Musaed Alzahrani

Endolymphatic Duct Blockage A Randomized Controlled Trial of a Novel Surgical Technique for Ménière’s Disease Treatment

Objectives To compare the effectiveness of the endolymphatic duct blockage (EDB) and the endolymphatic sac decompression (ESD) to control Ménière’s disease symptoms and to evaluate their effect on hearing level. Study Design Prospective nonblinded randomized study. Setting Tertiary medical center. Subjects and Methods Fifty-seven patients affected by a refractory Ménière’s disease were included out of which 22 underwent an ESD and 35 underwent an EDB. Five periods of follow-up were considered: 0 to 1 week, 1 week to 6 months, 6 to 12 months, 12 to 18 months, and 18 to 24 months. Mean outcome measurements consisted of vertigo control, tinnitus, aural fullness, instability, and hearing level. Hearing level was evaluated using pure-tone average (PTA) and speech discrimination score (SDS). Results There was no significant difference between the 2 groups in the number of vertigo spells per months preoperatively (P = .153). Twenty-four months postoperatively, 96.5% of the EDB group had achieved a complete control of vertigo spells against 37.5% of the ESD group with a statistically significant difference (P = .002). There was a better control of tinnitus and aural fullness with EDB (P = .021 and P = .014, respectively). There was no statistically significant difference in hearing level preoperatively (P = .976) and 24 months postoperatively (P = .287) between the 2 groups. Hearing level was preserved in each group with no significant difference between the preoperative and the postoperative levels (P > .05). Conclusion EDB is more effective than the traditional ESD in controlling the symptoms of Ménière’s disease. It is a novel surgical technique with promising results for a complete treatment of Ménière’s disease. There are no significant complications or adverse effect.

Growth factors expression in hyaluronic acid fat graft myringoplasty

To investigate the effect of hyaluronic acid (HA) associated to fat graft on growth factors expression during the healing process of tympanic membrane (TM) perforations in guinea pigs using the hyaluronic acid fat graft myringoplasty (HAFGM) technique.

Superior canal dehiscence: can we predict the diagnosis?

Objective Identify independent clinical and audiometric factors to predict a positive high-resolution computed tomography (HRCT) scan for superior canal dehiscence (SCD). Study Design Retrospective chart review. Setting Tertiary referral center. Patients Patients presenting SCD. Intervention(s) Audiogram, VEMP, temporal bone HRCT, and SCD symptoms and signs chart. Main Outcome Measure(s) ABG, VEMP threshold, and symptoms and signs. Results Approximately 106 patients with SCD symptoms were included: 62 had a positive and 44 had a negative CT scan. The positive scan group showed a higher average of cochlear symptoms than the negative CT scan group (4.3 versus 2.6) (p < 0.001), but no statistical difference for vestibular symptoms (2.2 versus 1.8) was identified. CVEMP thresholds of the positive and negative CT scan groups were of 66 and 81 dB, respectively (p < 0.001). The positive CT scan group showed higher ABGs at 250 Hz (24 versus 14 dB) and 500 Hz (17 versus 8 dB) (p = 0.008 and p = 0.008, resectively). No statistical significance was found when comparing both groups for air and bone conduction thresholds. Approximately 23% of the positive CT scan group showed a Valsalva-induced vertigo against 2.3% of the negative scan group (p = 0.003); 27% of the positive CT scan group showed speculum-induced vertigo but none of the negative scan patients (p < 0.001). Using logistic regression, we found that each 10-dB unit increase in the 250 Hz ABG is associated to an increase odd of having SCD of 51% (OR, 1.51; 95% CI, 1.10–2.08). Conclusion Nature and number of cochlear symptoms, Valsalva and pneumatic speculum-induced vertigo, VEMP thresholds, and ABGs seem to correlate with a positive HRCT. The ABG at 250 Hz is the most accurate predictor of SCD.

Tympanic membrane retraction pocket staging: is it worthwhile?

Our objectives were to review all reported staging systems of tympanic membrane (TM) retraction pockets (RP) and to report their reliability and utility to our daily clinical practice in terms of follow-up and decision making in the management of RP. We aim to propose a new management algorithm of TMRPs. We conducted a thorough research on Ovid Medline, Pubmed and Cochrane databases for English and French languages studies published between 1963 and 2012 on the retraction pocket. Studies were excluded if it were a short comments, photo clinical cases, experimental studies or round table articles. Cholesteatoma was not included in keywords, since it is considered as an advanced pathological entity with different staging and management approaches. We included 60 of 756 articles that met our inclusion criteria. Sadé and Berco proposed the first staging system of RP in 1976, while the last one was described by Borgstein et al. in 2007. From 1976 to 2007, 12 different staging systems have been described for tympanic membrane retractions. There are three broad categories of TMRPs: localized retractions of the pars tensa, generalized retractions of the pars tensa (atelectasis) and retraction of the pars flaccida. Most of the described staging systems are useful for following up the evolution of retractions over time. However, no consensus was found concerning the decision making in its management. In conclusion, proper management of TMRPs requires a reproducible, easily applicable staging system with low inter- and intra-observer variability. We propose a management algorithm that considers the functional handicap of the patient rather than the topographic description of the TM.

Common Features in Patients With Superior Canal Dehiscence Declining Surgical Treatment

Background Superior canal dehiscence (SCD) is a benign condition in which a surgical treatment may be considered depending on the patients’ tolerance of their symptoms. In this study, we aim to identify driving factors behind the patients’ choice of a surgical management over watchful waiting. Methods Sixty-two patients with cochlear and/or vestibular symptoms and a temporal bone high-resolution CT (HRCT) scan showing SCD were included in the study. All patients have been offered either surgical management or watchful waiting. Results Of these, 28 elected surgery and 34 declined it. The operated group showed more cochlear (6.6 vs. 2.4) symptoms than the non-operated group (P < 0.001) except for hypoacousis, but no significant difference (P = 0.059) was found for the number of vestibular symptoms between both groups (3.4 vs. 1.1). Footstep and eating hyperacousis were both present in 57.1% of operated vs. 3% of non-operated patients (P < 0.001). Oscillopsia with effort and with walking was found in 50% and 35.7% of operated patients, respectively, but none in the non-operated group (P < 0.001). Hearing tuning fork at malleolus and Valsalva and pneumatic speculum induced vertigo showed a statistically significant difference between the two groups (P = 0.003, P < 0.001, P = 0.010 respectively). Cervical vestibular-evoked myogenic potential (cVEMP) thresholds, air and bone conduction thresholds, and mean air-bone gap (ABG) were similar in the two populations (P > 0.05). The average dehiscence size was 4.7 mm (2.0 - 8.0 mm) and 3.8 mm (1.3 - 7.7 mm) in the operated and non-operated patients, respectively (P = 0.421). Conclusions The natures of cochleovestibular signs and symptoms were shown to be key factors in patients’ choice of a surgical management whereas paraclinical tests seem to be less significant in the patients’ decision for a surgical treatment.

Hearing loss in the shaken baby syndrome

OBJECTIVES To evaluate hearing in children diagnosed with shaken baby syndrome. METHODS A retrospective study conducted in a pediatric tertiary care center between 2006 and 2012. Children diagnosed with shaken baby syndrome were included for hearing evaluation by conventional audiometry, distortion product otoacoustic emissions and auditory brainstem responses. RESULTS Twenty-eight children were included (22 boys and 6 girls). The mean age of children at presentation was 8 months (range 1-26 months) and the mean delay before audiometric evaluation was 30 months (range 1-87 months). One child was diagnosed as having a moderate sensorineural hearing loss. The tympanic membrane mobility was normal (type A) for both ears in 22 children, one child had a reduced tympanic mobility in one ear, two children had a negative pressure, one child had a functional trans-tympanic tube and test was not performed in 2 patients. CONCLUSION This is the first study reporting hearing loss as a possible result of shaken baby syndrome. However, further studies with larger number of children would be preferable. We recommend hearing evaluation for these children to rule out hearing loss.

A Rare Case of Large Skull Base Meningioma Mimicking Otitis Media with Effusion

A 48-year-old woman presented with unilateral hearing loss and tinnitus for three years associated with middle ear effusion. Previous treatments, including antibiotics, corticoids, and transtympanic tube, were ineffective. Otomicroscopy showed a greyish retrotympanic mass associated with middle ear effusion. High resolution CT scan of the mastoid was in favor of chronic oto-mastoiditis without any evidence of tegmen dehiscence. Surgical exploration revealed a polypoid greyish mass filling the tympanic cavity. Histological examination postoperatively revealed a meningothelial meningioma. Postoperative magnetic resonance imaging (MRI) was obtained and showed a large skull base meningioma, extending from the clivus anteriorly to the porus acusticus posteriorly with middle ear invasion. After discussion with the multidisciplinary tumor board, it was managed by stereotactic radiotherapy due to the high surgical associated neurovascular risks. In conclusion, middle ear meningioma, although still a rare presentation, should be suspected in the presence of atypical chronic OME.

Eosinophilic otitis media diagnosis using flow cytometric immunophenotyping

Abstract Objectives: (1) To assess the ability of flow cytometric immunophenotyping to detect and quantitate eosinophils in patients with eosinophilic otitis media (EOM). (2) to evaluate the association of EOM to bronchial asthma. Methods: Twenty-one patients with chronic otorrhea or middle ear effusion (MEE) were included in this prospective cohort study. Group I composed of 10 patients (14 ears) and associated to bronchial asthma. Group II included 11 patients (11 ears) without bronchial asthma. Samples of MEE were sent for flow cytometric analysis at initial presentation. Patients with positive eosinophils on flow cytometric immunophenotyping were analyzed after one-month course of dexamethasone eardrops. Results: EOM was diagnosed in all patients of group I and in three patients of group II. The mean eosinophils percentage was 43.5% and 14.2% for group I and group II, respectively (p = .006). Those patients showed a significant response to dexamethasone eardrops, both on clinical examination and on flow cytometric analysis with a decrease in eosinophil levels post-treatment. However, this improvement was temporary and symptoms recurred after treatment cessation. Bronchial asthma was not associated to all patients with EOM. Conclusion: Diagnosis of EOM remained mostly clinical; flow cytometry immunophenotyping of MEE may be helpful as an additional tool in diagnosis and monitoring the response to treatment, particularly in non-asthmatic patients.

Morbidity Rate of the Retrosigmoid versus Translabyrinthine Approach for Vestibular Schwannoma Resection

Background and Objectives Controversy related to the choice of surgical approach for vestibular schwannoma (VS) resection remains. Whether the retrosigmoid (RS) or translabyrinthine (TL) approach should be performed is a matter of debate. In the context of a lack of clear evidence favoring one approach, we conducted a retrospective study to compare the morbidity rate of both surgical approaches. Subjects and Methods 168 patients underwent surgical treatment (2007-2013) for VS at our tertiary care center. There were no exclusion criteria. Patients were separated into two groups according to the surgical approach: TL group and RS group. Signs and symptoms including ataxia, headache, tinnitus, vertigo and cranial nerve injuries were recorded pre- and postoperatively. Surgical complications were analyzed. Perioperative facial nerve function was measured according to House-Brackmann grading system. Results Tumor resection was similar in both groups. Facial paresis was significantly greater in RS group patients preoperatively, in the immediate postoperative period and at one year follow-up (p<0.05). A constant difference was found between both groups at all three periods (p=0.016). The evolution of proportion was not found to be different between both groups (p=0.942), revealing a similar rate of surgically related facial paresis. Higher rate of ataxic gait (p=0.019), tinnitus (p=0.039) and cranial nerve injuries (p=0.016) was found in RS group patients. The incidence of headache, vertigo, vascular complications, cerebrospinal fluid leak and meningitis was similar in both groups. No reported mortality in this series. Conclusions Both approaches seem similar in terms of resection efficacy. However, according to our analysis, the TL approach is less morbid. Thus, for VS in which hearing preservation is not considered, TL approach is preferable.