Josef Elidan

Effect of Cyclosporine a on the Hearing Loss in Behçet's Disease:

Thirty-five patients with Behçets disease (20 under cyclosporine A [CyA] treatment and 15 under the conventional therapy), 12 patients suffering from endogenous uveitis, and 35 normal subjects were evaluated audiologically before entering the study and were followed up for at least a year. Twenty-eight Behçet patients (80%) showed some degree of hearing loss. The averaged pure tone audiogram of the Behçet group showed statistically significant auditory deficits in comparison with that of the control group. None of either the Behçet group or the uveitis group showed any hearing deterioration during the follow-up period. Five Behçet patients under CyA therapy demonstrated improvement in their hearing. The difference between the two groups of Behçet patients (CyA versus conventional treatment) was found to be statistically significant (p < .05). Thus, CyA might serve as an important mode of treatment of sensorineural hearing loss on an inflammatory “autoimmune” background.

Parapharyngeal abscess in children: the role of CT for diagnosis and treatment

Parapharyngeal abscess (PPA) in children is an uncommon deep neck space infection. Computerized tomography (CT) is an important diagnostic aid. However, CT scan is not specific in differentiating an abscess from cellulitis or inflammatory edema. A retrospective review of eight children with a CT diagnosis of PPA was undertaken. In three patients an abscess was surgically confirmed. In two patients surgical exploration did not reveal an abscess and in three the infection resolved with intravenous antibiotic therapy only. Although CT is a useful diagnostic tool for PPA, surgical intervention should be based mainly on the clinical status of the patient and the non-responsiveness to i.v. antibiotic therapy.

The imperative of the Sistrunk operation: Review of 160 thyroglossal tract remnant operations

Objective: Analysis of the pre- and postoperative features, long-term follow-up, and complications. Study Design and Methods: Case series with chart review of 160 thyroglossal tract remnant excisions over a 20-year period (1988-2007). Results: The mean age of diagnosis was 10.9 ± 14.2 years with 63.8 percent male predominance. There was a prior history of thyroglossal tract remnant infections in 70 percent of patients, and 30 percent presented with cutaneous fistulas. The majority had ultrasound imaging that identified cysts mainly (66.7%) in the infrahyoid region. Preoperative fine-needle aspirations in 18 patients were benign. On pathological reevaluation, 26.5 percent had thyroid tissue inside the remnant, with one case of papillary carcinoma. After the Sistrunk operation, postoperative complications occurred in 7.5 percent including a 1.9 percent recurrence rate. Conclusions: All age groups had similar clinical presentations and outcomes. Ultrasound is a reliable and appropriate imaging modality for most patients. Surgery must effectively incorporate the tract and cyst to allow low recurrence rates (<2%). Clinically diagnosed thyroglossal tract remnant may, in fact, be other pathologies in 10 percent of cases. Nevertheless, our recommendation is a Sistrunk procedure for all midline neck lesions suspected to be a thyroglossal tract remnant.

Imagination of body rotation can induce eye movements.

Objective Several studies have shown that spatiotemporal aspects of motion are stored and can be retrieved with the use of vestibular and somatosensory cues. The purpose of this study was to examine whether intentional imagination of body rotation can induce oculomotor activity similar to the typical vestibulo-ocular reflex (VOR). Material and Methods Normal subjects without known vestibular and/or oculometric abnormalities were instructed to imagine a sensation of accelerating body rotation in the horizontal plane (rightward or leftward) while sitting in darkness with closed eyes, using only vestibular and somatosensory cues and not imaginary visual cues. Eye movements were recorded during the imagery session and also during a full, routine electronystagmography (ENG) test. All subjects selected for this study showed normal results in the ENG test, and none of them had gaze-evoked or end-point nystagmus. Results In response to imaginary rotations, horizontal eye movements were found in 91/121 recordings (75%) in 10 subjects. A typical pattern of nystagmus (0.3–3 Hz, 3–30°/s maximal speed of slow component) was recorded in 53% of mental rightward rotations and 49% of leftward rotations. The fast component was always in the direction of the imaginary rotation (similar to a normal VOR). Other types of eye movement comprised either contralateral eye drift (≈17% of trials) or macro square waves. In 25% of the recordings no definite eye movements could be detected during the mental maneuvers. Conclusion These mentally induced eye movements seem to be due to a cortical process which can affect the normal input to the brainstem nuclei. A possible mechanism is discussed. This phenomenon may serve as an objective measurement of mental activity, may be used for testing the cognitive resources of patients and can probably be used for enhancing the rehabilitation process after acute vestibular insult.

Development of short latency vestibular evoked potentials in the neonatal rat

The development of short latency vestibular evoked potentials (VsEPs) was investigated in the neonatal rat. Using the appropriate stimulus (linear or angular acceleration impulses) and head orientation, responses elicited in various vestibular end-organs (utricle: x-VsEP; saccule: z-VsEP; lateral semi-circular canal: a-VsEP) were measured in rat pups at various ages between post-natal days (PND) 5 and 30, and compared to those recorded from adult animals. It was found that the VsEPs initially appeared on PND 6 (x-VsEPs and z-VsEPs) or 7 (a-VsEPs), and that by PND 8 the three responses could be recorded in all animals. The first wave of the responses, generated in the primary sensory nerve and reflecting end-organ activity, reached adult latencies and amplitudes by PND 10, showing rapid maturity of the responses. Auditory responses, on the other hand, develop at a later stage (from PND 11). The possible mechanisms involved in this differential maturation between vestibular and auditory activity are discussed.

Prevalence and Clinical Significance of Anticardiolipin, Anti-β2-Glycoprotein-1, and Anti-Heat Shock Protein-70 Autoantibodies in Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSNHL) is frequently classified as ‘idiopathic’ since the causative factor responsible for its onset is not identified in most cases. In the present study, we determined whether SSNHL is clinically associated with serum anti-heat shock protein-70 (anti-HSP70) and antiphospholipids (anti-PLs) autoantibodies and whether these autoantibodies have an impact on the prognosis of SSNHL. Sera from 63 patients with SSNHL were screened prospectively for the presence of anti-HSP70 and anti-PLs autoantibodies by an enzyme-linked immunosorbent assay test. Anti-PLs antibodies in this study consisted of anticardiolipin, and anti-β2-glycoprotein-1 antibodies. Serum was assayed for anti-HSP70 IgG antibodies using recombinant human HSP70. Demographic, clinical, and audiometric variables were analyzed to find the possible role of serum autoantibodies in SSNHL patients. Sixteen patients (25.4%) had demonstrable anti-HSP70 antibodies in serum. Twenty-one patients (33.3%) showed a positive result for at least one isotype (IgM or IgG) of anti-PLs. In 19% of the patients, anti-HSP70 and anti-PLs antibodies were positive in two combinations. A statistically significant association was found between anti-HSP70 antibodies and the Siegel recovery grade subgroup. SSNHL patients who were positive for anti-HSP70 antibodies showed a significantly higher rate of complete recovery and incomplete but partial recovery than SSNHL patients without anti-HSP70 antibodies (p = 0.0496). Statistically significant association was found between total anticardiolipin, total anti-β2-glycoprotein-1, total anti-PLs, and anti-PLs in combination with anti-HSP70 antibodies and age (p = 0.0229). The detection of autoantibodies to HSP70 and PLs offers a pliable explanation for the immune-mediated mechanism of SSNHL. The present study confirms and supports previous studies regarding the association between anti-HSP70 and anti-PLs antibodies with SSNHL, and is the first to identify a positive association between anti-HSP70 antibodies and a positive outcome of SSNHL. Further studies are necessary in order to identify and further clarify the immunologic role of the presence of autoantibodies and their impact on the prognosis of SSNHL.

Fibrovascular polyp of the esophagus

A 75-year-old patient came to our department for evaluation and treatment of bilateral vocal cord paralysis. Six months earlier she had undergone an emergency intubation in another hospital for respiratory failure during an exacerbation of ischemic heart disease. She was intubated for 6 days, and shortly after extubation stridor and dyspnea developed. Bilateral vocal cord paralysis was detected, and a tracheostomy was performed. On admission to our department she reported sensing a lump in her throat while coughing. A CT scan of the neck did not reveal any abnormality except for the adducted vocal cords, and findings of a barium swallow were normal. Fiberoptic laryngoscopy revealed bilateral vocal cord paralysis with the cords in a paramedian position. No other laryngeal abnormalities were detected. During the examination she started to cough, and a big polypoid mass suddenly appeared from the postcricoid area and obstructed the laryngeal inlet. After the patient stopped coughing, the mass disappeared. With the patient under general anesthesia, we performed a rigid esophagoscopy, which revealed a large polypoid lesion arising from the upper cervical esophagus (Fig. 1). We removed the lesion endoscopically using snare and cautery with minimal bleeding. This was followed by left-sided arytenoidectomy. Pathologic examination revealed a fibrovascular polyp. Several weeks later the patient was successfully decannulated, and since then she has been free of any of the above symptoms.

Transient Evoked Otoacoustic Emissions in Newborns in the First 48 Hours After Birth

Newborns are often discharged from hospital at the age of about 48 hours. At this age, transient evoked otoacoustic emissions (TEOAEs) are not necessarily recordable in all healthy newborns. In order to determine the factors which would enable the successful recording of TEOAEs before discharge to facilitate screening for hearing, 65 fullterm newborns under 48 hours of age were tested, the youngest being 10 hours old. The ears of those neonates in whom TEOAEs could not be obtained (N = 7 neonates bilaterally, 6 unilaterally) were examined otoscopically, cleaned of vernix and retested for TEOAEs. We were thus able to record in at least one ear in all neonates tested, if the ears were clean, if they were asleep and if the testing room was quiet.

Enterovirus, Cytomegalovirus, and Epstein-Barr Virus Infection Screening in Idiopathic Sudden Sensorineural Hearing Loss

Sudden sensorineural hearing loss (SSNHL) is frequently classified as ‘idiopathic’ since the causative factor is not identified in most cases. In the present study we determined whether SSNHL is associated with common viral infections, namely enterovirus, cytomegalovirus (CMV) and Epstein-Barr virus (EBV). Between April 2004 and March 2005, we conducted a prospective cohort study on 48 unselected patients with unilateral idiopathic SSNHL. Plasma samples obtained at presentation were analyzed for the presence of enterovirus RNA by reverse-transcription polymerase chain reaction (RT-PCR). Recent occurrence of CMV and EBV infection was determined by serological tests. Among 23 men and 25 women aged 18–84 years (mean age 51.67 years), none presented with clinical symptoms of a viral infection compatible with preceding or concurrent viral infection. One patient (2.08%) had evidence of enterovirus infection by RT-PCR, 3 patients (6.25%) had EBV IgM, and none were positive for CMV IgM. The majority of SSNHL patients (91.67%) did not have evidence of any of the three common viral infections upon presentation. The present study failed to identify recent or concurrent systemic viral infections among SSNHL patients, except for a small proportion who demonstrated recent viral infection. Therefore the theory that viral infection is a factor in SSNHL pathogenesis is not supported by this study. Further studies in larger patient populations and different epidemiological settings are required in order to verify the true role of viral infections in SSNHL.

Vertical Plane Short and Middle Latency Vestibular Evoked Potentials in Humans

In order to determine whether short and middle latency vestibular evoked potentials (VsEPs) can be recorded in humans in response to angular acceleration stimuli in the vertical plane, a drum, head-holder, and stepper motor were designed to deliver upward acceleration impulses of 10,000°/s2 (1.8° displacement) to the human head. Forehead and mastoid electrodes recorded electrical activity that was filtered, differentially amplified, and averaged in short (12.7 milliseconds) and middle (63.5 milliseconds) latency time frames. Control recordings were used to eliminate various types of artifact. Recordings were conducted in 7 normal subjects and in 4 control patients with congenital, profound hearing loss and absence of caloric responses. Short and middle latency VsEPs with high intrasubject and intersubject consistency were recorded in normal subjects and not in control patients. The middle latency responses were larger in amplitude than the short latency responses. The effects of stimulus intensity and repetition rate on VsEP waveform, latency, and amplitude were studied. Experiments have shown that the responses are not electrical artifact, nor are they contaminated by auditory, somatosensory, or passive eye movement potentials.