Audiovestibular Findings in Patients with Concurrent Superior Canal Dehiscence and Vestibular Schwannoma

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.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation?

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.

A regional-based newborn hearing screening program: the Emilia-Romagna model after ten years of legislation

Background

Hearing loss, occurring in 1-3/1,000 newborns in the well-babies population, is one of the most common congenital diseases, and hearing screening at birth still represents the only means for its early detection. Since 2011 the Emilia Romagna Regional Health Agency has recommended Newborn Hearing Screening for all babies at its birth points and for newborns moving to the region. The aims of this study are to analyze the results of this regional-based Newborn Hearing Screening program and to discuss the impact of the legislative endorsement on the organization.

Material and methods

This is an observational retrospective chart study. The recordings of well-babies and babies at Neonatal Intensive Care Units were collected during the period from January 1st 2015 to December 31st 2020. The following data were included: Newborn Hearing Screening coverage, percentage of refer at otoacoustic emissions, prevalence and entity of hearing loss, unilateral/bilateral rate, presence of audiological risk factors.

Results

More than 99% of a total of 198,396 newborns underwent the Newborn Hearing Screening test during the period January 1st 2015 to December 31st 2020, with a coverage ranging between 99.6% and 99.9%. Overall, the percentage of confirmed hearing loss cases was about 17-30 % of refer cases, 745 children received a diagnosis of hearing loss (prevalence 3.7/1,000). Considering profound hearing loss cases, these represent 13% of bilateral hearing loss.

Conclusion

A regional-based Newborn Hearing Screening program is valuable and cost-effective. In our experience, the centralization of the data system and of the data control is crucial in order to implement its efficiency and effectiveness. Healthcare policies, tracking systems and public awareness are decisive for a successful programme implementation.

Infants Born Following SARS-CoV-2 Infection in Pregnancy

OBJECTIVES

To evaluate outcomes of neonates born to mothers with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection during pregnancy, the dynamics of placental transfer of maternal antibodies, and its persistence during infancy.

METHODS

Cohort study enrolling neonates born to mothers with SARS-CoV-2 infection in pregnancy. All infants were evaluated at birth. Those born to women with infection onset within 2 weeks before delivery were excluded from further analyses. Remaining infants underwent cerebral and abdominal ultrasound, fundoscopy evaluation, and were enrolled in a 12 month follow-up. Qualitative immunoglobulin G (IgG)/immunoglobulin M and quantitative IgG to S1/S2 subunits of spike protein were assessed in mother-neonate dyads within 48 hours postdelivery and during follow-up.

RESULTS

Between April 2020 and April 2021, 130 of 2745 (4.7%) neonates were born to mothers with SARS-CoV-2 infection in pregnancy, with 106 of 130 infections diagnosed before 2 weeks before delivery. Rates of preterm and cesarean delivery were comparable between women with and without infection (6% vs 8%, P = .57; 22% vs 32%, P = .06). No clinical or instrumental abnormalities were detected at birth or during follow-up. There was a positive correlation between maternal and neonatal SARS-CoV-2 IgG levels (r = 0.81, P &lt; .001). Transplacental transfer ratio was higher after second-trimester maternal infections as compared with first and third trimester (P = .03). SARS-CoV-2 IgG level progressively decreased in all infants, with 89 of 92 (97%) infants seronegative at 6 months of age.

CONCLUSIONS

Clinical outcomes were favorable in all infants. Matching peak IgG level after infection and higher IgG transplacental transfer might result in the most durable neonatal passive immunity.

The effect of superior canal dehiscence size and location on audiometric measurements, vestibular-evoked myogenic potentials and video-head impulse testing

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.

Isolated horizontal canal hypofunction differentiating a canalith jam from an acute peripheral vestibular loss

OBJECTIVES

To describe a unique case of acute vertigo presenting with spontaneous horizontal nystagmus (SHN) and a clinical picture consistent with right acute peripheral vestibular loss (APVL) in which an isolated hypofunction of a horizontal semicircular canal (HSC) permitted to detect a spontaneous canalith jam and treat the patient accordingly.

METHODS

Case report and literature review.

RESULTS

A 74-year old woman presented with acute vertigo, left-beating SHN and a clinical picture consistent with right APVL. Nevertheless, vestibular evoked myogenic potentials were normal with symmetrical amplitudes and the video head impulse test (vHIT) revealed an isolated hypofunction of the right HSC. After repeated head shakings, the supine roll test evoked bilaterally a positioning paroxysmal geotropic horizontal nystagmus suggesting benign paroxysmal positional vertigo involving the non-ampullated arm of the right HSC. vHIT and caloric testing confirmed restitution of HSC function after repositioning maneuvers.

CONCLUSIONS

In case of acute vertigo with SHN, a complete functional assessment of vestibular receptors and afferents should always be given in order to avoid misdiagnosis. Canalith jam should be considered in case of spontaneous nystagmus and isolated canal hypofunction.

Superior canal dehiscence with tegmen defect revealed by otoscopy: Video clip demonstration of pulsatile tympanic membrane

Superior canal dehiscence is a pathologic condition of the otic capsule acting as aberrant window of the inner ear. It results in reduction of inner ear impedance and in abnormal exposure of the labyrinthine neuroepithelium to the action of the surrounding structures. The sum of these phenomena leads to the onset of typical cochleo-vestibular symptoms and signs. Among them, pulsatile tinnitus has been attributed to a direct transmission of intracranial vascular activities to labyrinthine fluids. We present the first video-otoscopic documentation of spontaneous pulse-synchronous movements of the tympanic membrane in two patients with superior canal dehiscence. Pulsating eardrum may represent an additional sign of third-mobile window lesion.

Primary vascular dysregulation syndrome: Possible implications for inner ear acute diseases?

Primary vascular dysregulation syndrome has been reported as a possible cause for different eye diseases. Signs or symptoms of this syndrome not only may consist in a series of ocular disorders, as they possibly concern or are associated to various systemic conditions; even the damage of another terminal sensory organ as the inner ear is reported among the possible associations. Herein, the analogies between eye and inner ear are outlined, analyzing the PVD profile that well corresponds to our widely described model of subject without organic cardiovascular impairment but prone to inner ear acute disturbances. Actually, in absence of a recognized cause the latter can be due to a systemic dysregulation like the described one concerning ocular disorders.

Inner ear symptoms: can we use them to approach cardiovascular diseases?

Sensory organs are programmed to detect external stimuli, and inform about possible threats. In general, they are characterized by a complex architecture, a highly energy-requiring function, a peripheral location and a vascular supply depending on a terminal circulation usually under systemic control. Their function may be highly sensitive to more general disorders primarily involving other organs or physiological systems. Consequently, the onset of transient or persistent symptoms of impairment of sensory organs might be the expression of abnormalities in the integrity of more general systems, especially in the elderly population. In the otologic area, despite the availability of evidence supporting the negative impact of some systemic conditions negatively affecting the local blood supply at the labyrinth level, the possibility that the inner ear can reveal the presence of sub-clinical, non-otologic disorders has never been the topic of a constructive investigation. The present review summarizes the preliminary available evidence suggesting a possible negative impact of early systemic hemodynamic changes on the function of the inner ear, as well as the possibility that some audiological symptoms may play some role in the early detection of cardiovascular diseases. In particular, we hypothesize that some cardiovascular diseases may cause an impairment in correct labyrinthine function as a result of a negative interaction between systemic hemodynamic changes, a reflex activation of the autonomic nervous system, and a local vascular response. A multidisciplinary approach to the interpretation of inner ear disorders may increase the possibility of an earlier recognition and understanding of systemic dysfunctions in clinical practice.

Prevalence of tinnitus in patients withhypertension and the impact of different anti hypertensive drugs on the incidence of tinnitus: A prospective, single-blind, observational study

BACKGROUND

Tinnitus is a common symptom in audiology and neurologypatients. Controversial data have been reported in the literature about the prevalence of tinnitus in hypertensive patients, whereas its relationship with the extent of blood pressure (BP) control has not been substantially explored.

OBJECTIVE

The aim of this study was to determine the prevalence of tinnitus in hypertensive patients, and the impact of different antihypertensive drugs on the incidence of tinnitus in these patients.

METHODS

This prospective, single-blind, observational study was conducted at the Hypertension Clinic, St. Orsola-Malpighi Hospital, Bologna, Italy. Patients aged 18 to 75 years with uncontrolled hypertension and receiving antihypertensive therapy were enrolled. Patients were asked to complete a standardized questionnaire to assess the presence, frequency, and duration of tinnitus and the apparent effect of their antihypertensive treatment on it. Patients considered by the investigator to have tinnitus, regardless of their audiologic condition, underwent a complete clinical cardiovascular examination, including supine systolic BP (SBP) and diastolic BP measurement and standard 12-lead electrocardiography. Twelve-hour ambulatory BP monitoring was also performed, and patients were asked to record, using patient diaries, times of the onset and resolution of tinnitus that occurred during those 12 hours. From these data, correlations between the onset of tinnitus and BP were calculated.

RESULTS

A total of 476 patients participated in the study (283 men, 193 women). Of these, 84 (17.6%) patients reported occasional or prolonged spontaneous tinnitus, whereas 392 (82.4%) reported no tinnitus. The incidence of tinnitus was significantly higher in patients receiving diuretics (72/265 [27.2%]) compared with those receiving angiotensin lI receptor blockers (5/37 [13.5%]), α-blockers (12/55 [21.8%]), or 3-hydroxy-3-methylglutaryl coenzyme A reduc tase inhibitors (9/73 [12.3%]) (all, P < 0.05). Mean (SD) SBP was significantly higher in patients without tinnitus compared with those with it (143.2 [11.1 ] vs 140.6 [10.3] mm Hg; P < 0.005). In 10 (11.9%) patients with tinnitus, the onset was correlated with a sudden decrease in SBP (<140 mm Hg).

CONCLUSIONS

In this study of tinnitus in patients receiving antihypertensivetherapy, tinnitus was found in 17.6% of patients. Tinnitus was associated with the use of diuretics and with low SBP. Further studies are needed.

Ocular vestibular evoked myogenic potentials in patients with acoustic neuroma

To assess the usefulness of vestibular testing in patients with acoustic neuroma, considering two main aspects: to compare diagnostic sensitivity of the current vestibular tests, especially considering ocular vestibular evoked myogenic potentials (OVEMPs) and to identify pre-operative localization of the tumor (inferior vestibular nerve vs. superior vestibular nerve) only with the help of vestibular electrophysiological data. Twenty-six patients with unilateral acoustic neuroma (mainly intracanalicular type) were studied with a full audio-vestibular test battery (pure tone and speech audiometry, caloric bithermal test, vibration-induced nystagmus test (VIN), cervical and OVEMPs). 18 patients (69 %) showed abnormal caloric responses. 12 patients (46.2 %) showed a pattern of VIN test suggestive of vestibular asymmetry. 16 patients (61.5 %) showed abnormal OVEMPs (12 only to AC, 4 both to AC and BC). 10 patients (38.5 %) showed abnormal cervical vestibular evoked myogenic potentials (5 both to AC and BC, 5 only to AC). In one case, results of vestibular evoked potentials and caloric test were confirmed by intra-operative and post-operative findings. Results of electrophysiological tests in AN patients could be helpful for planning the proper surgical approach, considering that sensitivity of every exam is quite low in intracanalicular lesion; clinical data allow a better interpretation of vestibular evoked myogenic potentials.

Do signs of natural plugging of superior semicircular canal dehiscence exist?

Our experience with 102 patients having superior semicircular canal dehiscence confirm that the clinical manifestations of the disease are very diverse; we also identified 3 patients who showed Meniere-like symptoms. Clinical examination during an acute vertigo attack of a patient with Meniere disease for several years and whom we subsequently diagnosed as having large superior semicircular canal dehiscence on the affected side allowed us to hypothesize that a natural plugging of the superior semicircular canal by the overhanging dura mater could be responsible for the recurrence of symptoms. Clinical and instrumental data were very similar to those recorded in 7 of 9 patients immediately after surgical plugging. The aim of the study was to understand which semiological and instrumental elements could be clinically useful, first in distinguishing Meniere disease from superior semicircular canal dehiscence and, secondly, in understanding if signs of natural plugging are present.

Tinnitus in elderly patients and prognosis of mild-to-moderate congestive heart failure: a cross-sectional study with a long-term extension of the clinical follow-up

BACKGROUND

The complex mechanism responsible for tinnitus, a symptom highly prevalent in elderly patients, could involve an impaired control of the microcirculation of the inner ear, particularly in patients with poor blood pressure control and impaired left ventricular (LV) function.

METHODS

In order to define the relationship between the presence of tinnitus and the severity and clinical prognosis of mild-to-moderate chronic heart failure (CHF) in a large population of elderly patients (N = 958), a cross-sectional study was conducted with a long-term extension of the clinical follow-up. Blood pressure, echocardiographic parameters, brain natriuretic peptide (BNP), hospitalization, and mortality for CHF were measured. Multivariate logistic regression analysis was used to assess the association between the presence of tinnitus and some of the prognostic determinants of heart failure.

RESULTS

The presence of tinnitus was ascertained in 233 patients (24.3%; mean age 74.9 ± 6 years) and was associated with reduced systolic and diastolic blood pressure (123.1 ± 16/67.8 ± 9 vs 125.9 ± 15/69.7 ± 9; P = .027/P = .006), reduced LV ejection fraction (LVEF%; 43.6 ± 15 vs 47.9 ± 14%, P = .001), and increased BNP plasma levels (413.1 ± 480 vs 286.2 ± 357, P = .013) in comparison to patients without symptoms. The distribution of CHF functional class was shifted toward a greater severity of the disease in patients with tinnitus. Combined one-year mortality and hospitalization for CHF (events/year) was 1.43 ± 0.2 in patients with tinnitus and 0.83 ± 0.1 in patients without tinnitus, with an adjusted hazard ratio (HR) of 0.61 (95% confidence interval (CI): 0.37 to 0.93, P <.002).

CONCLUSIONS

Our preliminary data indirectly support the hypothesis that tinnitus is associated with a worse CHF control in elderly patients and can have some important clinical implications for the early identification of patients who deserve a more aggressive management of CHF.

Meniere's disease and the use of proton pump inhibitors

PRINCIPLES

On the basis of previous observations we examined the possibility of a favourable effect of proton pump inhibitors (PPI) on Meniere's disease (MD). A preliminary step was made by retrospectively analysing the number of menieric crisis in group of patients suffering from MD and using PPI for other reasons as compared to a group of menieric subjects who had never used PPI.

METHODS

Between January 2001 and December 2006, 42 patients affected by MD were examined in the tertiary referral centre at the University Hospital of Bologna, Italy and in the private office of an ENT specialist in Cassino, Italy. Within the study group, 18 patients had used PPI for various reasons for at least 12 consecutive months, whilst 24 patients had never been prescribed them. We recorded the number of menieric crises reported in the observation period. The mean follow-up period was 21.9 months. Statistical analysis was performed by means of the x2 test and significance was defined when p<0.05.

RESULTS

Most of MD patients (72%) using PPI suffered less than one episode of menieric crisis/year. On the other hand patients who had never used a PPI, experienced considerably more episodes only 16.7% having less than one crisis per year. This difference was statistically significant (p<0, 001).

CONCLUSIONS

Even taking the limitations of this retrospective study into account the reported data nevertheless strongly suggest a possible role for proton pumps in the pathogenesis of MD. This could lead to interesting developments and contribute to a better definition of MD and the therapeutic possibilities.

Meniere's disease: update of etiopathogenetic theories and proposal of a possible model of explanation

Meniere's Disease (MD) is an affection consisting of an association of sensorineural hearing loss, tinnitus and vertigo initially presenting by crises. A review of the most considered possible causative factors and pathophysiologic interpretations allows us to underline the uncertainties which still exist about the genesis of this illness. We propose a mechanistic model based on the effect of a haemodynamic imbalance leading to transient ischaemia which could have an effect on the pH of the inner ear as well as on the work of the inner ear proton pumps. It is hypothesized that under ischaemic conditions and consequent metabolic acidity a preserved proton pump activity can generate an overload of anions in the endolymphatic partition, which is a closed system, thus resulting in an enhancement of osmolarity and consequently in the formation of a hydrops resulting in the development of fluctuating hearing loss, tinnitus and vertigo which characterize Meniere's Disease.

Langerhans cell histiocytosis: bilateral temporal bone involvement in an adult with diabetes insipidus

OBJECTIVE

To present a clinical case of an adult affected by Langerhans cell histiocytosis with bilateral, non-simultaneous, involvement of the temporal bone, associated with diabetes insipidus and to review the literature.

METHODOLOGY

A rare case of bilateral temporal bone involvement of Langerhans cell histiocytosis in a 42-year-old woman affected by diabetes insipidus is reported. We present patient's clinical history supported by radiologic, histopathologic and audiologic findings.

RESULTS

The patient was submitted to a series of otologic surgical procedures due to the progression of the disease. Ossicular chain was always preserved, so that conservative surgery (canal wall-up technique) was performed, permitting the achievement of good hearing results, bilaterally.

CONCLUSIONS

Temporal bone involvement of Langerhans cell histiocytosis may lead to a progressive chronic disease. However, the ossicular chain can remain uninvolved, making a conservative surgical treatment possible. Careful follow-up is essential for detecting new lesions and serial CT scans are mandatory.

Tinnitus as a warning for preventing vasovagal syncope

It has been widely outlined by our group the possibility that a sufferance of the inner ear can take place as a consequence of hemodynamic imbalance which could affect young and healthy people and recognize a merely functional origin. As reported in previous papers, an altered reaction of the autonomic nervous system could actually jeopardize the labyrinthine perfusion even in absence of other damages. From this standpoint, the hypothesis that a hyperactivity of the vagal response to an acute sympathetic drive may result in an inner ear sufferance deserves to be explored. A mechanism which appears to fit to this model is represented by the Bezold-Jarisch reflex (BJR), which is considered to be responsible for vasovagal syncope and is characterized by a dynamic reasonably compatible with our findings. According to these premises, especially considering that the inner ear has a less active protective mechanism against ischemia as compared to brain, in predisposed subjects tinnitus, when considered as an initial symptom of inner ear hypoperfusion, can represent a warning able to prevent the lack of consciousness related to the syncope.

Otoscopic examination: a diagnostic contribution for atherosclerotic disease?

Tympanosclerosis is a particular kind of chronic inflammatory response of the middle ear to mechanical injuries and/or infections. This condition is characterised by the formation of plaques presenting ultrastructural analogies with the atherosclerotic lesions, extended to the tympanic membrane and possibly to the ossicular chain. The less severe degree of tympanosclerosis is represented by asymptomatic and clinically unsignificant whitish plaques within the tympanic membrane, detectable at otoscopy. The pathogenesis of this phenomenon is supposed to present a tight relationship with the pathogenesis of atherosclerosis. This observation has been already reported in medical literature, but deserves further clinical confirmations to better define the real extent of the analogies of both affections. A practical implication of this matter of study could be the possibility to find out a fast and non-invasive test as an early marker of an increased risk of atherosclerotic disease: could otoscopy play such a role?

Could echocardiography yield a cardiovascular profile of the tinnitus prone subject?

The possible genesis of some damage of the inner ear from a hemodynamic imbalance of functional origin, possibly linked to hypotension followed by an abnormal vasomotor regulatory activity, has been pointed out by our group over the years. As tinnitus, which is often referable to an inner ear origin, can represent a signal of incoming sufferance of the organ of Corti and may not necessarily be linked to hearing impairment, it seemed of some utility to investigate on the prevalence of tinnitus under various well monitored hemodynamic conditions. This led to observe that the prevalence of this symptom, regardless of audiological features, was increased under "aggressive" antihypertensive therapy as well as in particularly severe degree of heart decompensation. These data represent a first step and encourage in searching for a profile of subject who could be more prone to the development of tinnitus with respect to the normal population, even in absence of pathological conditions. With this aim, echocardiography is thought to be able to yield useful informations in addition to standard and ambulatory blood pressure monitoring, in order to obtain a better definition of the correlations between cardiovascular function (and related changes) and inner ear insufficient perfusion.

Superior semicircular canal dehiscence: a series of 13 cases

Increasingly more detailed imaging techniques have recently highlighted the frequent occurrence of bony labyrinthine dehiscence. Among them, superior canal dehiscence (SCD) has been described in a number of cases presenting different features. Here, we report a series of 13 cases, in which the detection of vestibular evoked myogenic potentials (VEMPs) in response to stimuli of abnormally low intensity as compared to normal responses led us to suspect the presence of a 'third window effect'. An accurate HRCT investigation allowed the diagnosis of SCD. Anamnestic and symptomatologic differences seem difficult to explain, although in our opinion a dural rupture could be at the basis of the onset of pathologic manifestations after many years of silence of a probably malformative condition.

Could vestibular evoked myogenic potentials (VEMPs) also be useful in the diagnosis of perilymphatic fistula?

The role of vestibular evoked myogenic potentials (VEMPs) is at this time indisputable in the study of vestibular disorders. Furthermore, VEMPs are widely accepted as a diagnostic tool when a superior semicircular canal dehiscence (SCD) is suspected, presenting in such cases a lowering of threshold values able to raise a recordable response due to increased inner ear immittance. According to the same principle, the possibility of another kind of alteration having the same effect on the inner ear might be considered when high-resolution computed tomography has excluded the presence of an SCD. In this paper four cases are described in which high-resolution computed tomography showed normal features without any labyrinthine dehiscence and VEMP threshold values were lowered; the appropriateness of suspecting a perilymphatic fistula in such cases and resorting to VEMPs in detecting a perilymphatic fistula is discussed.

Is there a role for atrial peptides in the labyrinthine “disease”?

The important role of atrial natriuretic peptides (ANP) in regulating blood pressure and changing vascular permeability has been widely studied and assessed during the last ten years. Considering the characteristics of this mechanism, which is responsible for a hypotensive and hypovolemic effect, and the possible role of hypotension associated with a default of autoregulatory sympathetic reactions in inner ear unexplained disorders, it seems reasonable to hypothesize a possible involvement of ANP system in the genesis of such disorders. As a matter of fact, the presence of specific receptors for ANP in the inner ear has been widely reported in studies concerning both rat and human inner ear, although their precise role in the labyrinthine homeostasis has not been satisfactory explained until now. Some aspects concerning vascular and fluid regulation of the inner ear under different conditions still remain not totally clear, and consequently a detailed explanation to the possible mechanism causing inner ear disorders of functional origin is lacking; from this point of view, an investigation on the serum level of ANP in subjects with labyrinthine affections of uncertain origin could be of some utility in contributing to assess the role of this system in the inner ear fluid regulation and in the inner ear perfusion and to investigate on the possible influence of an abnormal ANP release in some kind of inner ear damage.

Is tinnitus useful in early detection of incoming heart decompensation?

In previous studies the possibility of a mechanism of hemodynamic imbalance consequent to a sharp decrease in blood pressure causing a more or less transient inner ear impairment was evaluated and to some extent demonstrated. In this scenario, tinnitus is very frequently present as a debilitating symptom associated to cochlear impairment. On the other hand, a possible cause of a sharp decrease in blood pressure is represented by major cardiovascular disorders, requiring an early assessment in order to avoid fatal consequences. In this paper, the hypothesis of resorting to tinnitus as a simple warning method for self detecting a possibly incoming cardiovascular imbalance in patients with heart failure (HF) is advanced.

Sudden sensorineural hearing loss in lupus erythematosus associated with antiphospholipid syndrome: case report and review

Systemic lupus erythematosus is a disease of unknown cause that manifests with tissue and cellular alterations due to the deposition of antibodies and pathogenic immune complexes. The disease can be associated with anticardiolipin antibody syndrome, a disorder of recurrent vascular thrombosis and thrombocytopenia associated with a persistent anticardiolipin test positivity. In this report, we describe the case of a young woman affected by lupus erythematosus and positive for anticardiolipin antibodies who was brought to our observation for a sudden sensorineural hearing loss in the right ear. The patient was successfully treated with osmotic therapy and, 13 months after the initial symptom, is now in good clinical condition with no recurrence of the hearing loss and normal bilateral hearing. Together with a critical review of the pertinent literature, this rare clinical case led us to formulate some original comments.

Bilateral Dehiscence of the Bony Cochlear Basal Turn

OBJECTIVE

To identify bony labyrinth defects as causing symptoms that might otherwise be difficult to understand.

DESIGN

Imaging investigation on cases of lowered vestibular evoked myogenic potentials (VEMP) threshold.

SETTING

Academic tertiary case-referral medical center.

PATIENTS

One patient with continuous bilateral tinnitus.

INTERVENTIONS

High-resolution computed tomography of petrous bone was performed after audiometry, impedance, and VEMP recording.

RESULTS

We found a previously unreported dehiscence of the bony plate between the basal turn of the cochlea and the carotid canal.

CONCLUSIONS

A VEMP study could prompt diagnostic imaging tests that might otherwise be neglected. Moreover, it is important to consider the possibility of a bony dehiscence involving not just the semicircular canals.

[Cisplatin and carboplatin-induced ototoxicity in children: clinical aspects and perspectives for prevention]

In 70% of the cases of malignant neoplasms in pediatric patients antiblast therapy is used. The administration of platinum compounds, Cisplatin (CDDP) or Carboplatin (CBDCA), often at high cumulative doses, necessarily implies a certain degree of toxicity which normally takes on secondary significance in the healing of the child. Among the side effects, early and delayed ototoxicity is well known and, in the child, take on particular aspects. While not abandoning the treatment of the base pathology, the therapeutic findings, increasingly comforting in terms of long-term survival, require more accurate evaluation and overall control of the quality of life of these young patients. Since initial cochlear damage can be reversible, auditory function must be carefully monitored in order to prevent the lesions from becoming permanent, in particular prior to the onset of speech. For this reason a retrospective study was made of a group of 26 children affected by malignant neoplasms all of whom had undergone a polychemotherapy protocol with the administration of CDDP in 14 cases and CBDCA in 12 cases. All these young patients were monitored with conventional audiometry. The presence of different variables (antiblastic drug administration schedule, course of the disease, general conditions) only permitted evaluation of a single correlation: between auditory function at the end of the treatment (or after a few cycles of therapy) and the overall dose of CDDP or CBDCA administered. In 16 cases (62%) typical bilateral perceptive deafness was detected progressively involving the hyperacute and acute frequencies. The finding of hearing loss was significantly greater in the patients treated with CDDP (86%) vs. those treated with CBDCA (33%). Moreover, analysis of the results showed that, within certain limits, ototoxicity can depend more on individual sensitivity to the drug than to the total dose administered. The results confirm the well-known ototoxicity of platinum compounds, in particular CDDP. As ever improved therapeutic results are achieved in the treatment of malignant neoplasms in pediatric patients, greater attention can be paid to the quality of life of these young patients after the disease has been healed. Careful monitoring of auditory function can be extremely important in the pursuit this objective; indeed, this makes it possible to adjust antiblast drug administration, particularly in the later stages of treatment, customizing the treatment schedule to individual patient sensitivity.