Different clinical course of BPPV according to the medical conditions.

Dizziness is one of the most prevalent complaints in medicine, and benign paroxysmal positional vertigo (BPPV) accounts for one-third of all cases. The present study was aimed at identifying differences in the course and prognosis of BPPV depending on the patient's medical condition during hospitalization. Patients in group 1 were hospitalized due to trauma, those in group 2 for scheduled surgery, and those in group 3 for medical treatment. The intervals from admission to symptom onset, surgery to symptom onset, and symptom onset to ENT department referral were compared. The interval from admission to symptom onset was shortest in group 1 (3.1 ± 8.0 days) and differed significantly from that in group 3 (20.0 ± 35.0 days, p < 0.001). The interval from surgery to symptom onset for group 2 was 5.6 ± 5.8 days and was significantly shorter than that from admission to symptom onset for group 3 (p = 0.014). The interval from symptom onset to ENT referral in group 3 (2.0 ± 2.8 days) was significantly shorter than in groups 1 and 2 (4.1 ± 5.1 and 4.0 ± 3.6 days, p = 0.008 and p = 0.002, respectively). The findings imply that the course of BPPV differed according to the patients' medical condition.

Double Primary Cancers of Earlobe Merkel Cell Carcinoma and Lung Adenocarcinoma.

Merkel cell carcinoma (MCC) is an aggressive neuroendocrine carcinoma with a high rate of metastasis. MCC is rarely suspected during clinical examination, thus requiring biopsy to establish a pathologic diagnosis. In addition, MCC sometimes occurs in double primary cancers. Although there have been reviews on double primary cancers, only a few cases involving MCC have been described. Herein, we report a case of a 54-year-old female patient who presented to our clinic with a diagnosis of earlobe MCC following an excisional biopsy performed by another clinic. Further evaluation, including chest imaging, revealed a mass in the lung. The patient underwent a wide excision of the right earlobe, and video-assisted thoracic surgery on the lung. Pathology confirmed MCC in the right earlobe and adenocarcinoma in the lung. The patient underwent postoperative adjuvant chemotherapy followed by radiotherapy. Up to this point, 3 years after the surgery, there has been no evidence of recurrence.

Primary Bilateral Tuberculous Otitis Media After Kidney Transplantation: A Case Report.

We report a case of primary bilateral tuberculous otitis media in a patient who underwent kidney transplantation. This case presents unusual clinical features and histopathology from those of classical tuberculous otitis media. A 75-year-old woman presented at the clinic with purulent ear discharge and hearing loss in both ears. She had undergone kidney transplantation 6 years prior and had been taking immunosuppressant medications. Otoscopic examination and imaging studies suggested acute otitis media, which was irresponsive to antibiotics. The patient underwent surgery to eradicate the disease, and histopathologic examination revealed multifocal granulomas with Langhans giant cells without caseous changes. Ziehl-Neelsen staining and polymerase chain reaction confirmed the diagnosis of tuberculous otitis media. While tuberculous otitis media is a very rare manifestation of extrapulmonary tuberculosis, this case is more noteworthy in that it occurred as a primary infection rather than as a reactivation of a prior infection. In addition, it did not show the classical triad of clinical manifestations, which occurred bilaterally, and its histopathology was different from those of classical tuberculous otitis media. This case presents a new clinical variation in tuberculous otitis media.

Objective Tinnitus of Nasopharyngeal Origin.

We report a rare case of objective tinnitus induced by nasopharyngeal muscle constriction. A 49-year-old female patient presented at the clinic with unintentional sounds coming from the nasal cavity while talking or swallowing, which were similar to the lip-smacking sound. Physical examination revealed a hypertrophic posterior nasopharyngeal wall and torus tubarius at rest. With voluntary effort, the posterior pharyngeal wall protruded prominently and collided with the torus tubarius on either side, generating a sound when they were separated. Botox injection was recommended but the patient refused. The diagnosis and treatment of objective tinnitus are well established, but in some cases, it may occur under unexpected conditions. We report a novel type of objective tinnitus. A thorough physical examination for tinnitus could reveal the cause.

Is sleep apnea truly associated with hearing loss? A nationwide, population-based study with STOP-BANG questionnaire.

Objectives: We aimed to investigate the effect of obstructive sleep apnea (OSA) on hearing ability. Methods: We retrospectively reviewed the population-based survey data collected by the Korean National Health and Nutrition Examination Survey between January 1, 2019 and December 31, 2020. The data included 3,575 participants who completed the STOP-BANG questionnaire (SBQ) and pure-tone audiometry. OSA risk was assessed using the SBQ, and the hearing level was compared between the risk groups. Results: Among the 3,575 participants, 2,152 (60.2%), 891 (24.9%), and 532 (14.9%) were classified as being low, intermediate, and high risk, respectively. The intermediate- and high-risk groups showed significantly worse hearing levels than the low-risk group. When age and sex were adjusted, the hearing level did not differ between the risk groups. Conclusion: The study found that the presence of OSA minimally affected hearing level. Because hearing loss due to hypoxic damage develops over a long period of time, further research on the association between the duration of OSA, rather than the presence or severity of OSA, and hearing loss is needed.

Neuromuscular retraining therapy combined with preceding botulinum toxin A injection for chronic facial paralysis.

BACKGROUND: Neuromuscular retraining therapy (NMRT) is the central treatment for synkinesis. The efficacy of botulinum toxin type A (BTX-A) may be enhanced with the addition of physical therapy. OBJECTIVES: To investigate the effects of NMRT combined with preceding BTX-A injection (NMRT-B) on facial synkinesis and asymmetry in chronic facial paralysis. MATERIALS AND METHODS: We recruited 99 patients with unilateral facial paralysis and no recovery for > 6 months who underwent NMRT-B for > 1 year. The patients were scheduled to receive NMRT after 1-2 weeks of BTX-A injection. We used a computer-based numerical scoring system to evaluate the facial functions. Primary, secondary, and final facial movement scores were evaluated before and after 1 year of treatment. RESULTS: Patients with chronic facial paralysis who underwent NMRT-B exhibited improved facial movement after 1 year of treatment. NMRT-B provided satisfactory control of synkinesis and improved the primary movements. The mean primary and final facial movement scores were significantly increased after treatment, while the mean secondary facial movement scores were significantly decreased. CONCLUSIONS AND SIGNIFICANCE: NMRT-B improved the final facial movement in patients with chronic facial paralysis and synkinesis, regardless of the degrees of facial synkinesis and asymmetry before treatment.

Multiple Pyogenic Granulomas in the External Auditory Canal.

Pyogenic granuloma is a benign vascular tumor of the skin or mucous membrane. One-third of pyogenic granulomas have been reported in the head and neck, but it is rarely present in the external auditory canal. Pyogenic granuloma mostly presents as a solitary granuloma, and only a few cases of multiple forms have been reported. This report describes a rare case of multiple pyogenic granulomas in the external auditory canal of a 36-year-old man along with a review of the literatures. Although it is very rare for PGs to occur in the EAC, it can be suspected in conditions such as after acute and/or chronic trauma, hormonal changes or systemic drug administration, rapid growth, and easy bleeding tendency with a friable surface. Some PGs may spontaneously resolve, but when they cause symptoms, excision is recommended for treatment and diagnosis. In the case of excision, the tumor should be excised down to the perichondrium level to prevent recurrence. Although PG mainly occurs in a solitary form, the present case shows a new clinical variation where multiple PGs were present in the EAC.

Sinonasal Manifestations of Severe Cherubism: A Case with 11-year Follow-up.

Cherubism, a type of fibroosteodysplasia, is a rare hereditary disease that causes variable degrees of facial deformity in children. Hypertrophy of the mandible is the most common symptom, but in severe cases, the disease affects the eyes, teeth, and sinonasal cavity. There have been few reports regarding sinonasal complications and no standard treatment has been established. This paper reports long-term treatment of severe cherubism that invaded the sinonasal cavity treated with consecutive endoscopic sinonasal surgeries.

Surgical Reconsideration of Traumatic Facial Paralysis.

INTRODUCTION: Despite the different pathophysiological mechanisms underlying Bell's palsy, in assessing severe traumatic facial paralysis, many surgeons rely on electrophysiological criteria to determine whether facial nerve exploration is warranted. To assess the value of preoperative electroneurography (ENoG) and the time of surgery, we analyzed data from three tertiary medical centers. MATERIALS AND METHODS: The records of 517 patients with a degenerative ratio (DR) greater than 80% on ENoG were collected, and two groups were defined: group A (90% DR ≤ ENoG) and group B (80% DR ≤ ENoG < 90% DR). The difference in effectiveness of surgery versus conservative treatment was analyzed based on the postoperative outcome determined by the House-Brackmann grading system. The independent-samples t test was used to compare surgery with conservative treatment for each day of surgical exploration. RESULT: In groups A and B, the average recovery time from facial paralysis was better in patients who had undergone surgical exploration than in those who had been treated conservatively. In group A, the difference was significant only for patients who underwent surgery within 8 days. In group B, a significant difference was found for patients who underwent surgery within 16 days but also for surgery performed 20 and 30 days after the onset of facial paralysis. DISCUSSION: In the surgical treatment of facial paralysis, the criteria for trauma patients should be distinguished from those of patients with Bell's palsy. In traumatic facial paralysis, some axons are more vulnerable to external collapse, and the degree of Wallerian degeneration of the peripheral nervous system will vary depending on the type of injury. The results of this study will help to identify those patients with traumatic facial paralysis who should be treated surgically and when they should be treated.

Comparison of Auditory Outcomes between Inpatient- and Outpatient-Based Treatment in Sudden Sensorineural Hearing Loss.

Objective: The primary treatment for sudden hearing loss is high-dose steroid therapy. In some countries, hospitalization has been taken for granted. Although most countries appear to treat sudden hearing loss on an outpatient basis, some other countries have considered hospitalization as necessary. Only a few studies have been conducted on the effect of hospitalization on hearing outcomes. Therefore, we compared the hearing outcome of inpatient- and outpatient-based treatments to determine whether hospitalization affects the recovery of sudden hearing loss. Methods: We conducted a retrospective case review of patients diagnosed with sudden sensorineural hearing loss (SSNHL). In total, 439 patients with SSNHL were enrolled and categorized as either inpatients (group I) or outpatients (group O). Pure-tone audiometry was initially performed before the treatment and 3 months post-treatment. "Recovery" was defined as a hearing gain of 15 dB HL and a final hearing of better than 25 dB. "No recovery" was defined as an improvement of hearing gain of <15 dB 3 months after treatment. To exclude the effect of the level of pretreatment hearing loss, we divided the patients into three subgroups based on their hearing level: <40 dB, 40−70 dB, and >70 dB. To assess the effect of the treatment modality, the patients were divided into three treatment subgroups: systemic steroids (SS), intratympanic steroids (ITS), and a combination of both (SS and ITS). Results: The pretreatment hearing level was significantly higher in group I (61.5 ± 25.4 dB) than in group O (50.3 ± 23.0 dB; p < 0.05). The hearing gain was significantly higher in group I (33.3 ± 24.4 dB) than in group O (24.0 ± 21.8 dB; p < 0.05). The "Recovery" ratio was significantly higher in group I (70.2%) than in group O (63.1%) (p < 0.05). A repeated measures ANOVA was performed to assess the statistical differences between hospitalization, treatment modalities, and pretreatment subgroups. The inpatient group showed a significant hearing improvement in all SSNHL patients (p < 0.05). There was a significant hearing improvement in the inpatient group with pretreatment hearing <40 and 40−70 dB (p < 0.05). There was no significant difference between the inpatient and outpatient groups in pretreatment hearing >70 dB (p > 0.05). Conclusions: This retrospective study showed that inpatient treatment for sudden hearing loss is more beneficial for hearing improvement than outpatient treatment. The positive effect of inpatient treatment appears to be significant in patients with a pretreatment hearing level of 70 dB or less.

Delayed Recovery in Idiopathic Sudden Sensorineural Hearing Loss.

Sudden hearing loss is an easily encountered disease in clinics, but its prognosis has not been completely elucidated. In the present study, we investigated the long-term prognosis of sudden hearing loss with 130 patients who were diagnosed based on strict criteria and provided uniform treatment. The patients with incomplete recovery were reevaluated after 2 months without receiving additional treatment. Hearing levels at different time points were compared. Moreover, the associated factors affecting the degree of hearing improvement over time were evaluated using stepwise multiple linear regression. After treatment, 73 out of the 130 (56.1%) patients attained incomplete recovery and were reevaluated after 2 months. Seventeen out of the seventy-three (23.3%) patients showed a grade promotion, fifty-four (74%) were constant, and two (2.7%) were aggravated. The mean interaural hearing differences (IHDs) showed significant improvement. Old age, poor initial IHD, and poor recovery grade were significantly associated with a profitable delayed hearing gain. Poorer hearing level at the time of onset might be a sign for slower recovery rather than a poorer prognostic factor. The treatment outcome of idiopathic sudden sensorineural hearing loss (ISSNHL) should be evaluated at least 2 months after treatment completion, and counseling is required due to the need for long-term follow-up in patients with ISSNHL.

Traumatic Stapes Luxation into the Vestibule.

We report a rare case of traumatic stapes luxation into the vestibule. A 31-year-old female visited an emergency room with sudden onset of vertigo and conductive hearing loss after accidental penetrating injury to the right ear. Temporal bone computed tomography detected pneumolabyrinth, with a shade of whole intact stapes in the vestibule. Under exploratory tympanotomy, we observed a separated incudostapedial joint, and the stapes was depressed into the vestibule. The stapes was pulled out to the middle ear, and stapedectomy was performed; the crus were cut, the suprastructure was removed, and the fractured footplate and the long process of the incus were connected with a piston wire. The stapes footplate was sealed with soft tissue and surgical glue. Vertigo rapidly subsided after surgery, and hearing was improved to normal range. However, hearing loss at high frequencies was not recovered, probably because of inner ear damage due to the stapes depressed into the vestibule or surgical manipulation within the vestibule. Traumatic ossicular dislocation is not an uncommon occurrence in otolaryngologic practice, but stapes luxation is rare. Here, we report a rare case with successful repair. This report could serve as a basis for proper treatment in similar cases in the future.

Saccular Pathology Is Most Commonly Found in Patients With General Vestibular Disorders.

OBJECTIVES: The first purpose of this study was to investigate the difference in the frequency of involvement of the superior vestibular nerve (SVN) and inferior vestibular nerve (IVN) territories in general vestibular disorders, and to identify which IVN territory was more commonly involved in patients with IVN lesions. The second purpose was to investigate the correlation of the degree of each saccular and posterior semicircular canal (PSCC) dysfunction, as represented by the parameters of cervical vestibular evoked myogenic potential (cVEMP) and video head impulse test (vHIT), in patients with pathology of the IVN territory. METHODS: In total, 346 patients with dizziness who underwent the caloric test, cVEMP, and vHIT were enrolled. Canal weakness in the caloric test, interaural amplitude difference (IAD) of cVEMP, and vestibulo-ocular reflex gain of the vestibulo-ocular reflex gain of the posterior semicircular canal (p-VOR) in vHIT were analyzed. RESULTS: Among the enrolled patients, 15.6% had total vestibular nerve dysfunction, 14.5% had solely SVN dysfunction, and 29.5% had solely IVN dysfunction. Isolated saccular pathology was most common in patients with IVN pathology, followed by those with total IVN dysfunction and PSCC dysfunction. IAD and p-VOR were statistically well correlated, and the correlation was strongest in patients with both pathologic IAD and pathologic p-VOR (n=23, r=0.944), followed by patients with normal IAD and pathologic p-VOR (n=27, r=0.762) and patients with pathologic IAD and normal p-VOR (n=106, r=0.339). CONCLUSION: Abnormal results were more common in vestibular tests investigating the IVN than in vestibular tests investigating the SVN in patients with general vestibular disorders. Isolated saccular pathology was more frequent than PSCC or combined pathology in patients with IVN dysfunction. Patients with abnormal p-VOR in vHIT had a higher probability of having both saccular and PSCC pathologies than patients with an abnormal IAD. This study describes the characteristics of vestibular-system subregions and provides guidance for clinically interpreting the combination of cVEMP and vHIT results.

A Case of Isolated Congenital Stapedial Suprastructure Fixation.

We report a case of conductive hearing loss caused by isolated congenital stapedial suprastructure fixation with normal footplate mobility. A 60-year-old woman visited the clinic for right-sided mixed hearing loss. Exploratory tympanotomy revealed a bony synostosis between the stapedial suprastructure and promontory, while all the ossicles were present and normally shaped. As the bony synostosis was separated, the stapes became mobile. This is the first report in the medical literature of this congenital ear anomaly. This case also illustrates that stapedial fixation can occur in the suprastructure as well as in the footplate; thus, one must be mindful of this when performing exploratory tympanotomy for stapes fixation.

Effect of Dexamethasone Combination with Gentamicin in Chemical Labyrinthectomy on Hearing Preservation and Vertigo Control in Patients with Unilateral Meniere's Disease: A Randomized Controlled Clinical Trial.

Chemical labyrinthectomy using gentamicin is a popular method for treating intractable vertigo attacks in Meniere's disease. However, the risk of hearing loss remains a major concern for clinicians. We investigated the effect of simultaneous dexamethasone and gentamicin application on hearing preservation and vertigo control in patients with intractable unilateral Meniere's disease. A single-institutional, prospective, single-blinded, randomized clinical trial was conducted. Gentamicin-soaked Gelfoam® was directly applied on the oval window following middle ear exploration. On the round window, dexamethasone-soaked Gelfoam® was applied in the gentamicin with dexamethasone group (GD group, n = 18), and saline-soaked Gelfoam® was applied in the gentamicin with sham reagent group (GO group, n = 19). The hearing change 8 weeks after the procedure and vertigo control 2-12 months after the procedure were investigated. The high-frequency hearing threshold was significantly increased in the GO group (p = 0.005 and 0.012 for 4 and 8 kHz, respectively), but not in the GD group. The short-term (2-6 months) vertigo control was more successful in the GD group (57.89% vs. 94.44%, p = 0.019), but long-term control (6-12 months) was insignificant. In conclusion, the combined application of gentamicin and dexamethasone in chemical labyrinthectomy is an effective method for protecting high-frequency hearing and vertigo control.

Cerebral Venous Thrombosis and Persistent Pulsatile Tinnitus After Sigmoid Sinus Resurfacing Surgery.

We report a case with rare complication of cerebral venous thrombosis, as well as an incomplete response, after sigmoid sinus resurfacing surgery for pulsatile tinnitus (PT). A 24-year-old female patient with PT originating from the sigmoid sinus underwent sigmoid sinus resurfacing surgery. The tinnitus was immediately resolved, but it recurred with headache 5 days after surgery. A cerebral venous thrombosis was identified and treated, but PT persisted, although its frequency and loudness decreased. Sigmoid sinus resurfacing surgery is a safe and effective method to treat PT, but in some patients, it can cause serious complications and/or persistent tinnitus. In our patient, factors such as changes in blood viscosity due to warfarin intake or increased blood flow due to weight loss may have influenced the persistence of the tinnitus. It is important to identify the various associated factors and the weight of each of these factors to provide more tailored treatment of PT for individual patients in the future and to reduce complications and increase the effectiveness of sigmoid sinus resurfacing surgery.

Occult parotid involvement in early-stage squamous cell carcinoma of the external auditory canal.

BACKGROUND: The importance of elective parotidectomy in early-stage squamous cell carcinoma (SCC) of the external auditory canal (EAC) is not well established. METHODS: A retrospective study of 43 patients with early-stage SCC of the EAC who underwent parotidectomy in conjunction with lateral temporal bone resection at three centers. RESULTS: Overall occult parotid involvement (OPI) rate in early-stage SCC of the EAC was 13.9% (6/43). When considering both the anteroposterior position and the bony-cartilaginous position, patients with SCC in both the anterior wall and cartilaginous portion exhibited significantly higher OPI than other locations (37.5% vs. 0%, p = 0.001), with an increase in the OPI predictive value. CONCLUSION: SCC located in either the anterior wall of the EAC or the cartilaginous portion of the EAC or both simultaneously showed a high prevalence of OPI, and elective parotidectomy should be considered in those patients.

Auditory experience, for a certain duration, is a prerequisite for tinnitus: lessons from subjects with unilateral tinnitus in the better-hearing ear.

Tinnitus has traditionally been considered an otologic disorder; however, recent advances in auditory neuroscience have shifted investigations toward the brain. The Bayesian brain model explains tinnitus as an auditory phantom percept. According to the model, the brain works to reduce environmental uncertainty, and thus the absence of auditory information due to hearing loss may cause auditory phantom percepts, i.e., tinnitus. As in animal studies, our recent human observational study revealed the absence of ipsilesional tinnitus in subjects with congenital single-sided deafness, suggesting that auditory experience is a prerequisite for the generation of tinnitus. Prompted by anecdotal cases, we hypothesized that subjects with acquired hearing loss would not develop tinnitus if their duration of auditory experience was not sufficiently long. We retrospectively enrolled 22 subjects with acquired asymmetric hearing loss and unilateral tinnitus in better ear (TBE). Twenty-two hearing threshold-matched controls with tinnitus in worse ear (TWE) were selected from our database of tinnitus patients. All 22 TBE subjects reported that their acquired hearing loss developed before the age of 20, and the reported duration of auditory deprivation in the ear without tinnitus in the TBE group was significantly longer than that of the TWE group. In other words, the TBE group with limited auditory experience in the worse ear did not develop tinnitus in the worse ear while subjects with enough auditory experiences in the worse ear developed ipsilesional tinnitus in the TWE group. These preliminary results support our hypothesis that both auditory experience itself, and an individually variable critical duration of auditory deprivation, are prerequisites for the generation of tinnitus.

The Effects of Preoperative Audiovisual Speech Perception on the Audiologic Outcomes of Cochlear Implantation in Patients with Postlingual Deafness.

INTRODUCTION: Patients with postlingual deafness usually depend on visual information for communication, and their lipreading ability could influence cochlear implantation (CI) outcomes. However, it is unclear whether preoperative visual dependency in postlingual deafness positively or negatively affects auditory rehabilitation after CI. Herein, we investigated the influence of preoperative audiovisual per-ception on CI outcomes. METHOD: In this retrospective case-comparison study, 118 patients with postlingual deafness who underwent unilateral CI were enrolled. Evaluation of speech perception was performed under both audiovisual (AV) and audio-only (AO) conditions before and after CI. Before CI, the speech perception test was performed under hearing aid (HA)-assisted conditions. After CI, the speech perception test was performed under the CI-only condition. Only patients with a 10% or less preoperative AO speech perception score were included. RESULTS: Multivariable regression analysis showed that age, gender, residual hearing, operation side, education level, and HA usage were not correlated with either postoperative AV (pAV) or AO (pAO) speech perception. However, duration of deafness showed a significant negative correlation with both pAO (p = 0.003) and pAV (p = 0.015) speech perceptions. Notably, the preoperative AV speech perception score was not correlated with pAO speech perception (R2 = 0.00134, p = 0.693) but was positively associated with pAV speech perception (R2 = 0.0731, p = 0.003). CONCLUSION: Preoperative dependency on audiovisual information may positively influence pAV speech perception in patients with postlingual deafness.