Isolated bilateral posterior semicircular canal hypofunction: comparison with bilateral vestibulopathy

BACKGROUND

Chronic unsteadiness is a common complaint at vestibular clinics. Bilateral vestibulopathy (BVP) is a major cause of chronic unsteadiness but is often overlooked. Although diagnostic criteria for BVP have been established by the Barany Society, isolated vertical canal hypofunction can remain undiagnosed. Recently, the video head-impulse test has enabled clinicians to assess vertical semicircular canal function at clinics.

OBJECTIVE

This study aimed to compare the features of isolated bilateral posterior semicircular canal hypofunction (IBPH) with those of BVP diagnosed based on the Barany criteria.

METHODS

The clinical data of 8 IBPH patients that had been diagnosed using our diagnostic criteria (sex, age, subjective symptoms, questionnaire, video head-impulse test and stabilometry) were analyzed and compared with those of 6 BVP patients diagnosed using the Barany criteria.

RESULTS

The IBPH patients were all aged >70 years, while the age range of the BVP patients was wider. While the BVP patients complained of both oscillopsia during body movement and unsteadiness in darkness, the IBPH patients complained of unsteadiness in darkness without oscillopsia during body movement. The IBPH patients exhibited milder clinical findings than the BVP patients.

CONCLUSION

IBPH can cause mild unsteadiness in the elderly.

SIGNIFICANCE

Clinicians should be aware that IBPH can cause unsteadiness in the elderly.

Diagnosis of Patients Presenting with Vertigo, Headache, and Epileptic Seizure: Evaluating Vestibular Patients by Using Cervical Vestibular Evoked Myogenic Potential and Auditory Middle Latency Responses in the Clinical Setting

Migraine and vertigo are common complaints seen in clinical practice, and in a few such cases, we also find epileptic manifestations, including migraine-triggered seizures. Currently, patients presenting with vertigo and headache are diagnosed according to established diagnostic criteria for Meniere's disease, vestibular migraine, or vestibular migraine/Meniere's disease overlapping syndrome. In addition to using those diagnostic criteria and the patient's history, cervical vestibular evoked myogenic potential and auditory middle latency responses are useful tools to better understand the physiological background of these patients and also to confirm the diagnosis. Here we report 2 cases: 1 of vestibular migraine/ Meniere's disease overlapping syndrome and 1 of vestibular migraine with epileptic manifestations. Each patient showed potentiation (lack of habituation) in auditory middle latency response, and each showed endolymphatic hydrops in cervical vestibular evoked myogenic potential. The potentiation in auditory middle latency response might be attributable to neuronal hyperexcitability in those patients with migraine or epilepsy, and neurogenic inflammation caused by migraine episodes might affect inner ear function.

Endoscopic endonasal management of esthesioneuroblastoma: A retrospective multicenter study

OBJECTIVE

The aim of the present study was to illustrate the safety and utility of the endoscopic endonasal approach (EEA) for the treatment of esthesioneuroblastomas (ENB).

METHODS

We retrospectively reviewed patients with a diagnosis of ENB between March 2008 and February 2016 at 10 tertiary referral hospitals in Japan, and assessed demographic data, stage of disease, surgical approach, outcomes and postoperative complications.

RESULTS

A total of 22 patients (10 males and 12 females; mean age at presentation, 49.0 years) underwent endoscopic endonasal resection of newly diagnosed ENBs. Dulguerov staging at presentation was T1, 6 patients; T2, 9 patients; T3, 5 patients; and T4, 2 patients. As surgical procedures, unilateral resection via EEA was performed in 12 patients aiming preservation of the contralateral olfactory system, and bilateral resection via EEA was done in 10 patients. Post-operative radiotherapy was done in 20 patients. Pathological margin studies revealed margin-free resections in 21 patients (95.5%). The mean period of follow-up was 44 months. Local recurrence was observed in one T2 patient 12 months after bilateral resection. All patients were alive at the last follow-up, and 21 patients showed no evidence of disease. No post-operative complications including bleeding, CSF leak and meningitis were identified. Preservation of olfactory function was achieved in 11 patients (91.7%).

CONCLUSION

The results of the present study indicate the safety and utility of multilayer resection using EEA for treatment of ENBs.

Nonsyndromic Isolated Unilateral Cochlear Nerve Aplasia without Narrow Internal Auditory Meatus: A Previously Overlooked Cause of Unilateral Profound Deafness in Childhood

Objectives:

Juvenile or adolescent unilateral profound sensorineural deafness (worldwide prevalence, 0.1% to 0.2%) has been attributed to postnatal viral infection, sudden deafness, prenatal and perinatal problems including maternal rubella and viral infections, congenital inner ear anomalies, and other factors. Herein, 2 cases are reported and another potentially important cause of unilateral profound hearing loss is proposed.

Methods:

Two nonsyndromic cases of a presently “very rare” cause of pediatric unilateral deafness are presented as a retrospective case study.

Results:

The 2 patients showed isolated aplasia of the cochlear nerve; other branches of the eighth cranial nerve, the seventh nerve, and the inner ear were spared, and there was no anomaly of the internal auditory meatus. Both functional and imaging studies confirmed the isolated lesion (absence) of the cochlear nerve.

Conclusions:

Because of the absence of bony abnormalities, such cases may have been overlooked. The authors would like to advocate this isolated anomaly of the cochlear nerve as an important cause of juvenile or adolescent unilateral profound deafness.

A submucosal esophageal fish bone foreign body surgically removed using intraoperative ultrasonography

A 68 year-old female was referred to our department with a history of swallowing a fish bone, she reported continuous pain when swallowing. The bone was not evident on endoscopic examination; however, on CT scans a foreign body was identified in the upper esophagus. The bone was buried in the mucosa of the upper esophagus and an emergent rigid esophagoscopy was performed under general anesthesia in order to remove it. The fish bone was successfully removed with the use of intraoperative cervical ultrasonography.

Utility of elastography for differential diagnosis of benign and malignant thyroid nodules

OBJECTIVE

1) To classify the appearance of thyroid nodules displayed on ultrasound elastography; 2) to explore the sensitivity and specificity of this examination for differentiating benign and malignant nodules, with histopathologic analysis as the reference standard; and 3) to evaluate its utility for avoiding unnecessary procedures.

STUDY DESIGN

Diagnostic test assessment.

SETTING

Community hospital.

SUBJECTS AND METHODS

Forty-seven thyroid nodules in 44 consecutive patients were examined with ultrasound elastography. The images we obtained were classified into four patterns. In addition, the mean strain index of the thyroid nodule and that of the sternocleidomastoid muscle were measured, and the nodule-to-muscle strain ratio was calculated. As the reference findings, the presence or absence of calcification, irregular margins, and hypoechogenicity of the thyroid nodules were examined using B-mode ultrasound.

RESULTS

Elastography patterns 3 and 4 were predictive of malignancy, with 73 percent sensitivity (95% confidence interval [CI]: 39%-94%) and 64 percent specificity (95% CI: 46%-79%). Additionally, all nodules without calcification and those that presented with patterns 1 or 2 were benign. A strain ratio greater than 1.5 was set as the predictor of thyroid malignancy. This criterion showed 90 percent sensitivity (95% CI: 59%-100%) and 50 percent specificity (95% CI: 33%-67%).

CONCLUSION

Although elastography can assist in the differential diagnosis of thyroid nodules, its diagnostic performance is not ideal at present. Further improvements in the technique and the diagnostic criteria are necessary for this examination to provide a useful contribution to diagnosis.

Peritonsillar abscess with parapharyngeal and retropharyngeal involvement: incidence and intraoral approach

CONCLUSION

This study illustrates common sites of infection seen in peritonsillar abscesses with involvement of the pharyngeal space and retropharyngeal space. Abscesses behind and/or inferior to the tonsil were encountered more frequently than expected. In these cases, the drainage had to be placed in the inferior pole of the tonsil and these types were frequently seen in older patients.

OBJECTIVES

The aim of this study was to assess to what extent abscesses spread in patients with peritonsillar abscess and to determine to what extent pus can be drained intraorally.

PATIENTS AND METHODS

The clinical charts of 45 patients with peritonsillar abscess involvement of the parapharyngeal space and/or retropharyngeal space were retrospectively reviewed.

RESULTS

In 45 cases, 21 patients were diagnosed with the superior type, and we could drain the pus intraorally in 90% of the patients. On the other hand, 24 cases were diagnosed with the inferior type and they were drained intraorally in 58% of the cases.

Effect of myringotomy on prognosis in pediatric acute otitis media

OBJECTIVE

In children with acute otitis media (AOM), we compared clinical outcomes between groups with and without myringotomy to elucidate the effect of this procedure on long-term clinical course and prognosis.

METHODS

Fifty-nine children (29 male, 30 female) with tympanic membrane bulging or middle ear fluid (MEF) at initial presentation were assigned to one of two treatment groups. Group A received oral antibiotics and also underwent myringotomy at initial enrollment (36 cases), while group B received oral antibiotics without myringotomy (23 cases). Clinical outcomes were evaluated by otolaryngologic specialists using pneumatic otoscopy and tympanometry at 5, 10, 15, 30 days and 12 weeks and then every 2 weeks after the initial treatment. Otitis media with effusion (OME), early recurrence and recurrent AOM were used as the evaluation criteria for the prognosis.

RESULTS

In group A, 6 children (16.7%) showed transition to OME, 11 (30.6%) showed early recurrence of AOM, and 9 (25.0%) developed recurrent AOM. In group B 10, 8, and 3 (43.5%, 34.8%, and 13.0%) showed these respective adverse outcomes. While early recurrence rates and recurrent AOM rates did not differ significantly between groups, progression of OME was significantly less frequent in group A than group B (P = 0.036).

CONCLUSIONS

Lower rates of progression to OME in the group undergoing myringotomy suggested that myringotomy might be effective in preventing this outcome.

Vestibular neuritis in a child with otitis media with effusion; clinical application of vestibular evoked myogenic potential by bone-conducted sound

Vestibular evoked myogenic potential (VEMP) has been applied for patients with vestibulo-cochlear disorders. The impairment of the sound transmission due to middle ear pathology affects VEMP results. In children, otitis media with effusion (OME) is well documented and it is difficult to apply conventional VEMP in such cases. To overcome the attenuation of stimulation due to middle ear pathology, VEMP by bone-conducted sound has been developed. We report a 3-year-old girl with vestibular neuritis and OME as a representative case of clinical application of VEMP by bone-conducted sound. VEMP by bone-conducted sound can be an alternative method to elicit vestibular-dependent potential.

Vestibular testing by electrical stimulation in patients with unilateral vestibular deafferentation: galvanic evoked myogenic responses testing versus galvanic body sway testing

OBJECTIVE

To investigate the agreement of a lesion site as indicated by two different vestibular tests with electrical stimulation, galvanic body sway testing (GBST) and galvanic evoked myogenic responses (galvanic vestibular evoked myogenic potential; galvanic VEMP) testing, in patients with unilateral vestibular deafferentation.

METHODS

Nineteen patients with unilateral vestibular deafferentation were studied, and the criteria for patient selection were as follows: (1) absence of a caloric response to ice water on the affected side in a supine position, and (2) absence of VEMP to 95 dBnHL clicks on the affected side. We assessed the postural response of the subjects to long duration galvanic stimulation (1 mA, 5 s) by measuring the lateral displacement at the center of foot pressure with a cathode electrode on the forehead, and an anode electrode on the mastoid (GBST). We also recorded the electromyographic (EMG) activities of the sternocleidomastoid muscle (SCM) to short duration galvanic stimulation (3 mA, 1 ms) (galvanic VEMP) with a cathode electrode on the mastoid, and an anode electrode on the forehead.

RESULTS

In 18 of the 19 patients, the lesion site indicated by GBST was identical to that indicated by galvanic VEMP. Fourteen patients had abnormal results in both tests while 4 patients had normal results in both tests. One patient with acoustic neuroma had normal results in GBST but abnormal results in galvanic VEMP.

CONCLUSIONS

These results suggest that electrical stimulation in these two tests stimulates the same area of the peripheral vestibular afferent system, although the duration of stimulation was different, and that the estimate of the lesion site indicated by these tests in patients with complete or nearly complete unilateral vestibular damages is reliable.

SIGNIFICANCE

These results suggest that short-duration galvanic stimulation as well as long-duration galvanic stimulation stimulates the vestibular system at the same level.

Role of respiratory viruses in children with acute otitis media

OBJECTIVE

The role of viral infection in acute otitis media (AOM) has not been fully elucidated. We determined the presence of various respiratory viruses in middle ear fluid (MEF) specimens from children with AOM in order to determine whether viral infection or combined effects of viral and bacterial infection enhance or prolong the inflammation in the middle ear, thus worsening clinical outcome.

METHODS

Multiplex nested reverse transcription-polymerase chain reactions was carried out to detect influenza A and B viruses, respiratory syncytial virus (RSV) types A and B, parainfluenza virus types 1, 2, and 3; rhinovirus; and adenovirus in 93 MEF specimens from 79 children with AOM. And we examined whether viral infection with or without an identifiable bacterial infection affect clinical outcomes in AOM. We considered persistent MEF (fluid accumulation in the middle ear persisting up to 1 month after treatment), early recurrence of AOM (within 1 month after initial improvement), and recurrent AOM (more than three recurrences during 6 months of follow up) as indicators for evaluating clinical outcomes.

RESULTS

One or more respiratory viruses were detected in 39 specimens (42%); a total of 42 viral infections identified (three specimens were infected by two viruses). Of the 42 infections, RSV type A was detected in 29, adenovirus in eight, rhinovirus in three, and influenza virus in two. RSV accounted for 73% of viral detections. In children younger than 2 years, RSV infection combined with Streptococcus pneumoniae or Hemophilus influenzae infection carried a higher risk for persistent middle ear effusion than infection with RSV infection alone or those bacterial infection alone.

CONCLUSIONS

Accordingly, vaccination of young children against RSV as well as S. pneumoniae and H. influenzae is important in improving the prognosis in AOM.

Factors associated with poor outcome in children with acute otitis media

OBJECTIVE

To identify factors determining poor outcome in children with acute otitis media (AOM).

MATERIAL AND METHODS

We considered the following factors in children with AOM: age; gender; the presence of group nursing; the presence of siblings; the duration of breastfeeding; and the type of bacteria isolated from the middle ear fluid (MEF) or nasopharynx. The 73 pediatric patients studied included 61 examined in outpatient clinics and 12 seen at a children's home.

RESULTS

Of the 61 children examined in outpatient clinics, 32 (52%) had persistent MEF (fluid accumulation in the middle ear persisting for up to 1 month after treatment); 14 (23%) had early recurrence of AOM (within 1 month following an initial improvement); and 14 (23%) developed recurrent AOM (> 3 recurrences during 6 months of follow-up). Using univariate and multivariate analyses, age < 2 years was found to be significantly related to the development of recurrent AOM and an absence of group nursing was found to be significantly related to the development of early recurrence. Persistent MEF was significantly related to the development of recurrent AOM. There was no difference between bacterial species isolated from the MEF or nasopharynx in terms of clinical outcome.

CONCLUSIONS

These findings indicate that particularly close long-term follow-up is necessary for children aged < 2 years and children with a middle ear effusion that persists for up to 1 month after treatment.

Multiplex nested reverse transcription-polymerase chain reaction for respiratory viruses in acute otitis media

Because respiratory viruses play an important role in the causation and pathogenesis of acute otitis media (AOM), determining which virus has infected a child is important with respect to vaccines and antiviral drugs. In some instances, this information might be used to prevent the occurrence of AOM. We used a rapid, economical, and sensitive diagnostic system involving a multiplex nested reverse transcription-polymerase chain reaction (RT-PCR) assay to detect various respiratory viruses in clinical specimens of middle ear fluid (MEF) from children with AOM in our hospital. Multiplex RT-PCR was completed on 40 MEF samples from 28 infants and children less than 6 years old with AOM. Viral RNA was detected in 17 MEF samples (43%). Respiratory syncytial virus type A was present in 12 samples, adenovirus in 3, rhinovirus in 2, and influenza A (H3N2) in 1. The multiplex RT-PCR assay is recommended to clinical laboratories that are considering adoption of a molecular technique for viral diagnosis.

The outcome of the canalith repositioning procedure for benign paroxysmal positional vertigo: are there any characteristic features of treatment failure cases?

To demonstrate the success rate of the canalith repositioning procedure (CRP) in our clinic and to establish any characteristic features of cases of treatment failure, we reviewed clinical records of 62 patients who were diagnosed with posterior semicircular canal-benign paroxysmal positional vertigo (BPPV) and treated with the CRP. The basic strategy of the CRP was to rotate the involved canal slowly in the plane of gravity so that free-floating materials could migrate into the utricle only once. After the procedure we instructed patients to keep their heads upright for 10 h and not to sleep on the affected ear for 2 weeks. After the initial treatment, successful results were obtained in 51 of the 62 patients (82.2%). After the second treatment, 56 patients (90.3%) experienced success. Six patients (9.7%) did not obtain resolution even after the second treatment. While 46 patients were diagnosed with idiopathic BPPV, in 16 patients a different diagnosis was determined (head injury in 7 patients, Ménière's disease in 2, vestibular neuritis in 2 and unilateral sensorineural hearing loss in 5). We categorized these 16 patients as having secondary BPPV. Patients with idiopathic BPPV showed a significantly higher success rate with CRP than those with secondary BPPV. Patients with secondary BPPV may have quantitatively or qualitatively different lesions than those with idiopathic BPPV.