Michiko Node

Furosemide loading vestibular evoked myogenic potential for unilateral Ménière's disease

Objective To investigate whether endolymphatic hydrops in Ménières Disease could be diagnosed by comparing vestibular evoked myogenic potential (VEMP) before and after furosemide administration (F-VEMP). Study Design Retrospective study. Setting University hospital. Intervention Furosemide administration. Patients Twenty-five affected ears of patients with unilateral Ménières Disease were studied. The patients had received confirmed diagnoses Ménières Disease; thus, the presence of endolymphatic hydrops was suggested. For the control, 22 ears of 11 normal healthy volunteers who had never had vertigo or hearing disturbance were used. Main Outcome Measure The amplitude of the p13–n23 biphasic wave before and after furosemide administration. Results The amplitude of the p13–n23 biphasic wave was significantly enlarged in 7 of 18 cases in which it could be detected before diuretic loading. The biphasic waves appeared after diuretic loading in 3 of 7 cases in which it could not be recorded before loading. Thus, the positive ratio of F-VEMP for unilateral Ménières Disease was considered to be 40% (10 of 25). The ratio was similar to that of the conventional examinations for endolymphatic hydrops such as the glycerol test, furosemide test, and electrocochleogram. Conclusion The F-VEMP test may be useful in the diagnosis of endolymphatic hydrops.

Frequency dynamics shift of vestibular evoked myogenic potentials in patients with endolymphatic hydrops.

Objective: To measure the frequency dynamics of the vestibular evoked myogenic potential in patients with endolymphatic hydrops. Study Design: A prospective study. Setting: A university hospital. Subjects: The endolymphatic hydrops group consisted of 28 affected ears of patients with definite unilateral Ménières disease and a control group of 36 ears of 20 healthy volunteers. Interventions: Vestibular evoked myogenic potentials generated by tone bursts at 250, 500, 700, 1,000, 1,500, 2,000, and 4,000 Hz were measured in both groups. Vestibular evoked myogenic potentials were also measured after furosemide administration in six patients in the endolymphatic hydrops group. Main Outcome Measure: The frequency sensitivity of vestibular evoked myogenic potential, as evaluated by p13-n23 normalized amplitude. Results: Peak amplitudes were noted at 500 Hz in the control group and at 1,000 Hz in the endolymphatic hydrops group. After furosemide loading, peak amplitude shifted to a lower frequency in four of six ears. Conclusion: The peak amplitude of vestibular evoked myogenic potentials in the endolymphatic hydrops group was at a higher frequency than in the control group. The frequency of the saccule (ν) should be proportional to √(τ/σ), where τ is the tension of membrane and σ is its density. We advocate the hypothesis that the shift in frequency dynamics of vestibular evoked myogenic potential in patients with endolymphatic hydrops originates from the morphologic features of the saccule, analogous to an expanded balloon.

Long-term observation on hearing change in patients with chronic otitis media

OBJECTIVE Very few reports are available in the literature to clarify the natural long course of hearing change in an individual patient with chronic otitis media (COM). We reviewed hearing change in patients suffering from perforated COM without an operation. METHODS Eighty-seven ears of 70 patients had COM with tympanic perforation and were observed without an operation. The mean follow-up period was 10.7 years (5-22 years) and the mean age at the first examination was 51.3 years. To minimize the effect of aging, 23 patients with normal ear drums on the other side were further analyzed. RESULTS All 87 ears tended to show deterioration of hearing gradually under long observation. In 23 patients, hearing deterioration was 0.13 dB/year in the control side and 0.61 dB/year in the COM side (P < 0.02). Although elevation of bone conduction hearing level tended to be larger at high frequencies than at low and middle frequencies, there was no significant difference between COM and normal ears. CONCLUSIONS Air conduction hearing levels deteriorated with the passage of time and surgery is recommended at the early stage of COM to prevent progress of hearing loss.

Three cases of cochleosaccular endolymphatic hydrops without vertigo revealed by furosemide-loading vestibular evoked myogenic potential test

Objective To describe possible cases of cochleosaccular endolymphatic hydrops without vertigo. Study Design Retrospective case report. Setting University hospital. Patients Three patients with possible cochleosaccular hydrops without vertigo were studied. The basis of diagnosis was positive result of the furosemide-loading vestibular evoked myogenic potential test, no canal paresis in the caloric test, and recurrent cochlear symptoms or fluctuating low-tone hearing loss. Case Report In case 1, a 47-year-old woman had recurrent left aural fullness and tinnitus and a few weeks later complained of a floating sensation and could not stand up. The furosemide-loading vestibular evoked myogenic potential test showed a positive result in the left ear. In case 2, a 24-year-old woman complained of a backward falling sensation lasting several seconds; subsequently, a severe floating sensation persisted and she could not stand up for several days. Audiography showed fluctuating low-tone hearing loss in the left ear, and the furosemide-loading vestibular evoked myogenic potential test showed a positive result. In case 3, a 41-year-old woman had a floating sensation while walking and subsequently complained of tinnitus in the left ear. She could not stand up because of a severe floating sensation and, moreover, complained of a sudden falling sensation lasting for several seconds. The furosemide-loading vestibular evoked myogenic potential test indicated a positive result in the left ear. Conclusions The patients in cases 2 and 3 complained of a short-lasting sensation of falling down. Severe disequilibrium that prohibited standing up was noted in all cases. It was suggested that these symptoms were caused by saccular hydrops.

Preliminary study on vestibular-evoked myogenic potential induced by bone-conducted stimuli.

Objective: To study the relationship between vestibular-evoked myogenic potential evoked by air-conducted stimuli (A-VEMP) and those evoked by bone-conducted stimuli (B-VEMP). Study Design: Prospective study. Setting: University Hospital. Patients: To determine the optimum stimulus conditions for B-VEMP, 40 ears of 20 healthy volunteers were used. To compare results of A-VEMP and B-VEMP, 60 ears of 30 healthy volunteers and 70 ears of 35 patients with unilateral vestibular disorder without conductive hearing loss were used. Main Outcome Measure: A-VEMP and B-VEMP were measured. Both examinations involved evaluation of the interaural ratio (IAR) of the p13-n23 peak-to-peak amplitude. To compare the relationship between A-VEMP and B-VEMP in healthy subjects and patients with unilateral vestibular disorder. Results: The optimum stimulus for B-VEMP seemed to be a tone-burst sound with 8-ms duration at 250 Hz. In all healthy subjects, both A-VEMP and B-VEMP could be recorded. The mean IAR of B-VEMP (0.5 ± 21.0%) was not significantly different from that of A-VEMP (0.2 ± 19.4%). In patients with unilateral vestibular disorder, B-VEMP could not be detected in 10 ears in which A-VEMP also could not be detected. The IAR of A-VEMP was strongly correlated with that of B-VEMP (correlation coefficient, 0.98). Conclusion: The results of B-VEMP were almost the same as those for A-VEMP, at least, for patients without conductive hearing loss.

Cholesteatoma otitis media with intact ossicular chain.

Thirty-one cases of cholesteatoma with intact ossicular chain were reviewed to examine the extension of cholesteatoma, operation procedures, pre- and postoperative hearing levels, and postoperative condition of the ear drum. They were operated on at Departments of Hyogo College of Medicine and Osaka University Medical School from 1989-1996, which were 20.4% of all of the primary cholesteatoma cases (n = 152). Twelve cases located at attic were operated by atticotomy or canal wall up and scutumplasty, 17 cases located at attic/antrum were operated by canal wall down and reconstruction, and two cases located around stapes were operated through the ear canal. Preoperative hearing level was mild (34.2 +/- 18.4 dB) and postoperative one was slightly improved (28.7 +/- 11.2 dB). In ossicular reconstruction, modified Wullstein type III method showed better hearing gain than Wullstein type I method. Postoperative attic retraction and/or pocket occurred in 15 cases (48.4%), but no recurrent cholesteatoma was found during the present follow-up period. These findings suggested that cholesteatoma with intact ossicular chain showed good postoperative hearing results, but postoperative retraction of the ear drum should be followed up for a long time.

Dermoid cyst in the middle ear

A case of a moderate essentially low tone unilateral conductive hearing loss without a previous history of secretory otitis media in a six-year-old female patient is described. The condition was found to be due to a dermoid cyst in the tympanic cavity, which was confirmed by pathological examination of the surgically removed specimen. This is the sixth documented case of dermoid cyst in the tympanic cavity.

Allograft stapes surgery for conductive hearing loss in patients with ossicular chain anomalies

An allograft stapes was used during surgical intervention for conductive hearing loss due to ossicular malformations in 11 ears of seven patients. The external auditory canal and tympanic membrane were normal in all ears. The surgical findings for the ossicles were stapes fixation (7 ears), stapes fixation with discontinuity of the incudostapedial joint (in both ears of one patient), a deformed incus and stapes crura compressed by the facial nerve (one ear in which the stapes was not fixed) and an anomaly of the incus and stapes combined with a dermoid cyst (in one ear in which the stapes was also not fixed). In all ears, the following procedures were performed: stapedectomy followed by sealing the oval window with a vein graft and placing an allograft stapes between the oval window and the lenticular process of the incus or the handle of the malleus. The allograft stapes was placed with its capitulum on the oval window in all cases, and fibrin glue was used for stabilizing the seal and the allograft stapes. The indications for stapedectomy for conductive hearing loss due to ossicular chain anomalies and the utility of allograft stapes are discussed.

A Case of Tullio's Phenomenon after Stapedotomy.

A 29-year-old male had complained of bilateral hearing loss and bilateral tinnitus since five years ago. He was diagnosed with otosclerosis, and a stapedotomy was performed in the right ear two years ago at another hospital. Following surgery, he complained of oscillopsia during loud sounds. His eye movements were subsequently recorded, during loud sound stimulation. With left ear stimulus nystagmus was not detected, but with right ear stimulus, pendular nystagmus in the vertical plane was seen with sounds of 500Hz 100dBHL. An exploratory tympanotomy was subsequently performed. Except for findings associated with poststapedotomy, there was no evidence of abnormalities, including leakage of perilymph. We thought that the piston wire might be stimulating the labyrinth membrane, so the wire was removed, together with the footplate. The oval window was closed with a vein graft and allograft stapes were inserted in the inverted position. Tullios phenomenon with downbeat and torsional nystagmus was seen during one month after surgery.Although the origin of vertical eye movement is unclear, observations suggest that Tullios phenomenon in this case was caused by hyperexcitability of the otolith organs.