Visual and Postural Motion-Evoked Dizziness Symptoms Are Predominant in Vestibular Migraine Patients.

Background: Vestibular migraine (VM) is one of the most common underdiagnosed disorders. We aimed to study the clinical characteristics of VM patients who were referred to a neurology-headache unit by otolaryngology after exclusion of peripheral causes of vertigo. Methods: One hundred and one patients diagnosed with VM in the headache unit were included. Description of vestibular symptoms, demographic and clinical features, trigger factors, accompanying diseases, and response to vestibular-suppressant medications and prophylactic migraine treatment were evaluated. Results: Vestibular symptoms were triggered by daily head and body movements and mainly consisted of brief attacks lasting seconds (60.4% of patients) although the total duration of the vestibular episode lasted hours or days. Other aggravating factors were moving visual stimuli, passive motion, and visually busy environments. Visually induced vestibular symptoms were defined by 71.3% of the patients, and positional motion-induced vestibular symptoms were described by 82.2% of the patients. Vestibular symptoms were mainly defined as feeling the ground slipping from under their feet (40.6%), feeling like there is an earthquake or swaying (27.7%), sensation of rocking on a boat (26.7%), and sensation as if stepping on empty space (24.8%). The majority of the patients (83.2%) previously used vestibular-suppressant drugs, and these drugs were effective temporarily only in 12.9%. Conclusions: Chronic recurrent dizziness symptoms, rather than internal or external vertigo, are predominant in our VM patients. Recurrent brief dizziness attacks induced upon routine visual and/or postural motion, longstanding symptoms with limited response to vestibular suppressants, and precipitation by typical migraine triggers are suggestive of VM.

Effects of polylactic acid film on middle ear mucosa and cochlear function in Guinea pigs.

Our aim was to assess the effects of polylactic acid (PLA) on middle ear mucosa and cochlea, to be used as a film barrier for postoperative adhesion prevention in the middle ear. Twenty-one albino Guinea pigs were included in the study. A window was opened on both tympanic bulla and on one side PLA material was placed in the middle ear and on the other side only fenestration was performed and used as a control. All Guinea pigs underwent evaluation of tympanic membranes microscopically; functional hearing was analyzed by auditory brainstem responses preoperatively, in the first and the sixth month. All Guinea pigs were killed on the sixth month for histopathologic evaluation of their temporal bones. There was no statistical difference between both groups regarding hearing thresholds, interpeak wave latencies preoperatively and on first and the sixth months postoperatively. Histopathological evaluation revealed no specific changes. There was a mild local inflammation both in the PLA implanted and control ears. PLA film barrier most likely has no toxic effects on Guinea pig middle ear and does not show any ototoxic side effects.

Methods and preliminary outcomes of pediatric auditory brainstem implantation.

OBJECTIVE: The objective was to provide information about methods used and preliminary outcomes for pediatric ABI (auditory brainstem implant). STUDY DESIGN: An analysis of outcome was performed in children who received an ABI. METHODS: Twelve children received a MED-EL ABI system. Progress in audition and language was monitored through parental reports, questionnaires, profiles, and closed-set tests. RESULTS: The median number of active electrodes was 9 of 12. Seven of 12 users consistently respond to sound, and 5 of 12 do not. Highest performers can recognize words in small sets and have begun to use some words. CONCLUSION: Auditory brainstem implants appear to be beneficial for some pediatric patients who cannot benefit from traditional cochlear implant surgery. Benefits in the short-term can be recognition of environmental sounds, recognition of some words and very commonly used phrases, and the beginning use of words. Although some of our ABI users demonstrate no response to sound, they do want to wear their sound processors all waking hours. The cause of lack of response may be related to the second intervention, which might have led to displacement of the electrode array, or presence of additional handicaps or syndromes. However, the results are less than optimal. The relatively short postoperative follow-up duration is a considered weakness of this study.

Quantitative measurement of m-RNA levels to assess expression of cyclooxygenase-II, inducible nitric oxide synthase and 12-lipoxygenase genes in middle ear cholesteatoma.

To assess expression of three main inflammatory genes, COX-II, ALOX-12 and i-NOS, quantitatively at transcriptional level in cholesteatoma matrix tissue. Ten patients who have chronic otitis media with primary acquired cholesteatoma were included in this study. Tissue samples obtained from cholesteatoma matrix and external ear canal skin (control tissue). Expression of the targeted genes (COX-II, i-NOS and LOX-12) was assessed using real-time quantitative polymerase chain reaction (RT-PCR) technique. The amount of COX2 mRNA was significantly higher in cholesteatoma matrix at transcriptional level (p = 0.038). There was no statistically significant difference regarding expression of iNOS and LOX12 mRNA levels (p > 0.05). There is a significant overexpression of the mRNA of COX-II in cholesteatoma matrix, which indicates a difference between the normal skin and cholesteatoma matrix at molecular level. COX-II gene overexpression seems to be associated with pathogenesis of cholesteatoma. This molecular change is similar to the molecular abnormalities observed in some benign and malignant neoplasms. Invasive and locally destructive nature of cholesteatoma may be due to COX-II overexpression. Absence of an increase in the gene expressions of i-NOS and LOX-12 in cholesteatoma matrix suggests that these mediators may not be related with the pathogenesis and evolution of cholesteatoma.

[Vascular compression syndromes: our 24 year endoscope-assisted microvascular decompression experiences]. / Vasküler kompresyon sendromlari: 24 yillik endoskop yardimli mikrovasküler dekompresyon deneyimlerimiz.

OBJECTIVES: This study aims to report our experience on endoscope-assisted microvascular decompression experiences performed due to vascular compression syndromes such as hemifacial spasm, trigeminal neuralgia, and cochleovestibular nerve compression. PATIENTS AND METHODS: Between March 1999 and June 2013, 55 patients (34 females, 21 males; mean age 44 years; range 24 to 77 years) underwent endoscope-assisted microvascular decompression surgery through a retrosigmoid approach due to vascular compression syndromes in our clinic. The diagnosis was based on history, neurological examination, magnetic resonance imaging findings and audio-vestibular tests. RESULTS: A total of 49 patients (89.1%) had complete relief of the symptoms and two had (3.6%) a partial relief, while four had (7.3%) no relief of the symptoms. Only two patients had (3.6%) cerebrospinal fluid leakages as a perioperative complication. The major offending vessels were anterior and inferior cerebellar arteries in 14 patients. Four patients with essential hypertension became normotensive after decompression of the left medulla oblongata as well. CONCLUSION: Microvascular decompression surgery provides a significant relief of the symptoms in patients with vascular compression syndromes. An angled endoscope as an adjunct to microscope contributes to the diagnosis of the offending vessel in the root entry zone of the cranial nerve.

A full-custom fully implantable cochlear implant system validated in vivo with an animal model.

Realizations of fully implantable cochlear implants (FICIs) for providing adequate solution to esthetic concerns and frequent battery replacement have lacked of addressing system level criteria as a complete device. Here, we present a full-custom FICI that considers design of both an implantable sensor for wide range sound sensing and a signal conditioning circuit for electrical stimulation of the auditory nerve. The microelectromechanical system (MEMS)-based acoustic sensor utilizes multiple cantilever beam structures to sense and filter the mechanical vibrations on the ossicular chain. The area optimized bilayer design of the piezoelectric sensor met with the volume limitation in the middle ear while achieving high signal-to-noise-ratio. The sensor outputs are processed by a current mode low-power signal conditioning circuit that stimulates the auditory neurons through intracochlear electrodes. The FICI is validated with an in vivo model where the electrical auditory brainstem response (eABR) of the animal was observed while applying sound excitation. The eABR results demonstrate that the system is able to evoke responses in the auditory nerves of a guinea pig for sound range of 45-100 dB SPL within the selected frequency bands.

Audiological correlates of tumor parameters in acoustic neuromas.

The objective of this study was undertaken to evaluate a correlation of pure tone audiometry, speech audiometry with tumor size, the presence of intrameatal extension, contralateral pure tone audiometry, and contralateral speech audiometry results at acoustic neuroma (AN) patients. Seventy-six patients with a unilateral-cerebellopontine angel tumor with/without internal acoustic canal (IAC) were included in this study. Data on pure tone audiometry, speech discrimination scores (SDS), speech reception thresholds (SRT), tumour size, and extension to IAC were analyzed retrospectively. As a result, patients with unilateral ANs had an asymmetric sensorineural hearing loss and had an asymmetric finding on the results of speech audiometry was present. We could not find any correlation between the size of the tumor and the hearing levels at each frequency. In addition, there appeared to be no significant correlation between the extension of tumor to the IAC and the audiological findings.

Complications of pediatric auditory brain stem implantation via retrosigmoid approach.

OBJECTIVE: We aimed to present the complications of auditory brain stem implantations (ABI) in pediatric patients which were performed via retrosigmoid approach. METHODS: Between March 2007 and February 2010, five prelingually deaf children underwent ABI (Medel device) operation via retrosigmoid approach. All children had severe cochlear malformations. The ages ranged from 20 months to 5 years. The perioperative complications encountered in 2 patients were evaluated retrospectively. RESULTS: No intraoperative complication was observed in the patients. Cerebrospinal fluid (CSF) leakage was the most common postoperative complication that was seen in 2 patients. The CSF leak triggered a cascade of comorbidities, and elongated the hospitalization. CONCLUSION: Pediatric ABI surgery can lead to morbidity. The CSF leak is the most common complication encountered in retrosigmoid approach. The other complications usually result from long-term hospital stay during treatment period of the CSF leak. Therefore, every attempt must be made to prevent occurrence of CSF leaks in pediatric ABI operations.

The Relationship of Vestibulo-Ocular Reflex With Self-Reported Dizziness Handicap in Patients With Vestibular Deafferentation.

The relationship between objective vestibular tests and subjective vestibular tests is a controversial topic. In this study, to contribute to this issue, the vestibulo-ocular reflex features and their relationship with balance perception at long-term follow-up in vestibular neurectomy (VN) and total labyrentectomy patients were evaluated. Prospectively, 19 VN and 18 labyrinthectomy patients were enrolled in this study. Patients underwent video head impulse test (VHIT) as objective vestibular test and dizziness handicap inventory (DHI) as subjective vestibular test when they attended to their control visit follow-up between March and September 2017. Lateral canal corrective saccades were classified as organized pattern and deorganized (scattered) pattern. In our results, the saccade pattern analysis (between organized and deorganized saccades) regarding the DHI scores gave P value as .039 for covert saccade pattern and .050 for overt saccade pattern. Therefore, we conclude that the presence of saccades, their patterns, and amplitudes provide extra information at assessing the results of the VHIT test, and the organized pattern of saccades is related to a stable vestibular system and better balance perception.

Management of cerebrospinal fluid leak following retrosigmoid posterior cranial fossa surgery.

OBJECTIVE: To detail our experience in the management of cerebrospinal fluid (CSF) leak following posterior cranial fossa surgery by the retrosigmoid approach. PATIENTS AND METHODS: 412 patients who underwent posterior cranial fossa surgery by the retrosigmoid approach for a variety of diseases were included in the study. RESULTS: There were 32 CSF leaks (7.7%) in the 412 patients. Of these, 16 were leaks from the incision site (50%) and 16 (50%) were CSF rhinorrheas. The CSF leaks were documented in 22 of the vestibular schwannoma surgeries (68.7%) and 10 of the vestibular nerve sectioning surgeries (31.3%). No CSF leak was seen following microvascular decompression and auditory brain stem implantation surgeries. Ten patients could be treated conservatively. Twelve patients needed the placement of a lumbar drainage. Surgical reexploration was performed in 10 patients. CONCLUSIONS: Initially, a conservative treatment should be instituted in the case of a CSF leak. If the conservative treatment fails, the placement of a lumbar drainage should be considered. Patients that do not respond to lumbar drainage require surgical reexploration. The abovementioned algorithm represents the safest and best option in the presence of a CSF leak, as confirmed by the absence of recurrences or multiple revisions in this study.

GJB2 and mitochondrial A1555G gene mutations in nonsyndromic profound hearing loss and carrier frequencies in healthy individuals.

This study aimed to assess mutations in GJB2 gene (connexin 26), as well as A1555G mitochondrial mutation in both the patients with profound genetic nonsyndromic hearing loss and healthy controls. Ninety-five patients with profound hearing loss (>90 dB) and 67 healthy controls were included. All patients had genetic nonsyndromic hearing loss. Molecular analyses were performed for connexin 26 (35delG, M34T, L90P, R184P, delE120, 167delT, 235delC and IVS1+1 A-->G) mutations, and for mitochondrial A1555G mutation. Twenty-two connexin 26 mutations were found in 14.7% of the patients, which were 35delG, R184P, del120E and IVS1+1 A-->G. Mitochondrial A1555G mutation was not encountered. The most common GJB2 gene mutation was 35delG, which was followed by del120E, IVS1+1 A-->G and R184P, and 14.3% of the patients segregated with DFNB1. In consanguineous marriages, the most common mutation was 35delG. The carrier frequency for 35delG mutation was 1.4% in the controls. 35delG and del120E populations, seems the most common connexin 26 mutations that cause genetic nonsyndromic hearing loss in this country. Nonsyndromic hearing loss mostly shows DFNB1 form of segregation.

Impact of Jacobson's (tympanic) nerve sectioning on middle ear functions.

OBJECTIVE: The purpose of this study was to evaluate the influence of sectioning of the Jacobson's (tympanic) nerve on middle ear functions. METHOD: Twenty-five adult New Zealand rabbits were included in this study. The Jacobson's nerve was cut in the left ear of the rabbits (study group), whereas only a small mucosal incision was performed while keeping the Jacobson's nerve intact in their right ear (control group). After the operation, the ears were assessed both otomicroscopically and histopathologically on Days 30, 60, and 90. RESULTS: On otomicroscopy, retraction pockets were observed in 48 and 4% of the ears in the study and control groups, respectively (p < 0.001). Middle ear effusion was observed in 56 and 12%, respectively (p < 0.01). Histopathologically, an inflammation in the middle ear mucosa was present in all ears in the study group, whereas it was present only in 20% of the control ears (p < 0.001). Goblet cells were observed in 48 and 20% in the study and control groups, respectively (p < 0.04). In the study group, the otomicroscopic and histopathologic findings were more prominent on Day 60 compared to Day 90 (p < 0.05). CONCLUSION: Tympanic glomus cells seem to act as middle ear chemosensory organs and are involved in the regulation of middle ear aeration. Disruption of these neural elements such as Jacobson's nerve negatively impacts on middle ear functions and may result in atelectasis.

Mini-incision for pediatric cochlear implantation with a MED-EL device.

OBJECTIVE: Minimal invasive approaches have been described for cochlear implantation. However, the number of reports about minimal invasive approaches for MED-EL devices is sparse. In this technical note, we describe our pediatric cochlear implantation and incision techniques for MED-EL devices. METHODS: Among 92 cochlear implantations performed between November 2002 and November 2006, there were 32 consecutive pediatric cochlear implantations with MED-EL devices which were performed between July 2005 and October 2006. In our technique, standard posterior tympanotomy and cochleostomy were performed after 4- to 5-cm mini-incisions in the postauricular region. However, suture fixations were not used for the implant receiver nor its electrode. RESULTS: There were 14 girls and 18 boys with a mean age of 3.9 years. The mean follow-up duration was 5.8 months. No flap necrosis, hematoma or infection, nor implant migration, extrusion or breakdown were encountered. Revision surgery was performed in 3 patients due to cochlear ossification, perilymph leakage and extracochlear implantation. CONCLUSION: MED-EL implantation can be performed using small incisions without suture fixation of the receiver and its electrode.

Surgical exposure in retrosigmoid approach: do we need cerebellar retractors?

BACKGROUND: The aim of this study was to present our technique of posterior fossa surgery and to evaluate whether cerebellar retractors are needed. METHODS: Since March 1989, more than 500 surgeries were performed through retrosigmoid approach, and our surgical technique was described. The data were evaluated whether or not cerebellar retractors were used in the operations. RESULTS: The surgeries were vestibular neurectomy, acoustic neuroma removal, and neurovascular decompression in 351, 135, and 14 patients, respectively. Cerebellar retractors have not been used in vestibular neurectomies and in most acoustic neuroma surgeries. The cerebellar retractors have been used in all of the neurovascular decompression surgeries where better exposure of the root entry zones of the cranial nerves is needed, and intracranial endoscopy is applied for further exposure and decompression of the vascular loop. CONCLUSION: There is no need for cerebellar retractors when adequate conditions such as patient positioning, adequate anesthesia techniques, and surgical manipulations are applied in posterior fossa approach except for neurovascular decompression and some of the acoustic neuroma surgeries.

Immediate repair of the tympanic membrane to prevent persistent perforation after intentional removal of long-lasting tubes.

OBJECTIVE: Our purpose was to evaluate efficiency of immediate repair of the tympanic membrane perforation after intentional removal of the long-lasting tubes. METHODS: This study was done in 36 ears of 27 patients who had either Goode-T or Paparella-II silicone tube insertion due to chronic OME or ROM and tube removal. Only the ears in which tube removal was performed due to no longer need for middle ear ventilation were included to the study. After removal of the tube, the perforation edges were refreshed and Steri-Strip (3M) patch was adhered on the perforation site. Otoscopic, tympanometric and audiologic data were reported. RESULTS: Mean duration of the tube persistence was 49.58+/-11.94 months. It was found that there were two subgroups in the study group: those under regular follow-up (20 ears), and the ears which were out of regular follow-up (16 ears). Mean tube persistence times were 34.10 and 52.11 months in these subgroups, respectively (chi2-test, p=0.056). In six ears (16.67%), persistent perforation (PP) was found. PP rate (PPR) was higher in group-B (25%) than in group-A (10%) (chi2-test, p>0.1). The rest perforation was anteriorly marginal in five of six PP (83.33%). The PPR in the ears in which rest perforation was anteriorly marginal was 35.71% (5/14) while it was 4.54% (1/22) in the ears with central rest perforation (chi2-test, p<0.02). CONCLUSIONS: Even immediate repair of the perforation after removal of the long-lasting tubes resulted in a high PPR. The data in this study documented that this high PPR was associated with type and localisation of rest perforation and tube persistence time. Anteriorly, marginal perforations had about eight times higher risk of PP and longer tube persistence caused higher anterior marginal perforations after tube removal.

Temporal bone paragangliomas: 15 years experience.

INTRODUCTION: Temporal bone paragangliomas (TBPs) are benign tumors arising from neural crest cells located along the jugular bulbus and the tympanic plexus. In general surgical excision, radiotherapy and wait-and-scan protocols are the main management modalities for TBPs. OBJECTIVE: In this paper we aim to present our clinical experience with TBPs and to review literature data. METHODS: The patients who were operated for tympanomastoid paraganglioma (TMP) or tympanojugular paraganglioma (TJP) in our clinic in the last 15 years were enrolled in the study. A detailed patient's charts review was performed retrospectively. RESULTS: There were 18 (52.9%) cases with TMPs and 16 (47.1%) cases with TJPs, a total of 34 patients operated for TBPs in this time period. The mean age was 50.3± 11.7 (range 25-71 years). The most common presenting symptoms were tinnitus and hearing loss for both TMPs and TJPs. Gross total tumor resection was achieved in 17 (94.4%) and 10 (62.5%) cases for TMPs and TJPs, respectively. Five patients (31.2%) with TJP experienced facial palsy following the operation. For all the patients the mean follow-up period was 25.8 months (range 4-108 months). CONCLUSION: In conclusion, based on our findings and literature review, total surgical excision alone or with preoperative embolization is the main treatment modality for TBPs. However radiotherapy, observation protocol and subtotal resection must be considered in cases of preoperative functioning cranial nerves, large tumors and advanced age.

Histopathological Effects of Parylene C (poly-chloro-p-xylylene) in the Inner Ear.

OBJECTIVE: To assess the histopathological effects of parylene C (PC) (poly-chloro-p-xylylene) in the inner ear. METHODS: Nine adult Dunkin Hartley guinea pigs (500-600 g) were included in the study. PC pieces were inserted into the cochlea in the right ear of the animals (study group). The round windows were punctured in the left ears comprised the control group. After three months, the animals were sacrificed, and the dissected temporal bones were examined under a light microscope. RESULTS: No significant difference was revealed between the study and control groups regarding histopathological findings such as perineural congestion, perineural inflammation, neural fibrosis, number of ganglion cells, edema, and degeneration of ganglion cells (p>0.05). CONCLUSION: PC did not cause any additional histopathologic damage in the cochlea. This finding may be promising regarding the use of PC in cochlear implant electrodes as an alternative to silicon materials in the future.

Combined retrosigmoid retrolabyrinthine vestibular nerve section: results of our experience over 10 years.

OBJECTIVE: We aimed to evaluate the results of our experience in vestibular nerve sectioning (VN), which was performed using combined retrosigmoid-retrolabyrinthine approach. STUDY DESIGN: Medical records of 280 patients who were consecutively operated on for incapacitating peripheral vertigo were retrospectively evaluated, and 210 patients who completed 2 years follow-up and had adequate follow-up data were found to be suitable for inclusion in the study. METHODS: Hearing results, vertigo control rates, and complications of the retrosigmoid-retrolabyrinthine VN were evaluated. RESULTS: The patients were suffering from vertigo for a mean period of 32.2 months. Bilateral Meniere's disease occurred in 5.7% of the patients in the follow-up period. A complete or substantial vertigo control could be achieved in 94.4% of the patients (191 [90.1%] in Class A and 9 [4.3%] in Class B). Preoperative speech reception threshold, pure-tone average, and speech discrimination score of the patients were 56.5 dB, 47.4 dB, and 73.6%, respectively. Postoperative corresponding values were 62.2 dB, 43.4 dB, and 68.5%, respectively (p > 0.05). The complication rate was low (2.5%). Most common complication was abdominal hematoma, which was seen in 4.5%. CONCLUSION: VN performed using retrosigmoid-retrolabyrinthine approach has low complication and high vertigo control and hearing preservation rates. It can be applied as an initial surgery or reserved as the last step when the other surgical treatments have failed to control vertigo.

The effects of sodium-2-mercaptoethanesulfonate application on the neural and neurovascular tissues: An experimental animal study.

BACKGROUND: Sodium-2-mercaptoethanesulfonate (MESNA) is a protective agent that is also used as "a chemical dissector" in various surgical fields. The aim of this study is to evaluate the toxic effects of MESNA on neural and neurovascular structures based on a morphological analysis and examine its safety in neurotological applications. METHODS: Three groups of guinea pigs were used as subjects. MESNA solution (50 and 100%) and saline solution were applied to the subarachnoid space over the brain tissue via a middle fossa approach of study and control groups, respectively. Effects of MESNA were assessed by means of light microscope. McNemar Chi-square test was used to evaluate the histopathological findings. Statistical significance of P < 0.05 was taken as criterion. RESULTS: No morphological changes were observed on vascular and neural structures in the study groups in both concentrations, compared to the control group. CONCLUSIONS: On a morphological basis, a single application of MESNA does not cause any morphological changes that indicate a toxicity in neural and neurovascular structures.

[Subdural hygroma after cerebellopontine angle tumor surgery: a case report]. / Serebellopontin köse tümörü cerrahisi sonrasi subdural higrom: olgu sunumu.

The primary treatment modality for cerebellopontine angle (CPA) tumors is surgery. In the postoperative period, collection of subdural hygroma (SDH) is a rarely encountered complication. This paper presents a 58-year-old male patient who underwent surgery for right acoustic neuroma and developed a SDH postoperatively. Subdural hygroma, even though rarely seen, is a serious complication following CPA tumor surgery, calling for early diagnosis and treatment. Definition, diagnosis, clinical aspects, and treatment of SDH are discussed.