The acute vestibular syndrome: prevalence of new hearing loss and its diagnostic value

OBJECTIVES

To assess the prevalence of new hearing losses in patients with acute vestibular syndrome (AVS) and to start to evaluate its diagnostic value for the differentiation between peripheral and central causes.

DESIGN

We performed a cross-sectional prospective study in AVS patients presenting to our Emergency Department (ED) from February 2015 to November 2020. All patients received an MRI, Head-impulse test, Nystagmus test and Test of skew ('HINTS'), caloric testing and a pure-tone audiometry.

RESULTS

We assessed 71 AVS patients, 17 of whom had a central and 54 a peripheral cause of dizziness. 12.7% had an objective hearing loss. 'HINTS' had an accuracy of 78.9% to diagnose stroke, whereas 'HINTS' plus audiometry 73.2%. 'HINTS' sensitivity was 82.4% and specificity 77.8% compared to 'HINTS' plus audiometry showing a sensitivity of 82.4% and specificity of 70.4%. The four patients with stroke and minor stroke had all central 'HINTS'. 55% of the patients did not perceive their new unilateral hearing loss.

CONCLUSIONS

We found that almost one-eighth of the AVS patients had a new onset of hearing loss and only half had self-reported it. 'HINTS' plus audiometry proved to be less accurate to diagnose a central cause than 'HINTS' alone. Audiometry offered little diagnostic accuracy to detect strokes in the ED but might be useful to objectify a new hearing loss that was underestimated in the acute phase. Complete hearing loss should be considered a red flag, as three in four patients suffered from a central cause.

The value of saccade metrics and VOR gain in detecting a vestibular stroke

OBJECTIVE

A normal video Head Impulse Test is the gold standard in the emergency department to rule-in patients with an acute vestibular syndrome and a stroke. We aimed to compare the diagnostic accuracy of vHIT metrics regarding the vestibulo-ocular reflex gain and the corrective saccades in detecting vestibular strokes.

METHODS

Prospective cross-sectional study (convenience sample) of patients presenting with acute vestibular syndrome in the emergency department of a tertiary referral centre between February 2015 and May 2020. We screened 1677 patients and enrolled 76 patients fulfilling the inclusion criteria of acute vestibular syndrome. All patients underwent video head impulse test with automated and manual data analysis. A delayed MRI served as a gold standard for vestibular stroke confirmation.

RESULTS

Out of 76 patients, 52 were diagnosed with acute unilateral vestibulopathy and 24 with vestibular strokes. The overall accuracy of detecting stroke with an automated vestibulo-ocular reflex gain was 86.8%, compared to 77.6% for cumulative saccade amplitude and automatic saccade mean peak velocity measured by an expert and 71% for cumulative saccade amplitude and saccade mean peak velocity measured automatically. Gain misclassified 13.1% of the patients as false positive or false negative, manual cumulative saccade amplitude and saccade mean peak velocity 22.3%, and automated cumulative saccade amplitude and saccade mean peak velocity 28.9% respectively.

CONCLUSIONS

We found a better accuracy of video head impulse test for the diagnosis of vestibular strokes when using the vestibulo-ocular reflex gain than using saccade metrics. Nevertheless, saccades provide an additional and important information for video head impulse test evaluation. The automated saccade detection algorithm is not yet perfect compared to expert analysis, but it may become a valuable tool for future non-expert video head impulse test evaluations.

Comparison of auditory brainstem response and electrocochleography to assess the coupling efficiency of active middle ear implants

Aim

This study aimed to compare the effectiveness of auditory brainstem response (ABR) and extracochlear electrocochleography (ECochG) in objectively evaluating the coupling efficiency of floating mass transducer (FMT) placement during active middle ear implant (AMEI) surgery.

Methods

We enrolled 15 patients (mean age 58.5 ± 19.4 years) with mixed hearing loss who underwent AMEI implantation (seven ossicular chain and eight round window couplings). Before the surgical procedure, an audiogram was performed. We utilized a clinical measurement system to stimulate and record intraoperative ABR and ECochG recordings. The coupling efficiency of the VSB was evaluated through ECochG and ABR threshold measurements. Postoperatively, we conducted an audiogram and a vibrogram.

Results

In all 15 patients, ABR threshold testing successfully determined intraoperative coupling efficiency, while ECochG was successful in only eight patients. In our cohort, ABR measurements were more practical, consistent, and robust than ECochG measurements. Coupling efficiency, calculated as the difference between vibrogram thresholds and postoperative bone conduction thresholds, was found to be more accurately predicted by ABR measurements (p = 0.016, R2 = 0.37) than ECochG measurements (p = 0.761, R2 = 0.02). We also found a non-significant trend toward better results with ossicular chain coupling compared to round window coupling.

Conclusion

Our findings suggest that ABR measurements are more practical, robust, and consistent than ECochG measurements for determining coupling efficiency during FMT placement surgery. The use of ABR measurements can help to identify the optimal FMT placement, especially with round window coupling. Finally, we offer normative data for both techniques, which can aid other clinical centers in using intraoperative monitoring for AMEI placement.

Wall Shear Stress and Pressure Fluctuations under Oscillating Stimulation in Helical Square Ducts with Cochlea-like Geometrical Curvature and Torsion. Annu Int Conf IEEE Eng Med Biol Soc 2023;2023:1-7. [PMID: 38083665 DOI: 10.1109/embc40787.2023.10340844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0]

Our study aims to provide basic insights on the impact of the spiral shape of the cochlea, i.e., of geometric torsion and curvature, on wall pressure and wall shear stress. We employed computational fluid dynamics in square duct models with curvature and torsion similar to those found in human cochleae. The results include wall pressures and wall shear stresses within the ducts under oscillating axial flow. Our findings indicate that the helical shape generates higher transverse wall shear stresses compared to exclusively curved or twisted ducts. The wall pressures and transverse wall shear stresses we found rise to amounts that may be physiologically relevant in the cochlea.Clinical relevance- The role of the spiral shape of the cochlea in hearing physiology remains, for a large part, elusive. For a better apprehension of hearing and its disorders, it is important to investigate the influence of geometric properties on biofluids motion and emerging phenomena in the cochlea.

Vestibular syndromes, diagnosis and diagnostic errors in patients with dizziness presenting to the emergency department: a cross-sectional study

OBJECTIVES

We aimed to determine the frequency of vestibular syndromes, diagnoses, diagnostic errors and resources used in patients with dizziness in the emergency department (ED).

DESIGN

Retrospective cross-sectional study.

SETTING

Tertiary referral hospital.

PARTICIPANTS

Adult patients presenting with dizziness.

PRIMARY AND SECONDARY OUTCOME MEASURES

We collected clinical data from the initial ED report from July 2015 to August 2020 and compared them with the follow-up report if available. We calculated the prevalence of vestibular syndromes and stroke prevalence in patients with dizziness. Vestibular syndromes are differentiated in acute (AVS) (eg, stroke, vestibular neuritis), episodic (EVS) (eg, benign paroxysmal positional vertigo, transient ischaemic attack) and chronic (CVS) (eg, persistent postural-perceptual dizziness) vestibular syndrome. We reported the rate of diagnostic errors using the follow-up diagnosis as the reference standard.

RESULTS

We included 1535 patients with dizziness. 19.7% (303) of the patients presented with AVS, 34.7% (533) with EVS, 4.6% (71) with CVS and 40.9% (628) with no or unclassifiable vestibular syndrome. The three most frequent diagnoses were stroke/minor stroke (10.1%, 155), benign paroxysmal positional vertigo (9.8%, 150) and vestibular neuritis (9.6%, 148). Among patients with AVS, 25.4% (77) had stroke. The cause of the dizziness remained unknown in 45.0% (692) and 18.0% received a false diagnosis. There was a follow-up in 662 cases (43.1%) and 58.2% with an initially unknown diagnoses received a final diagnosis. Overall, 69.9% of all 1535 patients with dizziness received neuroimaging (MRI 58.2%, CT 11.6%) in the ED.

CONCLUSIONS

One-fourth of patients with dizziness in the ED presented with AVS with a high prevalence (10%) of vestibular strokes. EVS was more frequent; however, the rate of undiagnosed patients with dizziness and the number of patients receiving neuroimaging were high. Almost half of them still remained without diagnosis and among those diagnosed were often misclassified. Many unclear cases of vertigo could be diagnostically clarified after a follow-up visit.

Measuring the Influence of Magnetic Vestibular Stimulation on Nystagmus, Self-Motion Perception, and Cognitive Performance in a 7T MRT

Strong magnetic fields induce dizziness, vertigo, and nystagmus due to Lorentz forces acting on the cupula in the semi-circular canals, an effect called magnetic vestibular stimulation (MVS). In this article, we present an experimental setup in a 7T MRT scanner (MRI scanner) that allows the investigation of the influence of strong magnetic fields on nystagmus as well as perceptual and cognitive responses. The strength of MVS is manipulated by altering the head positions of the participants. The orientation of the participants' semicircular canals with respect to the static magnetic field is assessed by combining a 3D magnetometer and 3D constructive interference in steady-state (3D-CISS) images. This approach allows to account for intra- and inter-individual differences in participants' responses to MVS. In the future, MVS can be useful for clinical research, for example, in the investigation of compensatory processes in vestibular disorders. Furthermore, it could foster insights into the interplay between vestibular information and cognitive processes in terms of spatial cognition and the emergence of self-motion percepts under conflicting sensory information. In fMRI studies, MVS can elicit a possible confounding effect, especially in tasks influenced by vestibular information or in studies comparing vestibular patients with healthy controls.

Artificial intelligence for early stroke diagnosis in acute vestibular syndrome

Objective

Measuring the Vestibular-Ocular-Reflex (VOR) gains with the video head impulse test (vHIT) allows for accurate discrimination between peripheral and central causes of acute vestibular syndrome (AVS). In this study, we sought to investigate whether the accuracy of artificial intelligence (AI) based vestibular stroke classification applied in unprocessed vHIT data is comparable to VOR gain classification.

Methods

We performed a prospective study from July 2015 until April 2020 on all patients presenting at the emergency department (ED) with signs of an AVS. The patients underwent vHIT followed by a delayed MRI, which served as a gold standard for stroke confirmation. The MRI ground truth labels were then applied to train a recurrent neural network (long short-term memory architecture) that used eye- and head velocity time series extracted from the vHIT examinations.

Results

We assessed 57 AVS patients, 39 acute unilateral vestibulopathy patients (AUVP) and 18 stroke patients. The overall sensitivity, specificity and accuracy for detecting stroke with a VOR gain cut-off of 0.57 was 88.8, 92.3, and 91.2%, respectively. The trained neural network was able to classify strokes with a sensitivity of 87.7%, a specificity of 88.4%, and an accuracy of 87.9% based on the unprocessed vHIT data. The accuracy of these two methods was not significantly different (p = 0.09).

Conclusion

AI can accurately diagnose a vestibular stroke by using unprocessed vHIT time series. The quantification of eye- and head movements with the use of machine learning and AI can serve in the future for an automated diagnosis in ED patients with acute dizziness. The application of different neural network architectures can potentially further improve performance and enable direct inference from raw video recordings.

Videooculography “HINTS” in Acute Vestibular Syndrome: A Prospective Study

Objective

A three-step bedside test (“HINTS”: Head Impulse-Nystagmus-Test of Skew), is a well-established way to differentiate peripheral from central causes in patients with acute vestibular syndrome (AVS). Nowadays, the use of videooculography gives physicians the possibility to quantify all eye movements. The goal of this study is to compare the accuracy of VOG “HINTS” (vHINTS) to an expert evaluation.

Methods

We performed a prospective study from July 2015 to April 2020 on all patients presenting at the emergency department with signs of AVS. All the patients underwent clinical HINTS (cHINTS) and vHINTS followed by delayed MRI, which served as a gold standard for stroke confirmation.

Results

We assessed 46 patients with AVS, 35 patients with acute unilateral vestibulopathy, and 11 patients with stroke. The overall accuracy of vHINTS in detecting a central pathology was 94.2% with 100% sensitivity and 88.9% specificity. Experts, however, assessed cHINTS with a lower accuracy of 88.3%, 90.9% sensitivity, and 85.7% specificity. The agreement between clinical and video head impulse tests was good, whereas for nystagmus direction was fair.

Conclusions

vHINTS proved to be very accurate in detecting strokes in patients AVS, with 9% points better sensitivity than the expert. The evaluation of nystagmus direction was the most difficult part of HINTS.

Multicenter Results With an Active Transcutaneous Bone Conduction Implant in Patients With Single-sided Deafness

OBJECTIVE

To evaluate the audiological and subjective benefit from hearing rehabilitation with an active bone conduction implant in subjects with single-sided sensorineural deafness (SSD).

STUDY DESIGN

Prospective, multicenter, single-subject repeated measures.

SETTING

Tertiary referral center, five clinics in Germany and Switzerland.

PATIENTS

Seventeen subjects aged 18 years and older with severe to profound unilateral sensorineural hearing loss and contralateral normal hearing were followed up for 24 months.

INTERVENTION

Active bone conduction implant.

MAIN OUTCOME MEASURES

Speech understanding in noise was assessed in three situations: with signal from front, deaf, or normal hearing side (with noise from front in all set-ups). Subjective benefit was evaluated using the Speech, Spatial, and Qualities of Hearing (SSQ-B) and Bern Benefit in Single-Sided Deafness (BBSS) questionnaire.

RESULTS

When the signal was coming from the deaf side the mean improvement of the speech reception threshold in noise ranged from 1.5 up to 2.2 dB with the device and was statistically and clinically significant at all tested timepoints. No significant difference between the aided and unaided situation was found when signal and noise were coming from the front. With the signal from the normal hearing side no clinically significant difference, that is, greater than 1 dB between the aided and unaided situation was found. The SSQ-B and BBSS questionnaire showed an overall improvement with no significant difference between time points.

CONCLUSIONS

The study demonstrates long-term efficacy and benefit of the device in adults with SSD. Patients reported substantial and persistent subjective benefit from the active bone conduction implant.

Influence of head orientation and implantation site of a novel transcutaneous bone conduction implant on MRI metal artifact reduction sequence

Purpose

The use of magnetic resonance imaging (MRI) is often limited in patients with auditory implants because of the presence of metallic components and magnets. The aim of this study was to evaluate the clinical usefulness of a customized MRI sequence for metal artifact suppression in patients with BONEBRIDGETM BCI 602 implants (MED-EL, Innsbruck, Austria), the successor of the BCI 601 model.

Methods

Using our in-house developed and customized metal artifact reduction sequence (SEMAC-VAT WARP), MRI artifacts were evaluated qualitatively and quantitatively. MRI sequences were performed with and without artifact reduction on two whole head specimens with and without the BCI 602 implant. In addition, the influence of two different implantation sites (mastoid versus retrosigmoid) and head orientation on artifact presence was investigated.

Results

Artifact volume was reduced by more than the 50%. Results were comparable with those obtained with the BCI 601, showing no significant differences in the dimensions of artifacts caused by the implant.

Conclusion

SEMAC-VAT WARP was once more proved to be efficient at reducing metal artifacts on MR images. The dimensions of artifacts associated with the BCI 602 are not smaller than those caused by the BCI 601.

Endoscopic and Robotic Stapes Surgery: Review with Emphasis on Recent Surgical Refinements

Purpose of Review

Stapes surgery has been established as the gold standard for surgical treatment of conductive hearing loss in otosclerosis. Excellent outcomes with very low complication rate are reported for this surgery. Recent advances to improve surgical outcome have modified the surgical technique with endoscopes, and recent studies report development of robotical assistance. This article reviews the use of endoscopes and robotical assistance for stapes surgery.

Recent Findings

While different robotic models have been developed, 2 models for stapes surgery have been used in the clinical setting. These can be used concomitant to an endoscope or microscope. Endoscopes are used on a regular base regarding stapes surgery with similar outcomes as microscopes. Endoscopic stapes surgery shows similar audiological results to microscopic technique with an advantage of less postoperative dysgeusia and pain. Its utility in cases of revision surgery or malformation is emphasized.

Summary

Endoscopic stapes surgery is used on a regular basis with excellent outcomes similar to the microscopic approach, while reducing surgical morbidity. Robotic technology is increasingly being developed in the experimental setting, and first applications are reported in its clinical use.

Bruns' nystagmus revisited: A sign of stroke in patients with the acute vestibular syndrome

Objective

Gaze‐evoked nystagmus (GEN) is a central sign in patients with the acute vestibular syndrome (AVS); however, discriminating between a pathological and a physiologic GEN is a challenge. Here we evaluate GEN in patients with AVS.

Methods

In this prospective cross‐sectional study, we used video‐oculography (VOG) to compare GEN in the light (target at 15° eccentric) in 64 healthy subjects with 47 patients seen in the emergency department (ED) who had AVS; 35 with vestibular neuritis and 12 with stroke. All patients with an initial non‐diagnostic MRI received a confirmatory, delayed MRI as a reference standard in detecting stroke.

Results

Healthy subjects with GEN had a time constant of centripetal drift >18 s. VOG identified pathologic GEN (time constant ≤ 18 s) in 33% of patients with vestibular strokes, specificity was 100%, accuracy was 83%. Results were equivalent to examination by a clinical expert. As expected, since all patients with GEN had a SN in straight‐ahead position, they showed the pattern of a Bruns’ nystagmus.

Conclusions

One third of patients with AVS due to central vestibular strokes had a spontaneous SN in straight‐ahead gaze and a pathological GEN, producing the pattern of a Bruns’ nystagmus with a shift of the null position. The localization of the side of the lesion based on the null was not consistent, presumably because the circuits underlying gaze‐holding are widespread in the brainstem and cerebellum. Nevertheless, automated quantification of GEN with VOG was specific, and accurately identified patients in the ED with AVS due to strokes.

Paradigm shift in acute dizziness: is caloric testing obsolete?

Objective

Cold and warm water ear irrigation, also known as bithermal caloric testing, has been considered for over 100 years the ‘Gold Standard’ for the detection of peripheral vestibular hypofunction. Its discovery was awarded a Nobel Prize. We aimed to investigate the diagnostic accuracy of Caloric Testing when compared to the video head impulse test (vHIT) in differentiating between vestibular neuritis and vestibular strokes in acute dizziness.

Design

Prospective cross-sectional study (convenience sample).

Setting

All patients presenting with signs of an acute vestibular syndrome at the emergency department of a tertiary referral center.

Participants

One thousand, six hundred seventy-seven patients were screened between February 2015 and May 2020 for Acute Vestibular Syndrome (AVS), of which 152 met the inclusion criteria and were enrolled. Inclusion criteria consisted of a state of continuous dizziness, associated with nausea or vomiting, head-motion intolerance, new gait or balance disturbance and nystagmus. Patients were excluded if they were younger than 18 years, if symptoms lasted < 24 h or if the index ED visit was > 72 h after symptom onset. Of the 152 included patients 85 completed testing. We assessed 58 vestibular neuritis and 27 stroke patients.

Main outcome measures

All patients underwent calorics and vHIT followed by a delayed MRI which served as a gold standard for vestibular stroke confirmation.

Results

The overall sensitivity and specificity for detecting stroke with a caloric asymmetry cut-off of 30.9% was 75% and 86.8%, respectively [negative likelihood ratio (NLR) 0.29] compared to 91.7% and 88.7% for vHIT (NLR 0.094). Best VOR gain cut-off was 0.685. Twenty-five percent of vestibular strokes were misclassified by calorics, 8% by vHIT.

Conclusions

Caloric testing proved to be less accurate than vHIT in discriminating stroke from vestibular neuritis in acute dizziness. Contrary to classic teaching, asymmetric caloric responses can also occur with vestibular strokes and might put the patient at risk for misdiagnosis. We, therefore, recommend to abandon caloric testing in current practice and to replace it with vHIT in the acute setting. Caloric testing has still its place as a diagnostic tool in an outpatient setting.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00415-021-10667-7.

Impaired fixation suppression of horizontal vestibular nystagmus during smooth pursuit: pathophysiology and clinical implications

Background and purpose

A peripheral spontaneous nystagmus (SN) is typically enhanced or revealed by removing fixation. Conversely, failure of fixation suppression of SN is usually a sign of a central disorder. Based on Luebke and Robinson (Vision Res 1988, vol. 28 (8), pp. 941–946), who suggested that the normal fixation mechanism is disengaged during pursuit, it is hypothesized that vertical tracking in the light would bring out or enhance a horizontal SN.

Methods

Eighteen patients with acute vestibular neuritis were studied. Eye movements were recorded using video‐oculography at straight‐ahead gaze with and without visual fixation, and during smooth pursuit. The slow‐phase velocity and the fixation suppression indices of nystagmus (relative to SN in darkness) were compared in each condition.

Results

During vertical tracking, the slow‐phase velocity of horizontal SN with eyes near straight‐ahead gaze was significantly higher (median 2.7°/s) than under static visual fixation (median 1.2°/s). Likewise, the fixation index was significantly higher (worse suppression) during pursuit (median 48%) than during fixation (median 26%). A release of SN was also suggested during horizontal pursuit, if one assumes superposition of SN on a normal and symmetrical pursuit capability.

[Cough from an allergological as well as from the ENT aspect]

Cough from an allergological as well as from the ENT aspect Abstract. Cough is a common problem in the allergological, but less so in the rhinological consultation. The differential diagnostic spectrum for cough is extensive and may range from rhinitis and asthma to eosinophilic esophagitis and rarer diseases. In the case of chronic cough (> 2 months), the four most frequent causes must be sought, or be excluded (upper airway cough syndrome, asthma [cough-variant-asthma], non-asthmatic eosinophilic bronchitis, gastroesophageal reflux disease). Aeroallergens such as pollen, house-dust mites or occupational substances play a major role in allergies. Nevertheless, it is not uncommon for cough to be a main symptom of an antibody deficiency or a Sicca symptom complex. The more chronic the cough, the more thoroughly an investigation is indicated - often interdisciplinary. Therapy depends on the cause of the cough. In allergic respiratory diseases, allergy-specific immunotherapy may be indicated.

Two-phase survey on the frequency of use and safety of MRI for hearing implant recipients

PURPOSE

Magnetic resonance imaging (MRI) is often used to visualize and diagnose soft tissues. Hearing implant (HI) recipients are likely to require at least one MRI scan during their lifetime. However, the MRI scanner can interact with the implant magnet, resulting in complications for the HI recipient. This survey, which was conducted in two phases, aimed to evaluate the safety and performance of MRI scans for individuals with a HI manufactured by MED-EL (MED-EL GmbH, Innsbruck, Austria).

METHODS

A survey was developed and distributed in two phases to HEARRING clinics to obtain information about the use of MRI for recipients of MED-EL devices. Phase 1 focused on how often MRI is used in diagnostic imaging of the head region of the cochlear implant (CI) recipients. Phase 2 collected safety information about MRI scans performed on HI recipients.

RESULTS

106 of the 126 MRI scans reported in this survey were performed at a field strength of 1.5 T, on HI recipients who wore the SYNCHRONY CI or SYNCHRONY ABI. The head and spine were the most frequently imaged regions. 123 of the 126 scans were performed without any complications; two HI recipients experienced discomfort/pain. One recipient required reimplantation after an MRI was performed using a scanner that had not been approved for that implant. There was only one case that required surgical removal of the implant to reduce the imaging artefact.

CONCLUSION

Individuals with either a SYNCHRONY CI or SYNCHRONY ABI from MED-EL can safely undergo a 1.5 T MRI when it is performed according to the manufacturer's safety policies and procedures.

Traumatic dislocation of middle ear ossicles: A new computed tomography classification predicting hearing outcome

Objectives

To assess the feasibility of radiologic measurements and find out whether hearing outcome could be predicted based on computer tomography (CT) scan evaluation in patients with temporal bone fractures and suspected ossicular joint dislocation.

Methods

We assessed 4002 temporal bone CT scans and identified 34 patients with reported ossicular joint dislocation due to trauma. We excluded those with no proven traumatic ossicular dislocation in CT scan and patients with bilateral temporal bone fractures. We measured four parameters such as malleus-incus axis distance, malleus-incus angle at midpoints, malleus- incus axis angle and ossicular joint space. The contralateral healthy side served as its own control. Hearing outcome 1–3 months after the index visit was analyzed. We assessed diagnostic accuracy and performed a logistic regression using radiologic measurement parameters for outcome prediction of conductive hearing loss (defined as >20dB air-bone gap).

Results

We found excellent inter-rater agreement on the measurement of axis deviation between incus and malleus in CT scans (interclass correlation coefficient 0.81). The larger the deviation of incus and malleus axis, the higher probability of poor hearing outcome (odds ratio (OR) 2.67 per 0.1mm, p = .006). A cut-off value for the axis deviation of 0.25mm showed a sensitivity of 0.778 and a specificity of 0.94 (p < .001) for discrimination between poor and good hearing outcome in terms of conductive hearing loss.

Conclusion

Adequate assessment of high resolution CT scans of temporal bone in which ossicular chain dislocation had occurred after trauma was feasible. Axis deviations of the incus and the malleus were strongly predictive for poor hearing outcome in terms of air conduction 1–3 months after trauma. We propose a 3-level classification system for hearing outcome prediction based on radiologic measures.

Alexander's Law During High-Speed, Yaw-Axis Rotation: Adaptation or Saturation?

Objective: Alexander's law (AL) states the intensity of nystagmus increases when gaze is toward the direction of the quick phase. What might be its cause? A gaze-holding neural integrator (NI) that becomes imperfect as the result of an adaptive process, or saturation in the discharge of neurons in the vestibular nuclei? Methods: We induced nystagmus in normal subjects using a rapid chair acceleration around the yaw (vertical) axis to a constant velocity of 200°/second [s] and then, 90 s later, a sudden stop to induce post-rotatory nystagmus (PRN). Subjects alternated gaze every 2 s between flashing LEDs (right/left or up/down). We calculated the change in slow-phase velocity (ΔSPV) between right and left gaze when the lateral semicircular canals (SCC) were primarily stimulated (head upright) or, with the head tilted to the side, stimulating the vertical and lateral SCC together. Results: During PRN AL occurred for horizontal eye movements with the head upright and for both horizontal and vertical components of eye movements with the head tilted. AL was apparent within just a few seconds of the chair stopping when peak SPV of PRN was reached. When slow-phase velocity of PRN faded into the range of 6-18°/s AL could no longer be demonstrated. Conclusions: Our results support the idea that AL is produced by asymmetrical responses within the vestibular nuclei impairing the NI, and not by an adaptive response that develops over time. AL was related to the predicted plane of eye rotations in the orbit based on the pattern of SCC activation.

VOR gain calculation methods in video head impulse recordings

BACKGROUND: International consensus on best practices for calculating and reporting vestibular function is lacking. Quantitative vestibulo-ocular reflex (VOR) gain using a video head impulse test (HIT) device can be calculated by various methods. OBJECTIVE: To compare different gain calculation methods and to analyze interactions between artifacts and calculation methods. METHODS: We analyzed 1300 horizontal HIT traces from 26 patients with acute vestibular syndrome and calculated the ratio between eye and head velocity at specific time points (40 ms, 60 ms) after HIT onset (‘velocity gain’), ratio of velocity slopes (‘regression gain’), and ratio of area under the curves after de-saccading (‘position gain’). RESULTS: There was no mean difference between gain at 60 ms and position gain, both showing a significant correlation (r2 = 0.77, p < 0.001) for artifact-free recordings. All artifacts reduced high, normal-range gains modestly (range –0.06 to –0.11). The impact on abnormal, low gains was variable (depending on the artifact type) compared to artifact-free recordings. CONCLUSIONS: There is no clear superiority of a single gain calculation method for video HIT testing. Artifacts cause small but significant reductions of measured VOR gains in HITs with higher, normal-range gains, regardless of calculation method. Artifacts in abnormal HITs with low gain increased measurement noise. A larger number of HITs should be performed to confirm abnormal results, regardless of calculation method.

[Dizziness and vertigo in a tertiary ENT emergency department]

BACKGROUND

Although vestibular symptoms are amongst the most frequent reasons for seeking emergency medical help, many patients remain undiagnosed.

OBJECTIVE

In this cross-sectional study, we investigated the spectrum of vertigo and dizziness in a tertiary ear, nose, and throat (ENT) emergency department (ED). Furthermore, we investigated the attendant symptoms, clinical signs, and the diagnostic tests performed.

METHODS

We screened all ED reports from 01/2013 to 12/2013 for adult patients with vestibular symptoms referred to the ENT department.

RESULTS

In total, we found 2596 cases with reported vestibular symptoms in the ED as a main or accompanying complaint. Of these, 286 were referred to the ENT specialist directly (n = 98) or via other major medical specialties (n = 188). Benign paroxysmal positional vertigo (BPPV) was the most frequent diagnosis in our study (n = 46, 16.1%), followed by vestibular neuritis (n = 44, 15.4%), otitis media (n = 20, 7%), and 9 patients (3.1%) had an ischemic stroke or a transient ischemic attack. In 70 (24.5%) cases, dizziness was not further specified.

CONCLUSION

BPPV is the most frequent diagnosis seen in the ED; however, physicians need to document nystagmus more precisely and perform diagnostic tests systematically, in order to make an accurate diagnosis. To avoid misdiagnoses, ED physicians and ENT specialists should be able to recognize central signs in patients with an acute vestibular syndrome. Every fourth patient does not receive a definitive diagnosis. Diagnostic ED workup for patients with dizziness needs further improvement.

Sinus floor elevation or referral for further diagnosis and therapy: A comparison of maxillary sinus assessment by ENT specialists and dentists using cone beam computed tomography

OBJECTIVES

To compare ear, nose, and throat (ENT) specialists and dentists assessing health or pathology of maxillary sinuses using cone beam computed tomography (CBCT).

MATERIAL AND METHODS

Two ENT specialists and two oral surgeons assessed 100 CBCT datasets of healthy patients referred for dental implant placement in the posterior maxilla and decided on the possibility of sinus floor elevation or the necessity for further diagnostic examinations based solely on radiographic findings. Inter-rater agreements within the same specialty were calculated with Cohen's kappa and overall agreements with Fleiss kappa, and factors influencing the decisions taken were evaluated using regression analyses.

RESULTS

The correlation between all four raters was generally fair to moderate. The intra-specialty comparison showed a lower correlation between dentists than between ENT specialists. Absence of membrane thickening and total or subtotal sinus opacification showed the highest predictive value for a consensus in favor of sinus floor elevation and ENT referral, respectively. Flat membrane thickening with an irregular surface morphology was associated with disagreement between the examiners. Dome-shaped membrane thickenings were often considered as to be referred by dentists but not by ENTs.

CONCLUSION

The assessment of maxillary sinuses using CBCT imaging exhibited unsatisfactory agreement between ENT specialists and oral surgeons. Referral guidelines based on accidental CBCT findings that aim to diagnose relevant sinus pathologies early and avoid unnecessary diagnostics and/or therapies are needed, and an initial proposal for such recommendations is provided. Further research on correct interpretation of sinus findings and a validation of the present recommendations are required.

Targeting the MET Receptor Tyrosine Kinase as a Strategy for Radiosensitization in Locoregionally Advanced Head and Neck Squamous Cell Carcinoma

Radiotherapy (RT) along with surgery is the mainstay of treatment in head and neck squamous cell carcinoma (HNSCC). Radioresistance represents a major source of treatment failure, underlining the urgent necessity to explore and implement effective radiosensitization strategies. The MET receptor widely participates in the acquisition and maintenance of an aggressive phenotype in HNSCC and modulates the DNA damage response following ionizing radiation (IR). Here, we assessed MET expression and mutation status in primary and metastatic lesions within a cohort of patients with advanced HNSCC. Moreover, we investigated the radiosensitization potential of the MET inhibitor tepotinib in a panel of cell lines, in vitro and in vivo, as well as in ex vivo patient-derived organotypic tissue cultures (OTC). MET was highly expressed in 62.4% of primary tumors and in 53.6% of lymph node metastases (LNM), and in 6 of 9 evaluated cell lines. MET expression in primaries and LNMs was significantly associated with decreased disease control in univariate survival analyses. Tepotinib abrogated MET phosphorylation and to distinct extent MET downstream signaling. Pretreatment with tepotinib resulted in variable radiosensitization, enhanced DNA damage, cell death, and G₂-M-phase arrest. Combination of tepotinib with IR led to significant radiosensitization in one of two tested in vivo models. OTCs revealed differential patterns of response toward tepotinib, irradiation, and combination of both modalities. The molecular basis of tepotinib-mediated radiosensitization was studied by a CyTOF-based single-cell mass cytometry approach, which uncovered that MET inhibition modulated PI3K activity in cells radiosensitized by tepotinib but not in the resistant ones.

Minimal Reporting Standards for Active Middle Ear Hearing Implants

There is currently no standardized method for reporting audiological, surgical and subjective outcome measures in clinical trials with active middle ear implants (AMEIs). It is often difficult to compare studies due to data incompatibility and to perform meta-analyses across different centres is almost impossible. A committee of ENT and audiological experts from Germany, Austria and Switzerland decided to address this issue by developing new minimal standards for reporting the outcomes of AMEI clinical trials. The consensus presented here aims to provide a recommendation to enable better inter-study comparability.

Comprehensive Genomic Profiling of Patient-matched Head and Neck Cancer Cells: A Preclinical Pipeline for Metastatic and Recurrent Disease

Metastases and tumor recurrence have a major prognostic impact in head and neck squamous cell carcinoma (HNSCC); however, cellular models that comprehensively characterize metastatic and recurrent HNSCC are lacking. To this end, we obtained genomic, transcriptomic, and copy number profiles of the UM-SCC cell line panel, encompassing patient-matched metastatic and recurrent cells. UM-SCC cells recapitulate the most prevalent genomic alterations described in HNSCC, featuring common TP53, PI3K, NOTCH, and Hippo pathway mutations. This analysis identified a novel F977Y kinase domain PIK3CA mutation exclusively present in a recurrent cell line (UM-SCC14B), potentially conferring resistance to PI3K inhibitors. Small proline-rich protein 2A (SPRR2A), a protein involved in epithelial homeostasis and invasion, was one of the most consistently downregulated transcripts in metastatic and recurrent UM-SCC cells. Assessment of SPRR2A protein expression in a clinical cohort of patients with HNSCC confirmed common SPRR2A downregulation in primary tumors (61.9% of cases) and lymph node metastases (31.3%), but not in normal tissue. High expression of SPRR2A in lymph node metastases was, along with nonoropharyngeal location of the primary tumor, an independent prognostic factor for regional disease recurrence after surgery and radiotherapy (HR 2.81; 95% CI, 1.16-6.79; P = 0.02). These results suggest that SPRR2A plays a dual role in invasion and therapeutic resistance in HNSCC, respectively through its downregulation and overexpression. IMPLICATIONS: The current study reveals translationally relevant mechanisms underlying metastasis and recurrence in HNSCC and represents an adjuvant tool for preclinical research in this disease setting. Underlining its discovery potential this approach identified a PIK3CA-resistant mutation as well as SPRR2A as possible theragnostic markers.

Cognitive Rehabilitation in Bilateral Vestibular Patients: A Computational Perspective

There is evidence that vestibular sensory processing affects, and is affected by, higher cognitive processes. This is highly relevant from a clinical perspective, where there is evidence for cognitive impairments in patients with peripheral vestibular deficits. The vestibular system performs complex probabilistic computations, and we claim that understanding these is important for investigating interactions between vestibular processing and cognition. Furthermore, this will aid our understanding of patients’ self-motion perception and will provide useful information for clinical interventions. We propose that cognitive training is a promising way to alleviate the debilitating symptoms of patients with complete bilateral vestibular loss (BVP), who often fail to show improvement when relying solely on conventional treatment methods. We present a probabilistic model capable of processing vestibular sensory data during both passive and active self-motion. Crucially, in our model, knowledge from multiple sources, including higher-level cognition, can be used to predict head motion. This is the entry point for cognitive interventions. Despite the loss of sensory input, the processing circuitry in BVP patients is still intact, and they can still perceive self-motion when the movement is self-generated. We provide computer simulations illustrating self-motion perception of BVP patients. Cognitive training may lead to more accurate and confident predictions, which result in decreased weighting of sensory input, and thus improved self-motion perception. Using our model, we show the possible impact of cognitive interventions to help vestibular rehabilitation in patients with BVP.

Electrical Impedance to Assess Facial Nerve Proximity During Robotic Cochlear Implantation

Reported studies pertaining to needle guidance suggest that tissue impedance available from neuromonitoring systems can be used to discriminate nerve tissue proximity. In this pilot study, the existence of a relationship between intraoperative electrical impedance and tissue density, estimated from computer tomography (CT) images, is evaluated in the mastoid bone of in vivo sheep. In five subjects, nine trajectories were drilled using an image-guided surgical robot. Per trajectory, five measurement points near the facial nerve were accessed and electrical impedance was measured (≤1 KHz) using a multipolar electrode probe. Micro-CT was used postoperatively to measure the distances from the drilled trajectories to the facial nerve. Tissue density was determined from coregistered preoperative CT images and, following sensitivity field modeling of the measuring tip, tissue resistivity was calculated. The relationship between impedance and density was determined for 29 trajectories passing or intersecting the facial nerve. A monotonic decrease in impedance magnitude was observed in all trajectories with a drill axis intersecting the facial nerve. Mean tissue densities intersecting with the facial nerve (971-1161 HU) were different (p <0.01) from those along safe trajectories passing the nerve (1194-1449 HU). However, mean resistivity values of trajectories intersecting the facial nerve (14-24 Ωm) were similar to those of safe passing trajectories (17-23 Ωm). The determined relationship between tissue density and electrical impedance during neuromonitoring of the facial nerve suggests that impedance spectroscopy may be used to increase the accuracy of tissue discrimination, and ultimately improve nerve safety distance assessment in the future.

Impaired math achievement in patients with acute vestibular neuritis

Broad cognitive difficulties have been reported in patients with peripheral vestibular deficit, especially in the domain of spatial cognition. Processing and manipulating numbers relies on the ability to use the inherent spatial features of numbers. It is thus conceivable that patients with acute peripheral vestibular deficit show impaired numerical cognition. Using the number Stroop task and a short math achievement test, we tested 20 patients with acute vestibular neuritis and 20 healthy, age-matched controls. On the one hand, patients showed normal congruency and distance effects in the number Stroop task, which is indicative of normal number magnitude processing. On the other hand, patients scored lower than healthy controls in the math achievement test. We provide evidence that the lower performance cannot be explained by either differences in prior math knowledge (i.e., education) or slower processing speed. Our results suggest that peripheral vestibular deficit negatively affects numerical cognition in terms of the efficient manipulation of numbers. We discuss the role of executive functions in math performance and argue that previously reported executive deficits in patients with peripheral vestibular deficit provide a plausible explanation for the lower math achievement scores. In light of the handicapping effects of impaired numerical cognition in daily living, it is crucial to further investigate the mechanisms that cause mathematical deficits in acute PVD and eventually develop adequate means for cognitive interventions.

In situ Probe Microphone Measurement for Testing the Direct Acoustical Cochlear Stimulator

Hypothesis: Acoustical measurements can be used for functional control of a direct acoustic cochlear stimulator (DACS).

Background: The DACS is a recently released active hearing implant that works on the principle of a conventional piston prosthesis driven by the rod of an electromagnetic actuator. An inherent part of the DACS actuator is a thin titanium diaphragm that allows for movement of the stimulation rod while hermetically sealing the housing. In addition to mechanical stimulation, the actuator emits sound into the mastoid cavity because of the motion of the diaphragm.

Methods: We investigated the use of the sound emission of a DACS for intra-operative testing. We measured sound emission in the external auditory canal (P_EAC) and velocity of the actuators stimulation rod (V_act) in five implanted ears of whole-head specimens. We tested the influence various positions of the loudspeaker and a probe microphone on P_EAC and simulated implant malfunction in one example.

Results: Sound emission of the DACS with a signal-to-noise ratio >10 dB was observed between 0.5 and 5 kHz. Simulated implant misplacement or malfunction could be detected by the absence or shift in the characteristic resonance frequency of the actuator. P_EAC changed by <6 dB for variations of the microphone and loudspeaker position.

Conclusion: Our data support the feasibility of acoustical measurements for in situ testing of the DACS implant in the mastoid cavity as well as for post-operative monitoring of actuator function.

A Clinical and Radiological Approach to the Management of Benign Mesenchymal Sinonasal Tumors

PURPOSE

Benign mesenchymal sinonasal neoplasms (BMSN) are rare and histologically heterogeneous. Differential diagnosis, appropriate management, and outcome are still a matter of debate. The aim of this study is to provide evidence for further refinement of assessment and treatment in the future.

PROCEDURES

We retrospectively reviewed data on 93 patients with neuroradiologically verified BMSN treated at our university reference center during the past 22 years.

RESULTS

The most frequent BMSN recorded in our cohort was osteoma of the frontal sinus. Only one-third of the patients affected were symptomatic at initial presentation. The 2 other common fibro-osseous tumor entities, fibrous dysplasia and ossifying fibroma, were confirmed in 12 and 6 patients, respectively. Patients with soft tissue tumor entities such as hemangioma, glomangiopericytoma, angiofibroma, and hamartoma were all symptomatic and underwent surgical resection.

CONCLUSION

Understanding and recognizing the spectrum of appearances of benign mesenchymal sinonasal tumors will improve patient assessment and clinical management. The pathognomonic neuroradiological signs of a particular tumor entity should be actively sought as the neuroradiological features may be the diagnostic clues. Computed tomography and magnetic resonance imaging play complementary roles in identifying the morphological details and locoregional staging of benign mesenchymal sinonasal tumors.

Acute peripheral vestibular deficit increases redundancy in random number generation

Unilateral peripheral vestibular deficit leads to broad cognitive difficulties and biases in spatial orientation. More specifically, vestibular patients typically show a spatial bias toward their affected ear in the subjective visual vertical, head and trunk orientation, fall tendency, and walking trajectory. By means of a random number generation task, we set out to investigate how an acute peripheral vestibular deficit affects the mental representation of numbers in space. Furthermore, the random number generation task allowed us to test if patients with peripheral vestibular deficit show evidence of impaired executive functions while keeping the head straight and while performing active head turns. Previous research using galvanic vestibular stimulation in healthy people has shown no effects on number space, but revealed increased redundancy of the generated numbers. Other studies reported a spatial bias in number representation during active and passive head turns. In this experiment, we tested 43 patients with acute vestibular neuritis (18 patients with left-sided and 25 with right-sided vestibular deficit) and 28 age-matched healthy controls. We found no bias in number space in patients with peripheral vestibular deficit but showed increased redundancy in patients during active head turns. Patients showed worse performance in generating sequences of random numbers, which indicates a deficit in the updating component of executive functions. We argue that RNG is a promising candidate for a time- and cost-effective assessment of executive functions in patients suffering from a peripheral vestibular deficit.

Pretherapeutic Staging of Recurrent Laryngeal Carcinoma: Clinical Findings and Imaging Studies Compared with Histopathology

OBJECTIVE: To assess the accuracy of preoperative imaging studies and clinical and endoscopic examinations for recurrent laryngeal carcinoma evaluation.

STUDY DESIGN AND SETTING: A retrospective comparative study was performed at a university department on 42 recurrent laryngeal carcinomas. Surgical specimens were cut into whole-organ slices. Histologic findings were compared with the findings of the different preoperative diagnostic modalities.

RESULTS: The craniocaudal tumor spread was correctly evaluated by endoscopy and imaging studies in 52% and 24%, respectively, and the contralateral tumor spread in 50% and 52%, respectively. The sensitivity, specificity, and accuracy for detection of tumor infiltration of the thyroid was 48%, 88%, and 64% and of the cricoid 47%, 80%, and 67%. The accuracy of recurrent tumor classification (crT) was 50%; most tumors were underclassified.

CONCLUSION: The inadequately evaluated tumor spread and the inadequately classified recurrent tumors were underestimated and underclassified in most cases, respectively.

Direct electrospinning of 3D auricle-shaped scaffolds for tissue engineering applications

Thirty-two poly(ε)caprolactone (PCL) scaffolds have been produced by electrospinning directly into an auricle-shaped mould and seeded with articular chondrocytes harvested from bovine ankle joints. After seeding, the auricle shaped constructs were cultured in vitro and analysed at days 1, 7, 14 and 21 for regional differences in total DNA, glycosaminoglycan (GAG) and collagen (COL) content as well as the expression of aggrecan (AGG), collagen type I and type II (COL1/2) and matrix metalloproteinase 3 and 13 (MMP3/13). Stress-relaxation indentation testing was performed to investigate regional mechanical properties of the electrospun constructs. Electrospinning into a conductive mould yielded stable 3D constructs both initially and for the whole in vitro culture period, with an equilibrium modulus in the MPa range. Rapid cell proliferation and COL accumulation was observed until week 3. Quantitative real time PCR analysis showed an initial increase in AGG, no change in COL2, a persistent increase in COL1, and only a slight decrease initially for MMP3. Electrospinning of fibrous scaffolds directly into an auricle-shape represents a promising option for auricular tissue engineering, as it can reduce the steps needed to achieve an implantable structure.

Radiation dose reduction in postoperative computed position control of cochlear implant electrodes in lambs - An experimental study

OBJECTIVE

Cochlear implants (CI) are standard treatment for prelingually deafened children and postlingually deafened adults. Computed tomography (CT) is the standard method for postoperative imaging of the electrode position. CT scans accurately reflect electrode depth and position, which is essential prior to use. However, routine CT examinations expose patients to radiation, which is especially problematic in children. We examined whether new CT protocols could reduce radiation doses while preserving diagnostic accuracy.

METHODS

To investigate whether electrode position can be assessed by low-dose CT protocols, a cadaveric lamb model was used because the inner ear morphology is similar to humans. The scans were performed at various volumetric CT dose-indexes CTDIvol)/kV combinations. For each constant CTDIvol the tube voltage was varied (i.e., 80, 100, 120 and 140kV). This procedure was repeated at different CTDIvol values (21mGy, 11mGy, 5.5mGy, 2.8mGy and 1.8mGy). To keep the CTDIvol constant at different tube voltages, the tube current values were adjusted. Independent evaluations of the images were performed by two experienced and blinded neuroradiologists. The criteria diagnostic usefulness, image quality and artifacts (scaled 1-4) were assessed in 14 cochlear-implanted cadaveric lamb heads with variable tube voltages.

RESULTS

Results showed that the standard CT dose could be substantially reduced without sacrificing diagnostic accuracy of electrode position. The assessment of the CI electrode position was feasible in almost all cases up to a CTDIvol of 2-3mGy. The number of artifacts did not increase for images within this dose range as compared to higher dosages. The extent of the artifacts caused by the implanted metal-containing CI electrode does not depend on the radiation dose and is not perceptibly influenced by changes in the tube voltage. Summarizing the evaluation of the CI electrode position is possible even at a very low radiation dose.

CONCLUSIONS

CT imaging of the temporal bone for postoperative electrode position control of the CI is possible with a very low and significantly radiation dose. The tube current-time product and voltage can be reduced by 50% without increasing artifacts. Low-dose postoperative CT scans are sufficient for localizing the CI electrode.

Thrombophlebitis of the temporal vein as an extracranial complication of acute bacterial rhinosinusitis

A 39-year-old white man presented with a swollen left upper eyelid secondary to progressive acute bacterial rhinosinusitis (ABRS). Physical examination found a 40% reduction in vision in the left eye and right-sided erythematous temporal swelling with tenderness to palpation. Computed tomography revealed the presence of an inflammatory lesion in the left orbit. Duplex ultrasonography demonstrated a thrombotic occlusion in the right superficial temporal vein (STV). For treatment of the complicated ARBS, the patient received intravenous antibiotics and underwent surgery. The STV thrombophlebitis was treated with low-molecular-weight heparin. Postoperatively, the patient recovered completely and his vision normalized; 10 days later, duplex ultrasonography showed a patent STV. The development of contralateral STV thrombophlebitis is conceivably facilitated by venous anastomoses of the scalp in the front of the head. As a result, embolic spread would be a possible complication of infectious ABRS foci communicating with intraorbital and pericranial veins. To the best of our knowledge, this is the first reported case of such a complication of ARBS in the literature.

Significant Artifact Reduction at 1.5T and 3T MRI by the Use of a Cochlear Implant with Removable Magnet: An Experimental Human Cadaver Study

Objective

Cochlear implants (CIs) are standard treatment for postlingually deafened individuals and prelingually deafened children. This human cadaver study evaluated diagnostic usefulness, image quality and artifacts in 1.5T and 3T magnetic resonance (MR) brain scans after CI with a removable magnet.

Methods

Three criteria (diagnostic usefulness, image quality, artifacts) were assessed at 1.5T and 3T in five cadaver heads with CI. The brain magnetic resonance scans were performed with and without the magnet in situ. The criteria were analyzed by two blinded neuroradiologists, with focus on image distortion and limitation of the diagnostic value of the acquired MR images.

Results

MR images with the magnet in situ were all compromised by artifacts caused by the CI. After removal of the magnet, MR scans showed an unequivocal artifact reduction with significant improvement of the image quality and diagnostic usefulness, both at 1.5T and 3T. Visibility of the brain stem, cerebellopontine angle, and parieto-occipital lobe ipsilateral to the CI increased significantly after magnet removal.

Conclusions

The results indicate the possible advantages for 1.5T and 3T MR scanning of the brain in CI carriers with removable magnets. Our findings support use of CIs with removable magnets, especially in patients with chronic intracranial pathologies.

Septic thrombosis of the internal jugular vein: Lemierre's syndrome revisited

OBJECTIVES/HYPOTHESIS

Study of the clinical evolution of a primary ear, nose, and throat infection complicated by septic thrombophlebitis of the internal jugular vein.

STUDY DESIGN

Retrospective case-control study.

PATIENTS AND METHODS

From 1998 to 2010, 23 patients at our institution were diagnosed with a septic thrombosis of the internal jugular vein. Diagnostics included microbiologic analysis and imaging such as computed tomography, magnetic resonance imaging, and ultrasound. Therapy included broad-spectrum antibiotics, surgery of the primary infectious lesion, and postoperative anticoagulation. The patients were retrospectively analyzed.

RESULTS

The primary infection sites were found in the middle ear (11), oropharynx (8), sinus (3), and oral cavity (1). Fourteen patients needed intensive care unit treatment for a mean duration of 6 days. Seven patients were intubated, and two developed severe acute respiratory distress syndrome. An oropharynx primary infection site was most prone to a prolonged clinical evolution. Anticoagulation therapy was given in 90% of patients. All 23 patients survived the disseminated infection without consecutive systemic morbidity.

CONCLUSION

In the pre-antibiotic time, septic internal jugular vein thrombophlebitis was a highly fatal condition with a mortality rate of 90%. Modern imaging techniques allow early and often incidental diagnosis of this clinically hidden complication. Anticoagulation, intensive antibiotic therapy assisted by surgery of the primary infection site, and intensive supportive care can reach remission rates of 100%.

Characteristics and dimensions of the sinus membrane in patients referred for single-implant treatment in the posterior maxilla: a cone beam computed tomographic analysis

PURPOSE

The purpose of the present study was to evaluate the thickness and anatomic characteristics of the sinus membrane using cone beam computed tomography (CBCT) in patients evaluated for implant surgery in the posterior maxilla.

MATERIALS AND METHODS

The study included 131 consecutive patients referred for dental implant placement in the posterior maxilla. A total of 138 CBCT images was obtained using fields of view of 4 × 4 cm, 6 × 6 cm, or 8 × 8 cm. Reformatted sagittal CBCT slices were analyzed with regard to the thickness and characteristics of the sinus membrane at single-tooth gaps in the posterior maxilla. Factors that might influence the dimensions of the sinus membrane, such as age, sex, endodontic status, and the season, were analyzed.

RESULTS

The mean thickness of the maxillary sinus mucosa varied between 2.1 and 2.69 mm in the three locations analyzed. Fewer than half of the evaluated sinuses exhibited a healthy mucosa (49 of 138, or 35.51%). Most of the pathologic findings were flat, shallow thickenings (63 of 138, or 45.65%). Sex did not influence the thickness of the sinus membrane at the root tips of the premolars or at single-tooth gaps, but there was a statistically significant correlation in the region of the maxillary molars. No other evaluated factors had a statistically significant effect on the dimensions of the antral mucosa.

CONCLUSIONS

In the present study, sex was the only factor influencing the dimension of the sinus membrane, whereas patient age, season, and the endodontic status of neighboring teeth had no significant effect on the thickness of the antral mucosa. Future studies should address which types of mucosal thickening require interdisciplinary therapy.

Cholesteatoma surgery in children: long-term results of the inside-out technique

OBJECTIVE

To present the anatomical and functional results of the inside-out technique applied in pediatric cholestetaoma surgery and to evaluate functionality with good hearing results against radicality with lower recurrence rate.

METHODS

Retrospective analysis and evaluation of the postoperative outcome in a consecutive series of 126 children or 130 ears operated between 1992 and 2008. With the inside-out technique, cholesteatoma is eradicated from the epitympanum toward the mastoid and, as a single stage procedure, functional reconstruction of the middle ear is achieved by tympanoossiculoplasty.

RESULTS

In 89.2% of all cases, the ear was dry postoperatively. 80.9% of the ears reached a postoperative air-bone gap of 30 dB or less and the median air conduction hearing threshold was 29 dB; in 60.9% of all cases, hearing was postoperatively improved. The recurrence rate was 16.2% in a mean postoperative follow-up 8.5 years. Altogether, 48 ears (36.9%) underwent revision surgery. The complication rate was 3.1% and involved only minor complications.

CONCLUSION

The inside-out technique allows a safe removal of cholesteatoma from the epitympanum toward the mastoid with a single-stage reconstruction of the ossicular chain. For this reason we support our individual approach, which allows creation of the smallest possible cavity for the size of the cholesteatoma. Our results confirm that the inside-out technique is effective in the treatment of pediatric cholesteatoma.

Limitations of balloon sinuplasty in frontal sinus surgery

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

Teratoma of the nasal septum in a neonate: an endoscopic approach

Initial presentation of a white female newborn delivered after normal pregnancy demonstrated a white mass obstructing the left nare. Primary biopsy revealed a focus of fibrotic nasal mucosa that included squamous and respiratory epithelium. After endoscopic resection of the mass, histopathologic examination resulted in the diagnosis of a teratoma. According to our literature review, this is the first case of a teratoma arising from the nasal septum in a white. Worldwide, 3 additional cases have been reported, but none included endoscopic management. This case illustrates our protocol for an endoscopic approach to an obstructive nasal mass in a neonate and our experience in the management of this rare disease.

Carcinoma ex pleomorphic adenoma: diagnostic difficulty and outcome

OBJECTIVE

To analyze a series of carcinoma ex pleomorphic adenoma (CXPA) and to assess the diagnostic difficulties.

STUDY DESIGN

The clinical presentation of 24 CXPAs was compared with 300 pleomorphic adenomas (PAs). Furthermore, pathohistological findings and follow-up results of CXPAs were evaluated.

RESULTS

Eight of 24 (33%) CXPAs versus 41 of 300 (14%) PAs were localized in the deep lobe (P < 0.05). Forty-two percent of CXPAs versus 6 percent of PAs, respectively, were greater than 4 cm (P < 0.05). The sensitivity in detecting CXPA by fine-needle aspiration cytology (FNAC) was 47 percent. The tumor was known to be malignant preoperatively in 10 (42%) patients. Six of 24 (25%) patients with CXPA developed a tumor recurrence. The overall 5-year survival rate of CXPA was 76 percent.

CONCLUSION

CXPAs are difficult to identify preoperatively. FNAC has a low accuracy and sensitivity. CXPAs versus PAs are significantly more frequently localized in the deep lobe and are significantly greater in size.