Insidious Cases of Enlarged Vestibular Aqueduct (EVA) Syndrome Resembling Otosclerosis: Clinical Features for Differential Diagnosis and the Role of High-Resolution Computed Tomography in the Pre-Operative Setting.

BACKGROUND: Enlarged vestibular aqueduct (EVA) syndrome can mimic otosclerosis in adults, presenting with an air-bone gap (ABG) and even absent stapedial reflexes. The ABG in inner-ear disorders is currently the object of several authors' studies and seems to be related to a third mobile window (TMW) phenomenon. This can lead to misdiagnosis and inappropriate treatment. Given that it would be inappropriate and harmful to perform CT scans in all patients with a clinical diagnosis of otosclerosis, this study aims to highlight some clinical features useful for the differential diagnosis between otosclerosis and these rare cases of EVA presenting with an ABG, thus enabling the identification of suspected cases to be tested with CT scans. METHODS: Between April and May 2024, a narrative review was conducted focusing on the differential diagnosis between some rare cases of EVA and otosclerosis. Clinical, audiological, and radiologic features of both conditions were investigated. RESULTS: This review demonstrates the diagnostic challenge in differentiating atypical cases of EVA from otosclerosis in a subset of patients. Clinical and audiological features are important for differential diagnosis, but may not always be sufficient. Therefore, high-resolution computed tomography (HRCT) of the temporal bone plays a pivotal role in definitive diagnosis. CONCLUSIONS: In some specific cases, pre-operative imaging assessment using HRCT emerges as an essential tool for differentiating these two conditions and avoiding unnecessary stapes surgery.

What should otolaryngologists know about dural venous sinus stenting?

Dural venous sinus stenting is an emerging and exciting area in otolaryngology in collaboration with neurosurgeons and neuroradiologists. The first cases were reported 20 years ago. It is now considered part of the routine treatment of increased intracranial pressure due to transverse sinus stenosis. ENT doctors are the first to see these patients in their clinics, as sinus headaches, pulsating tinnitus, and dizziness are the most common symptoms. Previously, with limited success, high-dose diuretics and intracranial shunts had been the only options for treating these patients. Other methods, such as covering the sigmoid sinuses with graft material, appear to cause a sudden increase in intracranial pressure that can lead to blindness and even death. This overview summarizes the clinical and imaging characteristics of patients who will benefit from endovascular sinus stenting for elevated intracranial pressure.

Role of Topical Estrogen in Outcomes of Myringoplasty: Does it Really Affect the Results of Graft Success and Hearing Thresholds?

The tympanic membrane forms a barrier between the external auditory canal and the middle ear. In the inactive mucosal type of chronic otitis media, there is a perforation in the tympanic membrane which is surgically managed by Myringoplasty. Estrogen as a growth factor has been shown to have a mitogenic effect on keratinocytes thus hastening the rate of epithelialization following injury. This property of estrogen is being studied in this study for its role in the outcomes of myringoplasty. This study was carried out from January 2021 to December 2022 in the Department of Otorhinolaryngology, of a tertiary teaching hospital in North India. Patients were assessed by history, examination, otoscopy, Audiometry, and oto-endoscopy. A total of 88 patients were taken out of which 44 patients underwent myringoplasty in which topical estrogen (estradiol valerate solution) was used, and the remaining 44 patients were taken as controls. Patients were then assessed post-operatively based on Audiometry results and graft uptake status. In the estrogen group successful Graft uptake was in seen 40 (90.9%) patients and failed in 4 (9.1%), while in the control group, it was successful in 37 (84.1%) patients and failed in 7 (15.9%), statistically there was no significant difference between two groups in terms of graft uptake (p value = 0.334). Post-operatively, in the estrogen group, the mean change in Air Conduction (AC) was 15.5 dB, the change in the air-bone gap (ABG) was 11.5 dB and for Bone Conduction (BC) it was 3.2 dB. However, in the control group mean post-operative changes in Air Conduction, Air-Bone Gap, and Bone Conduction were 12 dB, 10.7 dB, and 0.8 dB respectively. Statistically, there was a significant difference in postoperative changes in AC (p value = 0.011) and BC (p value = 0.009) between the two groups. There was no significant difference in post-operative changes in Air-Bone Gap (p value = 0.571). Topical Estrogen (Estradiol valerate) solution is cost-effective, with enriched growth factors that accelerate tympanic membrane perforation closure following myringoplasty and resulted in significant improvement in hearing thresholds both for Air Conduction and Bone Conduction.

Bilateral same-day myringoplasty: a feasible option?

PURPOSE: Retrospective evaluation of bilateral same-day myringoplasty outcomes. METHODS: Patients who underwent bilateral same-day myringoplasty from 2005 to 2019. RESULTS: Thirty-eight patients underwent bilateral myringoplasty. Mean age was 44.5 years and 55.3% patients were male. Tragal perichondrium-cartilage composite graft was the most frequently used graft material (82.9%). Perforation closure was achieved in 78.9%. Postoperative Pure Tone Average and Air-Bone Gap decreased significantly (p < 0.05), except for the Air-Bone Gap of the right ear (p = 0.058). The complications were cholesteatoma (1.3%), otorrhea (6.6%) and tympanic membrane retraction (1.3%). CONCLUSIONS: Bilateral same-day myringoplasty is a feasible procedure in selected patients. Good anatomic and functional outcomes, as well as a low rate of complications, are achieved with this procedure, improving patient comfort and allowing for a reduction in operation time and costs.

A tailored approach in cholesteatoma surgery.

PURPOSE: In recent years, new techniques have been added to cholesteatoma surgery, and established microsurgical approaches are being reconsidered. This study aims to present the importance of individualized decision-making for the selection of an intact canal wall (CWU) or canal wall down (CWD) surgical procedure for each patient. METHODS: Using the "ChOLE" classification we categorized 264 operations retrospectively. 162 CWU and 102 CWD surgeries were performed. We focus to determine why a CWD procedure was chosen quite frequently despite some low-stage cases. Furthermore, we evaluated recidivism and hearing outcomes. RESULTS: Smaller cholesteatomas (Ch-stage 1a, 1b & 2a) were found in 182 patients (70%), ossicular chain status feasible for straightforward reconstruction (O-stage 0, 1 & 2) was present in 186 patients (70%), minor complications due to the cholesteatoma (L-stage 1) were infrequent with 28 cases (11%) and a well-pneumatized mastoid was found in 144 cases (55%). Recidivism rates were low (7%) without any difference in both groups and a mean follow-up time of 4 years and 8 months. In primary surgeries there was a significant difference (p < 0.05) in postoperative mean air-bone gap (ABG) between CWU (17dB) and CWD (27dB). CONCLUSION: The main goals of cholesteatoma surgery remain the avoidance of recidivism and optimal hearing rehabilitation. We recommend a tailored approach in the treatment of cholesteatomas and not a dogmatic one. Surgeons should not hesitate to perform a CWD procedure if required. Performed correctly it results in a dry ear and CWD surgery should remain in the skill set of the otologic surgeon.

Degree of Hearing Improvement and Reduction of Air-Bone Gap After Tympanoplasty in a Tertiary Hospital in Saudi Arabia.

BACKGROUND:  A clinical condition known as chronic otitis media (COM) is characterized by tympanic membrane perforation, varying degrees of hearing loss, and otorrhea that lasts for two to six weeks. COM alone or with cholesteatoma may result in ossicular chain discontinuity and ossicular erosion. The hearing restoration procedure includes repairing the eardrum and building the ossicular chain in ears with damaged ossicles. Multiple studies suggest the predictive value of preoperative air-bone gap (ABG) to detect the ossicular chain status can help with proper preoperative planning for surgery. OBJECTIVE: To determine the degree of hearing improvement and reduction in ABG after tympanoplasty and to investigate the correlation between preoperative ABG and the status of the ossicular chain during surgery. Study design, setting, and date: This retrospective hospital file-based study was conducted at Aseer Central Hospital, Southern Region, Saudi Arabia, between November 2022 and April 2023. Hospital records of patients who underwent tympanoplasty during 2018-2023 were reviewed. Eighty-five patients were diagnosed with chronic suppurative otitis media (CSOM) between 2018 and 2023. A data collection sheet was employed to record extracted data, including the patient's age, sex, hearing assessment, type of surgical intervention, and outcome. We calculated the average of ABG decibels (dB) by summing the ABG values at 500 Hz, 1000 Hz, and 2000 Hz frequencies and dividing by three. RESULTS: In the present study, data from 85 patients who underwent tympanoplasty were analyzed. Approximately one-third of the patients were in the age group of 31 to 40 years (25, 29.4%), and 50 (58.8%) of them were females. Chronic medical conditions were observed in 30 (35.3%) patients, with diabetes being reported in 19 (63.3%) of those cases. CSOM was found to be present in the left ear of 47 (56.0%) patients. Among the patients, 25 (29.4%) had subtotal perforations, 12 (14.1%) had marginal perforations, and two (2.4%) had total tympanic membrane perforations. The majority of patients (67, 78.8%) exhibited conductive hearing loss, while the remaining 18 (21.2%) had mixed hearing loss. Of the patients, 13 (15.3%) and 20 (23.5%) had fixed and disrupted ossicular chains, respectively. In terms of ossicular disruption, incudostapedial joint (ISJ) fixing (21.2%), fixed stapes (18.2%), and ISJ dislocation (18.2%) were the most prevalent kinds. Prior to operations, the mean ± SD of ABG was 22.6 ± 7.5. ABG values were 19.0 ± 9.3 on average after surgery. The statistical difference between pre- and postoperative ABG was statistically significant (paired t-test, p = 0.007), with a mean difference of -3.7. There were no significant differences between the different statuses of ossicular chains and the type of tympanic membrane perforation. CONCLUSION: This study suggests that the degree of preoperative ABG (dB) is a valuable predictor of intraoperative ossicular chain status and can aid in preoperative planning for ossicular chain reconstruction. Furthermore, the study found that the type of tympanic membrane perforation preoperatively is not a reliable indicator of the ossicular chain status. Finally, tympanoplasty is considered a beneficial surgical procedure with a significant improvement in hearing status postoperatively.

Exclusive endoscopic management of incus long process major defects: conventional incus interposition versus malleostapediopexy.

PURPOSE: The aim of the current study is to compare the surgical and audiometric results of conventional incus interposition (IP) versus malleostapediopexy (MS) in incus long process large defects. METHODS: A total of 71 patients (incus IP group n = 37, MS group n = 34) were enrolled in this study. All patients enrolled in the current study underwent ossiculoplasty via an exclusive endoscopic transcanal approach. Pre- and postoperative audiometric measurements and air-bone gap (ABG) values were compared, and if the postoperative ABG value was less than 20 dB, ossiculoplasty was considered successful. Graft success rates and complications were also compared. RESULTS: The average auditory gain was 14.7 ± 4.2 dB in the incus IP group and 18.3 ± 5.1 dB in the MS group. The auditory gain was significantly greater in the MS group relative to the incus IP group (p = 0.012). Ossiculoplasty success (postoperative ABG value < 20 dB) rate was 70.3% in the incus IP group patients and 88.2% in the MS group patients (p < 0.001). There was no significant difference in terms of graft success rate between groups (p > 0.05) and the overall graft uptake rate was 91.5% (65/71). CONCLUSION: Malleostapediopexy-bridging of malleus and stapes using bone cement-is an effective, reasonable, and more efficient technique in terms of auditory outcomes relative to the conventional incus interposition in endoscopic transcanal management of incus long process major defects.

Does the Location of a Small Tympanic Membrane Perforation Affect the Degree of Hearing Loss in Adult Patients with Inactive Mucosal Chronic Suppurative Otitis Media?

BACKGROUND: Tympanic membrane perforation due to inactive mucosal chronic suppurative otitis media is a common problem in otolaryngology, with consequent conductive hearing loss. Still, there is controversy about the relationship between the location of the tympanic membrane perforation and the degree of hearing impairment. AIM OF THE STUDY: To assess the correlation between the location of a small tympanic membrane perforation and the degree of conductive hearing loss in adult patients with inactive mucosal chronic suppurative otitis media. PATIENTS AND METHODS: A prospective cross-sectional study enrolled 74 adult patients with small tympanic membrane perforations (perforation involves less than one quadrant of the tympanic membrane) and conductive hearing loss (airbone gap ≥ 20 dB HL) due to inactive mucosal chronic suppurative otitis media for at least 3 months. The locations of the tympanic membrane perforations were classified as anterosuperior, anteroinferior, posterosuperior, and poster inferior perforations. Audiometric analysis and a CT scan of the temporal bone were done for all patients. The means of the air and bone conduction pure tone hearing threshold averages at frequencies 500, 1000, 2000, and 4000 Hz were calculated, and consequently, the air-bone gaps were calculated and presented as means. The ANOVA test was used to compare the means of the air-bone gaps, and the Scheffe test was used to determine if there were statistically significant differences regarding the degree of conductive hearing loss in relation to different locations of the tympanic membrane perforation. RESULTS: The ages of the patients ranged from 20 to 43 years (mean = 31.9 ± 6.5 years), of whom 43 (58%) were females and 31 (42%) were males. The means of the air-bone gaps were 32.29 ± 5.41 dB HL, 31.34 ± 4.12 dB HL, 29.87 ± 3.48 dB HL, and 29.30 ± 4.60 dB HL in the posteroinferior, posterosuperior, anteroinferior, and anterosuperior perforations, respectively. Although the air-bone gap's mean was greater in the posteroinferior perforation, statistical analysis showed that it was insignificant (P-value=0.168). CONCLUSION: In adult patients with inactive chronic suppurative otitis media, the anteroinferior quadrant is the most common location of the tympanic membrane perforation, and there was an insignificant correlation between the location of a small tympanic membrane perforation and the degree of conductive hearing loss.

IMMEDIATE IMPLANT PLACEMENT WITH A SIMULTANEOUS BONE AUGMENTATION OF THE GAP-FILLING SITES CAN POTENTIALLY DECREASE BONE LOSS COMPARED WITH AUGMENTED SITES EXHIBITING GAPS WITH BONY DEFECTS.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Marginal bone level change of immediately restored implants with simultaneous guided bone regeneration: A systematic review. Lin, X., Yu, X., Wang, F., & Wu, Y. Clinical Implant Dentistry and Related Research 2023. SOURCE OF FUNDING: CAMS Innovation Fund for Medical Sciences (CIFMS), Grant/Award Number: 2019-I2M- 5-037; Clinical Research Plan of SHDC, Grant/Award Number: SHDC2020CR3049B; Huangpu District Industrial Support Fund, Grant/Award Number: XK2020014; Research Discipline Fund, Grant/Award Number: KQYJXK2020. TYPE OF STUDY/DESIGN: Systematic review.

Ossicular Reconstruction With Various Degrees of Malleus Preservation in Patients With Chronic Otitis Media.

Objective: We examined the relationship between factors of middle ear conditions and the outcome of ossiculoplasty in chronic otitis media (COM) by measuring the improvement in the air-bone gap (ABG) and air conduction threshold (TAC). Methods: This retrospective study analyzed 76 patients (77 ears) who underwent ossiculoplasty from among 520 COM patients who underwent tympanoplasty based on the maximum preservation of the original ossicles. The reconstructed ossicular chain was performed by preserving or utilizing the remaining malleus in all cases with the presence of the malleus manubrium. Patients with eardrum adhesion, cholesteatoma, and cholesterol granuloma were defined as having a compromised middle ear condition (Group A), and those without as having an uncompromised middle ear condition (Group B). In each group, pure-tone audiometry was performed preoperatively and postoperatively, and improvements in the ABG and TAC were compared. The effects of the types of tympanoplasty and the method of ossiculoplasty (columella versus incus interposition) on postoperative ABG and TAC were also compared. Results: The postoperative ABG improvement in Group B was significantly higher than that in Group A [ß = 7.31, 95% confidence interval (CI) = 1.93-12.69, P < .05]. Type III minor columella tympanoplasty yielded significantly better results than type III major and type Vb tympanoplasty (ß = 11.42, 95% CI = 5.16-17.68, P < .01). There were no significant differences in the postoperative ABG or TAC between the reconstruction groups with and without preservation of malleus. Conclusions: Our results indicate that complex cases compromised by adhesions, cholesteatoma, and cholesterol granuloma have worse outcomes regarding hearing improvement and success rates, while those with intact stapes suprastructure have better outcomes. Malleus was maximally preserved in the patients of this study; however, this showed no significant prognostic benefit in hearing.

Linear transmission between malleus and stapes in cases with incus necrosis.

OBJECTIVE: The outcome of cartilage interposition ossiculoplasty was assessed in cases of incus necrosis after posterior malleus repositioning in the plane of the stapes, in terms of hearing gain after ossicular reconstruction. METHODS: A retrospective observational study was conducted of 30 patients admitted to an Ain Shams University hospital from March 2021 to September 2021. All patients with ossicular disruption due to chronic suppurative otitis media and hearing loss of more than 40 dB were included in the study. Pure tone audiometry was conducted for each patient after three months, six months and one year post operation. RESULTS: The audiogram showed a post-operative air-bone gap of 20 dB or less in 83.33 per cent of patients (n = 25) at three months post-operatively and in 80 per cent of patients after six months; after one year, the results remained the same. CONCLUSION: The use of cartilage interposition after malleus posterior mobilisation represents an excellent partial ossicular replacement technique.

Study of the factors related to air-bone gap in enlarged vestibular aqueduct.

BACKGROUND: Over half of patients with enlarged vestibular aqueducts (EVA) will have an air-bonr gap (ABG), however, current research on audiology has focused on the influencing factors of air-conducted. OBJECTIVE: To retrospectively analyse the influencing factors and clinical manifestations of the bone-conduction threshold and ABG in patients with EVA. MATERIALS AND METHODS: We included 286 patients with EVA; among them, 126 had full SLC26A4 gene sequence results. We performed a descriptive analysis of the bone-conduction threshold and explored the effect of age. Finally, we analyzed the relationship of ABG and SLC26A4 genes with the degree of vestibular aqueduct (VA) enlargement. RESULTS: Among 555 ears, 312 (57.8%) ears had ABG; approximately 94% of the patients' bone-conduction hearing is almost completely lost at frequencies of 2 and 4 kHz. There was no linear correlation between age and bone-conduction threshold (p > 0.05). ABG did not significantly differ according to the degree of VA enlargement and number of SLC26A4 allele mutations (p > 0.05). CONCLUSIONS AND SIGNIFICANCE: Among patients with EVA, ABG is mainly produced at low frequencies and is not significantly correlated with age, size of the VA opening or SLC26A4 genes, which could be attributed to the biomechanical effects.

Reconstructive ossiculoplasty options in primary cholesteatoma surgeries with an intact stapes.

PURPOSE: In primary cholesteatoma patients, incus destruction with an intact and mobile stapes is a frequent finding. Different techniques have been described to restore the ossicular chain, including incus interposition, stapes augmentation and type III tympanoplasty. Controversy about postoperative hearing results in open versus closed surgical techniques exist. METHODS: We performed a retrospective analysis of clinical, surgical and audiometric data of patients with primary cholesteatoma surgery operated between 2010 and 2020, and a mobile stapes and one-stage ossicular reconstruction. Pre- and post-operative audiograms were compared for the different surgical groups, mainly focusing on postoperative air-bone gap. Mastoid pneumatization and ventilation was also considered. RESULTS: The mean postoperative air-bone gap (0.5-4 kHz) of the 126 included patients was 20 dB. Hearing after type III tympanoplasty (26 dB) was worse than incus interposition (19 dB) and stapes augmentation (20 dB). Hearing after an open (23 dB) versus closed (19 dB) surgical technique was significantly different. No improvement in air-bone gap was observed for the higher frequencies. CONCLUSION: A residual postoperative air-bone gap should be considered after primary cholesteatoma surgery with intact and mobile stapes. Incus interposition in closed cavity operation is the optimal situation, but open cavity surgery should not be avoided because of hearing. Extent of the disease is prioritized and poorer ventilation before and after surgery may affect postoperative hearing.

Low-Frequency Air-Bone Gap and Pulsatile Tinnitus Due to a Dural Arteriovenous Fistula: Considerations upon Possible Pathomechanisms and Literature Review.

Low-frequency air-bone gap (ABG) associated with pulsatile tinnitus (PT) and normal impedance audiometry represents a common finding in patients with third window syndromes. Other inner disorders, including Meniere's disease (MD), perilymphatic fistula and intralabyrinthine schwannoma, might sometimes result in a similar scenario. On the other hand, PT is frequently associated with dural arteriovenous fistula (DAVF), while conductive hearing loss (CHL) is extremely rare in this clinical setting. A 47-year-old patient was referred to our center with progressive left-sided PT alongside ipsilateral fullness and hearing loss. She also experienced headache and dizziness. Otoscopy and video-oculographic examination were unremarkable. Conversely, a detailed instrumental audio-vestibular assessment revealed low-frequency CHL with normal impedance audiometry, slight left-sided caloric weakness, slightly impaired vestibular-evoked myogenic potentials on the left and normal results on the video-head impulse test, consistent with an MD-like instrumental profile. Gadolinium-enhanced brain MRI revealed an early enhancement of the left transverse sinus, consistent with a left DAVF between the left occipital artery and the transverse sinus, which was then confirmed by angiography. A trans-arterial embolization with Onyx glue was performed, resulting in a complete recession of the symptoms. Post-operatively, the low-frequency ABG disappeared, supporting the possible role of venous intracranial hypertension and abnormal pressure of inner ear fluids in the onset of symptoms and offering new insights into the pathomechanism of inner ear CHL.

Fascial Arthroplastic Ossiculoplasty - A New Technique of Ossicular Reconstruction.

OBJECTIVE: Ossicular reconstruction with autologous materials has been practised for a long time, but the procedure may lead to stiffness of joints and bony ankyloses thus hampering the sound conduction mechanism. This paper describes a novel technique of creating joint capsule around the reconstructed joints with temporalis fascia strips hoping a firm and movable union with full functional restoration. MATERIALS & METHODS: This study is a prospective study of 35 patients requiring tympanomastoid surgery with ossicular reconstruction and were studied over a period of 2 years. The newly reconstructed ossicular joints were wrapped with temporalis fascia strips. Post-operatively air-bone gap closure were studied and statistically analysed. RESULTS: A significant air-bone gap closure was achieved in 23 patients, while moderate improvement was seen in remaining cases. Only 1 patient had tympanic membrane graft failure and rest all had well healed tympanic membrane. CONCLUSION: Fascial arthroplastic ossiculoplasty is a simple and safe procedure and the results are reproducible and more predictable. It provides an ossicular assembly which is near to normal in its physiological functions.

A Comparative Study to Determine Hearing Outcome in Type 1 Tympanoplasty With and Without Canaloplasty in Tubotympanic Type of Chronic Suppurative Otitis Media.

Background: Chronic suppurative Otitis Media is a common ear infection in India. Canaloplasty done with tympanoplasty helps to remove bony overhangs and provide complete visibility of fibrous annulus of tympanic membrane. Aim: 1. To determine the hearing outcome in chronic otitis media (mucosal type) patients undergoing type 1 tympanoplasty with canaloplasty. 2. To determine the hearing outcome in chronic otitis media (mucosal type) patients undergoing type 1 tympanoplasty without canaloplasty. 3. To compare the hearing outcome in the above mentioned 2 groups of patients. Materials and Methods: 56 patients of 15-60 years of age with mucosal type of Chronic otitis media, with central dry perforation and intact ossicles were included in our study. They were divided into group 1 (type 1 tympanoplasty + canaloplasty) and group 2 (type 1 tympanoplasty without canaloplasty), on alternate basis. AC, BC, Air bone gap avg was assessed via pure tone audiometry at 4 frequencies preoperatively and postoperatively at 3rd and 6th month, % closure of ABG average was calculated. Results: Type 1 tympanoplasty along with canaloplasty has better hearing improvement in pure tone audiometry compared to type 1 tympanoplasty alone, as % closure of ABG at postoperative 3rd and 6th month holds significant. Conclusion: The canaloplasty provides better surgical exposure via removing bony overhangs, aids in excellent functional outcome in the form of % closure of ABG. Hence canaloplasty is added as an adjunct to routinely performed aural surgeries to enhance hearing outcome.

Impaired Vestibulo-Ocular Reflex on Video Head Impulse Test in Superior Canal Dehiscence: "Spontaneous Plugging" or Endolymphatic Flow Dissipation?

Surgical plugging of the superior semicircular canal (SSC) represents an effective procedure to treat disabling symptoms in superior canal dehiscence (SCD), despite resulting in an impaired vestibulo-ocular reflex (VOR) gain for the SSC. On the other hand, SSC hypofunction on video head impulse test (vHIT) represents a common finding in patients with SCD exhibiting sound/pressure-induced vertigo, a low-frequency air-bone gap (ABG), and enhanced vestibular-evoked myogenic potentials (VEMPs). "Spontaneous canal plugging" has been assumed as the underlying process. Nevertheless, missing/mitigated symptoms and/or near-normal instrumental findings would be expected. An endolymphatic flow dissipation has been recently proposed as an alternative pathomechanism for SSC VOR gain reduction in SCD. We aimed to shed light on this debate by comparing instrumental findings from 46 ears of 44 patients with SCD exhibiting SSC hypofunction with post-operative data from 10 ears of 10 patients with SCD who underwent surgical plugging. While no difference in SSC VOR gain values was found between the two groups (p = 0.199), operated ears developed a posterior canal hypofunction (p = 0.002). Moreover, both ABG values (p = 0.012) and cervical/ocular VEMP amplitudes (p < 0.001) were significantly higher and VEMP thresholds were significantly lower (p < 0.001) in ears with SCD compared to operated ears. According to our data, canal VOR gain reduction in SCD should be considered as an additional sign of a third window mechanism, likely due to an endolymphatic flow dissipation.

Correlation Between Air-Bone Gap and Vestibular Aqueduct Size in Enlarged Vestibular Aqueduct Syndrome: A Systematic Review.

The purpose of this review was to evaluate the air-bone gap with vestibular aqueduct size in enlarged vestibular aqueduct syndrome. According to the PRISMA guidelines we conducted a systematic review of the literature. Published international articles in English from 2000 to 2022 were screened, checking for studies that evaluated the air-bone gap of patients affected by enlarged vestibular aqueduct syndrome and the size of vestibular aqueduct. Data related to the hearing assessment and imaging investigation of enrolled participants were extracted. The chosen primary outcome measure was the correlation between air-bone-gap and vestibular aqueduct size. The database search allowed us to screen 485 articles and to select 5 articles discussing this topic for a total of 349 patients. Two studies showed a positive correlation between air-bone gap and vestibular aqueduct size, one only a trend and two no correlation. To date, it is not possible to draw conclusions whether or not there is a positive correlation between air-bone gap and vestibular aqueduct size in enlarged vestibular aqueduct syndrome. Higher quality studies would be conducted with standardized outcome measures to clarify the specific research question.

Otosclerosis and stapedotomy: hearing improvement, complications, and analysis of potential prognostic factors in a series of 93 cases.

BACKGROUND: Stapedotomy is a common treatment for conductive hearing loss in otosclerosis patients. AIMS/OBJECTIVES: Results of stapedotomy were assessed in terms of hearing improvement and risk of complications. Potential prognostic factors affecting outcomes were identified. MATERIAL AND METHODS: Retrospectively, 93 stapedotomies were evaluated. The primary outcome was hearing improvement based on postoperative ABG ≤10 dB, Belfast rule of thumb, and AC gain ≥20 dB. Secondary outcomes were postoperative complications. Additionally, prognostic factors potentially affecting outcomes were analyzed (age, gender, comorbidity, preoperative audiometry, tinnitus, or vertigo). RESULTS: A mean ABG of ≤10 dB was achieved in 59%. According to the Belfast rule of thumb, 75% achieved interaural symmetry within ≤15 dB and/or a mean AC4 of ≤30 dB. A gain in AC4 of ≥20 dB was achieved in 57% of primary surgeries. The larger the preoperative ABG, the better hearing after surgery. There was no significant difference in hearing improvement at early and late follow-ups. Transient vertigo was the most common complaint (37%). Taste disturbances were the most frequent permanent complication (14%). CONCLUSION AND SIGNIFICANCE: Stapedotomy gave good audible improvement with a low risk of complications. Preoperative ABG was the only prognostic factor affecting the hearing outcome. Only one follow-up 6-12 months seems relevant.

背景：镫骨切开术是耳硬化症患者传导性听力损失的常见治疗方法。目的：根据听力改善和并发症风险评估镫骨切开术的结果。 确定影响结果的潜在预后因素。材料和方法：回顾性评估了 93 例镫骨切除术。 主要结果是听力改善, 基于术后 ABG ≤10dB、贝尔法斯特经验法则和 AC 增益 ≥20dB。次要结果是术后并发症。 此外, 分析了可能影响结果的预后因素（年龄、性别、合并症、术前听力检查、耳鸣或眩晕）。结果：59% 的患者取得平均 ABG ≤10dB。 根据贝尔法斯特经验法则, 75% 的患者实现 ≤15dB 以内的耳间对称性和/或平均 AC4≤30dB。 57% 的初次手术实现AC4 的增益≥20dB 。 术前ABG越大, 术后听力越好。早期和晚期随访时的听力改善没有显著差异。 短暂的眩晕是最常见的主诉（37%）。 味觉障碍是最常见的永久性并发症（14%）。结论和意义：镫骨切开术带来了良好的听觉改善, 且并发症风险较低。 术前 ABG 是影响听力结果的唯一预后因素。 仅一次6-12 个月的随访似乎是相关的。.

Transverse sinus pathologies, vestibular migraine and intracranial hypertension without papilledema.

BACKGROUND: In the absence of papilledema, the presentation of migraine and idiopathic intracranial hypertension (IIH) is very similar. In this respect, an IIH could be presented as a vestibular migraine. Our main objective in this case report is to demonstrate the similarities between IIH and vestibular migraine. CASES: This is a report of 14 patients who have IIH without papilledema presented as vestibular migraine to the clinic and followed from 2020 to 2022. RESULTS: The common presentation of patients was ear-facial pain, dizziness, and frequent pulsatile tinnitus. One-fourth of the patients reported episodes of true episodic vertigo. The average age was 37.8, the average BMI was 37.4, and the average lumbar puncture-opening pressure was 25.6 cm H2O. Transverse sinus venous flow alterations caused neuroimaging findings of sigmoid sinus dehiscence, empty sella, or tonsillar ectopia. Most patients improved with carbonic anhydrase inhibitors, and one patient was treated with a dural sinus stent. CONCLUSION: A transverse sinus stenosis, even in the non-dominant site, may elevate the CSF pressure in obese individuals. This stenosis causes dural sinus-related pulsatile tinnitus with characteristics different from those of an arterial origin. Dizziness is a common complaint in patients with IIH, just like VM. In our opinion, episodic vertigo in these patients is the direct effect of CSF flow alterations into the inner ear's vestibule. Patients with mild elevations will be presented to the clinic, similar to migraines with or without the presence of pulsatile tinnitus. Treatment requires lowering intracranial pressure and managing migraine symptoms.