Dennis C. Fitzgerald

Labyrinthine Enhancement on Gadolinium-Enhanced Magnetic Resonance Imaging in Sudden Deafness and Vertigo: Correlation with Audiologic and Electronystagmographic Studies

Sudden deafness with or without vertigo presents a difficult diagnostic problem. This article describes 12 patients with enhancement of the cochlea and/or vestibule on gadolinium–diethylenetriamine pentaacetic acid–enhanced magnetic resonance imaging (MRI), correlating the enhancement with the auditory and vestibular function. All patients were studied with T2-weighted axial images taken through the whole brain, enhanced 3-mm axial T1-weighted images taken through the temporal bone, and enhanced T1-weighted sagittal images taken through the whole brain. Cochlear enhancement on the side of hearing loss was found in all the patients. The vestibular enhancement correlated with both subjective vestibular symptoms and objective measures of vestibular function on electronystagmography. In 2 patients, the resolution of symptoms 4 to 6 months later correlated with resolution of the enhancement on MRI. No labyrinthine enhancement was seen in a series of 30 control patients studied with the same MRI protocol. Labyrinthine enhancement in patients with auditory and vestibular symptoms is a new finding and is indicative of labyrinthine disease. While abnormalities on electronystagmograms and audiograms are nonspecific and only indicate a sensorineural problem, enhanced MRI may separate patients with retrocochlear lesions, such as acoustic neuromas, from those in whom the abnormal process is in the labyrinth or the brain.

Intratympanic Steroids for Idiopathic Sudden Sensorineural Hearing Loss

Objectives: We undertook to evaluate the effectiveness of intratympanic (IT) steroid injections for treating idiopathic sudden sensorineural hearing loss (ISSHL) by performing a retrospective case series study in a private otology practice. Methods: A total of 21 eligible patients with ISSHL were included. We defined ISSHL as a hearing loss of 20 dB or more at at least 3 consecutive audiometric frequencies that develops within 72 hours or less and cannot be attributed to any commonly identifiable cause of sudden hearing loss. Three IT injections of 0.4 mL of 62.5 mg/mL methylprednisolone solution were administered 1 week apart. The end point for the study was a clinically significant change in audiometric values, with a positive response determined to be a 10-dB or greater improvement in the 4-tone pure tone average and/or a 15% or greater improvement in the word discrimination score. Audiometric data were recorded just before therapy and 1 week after the last IT treatment. The potentially confounding variables recorded included age, sex, “prompt treatment” (defined as treatment within 14 days from onset), concurrent or prior treatment with oral steroids, and severity of hearing loss. Results: The overall response rate to the IT steroid protocol was 67% (14 of 21 patients), with a 95% confidence interval of 43% to 85%. Backward stepwise logistic regression identified “prompt treatment” as the only variable that significantly affected the outcome. The response rate of the “prompt treatment” cohort was 91% (10 of 11 patients), with a 95% confidence interval of 59% to 100%. Conclusions: These findings support the use of IT steroids as an early intervention in the treatment of ISSHL.

VIRAL COCHLEITIS WITH GADOLINIUM ENHANCEMENT OF THE COCHLEA ON MAGNETIC RESONANCE IMAGING SCAN

Sudden hearing loss is a clinical diagnosis describing hearing losses of sensorineural origin. The time period before onset is usually 72 hours. Many also characterize the loss by a decrement of at least 30 dB in 3 contiguous test frequencies. 1 , 2 The causes are numerous, but one of the most frequent causes is a viral infection. 3 – 6 One strong indication of a viral cause is an acute antibody titer elevation with a subsequent 4-fold reduction in titer during the next 2 months. 3 – 6 Articles in the radiologic literature have chronicled the findings of enhancement of the inner ear with gadolinium MRI scans in cases of presumed viral infections. 7 , 8 This is the first article to report the MRI enhancement of the cochlea in 2 patients with seroconversion evidence of a viral cochleitis.

Perilymphatic Fistula: A Washington, D.C., Experience

One hundred ninety-seven patients who underwent surgical repair for a presumed unilateral perilymphatic fistula (PLF) were reviewed. Of those patients, 87% with vestibular symptoms reported complete or near-complete relief of their symptoms. Forty percent of the patients with sudden hearing loss had an improvement in their hearing levels. An analysis of several diagnostic tests revealed their sensitivity and specificity ratings. A review of the patients’ operative records showed a marked disparity between the visual identification of an actual fluid leak during surgery and their postoperative outcome. This review supports the premise that at the present time, the patient’s surgical outcome is the best way of documenting a successfully repaired PLF.

Pinch skin grafting for idiopathic inflammatory medial meatal fibrotizing otitis

Objectives: Idiopathic inflammatory medial meatal fibrotizing otitis is an uncommon disorder of the external auditory canal characterized by desquamation of the medial canal skin, chronic inflammation, and eventual canal stenosis. Medical treatment consists of regular debridement, topical and systemic steroids, and antimicrobials for acute infections. Surgical treatment of canal stenosis by removal of the fibrotic plug followed by split thickness skin grafting has been reported. However, skin grafting of the canal prior to development of complete stenosis has not been reported. Methods: Case report of a 72-year-old male hearing aid user who was referred for a 7-month history of recurrent external otitis and subsequent stenosis of the external auditory canals. On physical exam, he had erythema, granulation tissue, and synechia in the medial external auditory canals bilaterally. Treatment consisted of regular debridements, external canal wicks, high potency topical steroids, oral steroids, ear powder, and systemic and topical antibiotics. After 20 months of medical treatment, the external canals remained patent but failed to epithelialize. Pinch skin grafts from the posterior auricular area were applied to the medial canal tissue in the office under local anethesia. Results: After 6 weeks, the skin grafts have become adherent to the medial canal tissue and are beginning to epithelialize the canal. There has been no further stenosis. Conclusion: Pinch skin grafting in medial meatal fibrotizing otitis is a promising technique for restoring the epithelium in this chronic condition. The long-term viability of the epithelium and the affect on disease progression deserves further investigation.

MRI of the temporal bone and cerebellopontine angle

Educational objectives: To understand the applications of MRI scanning of the temporal bones, including infection, neoplasms, trauma, and autoimmune diseases; to evaluate more properly disorders of the temporal bone; and to better understand the role of gadolinium-enhanced MRI scanning of the temporal bone and cerebellopontine angle.