Decompensated labyrinthine weakness presenting as de novo peripheral vertigo: a discrete clinical entity?

OBJECTIVE: A distinct subgroup of patients, presenting with apparently spontaneous onset of vertigo, is described. RESULTS: Although vestibular evaluation revealed caloric weakness, the proximate cause of vertigo was not labyrinthine dysfunction, but rather the loss of vestibular compensation for an older and previously compensated labyrinthine injury. CONCLUSION: Instead of addressing the vestibular weakness, effective management needs to focus on the condition that has caused the loss of compensation.

Benign positional vertigo and endolymphatic hydrops: what is the connection?

BACKGROUND: Although benign paroxysmal positional vertigo and endolymphatic hydrops are considered to be distinct diagnoses, a minority of vertiginous patients exhibit features of both conditions. This coincidence has been reported previously in the literature, and is reviewed here in terms of possible aetiology. RESULTS AND CONCLUSION: A new hypothesis to account for both conditions is offered, implicating free-floating degenerating debris from the otolithic apparatus. It is postulated that the gelatinous/proteinaceous component may account for an osmotically induced hydrops, while the calcified fragments may induce positional vertigo.

Computed tomography of the anteverted internal auditory canal.

A symmetric variation in the course of the internal auditory canals, visualized best on axial computed tomographic views with thin sections, was observed in three of 75 patients examined mainly for hearing, vestibular, and facial nerve dysfunction. The incidence may be lower in an unselected population. In coronal section, with either pluridirectional or computed tomography, an anteverted internal auditory canal may mimic the normal configuration of "medial narrowing" because of the effect of partial sectioning of an angled cylinder with a thin beam. The pathologic significance of this finding is uncertain. In the three cases reported, it was associated with adult-onset uni- or bilateral hearing loss. Vestibular function may be compromised but may not be symptomatic. Facial nerve function was not impaired.

Chronic otitis media: diagnosis and treatment.

Very few problems are as frustrating as persistent otitis media and the draining ear. The draining ear may present in a variety of ways and may persist despite the use of routine otic drops and oral antibiotics. This article addresses the medical and surgical options available in the management of otitis media and its complications.

Experimental applications of porous (coralline) hydroxylapatite in middle ear and mastoid reconstruction.

Hydroxylapatite is a ceramic implant material which has been extensively investigated in the orthopedic and oral surgical literature. A set of animal experiments was carried out to determine the feasibility of the use of porous (coralline) hydroxylapatite for middle ear and mastoid reconstruction. Coralline hydroxylapatite was placed in the mastoid bulla of dogs and was carved into struts which were placed into the middle ear and against the tympanic membrane. Coralline hydroxylapatite is a highly biocompatible material which showed abundant ingrowth when in contact with host bone. There was also good soft-tissue ingrowth and fibrous tissue fixation within the middle ear and against the tympanic membrane. Hydroxylapatite is generally accepted to be osteoconductive, but not osteogenic. However, one of the specimens described with chronic inflammatory mucosal changes, shows de novo new bone formation within the pores of the graft. While normally the bone formed in coralline hydroxylapatite is secondary (lamellar), in this specimen primary (woven) bone was found. Porous (coralline) hydroxylapatite appears to be an excellent otologic graft material. It biointegrates with the host, is osteoconductive, and under certain circumstances may be osteogenic.

Major auricular malformations due to Accutane (isotretinoin).

Vitamin A and vitamin A derivatives have been described as etiologic factors for a number of congenital malformations. Two infants are presented with major auricular malformations including anotia and severe microtia. The infants were products of a pregnancy complicated by Accutane ingestion during the first trimester. Both infants had associated central nervous system malformations. With the increasing use of Accutane for the treatment of cystic acne in young women of child-bearing age, the dangers of teratogenesis in the head and neck area are greatly increased. This presentation will review two such cases as well as give an overview of the embryogenesis and teratogenesis of the auricle.

Laryngeal rheumatoid arthritis.

The classic sequence of pathologic changes associated with rheumatoid arthritis as they affect the cricothyroid and cricoarytenoid joints of five larynges is described. Although several previous reports have drawn attention to the presence of rheumatoid arthritis in the larnx, the current study emphasizes that the small joints of the larynx may be involved by the full spectrum of pathologic changes and that both cricothyroid and cricoarytenoid joints are equally prone to the various stages of inflammation, joint destruction and ankylosis that characterize the disease elsewhere. Rheumatoid nodules were seen in two cases and granulomatous areas surrounding cricothyroid joints were noted in two others.

Middle ear ventilation with HydroxylVent tube: review of the initial series.

Thirty HydroxylVent tubes were implanted in twenty-seven patients. The chief indications were unresolving eustachian tube dysfunction, with either collapse or perforation of the tympanic membrane. Every patient had undergone a lengthy course of treatment with conventional ventilation tubes. Twenty ears (66%) showed good results, with prolonged ventilation and restoration of middle ear function. Two tubes appeared to be open, with the development of a pinpoint perforation of the drum. Eight tubes occluded as a result of displacement of the tube, middle ear pathology, or debris. Indications and techniques of management are discussed, along with an analysis of complications.

A biointegrated hydroxylapatite ventilation tube for definitive treatment of chronic eustachian tube obstruction.

A dense hydroxylapatite ventilation tube has been designed for the purpose of providing prolonged ventilation of the middle ear. The tube is placed beneath the fibrous annulus of the eardrum, into a groove within the bony annulus and canal. The device takes advantage of the documented biocompatibility of hydroxylapatite to achieve biointegration with the soft tissues of the fibrous annulus, drum, and canal skin, as well as the bone of the deep ear canal. The tube does not appear to cause a foreign body reaction, and does not seem to extrude over time. The device is proposed for patients with unresolving eustachian tube obstruction who require a permanent tympanic stoma for normal middle ear function.

Sudden hearing loss due to AIDS-related cryptococcal meningitis--a temporal bone study.

We have presented the clinical history and temporal bone findings in a patient who manifested sudden hearing loss, and who subsequently was found to have cryptococcal meningitis associated with AIDS. The histopathologic findings are similar to earlier reports in patients without AIDS. Because cryptococcal infection is so much more common in AIDS patients than in the general population, it must be considered a causative factor when presented with an AIDS patient with progressive or sudden hearing loss. This offers the patient a chance for timely and effective treatment.

MRI findings in two cases of acute facial paralysis.

This article describes the use of magnetic resonance imaging (MRI) in the evaluation of the facial nerve paralysis of Bell's palsy and herpes zoster oticus. Identification of the nature of inflammatory facial nerve paralysis often presents a diagnostic dilemma. The site of involvement along the course of the nerve may have importance when treatment options are being considered. We have found MRI to be a unique method for localizing the site of nerve injury in both Bell's palsy and Ramsay Hunt syndrome.

Osteoma of the internal auditory canal. Case report and literature review.

Osteomas of the internal auditory canal are rare lesions, with only 12 reported cases in the world literature. Symptoms are those of eighth nerve compression, and include unilateral hearing loss and vestibular weakness, thus mimicking symptoms of acoustic neuroma. We report a patient with an osteoma of the internal auditory canal, along with a review of the literature. We note age and sex characteristics from the literature, give evidence of localized trauma as a possible etiologic factor for this lesion, and discuss the pitfalls of relying exclusively on magnetic resonance imaging in the workup of suspected retrocochlear lesions.

Semon's law revisited: an electromyographic analysis of laryngeal synkinesis.

Felix Semon's fascination with vocal fold paralysis led to his theory attributing medialization to isolated abductor paralysis. Later, the Wagner-Grossman hypothesis explained the vocal fold position on the basis of cricothyroid muscle activity. Other authors since that time have dispelled the notion of a role for the cricothyroid muscle in vocal fold position with paralysis. Utilizing laryngeal electromyography, several authors have found electrical activity suggestive of variable reinnervation and synkinesis. This current study included patients with persistent vocal fold immobility. Fourteen patients were studied: half with good voice and half with poor voice. The patients with good voice had a relatively normal arytenoid position and evidence of synkinesis. The group with poor voice had an arytenoid that tipped into the laryngeal inlet and had denervation or poor reinnervation. This suggests that the medialization and upright position of the arytenoid is due to synkinesis.

Leiomyosarcoma of the cervical trachea. Report of a case with reconstruction using a latissimus dorsi island flap.

A case of leiomyosarcoma of the cervical trachea is described, detailing clinical presentation, pathologic diagnosis and surgical management. The rarity of this tumor in this location accounted for difficulties in clinical diagnosis and pathologic classification. Surgical treatment involved resection of two thirds of the circumference of the infracricoid trachea, with partial resection of the cricoid cartilage and thyroid gland. The defect was reconstructed using bilateral "butterfly" advancement flaps and a latissimus dorsi myocutaneous island flap. The technique and advantages of the latissimus dorsi flap are briefly described.

Cholesteatoma: what is it, how did it get there, and how do we get rid of it?

Cholesteatoma has been recognized as a clinical entity for over 150 years. Our understanding of its pathogenesis and treatment has evolved over this time. This article traces our changing concepts of treatment from life-saving radical procedures to more purposeful and limited techniques.

Medical management of chronic otitis media.

Chronic otitis media can be successfully managed by purposeful and aggressive medical therapy. Frequent and meticulous debridement, topical treatment, and adjunctive systemic antibiotics should be used. Medical treatment is appropriate either as a curative measure, or for preoperative preparation of the ear.

Medical management of disorders of swallowing.

Disorders of swallowing in a given patient can result from abnormalities of dentition, the oral cavity (mouth and pharynx), the cricopharyngeal muscle, esophageal skeletal (proximal) or smooth (distal) muscle, the lower esophageal sphincter, and the stomach. Recent advances include refinements in esophageal manometric techniques with reclassification of motility disorders; newer drugs to treat gastroesophageal reflux; recognition of more frequent infections of the esophagus in immunosuppressed patients; and adaptation of the use of medications such as nitrates and calcium-channel blockers, which were previously primarily cardiotonic, for investigative treatment of esophageal motility abnormalities.

Mendelian genetics and cytogenetics in otolaryngology.

The numerous inherited disorders involving the head and neck are best understood against the background of Mendelian genetics. An appreciation of patterns of inheritance and the factors that modify or simulate then allows the clinician to weigh the importance of family history, to evaluate the basic mechanisms involved in the disorder, and to give advice concerning future generations.

Heredity hearing losses with delayed onset: mechanisms of expression.

Inherited hearing loss with a delayed onset is a feature of an intriguing group of disorders. The mechanisms whereby delayed hearing loss develops may be grouped as primary degenerative (abiotrophic) disorders, secondary degenerative disorders, dysgenerative disorders, and disorders of inappropriate response. Illustrative examples within these four groups are discussed. The difficulties in determining the preclinical latent state in inherited disorders are briefly outlined.

Neonatal respiratory distress: sequela of bilateral nasolacrimal duct obstruction.

Neonatal respiratory distress is a commonly seen entity whose causes are legion. Nasal obstruction secondary to intranasal masses is significant because neonates are obligate nasal breathers. Congenital nasolacrimal duct obstruction (NLDO) causing respiratory distress is an extremely rare event since most cases of NLDO do not compromise the nasal airway. We report two cases of neonatal respiratory distress secondary to bilateral NLDO with cystic mucocele formation and intranasal extension; only two similar cases have been previously described. Pertinent embryology and anatomy are reviewed as is a brief discussion of congenital NLDO. MRI and a nasal endoscopic photograph are provided demonstrating the nasolacrimal and nasal pathology. Treatment strategies are outlined. Consideration of nasolacrimal duct pathology in the differential diagnosis of neonatal respiratory distress and nasal obstruction is stressed.