Unintentional conversion of benign paroxysmal positional vertigo caused by repositioning procedures for canalithiasis: transitional BPPV.

BPPV when diagnosed before any repositioning procedure is called primary BPPV. Primary BPPV canalithiasis treatment with repositioning procedures sometimes results in unintentional conversion of BPPV form: transitional BPPV. Objectives were to find transitional BPPV forms, how they influence relative rate of canal involvement and how to be treated. This study is a retrospective case review performed at an ambulatory, tertiary referral center. Participants were 189 consecutive BPPV patients. Main outcome measures were detection of transitional BPPV, outcome of repositioning procedures for transitional canalithiasis BPPV and spontaneous recovery for transitional cupulolithiasis BPPV. Canal distribution of primary BPPV was: posterior canal (Pc): 85.7% (162/189), horizontal canal (Hc): 11.6% (22/189), anterior canal (Ac): 2.6% (5/189); taken together with transitional BPPV it was: Pc: 71.3% (164/230), Hc: 26.5% (61/230), Ac: 2.2% (5/230). Transitional BPPV forms were: Hc canalithiasis 58% (24/41), Hc cupulolithiasis 37% (15/41) and common crux reentry 5% (2/41). Treated with barbecue maneuver transitional Hc canalithiasis cases either resolved in 58% (14/24) or transitioned further to transitional Hc cupulolithiasis in 42% (10/24). In follow-up of transitional Hc cupulolithiasis we confirmed spontaneous recovery in 14/15 cases in less than 2 days. The most frequent transitional BPPV form was Hc canalithiasis so it raises importance of barbecue maneuver treatment. Second most frequent was transitional Hc cupulolithiasis which very quickly spontaneously recovers and does not require any intervention. The rarest found transitional BPPV form was common crux reentry which is treated by Canalith repositioning procedure. Transitional BPPV taken together with primary BPPV may decrease relative rate of Pc BPPV, considerably increase relative rate of Hc BPPV and negligibly influence relative rate of Ac BPPV. Transitional BPPV forms can be produced by repositioning maneuvers (transitional Hc cupulolithiasis) or by the subsequent controlling positional test (transitional Hc canalithiasis and common crux reentry); underlying mechanisms are discussed.

Conductive hearing loss in patients with active acromegaly.

OBJECTIVE: There have been rare conflicting results reported concerning possible higher frequency of hearing loss in acromegalic patients. Our goal was to determine whether there is higher frequency of conductive hearing loss in acromegalics and what may cause it if there is any. STUDY DESIGN: Prospective study. SETTING: Tertiary referral center. PATIENTS: Thirty previously untreated patients with acromegaly were compared with 20 age- and sex-matched healthy control subjects. INTERVENTIONS: In all subjects: Otomicroscopy, tuning fork tests, audiometry tympanometry, cochleostapedial reflex, otoacoustic emissions. In acromegalics: endocrinologic assessment, MRI and if necessary, epipharyngoscopy. MAIN OUTCOME MEASURES: We searched for: 1) Signs of ossicle fixation: absence of stapedial reflex in the presence of normal tympanogram, conductive hearing loss, and absence of or grossly disturbed OAE; 2) Disturbances of middle ear ventilation: excessive negative pressure (tympanogram type C), or middle ear effusion (tympanogram type B). RESULTS: The only statistically significant difference between untreated acromegalics and healthy subjects was the presence of middle ear ventilation problem: 7/30 acromegalics (23%) in comparison to none out of 20 healthy controls (0%), p = 0.033. The acromegalics with middle ear ventilation problem were significantly older, had longer duration of the disease, and lower mean growth hormone (GH) levels in comparison with acromegalics without this problem (51.6 +/- 1.7 vs. 44.4 +/- 2.5 years, 11.6 +/- 2.4 vs. 7.7 +/- 0.4 years, 21.68 +/- 4.89 vs. 49.98 +/- 12.54 microg/L respectively). CONCLUSION: Patients with active acromegaly have more frequent middle ear ventilation problem than normal population, especially those with longer duration of the disease. Possible causes are discussed.

Congenital cholesteatoma of the middle ear--uncommon clinical presentation.

INTRODUCTION: Congenital cholesteatoma of the middle ear is un uncommon and yet not well-defined disease. Only few cases of cholesteatoma in thefossa ovalis with unusual clinical presentation have been reported in medical literature. CASE REPORT: We reported a 16-year-old girl with congenital cholesteatoma in the fossa ovalis with minimal clinical presentation. A small mass was found occluding the fossa ovalis and mimicking otosclerotic process within tympanic cavity. The operation started as stapedotomy, and when the process was confirmed it converted to mastoidectomy via the retroauricular approach. CONCLUSION: The diagnosis of congenital cholesteatoma in children should always be considered, even if the clinical symptoms imitate other ear disorders, in our case otosclerosis.

Clinical outcome of early glottic carcinoma in Serbia.

OBJECTIVE: Proposed methods for treating early glottic carcinoma are cordectomy through laryngofissure, laser cordectomy, and radiotherapy. The aim of the study was to conduct comprehensive study to evaluate oncological and functional results of different treatment modalities for Tis and T1 glottic carcinoma, identify prognostic factors for the outcome of treatment and decide where we stand in applying worldwide standards of early glottic carcinoma treatment. METHODS: Prospective study was conducted on 221 patients treated with Tis and T1 glottic carcinoma from 1998 to 2003 (72 patients were treated endoscopically with CO2 laser, 75 patients with cordectomy through laryngofissure and 74 with radiotherapy), with follow-up period from 38 to 107 months. Important demographic and clinical variables were analyzed. Voice quality after the treatment was assessed using multidimensional voice analysis. RESULTS: Comparing oncological results of three modalities of treatment, there were no significant differences. Functional results of treatment were better after laser cordectomy and primary radiotherapy than following the open cordectomy. Five-year survival rate was almost identical in all three groups of patients, and important prognostic factors for survival were age and histological grade of the tumor. CONCLUSION: Considering that the choice of treatment in our country is also greatly influenced by other paramedical factors, such as distance from treatment facility, reliability of follow-up, significant time delay of radiotherapy because of small number of radiology centers and strong patients' surgeon and treatment preference, we consider endoscopic laser surgery highly efficient and preferred choice of treatment for early glottic carcinoma.

Predictors for sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions.

OBJECTIVE: To determine predicting value of otitis type, age, gender, ear suppuration, disease duration, mucosal changes, cholesteatoma spreading, labyrinthine fistula, size, localization of tympanic membrane perforation, type and stage of its retraction and ossicular chain disruption with sensorineural hearing loss in patients with tubotympanic otitis, cholesteatoma, and tympanic membrane retractions. STUDY DESIGN: Retrospective case review study. SETTING: Tertiary referral center. PATIENTS: Approximately 264 adult patients with unilateral chronic ear disease, 60 adult patients with tympanic membrane retractions, 78 with cholesteatoma, and 126 with tubotympanic otitis. INTERVENTIONS: Otomicroscopy, pure tone audiometry, impedancemetry were carried out preoperatively. Wall up, wall down tympanoplasty, or two-stage surgery was applied depending on pathology. MAIN OUTCOME MEASURE: Bone conduction thresholds for 512 to 4,096 Hz. RESULTS: Mean values of bone conduction thresholds for frequencies 512 to 4,096 Hz were significantly higher in otitis groups than in healthy ears (p = 0.000), without differences between the groups. Ossicular disruption correlated with sensorineural hearing loss in cholesteatoma and tubotympanic otitis for all frequencies; long incus process destruction in tubotympanic ears showed strong negative correlation with sensorineural hearing loss for 512 to 2,048 Hz (linear regression coefficient, intercept was -2.84, -2.48, and -2.41; p = 0.0024, 0.0207, and 0.0076, respectively). Perforation size correlated with sensorineural hearing loss for 512 to 2,048 Hz in tubotympanic otitis (Log regression p = 0.0008, 0.0252, and 0.0267; odds ratio, 1.13, 1.11, and 1.06). Atelectasis correlated with sensorineural hearing loss for 4,096 Hz (p = 0.022). CONCLUSION: Predictors for sensorineural hearing loss in chronic otitis are otitis itself, age, ossicular disruption, especially of long incus process, extensive labyrinthine fistula, perforation size, and type of retraction.

[Assessment of senses of hearing and balance in chronic suppurative otitis media].

Chronic suppurative otitis media is among the most frequent illnesses treated in ENT wards. To establish the diagnosis, otomicroscopy alone usually suffice. Assessing the sense of hearing, often the sense of balance, too, is mandatory. Assessment of hearing will show the extent of conductive and sensorineural hearing loss. Apart from this, sometimes, when the finding is not obvious, it is necessary to conduct audiological investigation in more detail in order to establish whether the diagnosis of chronic suppurative otitis media is correct. Existence and extent of conductive hearing loss or confirmation of tympanic membrane perforation by tympanometry can help a great deal. Also, some new results about the site of perforation and the middle ear volume influence on conductive hearing loss may help have a better insight into chronic suppurative otitis media. Assessing the sense of balance may show dysfunctions with not yet necessarily permanent damage: perilymphatic fistula and benign paroxysmal positional vertigo (BPPV). Unilateral or bilateral damage may be diagnosed with appropriate tests of vestibuloocular reflex (VOR): spontaneous nystagmus, head impulse test, head shaking test. These bedside tests do not require bulky, expensive equipment for stimulus delivery or special equipment for recording nystagmus. In addition, their significance is their ability to provide enough information without performing caloric testing which is contraindicated in chronic suppurative otitis media.

[Cyclotropia after unilateral vestibular damage]. / Ciklorotacija oka posle jednostranog perifernog vestibularnog ostecenja.

UNLABELLED: Influence of unilateral peripheral vestibular lesion on cyclotorsion of both eyes was assessed by fundus photography. Control group was composed of 24 healthy individuals. Ten patients suffering from Acute Unilateral Peripheral Vestibulopathy (AUPV), which is the other name for vestibular neurolabyrinthitis, were examined at the beginning of the disease, and again after one year. Also 3 patients were examined that had undergone unilateral vestibular neurectomy about 10 years ago. In this paper we propose measurement of a single angle that defines tilt in the roll plane of both eyes at the same time. We propose this measurement of cyclotorsion of both eyes only after peripheral lesions because here vestibular influence is the same on both eyes (contrary to central lesions). RESULTS: 1) Both eyes tilt in healthy population varies equally around zero, from 5 degrees left to 5 degrees right; 2) Both eyes tilt in AUPV patients at the beginning of the disease was oriented to the side of the lesion 12.3 degrees in average which significantly differs from healthy subjects. Here, because of present nystagmus component in the roll plane taking only 1 photograph may result in error up to 5 degrees. Therefore, we took 5 photographs of each eye and calculated arithmetic mean; 3) Both eyes tilt in AUPV patients after one year has elapsed was 1.06 degrees to the lesion side and did not significantly differ from healthy subjects; 4) Vestibular neurectomy patients 10 years later showed 2 degrees tilt to the side of the lesion which also did not significantly differ from healthy subjects. CONCLUSIONS: One year after AUPV and 10 years after vestibular neurectomy central compensation significantly diminished pathological cyclotorsion of both eyes. At the beginning of AUPV several photographs have to be taken (we recommend 5) to avoid error up to 5 degrees due to marked nystagmus component in roll plane. We recommend measurement and calculation of both eyes tilt angle as only one parameter that defines peripheral vestibular lesion influence on cyclotorsion of both eyes.

[The vestibulospinal test in unilateral neurolabyrinthitis]. / Upotrebljivost vestibulospinalnih testova kod jednostranog neurolabirintitisa

In this paper we wanted to assess clinical relevance of two vestibulospinal tests: standing test (derived from Romberg test) and past pointing test. In retrospective and prospective study 42 patients have been tested with standing test and 50 patients with past pointing test. All patients suffered from unilateral neurolabyrinthitis that had started from one day to two years prior to examination. All patients had unilateral areflexion, or hyporeflexion on caloric test using 10 degrees C water. Control group consisted of 32 healthy individuals for both tests. Results show that both tests correctly indicate side of the lesion but only during first week of illness. Moreover, even during that first week sensitivity of both tests was below 50%, which means that more then half results from patients fall within normal findings. We conclude that vestibulospinal tests do not deserve prominent place in assessing patients with vestibular syndrome. Conclusions must be made according to findings obtained from much more precise vestibuloocular tests.