Why should multiple dehiscences of the otic capsule be considered before surgically treating patients with superior semicircular canal dehiscence? A radiological monocentric review and a case series.

This review aims to draw attention to the multiple ipsilateral otic capsule dehiscences (OCDs), which may cause therapeutic failure in operated patients. A series of six severely disabled patients with symptoms and signs consistent with a superior semicircular canal dehiscence (SSCD) diagnosis, confirmed by a high-resolution CT scan, is presented here. Five of the patients underwent surgery, and in four of the cases, the postoperative results were poor and/or disappointing. The ethical principles underlying modern medicine encourage medical staff to learn from past experience even when the results are modest despite the accuracy of the treatment applied to a patient. Consequently, we reviewed the radiological records of symptomatic and asymptomatic patients diagnosed or referred to our center for confirmation over the past 5 years to determine the incidence of multiple OCD in this population. Multiple localizations of suspected OCD in the ipsilateral ear did not appear to be rare and were found in 29 of 157 patients (18.47%) in our retrospective review using high-resolution thin-sliced CT scans. The decision to perform surgery for a documented symptomatic superior SSCD should be made with caution only after ruling out concomitant lesser-known variants of OCD in the ipsilateral ear.

The clinical findings to notice mild elevation of intracranial pressure in an otology clinic.

Mildly elevated intracranial pressure appears to be a distinct pathology separate from idiopathic increased intracranial pressure and migraine. Many patients present with head fullness-pressure and dizziness, which is often suggestive of a clinical diagnosis of vestibular migraine. These patients may additionally have episodic vertigo as seen in endolymphatic hydrops and positional vertigo in addition to feeling dizzy. In most cases, hearing is normal. A long duration of the condition or a presence of associated ear pathologies, i.e., dehiscence, fistula, hypermobile footplate, or history of chronic ear infections can add hearing loss to clinical presentations. Low-pitch pulsatile tinnitus, when present, is an important symptom. The neuroimaging findings such as partially empty sella, blockage of the dural venous sinus or sigmoid sinus wall defects are frequently observed. The condition is diagnosed by measuring the lumbar puncture opening pressure. Typically, patients have normal cerebrospinal fluid chemistry and microscopy. Lowering the pressure during the lumbar puncture will resolve the patient's symptoms temporarily. Medical therapy is typically successful using carbonic anhydrase inhibitors and corrections of medical disorders that may be contributing to the increased pressure. A few require shunting or stenting procedures. In this review article, we define the condition in detail with illustrative cases that we collected from our practices.

Post-concussive Dizziness: A Review and Clinical Approach to the Patient.

Dizziness is a frequent complaint after head trauma. Among patients who suffer a concussion (mild traumatic brain injury or mTBI), dizziness is second only to headache in symptom frequency. The differential diagnosis of post-concussive dizziness (PCD) can be divided into non-vestibular, central vestibular and peripheral vestibular causes with growing recognition that patients frequently exhibit both central and peripheral findings on vestibular testing. Symptoms that traditionally have been ascribed to central vestibular dysfunction may be due to peripheral dysfunction. Further, our ability to test peripheral vestibular function has improved and has allowed us to identify peripheral disorders that in the past would have remained unnoticed. The importance of the identification of the peripheral component in PCD lies in our ability to remedy the peripheral vestibular component to a much greater extent than the central component. Unfortunately, many patients are not adequately evaluated for vestibular disorders until long after the onset of their symptoms. Among the diagnoses seen as causes for PCD are (1) Central vestibular disorders, (2) Benign Paroxysmal Positional Vertigo (BPPV), (3) Labyrinthine dehiscence/perilymph fistula syndrome, (4) labyrinthine concussion, (5) secondary endolymphatic hydrops, (6) Temporal bone fracture, and (7) Malingering (particularly when litigation is pending). These diagnoses are not mutually exclusive and PCD patients frequently exhibit a combination of these disorders. A review of the literature and a general approach to the patient with post-concussive dizziness will be detailed as well as a review of the above-mentioned diagnostic categories.

Comorbidities confounding the outcomes of surgery for third window syndrome: Outlier analysis.

Objective: Patients with third window syndrome and superior semicircular canal dehiscence (SSCD) symptoms whose surgical outcomes placed them as outliers were systematically studied to determine comorbidities that were responsible for their poor outcomes due to these confounding factors. Study Design: Observational analytic case-control study in a tertiary referral center. Methods: Twelve adult patients with clinical SSCD syndrome underwent surgical management and had outcomes that did not resolve all of their subjective symptoms. In addition to one of the neurotologists, 2 neurologists (one specializing in migraine and the other a neuro-ophthalmologist), and a psychologist clinician-investigator completed comprehensive evaluations. Neuropsychology test batteries included: the Millon Behavioral Medicine Diagnostic; Patient Health Questionnaire (PHQ-9) and Generalized Anxiety Disorder Screener (GAD-7); Adverse Childhood Experiences Scale; the Wide Range Assessment of Memory and Learning, including the 3 domains of verbal memory, visual memory, and attention/concentration; Wechsler Adult Intelligence Scale; and the Delis-Kaplan Executive Function System. The control cohort was comprised of 17 participants who previously underwent surgery for third window syndrome that resulted in the expected outcomes of resolution of their third window syndrome symptoms and cognitive dysfunction. Results: There was a high rate of psychological comorbidity (n = 6) in the outlier cohort; multiple traumatic brain injuries were also a confounding element (n = 10). One patient had elevated cerebrospinal fluid (CSF) pressure requiring ventriculoperitoneal shunting to control the recurrence of dehiscence and one patient with a drug-induced Parkinson-like syndrome and idiopathic progressive neurological degenerative process. Conclusions: Components of the Millon Behavioral Medicine Diagnostic, PHQ-9 and GAD-7 results suggest that these instruments would be useful as screening tools preoperatively to identify psychological comorbidities that could confound outcomes. The identification of these comorbid psychological as well as other neurological degenerative disease processes led to alternate clinical management pathways for these patients. Level of Evidence: 2b.

Acoustic neuroma neurophysiologic correlates: vestibular-preoperative, intraoperative, and postoperative.

By the nature of their origin, acoustic neuromas always result in some degree of vestibular dysfunction. The implications of this are typically more notable postoperatively, rather than preoperatively or intraoperatively. However, preoperative vestibular assessment can have implications on operative approach and postoperative rehabilitation. This paper details the preoperative vestibular findings that correlate with differing stages of acoustic neuroma growth. It also describes the findings that help localize the tumor origin to either the inferior or superior divisions of the vestibular nerve. Finally, and probably most importantly, we discuss the causes of persistent postoperative vestibular symptoms.

Evaluation of dizziness in the litigating patient.

Evaluation of dizziness in patients who are involved in litigation can deviate significantly from the evaluation of patients who have no ongoing litigation. This article presents the basic principles of the physician's role in the evaluation of litigating patients. Considerations for physical examination, diagnostic testing, and review of medical records are discussed. Topics of malingering and legal "pearls" are presented in the context of providing an objective and unbiased evaluation of the litigating patient.

The relationship between the modified somatic perception questionnaire and dynamic platform posturography.

OBJECTIVE: To analyze if patients whose vestibular symptoms are associated with nonorganic sway patterns show more evidence of somatization and/or malingering than patients whose vestibular symptoms are associated with normal or physiologically abnormal sway patterns observed in people with documented vestibular pathologic findings. PATIENTS: One hundred fifteen patients with complaints of vestibular dysfunction and hearing impairment. INTERVENTIONS: Computerized dynamic posturography (CDP) and completion of the Modified Somatic Perception Questionnaire (MSPQ)--a validated test for the detection of malingering. MAIN OUTCOME MEASURES: Computerized dynamic posturography results classified into 4 categories (normal, physiologic abnormal, borderline-aphysiologic, and aphysiologic) were correlated with the results of the MSPQ. RESULTS: A significant CDP group effect on the MSPQ, with the aphysiologic patients scoring significantly higher than the other groups. Moreover, a significantly higher proportion of aphysiologic patients scored more than the MSPQ cutoffs for malingering. CONCLUSION: Results indicate that patients who have aphysiologic CDP sway patterns are more likely to have higher MSPQ scores. Both aphysiologic CDP results and high MSPQ scores have been associated with intentional exaggeration. These results indicate that patients with both aphysiologic CDP findings and high MSPQ scores are more likely to be intentionally exaggerating their balance-related complaints and deficits.

Chronic suppurative otitis media, caloric testing, and rotational chair testing.

OBJECTIVE: To determine the incidence of caloric and rotational chair testing (ROT) abnormalities in a group of patients with chronic suppurative otitis media (CSOM) and to correlate caloric test results with ROT. PATIENTS: Twenty-five patients with CSOM with or without cholesteatoma who were to undergo tympanomastoid surgery. INTERVENTIONS: Caloric and ROT. MAIN OUTCOME MEASURES: History of dizziness. Vestibular test abnormalities defined by caloric weakness (CW), reduced gain, abnormal phase, or asymmetry on ROT. RESULTS: Among the 25 patients, 13 had bilateral CSOM-most with long-standing disease and history of previous surgical intervention. Of the 25 patients, 19 (76%) demonstrated either unilateral or bilateral CW. Eighteen (72%) demonstrated abnormalities on ROT. Eleven patients (44%) had complaints of vertigo/dizziness, although 2 of these patients had both normal caloric testing and ROT. Unilateral or bilateral CW was 80% accurate in predicting an ROT abnormality, whereas the symptom of vertigo/dizziness was only 48% accurate in predicting an ROT abnormality. CONCLUSION: The incidence of CW among CSOM patients in this study was high and correlated well with abnormalities on ROT. Interestingly, ROT results correlated better with CW than symptoms of dizziness/vertigo. Although CW findings can be the result of technical limitations in testing patients with CSOM, ROT corroboration of these results suggest that they are valid findings.

Viral titers and delayed facial palsy after acoustic neuroma surgery.

OBJECTIVE: Delayed facial palsy (DFP) after acoustic neuroma surgery has been reported to occur in up to one third of cases. Reactivation of latent virus has been proposed as an etiology for DFP. However, only retrospective case reports and case series have offered data to support this theory. The objective of this study was to correlate DFP with change in viral titers. PATIENTS AND METHODS: Twenty consecutive patients who underwent acoustic neuroma surgery were prospectively evaluated for viral titers immediately preoperatively and at 3 weeks postoperatively. Viral titers measured included herpes simplex virus 1 (HSV-1), herpes simplex virus 2 (HSV-2), and varicella zoster virus (VZV) and included both IgG and IgM titers. The status of facial nerve function was documented preoperatively and throughout the postoperative period. Patients were categorized according to the presence or absence of DFP. RESULTS: Seven patients developed DFP after acoustic neuroma surgery, while the remaining 13 patients did not. There was no difference in preoperative and 3-week postoperative IgG titers for any of the 3 viruses tested. However, IgM titers were much higher postoperatively in DFP patients for all 3 viruses tested. The average HSV-1 IgM titer rose 92% in DFP patients compared with only 4.5% in the patients who did not develop DFP. Average HSV-2 IgM titers rose 70% compared with a decline of 8.5% in non-DFP patients. Most strikingly, VZV IgM titers rose an average 495% postoperatively among DFP patients compared with a decline of 14% in the non-DFP patients. CONCLUSION: Elevation of the IgM titers of the viruses measured in this study implies that recrudescence of the virus has occurred. The absence of this rise among patients who did not develop DFP implies that viral recrudescence plays a role in the etiology of DFP. These findings support treatment or prophylaxis of DFP with antiviral therapy.