Erna Kentala

Prevalence of Menière's Disease in General Population of Southern Finland

OBJECTIVE: To study the prevalence of Menières disease (MD) in the general population of Southern Finland. STUDY DESIGN AND SETTING: Prospective study based on population register data. A questionnaire was sent to 5000 randomly selected persons aged 12 years or more living in the Helsinki University Hospital area. We enquired about whether recipients had experienced vertigo associated with a moving sensation, hearing loss, or tinnitus. For exclusion purposes, we also asked about general illnesses, ear infections, former head and ear traumas, noise exposure, medication, and use of tobacco and alcohol. To assess the validity of the population-based study, we randomly selected a sample of 100 people among those reporting vertigo. They were clinically examined at our vestibular unit. The clinical examination was supplemented by audiologic and otoneurologic tests. RESULTS: The response rate was 63%. In the final study sample of 3116 people, 216 reported the triad of vertigo, hearing loss, and tinnitus. By using the most recent criteria of the Committee on Hearing and Equilibrium of the American Academy of Otolaryngology–Head and Neck Surgery, we were able to identify 16 definite MD patients from the total sample, yielding a prevalence of 513 of 100,000 persons. Among the 16 MD subjects, 9 patients had already been diagnosed with MD and 1 patient was diagnosed during the clinical examination. A peak prevalence of 1709 of 100,000 was seen in the age group 61 to 70 years. CONCLUSIONS: Our population-based estimate of MD prevalence is much higher than in previous reports.

Classification and Consequences of Errors in Otolaryngology

Objective: To develop a preliminary classification system for errors in otolaryngology.

Clinical picture of vestibular schwannoma

PURPOSE To characterize the clinical picture with vestibular schwannoma, we retrieved 122 patients with vestibular schwannoma from the vestibular unit of the Helsinki University Central Hospital. PROCEDURES The patients filled out a questionnaire concerning their symptoms, earlier diseases, accidents, and the use of tobacco and alcohol. This information was then completed with results of audiometric, neurotologic and imaging studies. The data were prospectively stored to the database of neurotologic expert system called ONE. RESULTS The average tumor size was 21 mm. Most of the patients had hearing loss (94%) and tinnitus (83%) but only half of them (49%) had vertigo attacks. The most common initial symptom was hearing loss combined with tinnitus (34%, n=44). Vertigo only was the initial symptom for 12 patients. The mean duration of a vertigo attack was from 5 min to 4 h and the intensity of the attack was regularly mild (37%) or moderate (32%). The vertigo of the vestibular schwannoma patients differed from vertigo in other diseases by the absence (63%) or low intensity (18%) of nausea. Spontaneous nystagmus was present in 56 patients (46%), and caloric asymmetry (>25%) was observed in 66% (n=69). Caloric asymmetry increased with tumor size. The prevalence of headache was 18% (n=21). Sudden slips seldom (7%) occurred. CONCLUSION Hearing loss and tinnitus are the main symptoms of vestibular schwannoma. Only half of patients have vertigo. Screening to detect vestibular schwannoma is more yielding in sudden deafness patients rather than in patients with Menieres disease.

Database for vertigo.

An interactive database has been developed to assist the diagnostic procedure for vertigo and to store the data. The database offers a possibility to split and reunite the collected information when needed. It contains detailed information about a patients history, symptoms, and findings in otoneurologic, audiologic, and imaging tests. The symptoms are classified into sets of questions on vertigo (including postural instability), hearing loss and tinnitus, and provoking factors. Confounding disorders are screened. The otoneurologic tests involve saccades, smooth pursuit, posturography, and a caloric test. In addition, findings from specific antibody tests, clinical neurotologic tests, magnetic resonance imaging, brain stem audiometry, and electrocochleography are included. The input information can be applied to workups for vertigo in an expert system called ONE. The database assists its user in that the input of information is easy. If not only can be used for diagnostic purposes but is also beneficial for research, and in combination with the expert system, it provides a tutorial guide for medical students.

Factor H Binding as a Complement Evasion Mechanism for an Anaerobic Pathogen, Fusobacterium necrophorum

Fusobacterium necrophorum subspecies funduliforme is an obligate anaerobic Gram-negative rod causing invasive infections such as the life-threatening Lemierre’s syndrome (sore throat, septicemia, jugular vein thrombosis, and disseminated infection). The aim of our study was to understand if and how F. necrophorum avoids C activation. We studied 12 F. necrophorum subsp. funduliforme strains isolated from patients with sepsis. All strains were resistant to serum killing after a 1-h incubation in 20% serum. The bacteria bound, at different levels, the C inhibitor factor H (fH). Binding was ionic and specific in nature and occurred via sites on both the N terminus and the C terminus of fH. Bound fH remained functionally active as a cofactor for factor I in the cleavage of C3b. Interestingly, patients with the most severe symptoms carried strains with the strongest ability to bind fH. An increased C3b deposition and membrane attack complex formation on the surface of a weakly fH-binding strain was observed and its survival in serum at 3.5 h was impaired. This strain had not caused a typical Lemierre’s syndrome. These data, and the fact that fH-binding correlated with the severity of disease, suggest that the binding of fH contributes to virulence and survival of F. necrophorum subsp. funduliforme in the human host. Our data show, for the first time, that an anaerobic bacterium is able to bind the C inhibitor fH to evade C attack.

Short-Lasting Drop Attacks in Meniere's Disease:

OBJECTIVES: To study the vertigo attacks known as Tumarkin attacks or drop attacks (DA). DA are characterized by sudden loss of balance with or without falls but with preserved consciousness, and they are supposedly triggered by changes in the otolith function of Menieres disease (MD). STUDY DESIGN AND SETTING: Data from 243 consecutive MD patients were collected into a database of an otoneurologic expert system. RESULTS: DA was experienced by 72% (n = 173) of the patients with MD. It correlated with visually provoked vertigo. Gait difficulties, tinnitus, and anxiety were more common in the DA group. Long lasting vertigo attacks were more frequently provoked in the DA subjects by physical strain (58% vs 14%), head movements or changes in head position (71% vs 48%), pressure changes (54% vs 12%), or rapid movements in visual surroundings (65% vs 35%) than in the non-DA subjects. CONCLUSION: DA are common in MD patients. The abrupt occurrence of DA make them poorly tolerated. SIGNIFICANCE: DA are more common in advanced MD.

Effect of displacement, velocity, and combined vibrotactile tilt feedback on postural control of vestibulopathic subjects

Vibrotactile tilt feedback was used to help vestibulopathic subjects control their anterioposterior (AP) sway during sensory organization tests 5 and 6 of Equitest computerized dynamic posturography. We used four kinds of signals to activate the feedback. The first signal was proportional (P) to the measured tilt of the subject, while the second used the first derivative (D) of the tilt. The third signal was the sum of the proportional and one half of the first derivative signals (PD). The final signal used a prediction of the subjects sway projected 100 msec in advance. The signals were used to activate vibrators mounted on the front of the torso to signal forward motion, and on the back of the torso for backward motion. Subject responses varied significantly with the kind of feedback signal. Proportional and derivative feedback resulted in similar root mean squared tilt, but the PD signal significantly reduced the tilt compared to either P or D feedback. The predicted motion signal also reduced the response compared to the PD signal. These preliminary results are somewhat consistent with an inverted pendulum model of postural control, but need to be confirmed with a larger study that also considers mediolateral tilt and feedback. The improvement by using a predictor is consistent with compensating for a neural processing delay.

Hearing loss and tinnitus in Meniere's disease

OBJECTIVES To characterize hearing loss, tinnitus and associative factors in Menieres disease. METHODS From our vertigo database consisting of 1356 patients, we retrieved 243 patients with Menieres disease (MD). RESULTS Hearing loss was the initial symptom in 13% of cases. Altogether 64% (n=133) of the patients stated that their hearing was reduced during the vertigo attack. The hearing deteriorated more likely during the vertigo attack if the vertigo attack was very intense [r(206)=0.19]. Tinnitus was the initial symptom in 5% of cases. The tinnitus was mild in 38% (n=90), moderate in 32% (n=76) and severe in 30% (n=72) of patients. The intensity of tinnitus correlated with the occurrence of drop attacks [r(237)=0.29], vertigo provoked by head positioning [r(235)=0.25], by physical activity [r(230)=0.33], or by pressure changes [r(239)=0.27]. CONCLUSION Prolonged disease causes deterioration of hearing. Intense tinnitus is common in MD and is more often seen in late stage of the disease.

Depressive Symptoms Underestimated in Vertiginous Patients

OBJECTIVE: To assess the prevalence of depression in a group of vertiginous patients gathered by the use of a questionnaire. STUDY DESIGN AND SETTING: Prospective study on 100 randomly selected vertiginous individuals, who were invited for further investigations to the Helsinki University ENT clinic. They also filled in a Beck Depression Index, Zung anxiety scale and DIP-Q, which are self-rating scales to investigate psychiatric symptoms. RESULTS: The prevalence of depression was 19%, and affected more men than women No significant differences appeared in ENT diagnoses or symptoms between depressed and nondepressed patients. Depression correlated positively with vertiginous relatives (P < 0.01) and subjective sense of disability (P < 0.01). Of depressed vertiginous patients, 89% were without appropriate antidepressive care. CONCLUSION: Nearly 20% of vertiginous patients also have depressive symptoms. Assessment of psychiatric and psychosomatic symptoms should accompany neuro-otologic evaluation to achieve the best treatment strategy and prevent chronic outcome.

Evaluation of vertiginous children

Our objective was to evaluate, using a structured approach method, the history and findings in vertiginous children as compared with a group of healthy children. We evaluated 24 vertiginous children (15 girls, 9 boys) with episodes of true vertigo of unknown etiology and 12 healthy age- and gender-matched controls. A detailed medical history was obtained using a structured approach technique. Vertiginous and healthy children underwent general and otoneurologic examinations, including audiogram, electronystagmography, and tympanometry, at the Helsinki University Hospital ENT clinic. Characteristics of patient histories and clinical findings were compared between the groups. The vertiginous children reported significantly more head traumas and headaches than the controls. The structured data collection approach improved the evaluation process. The predominant diagnoses were benign paroxysmal vertigo of childhood, otitis media-related vertigo, and migraine-associated dizziness.