The Basic Symptom Inventory-53 and its use in the management of patients with psychogenic dizziness.

OBJECTIVE: To identify an accurate psychological screening questionnaire to assist in the management of patients with psychogenic dizziness. STUDY DESIGN: Patients referred to the Balance Center of the University of Pennsylvania with a presumptive diagnosis of psychogenic dizziness based on neurotologic assessment were administered a Basic Symptom Inventory-53 (BSI-53) psychological screening questionnaire and were referred for psychiatric assessment. Neither the patients nor the psychiatrist were aware of the results of the BSI-53. The results of the neurotologic assessment, the BSI-53, and the psychiatric assessment were then compared for their degree of association. RESULTS: Strong associations were demonstrated between the results of the BSI-53 questionnaire and the results of the neurotologic and psychiatric assessments. CONCLUSIONS: The BSI-53 is an easily administered, objective, and accurate tool useful in identifying the presence of psychopathology in patients thought to have psychogenic dizziness. It is recommended as a valuable addition to the battery of tests performed when evaluating the dizzy patient.

Management of far advanced otosclerosis in the era of cochlear implantation.

OBJECTIVE: To evaluate issues pertaining to cochlear implantation in patients with far advanced cochlear otosclerosis. STUDY DESIGN: Prospective cohort. SETTING: Tertiary care referral center. PATIENTS: Eight adult patients (18 years of age or older) referred for management of profound hearing loss, the cause of which was determined to be otosclerosis. INTERVENTION: Cochlear implantation with multichannel cochlear implant device. MAIN OUTCOME MEASURES: Benefit from cochlear implant as measured by CID sentence scores, incidence and management of facial nerve stimulation, and technical issues pertaining to cochlear implantation in this patient population. RESULTS: All patients demonstrated significant improvement in auditory function as measured by performance on CID sentence scores and ability to engage in telephone conversation. Facial nerve stimulation was present in two of eight patients and was managed with deactivation of the stimulating electrodes. Ossification in the basal turn of the cochlea, detected on preoperative computed tomography, necessitated placement of the electrode into the scala vestibuli in two patients and use of a thinner electrode (Nucleus 24) in a third patient. CONCLUSION: Patients with profound hearing loss secondary to otosclerosis derive excellent benefits from cochlear implantation. Surgical implantation may be complicated by ossification of the cochlea, which can be detected on preoperative computed tomography. Electrode activation may be complicated by facial nerve stimulation, which can be addressed with programming strategies.

Therapeutic efficacy of the Epley canalith repositioning maneuver.

OBJECTIVES/HYPOTHESES: The hypotheses of the current study are as follows: 1) That if the Epley canalith repositioning maneuver is an effective treatment for benign positional vertigo (BPV), relief from the vertigo should occur virtually immediately after the performance of the maneuver; 2) that the Epley canalith repositioning maneuver does provide almost immediate relief in BPV and should be the established treatment of choice for this disorder in both primary and tertiary care settings; and 3) that residual symptoms of lightheadedness and imbalance do persist after the resolution of the vertigo. The distinction of these symptoms from the vertigo is required for the accurate evaluation of the efficacy of positional maneuvers. STUDY DESIGN: Prospective cohort study in a tertiary care balance center. METHODS: Eighty-six patients (95 cases) with a history and physical examination consistent with active BPV were entered in the study. Patients were treated with a modified Epley canalith repositioning maneuver. A modified 360 degrees roll was used to treat those patients with horizontal canal BPV. Patients were provided with a preprinted diary in which they were to circle the answer most relevant to their symptoms for 14 days after the maneuver. Patients were then re-evaluated in the office at 2 weeks after the maneuver. RESULTS: The mean duration of the BPV before treatment was 9 weeks. Seventy-four percent of cases that were treated with one or two canalith repositioning maneuvers had a resolution of vertigo as a direct result of the maneuver. A resolution attributable to the first intervention was obtained in 70% of cases within 48 hours of the maneuver. An additional 14% of cases that were treated had a resolution of vertigo; however, it is not possible to say that these patients definitely benefited from the canalith repositioning maneuver. Only 4% of cases (three patients) manifested BPV that persisted after four treatments. Residual symptoms of lightheadedness or imbalance, or both, were frequent (47% of cases) but rarely required formal intervention with vestibular rehabilitation physical therapy. CONCLUSIONS: The Epley canalith repositioning maneuver results in a resolution of vertigo in the majority of patients (70% of cases) immediately after one treatment. It is safe and requires no special equipment or investigations. It should be established as the treatment of choice for BPV in both primary and tertiary care settings.

Tinnitus suppression in patients with cochlear implants.

OBJECTIVE: To determine the degree of tinnitus suppression provided by currently available multichannel cochlear implants and to determine factors that can influence this process. STUDY DESIGN: Prospective cohort. SETTING: Tertiary-care referral center. PATIENTS: Thirty-eight adult patients (18 years of age or older) with severe-to-profound hearing loss and tinnitus who met criteria for cochlear implantation. INTERVENTION: Cochlear implantation with a multichannel cochlear implant device. MAIN OUTCOME MEASURES: Patients rated the intensity of their tinnitus using a semiquantitative scale before and after cochlear implantation. These data were analyzed to determine the significance of the reduction of tinnitus after implantation. Tinnitus levels after implantation were also analyzed to determine whether the level of speech recognition, patient gender, or the implant type influenced the degree of tinnitus reduction. RESULTS: Statistical analysis revealed a significant reduction in tinnitus intensity in patients using cochlear implants, with 35 of 38 patients (92%) experiencing a reduction in tinnitus intensity. All multichannel implants studied afforded similar degrees of tinnitus suppression. The degree of tinnitus reduction was not correlated with speech recognition, as measured by CID Everyday Sentence scores. Female patients had significantly greater degrees of tinnitus before implantation, but both male and female patients demonstrated similar levels of tinnitus after implantation. No patient experienced greater levels of tinnitus after implantation. CONCLUSION: All currently available multichannel cochlear implant devices provide effective and similar levels of tinnitus suppression when activated. Exacerbation of tinnitus as a result of cochlear implantation does not represent a significant risk. The mechanisms by which cochlear implants exert tinnitus suppression are, as yet, unclear.

Magnetic resonance imaging of the paranasal sinuses: incidental abnormalities and their relationship to patient symptoms.

OBJECTIVES: Magnetic resonance imaging (MRI) is able to demonstrate a wide range of abnormalities in the paranasal sinuses, which are often reported as incidental findings on scans performed for indications other than the evaluation of paranasal sinus pathology. However, the clinical significance of these findings remains undefined. We present a prospective study that determines the prevalence of abnormalities in the paranasal sinuses in a population undergoing MRI scans for suspected intracranial disease. These findings are correlated with clinical data pertaining to nasal and sinus symptoms. STUDY DESIGN: Prospective, cross-sectional study. METHODS: Patients undergoing MRI scans for suspected intracranial pathology were asked to complete a questionnaire pertaining to symptoms of nasal/sinus pathology. The T2-weighted scans of 86 patients (mean age = 51 years) were then reviewed for evidence of paranasal sinus pathology using a standardized method for evaluation and reporting of results. These results were then correlated with those obtained from the patient questionnaire. RESULTS: Radiologic abnormalities were found in the paranasal sinuses of 33 (38%) patients. Abnormalities were most commonly seen in the ethmoid sinuses (44.8%) followed by the maxillary (38%), sphenoid (14%), and frontal (3%) sinuses. Analysis of the clinical data revealed no significant relationship between the presence of clinical symptoms of nasal and sinus pathology and abnormalities on MRI scan. CONCLUSION: The assessment of inflammatory sinus pathology remains controversial. Based on the results of this study, incidental abnormalities of the paranasal sinuses detected on MRI scan do not appear to be related to clinical symptoms.

Balance function testing: a rational approach.

Recent advances in the area of balance function testing have left clinicians with a wide variety of diagnostic tests that provide insights into the function of the balance system. Laboratory tests used to evaluate the balance system include electronystagmography, rotational chair, and dynamic posturography. This article summarizes the currently available balance function testing protocols. A cost-effective and rational protocol for the application of these tests is provided.

Vertigo and dysequilibrium with associated hearing loss.

There are numerous disorders that can present with hearing loss and vertigo or dysequilibrium. The combination of vertigo and imbalance associated with hearing loss are symptoms suggestive of a peripheral vestibular disorder. This article summarizes presentation, diagnosis, and treatment of the various common and rare peripheral vestibular disorders that can present with these symptoms.

Strial dysfunction in the MRL-Fas mouse.

The MRL-Fas(lpr) mouse, a model of multisystemic autoimmune disease, has been proposed as a potential model of autoimmune inner ear disease. Cochlear pathology, consisting of hydropic degeneration of the stria vascularis, has been documented to occur coincident with the establishment of systemic disease in this animal. Because the cochlear pathology is restricted to the stria, this study was designed to evaluate whether the endocochlear potential (EP) would be diminished in these animals because of a loss in strial Na, K-ATPase. Experimental (MRL-Fas(lpr)) mice, with established systemic disease, had auditory brain stem response thresholds and EPs recorded. MRL-+/+ mice served as controls. Animals were then euthanized, and their cochleas were processed for immunohistologic assay for the alpha1 and beta2 subunits of Na,K-ATPase. Density of staining was evaluated by use of quantitative means with densitometry image analysis of digitized images. MRL-Fas(lpr) mice revealed significant elevations in auditory brain stem response thresholds and reductions in EPs but no reductions in Na,K-ATPase levels, as evidenced by immunohistochemical assay. The reduction of EP likely occurs as a result of cellular degeneration within the stria vascularis and likely results from an abrogation of the strial perilymph/endolymph barrier and not from a reduction in strial Na, K-ATPase levels.

Ultrastructural pathology in the stria vascularis of the MRL-Fasl(lpr) mouse.

The MRL-Fas(lpr) mouse, a model of multisystemic, organ nonspecific autoimmune disease, has been proposed as a model of immune-mediated inner ear disease. A preliminary study employing light microscopy indicated that it develops cochlear pathology that appeared most striking in the stria vascularis, where cells underwent edema and degeneration. However, other structures, including the inner and outer hair cells and the supporting cells, also appeared to display pathology. The current study analyzed cochlear ultrastructure using transmission electron microscopy to better delineate the cochlear lesions found in these animals. MRL-Fas(lpr) animals were allowed to develop systemic disease (20 weeks old) and then had auditory brainstem response (ABR) thresholds determined. Animals were then killed and their cochleas prepared for electron microscopy. Age-matched MRL-+/+ and BALB/c mice served as controls. Results indicated that MRL-Fas(lpr) mice demonstrated elevated ABR thresholds. In contrast to a preliminary report, the cochlear pathology was observed exclusively in the stria vascularis, where cells demonstrated hydropic degeneration. Strial capillary structure was normal as were the rest of the cellular cochlear constituents. No inflammatory infiltrate was noted. These studies confirm that the MRL-Fas(lpr) mouse develops cochlear abnormalities focused in the stria vascularis. Whether the mechanism of the cellular degeneration involves autoimmune, genetic, or uremic processes has yet to be determined.

Effects of immunosuppression on the development of cochlear disease in the MRL-Fas(lpr) mouse.

OBJECTIVES: The MRL-Fas(lpr) mouse, an animal that spontaneously develops multisystemic autoimmune disease, has been proposed as model of immune-mediated inner ear disease. Previous studies revealed that this mouse manifested elevated auditory brainstem response thresholds, hydropic degeneration of strial cells, and antibody deposition within strial capillaries. As the etiology of the observed strial disease may be immune, genetic, or uremic, a study was designed to attempt to delineate between these possible etiologic factors. STUDY DESIGN: Prospective, controlled animal study. METHODS: Dexamethasone, which is known to suppress autoantibody production and glomerulonephritis in these animals, was administered systemically on a daily basis to experimental animals, beginning at 6 weeks of age. Control animals received no treatment. Animals were allowed to age, with control animals predictably manifesting systemic disease at 20 weeks of age, at which point all animals were sacrificed. RESULTS: Animals receiving dexamethasone treatment manifested a significant reduction in serum immunoglobulin levels, lymphoid hyperplasia, and a significant improvement in the level of renal function. However, morphologic analysis revealed a persistence of strial disease despite the elimination of strial antibody deposition. CONCLUSION: The results of this experiment support the hypothesis that genetic mechanisms may be responsible for the observed strial disease. Further studies are under way to confirm these findings.

Antibody deposition in the stria vascularis of the MRL-Fas(lpr) mouse.

The MRL-Fas(lpr) mouse, a model of multisystemic, organ non-specific autoimmune disease, has been proposed as a model of immune-mediated inner ear disease. Preliminary studies indicate that it develops cochlear pathology focused in the stria vascularis including intracellular edema and degeneration which develops in the absence of an inflammatory infiltrate but in the presence of antibody deposition. It was thus hypothesized that the antibodies found in the stria were mediating a direct pathologic effect on this structure, without recruiting classical inflammatory mediators. It was further hypothesized that the antibodies deposited within the stria would be derived from the non-complement fixing isotypes and subclasses, which are known to be able to mediate direct pathologic effects on target tissues. This study utilized immunohistologic techniques to identify the antibody isotypes and subclasses deposited within the stria vascularis of the MRL-Fas(lpr) mouse. Results indicate that all antibody isotypes and subclasses can be identified within the stria vascularis in the absence of complement. Thus, antibody deposition was not restricted to non-complement fixing antibodies. While it is possible that antibodies are mediating direct pathologic effects within the stria, the non-specific nature of the antibody deposition may indicate that these antibodies are not responsible for the observed pathology. Rather, other mechanisms, such as metabolic and genetic etiologies, must also be considered.

Evaluating facial paralysis. Expensive diagnostic tests are often unnecessary.

In most cases, the cause of facial paralysis can be determined on the basis of the clinical evaluation, and expensive diagnostic tests can be avoided. Because Bell's palsy is not always the cause, physicians need to be able to identify critical findings on history and physical examination that indicate an alternative diagnosis. Once identified, these findings can lead to a specific and directed evaluation.

Lateral skull-base surgery--a review of recent advances in surgical approaches.

OBJECTIVE: The expanding field of lateral skull-base surgery is reviewed. The rapid evolution of this subspecialty of otolaryngology--head and neck surgery has occurred subsequent to the primary postgraduate training of many practitioners of our specialty. Furthermore, it can be difficult for many resident physicians to acquire concise, up-to-date references pertaining to this area of subspecialization. This article is designed to provide a succinct, up-to-date review of the field of lateral skull-base surgery. MATERIALS AND METHODS: The current literature is reviewed. RESULTS: Lateral skull-base surgery is a rapidly evolving discipline involving neurologists and neurosurgeons in the resection of complex lesions of the skull base that had previously been difficult or impossible to adequately access. Otolaryngologists,via the subspecialty of neurotology, have been leaders in developing and applying the different lateral skull-base approaches. CONCLUSIONS: This article categorizes the various lateral skull-base approaches, outlines the principles of the surgical exposures, and discusses the indications for their use.

An accurate, cost-effective approach for diagnosing retrocochlear lesions utilizing the T2-weighted, fast-spin echo magnetic resonance imaging scan.

Recent data indicate that the auditory brainstem response (ABR) fails to identify a significant number of retrocochlear lesions. Although the magnetic resonance imaging (MRI) scan with paramagnetic enhancement is highly accurate at detecting these lesions, it is time consuming and expensive. We report on our prospective evaluation of a cohort of 155 patients who underwent T2-weighted, fast-spin echo MRI scans designed to screen for retrocochlear lesions. This imaging technique is rapidly performed and provides superb visualization of the relevant anatomic structures at a global cost of $475. Four tumors were identified with this technique. Cost analysis indicates that supplanting ABR with this limited MRI may well represent a cost-effective approach for evaluating patients with suspected retrocochlear lesions.

Ototoxic effects of supradose cisplatin with sodium thiosulfate neutralization in patients with head and neck cancer.

OBJECTIVE: To assess the incidence and magnitude of ototoxicity in patients undergoing an experimental targeted chemoradiation protocol incorporating extremely high-dose intra-arterial cisplatin therapy with systemic sodium thiosulfate neutralization for the treatment of advanced carcinomas of the head and neck. DESIGN: Inception cohort study. SETTING: University-based, tertiary care referral center for advanced head and neck malignant disease. PATIENTS: The first 70 patients with advanced carcinomas of the head and neck consecutively entered in the protocol. INTERVENTION: Patients received up to 4 weekly courses of intra-arterial cisplatin (150 mg/m2 per infusion), together with systemic sodium thiosulfate and external beam radiation (68-70 Gy). Audiometric analysis was performed before the initiation of therapy, and subsequent to the second and fourth cisplatin infusions. MAIN OUTCOME MEASURES: Audiometric thresholds. Ototoxicity was defined as an increase in pure-tone threshold of 15 dB at 1 frequency or 10 dB at 3 frequencies, between 250 and 4000 Hz. RESULTS: The incidence of ototoxicity was 25% at 150 mg/m2, 50% at 300 mg/m2, 64% at 450 mg/m2, and 60% at 600 mg/m2. Hearing at frequencies of 2000 Hz or less was minimally or not affected. Previous hearing loss did not appear to affect the incidence of ototoxicity. A plateau of hearing loss at 60-dB hearing level, as noted by other authors, was not observed. There were no cases of debilitating tinnitus or of vestibular loss. CONCLUSIONS: Ototoxicity did occur but was largely confirmed to the higher frequencies. Hearing losses resulting from this chemoradiation protocol were not sufficiently severe to alter its application.

Efficacy of antimigrainous therapy in the treatment of migraine-associated dizziness.

OBJECTIVE: To assess the effects of antimigrainous therapy on migraine-associated dizziness/vertigo. We hypothesized that a medication's ability to ameliorate dizziness/vertigo in this patient population would be directly correlated with its efficacy in improving headache symptoms. STUDY DESIGN: Patient survey. SETTING: Patients were entered into the study from the University of California, San Diego (UCSD) Headache Clinic, a tertiary care referral clinic. PATIENTS: All patients presenting to the UCSD headache clinic are entered into its comprehensive database. Patients who identified dizziness or vertigo as symptoms were entered into this study and were surveyed. MAIN OUTCOME MEASURES: Patients were surveyed as to the nature of their vestibular symptoms, and the therapeutic response of these symptoms and their headaches to various antimigrainous medications. Patients were asked to rank therapeutic efficacy utilizing a numeric scale. These results were then subjected to statistical analysis (Spearman rank correlation) to identify any correlation between the efficacies of the medications in improving headache and dizziness/vertigo. RESULTS: The efficacy of the medications in treating migraine-associated dizziness was directly correlated with their ability to alleviate headaches. CONCLUSION: We conclude that antimigrainous therapy may offer specific treatment to patients suffering from the spectrum of migraine-associated vestibular disorders. This would include the entity known alternately as vestibular Meniere's disease, benign recurrent vertigo, or recurrent vestibulopathy. Given the potential benefits that may be derived from this therapy, clinicians should be sensitive to a history of migraines in patients complaining of dizziness, particularly in those complaining of recurrent episodic vertigo.

Advantages of a new, atraumatic, self-retaining electrode for direct cochlear nerve monitoring.

Direct cochlear nerve monitoring during posterior fossa surgery offers the surgeon real-time information concerning auditory stams. However, routine utilization of this monitoring technique has been hampered by electrode designs that have not allowed the maintenance of a consistent contact between the nerve and electrode. We report on our experience with a new electrode designed to maintain consistent, atraumatic contact with the cochlear nerve and discuss the advantages of this electrode over existing wick and ball type electrodes.The utilization of this electrode during 18 posterior fossa surgeries, performed at Kaiser Permanenie Hospital, San Diego, including 8 vestibular schwannoma resections, allowed for consistent recording of high amplitude cochlear compound action potentials. Long-term exposure to pulsating cerebrospinal fluid (CSF) did not displace the electrode. Minimal cochlear nerve action potential amplitude change was noted with the electrode imrnersed in CSF. The electrode caused no trauma to the nerve, even in cases where it was accidentally dislodged from the nerve. It is hoped that by overcoming the problems previously associated with direct cochlear nerve monitoring, this electrode will allow for increased use of this advantageous monitoring technique. As a by product of the real-time data provided to the surgeon, we anticipate increased rates of hearing preservation during cerebellopontine angle surgery.