Dae Bo Shim

Benign paroxysmal positional vertigo with simultaneous involvement of multiple semicircular canals.

Background and Objectives Benign paroxysmal positional vertigo (BPPV) generally involves a single semicircular canal (single canal BPPV) but it has been reported that more than one semicircular canal on either the same or the opposite side can be involved in 6.8-20% of the cases (multiple canal BPPV). In this study, the clinical characteristics of multiple canal BPPV were analyzed and compared to those of single canal BPPV. Materials and Methods Retrospective analysis was performed on 1054 consecutive patients diagnosed with BPPV. Multiple canal BPPV was diagnosed when the combination of typical nystagmus was provoked by the Dix-Hallpike and supine head roll tests. Canalith repositioning maneuver was performed sequentially starting with the semicircular canal causing more severe nystagmus or symptoms. Clinical characteristics and the treatment course were statistically compared between single canal BPPV and multiple canal BPPV. Results Among the 1054 patients, single canal BPPV was diagnosed in 1005 patients (95.4%) while multiple canal BPPV was diagnosed in 49 patients (4.6%). BPPV involving semicircular canals on the same side was more common (79.6%) than BPPV with bilateral involvement. The most common combination of the involved canals was ipsilateral posterior and horizontal semicircular canals (63.3%). Multiple canal BPPV was significantly more associated with underlying otologic diseases, especially labyrinthitis. Multiple canal BPPV required more treatment sessions and longer duration of treatment to achieve resolution of nystagmus and symptoms. Conclusions As all cases of multiple canal BPPV were treated successfully although a longer duration of treatment and more treatment sessions were required compared to single canal BPPV, the results of our study could aid in making an accurate diagnosis and providing appropriate treatment of multiple canal BPPV.

Surgical management of labyrinthine fistula in chronic otitis media with cholesteatoma

OBJECTIVE To present the surgical outcomes of complete removal of the matrix of labyrinthine fistulas in a large series of middle ear cholesteatomas. PATIENTS AND METHODS This is a retrospective study. We analyzed 38 of 778 patients who were operated on for cholesteatoma and were proved to have labyrinthine fistula from 1991 to 2007. For this study, a more aggressive strategy was adopted that compromised immediate total removal of the matrix, regardless of size. To evaluate the safety and efficacy of the procedure, pre and postoperative pure-tone audiometry were compared and the recurrence rate was analyzed. Relevant data from the literature using a wide array of strategies were compared with our results. RESULTS Only two patients suffered from postoperative hearing deterioration of bone conduction of more than 10dB HL. There was no relationship between the size of labyrinthine fistulas and postoperative hearing deterioration. Recurrence of labyrinthine fistulas was not found. CONCLUSIONS Total removal of the cholesteatoma matrix in one step is a safe and effective method for the treatment of labyrinthine fistulas.

An ectopic hamartomatous thymoma

An ectopic hamartomatous thymoma is an extremely rare benign tumor of the lower neck that is the most common in middle-aged males. Pathologically, the tumor is characterized by a mixture of spindle cells, epithelial cells, mature adipose tissue, and lymphocytes. The histogenesis of this tumor is controversial. Recently, an origin from a remnant of the cervical sinus of His was proposed. Malignant lesions such as synovial sarcomas or malignant peripheral nerve sheath tumors can have similar clinical features and radiologic images. Thus, recognition of this tumor is important because it follows a benign clinical course and conservative surgical excision is the treatment of choice. Here, we report the case of a 34-year-old man with an ectopic hamartomatous thymoma in the left supraclavicular region and a review of the literature on this tumor.

Persistent Spontaneous Nystagmus Following a Canalith Repositioning Procedure in Horizontal Semicircular Canal Benign Paroxysmal Positional Vertigo

IMPORTANCE Nystagmus can occur spontaneously from multiple causes. Direction-changing positional nystagmus on the supine roll test is a characteristic clinical feature in horizontal semicircular canal benign paroxysmal positional vertigo. One of several mechanisms of spontaneous nystagmus is plugging of the otoconia, which has been described as a canalith jam. OBSERVATIONS We evaluated a 52-year-old woman with a history of geotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo on the right side who had been treated with a modified Lempert maneuver 3 months earlier. The patient had persistent spontaneous nystagmus, despite a positional change after the canalith repositioning procedure. A bithermal caloric test result demonstrated unilateral canal paresis on the right side. The following day, the patients symptoms and nystagmus had subsided. On a repeated bithermal caloric test, a normal response was demonstrated on both sides. CONCLUSIONS AND RELEVANCE To our knowledge, this is the first report of a case that shows on video persistent nystagmus findings consistent with a canalith jam. We discuss a possible mechanism underlying this phenomenon.

Useful surgical techniques for facial nerve preservation in tumorous intra-temporal lesions

The management of the facial nerve in tumorous temporal lesions is particularly challenging due to its complex anatomic location and potential postoperative complications, including permanent facial paralysis. The most important concern regarding surgical treatment of a tumorous temporal lesion is the inevitable facial paralysis caused by nerve injury during the tumor removal, especially in patients with minimal to no preoperative facial nerve dysfunction. We describe successful four cases in which various surgical techniques were developed for the preservation of the facial nerve in treatment of intratemporal tumorous lesions.

Severe to profound hearing loss in patients with progressed Alport's syndrome.

Conclusion: The concept of hearing loss severity must be redefined, as there is a clear need for more active hearing management in Alports syndrome patients with severe and profound hearing loss. Objectives: Sensorineural hearing loss (SNHL) caused by Alports syndrome generally does not exceed 60–70 dB, because a cochlear lesion is responsible for this hearing loss. Careful management of renal function improves the prognosis and the longevity of Alports syndrome patients; it is useful to reassess SNHL caused by Alports syndrome. Patients and methods: Thirty-two patients with Alports syndrome were analyzed retrospectively. Pure tone audiograms (PTAs), speech audiograms, and transiently evoked otoacoustic emissions (TEOAEs) were performed. Hearing loss severity was compared to duration of disease and severity of renal dysfunction. We also evaluated the correlation between OAEs and PTAs according to the hypothesis that evoked OAEs would be abnormal even in early stage SNHL in Alports syndrome. Results: The level of hearing was positively correlated with disease duration. The hearing of the end-stage renal disease (ESRD) group, whose hearing threshold could exceed 70 dB, was worse than that of the non-ESRD group. OAEs were found in patients with normal hearing and mild hearing loss and had no significant early detection value.

Three-point fix tympanoplasty

Abstract Conclusion: The three-point fix tympanoplasty procedure is a stable and effective technique – with a high degree of graft take and satisfactory hearing results – for reconstruction of most tympanic membrane (TM) perforations. Objective: It is difficult to repair a TM perforation, including subtotal perforation, involving the anterior part of the annulus. Reperforation can occur when an underlay graft technique is used. An overlay graft technique may result in anterior blunting/lateralization. We introduce a three-point fix tympanoplasty procedure, which can provide additional support to yield a stable graft. Methods: The study enrolled a total of 234 patients who underwent a three-point fix tympanoplasty procedure from November 2005 to June 2011. Anatomic success was defined as an intact, repaired TM, while functional success was defined as a significant decrease in the air–bone gap at the end of follow-up compared with preoperative hearing (air–bone gap). The complication rate was also analyzed. Results: The anatomic success rate was 93.2% (218/234 patients). The functional success rate after an average of 1 year was 73.5%. The postoperative average pure-tone air–bone gap (15.4 ± 11.4 dB) decreased successfully in comparison with the preoperative average air–bone gap (20.6 ± 12.1 dB). There were few postoperative complications (7.7%).

Typical sensory organization test findings and clinical implication in acute vestibular neuritis

OBJECTIVE Sensory organization test (SOT) is used to evaluate postural instability. We wanted to characterize the SOT findings in patients with acute vestibular neuritis (VN). METHODS Eighty-seven patients with VN were enrolled. The bithermal caloric and SOT were performed, and the results were compared with those from the dizziness handicap inventory (DHI). Abnormal SOT patterns were classified: severe, visual vestibular, vestibular, inconsistent, or normal patterns. The results were also analyzed by sensory analysis (somatosensory, visual, vestibular, and visual preference) and composite scores. RESULTS Sixty-one patients (70%) showed abnormal findings for conditions 5 and/or 6 (vestibular pattern), and half (30 of 61, 49%) of them showed additional abnormal results in more than conditions 5 and 6. In pattern analysis, the vestibular pattern (abnormal in conditions 5 and 6) was the most common pattern (36%), and the visual vestibular pattern (abnormal in conditions 4, 5, and 6) was the second most common (24%). In sensory analysis, vestibular dysfunction was observed in 59 patients (68%), visual dysfunction in 37 (43%), visual preference in 17 (20%), and somatosensory dysfunction in 5 (6%). Composite scores of SOT showed a significant correlation with the DHI scores, though no correlation was observed between DHI and caloric results (p<0.05). CONCLUSION VN can adversely influence on postural instability, with more severe patterns as well as classical vestibular patterns, indicating that abnormal vestibular inputs can influence postural stability in all SOT conditions and subjective symptom in patients with acute VN is more closely associated with the postural instability rather than canal dysfunction.

A Case of Labyrinthine Fistula by Cholesteatoma Mimicking Lateral Canal Benign Paroxysmal Positional Vertigo

Acute peripheral vestibulopathy, of which the chief complaint is positional vertigo, comprises benign paroxysmal positional vertigo (BPPV), labyrinthitis, labyrinthine fistula, and cerebellopontine angle tumors. Since the typical presentation of labyrinthine fistulas may be sensorineural hearing loss, positional vertigo, or disequilibrium, it is often difficult to distinguish from BPPV or Menieres disease. Herein we report a 61-year-old female patient with typical symptoms and signs attributable to geotropic type variant of the lateral semicircular canal BPPV on the left side, who eventually was confirmed as having a labyrinthine fistula from chronic otitis media with cholesteatoma on the left side. This is another case where, even in the presence of isolated vertigo showing typical findings of acute peripheral vestibulopathy, other otologic symptoms and signs must not be overlooked.

Can the affected semicircular canal be predicted by the initial provoking position in benign paroxysmal positional vertigo

The study evaluated the relationship between the position that initially provoked vertigo and the affected semicircular canal (SCC) in patients with benign paroxysmal positional vertigo (BPPV), and aimed to predict the side affected by BPPV through history taking regarding the provoking position.