Dennis G. Pappas

Autonomic related vertigo

Objectives: To demonstrate clinical evidence that vestibular symptomatology can occur in relation to autonomic dysfunction. Characterization of clinical findings and treatment response would then allow autonomic related vertigo to be differentiated from other vertiginous conditions that present in a like manner. Study Design: This was a retrospective review of 113 patients that described symptoms consistent with spontaneous, rotational vertigo and autonomic dysfunction. Methods: Vestibular, otologic, and autonomic symptoms are presented along with the results of audiologic, orthostatic, and autonomic testing. Medical management included fluid loading, dietary changes, exercise, and patient education. Treatment results were analyzed according to the effectiveness in control of vestibular and otologic symptoms. Results were compared with a control group that demonstrated a similar vestibular and otologic presentation without autonomic symptomatology. Results: All patients described spontaneous, rotational vertigo, with complete or substantial vertigo control obtained in 93 (85%) of 110 patients. Postural vertigo and distinct lightheadedness were also documented in 53% and 97% of cases, respectively. Vertigo failed to improve or worsened with prior treatment of low sodium diet or diuretic in 53 (91%) of 58 cases. Vertigo improvement was subsequently achieved in 48 (86%) of 56 cases with an autonomic treatment regimen. Long‐term vertigo control was obtained in 56 (88%) of 64 patients followed for at least 18 months. Tinnitus was reported in 97 (86%) patients, aural fullness in 93 (82%) patients, and subjective hearing loss (HL) in 46 (41%) of 111 cases. Bilateral tinnitus and aural fullness occurred in 65% and 63%, respectively. Tinnitus improved with treatment in 56 (67%) of 84 patients, whereas aural fullness improved in 59 (74%) of 80 patients. Autonomic symptoms included palpitations in 103 (91%) patients, chronic fatigue in 102 (90%) patients, cold extremities in 91 (81%) patients, and previous fainting in 72 (64%) patients. A history of mitral valve prolapse was documented in 51 (45%) of cases and demonstrated with echocardiogram in 68 (93%) of the 73 patients tested. Audiologic testing was normal in 104 (95%) of 109 patients, and electrocochleography was abnormal in 42 (40%) of 105 patients. Orthostatic blood pressure and heart rate testing met the criteria for orthostatic hypotension in 16 (15%) of 104 patients. Autonomic testing was obtained in 34 cases, with orthostatic intolerance demonstrated in 33 (97%) patients and orthostatic hypotension demonstrated in 13 (38%) patients. Overall, orthostatic hypotension was documented through combined testing results in 23 (21%) of 107 patients. Vertigo was reproduced during autonomic testing in 17 (77%) of 22 patients, and otologic symptoms were reproduce in 9 (47%) of 19 patients. Comparison of the study population with a control group without autonomic symptoms revealed statistically significant differences in orthostatic testing and treatment results. There was no statistical difference noted in findings between patients of this study that demonstrated or failed to demonstrate orthostatic hypotension. Conclusions: There is a subgroup of patients with spontaneous vertigo who also demonstrate symptoms and findings consistent with poor autonomic regulation. These patients report vertigo improvement with a treatment strategy that aims to improve autonomic dysfunction through expansion of effective circulating volume. Clinical findings and treatment results of this study suggest an underlying autonomic influence in the production of vertigo and otologic symptoms.

A study of the high-risk registry for sensorineural hearing impairment.

In the medical evaluation, rehabilitation, and education of the hearing impaired, the first line of defense is the high-risk factor screening for sensorineural damage of all neonates. The most efficacious means of neonatal screening for those factors affecting sensorineural hearing damage is the employment of a high-risk registry. Based on a retrospective study of 109 children with sensorineural loss, high-risk factors and how improved use of the high-risk registry permits earlier detection (and statistically more successful rehabilitation) for such auditory-impaired children are discussed. The importance of pediatric screening of all neonates for hearing loss, in addition to use of the high-risk registry, is evidenced by the fact that only 46% of the children retrospectively identified in our study would have routinely appeared among the high-risk infants were the registry used alone.

Petrous Jugular Malposition (Diverticulum)

Jugular bulb anatomy is variable. A “high-riding” bulb extending into the tympanic cavity is a well-described anomaly. Petrous jugular malposition (diverticulum) (PJMD), however, is rare. The relationship between PJMD and clinical symptoms is questionable because the differentiation between PJMD as an anatomic variant and pathologic process is unproved. A literature review reveals 14 previously documented cases. We report an additional four cases. Diagnostic and management dilemmas are discussed, with the importance of high-resolution CT Stressed.

Arachnoid Cysts of the Posterior Fossa

The clinical symptoms and signs of four patients with arachnoid cysts in the posterior fossa are discussed. In three patients, the cyst was in the internal auditory canal; one patient had an acoustic neuroma and two large cysts in the cerebellum. Whereas the conventional diagnostic tests for acoustic neuroma cannot differentiate between neuromas and arachnoid cysts, the newer thin section body scanners can show a lesion with no enhancement in the case of the cyst. Surgical approaches for removal of this lesion must take into consideration the preservation of hearing in the involved ear.

Otology through the ages.

Recounted are some, not all, of the most significant contributions to otology. The history of otology has, for the most part, followed the history of medicine: Little was known of otology by the ancient physicians, but their work must be reviewed to appreciate the progress that has been made. Most of the otology produced during the Middle Ages was limited to those structures that were readily accessible; otologic surgery was confined to trauma and removal of foreign bodies from the external auditory canals. Examination of the ear began after studies of the ear by Italian anatomists during the seventeenth century. It was not until the end of the eighteenth century that magnification was used so that the minute anatomic details could be observed. The clinical specialty of otology started in France (1850s), emerged as a scientific specialty in England, and received explosive progress from the German-speaking countries at the end of the nineteenth century. Otology has a remarkable background.

Dizziness and the Autonomic Dysfunction Syndrome

Dizziness resulting from inner ear or CNS disease has been well described. However, there is a large number of patients for whom dizziness does not seem to be related to either the ears or the CNS. We postulate an abnormality in the autonomic nervous system of such patients and have used standard tilt testing and Valsalva methods to assess the abnormality. Based on the results of these tests, we can suggest therapeutic options.

Facial nerve outcome in lateral skull base surgery for benign lesions

Objective: To statistically identify factors most important in affecting CN7 outcome in lateral skull base surgery for benign lesions. Study Design: A retrospective review of 217 nonmalignancy lateral skull base procedures from 1970 to 1995 at the Otology Group in Nashville. Methods: Charts were reviewed for epidemiology, histopathology, staging, type of CN7 mobilization (none, short, long, severance with reanastomosis, and resection), preoperative and postoperative CN7 function, surgery performed, and survival. Results: Average House‐Brackman (HB) scores for mobilizations were as follows: short, 1.65: long, 2.74: and grafting, 4.33. Factors found to affect outcome in a statistically significant fashion were preoperative HB score, staging, type of CN7 manipulation, and surgical approach. Meningiomas were found to have a worse outcome than glomus tumors. Conclusions: Complete resection of tumors should be performed with minimal manipulation of the facial nerve based on regional anatomy and tumor anatomy. Laryngoscope, 108:1480–1484, 1998

The management of childhood hearing losses

Educational objectives: To provide appropriate management for children with sensorineural hearing loss and to select appropriate speech and language rehabilitation strategies.