Vincent B. Ostrowski

Tullio phenomenon with dehiscence of the superior semicircular canal

Hypothesis The goal of the investigation was to determine if vector analysis of nystagmus in a patient with the Tullio phenomenon could determine the source of the nystagmus. Background The Tullio phenomenon consists of the combination of vertigo and abnormal eye and/or head movements provoked by sound. Dehiscence of the superior semicircular canal can be found in certain patients with the Tullio phenomenon. Methods The patient was tested with pure tones ranging from 250 to 3000 Hz at 95dB HL. The time course of the three-dimensional vector of eye movement, including torsion and vertical and horizontal displacement angles was determined by individual stop-frame analysis of digitized video. Results Torsion amplitude varied from 1 to 7 degrees; vertical amplitude varied from 1 to 5 degrees; and horizontal amplitude varied less than 1.5 degrees. The maximal response occurred on stimulation of the right ear with a 1250-Hz 95-dB HL tone. This elicited a reliable counterclockwise torsional and down-beating fast phase nystagmus as seen from the examiners point of view. Comparison of the nystagmus with known canal vectors identified the right superior semicircular canal as the source of stimulation. High-resolution computed tomography scan of the temporal bone showed a definite right superior canal dehiscence. Conclusion The origin of nystagmus from the Tullio phenomenon can be identified by calculating the three-dimensional vector of the observed nystagmus. We show that vector analysis of the observed eye movement can be used to infer the source of nystagmus in these patients. The development of real-time, three-dimensional vector analysis of nystagmus is desirable.

Endolymphatic sac-vein decompression for intractable meniere’s disease: long term treatment results

OBJECTIVES We sought to determine the long-term efficacy of endolymphatic sac-vein decompression surgery on patients with classic Menieres disease. STUDY DESIGN AND SETTING Using the 1995 American Academy of Otolaryngology-Head and Neck Surgery Committee on Hearing and Equilibrium criteria, starting stage, functional level, vertigo class, and hearing results were addressed. We studied 68 patients with classic Menieres disease from a tertiary, private otology-neurotology practice. Patient data were gathered by retrospective chart review, questionnaire, and patient interview. All patients underwent endolymphatic sac-vein decompression with an average follow-up period of 55 months. RESULTS Median functional level before surgery was level 4, improving to level 2 after surgery. Eighty-one percent of patients showed improvement in functional level, 12% remained stable, and 7% declined. Long-term vertigo control was 47% in class A, 25% in class B, 9% in class C, 3% in class D, and 16% in class F. Twenty percent of patients were in hearing stage I Menieres disease; 31%, stage II; 44%, stage III; and 5%, stage IV. Eighteen percent of patients showed improvement in hearing class, 64% were stable, and 18% declined. CONCLUSION Endolymphatic sac-vein decompression surgery is a safe, nondestructive surgical option for Menieres disease that offers durable control of vertigo and stabilization of hearing for the majority of symptomatic patients. SIGNIFICANCE The beneficial long-term outcome of the endolymphatic sac-vein decompression supports its continued use as a first-line treatment option in intractable Menieres disease.

Synchronous ipsilateral cerebellopontine angle glossopharyngeal schwannoma and parotid adenoid cystic carcinoma.

A 49-year-old woman presented to our clinic with a several-month history of right aural fullness, facial pain, headache, and a parotid mass. She had no symptoms of dysphagia, weight loss, hoarseness, or other otologic complaints. She denied changes in vision, gait, or coordination. Past medical history was significant for an ectopic pregnancy, adenotonsillectomy, and depression. Family history was noncontributory. Medications included Zoloft and Pepcid. Physical examination was remarkable for an ill-defined, tender, 2 × 2-cm right parotid mass without palpable cervical adenopathy. A right serous effusion was present. All cranial nerves were intact with no gross cerebellar findings. Preoperative brain magnetic resonance imaging (MRI) revealed a 2.4-cm enhancing lesion of the right cerebellopontine angle with fourth ventricle compression compatible with a vestibular schwannoma (Fig 1). Computed tomography scanning and MRI of the neck and skull base revealed a 2 × 3-cm right parotid mass with extension to the mastoid, middle ear, and marrow of the occipital condyle. The patient underwent a fine needle biopsy of the parotid mass and results were consistent with adenoid cystic carcinoma (Fig 2). In addition, a nonenhancing lytic lesion of the anterior midline vertebral body of C6 was noted. This lesion was suspicious for metastatic disease. To relieve fourth ventricle compression, the cerebellopontine mass was removed through a posterior fossa craniotomy. Intraoperatively, the lesion was consistent with a glossopharyngeal schwannoma. On the first postoperative day, the patient had a grade 4/6 right facial paresis, a right tongue deviation, and an intact gag reflex. The patient had dysphagia with mild aspiration. Three weeks later, the patient underwent a right radical parotidectomy, modified lateral neck dissection (levels II and III), subtotal temporal bone resection, partial occipital condylectomy, and a C6 corpectomy. A microvascular rectus muscle free flap was used to reconstruct the surgical defect. Postoperatively the patient had deficits of cranial nerves VII, IX, and X. Postoperative radiation therapy is planned.

A case of tullio phenomenon with superior canal dehiscence

Results: The sensitivity of CT scanning was high (>70%) for evidence of soft tissue disease and bone erosion. However, it was less convincing in cases where there was exposed dura, ossicular discontinuity, and facial nerve dehiscence (50%70%). The evaluation of lateral semicircular canal fistulae was enhanced by axial as well as the routine coronal MRI scans. Vascular abnormalities and petrous apex lesions were universally well demonstrated. Conclusion: This study has demonstrated the relative strengths and weaknesses of routine preoperative CT scanning in patients with middle ear disease. This will give insight into realistic advantages of using this diagnostic tool. Clinical Significance: This will provide useful information for preoperative planning, improved patient counseling, and the demonstration of individual patient anatomy in a resident teaching scenario. There is also the advantage of objective demonstration of various pathological and anatomical features in a court of law.