Molecular Mediators of Estrogen Reduction-induced Otolith Shedding

OBJECTIVE

Previous study suggested that estradiol (E2) plays an important role in otolith shedding by regulating the expression of otoconin 90 (OC90). The purpose of this article is to provide further data on the effect and mechanism of E2 on the morphology of otolith.

METHODS

The rats receiving bilateral ovariectomy (OVX) were used as animal models. Co-immunoprecipitation was used to observe the relationship between estrogen receptor (ER) and estrogen-related receptor α (ERRα). The morphology of otolith was observed under the scanning electron microscopy. Western blotting and qPCR were used for quantitative analysis of the roles of ER and ERRα in regulating OC90 expression.

RESULTS

The looser otoliths were observed in rats receiving bilateral OVX, which could be reversed by supplementation with E2. The level of ERRα was decreased in bilateral OVX rats. ER and ERRα interacted with each other on the regulation of the expression of OC90.

CONCLUSION

Our results suggest ER and ERRα are both important downstream receptors involved in regulating OC90 expression in utricles of rats, and ERRα probably functions by interacting with ER. This provides evidence for the mechanism of otolith shedding. And it may be significant for future studies of targeted prevention and therapies for benign paroxysmal positional vertigo.

Gene therapy for hereditary hearing loss by SLC26A4 mutations in mice reveals distinct functional roles of pendrin in normal hearing

Rationale: Mutations of SLC26A4 that abrogate pendrin, expressed in endolymphatic sac, cochlea and vestibule, are known to cause autosomal recessive sensorineural hearing loss with enlargement of the membranous labyrinth. This is the first study to demonstrate the feasibility of gene therapy for pendrin-related hearing loss. Methods: We used a recombinant viral vector to transfect Slc26a4 cDNA into embryonic day 12.5 otocysts of pendrin-deficient knock-out (Slc26a4∆/∆ ) and pendrin-deficient knock-in (Slc26a4tm1Dontuh/tm1Dontuh ) mice. Results: Local gene-delivery resulted in spatially and temporally limited pendrin expression, prevented enlargement, failed to restore vestibular function, but succeeded in the restoration of hearing. Restored hearing phenotypes included normal hearing as well as sudden, fluctuating, and progressive hearing loss. Conclusion: Our study illustrates the feasibility of gene therapy for pendrin-related hearing loss, suggests differences in the requirement of pendrin between the cochlea and the vestibular labyrinth, and documents that insufficient pendrin expression during late embryonal and early postnatal development of the inner ear can cause sudden, fluctuating and progressive hearing loss without obligatory enlargement of the membranous labyrinth.

Bilateral vestibulopathy

The leading symptoms of bilateral vestibulopathy (BVP) are postural imbalance and unsteadiness of gait that worsens in darkness and on uneven ground. There are typically no symptoms while sitting or lying under static conditions. A minority of patients also have movement-induced oscillopsia, in particular while walking. The diagnosis of BVP is based on a bilaterally reduced or absent function of the vestibulo-ocular reflex (VOR). This deficit is diagnosed for the high-frequency range of the angular VOR by a bilaterally pathologic bedside head impulse test (HIT) and for the low-frequency range by a bilaterally reduced or absent caloric response. If the results of the bedside HIT are unclear, angular VOR function should be quantified by a video-oculography system (vHIT). An additional test supporting the diagnosis is dynamic visual acuity. Cervical and ocular vestibular-evoked myogenic potentials (c/oVEMP) may also be reduced or absent, indicating impaired otolith function. There are different subtypes of BVP depending on the affected anatomic structure and frequency range of the VOR deficit: impaired canal function in the low- and/or high-frequency VOR range only and/or otolith function only; the latter is very rare. The etiology of BVP remains unclear in more than 50% of patients: in these cases neurodegeneration is assumed. Frequent known causes are ototoxicity mainly due to gentamicin, bilateral Menière's disease, autoimmune diseases, meningitis and bilateral vestibular schwannoma, as well as an association with cerebellar degeneration (cerebellar ataxia, neuropathy, vestibular areflexia syndrome=CANVAS). In general, in the long term there is no improvement of vestibular function. There are four treatment options: first, detailed patient counseling to explain the cause, etiology, and consequences, as well as the course of the disease; second, daily vestibular exercises and balance training; third, if possible, treatment of the underlying cause, as in bilateral Menière's disease, meningitis, or autoimmune diseases; fourth, if possible, prevention, i.e., being very restrictive with the use of ototoxic substances, such as aminoglycosides. In the future vestibular implants may also be an option.

[CROATIAN GUIDELINES FOR DIAGNOSIS AND MANAGEMENT OF BENIGN PAROXYSMAL POSITIONAL VERTIGO (BPPV)]

BPPV is generally the most common cause of vertigo, caused by a pinch-off of tiny calcium carbonate crystals (called the otoconia or the otoliths) from the macula utriculi, most frequently due to the degenerative processes or a trauma, whereby the crystals, under the action of gravity in certain head positions coinciding with its direction, arrive to some of the semicircular canals, usually the posterior one, due to the existent anatomical circumstances and relationships, thus creating an inadequate stimulus of the cupular senses while floating through the endolymph and provoking symptoms of a strong and short-term dizziness. Two main clinical forms can be distinguished: canalolythiasis, with an accommodation of otolithic debris in the semicircular canal, and cupulolythiasis, with their location immediately next to the cupular sense. The diagnosis is established by a positive positioning test, Dix-Hallpike for the posterior and the supine roll for the lateral canal. Although one can expect a spontaneous recovery subsequent to few weeks or months, various methods of otolith repositioning to a less sensitive place lead to a prompt improvement while reducing or withdrawing the symptoms completely. These guidelines are intended for all who treat the BPPV in their work, with an intention to assist in the diagnosis and application of an appropriate therapeutic method.

Three-dimensional cone beam computed tomography imaging of the membranous labyrinth in patients with Meniere's disease

CONCLUSION

Three-dimensional cone beam computed tomography (3DCT) images revealed characteristic malformations of the membranous labyrinth of the inner ear in Meniere's disease (MD). The morphology of the membranous region between the vestibular cecum of the cochlea and the saccule of ears with MD was compared to that of healthy ears. The present study supports the hypothesis proposed earlier that reuniting duct blockade is a result of the dislodgement of saccular otoconia.

OBJECTIVE

To visualize the membranous labyrinth using 3DCT and to investigate the pathology of MD.

METHODS

A preparatory study was conducted to determine the optimal 3DCT window settings for the detection of water, muscle, calcium carbonate (CaCO3), and bone. Based on this preparatory study, the ears of 13 healthy volunteers and 25 MD patients definitely diagnosed according to the criteria issued by the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology, Head and Neck Surgery (AAO-HNS), were visualized.

RESULTS

The differences in the membranous labyrinth between MD ears and healthy ears could be visualized using 3DCT. The images were classified into three types based on their morphological pattern. The ears of patients with MD were different from normal ears in terms of this classification.

Retinoic acid deficiency impairs the vestibular function

The retinaldehyde dehydrogenase 3 (Raldh3) gene encodes a major retinoic acid synthesizing enzyme and is highly expressed in the inner ear during embryogenesis. We found that mice deficient in Raldh3 bear severe impairment in vestibular functions. These mutant mice exhibited spontaneous circling/tilted behaviors and performed poorly in several vestibular-motor function tests. In addition, video-oculography revealed a complete loss of the maculo-ocular reflex and a significant reduction in the horizontal angular vestibulo-ocular reflex, indicating that detection of both linear acceleration and angular rotation were compromised in the mutants. Consistent with these behavioral and functional deficiencies, morphological anomalies, characterized by a smaller vestibular organ with thinner semicircular canals and a significant reduction in the number of otoconia in the saccule and the utricle, were consistently observed in the Raldh3 mutants. The loss of otoconia in the mutants may be attributed, at least in part, to significantly reduced expression of Otop1, which encodes a protein known to be involved in calcium regulation in the otolithic organs. Our data thus reveal a previously unrecognized role of Raldh3 in structural and functional development of the vestibular end organs.

The effect of otolith malformation on behavior and cortisol levels in juvenile red drum fish (Sciaenops ocellatus)

Captive-raised red drum fish were observed with phenotypic abnormalities, including deformities of the spine, jaw, and cephalic region, that were consistent with vitamin C deficiency during the larval stage. In light of their visible exterior skeletal abnormalities, we suspected that the affected fish would also have abnormal otoliths. Otoliths are dense calcareous structures that function in fish hearing. We hypothesized that abnormal fish would have irregular otoliths that would alter behavior and cortisol levels as compared with those of phenotypically normal fish. The normal and abnormal fish had statistically significant differences in behavior, cortisol levels, and otolith volume and density. MicroCT assessment of abnormal fish revealed operculum abnormalities, malocclusions, and several types of otolith malformations. Therefore, the affected fish had not only an abnormal skeletal appearance but also significantly abnormal behavior and cortisol responses.

Changes in population, growth, and physiological indices of Longnose dace (Rhinichthys cataractae) in the Red Deer River, Alberta, Canada

The Red Deer River, Alberta, Canada is a prairie river that is impacted by the point-source input of Red Deer's municipal wastewater effluent and non-point- source agricultural runoff. We used population, growth, and physiological performance end points in longnose dace (Rhinichthys cataractae), an endemic and abundant minnow, to evaluate changes in fish health over a 220 km section of the Red Deer River. Longnose dace immediately downstream of Red Deer had elevated catch per unit effort with larger body and liver sizes compared to upstream of Red Deer sites, likely due to elevated riverine productivity from Red Deer's wastewater effluent. Longnose dace immediately downstream of Red Deer showed depressed testosterone production capacity and elevated ethoxyresorufin-O-deethylase (EROD) activity, which is consistent with exposure to endocrine-disrupting compounds and aromatic hydrocarbons, respectively. Longnose dace 150-180 km downstream of Red Deer had reduced liver and gonad sizes, elevated EROD, and increased 11-ketotestosterone production capacity compared to upstream of Red Deer sites, possibly related to a non-point-source agricultural influence on water quality. Longnose dace populations at the most downstream sites were missing the oldest age classes and might reach sexual maturity faster than at upstream sites, which is consistent with a younger age structure. Our results highlight the importance of assessing multiple performance end points to reveal physiological or reproductive effects in natural fish populations. We have demonstrated how longnose dace populations change over a river impacted by municipal wastewater and agricultural runoff; further studies are required to determine if these changes will influence the long-term viability of longnose dace in the Red Deer River.

Short-term efficacy of Epley's manoeuvre: a double-blind randomised trial

BACKGROUND

Benign paroxysmal positional vertigo of the posterior canal (PC-BPPV) is a common vestibular disorder and can be easily treated with Epley's manoeuvre. Thus far, the short-term efficacy of Epley's manoeuvre for treatment of PC-BPPV is unknown.

OBJECTIVES

To evaluate the efficacy of Epley's manoeuvre for treatment of PC-BPPV 24 h after applying the manoeuvre.

METHODS

The short-term efficacy of Epley's manoeuvre was compared with a sham procedure in 66 patients with PC-BPPV by using a double-blind randomised study design.

RESULTS

24 h after treatment, 28 of 35 (80%) patients in the Epley's manoeuvre group had neither vertigo nor nystagmus on positional testing compared with 3 of 31 (10%) patients in the sham group (p<0.001).

CONCLUSION

Epley's manoeuvre is shown to resolve PC-BPPV both effectively and rapidly.

Otolith Function Assessed with the Subjective Postural Horizontal and Standardised Stance and Gait Tasks

If otolith function is essential to maintain upright standing while moving along slanted or uneven surfaces, subjects with an otolith deficit should have difficulty judging whether the inclination of the surface on which they are standing is tilted or not. We tested this judgement and compared it with the ability to control trunk sway during standardised stance and gait tests. Thirteen patients with unilateral vestibular nerve neurectomy at least 6 months prior to testing and 39 age-matched controls were asked to move a dynamic posturography platform on which they were standing back to their subjective 'horizontal' position after the platform had been slowly tilted at 0.4 degrees/s to 5 degrees in 8 different directions. Normal subjects left the platform deviated in pitch (forwards-backwards) at about 0.7 degrees on describing the platform as levelled off for all directions of tilt. Patients showed larger deviations of about 1.3 degrees in pitch with significant differences for forward right tilt (1.58+/-0.73 degrees compared to 0.73+/-0.11 degrees for normals; mean and SEM) and for forward left. Roll (lateral) deviations were about 0.4 degrees for normals and 0.5 degrees larger for the patients (for example, for backward left, 1.13+/-0.24 degrees compared to 0.4+/-0.07 degrees in normals). Except for a tendency towards greater deviations to the lesion side of patients with eyes closed, no differences were noted between tests under eyes open and closed conditions. However, for backward and roll tilts patients needed to steady themselves first by grasping a handrail when tested with eyes closed. Stance tests on foam showed increases in roll and pitch trunk sway with respect to controls. Patients had significantly larger trunk roll sway deviations during 1-legged stance tests and during gait trials. For stance trials, the patients lost their balance control prior to the end of the standard 20-second recording time. We conclude that a unilateral loss of otolith inputs due to nerve resection permanently impairs the ability to judge whether the support surface is horizontal, and leads to excessive trunk sway when standing on a compliant surface as well as excessive trunk roll sway during gait.

Self-treatment for benign paroxysmal positional vertigo of the posterior semicircular canal

The authors compared the efficacy of the Epley procedure with and without self-treatment in 80 patients with benign paroxysmal positional vertigo of the posterior semicircular canal. The self-treatment group (88%) had better results than the Epley-alone group (69%) based on both symptoms and nystagmus (p = 0.048). Complications occurred in 2.6% of the Epley-alone group and in 7.5% of the self-treatment group (p = 0.62).

Observation of the morphology and calcium content of vestibular otoconia in rats after simulated weightlessness

Reduction in bone formation may have been the main reason for the lower calcium content of the otoconia after simulated weightlessness in rats. The head-ward distribution of blood volume may explain the morphological changes observed in the middle and inner ears. To observe morphological changes in the vestibular organs and measure the calcium content of otoconia in rats after simulated weightlessness. We used a tail suspension model of simulated weightlessness and then investigated changes in the vestibular organs using scanning electron microscopy and X-ray microanalysis. In comparison to untreated rats, the vestibular otoconia of the rats subjected to simulated weightlessness were small, irregularly shaped or fissured, and were arranged loosely and out of order. In addition, the calcium content of the otoconia was markedly decreased.

Repeated vs single physical maneuver in benign paroxysmal positional vertigo

OBJECTIVES

To evaluate the effectiveness and possible side effects of a single session of repeated particle repositioning maneuver (PRM) to treat posterior canal benign paroxysmal positional vertigo (BPPV) and the usefulness of post-treatment restrictions.

MATERIALS AND METHODS

A total of 125 consecutive patients with idiopathic BPPV participated in the study. Fifty patients received a single session of repeated PRM only (group I). Results were compared with those of 50 patients with BPPV who received a single PRM (group IIb), and 25 patients who received a single PRM followed by the use of a neck collar and keeping the head upright for 48 h (group IIa).

RESULTS

Forty-six patients (92%) of group I, 40 patients (80%) of group IIb, and 21 patients (84%) of group IIa were completely free of signs and symptoms when re-examined 1 week after treatment. Transient nausea and disequilibrium following treatment were reported equally in all subgroups and well tolerated. Nearly all patients of group IIa considered the post-treatment restrictions very inconvenient.

CONCLUSIONS

A single session of repeated physical procedure seems to be clinically superior to one single maneuver and well tolerated. Additional post-treatment measurements are inconvenient and should be abandoned.

On the origin of susceptibility to kinetotic swimming behaviour in fish: a parabolic aircraft flight study

Humans taking part in parabolic aircraft flights (PAFs) may suffer from motion sickness (SMS, a kinetosis; it comprises a dynamic and a static component). It has been argued that the so-called static variety of SMS during PAFs might be based on asymmetric statoliths (i.e., differently weighed statoliths on the right and the left side of the head), with asymmetric inputs to the brain being disclosed in microgravity. Since it has been repeatedly shown earlier that some fish of a given batch reveal a kinetotic behaviour during PAFs (especially so-called spinning movements and looping responses), we investigated whether fish swimming kinetotically in microgravity have a pronounced inner ear otolith asymmetry. Therefore, the swimming behaviour of larval cichlid fish was video-recorded during PAFs and subsequently, size and asymmetry (size difference between the left and the right side) of inner ear otoliths were determined. The asymmetry of utricular otoliths of kinetotic samples was found to be significantly higher than that of normally behaving experimental specimens. Regarding the asymmetry of saccular otoliths of the two groups, statistically different results were not obtained. The findings strongly support the earlier theoretical concept, according to which otolith asymmetry causes (static) SMS.

Histology of the utricle in kinetotically swimming fish: a parabolic aircraft flight study

OBJECTIVES

Humans taking part in parabolic aircraft flights (PAFs) may suffer from space motion sickness, which is a form of kinetosis. As it has been repeatedly shown that some fish in a given batch also reveal kinetotic behaviour (especially so-called spinning movements and looping responses) during PAFs, and as a result of the homology of the vestibular apparatus of all vertebrates, fish can be used as model systems to investigate the origin of susceptibility to motion sickness. Therefore. we were prompted to examine the utricular maculae, which are responsible for the internalization of gravity in teleosteans of fish swimming kinetotically in microgravity (microg) in comparison with those of animals from the same batch who swam normally.

MATERIAL AND METHODS

Larval cichlid fish (Oreochromis mossambicus) were subjected to PAFs. Post-flight, animals which had behaved normally or kinetotically during the microg phases were examined histologically The sizes of the inner ear utricular maculae as well as the numbers of sensory and supporting cells were determined.

RESULTS

The total numbers of both sensory and supporting cells of the utricular maculae did not differ between kinetotic and normally swimming fish. Cell density (number of sensory and supporting cells/100 microm2) was, however, reduced in kinetotic animals (p < 0.0001), which seemed to be due to the presence of malformed epithelial cells of increased size in the kinetotic specimens.

CONCLUSION

These results indicate that susceptibility to kinetosis may originate from genetically predisposed malformed sensory epithelia.

A drop-tower experiment to determine the threshold of gravity for inducing motion sickness in fish

It has been repeatedly shown earlier that some fish of a given batch reveal motion sickness (a kinetosis) at the transition from 1 g to microgravity. In the course of parabolic aircraft flight experiments, it has been demonstrated that kinetosis susceptibility is correlated with asymmetric inner ear otoliths (i.e., differently weighed statoliths on the right and the left side of the head) or with genetically predispositioned malformed cells within the sensory epithelia of the inner ear. Hitherto, the threshold of gravity perception for inducing kinetotic behavior as well as the relative importance of asymmetric otoliths versus malformed epithelia for kinetosis susceptibility has yet not been determined. The following experiment using the ZARM drop-tower facility in Bremen, Germany, is proposed to be carried out in order to answer the aforementioned questions. Larval cichlid fish (Oreochromis mossambicus) will be kept in a camcorder-equipped centrifuge during the microgravity phases of the drops and thus receive various gravity environments ranging from 0.1 to 0.9 g. Videographed controls will be housed outside of the centrifuge receiving 0 g. Based on the video-recordings, animals will be grouped into kinetotically and normally swimming samples. Subsequently, otoliths will be dissected and their size and asymmetry will be measured. Further investigations will focus on the numerical quantification of inner ear supporting and sensory cells as well as on the quantification of inner ear carbonic anhydrase reactivity. A correlation between: (1) the results to be obtained concerning the g-loads inducing kinetosis and (2) the corresponding otolith asymmetry/morphology of sensory epithelia/carbonic anhydrase reactivity will further contribute to the understanding of the origin of kinetosis susceptibility. Besides an outline of the proposed principal experiments, the present study reports on a first series of drop-tower tests, which were undertaken to elucidate the feasibility of the proposal (especially concerning the question, if some 4.7 s of microgravity are sufficient to induce kinetotic behavior in larval fish).

Size and cell number of the utricle in kinetotically swimming fish: a parabolic aircraft flight study

Humans taking part in parabolic aircraft flights (PAFs) may suffer from space motion sickness (SMS, a kinetosis). Since it has been repeatedly shown earlier that some fish of a given batch also reveal a kinetotic behavior during PAFs (especially so-called spinning movements and looping responses) and due to the homology of the vestibular apparatus among all vertebrates, fish can be used as model systems to investigate the origin of susceptibility to motion sickness. Therefore, we examined the utricular maculae (they are responsible for the internalization of gravity in teleosteans) of fish swimming kinetotically at microgravity in comparison with animals from the same batch who swam normally. On the histological level, it was found that the total number of both sensory and supporting cells of the utricular maculae did not differ between kinetotic animals as compared to normally swimming fish. Cell density (sensory and supporting cells/100 micrometers2), however, was reduced in kinetotic animals (p<0.0001), which seemed to be due to malformed epithelial cells (increase in cell size) of the kinetotic specimens. Susceptibility to kinetoses may therefore originate in malformed sensory epithelia.

Determination of the threshold of gravity for inducing kinetosis in fish: a drop-tower experiment

It has been repeatedly shown earlier that some fish of a given batch reveal motion sickness (a kinetosis) at the transition from 1 g to microgravity. In the course of parabolic aircraft flight experiments, it has been demonstrated that kinetosis susceptibility is correlated with asymmetric inner ear otoliths (i.e., differently weighed statoliths on the right and the left side of the head) or with genetically predispositioned malformed cells within the sensory epithelia of the inner ear. Hitherto, the threshold of gravity perception for inducing kinetotic behaviour as well as the relative importance of asymmetric otoliths versus malformed epithelia for kinetosis susceptibility has yet not been determined. The following experiment using the ZARM drop-tower facility in Bremen, Germany, is proposed to be carried out in order to answer the aforementioned questions. Larval cichlid fish (Oreochromis mossambicus) will be kept in a camcorder-equipped centrifuge during the microgravity phases of the drops and thus receive various gravity environments ranging from 0.1 to 0.9 g. Videographed controls will be housed outside of the centrifuge receiving 0 g. Based on the videorecordings, animals will be grouped into kinetotically and normally swimming samples. Subsequently, otoliths will be dissected and their size and asymmetry will be measured. Further investigations will focus on the numerical quantification of inner ear supporting and sensory cells as well as on the quantification of inner ear carbonic anhydrase reactivity. A correlation between (1) the results to be obtained concerning the g-loads inducing kinetosis and (2) the corresponding otolith asymmetry/morphology of sensory epithelia/carbonic anhydrase reactivity will further contribute to the understanding of the origin of kinetosis susceptibility. Besides an outline of the proposed principal experiments, the present study reports on a first series of drop-tower tests which were undertaken to elucidate the feasibility of the proposal (especially concerning the question, if some 4.7 s of microgravity are sufficient to induce kinetotic behaviour in larval fish).

Otolithiasis in three dogs

Mineral opacities within the tympanic bullae, termed otoliths, were detected in three dogs by means of radiography and computed tomography. Radiographic signs of otitis externa were present in two dogs. One dog had clinical signs of vestibular disease, whereas the other two dogs had no clinical evidence of ear disease. Otolithiasis may represent mineralized necrotic material of a current or previous case of otitis media.

The incidence and distribution of cupular deposits in the pediatric vestibular labyrinth

OBJECTIVES

Deposits of basophilic material on the cupulae of the semicircular ducts have been described in adult human temporal bones, and such deposits have been implicated in the clinical phenomenon of benign paroxysmal positional vertigo (BPPV). Although relatively rare, BPPV has been reported to occur in children. The goal of this study was to evaluate the occurrence of cupular deposits in pediatric material.

STUDY DESIGN

Basic science, two-center histopathologic temporal bone study.

METHODS

We examined 186 temporal bones from 121 individuals between the ages of newborn and 10 years. The average age was 14.7 months. All temporal bones were acquired at autopsy, embedded in celloidin, and sectioned for light microscopic study. The cupulae of the semicircular ducts were identified and any deposits found were graded according to their size and position on the cupula.

RESULTS

A total of 276 cupulae were identified, and in 35 (12.7%) of these a basophilic deposit was found. In many cases the deposits contained recognizable otoconial crystals. Most deposits were small and they were almost equally distributed between the three semicircular ducts. However, the lateral and posterior cupulae were somewhat more involved than the superior cupula. Our data showed that cupular deposits are less frequently found in the pediatric labyrinth, compared with adults as reported in previous studies.

CONCLUSIONS

The lower occurrence in children versus adults suggests that the deposits may be a phenomenon of the aging vestibular labyrinth.

The canalith repositioning procedure for the treatment of benign paroxysmal positional vertigo: a randomized controlled trial

OBJECTIVE

To compare the canalith repositioning procedure (CRP) with a sham maneuver for the treatment of benign paroxysmal positional vertigo.

PATIENTS AND METHODS

We recruited 50 patients with a history of positional vertigo and unilateral positional nystagmus on physical examination (Dix-Hallpike maneuver). Patients were randomized to either the CRP (n = 24) or a sham maneuver (n = 26). Measured outcomes included resolution of vertigo and positional nystagmus at follow-up examination.

RESULTS

The mean duration of follow-up was 10 days for both groups. Resolution of symptoms was reported by 12 (50%) of the 24 patients in the CRP group and by 5 (19%) of the 26 patients in the sham group (P = .02). The results of the Dix-Hallpike maneuver were negative for positional nystagmus in 16 (67%) of 24 patients in the CRP group and in 10 (38%) of 26 patients in the sham group (P = .046).

CONCLUSION

The CRP is effective treatment of benign paroxysmal positional vertigo, and this procedure can be performed by general internists on outpatients with this disorder.

The familial incidence of benign paroxysmal positional vertigo

The goal of this investigation was to determine whether there is a familial tendency in the development of benign paroxysmal positional vertigo (BPPV). We hypothesized an increased frequency of BPPV among relatives of patients with the same diagnosis. BPPV is caused by dislodged otoconia from the utricular macula floating in the semicircular canals. At least half of BPPV cases are idiopathic and most pathological associations provide no clue as to the reason otoconia become dislodged. We have noted a number of BPPV patients with family histories of BPPV, suggesting a genetic predisposition to the condition. We surveyed 120 successive BPPV patients and 120 successive dizzy patients without BPPV regarding the frequency of dizziness and BPPV (diagnosed by a physician) among family members. Patients in our group with BPPV were 5 times as likely to have relatives with BPPV compared to the dizzy control group (chi2=5.95, DF=1, p=0.015). We have demonstrated that there is a familial tendency for the occurrence of BPPV. There is nothing in our data that would distinguish between a hereditary or environmental influence in the development of the disease, however.

[Individual differences in susceptibility to motion sickness]

Several different theories exist about the origin of kinetosis and the space adaptation syndrome, with individual sensitivities differing significantly. One explanation involves the hypothesis of a different otolith mass between the right and left statolith organ and especially a difference in the utricles. A difference in mass results in a different sensitivity to acceleration. For this reason we measured interindividual variances in saccular and utricular otolith mass. Since the anatomy of the vestibular organ in vertebrates is based as similar principles, we selected fish (salmon and trout) as our study model to facilitation preparations. The maximum difference in mass in the saccule was 17% and was generally smaller in the utricle, although in individual cases was much higher. We assume that a misbalanced sensitivity of the statolith organs occurs but is totally compensated for by the vestibular system as long as physiological motion patterns take place. Decompensation leads to kinetosis under non-physiological motion patterns. When the vestibular system is better balanced and has an equally distributed otolith mass to both sides, the possibility for developing kinetosis or space adaptation syndrome is much less likely.

Particulate matter in the posterior semicircular canal

The pathoetiology of benign paroxysmal positional vertigo (BPPV) is controversial. Particulate matter within the posterior semicircular canal has been identified intraoperatively in patients with BPPV but has also been reported in non-BPPV patients at the time of translabyrinthine surgery (Parnes LS, McClure JA. Free-floating endolymphatic particles: a new operative finding during posterior semicircular canal occlusion. Laryngoscope 1992;102:988-92; Schuknecht HF, Ruby RRF. Cupulolithiasis. Adv Otorhinolaryngol 1973;20: 434-43; Kveton JF, Kashgarian M. Particulate matter within the membranous labyrinth: pathologic or normal? Am J Otol 1994;15:173-6). The nature of the particulate matter remains unknown. The purpose of this study was to prospectively examine the posterior semicircular canal of patients with and without a clinical history of BPPV for the presence of particulate matter. Seventy-three patients without BPPV symptoms undergoing labyrinthine surgery (vestibular schwannoma excision or labyrinthectomy) and 26 patients with BPPV undergoing the posterior semicircular canal occlusion procedure were compared. Additionally, 70 archived temporal bones without a history of BPPV were examined microscopically for the presence of particulate matter within the lumen of the membranous labyrinth. No particles were observed intraoperatively in any of the 73 patients without a history of BPPV. Particulate matter was observed in 8 of 26 patients at the time of the posterior semicircular canal occlusion procedure for intractable BPPV. Of the 70 temporal bones examined, 31 did not show significant postmortem changes and also did not demonstrate cupulolithiasis or canalithiasis. Particulate matter from within the membranous posterior semicircular canal was removed from one patient at the time of posterior semicircular canal occlusion for intractable BPPV symptoms and was examined by scanning electron microscopy. The particulate matter appeared morphologically consistent with degenerating otoconia. These data show a statistically significant association between the presence of particles within the posterior semicircular canal in this study and the symptom complex of BPPV.

[Observation of inner ear injury after landing impact in sitting position in Rhesus monkeys]

Tolerance limits of different tissues to landing impact were studied by doing experiment in Rhesus monkeys. 10 Rhesus monkeys were divided into three groups, each suffered a different landing load. The monkeys were killed lh after the experiment, and heart, liver, spleen, lung, and temporal bone were fixed, sliced, and then observed under microscope. Injuries of inner-ear were also observed. The results showed that when acceleration measured at the impact platform was less than 25 G, only slight injuries were found in the various organs and no injury was found in the inner ear; when platform acceleration was 25-35 G intermediate injuries were found in the various internal organs, and slight injury was found in the inner ear, such as detachment of otolith from macula of saccule and separation of epithelium in the ampulla.

Benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo should be considered when a patient complains of attacks of dizziness of brief duration, that seem to occur under particular circumstances related to the position of the head. The true nature of the disorder may be missed unless examination is carried out in a certain way: the head must be positioned below the rest of the body and turned to one or other side. Diagnosis then depends on the occurrence of vertigo and on noting the transient nystagmus. There are a number of causes of benign paroxysmal positional vertigo-head injury is a relatively frequent one. It has been suggested that this disorder is due to deposits on the cupula of the precipitating posterior semicircular canal. Indeed, exercises designed to dislodge such deposits can be successful. If not, and the vertigo lasts for more than a few months, surgery can be considered.

Particle repositioning for benign paroxysmal positional vertigo

Benign paroxysmal positional vertigo is a common condition that can be severely incapacitating. The causative mechanism is usually displaced dense particles (canaliths) in a semicircular canal. By means of canalith repositioning, these particles can be moved into the utricle and the symptoms completely resolved in a high percentage of cases. The protocol for procedure is discussed as well as the management of complications and recurrences.

Update on posterior canal occlusion for benign paroxysmal positional vertigo

Most, if not all, cases of BPPV appear to result from free-floating posterior semicircular canal endolymph particles. Particle repositioning alleviates symptoms and findings in the vast majority of patients. For the small intractable group of nonresponders, posterior semicircular canal occlusion remains a safe and highly efficacious procedure. This new technique has also paved the way for even newer and most invasive inner ear procedures.

Basophilic deposits on the cupula: preliminary findings describing the problems involved in studies regarding the incidence of basophilic deposits on the cupula

In this study, the possibility of whether basophilic deposits adhered to the cupulas in the semicircular canals was investigated histologically. Results indicated that basophilic deposits were present in all three cupulas of the semicircular canals. The overall incidence of basophilic deposits in the superior, lateral and posterior semicircular canal cupulas was 26%, 41% and 37%, respectively. The incidence of basophilic deposits bound to the cupulas increased with age. The possible origin of these basophilic deposits on the cupulas and the increased incidence of basophilic deposits with increasing age are discussed.

Vestibular morphology in relation to age and circling behavior

The DBA/2 strain of mice have genetically induced vestibular dysfunction that presents grossly at an early age as circling behavior and abnormal righting reflexes. The vestibular morphology of this strain has not previously been examined. DBA/2 mice of different ages that showed circling behavior were sacrificed and then had their inner ears immediately removed and fixed in glutaraldehyde. The specimens were prepared for light, transmission and scanning electron microscopy. Additional specimens at 10 months of age were fixed with paraformaldehyde for immunohistochemical investigation and labelling of alpha-actinin. Non-circling litter mates served as controls. The morphology and immunohistochemistry of the vestibular end-organs were evaluated as a function of age and circling behavior. The sensory epithelium of the ampulla and utricle in the circling mice showed softening of the cuticle, hair cell cytoplasmic herniation, expelled cellular debris, fused stereocilia and giant hair cells that progressively increased in severity with age. The non-circling litter mates showed similar but less severe pathology of the vestibular sensory epithelium. The immunohistochemical analysis showed no differences at a magnification of 400 x.

Torsional vestibulo-ocular reflex measurements for identifying otolith asymmetries possibly related to space motion sickness susceptibility

Recent studies by Diamond and Markham have identified significant correlations between space motion sickness susceptibility and measures of disconjugate torsional eye movements recorded during parabolic flights. These results support an earlier proposal by von Baumgarten and Thumler which hypothesized that an asymmetry of otolith function between the two ears is the cause of space motion sickness. It may be possible to devise experiments that can be performed in the 1 g environment on earth that could identify and quantify the presence of asymmetric otolith function. This paper summarizes the known physiological and anatomical properties of the otolith organs and the properties of the torsional vestibulo-ocular reflex which are relevant to the design of a stimulus to identify otolith asymmetries. A specific stimulus which takes advantage of these properties is proposed.

Paroxysmal positional vertigo in the elderly

In a retrospective study of 806 patients 70 years of age or older complaining of dizziness, 328/806 (40.7%) patients gave a history strongly suggestive of paroxysmal positional vertigo. This prevalence was higher than in other age groups of 7,269 patients seen in our Dizziness Clinic (33.7% in patients 50 years of age or younger; 26.6% in patients 40 years of age or younger). In 158/328 patients, the paroxysm was elicited and nystagmus occurred; in 135/158 patients, the observed nystagmus, during the paroxysm, was identified and in 131/135 patients, it was of the type described by Barany. It is concluded that: (a) the prevalence of paroxysmal positional vertigo increases with advancing age; (b) the usually observed nystagmus, during the paroxysm, in the elderly is of the type described by Barany, and similar to the nystagmus observed in other age groups.

Statoconia displacement in squirrel monkey ears

When findings in squirrel monkey temporal bones after streptomycin sulfate intoxication were compared with those after application of intense linear acceleration, the dislocated utricular statoconia were more frequently found around the cupula of the crista ampullaris posterior in the latter group, whereas statoconia were rather widely disseminated within three semicircular canals (cupula, ampulla, and duct) after streptomycin intoxication. This difference is most probably due to the fact that, in the linear acceleration group, normal statoconia were instantaneously dislodged in a block (or forming a large-sized mass) and thereafter moved in the gravity direction, whereas in the streptomycin group, degenerated statoconia formed smaller groups and were more freely disseminated. In the endolymphatic sac, dislocated statoconia were readily phagocytosed by the epithelium of the intermediate portion and rugous portion (and transitory portion). The incidence of phagocytosis was found more in the streptomycin group, compared to the linear acceleration group.

Abnormal otoconia and calcification in the labyrinths of deaf Dalmatian dogs

Abnormal mineral deposits from the membranous labyrinths of deaf Dalmatian puppies were examined microscopically. Most such deposits were located on the saccular otoconial membrane and were associated with collapse of the saccule and of Reissner's membrane. In both ears of one pup, crystals resembling otoconia were found on the surface of the stria vascularis. In two others, grossly abnormal crystals were seen on the utricular otoconial membrane, and in one of these crystals were also attached to the cupula of the left horizontal canal. In four animals the tectorial membrane was calcified. Most deposits consisted of apatite spherulites, but large multiple crystals (probably of calcite) were occasionally present. Some of the abnormal mineral deposits in the Dalmatian closely resemble those found in man, and they may originate in the same way.

Cupulolithiasis and posterior ampullary nerve transection

Schuknecht's description of a degenerated otoconial mass embedded in the cupula of the posterior canal crista of the downmost ear in the Hallpike test has been termed cupulolithiasis to reflect the pathophysiology in the syndrome described by Barany. The hypothesis that the otoconial mass renders the cupula of the posterior canal gravity-sensitive has received considerable experimental and clinical support. Clinical support is provided here by the observation that complete relief of the paroxysmal positional vertigo followed transection of the posterior ampullary nerve (singular nerve) in 31 ears of 29 patients complaining of chronic cupulolithiasis. Two patients in the series exhibited bilateral cupulolithiasis and were relieved by sequential bilateral singular neurectomies. Twenty-seven patients were relieved by unilateral singular neurectomy. Although there were three instances of sensorineural hearing loss following surgery in the first 15 patients, no hearing loss has been observed following surgery in the last 16 operations. This low incidence of sensorineural hearing loss has resulted from modifications in surgical technique.

Microprobe analysis of human otoconia

Utricular and saccular otoconia (N = 510) from 1 fetus (39th gestational week; Trisomy-18), 2 babies (1 1/2 and 2 months) and 3 adults (58, 61 and 77 years) were analysed with an energy dispersive X-ray microprobe. In all otoconia the elemental composition showed an extremely high concentration of Ca but also Na, Mg, P, S, Cl and K were identified. The presence of non-Ca elements was interpreted as being due to a protein nucleus of the otoconia. Non-Ca elements are more prominent during fetal age and early post-natally than later in life. Old age otoconia contained high concentrations of P which indicates that a ' phosphatization ' of aging otoconia occurs, i.e. calcite otoconia are transformed in situ into apatite by reaction with phosphate ions. The elemental composition of otoconia in Trisomy-18 was similar to that in early postnatal inner ears.

The effect of stapedectomy on hearing of patients with otosclerosis and Meniere's disease

To determine new guidelines for stapedectomy in patients with both Meniere's disease and otosclerosis, we studied the position of the saccular membrane and Reissner's membrane in relation to the stapes footplate in eight temporal bones from patients with Meniere's disease. We also reviewed charts of four patients with both otosclerosis and Meniere's disease who had stapedectomy. Histologic and clinical findings were compared with preoperative bone conduction levels at 500 Hz and at high frequencies. We found that the saccular and Reissner's membranes did not contact the stapes footplate ain bones of patients with preoperative bone conduction levels of 35 dB or better at 500 Hz and no high-frequency loss. We also found that stapedectomy was successful in patients with the same criteria. We therefore conclude that stapedectomy does not increase the risk of sensorineural hearing loss for patients with otosclerosis and Meniere's disease who have bone conduction levels of 35 dB o better at 500 Hz and no high-tone loss, but it is contraindicated for patients with 45 dB at 500 Hz or worse and with high-tone loss.

Normal and altered otoliths of guinea pigs. Scanning electron microscopy observations

Normal morphology and structural alterations of the otoliths were observed in 20 young albino guinea pigs. Ten animals had been exposed to long-term treatment with an aminoglycoside antibiotic and ten others, which had not been treated, have been analyzed as a control group. The observations were carried out using scanning electron microscopy. All the animals survived the period of stabling and treatment. They were sacrificed and the temporal bones were dissected and fixed with 2% osmium tetroxide buffered at pH 7.4. The inner ear was subsequently dehydrated, microdissected, dried with CO2, and coated with gold. Different kinds of deterioration were observed and valued according to the appearance of the otoliths, which looked as if they had been melted, with many pores and wide and prominent cavitations probably due to chemical etching.