Signal Alteration of the Inner Ear on High-Resolution Three-Dimensional Constructive Interference in Steady State Sequence in Patients with Ménière's Disease and Labyrinthitis.

INTRODUCTION: The aim of this study is to evaluate signal alteration in the inner ear using three-dimensional (3D)-constructive interference in steady state (CISS) sequence in patients with Ménière's disease and labyrinthitis and its correlation with clinical and audiological parameters. METHODS: The medical records of the department of otorhinolaryngology were searched for patients with Ménière's disease or labyrinthitis who underwent MRI with 3D-CISS sequence. Blinded analysis of these patients and of MRI from control subjects without middle or inner ear symptoms was performed to detect any signal asymmetry of the inner ear structures. The results were correlated with clinical symptoms and results of audiological and vestibular tests. RESULTS: Fifty-eight patients with definite Ménière's disease and 5 patients with labyrinthitis as well as 41 control exams were included. A separate analysis was performed for patients with probable Ménière's disease (n = 68). A total of 172 3D-CISS sequences were analyzed by 2 blinded independent neuroradiologists. A CISS-hypointense signal of the inner ear structures was found in 3 patients with definite Ménière's disease (5.2%), in 4 patients with probable Ménière's disease (5.9%), and 2 patients with labyrinthitis (40%). No CISS hypointensity was found in the control group. Although no significant difference in symptoms or audiological test results was found between patients with and without this signal change, the side of hypointensity was frequently correlated with the symptomatic side and with hearing impairment. DISCUSSION/CONCLUSION: CISS hypointensity of the inner ear structures was evident in patients with clinical conditions other than vestibular schwannoma - more frequently in labyrinthitis than in Ménière's disease. This signal alteration was frequently encountered on the same symptomatic side as that of the pathological audiology tests, but it is not a predictor for hearing or vestibular impairment.

Histopathology of Labyrinthitis Ossificans From an Intralabyrinthine Surgical Specimen.

OBJECTIVE: Histologic characterization of labyrinthitis ossificans (LO) has mostly been limited to postmortem samples. In this report, we describe the histology of LO from a surgical specimen obtained from a patient undergoing labyrinthectomy with simultaneous cochlear implantation. PATIENT: A 38-year-old woman initially presenting to the emergency room with acute vertigo, left-sided hearing loss, tinnitus, and aural fullness. INTERVENTIONS: Contrast-enhanced magnetic resonance imaging (MRI) and computerized tomography (CT) were performed for the patient before labyrinthectomy and cochlear implantation. Audiometric testing was performed before and after surgical intervention. Histologic analysis was performed on a specimen obtained from the left lateral semicircular canal (SCC) during surgery. MAIN OUTCOME MEASURES: Preoperative CT and MRI findings, preoperative and postoperative hearing thresholds via air conduction and bone conduction, hematoxylin and eosin (H&E) stain of the surgical sample, and CD45 immunostain of the surgical sample. RESULTS: Preoperative CT and MRI confirmed the diagnosis of isolated LO of the left lateral SCC. Audiometric testing revealed significant improvement in hearing after labyrinthectomy and cochlear implantation. H&E stain demonstrated fibrosis and ossification in the left lateral SCC, and CD45 immunostain was negative. CONCLUSIONS: Histopathology of LO based on a surgical sample is comparable to heterotopic ossification (HO) seen in other human tissue. Given the similarities between LO and HO, agents effective in preventing HO may have utility in preventing LO.

Inner ear modifications in Dar-es-Soltane II H5 (Morocco): A case of labyrinthitis ossificans.

OBJECTIVE: This paper presents the inner ear modifications in Dar-es-Soltane II H5, an Aterian fossil possibly dated to 100 ka. MATERIAL: The remains consist of a large portion of the cranium including the face, the left frontal and temporal bones, part of the left parietal bone and greater wing of the sphenoid. METHODS: The bony labyrinth anatomy was investigated on existing micro-CT data acquired by the MPI-EVA. RESULTS: The observation of micro-CT sections revealed a partial filling of the semi-circular canals that raises question about its origin. A careful examination of the micro-CT sections shows that the elements present in the semicircular canals were denser than the sediments observed in other regions and cavities of the temporal bone. CONCLUSIONS: The current evidence suggests a pathological origin of this condition with partial ossification of the membranous labyrinth. The differential diagnosis indicates a case of labyrinthitis ossificans in its early stages. SIGNIFICANCE: This pathological condition can be responsible for permanent hearing loss and is associated with dizziness and vertigo. Along with the Singa skull, Dar-es-Soltane II H5 represents one of the oldest known cases of labyrinthitis ossificans. LIMITATIONS: The early stage of disease and the absence of the right temporal bone limit conclusions about the degree of disability of the individual and their dependence on the rest of the group. SUGGESTIONS FOR FURTHER RESEARCH: To carry out a paleopathological study of all the fossils from Dar-es-Soltane II.

Labyrinthitis and Labyrinthitis Ossificans - A case report and review of the literature.

Labyrinthitis most commonly results from an infectious and less commonly from an inflammatory process of the inner ear, but it can be associated with temporal bone trauma, hemorrhage, or tumor. This inflammation (regardless of the etiology) disrupts the transmission of sensory information from the ear to the brain. Labyrinthitis ossificans is the pathological ossification of the membranous labyrinthine spaces in response to an insult to the inner ear involving membranous labyrinth or the endosteum of the otic capsule. Herein, we present a case of a 67-year-old female with progressive bilateral sensorineural hearing loss and positional vertigo.

Human Otopathology of Cochlear Implant Drill-out Procedures.

OBJECTIVE: Human otopathology following drill-out procedures for cochlear implantation (CI) in cases with labyrinthitis ossificans (LO) has not been previously described. This study uses the high sensitivity of histopathology to (1) evaluate surgical drill-out technique with associated intracochlear findings and (2) quantify spiral ganglion neuron populations in a series of patients with LO who underwent CI. STUDY DESIGN: Retrospective otopathology study. SETTING: Otopathology laboratory. SUBJECTS AND METHODS: Temporal bone (TB) specimens from cases with evidence of preoperative intracochlear fibroossification that required a drill-out procedure for CI electrode array insertion were included. All cases were histopathologically evaluated and 3-dimensional reconstructions of the cochleae were performed to interpret drilling paths and electrode trajectories. RESULTS: Five TB specimens were identified, of which 4 underwent drill-out of the basal turn of the cochlea and 1 underwent a radical cochlear drill-out. In multiple TBs, drilling was imprecise with resultant damage to essential structures. Two TBs showed injury to the modiolus, which was associated with substantially decreased or even absent neuronal populations within these areas. In addition, 2 cases with inadequate drill-out or extensive LO of the basal turn resulted in extracochlear placement of electrode arrays into the vestibule due to persistent obstruction within the basal turn. CONCLUSION: Otopathology highlights the challenges of drill-out procedures in cases of LO. Imprecise drilling paths, due to distortion of normal cochlear anatomy, risk injury to the modiolus and adjacent neurons as well as extracochlear placement of electrode arrays, both of which may contribute to poorer hearing outcomes.

Direction-Changing Positional Nystagmus in Acute Otitis Media Complicated by Serous Labyrinthitis: New Insights into Positional Nystagmus.

OBJECTIVE: To demonstrate characteristic nystagmus findings in acute otitis media (AOM) complicated by serous labyrinthitis and discuss the mechanism of direction-changing positional nystagmus (DCPN) in this condition. PATIENTS: A patient with AOM complicated by serous labyrinthitis on the left side. INTERVENTION: Video nystagmography and 3D fluid attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI). MAIN OUTCOME MEASURES: Characterize positional nystagmus in a head-roll test observing the change of nystagmus direction in process of time and compare findings of temporal bone 3D FLAIR MRI. RESULTS: A previously healthy 50-year-old man who complained of acute otalgia, hearing loss, and vertigo was diagnosed with AOM complicated by serous labyrinthitis on the left side. A head-roll test performed on the day when vertigo developed showed persistent geotropic DCPN. While pre- and postcontrast T1-weighted MRI showed no signal abnormality in both inner ears, 10-minute delay postcontrast 3D FLAIR image showed enhancement in the inner ear on the left side. Four-hour-delay postcontrast 3D FLAIR images showed more conspicuous enhancement of the whole cochlea, vestibule, and semicircular canals on the left side. CONCLUSIONS: In AOM complicated by serous labyrinthitis, density of perilymph may increase due to direct penetration of cytokines and other inflammatory mediators from the middle ear into perilymph and breakdown of blood-labyrinth barrier that causes vascular leakage of serum albumin into perilymph. The density difference between perilymph and endolymph makes the semicircular canal gravity sensitive. A buoyant force is also generated by gravity, causing indentation of endolymphatic membrane in the ampulla and cupula displacement. Thus, at the early stage of serous labyrinthitis, a head-roll test may elicit persistent geotropic DCPN, of which the direction can be changed over time.

Cleaved Cochlin Sequesters Pseudomonas aeruginosa and Activates Innate Immunity in the Inner Ear.

In the inner ear, endolymph fluid surrounds the organ of Corti, which is important for auditory function; notably, even slight environmental changes mediated by trauma or infection can have significant consequences. However, it is unclear how the immune response is modulated in these tissues. Here, we report the local immune surveillance role of cleaved cochlin LCCL (Limulus factor C, Cochlin, and Lgl1) during Pseudomonas aeruginosa infection in the cochlea. Upon infection, the LCCL domain is cleaved from cochlin and secreted into the perilymph. This cleaved fragment sequesters infiltrating bacteria in the scala tympani and subsequently recruits resident immune cells to eliminate the bacteria. Importantly, hearing loss in a cochlin knockout mouse model is remedied by treatment with a cochlin LCCL peptide. These findings suggest cleaved cochlin LCCL constitutes a critical factor in innate immunity and auditory function and may be a potential therapeutic target to treat chronic otitis media-induced hearing loss.

Etiology-Specific Mineralization Patterns in Patients with Labyrinthitis Ossificans.

BACKGROUND AND PURPOSE: Our aim was to identify whether specific patterns of ossification in labyrinthitis ossificans are associated with the known risk factors. Labyrinthitis ossificans has been described as sequela of prior temporal bone trauma, prior infection, and other disorders including sickle cell disease. Specific patterns of mineralization in the membranous labyrinth associated with these risk factors has not been previously described. MATERIALS AND METHODS: This was a retrospective study evaluating temporal bone CT scans at our institution from November 2005 to May 2018 in patients with labyrinthitis ossificans. Membranous labyrinthine structures evaluated for ossification included the following: basal, middle, and apical cochlear turns; lateral, posterior, and superior semicircular canals; and the vestibule for both ears in all patients. These structures were assigned a severity score, 0-4, based on degree of mineralization. Clinical records were reviewed for potential labyrinthitis ossificans risk factors. Basic descriptive statistics and a mixed model were used to correlate the degree and patterns of ossification with clinical history. RESULTS: Forty-four patients (58 ears) with labyrinthitis ossificans were identified and evaluated. The most common risk factors were chronic otomastoiditis (n = 18), temporal bone surgery (n = 9), temporal bone trauma (n = 6), sickle cell disease (n = 5), and meningitis (n = 4). For all etiologies, the semicircular canals were most severely affected, and the vestibule was the least. In patients with prior temporal bone surgery, significantly greater mineralization was seen in the basal turn of the cochlea (P = .027), the vestibule (P = .001), and semicircular canals (P < .001-.008). No significant pattern was identified in patients with meningitis, sickle cell disease, or trauma. CONCLUSIONS: Significant patterns of mineralization in labyrinthitis ossificans were observed in patients with prior temporal bone surgery. For all etiologies, the semicircular canals were most severely affected. No significant mineralization pattern was observed in patients with chronic otomastoiditis, meningitis, sickle cell disease, or prior temporal bone trauma.

"Emergency" Cochlear Implantation in Labyrinthitis Ossificans Secondary to Polyarteritis Nodosa: How to Face a Rare Entity.

Polyarteritis nodosa (PAN) is a systemic vasculitis affecting the small- and medium-sized arteries that may present with hearing impairment. In rare cases, PAN may be associated with progressive labyrinthitis ossificans (LO), an otologic emergency requiring early cochlear implantation (CI) to restore hearing before the complete, irreversible cochlear ossification. We report the first case in the literature of a patient affected by PAN with bilateral sudden sensorineural hearing loss and rapid LO who underwent "emergency" bilateral simultaneous CI. This case report emphasizes the importance of an early audiological evaluation in patients with PAN when LO is suspected. Multidisciplinary approach is mandatory when facing organ-specific manifestations in patients with PAN. Detailed discussion is provided with particular regard to clinical and radiological presentation as well as CI outcomes in such a rare and challenging case.

Bilateral tympanokeratomas (cholesteatomas) with bilateral otitis media, unilateral otitis interna and acoustic neuritis in a dog.

BACKGROUND: An aural cholesteatoma, more appropriately named tympanokeratoma, is an epidermoid cyst of the middle ear described in several species, including dogs, humans and Mongolian gerbils. The cyst lining consists of stratified, keratinizing squamous epithelium with central accumulation of a keratin debris. This case report describes vestibular ganglioneuritis and perineuritis in a dog with chronic otitis, bilateral tympanokeratomas and presumed extension of otic infection to the central nervous system. CASE PRESENTATION: An 11-year-old intact male Dalmatian dog with chronic bilateral otitis externa and sudden development of symptoms of vestibular disease was examined. Due to the dog's old age the owner opted for euthanasia without any further examination or treatment and the dog was submitted for necropsy. Transection of the ears revealed grey soft material in the external ear canals and pearly white, dry material consistent with keratin in the tympanic bullae bilaterally. The brain and meninges were grossly unremarkable. Microscopical findings included bilateral otitis externa and media, unilateral otitis interna, ganglioneuritis and perineuritis of the spiral ganglion of the vestibulocochlear nerve and multifocal to coalescing, purulent meningitis. A keratinizing squamous epithelial layer continuous with the external acoustic meatus lined the middle ear compartments, consistent with bilateral tympanokeratomas. Focal bony erosion of the petrous portion of the temporal bone and squamous epithelium and Gram-positive bacterial cocci were evident in the left cochlea. The findings suggest that meningitis developed secondary to erosion of the temporal bone and ganglioneuritis and/or perineuritis of the vestibulocochlear nerve. CONCLUSIONS: Middle ear tympanokeratoma is an important and potentially life-threatening otic condition in the dog. Once a tympanokeratoma has developed expansion of the cyst can lead to erosion of bone and extension of otic infection to the inner ear, vestibulocochlear ganglion and nerve potentially leading to bacterial infection of the central nervous system.

Histopathology of the Human Inner Ear in the Cogan Syndrome with Cochlear Implantation.

The Cogan syndrome is a rare disorder characterized by nonsyphilitic interstitial keratitis and audiovestibular symptoms. Profound sensorineural hearing loss has been reported in approximately half of the patients with the Cogan syndrome resulting in candidacy for cochlear implantation in some patients. The current study is the first histopathologic report on the temporal bones of a patient with the Cogan syndrome who during life underwent bilateral cochlear implantation. Preoperative MRI revealed tissue with high density in the basal turns of both cochleae and both vestibular systems consistent with fibrous tissue due to labyrinthitis. Histopathology demonstrated fibrous tissue and new bone formation within the cochlea and vestibular apparatus, worse on the right. Severe degeneration of the vestibular end organs and new bone formation in the labyrinth were seen more on the right than on the left. Although severe bilateral degeneration of the spiral ganglion neurons was seen, especially on the right, the postoperative word discrimination score was between 50 and 60% bilaterally. Impedance measures were generally higher in the right ear, possibly related to more fibrous tissue and new bone found in the scala tympani on the right side.

Deterioration of Vestibular Cells in Labyrinthitis.

OBJECTIVE: To quantitatively assess the effect of serous labyrinthitis, suppurative labyrinthitis, and labyrinthitis ossificans on vestibular hair cells, dark cells, and transitional cells. METHODS: We examined human temporal bone specimens with serous labyrinthitis, suppurative labyrinthitis, and labyrinthitis ossificans, then compared them with age-matched control groups without labyrinthitis. We evaluated the density of type I and II vestibular hair cells, dark cells, and transitional cells in the peripheral sensorial organs. RESULTS: The mean density of type I vestibular hair cells in the maculae of the saccule significantly differed between the serous labyrinthitis group and its control group. The loss of type I and II vestibular hair cells in all of the peripheral sensorial organs was significantly higher in the suppurative labyrinthitis group than in its control group. The mean density of dark cells in the lateral and posterior semicircular canals was significantly lower in the suppurative labyrinthitis group than in its control group. The mean density of type I and II vestibular hair cells, dark cells, and transitional cells was significantly lower in the labyrinthitis ossificans group than in its control group. CONCLUSION: The loss of vestibular hair cells and degenerative changes in dark cells and transitional cells could affect vestibular function in patients with labyrinthitis.

Pathologic Findings of the Cochlea in Labyrinthitis Ossificans Associated with the Round Window Membrane.

OBJECTIVE: To quantitatively demonstrate and classify the histopathologic changes in the cochlea of the human temporal bones with labyrinthitis ossificans (LO). STUDY DESIGN: Comparative human temporal bone study. SETTING: Tertiary academic medical center. SUBJECTS AND METHODS: We compared 23 temporal bone specimens from 19 deceased donors with LO associated with the round window membrane (RWM) and 27 age-matched specimens from 20 deceased donors without any otologic diseases. We focused on the location of LO in the inner ear, the intensity of endolymphatic hydrops, the number of spiral ganglion cells and cochlear hair cells, and the areas of the stria vascularis and spiral ligament. In addition, we created a new pathologic grading system for temporal bone specimens from deceased donors with LO associated with the RWM. RESULTS: We most often observed LO in the scala tympani of the basal cochlear turn. In the LO group (as compared with the control group), the intensity of endolymphatic hydrops was significantly increased; the number of spiral ganglion cells was significantly decreased in all segments; the loss of outer and inner hair cells was significantly increased in all turns of the cochlea; the atrophy of the stria vascularis was significantly greater in all turns of the cochlea; and atrophy of the spiral ligament was significantly greater in the basal and middle cochlear turn. CONCLUSION: LO was associated with significant cochlear damage (to the spiral ganglion cells, cochlear hair cells, stria vascularis, and spiral ligament) and with increased intensity of endolymphatic hydrops.

Quantitative Assessment of Cochlear Histopathologic Findings in Patients With Suppurative Labyrinthitis.

IMPORTANCE: Better understanding of the effects of suppurative labyrinthitis (SL) on cochlear elements will aid the development of new approaches to treat its sequelae and complications in the ear. OBJECTIVE: To quantitatively evaluate the effects of SL on cochlear elements in humans. DESIGN, SETTING, AND PARTICIPANTS: A comparative study was conducted at a tertiary academic medical center from October 20, 2014, to January 3, 2015, of the histopathologic characteristics of 28 archived human temporal bone samples from 19 deceased patients with SL and 20 temporal bone samples from 14 deceased, age-matched controls. EXPOSURES: Evaluation of archived human temporal bone samples. MAIN OUTCOMES AND MEASURES: The locations of SL in the inner ear and the degree of endolymphatic hydrops were noted; the area of the stria vascularis and the spiral ligament in all turns of the cochlea at the midmodiolar level and in the adjacent 2 sections were measured; and the number of remaining outer and inner hair cells of the cochlea were counted to calculate the loss of both types of cells. To evaluate the loss of fibrocytes in the spiral ligament, a rating scale in each cochlear turn was used. For each segment of the cochlea, the number of spiral ganglion cells was determined. Outcomes between the group with SL and the control group were compared. RESULTS: Of the 28 temporal bone samples from the 19 deceased patients (16 men and 3 women; mean [SD] age, 23.1 [24.6] years) with SL, all showed SL in the scala tympani of the basal turn. In the group with SL vs the control group, the mean (SD) loss of outer hair cells was significantly higher in the lower (28.6% [11.4%] vs 12.4% [6.2%]; P = .02) and upper (22.3% [9.7%] vs 8.8% [3.2%]; P = .01) basal cochlear turn, the mean (SD) loss of inner hair cells was significantly higher in the lower (15.4% [6.7%] vs 2.6% [1.1%]; P = .02) and upper (10.6% [4.6%] vs 2.2% [0.7%]; P = .03) basal cochlear turn, the mean (SD) total number of spiral ganglion cells (28,132 [2068] vs 30,358 [2036]; P = .001) and the mean (SD) number of spiral ganglion cells in segment I (3554 [847] vs 4223 [649]; P = .003) was significantly decreased, the mean (SD) degree of atrophy of the stria vascularis in the lower (8455 [924] vs 9368 [1049] µm2; P = .003) and upper (7911 [837] vs 8474 [813] µm2; P = .02) basal cochlear turn was significantly greater, and the degree of endolymphatic hydrops was significantly greater (10 bone samples [36%] vs 1 [5%]; P = .006). No significant differences were found between the 2 groups in the number of fibrocytes and in the presence of atrophy of the spiral ligament in any cochlear turn. CONCLUSIONS AND RELEVANCE: This study demonstrates that SL can lead to cochlear damage, especially in the basal turn of the cochlea. These pathological observations have formed the basis for clinical findings of hearing loss and tinnitus detected in those patients with SL.

Differences in perilymphatic space enhancement and adverse inflammatory reaction after intratympanic injection of two different gadolinium agents: A 9.4-T magnetic resonance imaging study.

PURPOSE: To compare the inner ear enhancement after intratympanic injection of two widely used gadolinium (Gd) agents by 9.4 T micro-magnetic resonance imaging (MRI) and to investigate the effects of Gd on the inner ear. METHODS: Twelve ears of six rats received intratympanic administration of 1/5 diluted Gd agents: gadoterate meglumine (Gd-DTPA) for the left ear and gadodiamide (Gd-DTPA-BMA) for the right ear. MRI was performed every 30 min from 1 to 4 h after administration. The normalized signal intensity was evaluated by quantitative analysis at each cochlear fluid compartment. Eight, six, and seven ears treated with Gd-DTPA, Gd-DPTA-BMA, and nothing as controls, respectively, were processed for histological evaluation after MRI. After hematoxylin & eosin staining, adverse inflammatory reactions were evaluated for turbid aggregation and lymphocytes. RESULTS: The perilymphatic enhancement of Gd-DTPA was superior to that of Gd-DTPA-BMA regardless of cochlear turn, compartment, and time point. Inflammatory reactions were found in 4/8 (50.0%) and 4/6 (66.6%) ears administered Gd-DTPA and Gd-DTPA-BMA, respectively. Regardless of the contrast agent used, inflammatory reactions were most definite in the scala tympani of the basal turn, i.e., near the round window. Slightly greater inflammatory reactions were observed in ears injected with Gd-DTPA-BMA compared to Gd-DTPA although the difference was not statistically significant. No inflammatory reaction was observed in any of the seven controls. The auditory brainstem response threshold was 11.8 ± 2.5 dB SPL before IT Gd injection and it did not change for up to 5 days (15.4 ± 6.6 dB SPL) post-injection. CONCLUSIONS: Gd-DTPA was superior to Gd-DTPA-BMA for visualization of the inner ear. Administration of diluted Gd agents intratympanically may induce considerable inflammatory reactions in the inner ear.

Effects of Intralabyrinthine Hemorrhage on the Cochlear Elements: A Human Temporal Bone Study.

HYPOTHESIS: To compare histopathologic findings in the cochlea of human temporal bones with versus without intralabyrinthine hemorrhage. BACKGROUND: Hemorrhagic labyrinthitis can cause sensorineural damage, sudden hearing loss, and vertigo. Yet, to our knowledge, no studies have quantitatively described histopathologic effects of intralabyrinthine hemorrhage on the elements of the cochlea. METHODS: We analyzed 46 human temporal bone samples from 23 patients with unilateral intralabyrinthine hemorrhage (23 samples from ears with intralabyrinthine hemorrhage and 23 samples from contralateral ears without). We noted the location of hemorrhage in the inner ear, the degree of endolymphatic hydrops, the number of spiral ganglion cells and hair cells, mean loss of fibrocytes in spiral ligament, and areas of the stria vascularis and spiral ligament. RESULTS: Intralabyrinthine hemorrhage caused significant loss of outer hair cells in the lower basal (p = 0.001), upper basal (p = 0.005), and lower middle (p = 0.012) cochlear turns. The degree of endolymphatic hydrops was significantly different between the hemorrhagic and contralateral sides (p = 0.011). But we found no significant difference between the 2 sides in the number of inner hair cells, spiral ganglion cells, and fibrocytes, or in the areas of the stria vascularis and spiral ligament between the two groups (p > 0.05). CONCLUSION: These findings suggest that such patients could be good candidates for hearing aid or cochlear implant if they have profound sensorineural hearing loss.

Trichosporon asahii sepsis in a patient with pediatric malignancy.

Trichosporon asahii is a rare opportunistic infection, especially in children, causing a life-threatening fungal infection underlying hematologic malignancies. Predisposing factors for infection with this pathogen are immunodeficiency including underlying malignancy, organ transplantation, extensive burns, human immunodeficiency virus infection, corticosteroid therapy, prosthetic valve surgery, and peritoneal dialysis. In the literature, a breakthrough under caspofungin, micafungin therapy is reported. In this article we report on a 16-year-old patient with Ewing sarcoma who had T. asahii sepsis. The patient died although he had been receiving caspofungin for less than 3 months and amphotericin B therapy for 3 days. A postmortem study of conchal tissues revealed T. asahii and mucormycosis histopathologically, and blood culture grew T. asahii.

Clinical-pathological findings of otitis media and media-interna in calves and (clinical) evaluation of a standardized therapeutic protocol.

BACKGROUND: The aims of this field trial were to describe the clinical-pathologic findings in calves with otitis media (OM) and media-interna (OMI), to evaluate, through the development of a scoring system, the effectiveness of a standardized therapeutic protocol, and to identify the causative pathogens and their possible correlation with concurrent respiratory disease. All animals underwent physical and neurological examinations at three experimental time points: at diagnosis/beginning of treatment (T0), 1 week (T1) and 2 weeks (T2) after therapy was started, respectively. Follow-up telephone interviews with animal owners were conducted 1 month later. The therapeutic protocol consisted of tulathromycin (Draxxin®; Zoetis), oxytetracycline hydrochloride (Terramicina 100®; Zoetis), and carprofen (Rimadyl®; Zoetis). RESULTS: Twenty-two calves were enrolled. Physical and otoscopic examination at T0 revealed monolateral and bilateral otorrhea in 16 and 6 calves, respectively, with peripheral vestibular system involvement in calves presenting with neurological signs (n = 17; 77 %). A significant improvement of clinical and neurological scores was observed in 20 (90 %) calves, a full recovery in only 1 (5 %). One calf worsened between T0 and T1 and it was removed from the study. None of the other animals showed a worsening of clinical conditions and/or required further treatments at one month follow up. Mycoplasma bovis was isolated in 89 % of the affected ears either alone or together with P. multocida (n = 5), Streptococcus spp. (n = 1), Staphylococcus spp. (n = 1), and Pseudomonas spp. (n = 1). M. bovis either alone or together with these bacteria was also isolated from the upper and/or lower respiratory tract in 19 (86 %) calves. CONCLUSIONS: This is the first prospective study to evaluate the effectiveness of a standardized therapeutic protocol for the treatment of OM/OMI in calves. The therapy led to clinical improvement in the majority of the calves. Persistence of mild clinical-neurological signs did not compromise productive performance. The numerical scoring system for clinical and neurological signs permitted objective evaluation of response to therapy. M. bovis was the pathogen most often isolated. This finding should be considered in the treatment of OM/OMI in calves. Moreover, respiratory tract infection should not be underrated, since it is one of the major risk factors for the development of OM/OMI.

Refractory Positional Vertigo With Apogeotropic Horizontal Nystagmus After Labyrinthitis: Surgical Treatment and Identification of Dysmorphic Ampullae.

OBJECTIVES: To describe the rationale, intraoperative details, and histopathologic findings discovered when treating an unusual case of apogeotropic horizontal canal positional vertigo with a transmastoid labyrinthectomy. PATIENT: A single case report. INTERVENTION: Therapeutic. MAIN OUTCOME MEASURES: Resolution of apogeotropic nystagmus and improvement of positional vertigo. RESULTS: The apogeotropic variant of horizontal canal positional vertigo can be a difficult entity to treat. This report describes a patient who developed profound sensorineural hearing loss and vertigo after an acute left labyrinthitis. Ten months later, she developed vertigo with apogeotropic positional nystagmus involving the left horizontal semicircular canal. Particle repositioning maneuvers and vestibular physical therapy were unsuccessful. In addition, she developed intermittent positional vertigo affecting the ipsilateral vertical semicircular canals. Given the persistence of her vertigo, multiple canal involvement, and patient preference for definitive treatment, a transmastoid labyrinthectomy was performed. Intraoperatively, the ampulla of the horizontal canal as well as that of the other canals was grossly abnormal as later confirmed on histology. After surgery, her apogeotropic nystagmus and vertigo resolved, and her balance ability gradually improved to a highly functional level. CONCLUSION: This case illustrates a unique form of positional vertigo that developed and persisted after acute labyrinthitis. Conservative measures were unsuccessful and a transmastoid labyrinthectomy documented dense inflammatory tissue involving all three ampullae. We postulate that the post-labyrinthitic inflammatory changes resulted in mass loading of the membranous ampullae, causing abnormal nystagmus patterns and positional vertigo, which resolved after the labyrinthectomy.