Demographic analysis of benign paroxysmal positional vertigo as a common public health problem.

BACKGROUND: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular problem. However, demographic analysis is few. AIM: The aim of this study was to document the demographic data of patients with BPPV regarding distribution of gender, age, associated problems, most common form, symptom duration, severity of nystagmus and cure rate. SUBJECTS AND METHODS: A total of 263 patients with video-nystagmography confirmed BPPV were enrolled in this retrospective study (2009-2013). The data were collected in Anadolu Medical Center. Distribution of gender, age and affected side were reviewed. Associated problems were noted. Patients were analyzed according to the canal involvement, age, duration of symptoms, duration of nystagmus and recurrence. Mean values and standard deviations were calculated. One-way ANOVA test was used for the analysis of the data (Statistical Package for the Social Sciences 17.0 version, IBM, Chicago, III, USA). Statistical significance was set at P < 0.05. RESULTS: Women were affected more frequently than men (1:1.5). Comparative analysis of average age between the two gender groups was not statistically significant (P = 0.84). BPPV was common at middle age group. The incidence of affected side was not significant (P = 0.74). Posterior canal-BPPV (PC-BPPV) was the most leading one (129/263; 49%) followed by lateral canal (LC)-canalolithiasis (60/263; 22.8%), LC-cupulolithiasis (38/263; 14.5%) and superior canal-BPPV (9/263; 3.4%). 55.1% of patients were defined as idiopathic (145/263). Associated problems were migraine (31/263; 11.8%), trauma (19/263; 7.2%), inner ear disorders (18/263; 6.8%) and other systemic problems (50/263; 19.1%). 72.6% of patients had symptoms <2 months (191/263). 23,6% of patients had intensive nystagmus lasting more than a minute regardless of canal involvement (62/263). 33% of patients required two or more maneuvers for the relief of symptoms (87/263). CONCLUSION: Symptoms are prone to recur in those of traumatic origin, associated inner ear problems and systemic disorders. As the prognostic factors are illuminated, preventive measures will be more effective and more patients will be cured properly.

Vertical nystagmus during the seated-supine positional (straight head-hanging) test in patients with benign paroxysmal positional vertigo.

OBJECTIVE: This study describes the clinical features of up-beating vertical nystagmus observed during the seated-supine positional (straight head-hanging) test in patients with benign paroxysmal positional vertigo. METHODS: A total of 190 patients with benign paroxysmal positional vertigo symptoms who had presented between 2009 and 2012 were enrolled for this retrospective case series. Twelve patients with positional up-beating vertical nystagmus, as confirmed by video-nystagmography during the seated-supine positional test, were selected. RESULTS: The incidence and duration of symptoms of multiple canal benign paroxysmal positional vertigo were significantly lower compared with the other types of benign paroxysmal positional vertigo (p = 0.029 and p = 0.048 respectively). Trauma was the leading aetiological factor in those patients (p = 0.012). The average number of therapeutic manoeuvres required for the relief of symptoms in patients with multiple canal involvement was significantly higher than in the other groups (p = 0.041). CONCLUSION: In patients with benign paroxysmal positional vertigo, the presence of vertical up-beating nystagmus while lying down is a unique peripheral sign and could indicate multiple canal involvement. Therefore, the seated-supine positional test should always be included in the test battery.

Effectiveness of hyperbaric oxygen therapy in idiopathic sudden hearing loss.

The aim of this study was to investigate the efficacy of hyperbaric oxygen (HBO) therapy in idiopathic sudden sensorineural hearing loss (ISSHL) by comparing hearing gain and improvement rate in patients who have been placed on both HBO and medical treatment (MT) (37 patients), and patients who have received MT only (17 patients). Both groups were compared with reference to pure tone average (PTA) and the number of patients who experienced hearing gain. Of 37 patients (40 ears) who received HBO + MT, 24 (60 per cent) experienced > or = 10 decibels (dB) improvement in PTA compared to 13 (76.4 per cent) of 17 patients who were placed on MT only. Inter- or intra-group comparison of age stratification (< 50 and > or = 50 ages) did not produce significant differences in PTA and in the number of patients who experienced hearing gain. Although there are numerous studies showing efficacy of HBO therapy; this study did not reveal a trend in favour of HBO therapy.

Craniocerebral gunshot wounds: results of less aggressive surgery and complications.

Four hundreds patients who suffered from cranial gunshot wounds injuries were analyzed. Surgical therapy, primary and secondary debridement, including repair of dural defects and removal of retained intracranial bone and metal fragments were applied. Central nervous system infections were mostly observed in cases with cerebrospinal fluid (CSF) fistulas. In 130 of 400 patients, bone and metal fragments were determined on control CT scans. Most of the deaths in this group of patients were attributed to the influence of brain injury and occurred within the first month after injury. Fragments retained after first debridement were followed periodically by CT scans. Surgery was not performed until the infection developed. Retained fragments did not increase the infection risk but high rates of infection did occur in cases with CSF fistulas. The presence of diffuse brain damage, brainstem injury, CNS infection, or ventricular injury was associated with a poor outcome. The prognostic importance of complications such as intracranial haemorrhage, epileptic seizures, hydrocephalus, was also investigated.

Analysis of different surgical approaches for the treatment of cerebrospinal fluid rhinorrhea.

The current treatment method for cerebrospinal fluid (CSF) rhinorrhea is surgical repair of the fistula. The aim of this study was to analyse different surgical approaches used for the treatment of CSF rhinorrhea regarding several preoperative and postoperative variables to determine the optimal method in these patients. Patients' charts were retrospectively reviewed to get the required data. Twenty-six patients who underwent different types of surgical approach for the treatment of CSF rhinorrhea were included in the study. Patients who had extensive comminuted fractures of the anterior cranial base and additional brain injury besides CSF rhinorrhea, mostly as a result of gunshot injuries, underwent craniotomy (n = 14). Osteoplastic frontal sinusotomy was used in two patients with a dural defect located at the posterior wall of the frontal sinus. Uncomplicated CSF fistulas in ten patients, located at the anterior and posterior ethmoid roof and in the sphenoid sinus, were closed with an endonasal endoscopic approach. Postoperative success rate was higher (97 % for intracranial approach, 100 % for extracranial external and endonasal endoscopic approach) for all techniques. Anosmia was the most frequent permanent complication (n = 5), seen after craniotomy. In conclusion, endonasal endoscopic approach can be preferred for the closure of uncomplicated CSF fistula, located at the anterior or posterior ethmoid roof and in the sphenoid sinus, due to its minimal postoperative morbidity. Uncomplicated CSF fistula, located at the posterior wall of frontal sinuses can be repaired extradurally with osteoplastic frontal sinusotomy. Intracranial approaches should be reserved for more complicated CSF rhinorrhea which results from extensive comminuted fractures of the anterior cranial base and is accompanied with intracranial complications.

Idiopathic hypogonadotrophic hypogonadism associated with arachnoid cyst of the middle fossa and forebrain anomalies: presentation of an unusual case.

We report a 22-yr-old male patient with hypogonadotrophic hypogonadism (HH) associated with a giant middle fossa arachnoid cyst (AC) diagnosed by magnetic resonance imaging (MRI). He presented with pubertal and growth delay. He also had learning disabilities and anosmia. Laboratory investigation revealed pre-pubertal levels of testosterone and normal results of the combined test of anterior pituitary function, except for in GnRH acute and prolonged test. Cranial MRI showed an AC in left middle fossa with expansion to suprasellar cisterna and several abnormalities like left temporal lobe hypoplasia, left optic tract and bilateral olfactory bulb hypoplasia and left hypothalamic hypoplasia.

Vestibular diuresis in suspected Meniere patients.

OBJECTIVE: Diagnosis of Meniere's disease in patients without classical symptoms may present some difficulty. Detection of hydrops in patients with normal or near to normal hearing or presenting unpredictable balance problem with great variability of severity, periodicity and duration is the major concern in reaching the accurate diagnosis to start the therapy as early as possible. METHOD: To investigate the diagnostic role of vestibular diuresis, electronystagmographic (ENG) evaluation of 20 patients with "probable" or "possible" Meniere's disease before and after intravenous furosemid administration has been reviewed in a prospective and blinded study and the results have been compared with 20 age-matched control subjects. RESULT: Eleven of 20 patients with Meniere's disease (55%) and one of 20 subjects in the control group (5%) demonstrated canal paresis at initial ENG testing. Thirteen patients from Meniere group (65%) and 1 subject from control group (5%) demonstrated positive response to furosemid. Seven of 11 patients with canal paresis in the patient group (63.7%) and 6 of 9 patients with no canal paresis at initial testing demonstrated positive response (66%) to furosemid. No statistical difference between these 2 subgroups was found when compared as response to furosemid. It has been found that there is no clear correlation between the duration of the disease and the positive response to furosemid. CONCLUSION: It has been concluded that, although some limitation exists, the sensitivity of furosemid test for evaluation of vestibular function in Meniere's disease is promising as compared with controls.

Revision myringoplasty with solvent-dehydrated human dura mater (Tutoplast).

OBJECTIVES: Several grafting materials have been used in the reconstruction of the perforations of the tympanic membrane. The use of dehydrated dura homografts as a substitute for the tympanic membrane has not been fully documented. On the other hand, revision surgery is more critical in terms of patients' expectations. The aim of this study is to determine the tissue stiffness, the compliance, and the wound healing rate of dura homografts in revision surgery of perforations of the tympanic membrane. STUDY DESIGN AND SETTING: The charts of 45 patients who have received dura grafts because of re-perforation or failure of the myringoplasty have been reviewed retrospectively. The healing process of the myringoplasty, graft take rate, pure-tone hearing level, and tympanogram were reviewed. RESULTS AND CONCLUSION: It has been concluded that dura homografts, which have excellent tissue-compatibility, stability, and an 86.7% graft success rate, are preferred in patients in whom their own temporalis fascia cannot be used because of previous operations. It has been demonstrated by tympanometric analysis that the compliance of the graft during various pressure applications is as good as the normal eardrum.

Sphenochoanal polyp: endoscopic surgery.

Sphenochoanal polyp is a rare entity originating from sphenoid sinus. It may be confused with antrochoanal polyp on anterior rhinoscopy because of its similar appearance. Computerized tomography and nasal endoscopy have contributed to an increase of accuracy in the diagnosis of these masses. Simple polypectomy that leaves some part of the polyp inside the sphenoid sinus carries a high risk of recurrence. Destructive external approaches to gain access to the sphenoid sinus are also not advisable in children for a benign disease. We present two cases of sphenochoanal polyps in two children that were operated by endonasal endoscopic approach. They were free of symptoms after surgery. No complications and recurrences were observed at 28 and 18 months of follow-up periods respectively.

Plasmacytoma of the temporal bone: management with a combination of surgery and radiotherapy.

The diagnosis of solitary plasma cell neoplasm is based on clinical, radiological and laboratory findings and it can be accepted as the precursor lesion of multiple myeloma as spread of disease occurs in 30-50% of affected patients. However, solitary plasmacytoma of the temporal bone is a rare pathology. We present an interesting case of plasmacytoma of the temporal bone which was controlled by a combination of surgery and radiotherapy.

Otolaryngological aspects of relapsing polychondritis: course and outcome.

Relapsing Polychondritis (RP) is a rare disorder characterised by episodic inflammation of the cartilaginous structures. Differential diagnosis of this pathology is a challenging enigma since it appears only intermittently and none of the clinical features are pathognomonic, although most of the patients are usually referred to an ENT physician initially. The natural history of the disease is unpredictable. Initiating effective treatment sooner considerably reduces the rate of mortality. Patients with RP should be seen on a regular basis even if the patient is non-symptomatic. This study reports a retrospective analysis of the otolaryngological manifestations of 7 patients with RP as well as their long-term progress and reviews the symptomatology, histopathology, immunology and management.

Osteoma of the middle ear.

Osteomas are benign pedunculated tumours of the lamellar bone, which commonly originates from paranasal sinuses. Within the temporal bone they are seen commonly in the external ear canal. Osteomas originating from the middle ear are very rare. There are only 12 cases reported in the medical literature up to now. Five of those cases caused conductive hearing loss and the others were asymptomatic and diagnosed incidentally.

Acoustic characteristics of reconstructed ear canal after atresia surgery.

The acoustic properties of the reconstructed ear canals of 13 patients after atresia surgery were investigated by comparing them with those of contralateral healthy ear canals. In the third post-operative month, resonant frequency, amplitude and bandwith of the ear canals with Q-factor were measured. Probe microphone measurements showed a significant shift in resonant frequency in the direction of the higher frequencies, and a non-significant change in bandwith in the atresia surgery group. The suggested reason may be a change in ear canal curvature, altered vibration pattern and sound-absorption characteristics of the skin graft lining the reconstructed ear canal.

Vestibular disturbance in patients with large vestibular aqueduct syndrome (LVAS).

Large vestibular aqueduct syndrome (LVAS) is a common inner ear anomaly responsible for some unusual vestibular and audiological symptoms. The gross appearance of CT scan of the inner ear is generally normal. However, precise measurement of the inner ear components reveals abnormal dimensions, which may account for accompanying auditory or vestibular dysfunction. It has been reported that sudden increase in cerebrospinal fluid pressure can cause further deterioration of hearing due to transmission of pressure to the inner ear through the enlarged vestibular aqueduct. However, vestibular function is not often studied. In this report, audiovestibular function of 10 patients with large vestibular aqueducts was analysed and compared with the severity of the radiological deformity. The literature was reviewed and typical findings were discussed to emphasize varying aspects of audiovestibular function. It was found that some patients with LVAS have some spontaneous or provoked vestibular disturbance such as vertigo after watching revolving objects. The mean value of electronystagmographic abnormality in patients with hearing loss is greater than in patients with normal hearing. However, there is no statistical correlation between the level of hearing loss, electronystagmographic abnormality and severity of radiological deformity.

Antrochoanal polyps: analysis of 16 cases.

Antrochoanal polyps are rare lesions. Several surgical techniques have been reported to provide complete cure of the disease. However, inadequate treatment may result in a high rate of recurrences. The aetiological as well as predisposing factors are not well understood. We present a literature review and discuss the clinical, pathological and histological features of 16 patients with antrochoanal polyps, who have been surgically treated by either an endoscopical or conventional approach. It has been found that allergy has no role in the aetiology of antrochoanal polyps. However, the majority of the patients have sinonasal disease. The most common pre-operative radiological finding is the mucocoele-like appearance, which has also been confirmed in surgery. It is remarkable that antrochoanal polyps have recurred in 4 out of 8 patients, who have underwent simple intranasal polypectomy and inferior turbinectomy. As compared to conventional technique, the endoscopic approach proves to be superior.

High-velocity gunshot wounds to the head and neck: a review of wound ballistics.

Patients who sustain gunshot injuries to the head and neck face heavy tissue damage and eventually life-threatening conditions. A very significant factor that determines the degree of injury is the course and extent of the missile track. The missile track is well correlated with bullet structure, size, and velocity, which have distinct features in civilian and military firearm injuries. The missile entrance or exist wound may be out of sight in some injuries, and often it is difficult to predict the severity of the injury in the chaotic circumstances of the battlefield. We studied the wound ballistics in five soldiers who suffered penetrating cranial and cervical firearm injuries.

Elongated styloid process: diagnostic problems related to symptomatology.

A certain number of patients with elongated styloid process may not have the classic cervicofacial complaints which were originally described by W. Eagle in 1937. Some of those cases who have radiologic evidence of elongated styloid process are symptom free and can be accepted as normal anatomical variants. On the other hand, some of those symptomatic cases may present uncommon neurologic signs and can be misdiagnosed as neurologic or infectious disease. Sometimes, the radiologic presence of an elongated process may cause the clinician to miss another pathology. Therefore, it is essential for the clinician to be aware of the clinical variants with different symptomatology or to particularly seek the origin of the pain in the head and neck before reaching a conclusion, since the only effective treatment in symptomatic cases is the surgical shortening of the process. We report five patients with elongated processes. Problems related to an elongated styloid process with different symptomatology are discussed and the associated literature is reviewed.

Migraine-related vestibulopathy.

Migraine has been associated with specific vestibular disorders, including benign paroxysmal vertigo of childhood and benign recurrent vertigo in adults. Migraine may also play a role in chronic nonspecific vestibulopathy. Because scant data exist that describe the clinical findings and vestibular function abnormalities in suspected migraine-related vestibulopathy, we reviewed the history, physical examination, vestibular tests (electronystagmography, rotational chair, posturography), and response to treatment of 100 patients with diagnoses of migraine-related vestibulopathy. Dominant clinical features included chronic movement-associated dysequilibrium, unsteadiness, space and motion discomfort, and occasionally, episodic vertigo as an aura prior to headache, or true vertigo without headache. Common vestibular test abnormalities included a directional preponderance on rotational testing, unilateral reduced caloric responsiveness, and vestibular system dysfunction patterns on posturography. Treatment was usually directed at the underlying migraine condition by identifying and avoiding dietary triggers and prescribing prophylactic anti-migraine medications. Symptomatic relief was also provided using anti-motion sickness medications, vestibular rehabilitation, and pharmacotherapy directed at any associated anxiety or panic disorder.

Patient selection and surgical results in obstructive sleep apnea.

In recent years, therapeutic methods have been effective in the management of snoring and sleep apnea. Successful results have been possible through conservative and surgical approaches when the nature and site of obstruction is ascertained by careful investigation. Sagittal magnetic resonance imaging (MRI) of the upper respiratory tract has been the most valuable diagnostic tool in patients with obstructive sleep apnea. This has made it possible to measure the dimensions and distance of the hard and soft palate and tongue base to the posterior pharyngeal wall. Surgery is only indicated when a site of obstruction can be completely determined. In this study, surgical approaches and results obtained in 50 patients after surgery for sleep apnea are presented. Uvulopalatopharyngoplasty (UPPP) had a higher success rate in patients with obstruction at the level of the soft palate, but this rate decreased when it was associated with hypopharyngeal obstruction or when there was hypopharyngeal obstruction alone. UPPP was found to be beneficial in patients with central apnea. Nasal pathologies also played an important role in sleep apnea. Better results were obtained when UPPP was performed in patients who were young, not obese and an apnea-hypopnea index was below 40. Some unusual pathologies included lingual tonsil hypertrophy in the adult, sublingual dermoid cysts and angioma of soft palate and were found to be the cause of OSA. After surgical excision of these pathologies, apneic periods disappeared.

Localizing retrocochlear hearing loss.

PURPOSE: The origin of acute/sudden hearing loss is multifactorial. The association of vestibular symptoms does not necessarily isolate the pathologic condition to the inner ear. The audiogram provides a screen for differentiating conductive from sensorineural loss but often fails to provide more localizing information. METHODS: Three unusual patients with a variety of retrocochlear presentations of hearing loss are presented. Along with conventional auditory brainstem response (ABR) testing, newer auditory tests, including otoacoustic emissions and three-dimensional ABR analysis, can facilitate site-of-lesion testing. Magnetic resonance imaging (MRI) also provides graphic documentation for sources of retrocochlear hearing loss. RESULTS: One patient had gamma-knife treatment of an arteriovenous malformation, incurring a localised lesion to the inferior colliculus contralateral to the side of hearing loss. This effectively eliminated wave V, as confirmed by three-dimensional ABR analysis. A second patient with human immunodeficiency virus developed sudden complete hearing loss with retained otoacoustic emissions, confirming a retrocochlear lesion. A third patient with acute otitis media with sudden hearing loss and vertigo had an abnormal ABR and "mass lesion" on MRI. Hearing subsequently returned to normal, as did a repeated scan. CONCLUSIONS: The unique aspects of each case of retrocochlear hearing loss and the applied auditory electrophysiologic tests are reviewed.