Ektor Tsuneo Onishi

Intracranial complications of otitis media: 15 years of experience in 33 patients:

OBJECTIVES: Complications in the central nervous system (CNS) from acute otitis media (AOM) and chronic otitis media (COM) are becoming fewer, although they still represent a challenge for early recognition, adequate treatment, and satisfactory results. This retrospective study analyzed clinical data and therapeutic options in 33 patients with intracranial involvement resulting from otitis media. Important clinical features of intracranial complications and the sequence of the most efficient therapeutic maneuvers are discussed. METHODS: Charts of six patients with AOM and 27 patients with COM associated with CNS complications were analyzed for clinical presentation, imaging, and therapeutic approach. RESULTS: Ages ranged from 6 months to 79 years, with no gender predilection. Persistent fever, headache, and purulent otorrhea were the main symptoms. Proteus mirabilis, Enterococcus, and Pseudomonas aeruginosa were the most common microorganisms in COM, and Pneumococus and Haemophilus were the most common microorganisms in AOM. Nineteen patients (58%) presented with more than 1 CNS complication, resulting in a total of 56 complications, including 26 cases of otogenic brain abscess, 21 cases of meningitis, 5 cases of lateral sinus thromboses, two cases of subdural empyemas, 1 case of epidural empyema, and 1 case of meningocele. Surgical interventions included craniotomy and drainage of the abscess (n = 17), open mastoidectomy with abscess drained through the mastoid (n = 10), open mastoidectomy alone (n = 8), and closed mastoidectomy (n = 2). Twelve patients who underwent craniotomy had subsequent mastoidectomy for recurrent abscess. At the 6-month, 66% of patients presented without sequelae, 24% presented with sequelae, and 9% died. CONCLUSION: Early identification and prompt clinical and surgical intervention with mandatory drainage of the middle ear (primary disease), was essential for better outcome.

Tinnitus handicap inventory: adaptação cultural para o Português brasileiro

TEMA: o zumbido pode provocar muitos prejuizos na qualidade de vida dos pacientes. A avaliacao de quanto a qualidade de vida e prejudicada pelo zumbido pode ser util para o melhor conhecimento do paciente em relacao as limitacoes impostas por este sintoma, a programacao terapeutica e a verificacao da eficacia terapeutica, quando aplicado antes e apos o tratamento. OBJETIVO: adaptar culturalmente o Tinnitus Handicap Inventory (THI) para aplicacao na populacao brasileira e avaliar a sua reprodutibilidade. METODO: a adaptacao cultural do THI (Newman et al., 1996) seguiu as etapas indicadas por Guillemin et al. (1993), que incluem a traducao do idioma Ingles para o Portugues, adaptacao linguistica e revisao das equivalencias gramatical e idiomatica. Realizou-se, tambem, a avaliacao das reprodutibilidades inter e intra-pesquisadores deste questionario. Participaram 30 pacientes com zumbido, dos sexos feminino 19 (63,3%) ou masculino 11 (36,7%), com idade entre 39 e 79 anos (media 56,8 anos), encaminhados a partir de ambulatorio especifico em otoneurologia. RESULTADOS: o THI foi adaptado para ser aplicado na populacao brasileira, denominado THI Brasileiro. Nao houve diferenca estatisticamente significante quanto a reprodutibilidade inter-pesquisadores nos resultados obtidos a aplicacao da versao brasileira deste questionario, bem como da reprodutibilidade intra-pesquisadores. Verificou-se prejuizo da qualidade de vida em relacao aos aspectos emocionais, funcionais e/ou catastroficos em todos os pacientes avaliados. CONCLUSAO: o THI foi traduzido e adaptado culturalmente para ser aplicado na populacao brasileira, mostrando-se um instrumento confiavel para verificacao do prejuizo causado pelo zumbido na qualidade de vida.

O uso da acupuntura para alívio imediato do zumbido

O zumbido, definido como percepcao consciente de um som originado nas orelhas ou no sistema nervoso do paciente, representa ate os dias atuais um grande desafio no que concerne seu tratamento, baseia-se na estimulacao com agulhas de pontos especificos definidos sobre a anatomia humana. A utilizacao da Acupuntura (ACP) em sintomas como o zumbido assemelha-se ao modelo aplicado nos quadros algicos, ja que ambos estao relacionados como experiencia sensorial e emocional subjetiva e desagradavel. OBJETIVO: Estudar a eficacia da acupuntura no alivio sintomatico de forma aguda no zumbido. FORMA DE ESTUDO: Clinico prospectivo. MATERIAL E METODO: Foi realizado um estudo prospectivo, randomizado e duplo-cego em 76 pacientes atendidos no Ambulatorio de Zumbido do Departamento de Otorrinolaringologia e Cirurgia de Cabeca e Pescoco da UNIFESP-EPM no periodo compreendido entre abril e junho de 2005. Todos os pacientes tinham queixa de zumbido e foram submetidos a anamnese clinica, exame fisico e exames subsidiarios a fim de se investigar sua etiologia. Os pacientes eram entao encaminhados a um primeiro pesquisador que determinou um valor numerico subjetivo inicial do zumbido atraves de Escala Visual Analogica (EVA), variando de 0 a 10 pontos. Apos isto, foram encaminhados para outra sala na qual um medico acupunturista, que nao tinha acesso a avaliacao inicial, separou os pacientes em Grupo Controle e Grupo Estudo de acordo com a ordem de atendimento, de maneira alternada. O ponto de ACP utilizado nos pacientes do Grupo Estudo situa-se a 6,5cm acima do apice do pavilhao auditivo na regiao temporo-parietal. O ponto utilizado no Grupo Controle situa-se 3cm acima do ponto anterior, na mesma linha vertical. Foram entao encaminhados a sala inicial para uma nova avaliacao pelo primeiro pesquisador, onde foram orientados a redefinir o escore subjetivo do zumbido. RESULTADOS: Dos 76 pacientes estudados, 29 eram do sexo masculino (38,2%) e 47 do sexo feminino (61,8%), com idade media 56,9 + 12,0 anos. Os Grupos Estudo e Controle contaram com 38 pacientes cada. Atraves do teste Anova foi constatado que houve diferenca significante (p<0,001) entre os momentos pre e pos-agulhamento e que no grupo Estudo essa melhora e bem maior (p = 0,0127). O teste t-independente mostrou que houve uma diferenca significante (p=0,017) entre os escores pre e pos-agulhamento nos grupos Estudo e Controle. CONCLUSAO: Concluimos que houve reducao significante da contagem dos momentos pre e pos-agulhamento em ambos os grupos (controle e estudo), sendo que no grupo estudo a reducao e maior que no grupo controle.

Acupuncture for tinnitus immediate relief

The treatment of tinnitus, which is defined as conscientious perception of a sound originated in the ears or nervous system, represents until the current days a great challenge. The use of Acupuncture (ACP) is based on the stimulation with needles of specific points on the human anatomy. A prospective, randomized and double-blinded study was carried through in 76 patients taken care of in the Clinic of Tinnitus of the Department of Otorhinolaryngology and Head and Neck Surgery of the UNIFESP-EPM in the period understood between April and June of 2005. All the patients had humming complaint and had been submitted to clinical anamnese, physical examination and subsidiary exams in order to investigate its etiology. The patients then were directed to a first researcher that determined an initial numeric value of the humming through Visual Analoge Scale(VAS), varying from 0 to 10 points. After this, had been directed for another room in which an acupuncturist doctor, who did not have access to the initial evaluation, separated the patients in Group Control and Group Study according to the attendance order, in alternating way. The ACP point used in patients of the Group Study places 6,5 cm above of the apex of the auditory pavilion in the parietal region. The point used in the Group Control places 3 cm above of the previous point, in the same vertical line. Then they had been sent back to the initial room for a new evaluation by the first researcher, where they had been guided to redefine the subjective score of the humming. Among the 76 studied patients, 29 were male (38,2%) and 47 female (61,8%), with average age 56,9 + 12,0 years. The Groups Study and Control had counted on 38 patients each. Through the Anova test it was evidenced that it had significant difference (p<0,001) between the moments pre and post needling and that in the group Study this improvement is more evident (p=0,0127). The t-independent test showed that it had a significant difference (p=0,017) between the two moments in the groups Study and Control. We conclude that there was significant reduction of the counting of the moments pre and post needling in both the groups, and in the group study the reduction is greater that in the group control.

Impact of acupuncture on otoacoustic emissions in patients with tinnitus.

UNLABELLED The treatment of tinnitus is still a challenge. Acupuncture is recommended for the relief of tinnitus in traditional Chinese Medicine, although scientific evidence is lacking. AIM The aim of this study was to assess the effect of acupuncture on the cochlear function in patients with tinnitus by analyzing otoacoustic emissions. METHODS Thirty eight patients with tinnitus were included in the prospective clinical study. Measures of transitory otoacoustic emissions and suppression of otoacoustic emissions were obtained from all subjects before and after acupuncture. Patients were assigned to one of two groups: intervention group 1 (n=19), in which needle acupuncture was applied at the temporoparietal point corresponding to the vestibulocochlear area, and intervention group 2 (n=19), in which the needle was applied 3 cm cranially to this area (which is not a recognized acupuncture point). RESULTS There was a significant difference between the amplitude of otoacoustic emissions assessed before and after acupuncture in intervention group 1. No difference was observed in intervention group 2. CONCLUSION Acupuncture had a significant effect on otoacoustic emissions in patients with tinnitus.

Memory Networks in Tinnitus: A Functional Brain Image Study

Tinnitus is characterized by the perception of sound in the absence of an external auditory stimulus. The network connectivity of auditory and non-auditory brain structures associated with emotion, memory and attention are functionally altered in debilitating tinnitus. Current studies suggest that tinnitus results from neuroplastic changes in the frontal and limbic temporal regions. The objective of this study was to use Single-Photon Emission Computed Tomography (SPECT) to evaluate changes in the cerebral blood flow in tinnitus patients with normal hearing compared with healthy controls. Methods: Twenty tinnitus patients with normal hearing and 17 healthy controls, matched for sex, age and years of education, were subjected to Single Photon Emission Computed Tomography using the radiotracer ethylenedicysteine diethyl ester, labeled with Technetium 99 m (99 mTc-ECD SPECT). The severity of tinnitus was assessed using the “Tinnitus Handicap Inventory” (THI). The images were processed and analyzed using “Statistical Parametric Mapping” (SPM8). Results: A significant increase in cerebral perfusion in the left parahippocampal gyrus (pFWE <0.05) was observed in patients with tinnitus compared with healthy controls. The average total THI score was 50.8+18.24, classified as moderate tinnitus. Conclusion: It was possible to identify significant changes in the limbic system of the brain perfusion in tinnitus patients with normal hearing, suggesting that central mechanisms, not specific to the auditory pathway, are involved in the pathophysiology of symptoms, even in the absence of clinically diagnosed peripheral changes.

Efeito da acupuntura sobre as emissões otoacústicas de pacientes com zumbido

The treatment of tinnitus is still a challenge. Acupuncture is recommended for the relief of tinnitus in traditional Chinese Medicine, although scientific evidence is lacking. AIM: The aim of this study was to assess the effect of acupuncture on the cochlear function in patients with tinnitus by analyzing otoacoustic emissions. METHODS: Thirty eight patients with tinnitus were included in the prospective clinical study. Measures of transitory otoacoustic emissions and suppression of otoacoustic emissions were obtained from all subjects before and after acupuncture. Patients were assigned to one of two groups: intervention group 1 (n=19), in which needle acupuncture was applied at the temporoparietal point corresponding to the vestibulocochlear area, and intervention group 2 (n=19), in which the needle was applied 3cm cranially to this area (which is not a recognized acupuncture point). RESULTS:There was a significant difference between the amplitude of otoacoustic emissions assessed before and after acupuncture in intervention group 1. No difference was observed in intervention group 2. CONCLUSION: Acupuncture had a significant effect on otoacoustic emissions in patients with tinnitus.

Effectiveness of sound therapy in patients with tinnitus resistant to previous treatments: importance of adjustments

INTRODUCTION The difficulty in choosing the appropriate therapy for chronic tinnitus relates to the variable impact on the quality of life of affected patients and, thus, requires individualization of treatment. OBJECTIVE To evaluate the effectiveness of using sound generators with individual adjustments to relieve tinnitus in patients unresponsive to previous treatments. METHODS A prospective study of 10 patients with chronic tinnitus who were unresponsive to previous drug treatments, five males and five females, with ages ranging from 41 to 78 years. Bilateral sound generators (Reach 62 or Mind 9 models) were used daily for at least 6h during 18 months. The patients were evaluated at the beginning, after 1 month and at each 3 months until 18 months through acuphenometry, minimum masking level, the Tinnitus Handicap Inventory, visual analog scale, and the Hospital Anxiety and Depression Scale. The sound generators were adjusted at each visit. RESULTS There was a reduction of Tinnitus Handicap Inventory in nine patients using a protocol with a customized approach, independent of psychoacoustic characteristics of tinnitus. The best response to treatment occurred in those with whistle-type tinnitus. A correlation among the adjustments and tinnitus loudness and minimum masking level was found. Only one patient, who had indication of depression by Hospital Anxiety and Depression Scale, did not respond to sound therapy. CONCLUSION There was improvement in quality of life (Tinnitus Handicap Inventory), with good response to sound therapy using customized settings in patients who did not respond to previous treatments for tinnitus.

Fístula perilinfática em cobaias: comparação entre evolução natural e correção cirúrgica

Perilymphatic fistulas still represent a major treatment challenge. In some cases, its surgical closure can reduce auditory and vestibular sequelae. AIM: to compare the behavior of cochlear window perilymphatic fistulas in guinea pigs as to their natural evolution and immediate surgical closure. MATERIALS AND METHODS: Experimental study. Forty guinea pigs were submitted to cochlear window membrane lesion and randomly broken down into two groups: open fistula (OF) and surgically closed fistula (SCF). We found the summation potential (SP) and action potential (AP) latencies and amplitudes and the SP/AP ratio at three times: pre-fistula (PRE), immediate post-fistula (IPF) and late post-fistula (LPF). RESULTS: There was a significant drop in amplitudes and raise in SP and AP latencies among the times studied. As to the SP/AP ratios, there was a reduction between PRE and IPF, both were significant. There was no behavior difference between the OF and SCF. CONCLUSIONS: Within the time frame considered, guinea pigs submitted to cochlear window membrane lesions evolved with a worsening in potentials and latencies. Despite the partial improvement in electrophysiological parameters, surgical closure did not prove statistically more effective than natural evolution.

Translation, validation and cultural adaptation of “The Eustachian Tube Dysfunction Questionnaire-7” (ETDQ-7) to Brazilian Portuguese (BR)

INTRODUCTION Chronic Eustachian tube dysfunction can cause several symptoms and middle ear conditions that can impact patient quality of life. It is estimated to be relatively frequent, affecting approximately 5% of adults. The diagnostic tools for this condition are still inadequate. In 2012, McCoul et al. published a questionnaire for the evaluation of Eustachian tube dysfunction named ETDQ-7. They established its replicability and validity. The cutoff point for the diagnosis of chronic Eustachian tube dysfunction was equal to or greater than 14.5, with 100% sensitivity and 100% specificity. OBJECTIVE To translate, adapt and validate the ETDQ-7 questionnaire to Brazilian Portuguese. METHODS We translated the questionnaire into Brazilian Portuguese and applied it to 50 patients, 20 of whom had chronic Eustachian tube dysfunction, and 30 controls. RESULTS The results obtained with the North-American questionnaire were confirmed in its Brazilian version. The cut-off point for the diagnosis of chronic Eustachian tube dysfunction was ≥14, also exhibiting high sensitivity and specificity, very similar to that of ETDQ-7. CONCLUSION It is recommended that ETDQ-7 be used to complement the clinical history of patients with chronic Eustachian tube dysfunction; it can also be used as an important tool for diagnosis, patient follow-up and treatment management.