Results of otovestibular tests in mild head injuries.

The neurotological workup of patients with minor head trauma was carried out prospectively. The preliminary results of the ongoing study were derived from 38 subjects (12 female, 26 male) at an average age of 33.5 years. All had been hospitalized after having suffered minimum head trauma followed by a temporary loss of consciousness, by amnesia, or by vomitting. The 38 subjects underwent the examination within 72 hours of the event and were summoned for a follow-up visit 3 months later. The anamnestic data show that the most frequent complaint was dizziness (81%). Tinnitus was noted in fewer than one-half of the patients, with a variety of descriptions. Twenty-six percent complained of hearing loss. The correlation between reported hearing loss and the finding on subsequent behavioral audiometry (within 72 hours after the event) was studied. The sensitivity of hearing loss (as complaint) was found to be only 40%, but its specificity was much higher at 83%. The overall equilibrium reflected in the composite score of the sensory testing in computed dynamic posturography actually worsened between tests. A good correlation was found between posturography results and symptomatology. We concluded that, after minor head trauma, most patients suffer from dizziness, and more than one-half complain of tinnitus or hearing loss. The unsteadiness does not subside within 3 months after concussion. A more protracted follow-up is required to summarize the outcome of head injury from a neurootological point of view. A clear correlation is found between complaints and posturography results. After minor head trauma, pure vestibular injuries are much less frequent than are central lesions. Motor dysfunction is less frequent than are the sensory abnormalities.

Tinnitus as a prognostic sign in idiopathic sudden sensorineural hearing loss.

Idiopathic sudden sensorineural hearing loss remains a controversial problem with respect to etiology and the factors that might predict a favorable prognosis. This study evaluated the possible prognostic factors of recovery in 67 patients with idiopathic sensorineural hearing loss treated with steroids (prednisone), plasma expanders (intravenous dextran), and vasodilators (papaverine). Clinical recovery was estimated by contrasting the audiometric results on admission and those at discharge 10 days later. The correlation between various potential prognostic factors and audiological improvement was calculated. Only two factors were found to be associated significantly with hearing improvement: tinnitus (p < .04) and the slope of audiogram on admission (p < .045). Tinnitus and the presence of an ascending audiogram were found to be correlated with a favorable outcome in idiopathic sensorineural hearing loss.

Cat-scratch disease of the parotid gland: an often-misdiagnosed entity.

A case of cat-scratch disease involving the parotid area in a young adult is presented. Thanks to meticulous history-taking, the correct diagnosis was suggested and later established, thus preventing unnecessary surgery. The pertinent literature is discussed.

Sonovestibular symptoms evaluated by computed dynamic posturography.

The investigation of stability under bilateral acoustic stimulation was undertaken in an attempt to mimic the real-life conditions of noisy environment (e.g., industry, aviation). The Tullio phenomenon evaluated by computed dynamic posturography (CDP) under acoustic stimulation is reflected in postural unsteadiness, rather than in the classic nystagmus. With such a method, the dangerous effects of noise-induced instability can be assessed and prevented. Three groups of subjects were submitted. The first (group A) included 20 patients who complained of sonovestibular symptoms (i.e., Tullio phenomenon) on the background of an inner-ear disease. The second group (B) included 20 neurootological patients without a history of Tullio phenomenon. Group C consisted of 20 patients with normal hearing, as controls. A pure-tone stimulus of 1,000 Hz at 110 dB was delivered binaurally for 20 seconds during condition 5 and condition 6 of the CDP sensory organization test. The sequence of six sensory organization conditions was performed three times with two intermissions of 15-20 minutes between the trials. The first was performed in the regular mode (quiet stance). This was followed 20 minutes by a trial carried out in quiet stance in sensory organizations tests (SOTs) 1 through 4, and with acoustic stimulation in SOT 5 and SOT 6. The last test was performed in quiet stance throughout (identical to the first trial). A significant drop in the composite equilibrium score was witnessed in group A patients upon acoustic stimulation (p < .0001). This imbalance did not disappear completely until 20 minutes later when the third sensory organization trial was performed. In fact, the composite score obtained on the last SOT was still significantly worse than the baseline. Group B and the normal subjects (group C) showed no significant change in composite score. As regards the vestibular ratio score, again, group A marked a drop on stimulation with sound (p < .004). This decrease contrasted once more with the other two groups. The leading sensory organization pattern was vestibular dysfunction (i.e., 40%, 10%, and 0% before acoustic stimulation in groups A, B, and C, respectively). The initial proportion of vestibular dysfunction increased on acoustic stimulation to 55% in group A, but this subsequently decreased in the third trial. The percentages of vestibular dysfunction remained constant during repeated trials in the other two groups. The positive medical history of sonovestibular symptoms was confirmed objectively by CDP with sound stimulation with a high statistical significance. This establishes the described method as a sensitive testing technique for validating the existence of the Tullio phenomenon in patients with a variety of disorders of the inner ear, especially chronic noise-induced hearing loss and acute acoustic trauma. All patients who suffered phonic trauma, chronic exposure to noise (e.g., aviation employees, industry and army personnel), or other neurootological disorders and who complain of sonovestibular symptoms should be tested for the presence of the Tullio phenomenon. This should be carried out preferably by means of CDP with acoustic stimulation for an objective corroboration of their complaint before continuing activity in a noisy environment, thus preventing dangerous loss of balance when exposed to noise.

Computerized dynamic posturography and seasickness susceptibility.

OBJECTIVE/HYPOTHESIS: The neural mismatch theory emphasizes the role of conflicting multimodal sensory interactions in producing both motion sickness and the rearrangement process that finally leads to habituation to the adverse motion conditions. If this theory is, indeed, correct, the patterns of the response to the integrated signal from simultaneous multisensory stimulation, characterized by unusual relationships between the senses responsible for spatial orientation, should differ according to motion sickness susceptibility. Computerized dynamic posturography (CDP) provides the opportunity to simultaneously change the interactions between visual, somatosensory, and vestibular inputs, thus giving an indication of the relative importance of these senses in maintaining balance. The objective was to investigate balance strategies in naval crew members with differing susceptibility to sea conditions using CDP. STUDY DESIGN: Cross-sectional, parallel-group design. METHODS: Twenty subjects susceptible to seasickness (SS) and 20 nonsusceptible subjects (NSS), healthy male volunteers aged 18 to 25, were tested using the EquiTest system (NeuroCom, Inc., Clackamas, OR). RESULTS: The SS group exhibited significantly less stability than the NSS group in condition 5 of the sensory organization test (SOT). The ratio of the SOT scores of conditions 5 to 1 (the vestibular organization pattern) was also found to be significantly lower in the SS group. CONCLUSIONS: The results suggest that SS might be more dependent on somatosensory and visual inputs and less on vestibular inputs for maintenance of balance compared with NSS. Higher susceptibility to seasickness might reflect abnormal weighting of sensory modalities during the integration process. This would result in disruption of the integration process required to maintain balance and a sense of orientation in space in conditions producing conflicting sensory inputs.

Correlations between audiogram and objective hearing tests in sensorineural hearing loss.

Owing to its subjective nature, behavioral pure-tone audiometry often is an unreliable testing method in uncooperative subjects, and assessing the true hearing threshold becomes difficult. In such cases, objective tests are used for hearing-threshold determination (i.e., auditory brainstem evoked potentials [ABEP] and frequency-specific auditory evoked potentials: slow negative response at 10 msec [SN-10]). The purpose of this study was to evaluate the correlation between pure-tone audiogram shape and the predictive accuracy of SN-10 and ABEP in normal controls and in patients suffering from sensorineural hearing loss (SNHL). One-hundred-and-fifty subjects aged 15 to 70, some with normal hearing and the remainder with SNHL, were tested prospectively in a double-blind design. The battery of tests included pure-tone audiometry (air and bone conduction), speech reception threshold, ABEP, and SN-10. Patients with SNHL were divided into four categories according to audiogram shape (i.e., flat, ascending, descending, and all other shapes). The results showed that ABEP predicts behavioral thresholds at 3 kHz and 4 kHz in cases of high-frequency hearing loss. Also demonstrated was that ABEP threshold estimation at 3 kHz was not affected significantly by audiogram contour. A good correlation was observed between SN-10 and psychoacoustic thresholds at 1 kHz, the only exception being the group of subjects with ascending audiogram, in which SN-10 overestimated the hearing threshold.

Accuracy of exercise-induced left axis QRS deviation as a specific marker of left anterior descending coronary artery disease.

In this prospective study, we examined the diagnostic accuracy of exercise-induced left QRS axis deviation as a marker of LAD coronary artery stenosis. The mean frontal QRS axis of 66 consecutive patients with chest pain and exercise-induced ST segment depression referred for diagnostic coronary angiography was analyzed and related to the angiographic findings. An exercise-induced leftward QRS axis deviation was found in 9/40 patients with and 0/26 patients without obstructive (> or = 70%) LAD disease (sensitivity 23%, specificity 100%, p = 0.025). In 7 of the 9 patients with left axis deviation, the lesion was proximal to and in 2 in the region of the first septal perforator. Inclusion of patients with 0 degrees exercise-induced QRS axis deviation provided a more sensitive but less specific marker of LAD disease [sensitivity 53% (21/40), specificity 81% (21/26), p = 0.015]. The findings were similar in patients with single and with multivessel coronary artery disease. Grouping all patients in the present prospective and two previous retrospective studies (n = 165), the sensitivity was 29% and specificity 100% (p < 0.0001). Exercise-induced left QRS axis deviation was a highly specific marker of LAD coronary artery stenosis.

[Local treatment of purulent chronic otitis media with ciprofloxacin].

We evaluated the efficacy of ciprofloxacin eardrops compared to tobramycin and to a placebo in the treatment of chronic suppurative otitis media. 60 ears were randomly assigned to treatment for 3 weeks with ciprofloxacin, tobramycin or placebo eardrops. The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. The clinical responses were 78.9% and 72.2%, respectively, in the ciprofloxacin and tobramycin groups, while it was only 41.2% in the placebo group. Treatment with ciprofloxacin eardrops seemed to be at least as efficient as treatment with tobramycin. Considering the lack of ototoxicity of ciprofloxacin, this treatment may be best for chronic otitis media.

Ventriculoatrial conduction capability and prevalence of 1:1 retrograde conduction during inducible sustained monomorphic ventricular tachycardia in 305 implantable cardioverter defibrillator recipients.

Despite the advent of dual chamber ICDs, differentiation of VT (SMVT) with 1:1 VA conduction will remain a challenge. In this study, VA conduction capability and prevalence of inducible sustained monomorphic (SM) VT with 1:1 VA conduction was assessed in 305 ICD recipients. SMVT with a mean cycle length (CL) of 304 +/- 61 ms was induced in 161 (53%) patients. Twenty-six percent of the patients maintained 1:1 VA conduction to CL < or = 400 ms during incremental ventricular pacing, regardless of presenting tachyarrhythmia or presence of inducible SMVT. Among ten patients who had inducible SMVT with possible 1:1 VA conduction (based on SMVT CL comparable to the shortest CL associated with 1:1 retrograde conduction during ventricular pacing), all seven with available intracardiac tracings had documented 1:1 VA conduction during the induced SMVT--representing 4.4% of the patients with inducible SMVT (95% CI 1.2%-7.6%), and 2.3% of the entire ICD cohort (95% CI 0.6%-4.0%). We conclude that about one-fifth of ICD recipients possess 1:1 VA conduction to CL < or = 400 ms and that inducible SMVT with 1:1 VA conduction can be demonstrated in a small but nonnegligible proportion of ICD recipients. These data are relevant to the design of tachyarrhythmia-discrimination algorithms for dual chamber ICDs.

In vivo measurement of human nasal mucociliary motility using a laser light scattering instrument.

The mucociliary system is one of the most important airway defense mechanisms, and knowledge of the mucociliary wave frequency (MWF) is important in the understanding of this system. Employing a laser light scattering technique and a thin, flexible fiberoptic probe, we developed and tested a simple and practical device for real-time in vivo measurements of mucociliary activity in the human nose. The laser instrument is user-friendly and does not produce any discomfort to the patient. The mean +/- SE of MWF of 36 measurements in 16 normal subjects was 7.7 +/- 0.5 Hz. The mean MWF of 17 measurements in 7 patients with allergic rhinitis was 5.5 +/- 0.2 Hz (p < .005), and the mean MWF of 56 measurements in 17 patients with septum deviation was 5.8 +/- 0.2 Hz (p < .001). The instrument presented in this study might provide a new and convenient method of studying the mucociliary activity in the respiratory tract.

Chronic otitis media treated topically with ciprofloxacin or tobramycin.

OBJECTIVE: To evaluate the efficacy of ciprofloxacin compared with tobramycin and placebo ear drops in the treatment of chronic suppurative otitis media without cholesteatoma. DESIGN: Sixty ears (in 51 patients) were randomly divided into 3 treatment groups: ciprofloxacin hydrochloride, tobramycin, and placebo interventions. SETTING: The otolaryngology department of a university teaching hospital. INTERVENTION: All ears were treated topically for 3 weeks. MAIN OUTCOME MEASURES: Each patient received a small, numbered bottle and was instructed to instill 5 drops 3 times daily for 3 weeks. The final clinical and bacteriologic assessment was made after 3 weeks. RESULTS: The organism most commonly isolated from the ear discharge was Pseudomonas aeruginosa. Its sensitivity to ciprofloxacin and tobramycin was 94.2% and 70.6%, respectively. The clinical response was 78.9%, 72.2%, and 41.2% in the ciprofloxacin, tobramycin, and placebo groups, respectively. The bacteriologic response rate was 66.7% for the ciprofloxacin and tobramycin groups and 20% for the placebo group. Treatment with ciprofloxacin ear drops seemed to be as effective as treatment with tobramycin. CONCLUSION: While the lack of ototoxicity of ciprofloxacin was not tested in our study, this treatment may be considered as a potential topical therapy for cases of chronic suppurative otitis media.

Endothelial injury of capillaries in the stria vascularis of guinea pigs treated with cisplatin and gentamicin.

The drugs cisplatin and gentamicin are used for treatment of various cancer patients suffering from infection. The authors report a detailed electron microscopic study of blood vessels in stria vascularis of guinea pigs after treatment with cisplatin alone and in combination with gentamicin. The most distinctive features expressing endothelial cellular injury were mitochondrial, including occasional paracrystalline inclusions; electron-lucent foci with depleted organelles; intracytoplasmic vacuole formations; lipid bodies; cytoplasmic extrusions located on the luminal surface; and severe luminal constriction of part of the vessels from animals treated with the combined drugs. The study suggests that the damage to strial capillaries due to treatment with cisplatin alone and in combination with gentamicin may contribute to the injurious effects of these drugs on the strial tissue. Furthermore, the results of this study may enlarge the awareness of the potential vascular damage and vascular complications in additional body systems after medical use of cisplatin alone or in combination with gentamicin.

Preauricular tags and pits in the newborn: the role of hearing tests.

The aim of this study was to determine the role of audiometry in a group of newborn infants with preauricular tags or pits. During the 2 years of prospective study, 26 infants were born with preauricular tags or pits (5.7 per 1,000 livebirths) and were assessed for hearing impairment by performing behavioural audiometry on day 3 of life and brainstem-evoked response audiometry at 4 months of age. Five infants had associated congenital anomalies (19%). The behavioural audiometry was abnormal in seven infants (27%). The evoked response audiometry was abnormal in 4/23 (17%) newborn infants with isolated tags or pits, and revealed both conductive and/or sensorineural hearing impairment. The incidence of hearing impairment with isolated preauricular tag/pit was significantly higher (p < 0.001) than the incidence reported in preschool children. We conclude that hearing assessment is recommended in the routine evaluation of the newborn with isolated preauricular tags or pits. This policy may facilitate early diagnosis and treatment of hearing impairment in this population.

Pediatric and Geriatric Tinnitus.

The subject of tinnitus in the population extremes-children and the elderly-is ignored by the literature, probably because children do not complain of tinnitus spontaneously, whereas it is only one challenge among other major health problems in the elderly. A short review of the literature on this subject is presented. Presbytinnitus, defined as tinnitus that accompanies the progressive hearing loss of presbycusis is classified as: type 1 (normal aging affecting the cochlea), and type II (preexistent sensorineural hearing loss accompanied by multiple systemic complaints, especially of sensory ones). The incidence of tinnitus in presbycusis is 11%. Like in other age groups, there is no significant gender predilection in the prevalence of tinnitus, but a correlation was demonstrated between the severity of tinnitus and exposure to noise. Hypertension was associated with a lower incidence of tinnitus, as compared to normotension and hypotension. Several treatment modalities of geriatric tinnitus are reviewed: the superiority of the band-noise masker in patients with presbycusis, as compared to electrical promontory stimulation; amino-oxyacetic in presbycusis and Meniere's disease; zinc supplementation in marginally zinc-deficient elderly patients in improving sensorineural hearing loss and tinnitus; aeration of the middle ear in presbycusis caused by secretory otitis media. Pediatric tinnitus has an incidence of 13% in children who passed an audiometric screening test, and 23-60% in those with hearing loss, 44% in secretory otitis media, but only 3% complain spontaneously because that the child considers tinnitus to be a normal event. There is no significant difference between children with tinnitus and those without in terms of hearing level, age, gender, or etiology of the deafness. Despite the fact that often children do not mention it, tinnitus may incite behavioral problems.

Autoimmune aberration in sudden sensorineural hearing loss: association with anti-cardiolipin antibodies.

In view of the presence of autoantibodies against inner ear antigens, the pathogenesis of sudden deafness (SD) and progressive sensorineural hearing loss (PSNHL) is suggested to be of an autoimmune nature. However, microthrombosis of the inner ear may result from pathogenic anti-cardiolipin antibody (aCL) activity. We studied 30 patients (17 females and 13 males, age range 20-52 y), of whom 11 suffered from SD and 19 from PSNHL. All were clinically and serologically evaluated for association with autoimmune disorders (serological examination included: aCL, ANA, ENA, ANCA, proteinelectrophoresis, and complement levels). Twenty healthy matched subjects served as controls. None of the control group were aCL positive, whereas 8 out of 30 (27%) patients demonstrated low-moderate titers (P < 0.02), of whom 5 out of 8 suffered from SD. In addition, 2 aCL negative patients with PSNHL demonstrated hypergammaglubolinemia accompanied by hypocomplementemia, whereas none with SD had such abnormalities. Our data suggests that aCL is detected in patients with sudden sensorineural hearing loss and therefore may play an important role in the pathogenesis of this disability. If sustained by additional studies, these findings would warrant the consideration of anticoagulant therapy.

Amiodarone instilled into the canine pericardial sac migrates transmurally to produce electrophysiologic effects and suppress atrial fibrillation.

INTRODUCTION: We investigated whether amiodarone delivered into the pericardial sac exerted an effect on atrial and ventricular refractoriness, impulse generation, and conduction and on induced atrial fibrillation. METHODS AND RESULTS: All animals were anesthetized with alpha-chloralose. After a sternotomy, the pericardium was opened and cradled to produce a "container" of approximately 75 mL. Part I experimental animals received amiodarone, 0.5, 1.0, or 5.0 mg/mL, dissolved in 3 mL polysorbate 80 and 5% dextrose in water (D5W) instilled into their pericardial sac for 3-hour intervals. Part II experimental animals received either 1.0 or 5.0 mg/mL of amiodarone. Control dogs received a pericardial solution of 3 mL polysorbate 80 in D5W. Pre- and postinstillation electrophysiologic studies were performed. In part I, the increase in sinus cycle length, 1:1 AV conduction, and effective refractory period (ERP) of atrium, right ventricular (RV) and left ventricular epicardium, and RV endocardium were significantly greater in animals receiving amiodarone compared with controls. Amiodarone concentrations in the tissue samples were highest in the superficial sites of the atria, sinoatrial node, and ventricular epicardial samples and lowest in the interventricular septum. Only trace concentrations of amiodarone and no desethylamiodarone were found in the blood samples. In part II, atrial ERP significantly increased in the animals receiving amiodarone, and the number of episodes of sustained atrial fibrillation that could be induced decreased. CONCLUSIONS: Amiodarone instilled into the pericardial sac migrates transmurally to produce significant electrophysiologic effects at superficial sites and appears to suppress electrically induced atrial fibrillation.

Cardiomyoplasty--the beginning of a new era.

Cardiomyoplasty is a surgical treatment for a well-defined group of patients who suffer from congestive heart failure. The procedure is not a contraindication to perform a future heart transplantation, when indicated. The clinical results up to 7 years after cardiomyoplasty are encouraging, but there is still a gap between the significant functional capacity improvement of the patients after cardiomyoplasty and the moderate hemodynamic change. Experimental data and recent measurements in patients provide new insights in understanding the physiologic effect of cardiomyoplasty.

Tympanoplasty in adults: a five-year survey.

In order to identify factors that could influence the success of tympanoplasties in adults, a retrospective study of 291 tympanoplasties performed on patients aged 15 years and older during the years 1984-1989 was carried out. Surgical success was defined as an intact membrane after two years follow-up and hearing improvement of at least 15 decibels. The success rate of the tympanoplasties was 90%. A functioning eustachian tube was found to be important for graft take. No difference was found in the rate of graft take regardless of whether fascia of the temporal muscle or tragal perichondrium was used or if fibrin glue was used. An audiological improvement was seen in 77% of the patients, and no significant difference regarding hearing gain was found between the different prostheses. It is concluded that tympanoplasty in adults is a simple operation with a high probability of success which can improve the quality of life of those operated upon.