A case of intractable suspected perilymph fistula with severe depression.

A 68-year-old woman presented dizziness whenever she put her finger into the right ear and also complained of water-streaming tinnitus, which indicated she would have been suffering from perilymph fistula. An exploratory tympanotomy was conducted. Leakage of perilymph from the round window was suspected, although the cochlin-tomoprotein (CTP) results were negative. After the procedure, the patient's finger-induced dizziness, tinnitus, and vertigo spells disappeared completely. However, her dizzy symptom did not improve. The patient also complained of general fatigue, weight loss, and insomnia, which led us to suspect comorbid depression. Antidepressants and vestibular rehabilitation treatment resulted in a significant improvement in her dizziness. Although it is not apparent whether the patient had a perilymph fistula, this case demonstrates the importance of evaluating not only physical symptoms but also psychological comorbidity, especially when the physical symptoms are intractable despite treatment.

Successful treatment of relapsed Ménière's disease using selective serotonin reuptake inhibitors: A report of three cases.

Patients with Ménière's disease who have relapsed following endolymphatic sac surgery (EDS) or intratympanic gentamicin injection are occasionally treated with intratympanic gentamicin injections or revision surgery. However, there is a potential link between Ménière's disease and anxiety or depression. The use of serotonin selective reuptake inhibitors (SSRIs) is likely be beneficial in the treatment of patients with Ménière's disease. The aim of this report is to describe the benefits of SSRIs in patients with relapsed Meniere's disease. Over the course of two years, three patients were treated for symptoms associated with Ménière's disease with an SSRI (sertraline), with the complete resolution, or significant improvement, of symptoms. In these cases, the SSRI may have treated the associated morbidity and not Ménière's disease itself. Ménière's disease that appears to be resistant to typical otological treatment may not be just Ménière's disease. Ménière's disease may co-exist with three other conditions that are able to cause vestibular symptoms and respond to SSRIs: migraine-associated vertigo (MAV), panic disorders and chronic subjective dizziness (CSD).

[The clinical features of migraine-associated vertigo].

Migraine-associated vertigo (MAV) is proposed as a new clinical entity on the basis of the assumption that the typical migraine and vertigo or dizziness have a common pathophysiology. Some of the patients with recurrent vertigo syndromes with unknown pathology may have MAV. We performed a retrospective study to clarify the clinical characteristics of MAV in the Japanese population. The following were considered as diagnostic criteria: (1) recurrent vestibular symptoms, (2) migraine headache as defined by the International Headache Society (IHS) criteria, (3) at least one instance of synchronization of a vertiginous attack with a migraine headache, (4) no associated unilateral hearing loss, and (5) absence of other diseases that may have caused vertiginous attacks. Of 552 patients with dizziness or vertigo, 46 (8.3%) were diagnosed as having MAV. A typical feature of this clinical entity is that migraine occurs before the onset of vertigo in women aged 30-40 years. Usually the attacks occur once in a year for 1 to 10 years. An attack lasts for 1-24 h and presents as vertigo and unsteadiness with simultaneous headache. The presence of hearing loss presents an important clinical dilemma. Whether the condition in patients experiencing hearing loss should be defined as MAV or not is still a matter for discussion.

[Migraine-associated vertigo with hearing loss and recurrent vertigo attack].

The clinical features of Ménière's disease and migraine-associated vertigo are quite similar. Both disorders are characterized by repeated vertigo spells. Several diagnostic criteria are used to diagnose migraine-associated vertigo. None of these criteria has been internationally defined, although the criteria proposed by Neuhauser are wieldy accepted. Hearing impairment is believed to be a key factor for diagnosing Ménière's disease. We report herein on a case of repeated vertigo spells with sensorineural hearing loss in the right ear. Initially, the condition was diagnosed as Ménière's disease. Treatment for improving endolymphatic hydrops did not have an effect on the vertigo spells. On careful questioning, we noted the coexistence of migraines without any aura. Treatment with Ca antagonists to prevent the migraine attacks successfully stopped the patient's vertigo spells. On the basis of this clinical course, it is safe to assume that the patient had migraine-associated vertigo with sensorineural hearing loss rather than Ménière's disease. For a patient experiencing migraines together with sensorineural hearing loss, an accurate diagnosis requires careful evaluation. The coexistence of migraines should be carefully ruled out, even if Ménière's disease with hearing loss is strongly suspected.

[Treatment of chronic subjective dizziness by SSRIs].

It has been reported that the dizziness or vertigo in about 10 to 30 patients visiting an otolaryngologist is of psychiatric origin. Since otolaryngologists are not familiar with the treatment for these patients, such treatment is usually not adequate. The clinical entity of chronic subjective dizziness (CSD) is one of psychiatric dizziness proposed by Staab and Ruckenstein. Fourteen percent (40/285) of patients were diagnosed as having psychiatric dizziness in Hino Municipal Hospital last year. Among them we had 7 cases with CSD. We report herein on the result of the clinical examinations and pharmacological treatment. In most of the cases, subjective symptoms were significantly improved after the pharmacological treatment with SSRIs (Serotonin reuptake inhibitors). From these results, CSD is important clinical entity treatable by otolaryngologist with SSRIs. To prescribe SSRIs, it is important to know the common adverse reactions associated with SSRIs. These include gastrointestinal symptoms including nausea and activation syndromes especially in early stage of treatment. CSD is an important clinical entity, which should be diagnosed and is treatable by otolaryngologists.

Characteristic electroencephalographic findings by photic driving in patients with migraine-associated vertigo.

CONCLUSIONS: Patients with migraine-associated vertigo (MAV) may have a higher incidence of photic-driven electroencephalography (EEG) response. The occurrence of photic-driven responses for stimulation at frequencies of 10, 12, and 15 Hz can be considered a positive indicator for MAV. Although photic driving is not specific to migraine, patients with MAV have a higher incidence of photic driving. The distinction between Ménière's disease and MAV by means of EEG would be another interesting topic of research. OBJECTIVE: The objective of this study was to distinguish between patients with MAV and patients with other vestibulopathies (VPs) using EEG. METHODS: EEG with intermittent photic stimulation (PS) at frequencies between 3 and 24 Hz was recorded to quantify photic driving in patients with MAV (n = 21) and VPs (n = 15). The presence or absence of photic driving was determined; a score of 1 was counted for response to a particular frequency. RESULTS: Total scores were calculated for each patient for statistical comparison. There was a significant difference in the average total score between MAV and VP patients (p < 0.05), and photic-driven responses were observed for 10, 12, and 15 Hz stimulation.

Interaction between titanium and cadmium in various guinea pig organs.

Titanium (Ti) is used in many fields, while cadmium (Cd) is known to cause the itai-itai disease. In the present study, possible interactions between titanium and cadmium were investigated. Aorta, taenia coli, and liver were removed from male guinea pigs. Muscle tension was measured using intact aorta and taenia coli and using ß-escin-permeabilized taenia coli in a physiological salt solution and a hyperpotassium solution containing Cd and/or Ti. Cellular Cd contents were determined using all tissues after washout with EDTA solution. Cadmium-induced relaxation in the hyperpotassium solution recovered significantly (P < 0.01) following Ti treatment in taenia coli, but not in the aorta. In ß-escin-permeabilized taenia coli, the percentage recoveries after Cd treatment and after Ti plus Cd treatment were 67.3 ± 8.7 % (n = 4) and 87.7 ± 3.8 % (n = 4), respectively, compared with Ca-induced control contraction. Cellular Cd contents in taenia coli decreased significantly following treatment with Ti 10(-4) M. Although similar results were obtained using the aorta and the liver, there were no significant differences between the control and Ti 10(-5) M. High concentrations of Ti may reduce cellular Cd content.

Objective evaluation of neck muscle tension and static balance in patients with chronic dizziness.

CONCLUSION: Increase in the average value of bilateral neck muscle tension (ANT) indicates the increase in neck muscle tension to stabilize static posture resulting from vestibular compensation. Asymmetry of neck muscle tension was closely related to postural imbalance. OBJECTIVE: Patients with dizziness often complain of neck symptoms with stiff neck. This study was conducted to clarify the pathophysiological mechanism of neck symptoms in patients with dizziness. METHODS: We objectively measured bilateral trapezius muscle tension in patients with chronic dizziness and determined its relationship with static postural perturbation. The study included 26 patients with chronic dizziness caused by unilateral vestibular deficit and 24 healthy controls. The tension of bilateral trapezius muscles was objectively measured using a neck muscle tension meter. ANT and the ratio (right/left) of the bilateral neck muscle tension (RNT) were calculated. Static posturography was performed to measure total length of path (LNG). RESULTS: ANT was negatively correlated to LNG under the eyes closed (EC) condition only in the case of the patients (r = -0.44, p < 0.05). In the case of both the controls and the patients with a unilateral vestibular deficit, RNT was positively correlated to LNG under the EC condition.

[Application of antidepressant to treat patients in the department of otolaryngology].

There are some patients complaining of somatic symptom who has depression. The use of antidepressant to these patients would be quite useful. Patients with dispersion have a variety sort of physical symptom. The evaluation of depression based on physical complaints may be difficult for otorhinolaryngologists, but it is important to do so where possible to increase the focus on the subject's physical illness. The prevalence of somatic complaints in hospitalized patients whose chief complaint was either dizziness or vertigo was very high. These patients were usually accompanied with depression. Then the effect of paroxetine to the patients with tinnitus was investigated. The paroxetine may be effective in treating distressed tinnitus patients with depression and anxiety by reducing their tinnitus severity as well as their depression and anxiety.

Lateral semicircular canal plugging with endolymphatic sac decompression as new surgical treatment for intractable Meniere's disease.

CONCLUSION: Lateral canal plugging with endolymphatic sac decompression (LCPESD) is a new therapeutic approach to intractable Meniere's disease. Further clinical data will be required. OBJECTIVE: The objective of this paper is to present a new surgical procedure, i.e. lateral canal plugging (LCP) with endolymphatic sac decompression (ESD), which we defined as LCPESD. Two cases of intractable Meniere's disease, a 48-year-old male and a 48-year-old female, were successfully treated by this method. METHODS: LCPESD was performed under general anesthesia. First ESD was undertaken followed by LCP. The bone was drilled up to the 'blue line' in the central portion of the bony lateral canal; then a 2 mm segment of canal was skeletonized to create a fenestra. A plug comprising temporalis fascia, bone pate, and fibrinogen glue was inserted through the fenestra to compress the endosteum and membranous labyrinth. RESULTS: The attack of Meniere's disease was completely controlled and the hearing threshold did not change after the surgery for 2 years. Obliteration of the horizontal canal was confirmed by MRI.

Various levels of plasma brain-derived neurotrophic factor in patients with tinnitus.

OBJECTIVE: Thus far, no objective measure has been developed to evaluate tinnitus severity. There is a close relationship between tinnitus and depression, in which brain-derived neurotrophic factor (BDNF) has a pathophysiological role. To determine whether BDNF levels could be used to evaluate tinnitus severity, we evaluated plasma BDNF levels in patients with tinnitus. METHODS: Plasma BDNF levels were measured in 43 tinnitus patients and 30 healthy control patients. The severities of tinnitus, depression, and anxiety were measured using the tinnitus handicap inventory (THI) and the hospital anxiety and depression scale (HADS), respectively. Patients with tinnitus were divided into 2 groups depending on their THI scores: mildly handicapped (<36) and severely handicapped (>38). We also divided our subjects into 2 groups depending on the HADS score, which represents patient mood, including depression and anxiety. RESULTS: Plasma BDNF levels were significantly higher in the mildly handicapped group than in the severely handicapped and control groups (P<0.01). Patients with HADS scores of ≤14 had significantly lower THI scores (P<0.05) and higher BDNF levels (P<0.01). CONCLUSIONS: Our findings show for the first time that plasma BDNF levels vary with the severity of tinnitus, suggesting that plasma BDNF level is a useful tool for objective evaluation of tinnitus.

Hidden depression in otolaryngology patients with medically unexplained symptoms.

OBJECTIVE: To investigate the prevalence of depression among otolaryngology patients with medically unexplained symptoms (MUS) and the outcome of treatment with selective serotonin reuptake inhibitors (SSRIs). METHOD: Ninety patients with MUS from a population of 983 consecutive otolaryngology outpatients were enrolled. The Self-Rating Depression Scale (SDS) was used to screen for depression. In addition to standard treatment, all depressed and nondepressed patients received SSRIs for 8 weeks. The Clinical Global Impression-Improvement (CGI-I) scale was used to evaluate clinical changes in patients with MUS. RESULTS: There were 49 patients with depression among those with MUS, according to the SDS criteria. The patients with depression showed a better outcome than those without depression, demonstrating more significantly improved CGI-I scores. CONCLUSION: More than half of the individuals with otolaryngological MUS had depression, and their MUS were successfully treated with SSRIs.

Neurally mediated syncope presenting with paroxysmal positional vertigo and tinnitus.

A 72-year-old man with positional vertigo and tinnitus was referred to us. He did not want to perform provoking test except once due to his fear. No positional nystagmus was provoked. He found that his attacks usually occurred when he lay on his right ear. From his clinical history, benign paroxysmal positional vertigo was suspected. Conventional pharmacotherapy as well as non-specific physical therapy did not have significant effect. His feeling of positional vertigo with pyrosis was actually presyncope. We suspected cardiovascular disorders, and referred him to a cardiologist. Portable cardiogram monitoring revealed paroxysmal bradycardia. He was diagnosed with neurally mediated syncope, and a pacemaker was implanted. His paroxysmal dizziness soon disappeared. It is important to study the clinical history of the patients in detail, as they are not always able to accurately explain their symptoms. We should carefully rule out cardiovascular disorders, especially when we see the patients with suspected BPPV without the characteristic positional nystagmus.

Effect of chewing gum on static posturography in patients with balance disorders.

CONCLUSION: The chewing gum indirectly affects postural control by influencing vestibular function to stabilize posture during upright standing. OBJECTIVES: This study aimed to evaluate the effect of chewing gum on static posturography in patients. METHODS: The subjects were 26 patients with chronic balance disorders. The subjects were instructed to stand as stably as possible on the force platform. The recording was conducted four times. For the first evaluation, postural sway was measured during motionless standing. Two weeks after the recording, the postural sway was recorded again as a second evaluation. Thereafter, the subjects were instructed to chew gum for 3 min. The third evaluation was conducted while the subjects continued to chew gum. Then 1 h after the subject had stopped chewing gum, a fourth evaluation was obtained. The total path length (LNG) and rectangle area (REC) were analyzed. RESULTS: We found that postural stability tended to improve while the subjects masticated gum. Both LNG and REC were significantly improved while the subjects chewed gum with their eyes closed. In patients without canal paralysis (CP), the measurements of LNG with eyes closed and REC with eyes open were significantly decreased while masticating gum. In patients with CP, the REC, but not LNG, was significantly decreased while masticating gum both with eyes open and eyes closed.

The Japanese version of the Dizziness Handicap Inventory as an index of treatment success: exploratory factor analysis.

CONCLUSION: The Japanese version of the Dizziness Handicap Inventory (DHI) is a reliable, comprehensively validated, and clinically useful tool to measure self-perceived handicap associated with dizziness. OBJECTIVES: The DHI is a useful instrument to document the consequences of vestibular and/or balance impairment. A Japanese version of this self-assessment inventory is needed to evaluate the handicapping effects imposed by vestibular system disease in Japanese patients. The purpose of this study was to determine the internal consistency of the reliability of the Japanese version of the DHI. METHODS: We recruited 176 patients between January and September 2008 from the outpatients of the Department of Otolaryngology, Hino Municipal Hospital, Japan. The DHI was translated into Japanese, and the test was independently completed by each subject. We used principal component analysis to evaluate the different dimensions of the DHI. The internal consistency of the retained factors was investigated by estimating Cronbach's alpha coefficients and corrected item-total correlations. RESULTS: Cronbach's coefficients for internal consistency were high for the total scale (0.93) and good for the subscales: functional subscale (0.87), physical subscale (0.82), and emotional subscale (0.85). The correlation matrix demonstrated that the variables were suited for factor analysis. The determinant was 1.26E(-6), which is slightly under the recommended value. Bartlett's test was highly significant (p < 0.0001), and the Kaiser-Meyer-Olkin measure of sampling adequacy was 0.91.

Concurrent chemoradiotherapy for organ function preservation in advanced patients with hypopharyngeal and laryngeal cancer.

Preservation of the larynx is the most critical factor influencing quality of life in the treatment of head and neck cancer. This clinical study focuses on laryngeal function-preserving chemoradiotherapy for locally advanced hypopharyngeal and laryngeal cancer. Thirty-two resectable cases with histologically proven squamous cell carcinoma undergoing function-preserving therapy were examined. Induction chemotherapy comprised cisplatin and 5-fluorouracil, and another cycle of chemotherapy was performed for responders. Chemoradiotherapy comprised conventional irradiation and weekly chemotherapy (nedaplatin plus docetaxel). Non-responder patients were excluded from further chemotherapy and were changed to other surgical treatment. Three patients were non-responders for induction chemotherapy, and 29 patients were treated with chemoradiotherapy. Thus, 21 out of 29 patients obtained preserved laryngeal function. Initial larynx preservation rate with these treatment strategies was 93.8%. This study provides a new concept for laryngeal function-preserving treatment that should be considered for locally advanced laryngeal and hypopharyngeal cancer.

Renal toxicity induced by folic acid is associated with the enhancement of male reproductive toxicity of di(n-butyl)phthalate in rats.

Reproductive effects have been observed in experimental animals treated with di(n-butyl)phthalate (DBP), one of phthalate esters used in soft plastics and a variety of consumer products. In this study, we investigated whether testicular toxicity of DBP is influenced by diminished renal function. To generate an experimental condition reflecting chronic renal disease in man, adult male F344 rats were given five consecutive weekly subcutaneous injections of folic acid at a dose of 300 mg/kg and then a diet containing 1200, 5000, and 20,000 ppm of DBP for 4 weeks. These concentrations roughly correspond to 60, 250, and 1000 mg/kg per day per rat, respectively. Folic acid clearly induced interstitial nephritis accompanied by impairment of renal function. Seminiferous degeneration, diminished spermatogenesis and increase in the number of morphologically abnormal sperm were more prominent in rats given folic acid and then 20,000 ppm DBP as compared to those exposed to DBP alone. These data suggest that DBP-induced male reproductive toxicity can be increased by folic acid-induced renal dysfunction.

Lack of carcinogenic risk in the prostate with transplacental and lactational exposure to bisphenol A in rats.

The current study was designed to examine the modulating effects of bisphenol A (BPA) on prostate cancer risk in male offspring exposed transplacentally and lactationally. BPA was administered to F344 female rats by gavage at 0, 0.05, 7.5, 30, 120 mg/kg/day during pregnancy and lactation periods. When F1 males reached 5 weeks old, they were given 10 subcutaneous injections of 3,2'-dimethyl-4-aminobiphenyl (DMAB) or corn oil vehicle and rats were then sacrificed under ether anesthesia at week 60. There were no observable effects on the accessory sex organ weights of male offspring. Transplacental and lactational exposure to BPA did not affect the incidences of preneoplastic and neoplastic lesions in the accessory sex organs (prostate and seminal vesicle) of F1 rats and did not induce any proliferating lesions without DMAB. Our data suggest that maternal exposure to BPA during the period of pregnancy and lactation does not affect the risk of prostate carcinogenesis in male offspring.