Sady Selaimen da Costa

Meniere's disease: overview, epidemiology, and natural history.

Menieres disease is a disease of the inner ear characterized by a triad of symptoms: vestibular symptoms, auditory symptoms, and pressure. The pathologic correlate of Menieres disease is endolymphatic hydrops and the etiopathogenesis involves a deficiency in the absorption of endolymph. The pathophysiology of the symptoms is still disputed: membranous ruptures, pressure and mechanical displacement of the end organs, or obstruction followed by an abrupt clearance of the endolymphatic duct. The course of the disease may be progressive or nonprogressive and, in addition to the typical presentation of Menieres disease, two variations of the disorder have been identified: cochlear Menieres disease, and vestibular Menieres disease. It can be further broken into two subsets: Menieres syndrome, with a known and well-established cause, and Menieres disease, in which the cause seems to be idiopathic. It is likely that there are racial (genetic) as well as environmental factors that influence differences in incidence among countries and among various sections of countries. The disease is much more common in adults, with an average age of onset in the fourth decade, the symptoms beginning usually between ages 20 and 60 years. Menieres disease is (grossly) equally common in each sex, and right and left ears are affected with fairly equal frequency. The diagnosis of Menieres disease is by exclusion, and a careful history is the most important guide to a correct diagnosis. Its medical treatment is largely empiric. Surgery can be considered when, even after medical therapy, the disease progresses and the symptoms become intractable. Surgery may be either conservative or destructive. Bilaterality must be considered when deciding the best surgical option for a patient with Menieres disease. It is the authors opinion that endolymphatic sac surgery is an extension of conservative treatment.

Sensorineural hearing loss in patients with chronic otitis media.

Chronic otitis media is generally associated with some degree of hearing loss, which is often the patient’s chief complaint. This hearing loss is usually conductive, resulting from tympanic membrane rupture and/or changes in the ossicular chain due to fixation or erosion caused by the chronic inflammatory process. When cholesteatoma or granulation tissue is present in the middle ear cleft, the degree of ossicular destruction is even greater. An issue that has recently gained attention is additional sensorineural hearing loss due to chronic otitis media. While the conductive loss can be minimized through surgery, sensorineural hearing loss constitutes a permanent after effect, attenuated only through the use of a hearing aid. However, a few groups have reported a decrease in sensorineural function in these patients as well. This survey study performed at a referral center evaluates the occurrence of sensorineural hearing loss in ambulatory patients with this disease. We reviewed the files of patients with unilateral chronic otitis media. One hundred and fifty patients met the inclusion criteria: normal otoscopy and normal hearing in the contralateral ear. Main outcome measure: bone-conduction threshold averages were calculated for frequencies of 500, 1,000, 2,000, 3,000 and 4,000 Hz, with comparison between the normal ear and the ear with chronic otitis media. Thresholds were examined separately for each frequency. The bone-conduction threshold averages for the normal side were lower than those for the ear with chronic otitis media. The threshold shift was statistically significant for each frequency (P < 0.0001, Student’s t test). There were differences between the groups when analyzed for age (500 and 1,000 Hz) or the presence of cholesteatoma (1,000 Hz). This study shows that chronic otitis media is associated with a decrease in cochlear function.

Comparison of acquired cholesteatoma between pediatric and adult patients

The quantification of angiogenesis and metalloproteinases may be useful in cholesteatoma behavior assessment as markers of its aggressiveness. The objective of this study is to compare markers CD31, MMP2 and MMP9 in pediatric and adult patients. This study is based on cross-sectional studies of pediatric (≤18xa0years old) and adult groups (≥19xa0years old). Samples of 120 cholesteatomas were fixed in 10% formol, prepared on five slides of each sample through habitual histological techniques, and number of blood vessels (CD31), marking with MMP2 and MMP9, number of matrix cells and thickness at perimatrix cell were observed. Data were analyzed through SPSS using Spearman and Mann–Whitney coefficients. Cholesteatomas were equally distributed: 60 in pediatric patients (11.77xa0±xa03.57xa0years); 60 in adult patients (38.29xa0±xa014.51xa0years). When correlating the number of blood vessels and metalloproteinases with perimatrix thickness, we obtained the following values: pediatric CD31, 7 (4–11); adult CD31, 4 (0–10) (Pxa0=xa00.044); pediatric cytoplasmatic MMP2, 1 (0–3); adult cytoplasmatic MMP2, 0 (0–1) (Pxa0=xa00.006); pediatric nuclear MMP2, 0 (0–1); adult nuclear MMP2, 0 (0–1) (Pxa0=xa00.056); pediatric MMP9, 2 (0–4); adult MMP9, 0 (0–4) (Pxa0=xa00.049). In conclusion, pediatric cholesteatomas present a more exacerbated inflammatory degree, produce more metalloproteinases, factors that, when combined, could characterize pediatric cholesteatomas as more aggressive than adult cholesteatomas.

Sensorineural hearing loss among sickle cell disease patients from southern Brazil.

PURPOSEnA case-control study was done to confirm the higher prevalence of sensorineural hearing loss (SNHL) among sickle cell patients (HbSS) from southern Brazil.nnnPATIENTS AND METHODSnTwenty-eight patients and 28 matched normal controls were studied. Besides complete anamneses and physical otolaryngological examination, all individuals had audiometric and tympanometric testings to determine the presence of SNHL or middle ear problems. The only significant difference between groups was the presence of a positive history of otologic symptoms (hearing loss, dizziness or tinnitus) and neurological sequelae in the HbSS patients.nnnRESULTSnSix patients (21.4%) presented with SNHL compared with one control (3.6%) (Fishers one-tailed P = .05; OR, 7.36 (95% CI, 0.82, 65.83). The average age of HbSS diagnosis was higher among the patients with SNHL (10 years +/- 8.3) than those without SNHL (5.43 years +/- 5.65), but this was not significant (analysis of variance P > .05). More patients 25 years and older on the examination date had SNHL than younger patients (Fishers 2-tailed P < .05). Sixty-seven percent of the patients with SNHL had alterations in the acoustic reflex, and a surprising 27% of the patients without NSHL also presented with some elevation or an absence of acoustic reflex.nnnCONCLUSIONSnThese data indicate that patients with HbSS from southern Brazil are more predisposed to the development of sensorineural hearing problems than the general population.

Diagnosis of Meniere's disease: routine and extended tests

Menieres disease can compromise the quality of life of some patients in a manner so seriously that it can cause social segregation, even from family. Hearing loss, tinnitus, aural pressure, and disturbances in equilibrium added to an emotional instability frequently present in these patients may take them to a progressive state of solitude and depression, marking their lives by personal tragedy and making life a living hell. The clinical picture of Menieres disease fluctuates, however. Individually, subsidiary examinations become impotent in diagnosing Menieres disease. To be called Menieres disease, the cause must be unknown; otherwise it would constitute Menieres syndrome. Taking all of this into consideration, one would call this an unusual situation, or at least confusing. The lack of an etiologic diagnosis in medicine always creates anxiety for doctors and patients. What is considered to be either a routine or an extended test may change from service to service. The physician does not need to order all tests. What the physician needs is a protocol he or she trusts. Test results can vary, even depending on the moment when they are performed. More important than the number of tests ordered is the strategy by which the tests should be put together at that certain moment. The authors believe that one should have his or her own protocol for diagnosis, always beginning with a detailed history taking being guided by them most of the time. It is the authors understanding that patients with Menieres disease should be followed closely by their ear, nose, and throat doctor in episodes of vertigo or fluctuation of their hearing, tinnitus, or aural pressure. Should the patient be experiencing a stable period, a clinical visit along with an audiovestibular workup should be performed at least once a year. By monitoring the course of the disease, clinicians would be able to detect early changes in symptoms and/or test results, giving them the possibility to intervene clinically as early as possible in acute episodes of vestibulocochlear disorganization, protecting the inner ear, and minimizing sequelae from spells of hydrops. The authors believe that only the association of clinical sense and as many subsidiary tests as are useful will lead to a desirable level of certainty in the diagnosis of Menieres disease, and will allow clinicians to presume bilateral involvement, monitor the development of the disease, intervene in its natural course, and idealize appropriate treatment.

Tympanostomy tube sequelae in children with otitis media with effusion: a three-year follow-up study

UNLABELLEDnTympanostomy tube (TT) insertion is one of the most frequently performed procedures in otolaryngology. Otorrhea, tympanosclerosis, retraction, perforation, and cholesteatoma are complications reported in the literature after its application.nnnAIMnTo determine the incidence and the type of TT insertion sequelae/complications in children presenting with recurrent otitis media and chronic otitis media with effusion undergoing myringotomy and tube placement.nnnSTUDY DESIGNnProspective cohort study.nnnMATERIAL AND METHODnA total of 75 children (150 ears) aged 11 months to 10 years were regularly followed up for up to 38 months after TT insertion.nnnRESULTSnIncidence of sequelae/complications: otorrhea--47.3% of the ears; perforation--2.1%; retractions--39.7%; tympanosclerosis--23.3%. Average length of stay: 12.13 months. Mean age at initial tube placement of children not requiring a second set of tubes = 35.9 months and mean age at initial tube insertion of children requiring an additional set of tubes = 25.6 months (P = 0.04). TT stayed longer in the ears that had more episodes of otorrhea (P = 0.01). TT insertion with adenoidectomy was associated with a smaller number of otorrhea episodes (P = 0.02)nnnCONCLUSIONSnOtorrhea was the most frequently found complication. TT placement with adenoidectomy was associated with fewer otorrhea episodes. TT extruded later in those ears that had more episodes of otorrhea. Younger age at the time of the initial tube placement is associated with higher incidence of additional tube placement. One in six patients will probably require a second set of ventilation tubes.

Histologic description of acquired cholesteatomas: comparison between children and adults

UNLABELLEDnCholesteatoma is constituted of matrix, perimatrix and cystic content. Some authors affirm that, in children, its clinical behavior is more aggressive of the than in adults.nnnAIMSnHistologic compared cholesteatomas of children and adults.nnnMETHODOLOGYn74 cholesteatomas been analyzed, being 35 of pediatrics patients (<18 years). The average number of cellular layers and hyperplasia in the matrix had been evaluated; thickness, delimitante epithelium, fibrosis, inflammation and granuloma in the perimatrix. The analysis statistics was carried through with program SPSS 10.0, using the coefficients of Pearson and Spearman, test of chi-square and t test. The number of cellular layers in the matrix was of 8.2+/-4.2. The hyperplasia appears in 17%, fibrosis in 65%, granuloma in 12% and the delimitante epithelium in 21%. The perimatrix presented a medium one of 80 micrometers (37 the 232), minimum value zero and maximum value 1.926. The histological degree of inflammation was considered of moderate the accented one in 60%. When applying the coefficient of Spearman enters the inflammation degree and average of cellular layers of the matrix with the variables of the measure of thickness of the perimatrix we find correlations, significant, with moderate magnitudes of the great ones (rs=0.5 and P<0.0001).nnnCONCLUSIONnAdults colesteatomas of and child had not been identified to morphologic differences between. We find correlation enters the intensity of the inflammation and of the average of cellular layers of the matrix with the thickness of the perimatrix, what it can predict its aggressiveness, more studies are necessary to define the paper of this finding in pathogenesis of cholesteatoma.

Effects of Velopharyngeal Dysfunction on Middle Ear of Repaired Cleft Palate Patients

Objective Cleft palates are strongly associated with the development of otitis media due to the anatomic and functional defect of the soft palate musculature and the associated alterations of velopharyngeal muscle insertion on tubal cartilage, or even intrinsic alterations of the cartilage, which affects eustachian tube function. This study will assess velopharyngeal muscle adequacy after palatoplasty through videonasoendoscopy and verify if there is a correlation with otologic status. Design Transversal study. Setting Otorhinolaryngology and cleft palate outpatient service of the Hospital de Clinicas de Porto Alegre (HCPA), Porto Alegre, Brazil. Patients Seventy-three patients with cleft palate or cleft lip and palate between the ages of 6 and 12 years who had already undergone palatoplasty. Interventions Videonasoendoscopy for evaluation of velopharyngeal function and videotoscopy to assess middle ear status. Main Outcome Measures Severity scale for videonasoendoscopic and videotoscopic findings. Results There was no significant correlation between the videonasoendoscopic and the videotoscopic scores in the population studied. Discussion and Conclusions Intrinsic defects of the eustachian tube cartilage and of the insertion of the velopharyngeal muscles seem to contribute to the evolution of otitis media in patients with cleft palate, in addition to the actual defect of the soft palate. There was no correlation between the severity of the otoscopic findings and the degree of velopharyngeal dysfunction.

Algumas considerações sobre colesteatomas adquiridos pediátricos e adultos

Authors debate about cholesteatomas, from the first time this word was employed, by Muller, in 1838, until the recent updates. They dissert about its definition, etiology and pathology and present basic concepts about its biology. They also make a wide review about pediatric cholesteathoma, its epidemiology and biology, and compare it with adult cholesteatoma. Finally, they describe some articles about ossicle chain erosion and its correlation with cholesteatoma perimatrix, collagen and collagenase.

Estudo da orelha contralateral na otite média crônica: "Efeito Orloff ®"

Introducao: A otite media cronica (OMC) representa entidade de alta prevalencia e distribuicao mundial. Apesar da grande quantidade de estudos publicados a respeito, ainda nao ha, na literatura pertinente, consenso sobre a patogenese da OMC. Uma das hipoteses e a do continuum, que apresenta a otite media cronica como uma serie de eventos continuos, onde insultos iniciais desencadeiam uma cascata de alteracoes. Partindo entao da ideia de continuum, pesquisamos a orelha contralateral (OCL) de individuos com diagnostico de OMC, descrevendo as alteracoes encontradas. Forma de estudo: Clinico prospectivo randomizado. Material e Metodos: Foram selecionados 108 pacientes com diagnostico de OMC nao-colesteatomatosa (OMC NC) ou colesteatomatosa (OMC C) acompanhados no ambulatorio do Grupo de Pesquisa em Patologia da Orelha Media do Hospital de Clinicas de Porto Alegre. Nestes, foi realizada otoendoscopia com fibra optica bilateral. A orelha mais estavel foi considerada contralateral (OCL), sendo classificada como normal ou alterada (e as alteracoes descritas). Resultados: Dentre os pacientes avaliados, 59,2% portavam OMC NC e 40,8% OMC C. 46,3% de todos os pacientes apresentaram alteracoes significativas na OCL. Dos pacientes com OMC C, 57% apresentavam alteracao na OCL, sendo que 39% dos pacientes com OMC NC tinham OCL alterada. A alteracao mais frequentemente encontrada foi retracao de MT, em ambos os grupos. Conclusoes: Os dados encontrados sugerem que pacientes que apresentam OMC tem maior probabilidade de apresentarem patologia na OCL, o que corrobora a ideia que a OMC se trata de um evento constitucional e nao isolado da orelha media.