demonstrate bilateral hypoplasia of the endolymphatic sac (ES) upon histological and radiological examination of their inner ears. Here, we seek to validate a radiological marker for ES hypoplasia that predicts the risk for future progression to bilateral MD in individual patients. Methods: Patients with unilateral MD and radiological evidence for ES hypoplasia in either the clinically affected inner ear (cohort MDuni-hpuni) or both inner ears (cohort MDuni-hpbi) were included. Given our hypothesis that ES hypoplasia critically predisposes the inner ear to MD, we expected progression to bilateral MD only in the MDuni-hpbi cohort. To investigate eventual progression to bilateral MD, clinical, audiometric, and imaging data were retrospectively collected over follow-up periods of up to 31 years. Results: A total of 44 patients were included in the MD-hpuni (n = 15) and MDuni-hpbi (n = 29) cohorts. In line with our radiology-based predictions, none (0/15) of the MD-hpuni patients exhibited progression to bilateral MD, whereas 20/29 (69%) MD-hpbi patients have already progressed to bilateral MD. Using the Kaplan–Meier estimator, bilateral disease progression would be observed in 100% of MD-hpbi patients 31 years after the initial diagnosis with an estimated median time to bilateral progression of 12 years. The nine MD-hpbi patients who, so far, remained with unilateral disease demonstrated a median time since initial (unilateral) MD diagnosis of only 6 years and are thus still expected to progress to bilateral disease. Conclusion: Progression to bilateral MD adheres to predictions based on the radiological presence or absence of ES hypoplasia. This prognostic tool, if validated by prospective long-term studies, will provide clinically relevant information about a patient's future disease burden and will help to select more personalized treatment regimens.
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Affiliation(s)
- David Bächinger
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | | | - Julia Dlugaiczyk
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
| | - Andreas H Eckhard
- Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Zurich, Zurich, Switzerland.,University of Zurich, Zurich, Switzerland
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Suh MJ, Jeong J, Kim HJ, Jung J, Kim SH. Clinical Characteristics of Bilateral Meniere's Disease in a Single Asian Ethnic Group. Laryngoscope 2018; 129:1191-1196. [PMID: 30284277 DOI: 10.1002/lary.27423] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/12/2018] [Indexed: 01/21/2023]
Abstract
OBJECTIVES/HYPOTHESIS To identify the clinical characteristics of patients with bilateral Meniere's disease (MD) in an Asian population. STUDY DESIGN Cross-sectional retrospective study. METHODS We compared the clinical features of bilateral MD (BMD) and unilateral MD (UMD) in 320 Asian patients with single ethnicity. Demographic variables; age of onset; inner ear function; the coexistence of related disorders such as vestibular migraine, delayed MD, systemic autoimmune diseases, and familial MD; and prognoses were analyzed and compared. RESULTS The overall prevalence of BMD was 5.6%. The mean age of disease onset was 40.3 ± 14.8 and 47.0 ± 14.1 years for patients with BMD and UMD, respectively (P = .07). Demographic variables were not significantly different between patients with BMD and UMD (P > .05). Inner ear function, evaluated by hearing thresholds, caloric tests, and cervical vestibular evoked myogenic potentials, was significantly more deteriorated in the first involved ear of patients with BMD than in the second involved ear or the affected side of patients with UMD (P < .05). Among the comorbid conditions, only the prevalence of delayed MD was significantly higher in patients with BMD than in patients with UMD. Systemic autoimmune disease was found in only three patients with UMD. There was no significant prognostic difference between patients with UMD and BMD (P > .05). CONCLUSIONS A low prevalence of BMD, a higher frequency of delayed MD in BMD patients, and a low frequency of systemic autoimmune diseases in both UMD and BMD patients are significant findings in an Asian population. LEVEL OF EVIDENCE 4 Laryngoscope, 129:1191-1196, 2019.
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Affiliation(s)
- Michelle J Suh
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Junhui Jeong
- Department of Otorhinolaryngology, National Health Insurance Service Ilsan Hospital, Goyang, South Korea
| | - Hyun Ji Kim
- Department of Otorhinolaryngology, Inha University College of Medicine, Incheon, South Korea
| | - Jinsei Jung
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea
| | - Sung Huhn Kim
- Department of Otorhinolaryngology, Yonsei University College of Medicine, Seoul, South Korea.,Airway Mucus Institute, Yonsei University College of Medicine, Seoul, South Korea
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MORENO-BRAVO A, SÁNCHEZ-GÓMEZ H, AGUILERA-AGUILERA GA, GONZÁLEZ-SÁNCHEZ M, SANTA CRUZ-RUIZ S, BATUECAS-CALETRÍO Á. Implante coclear en enfermedad de Ménière bilateral. Descripción de un caso. REVISTA ORL 2017. [DOI: 10.14201/orl201674.14699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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Cochlear implantation in patients with definite Meniere's disease. Eur Arch Otorhinolaryngol 2016; 274:751-756. [PMID: 27783138 DOI: 10.1007/s00405-016-4356-z] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2016] [Accepted: 10/20/2016] [Indexed: 10/20/2022]
Abstract
The exact pathomechanism of deafening in Meniere's disease (MD) is still unknown; intoxication of hair cells and neural damage from endolymphatic hydrops is discussed. In the literature, there are only a few reports on hearing outcome of MD patients after treatment with cochlear implantation (CI) whereby especially the comparison of MD vs. non-MD patients with CI differs. In this retrospective study, results in speech understanding [Freiburger Einsilber (FES65) and Hochmair-Schulz-Moser test in quiet (HSM) and in noise (HSM + 10 dB)] of 27 implanted MD patients were collected and compared to a matched standard CI cohort. Alternative diagnoses were excluded as far as possible by re-analyzing neuroradiologic imaging. After first fitting, MD patients showed significantly better results in FES and HSM testing compared to controls. At 1-year refitting, this effect could not be seen anymore. To conclude, cochlear implantation is a safe and effective treatment for deafness in MD patients. Results in speech understanding are at least equal compared to general CI recipients. To the best of our knowledge, this retrospective study examined the largest collective of CI users deafened by MD so far.
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Abstract
BACKGROUND/OBJECTIVES Ménière's disease (MD) that results in bilateral severe to profound sensorineural hearing loss is a rare indication for cochlear implantation; only a few studies exist documenting performance in these patients. The primary objective was to compare the difference in preoperative to 12-month postoperative speech perception scores among subjects with MD and controls. Groupwise comparisons of secondary postoperative outcomes (Tinnitus Handicap Inventory [THI] scores, 36-Item Short Form [SF-36] scores, and postoperative dizziness) were also performed. METHODS A retrospective cohort study was conducted. Subjects with MD and controls matched by age, device manufacturer and model, preoperative sentence score, and sentence test used for preimplantation and postimplantation performance assessments were identified from 1,130 patients in the prospectively maintained cochlear implant database at our center. Speech perception, THI, and SF-36 scores and demographic variables were obtained from the database. Vestibular outcomes were obtained by retrospective chart review. Statistical comparisons were performed to compare preoperative to postoperative change between groups. RESULTS Twenty patients with MD were identified. At 1 year after CI, improvements in sentence and word understanding did not differ in magnitude from the controls. Tinnitus was reduced significantly in patients with MD, whereas there was a trend for improvement in the controls. Quality of life as measured by the SF-36 improved in both groups. Patients with MD had significant improvements in 1 domain compared with 5 domains for the controls. Subjects with MD had significantly more chronic dizziness in the postoperative period than did controls. CONCLUSIONS Patients with MD who have bilateral severe to profound sensorineural hearing loss benefit significantly from CI. Ongoing dizziness in some patients with MD may result in quality of life improvements that are slightly less than seen for the average adult patient with CI. Larger studies are needed to corroborate the results.
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Belinchon A, Perez-Garrigues H, Tenias JM. Evolution of symptoms in Ménière's disease. Audiol Neurootol 2011; 17:126-32. [PMID: 21985844 DOI: 10.1159/000331945] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2011] [Accepted: 08/13/2011] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To investigate the sequence and correlation of symptoms of Ménière's disease (MD) depending on their order of manifestation. METHODS Descriptive, longitudinal study of the symptoms in 237 tertiary hospital patients who had been diagnosed with definite MD according to the criteria of the American Academy of Otolaryngology. Patients were followed for 1-31 years. RESULTS Disease began with the three classic symptoms in only 40% of the patients. We recorded the mean, median and maximum time needed to complete the symptoms as well as the time elapsed in some patients from disease onset in one ear to bilateral involvement. CONCLUSIONS We reckon that this study may be of great help in ruling out a diagnosis of MD when the patient presents with only one or two symptoms of the triad. Furthermore, regarding the planning of treatment, the time interval between unilateral and bilateral involvement (5-7 years) is very important since bilateral involvement has great repercussions on treatment, especially surgical treatment.
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Affiliation(s)
- Antonio Belinchon
- Department of Otorhinolaryngology, Complejo Hospitalario Universitario Albacete, Albacete, Spain.
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Dispenza F, De Stefano A, Flanagan S, Romano G, Sanna M. Decision Making for Solitary Vestibular Schwannoma and Contralateral Meniere’s Disease. Audiol Neurootol 2007; 13:53-7. [PMID: 17848792 DOI: 10.1159/000108109] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Accepted: 06/01/2007] [Indexed: 11/19/2022] Open
Abstract
The existence of dual inner ear pathology such as unilateral Meniere's disease (MD) with a contralateral vestibular schwannoma (VS) is very rare, but provides the otologist with a significant management dilemma. In this study, we present 5 cases of unilateral disabling MD with a contralateral VS in the better hearing ear. Conservative management of the VS is mandated unless there are impending complications, with management directed toward controlling the vertigo attributed to MD. If and when the VS requires intervention, or the hearing in that ear deteriorates to unserviceable levels, cochlear implant of the ear affected by MD prior to addressing the VS provides optimal management.
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Affiliation(s)
- Francesco Dispenza
- Dipartimento di Scienze Otorinolaringoiatriche, Università degli Studi di Palermo, Palermo, Italia.
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House JW, Doherty JK, Fisher LM, Derebery MJ, Berliner KI. Meniere's Disease: Prevalence of Contralateral Ear Involvement. Otol Neurotol 2006; 27:355-61. [PMID: 16639274 DOI: 10.1097/00129492-200604000-00011] [Citation(s) in RCA: 92] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Determine the prevalence and time interval for conversion from unilateral to bilateral involvement in Meniere's disease and cochlear hydrops. STUDY DESIGN AND SETTING Retrospective chart review in a tertiary otologic referral center. PATIENTS 232 patients diagnosed with Meniere's Disease (n=186) or cochlear hydrops (n=46) between 1959 and 2001, who visited the clinic over a five-year period between 1997-2001 and have at least 2 audiograms more than 12 months apart. MAIN OUTCOME MEASURES Prevalence of cochlear hydrops relative to Meniere's Disease, rate of progression from unilateral to bilateral involvement; interval between unilateral onset of symptoms and bilateral involvement; and rate of progression from cochlear hydrops to Meniere's disease. RESULTS Initial diagnosis was Meniere's disease in 71% and cochlear hydrops in 29% of all 950 hydropic patients presenting between 1997 and 2001. In the study sample, Meniere's disease was bilateral at presentation in 11%; an additional 12% (14% of unilaterals) became bilateral during the follow-up period. At presentation, 6.5% of cochlear hydrops patients were bilateral, with another 26% becoming bilateral. Conversion from cochlear hydrops to Meniere's disease occurred in 33% and some of these are included among the bilateral. The average time interval for conversion from unilateral to bilateral Meniere's was 7.6 years (SD=7.0 years). CONCLUSION Most otologists are aware of the potential for contralateral ear involvement and conversion from cochlear hydrops to Meniere's disease after diagnosis. These changes are significant, require long-term follow-up for detection, and may necessitate further treatment. Patients should be counseled regarding this potential when interventions are considered, especially with respect to ablative treatments.
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Affiliation(s)
- John W House
- House Clinic and House Ear Institute, Clinical Studies Department, Los Angeles, CA 90057, USA.
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Lustig LR, Yeagle J, Niparko JK, Minor LB. Cochlear implantation in patients with bilateral Ménière's syndrome. Otol Neurotol 2003; 24:397-403. [PMID: 12806291 DOI: 10.1097/00129492-200305000-00009] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the indications and clinical outcomes (audiologic and vestibular) in patients with Ménière's syndrome who have undergone cochlear implantation. STUDY DESIGN This is a retrospective review of patients at a large tertiary academic medical center. PATIENTS Nine patients were included in the study with AAO-HNS criteria for diagnosis of Ménière's syndrome as well as bilateral severe to profound sensorineural hearing loss as an indication for undergoing cochlear implantation. Audiologic criteria for implantation were considered in the context of speech recognition performance with well-fit, powerful hearing aids noting large fluctuations in performance levels in some patients. In all cases, the poorer hearing ear was implanted. Seven subjects had bilateral disease and had progressed to profound sensorineural hearing loss. The average age of the patients was 61 years. Six patients had undergone previous surgery to control vertigo, including endolymphatic shunt surgery and vestibular nerve section. No patient had received previous treatment with intra-tympanic gentamicin. Symptoms of Ménière's syndrome had been present in all patients for at least 10 years before implantation. INTERVENTION Cochlear Implantation. MAIN OUTCOME MEASURES Pre- and Postoperative audiometric scores (monosyllable words/phonemes, Central Institute for the Deaf (CID) sentences, Hearing in Noise Test (HINT) in quite/noise (+10 db)), pre- and postoperative vestibular symptoms (number of vestibular attacks, aural fullness, tinnitus). RESULTS Follow-up after implantation ranged from 1 to 5 years. Average 6 month postimplantation scores were: monosyllable words/phonemes = 52%/65%, CID sentences = 82%, HINT in quiet/noise = 70%/50%. Average 1-year postimplant scores were: monosyllable words/phonemes = 60%/76%, CID sentences = 97%, HINT in quiet/noise = 89%/78%. Postoperative speech recognition scores were, on average, substantially greater than preoperative scores. While there were few complications associated with implantation, some patients experienced alterations in their implant performance in association with fluctuations in vestibular symptoms. CONCLUSIONS Patients with advanced binaural involvement with Ménière's Disease may present a challenge to conventional criteria for cochlear implant candidacy because of fluctuating symptoms. We observed significant benefit over baseline in a consecutive series of patients with Ménière's syndrome who progressed to bilateral, severe-to-profound sensorineural hearing loss and underwent cochlear implantation. Further, previous vestibular surgery, including labyrinthectomy, does not contraindicate cochlear implantation.
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Affiliation(s)
- Lawrence R Lustig
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins University, Baltimore, Maryland 21287, USA.
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Abrol R, Nehru VI, Venkatramana Y. Prevalence and etiology of vertigo in adult rural population. Indian J Otolaryngol Head Neck Surg 2001; 53:32-6. [PMID: 23119748 PMCID: PMC3450865 DOI: 10.1007/bf02910976] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
A survey on 10.000 adults between the age of 20 and 79 years out of a total population of 66.186 persons in rural settlements under the inrisduction of Union Territory of Chandigarh between June 1993 to June 1995 was conducted to find out the prevalence and various causes of vertigo. In general community, in rural population, we found that more people suffer from non-otologic vertigo rather than otologic vertigo. We found overall prevalence of vertigo in rural adult community to be 0.71%. Vertigo secondary to cardiovascular disease was most common and prevalent in 0.32% of population. Neurologic disease accounted for vertigo in 0.14%, metabolic disease in 0.09% and otologic disease 0.08%. Miscellaneous disorders were present in remaining 0.08% of population studied. To the best of our knowledge this study represents the first population based survey of prevalence of various causes of vertigo in general community in adult rural population.
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Affiliation(s)
- R Abrol
- Dept. of ENT, Post Graduate Institute of Medical Education and Research, Sector-12, 160012 Chandigarh, India
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