Eric W. Sargent

Posterior semicircular canal occlusion for benign paroxysmal positional vertigo—CO2 laser‐assisted technique: Preliminary results

Benign paroxysmal positional vertigo (BPPV) is a common vestibular end‐organ disorder that in the majority of patients resolves with conservative management. In the occasional patient who has unremitting BPPV despite conservative treatment, posterior semicircular canal occlusion (PCO) may be effective in eliminating symptoms. In an attempt to minimize the risk of hearing loss, a modified procedure was developed that uses the CO2 laser to shrink the membranous vestibular posterior semicircular canal prior to mechanically plugging the canal. Preliminary results of this CO2 laser‐assisted occlusion technique used in four patients are presented.

Tumors and Pseudotumors of the Endolymphatic Sac

This article reports on the presentation, diagnosis, management, and treatment outcomes of lesions of the endolymphatic sac in patients treated at a tertiary neurotology referral center. It summarizes survival results in the largest series groups and presents a new diagnostic entity of pseudotumor of the endolymphatic sac. The study includes retrospective review of all patients diagnosed with lesions of the endolymphatic sac within our practice between 1994 and 2005 as well as review of the literature. The primary outcome measure was survival, and the secondary outcome measure was disease-free survival following definitive resection. Postoperative complications were assessed. Survival characteristics of the largest reported case series groups were reviewed. Five cases of endolymphatic sac lesions were identified. Of these, three were true endolymphatic sac tumors and two were inflammatory pseudotumors of the endolymphatic sac. All three of the endolymphatic sac tumors patients survived (100%), and two of the three had disease-free survival (67%). Two of three patients maintained persistent facial paresis postoperatively. Both patients with benign pseudotumors survived (100%). Our study concluded that endolymphatic sac tumors are rare neoplasms of the temporal bone that, although locally aggressive and invasive, have excellent prognosis for survival with complete resection. We report a new entity of pseudotumor of the endolymphatic sac that mimics true sac tumors in every respect on presentation but which is non-neoplastic in origin.

Idiopathic Bilateral Vestibular Loss

We describe the clinical and laboratory features of 13 patients with bilateral loss of peripheral vestibular sensitivity of no known cause. In the office, screening for this condition was possible using illegible e-testing and examination of the patient for refixation saccades after brisk head movements while attempting visual fixation. Diagnosis was confirmed by bilaterally reduced caloric responses (< 20 degrees/second on all 4 caloric irrigations) and abnormally low gain of the vestibulo-ocular reflex on rotational chair testing. The mean age of the patients was 68 years. We noted two patterns of symptom onset: onset associated with vertigo (10 patients) and insidious progressive disequilibrium not associated with vertigo (3 patients). Only 38% of the patients complained of subjective oscillopsia. The subjects performed poorly on platform posturography, particularly when deprived of visual and somatosensory feedback. When associated with vertigo, bilateral vestibular loss may be the result of bilateral sequential vestibular neuritis; when not associated with vertigo, disequilibrium may be caused by slow, symmetrical loss of peripheral function as a result of aging. Although the subjects in this report were elderly, idiopathic bilateral vestibular loss has been reported in patients of all ages.

The learning curve revisited: Stapedotomy

OBJECTIVE : To determine whether the outcome of stapedotomy changes with experience. STUDY DESIGN AND SETTING : Retrospective case review of an academic otologic practice of a fellowship-trained otologist that consisted of 50 consecutive patients who underwent primary stapedotomy. The main outcome measures were preoperative and postoperative audiograms for both the operated ear and the opposite ear (control). RESULTS : There were no major complications or loss of hearing among the 50 patients. Minor complications included 1 middle ear infection, 2 torn flaps, and 1 tympanic membrane perforation. One patient had worse conductive hearing loss after surgery. The hearing of 2 patients was unchanged. Hearing for the entire group improved (P > 0.001) from a speech reception threshold of 55 dB (SD, 17 dB) to 30 dB (SD, 19 dB). Complete closure of the air-bone gap was achieved in 20% of the first 10 patients and 30% of the last 10 patients. CONCLUSIONS : The results of stapedotomy improve with experience, although the learning curve seems less steep than has been reported for total or near-total footplate removal. SIGNIFICANCE : Stapedotomy can be successfully performed early in surgical experience, but the learning curve should be acknowledged and discussed with the patient.

Acoustic Reflex Screening of Conductive Hearing Loss for Third Window Disorders

Objective This study examines the effectiveness of acoustic reflexes in screening for third window disorders (eg, superior semicircular canal dehiscence) prior to middle ear exploration for conductive hearing loss. Study Design Case series with chart review. Setting Outpatient tertiary otology center. Subjects and Methods A review was performed of 212 ears with acoustic reflexes, performed as part of the evaluation of conductive hearing loss in patients without evidence of chronic otitis media. The etiology of hearing loss was determined from intraoperative findings and computed tomography imaging. The relationship between acoustic reflexes and conductive hearing loss etiology was assessed. Results Eighty-eight percent of ears (166 of 189) demonstrating absence of all acoustic reflexes had an ossicular etiology of conductive hearing loss. Fifty-two percent of ears (12 of 23) with at least 1 detectable acoustic reflex had a nonossicular etiology. The positive and negative predictive values for an ossicular etiology were 89% and 57% when acoustic reflexes were used alone for screening, 89% and 39% when third window symptoms were used alone, and 94% and 71% when reflexes and symptoms were used together, respectively. Conclusion Acoustic reflex testing is an effective means of screening for third window disorders in patients with a conductive hearing loss. Questioning for third window symptoms should complement screening. The detection of even 1 acoustic reflex or third window symptom (regardless of reflex status) should prompt further workup prior to middle ear exploration.

Patient, disease, and outcome characteristics of benign paroxysmal positional vertigo with and without Meniere’s disease

Abstract Background: Meniere’s disease (MD)-associated benign paroxysmal positional vertigo (BPPV) is complex and difficult to diagnose, and reports of its prevalence, pathologic features and outcomes are sparse and conflicting. Objective: Report disease characteristics and outcomes associated with the presence of MD in patients with BPPV. Materials/methods: A retrospective study of patients with BPPV between 2007 and 2017 at a single, high-volume institution. Results: Of 1581 patients with BPPV identified, 7.1% had MD and 71.9% of those patients had BPPV in the same ear(s) as MD. Patients with MD were more likely to have lateral semicircular canalithiasis (11.6% vs. 5.5%, p = .009) and multiple canalithiasis (7.1% vs. 2.5%, p = .005). MD was associated with an increased rate of resolution of BPPV (p = .008) but also increased time to resolution (p = .007). There was no association between MD and recurrence of BPPV. Conclusions: MD is associated with lateral canalithiasis. Contrary to prior reports, BPPV in MD can affect either ear and was not associated with poorer outcomes than idiopathic BPPV. Significance: The largest series to date investigating disease and outcome characteristics for BPPV in MD is presented. These data inform diagnosis and expectations in the management of these complex patients.

Factors Influencing Cochlear Patency after Translabyrinthine Surgery

Objective To determine predictive factors for cochlear obliteration after translabyrinthine surgery for vestibular schwannoma. Study Design Case series with chart review. Setting Neurotology referral center. Subjects and Methods In total, 345 charts were reviewed, resulting in 103 patients who underwent translabyrinthine surgery between January 2010 and July 2015 and had postoperative magnetic resonance imaging (MRI) for review. Surveillance MRI performed after translabyrinthine resection of vestibular schwannomas was reviewed. Heavily T2-weighted MRI obtained an average of 21.8 months after surgery was reviewed to assess cochlear patency. Tumor size, preoperative audiograms, and MRI cochlear fluid-attenuated inversion recovery (FLAIR) intensity were compared between patients with retained cochlear patency and those without. Results Fifty-four percent of patients retained cochlear patency after translabyrinthine surgery. Tumor size did not differ statistically between the 2 groups. There was no statistically significant difference in speech reception thresholds, pure-tone average, or word recognition scores between patent and nonpatent groups. Preoperative MRI FLAIR intensity did not differ between groups. Conclusions More than half of patients retain cochlear patency after translabyrinthine vestibular schwannoma surgery. Cochlear patency is required for cochlear implant in patients with unilateral deafness. Preoperative tumor size, hearing performance, and intensity on MRI FLAIR do not predict cochlear patency. To prevent loss of opportunity for cochlear implantation, simultaneous implantation and cochlear lumen keeper placement are options.

Posterior Semicircular Canal Occlusion and Application of the Dizziness Handicap Inventory

OBJECTIVES To determine the long-term efficacy and patient satisfaction of posterior semicircular canal occlusion (PSCO) as a treatment for intractable benign paroxysmal positional vertigo (BPPV). STUDY DESIGN AND SETTING Retrospective analysis of patients with BPPV who underwent PSCO was conducted in a tertiary referral center. Demographic data, clinical records, and audiometric data were reviewed. Dix-Hallpike maneuver, dizziness handicap inventory (DHI), and a specific PSCO questionnaire (PCOQ) were used to measure outcome. RESULTS Twenty-eight patients underwent PSCO. The mean follow-up time was 40 months. All patients had normalization of the Hallpike test. DHI scores of 20 patients were recorded. The mean preoperative score was 70 compared with postoperative mean of 13 (P < 0.001). Mild hearing loss was found in 1 patient. CONCLUSIONS AND SIGNIFICANCE PSCO is highly successful. The DHI scores postoperatively show significant improvement. The PCOQ revealed an overall 85% patient satisfaction rate. PSCO is a safe and effective intervention for intractable BPPV with a high patient satisfaction rate. EBM RATING C-4.

Intracranial blood flow velocities and CO2 reactivity in diagnosing migraine-related dizziness

OBJECTIVE: Migraine-related dizziness can present with or without headache, often making diagnosis difficult. Flow velocity and CO2 reactivity testing using transcranial Doppler (TCD) measurement of intracranial blood flow has been described as abnormal in patients with classic or common migraine. This study sought to determine the utility, if any, of this noninvasive technique in the diagnosis of migraine-related dizziness. STUDY DESIGN AND SETTING: A prospective, controlled study in academic neurotology and neurology practices was conducted. Nine patients with migraine-related dizziness and 10 patients with no history of migraine or dizziness were tested with transcranial Doppler ultrasound in a blinded fashion. RESULTS: No statistically significant differences in intracranial blood flow velocities or in cerebrovascular reactivity to hypocapnia were found between patients and controls. CONCLUSIONS: Assessment of intracranial blood flow velocity and CO2 reactivity using TCD does not help in the diagnosis of migraine-related dizziness. SIGNIFICANCE: A reliable objective test for the diagnosis of migraine-related dizziness remains elusive, and the diagnosis of this patient group continues to be suboptimal.

Idiopathic Bilateral Vestibular Loss: Diagnosis and Management

Reconstruction of scutal defects following canal wall up mastoidectomies with cartilage remains controversial. Theoretically the cartilage is used to reinforce the scutal defect and thus prevent future retraction pockets and recurrence of cholesteatoma. To evaluate whether cartilage reconstruction of the scutum is useful in our hands, we performed a retrospective chart review of all patients who underwent a canal wall up mastoidectomy from 1980 to 1993 for cholesteatoma. A total of 103 canal wall up mastoidectomies were performed in this time period. Of these 103 mastoidectomies, the scutum was reconstructed with cartilage in 37 cases, whereas in 66 cases the scutum was not reconstructed. Of the 37 patients who underwent reconstruction with cartilage, 66% did not develop further retraction pockets. Of the 33% that did develop a retraction pocket, only one third required further surgery. Of the 66 patients who did not undergo reconstruction, 47% did not develop retraction pockets. Of the 53% who did develop a retraction pocket, one third required further surgery. Age was assessed as a variable but did not seem to change the outcome of these results. Thus it would appear that reconstruction of scutal defects with cartilage may be of some benefit in preventing future retraction pockets and recurrence of cholesteatoma in our hands.