Atypical clinical manifestations of herpes zoster oticus: diagnostic usefulness of magnetic resonance imaging.

Typical symptoms of Ramsay Hunt syndrome (RHS) consist of painful vesicular eruptions in the external ear, unilateral facial palsy, and/or vestibulocochlear deficit. When RHS patients show atypical clinical manifestations, correct diagnosis can be delayed, and ideal treatment timing for antiviral therapy may be missed. The aim of this study is to describe RHS patients with atypical clinical manifestations and evaluate the usefulness of magnetic resonance imaging (MRI) for early differential diagnosis. We retrospectively reviewed the clinical data and investigated the findings of internal auditory canal (IAC) MRI of seven patients diagnosed with RHS presenting "atypical" clinical manifestations between January 2013 and December 2016. "Typical" symptoms of RHS consist of herpetic vesicular eruption and facial palsy with or without vestibulocochlear deficit. Regardless of symptomatic presentations, IAC MRI demonstrated post-contrast enhancement of cranial nerve (CN) VII, CN VIII, and IAC dura in patients with atypical clinical manifestations. In cases with multiple lower CN palsy, enhancement along the involved nerve was observed on IAC MRI. When RHS was complicated by acute parotiditis, diffuse enhancement of the parotid gland was demonstrated. The present study shows that in IAC MRI of RHS patients with atypical clinical manifestations, post-contrast enhancement was not confined to the facial nerve but also observed in CN VIII and IAC dura regardless of the symptoms, which may facilitate early diagnosis of RHS.

Comorbid Cupulolithiasis Is Rare in Patients With Horizontal Semicircular Canal Canalolithiasis.

OBJECTIVES: Considering that otolith particles pass through the canal until attaching to the cupula in the canal-side horizontal semicircular canal (HSCC) cupulolithiasis, comorbidity of HSCC canalolithiasis and cupulolithiasis may occur. We aimed to investigate the incidence of comorbidity of cupulolithiasis in patients with HSCC canalolithiasis and to improve treatment efficacy. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral academic center. PATIENTS: Ninety-seven consecutive patients with HSCC canalolithiasis between March 2017 and March 2019 were included. MAIN OUTCOME MEASURES: Coexistence of HSCC cupulolithiasis was hierarchically investigated. 1) Spontaneous reversal of initial nystagmus is observed bilaterally in a head-roll test (HRT), 2) nystagmus is in the same direction at each of the three times the supine position was tested, and 3) both bowing and leaning nystagmus with opposite direction are observed. RESULTS: Of 97 patients with HSCC canalolithiasis, 2 patients (2%) had comorbid HSCC cupulolithiasis. CONCLUSIONS: Although coexistence of HSCC canalolithiasis and cupulolithiasis should be considered when spontaneous reversal of nystagmus direction is observed without position change during a HRT, the incidence of coexistence is very low. However, canalith repositioning maneuvers for both canalolithiasis and cupulolithiasis should be performed in cases with comorbidity.

Temporomandibular joint herniation into the middle ear: A rare cause of mastication-induced tinnitus.

A 75-year-old patient complained of mastication-induced clicking tinnitus on the left side, and otoendoscopic examination revealed that the left tympanic membraneTM was outwardly bulged by clenching her teeth. Temporal bone computed tomography demonstrated that the posteromedial bony wall of the glenoid was partially dehiscent, allowing herniation of soft tissue contents of temporomandibular joint into the middle ear. Increased middle ear pressure due to soft tissue herniation can induce left tympanic membrane bulging and accompanying clicking tinnitus. Herniation of temporomandibular joint soft tissue into the middle ear should be considered as a differential diagnosis when clicking tinnitus is evoked by mastication.

Benign Paroxysmal Positional Vertigo in the Elderly: A Single-center Experience.

OBJECTIVES: Dizziness and balance problems are common in the elderly, and benign paroxysmal positional vertigo (BPPV) is one of the most common causes of dizziness. The aim of this study is to investigate the subtype distribution of geriatric BPPV in a single tertiary referral center, and compare the treatment efficacy according to the subtype of BPPV. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral academic center. PATIENTS: The consecutive 316 elderly patients diagnosed with BPPV between March 2013 and March 2019 were included. MAIN OUTCOME MEASURES: Using a head-roll and Dix-Hallpike tests, subtype of BPPV was determined. Once the diagnosis of BPPV was made, patients were treated by its corresponding canalith repositioning maneuver (CRM). RESULTS: Among 316 elderly patients with BPPV, 143 patients (45%) were diagnosed with posterior semicircular canal BPPV, 46 patients (15%) were diagnosed with lateral semicircular canal (LSCC) canalolithiasis, 126 patients (40%) were diagnosed with LSCC cupulolithiasis, and 1 patient (0%) was diagnosed with anterior semicircular canal BPPV. While 66 and 63% of the patients with posterior semicircular canal BPPV and LSCC canalolithiasis recovered after one session of CRM, only 32% of the patients with LSCC cupulolithiasis recovered after one session of CRM. CONCLUSION: The proportion of LSCC cupulolithiasis was higher in the elderly, and treatment efficacy by CRM is lower in LSCC cupulolithiasis than other subtypes of BPPV. High prevalence of LSCC cupulolithiasis may be explained by a delay between onset of BPPV and patient's presentation to the tertiary referral hospital or pathophysiology of ageotropic positional nystagmus other than otoconial attachment on the LSCC cupula in the elderly.

Direction-Changing Positional Nystagmus in Acute Otitis Media Complicated by Serous Labyrinthitis: New Insights into Positional Nystagmus.

OBJECTIVE: To demonstrate characteristic nystagmus findings in acute otitis media (AOM) complicated by serous labyrinthitis and discuss the mechanism of direction-changing positional nystagmus (DCPN) in this condition. PATIENTS: A patient with AOM complicated by serous labyrinthitis on the left side. INTERVENTION: Video nystagmography and 3D fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI). MAIN OUTCOME MEASURES: Characterize positional nystagmus in a head-roll test observing the change of nystagmus direction in process of time and compare findings of temporal bone 3D FLAIR MRI. RESULTS: A previously healthy 50-year-old man who complained of acute otalgia, hearing loss, and vertigo was diagnosed with AOM complicated by serous labyrinthitis on the left side. A head-roll test performed on the day when vertigo developed showed persistent geotropic DCPN. While pre- and postcontrast T1-weighted MRI showed no signal abnormality in both inner ears, 10-minute delay postcontrast 3D FLAIR image showed enhancement in the inner ear on the left side. Four-hour-delay postcontrast 3D FLAIR images showed more conspicuous enhancement of the whole cochlea, vestibule, and semicircular canals on the left side. CONCLUSIONS: In AOM complicated by serous labyrinthitis, density of perilymph may increase due to direct penetration of cytokines and other inflammatory mediators from the middle ear into perilymph and breakdown of blood-labyrinth barrier that causes vascular leakage of serum albumin into perilymph. The density difference between perilymph and endolymph makes the semicircular canal gravity sensitive. A buoyant force is also generated by gravity, causing indentation of endolymphatic membrane in the ampulla and cupula displacement. Thus, at the early stage of serous labyrinthitis, a head-roll test may elicit persistent geotropic DCPN, of which the direction can be changed over time.

Utility of the bow and lean test in predicting subtype of benign paroxysmal positional vertigo.

OBJECTIVES/HYPOTHESIS: To investigate the role of the bow and lean test (BLT) in the diagnosis of benign paroxysmal positional vertigo (BPPV). STUDY DESIGN: Retrospective case-control study. METHODS: Between March 2015 and June 2017, we enrolled 113 patients with posterior semicircular canal (PSCC) BPPV, 74 patients with lateral semicircular canal (LSCC) canalolithiasis, 53 patients with LSCC cupulolithiasis, and 32 patients with light cupula. We retrospectively assessed bowing nystagmus (BN) and leaning nystagmus (LN). RESULTS: In PSCC BPPV, 75% of the patients showed at least one of BN and LN, and direction of nystagmus provoked by a Dix-Hallpike test on the affected side was consistent with that of LN and opposite to that of BN. In LSCC canalolithiasis, 65% (48 of 74) of the patients showed both BN and LN, which were in the same direction in 38 patients (of 48) and in the opposite direction in 10 patients (of 48). The affected side can be determined according to the results of THE BLT in 74% (55 of 74) of LSCC canalolithiasis patients, and among them, the side determined according to the results of head-roll test was discordant with that according to the BLT in 20 of 55 patients (36%). In LSCC cupulopathy (n = 85), both BN and LN were persistent and observed in all cases, but we could not distinguish LSCC cupulolithiasis from light cupula according to nystagmus direction in the BLT. CONCLUSIONS: Although a BLT yields better lateralization in LSCC canalolithiasis, it may be more useful in predicting the diagnosis and lateralization of PSCC BPPV than LSCC canalolithiasis. LEVEL OF EVIDENCE: 4 Laryngoscope, 2600-2604, 2018.