Kazumasa Kondoh

Steroid effects on vestibular compensation in human

Abstract Vestibular neuritis (VN) rapidly damages unilateral vestibular periphery, inducing severe balance disorders. In most cases, such vestibular imbalance is gradually restored to within the normal level after clinical therapies. This successive clinical recovery occurs due to regeneration of vestibular periphery and/or accomplishment of central vestibular compensation. We experienced 36 patients with VN treated at our hospital, including cases in our previous preliminary report. To elucidate effects of steroid therapy both on the recovery of peripheral function and on the adaptation of central vestibular compensation, we examined caloric test and several questionnaires with two randomly divided groups, 18 steroid-treated and 18 nonsteroid-treated patients, over two years after the onset. These examinations revealed that steroid-treated patients had a tendency of better canal improvements (13/18, 72%) than nonsteroid-treated ones (10/18, 55.6%). However, there was no significant difference between these two groups. In cases with persistent canal paresis, steroid-treated patients (n = 5) reduced handicaps in their everyday life due to the dizziness induced by head and/or body movements and the disturbance of their mood, more effectively than those with nonsteroid therapy (n = 8). These findings suggest that steroid therapy with VN could be effective on not only vestibular periphery but central vestibular system, to restore the balance.

The Investigation of the Recurrence Rate of Cholesteatoma Using Kaplan-meier Survival Analysis

Objectives: To investigate the recurrence rate of cholesteatoma using Kaplan-Meier survival analysis. Study Design: Retrospective study. Setting: Tertiary referral center. Patients: Three hundred forty-five patients with middle ear cholesteatoma operated on by the same surgeon between 1987 and 2002. Methods: The cumulative recurrence rate of cholesteatoma during a 5-year follow-up period was calculated using Kaplan-Meier survival analysis. Results: The overall 5-year recurrence rate was 11.8%. The recurrence rate increased with the follow-up time. The 5-year recurrence rate was 3.9% in patients treated with canal wall down tympanoplasty (CWDT) and 16.7% in patients treated with intact canal wall tympanoplasty (ICWT) or canal wall reconstruction (CWR) after CWDT with a significant difference (p < 0.01). The 5-year recurrence rate was 26.0% in patients operated on between 1987 and 1996 and 0.7% in patients operated on between 1997 and 2002, again with a significant difference (p < 0.001). Conclusion: Kaplan-Meier survival analysis should be used for calculating the recurrence rate of cholesteatoma. Although this analytic method further demonstrates that CWDT is a more reliable surgical method than ICWT/CWR in reducing cholesteatoma recurrence, clinical judgment should be exercised, and we continue to recommend that a flexible approach should be adopted in deciding whether to perform CWDT or ICWT/CWR for individual cases.

Long-term hearing outcomes after ossiculoplasty in comparison to short-term outcomes.

Objectives: To investigate long-term hearing outcomes after ossiculoplasty. Study Design: Retrospective study. Setting: Tertiary referral center. Patients: One hundred ninety-nine patients who underwent ossiculoplasty between 1989 and 2001 by the same surgeon and were followed for more than 5 years. Methods: Postoperative hearing outcomes were considered successful if the postoperative air-bone gap was within 20 dB. The outcomes after 6 months and 5 years were analyzed. Results: The overall rate of successful outcomes was 61.3% after 6 months and 54.3% after 5 years. There was a significant difference between 6 months and 5 years (p < 0.05). The significant deterioration of long-term hearing outcomes was found in malleus-present ears, ears with cholesteatoma/atelectasis, adults, and ears treated by one-stage operation. The reasons for long-term unsuccessful outcomes were adhesion or retraction of the ear drum in 13 ears (54.2%). Conclusion: The hearing outcomes after ossiculoplasty showed significant deterioration on long-term follow-up. Innovative approaches to the management of cholesteatoma/atelectasis are necessary to improve and stabilize long-term hearing outcomes.

Surgical Management of Special Cases of Intractable Meniere's Disease: Unilateral Cases with Intact Canals and Bilateral Cases

If a clinician seeks to allow patients with vertigo to return to work as soon as possible, it is very important to determine the appearance of vestibular symptoms during convalescence just after treatment, as well as the long-term results. Apprehensive patients with vertigo may undergo severe psychological torment if treatment requires long-term rest in bed before they can return to daily life. In this paper, we observed postoperative vestibular symptoms (subjective sensation and objective nystagmus) in 50 patients with intractable Menieres disease, including cases from our previous preliminary report, during the period of convalescence just after endolymphatic sac drainage and steroid instillation surgery (EDSS). All symptoms were eliminated within 8 days after EDSS. There was no significant difference in the duration of any vestibular symptoms between bilateral (n = 8) and unilateral cases (n = 42). This result indicates that EDSS could be as safe a treatment for bilateral Menieres disease as for unilateral disease. In unilateral cases with intact semicircular canal function (n = 17), postoperative evoked vestibular sensation, positional, and positioning (Dix-Hallpike) nystagmus disappeared significantly earlier than in those with canal paresis (n = 25). This result indicates that EDSS could keep the vestibular peripheral function of patients with unilateral Menieres disease with intact canals quite stable after surgery. Therefore, EDSS could be recommended as an initial, less-invasive surgical treatment for intractable Menieres disease, especially in unilateral cases with intact canals and in bilateral cases.

Management of Hemorrhagic High Jugular Bulb with Adhesive Otitis Media in an Only Hearing Ear: Transcatheter Endovascular Embolization Using Detachable Coils

A 51-year-old woman had a hemorrhagic high jugular bulb protruding into the posterosuperior part of the tympanic cavity in her left ear. This (only hearing) ear had severe adhesive otitis media resulting in repetitive hemorrhage from the jugular bulb. Therefore, treatment to stop the bleeding was required. Since invasive middle ear surgery in an only hearing ear would involve a high risk of hearing loss and massive bleeding, transcatheter endovascular embolization using detachable coils was selected for this special case; it safely blocked the blood flow and preserved the patients hearing level. This is the first such report in the otosurgical field, showing that transcatheter endovascular embolization using detachable coils was quite effective in a difficult case of a hemorrhagic high jugular bulb with severe adhesive otitis media in an only hearing ear.

Vestibular function and vasopressin.

OBJECTIVE To investigate the relation between the vestibular system and vasopressin (AVP). MATERIAL AND METHODS We examined the effects of electrical and caloric vestibular stimulation on plasma AVP levels in anesthetized rats. Plasma AVP levels of patients with intractable Ménières disease who were subjected to endolymphatic drainage and steroid instillation surgery (EDSS) or intratympanic gentamicin (GM) injection were measured before and after these interventions. RESULTS Electrical vestibular stimulation increased plasma AVP levels in a current intensity-dependent manner. Plasma AVP levels were also increased by caloric stimulation with cold water. Plasma AVP levels decreased rapidly after EDSS, and were maintained at a low level even 6-12 months following EDSS or intratympanic GM injection. CONCLUSIONS Vestibular activation or inhibition-induced imbalance of intervestibular activities increased plasma AVP levels in rats. Therefore, vestibular disorder would seem to increase plasma AVP and thus worsen endolymphatic hydrops. EDSS rapidly decreased plasma AVP and would seem to reduce hydrops. Inhibition of vertigo spells by EDSS or intratympanic GM injection would reduce a possible stress response, resulting in a decrease in plasma AVP levels a long time after the treatments. This resultant decrease in AVP would beneficially inhibit the formation and/or maintenance of hydrops and thus prevent vertigo spells.

Changes in caloric responses after temporal bone surgery with posterior tympanotomy

OBJECTIVE To elucidate the role of facial recess bony plate in the thermal transmission route from external auditory canal to lateral semicircular canal during caloric stimulation test, we performed the test on patients before and after removal of the plate, i.e. posterior tympanotomy. In the present study, we adopted facial nerve decompression (FND) as posterior tympanotomy without surgery-induced inner ear damages and cochlear implantation (CI) as posterior tympanotomy with surgery-induced inner ear damages. METHODS Between 1999 and 2003, we performed FND on 19 patients with unilateral facial nerve paresis due to Bells palsy (n=7), Ramsay-Hunt syndrome (n=7) or facial nerve trauma (n=5) at Osaka Rosai Hospital. We also performed CI on 34 patients with bilateral deafness at Osaka University Hospital. To examine effects of FND or CI on caloric responses in vestibular periphery, caloric stimulation (30 degrees C cold water and 44 degrees C hot water) with ENG was performed twice, just before and 6 months after surgery in each subject. The caloric-induced nystagmus was recorded by using ENG under dark and open-eyes situation to calculate the maximum slow phase eye velocity. RESULTS In cases of FND (n=19), there were significant decreases between pre- and post-operative 30 degrees C responses (t-test: p=0.049<0.05). There were no significant differences between pre- and post-operative 44 degrees C responses (t-test: p=0.467>0.05). In cases of CI (n=34), there were significant changes between pre and post-operative responses in both temperatures (t-test: p<0.0001 in 30 degrees C; p=0.011<0.05 in 44 degrees C). CONCLUSION The insertion of electrodes during CI did some damages to vestibular peripheral function and reduced both hot and cold caloric responses according to the results of CI. However, the procedure during posterior tympanotomy could also decrease caloric responses especially in cold stimulation according to the results of FND. Therefore, we should consider the effect of structural change in temporal bone on the thermal transmission in case of evaluation of vestibular peripheral function by using caloric stimulation test.

Two cases of spinal cord extramedullary tumor with positional vertiginous sensation

Conclusions. We conclude that neck imaging should be carried out for patients with persistent paroxysmal positional vertigo following diagnostic and/or therapeutic maneuvers. Objective. It is sometimes complicated to diagnose patients with vertigo that is transiently induced by head and neck positioning. Neck-vestibular diseases also induce vertiginous sensation with head and neck movement and need to be ruled out for the diagnosis of benign paroxysmal positional vertigo (BPPV). Patients and methods. Two elderly female patients visited our hospital with complaints of transient vertigo induced by Dix-Hallpike positioning, suggesting posterior canal BPPV. We carried out gadolinium-enhanced neck MRI in both these cases. Results. The positional nystagmus was not clearly observed or vertiginous sensation did not show any decay during repeated vestibular examination in either case. These cases were finally diagnosed as spinal cord intradural extramedullary tumor (C3–C4) by means of neck MRI.

Bilateral Traumatic Facial Nerve Palsy and Ossicular Chain Dislocations; Case Report.

Cases of bilateral traumatic facial nerve palsy are seen in 2.5%-4.3% of all cases. We report a rare case of bilateral traumatic palsy accompanied with bilateral ossicular chain dislocations. Additionally, we review the literature for past cases and consider the cause of this unusual case.A 41-year-old male received injuries from having his head squeezed between concrete walls on a building construction site. Bilateral hearing loss and bilateral facial nerve palsy appeared soon after the accident. After treatment for his more lethal disorders, the patient was referred to our hospital a month after the accident. His expressions were very poor and he had bilateral hearing disturbances. He was diagnosed with bilateral traumatic facial nerve palsy and ossicular chain dislocations according to the findings of middle-ear CT. We decided to perform tympanoplasty and facial nerve decompression. Six months after surgery, his facial score had improved to grade II (pre-op grade V). His conductive hearing loss was also cured, the air-bone gap having disappeared.