One-Year Results for Patients with Unilateral Hearing Loss and Accompanying Severe Tinnitus and Hyperacusis Treated with a Cochlear Implant.

OBJECTIVE: To show that patients with unilateral hearing loss (UHL), with one ear fulfilling cochlear implant (CI) indication criteria, and an additional severe tinnitus handicap can be treated effectively with a CI. METHOD: A prospective multi-centre study was conducted in five Spanish centres. Sixteen adult patients with UHL and a mean Tinnitus Handicap Inventory (THI) score of at least 58 were implanted. The study design included repeated within-subject measures of quality of life (Health Utility Index Mark 3 [HUI3]), tinnitus (THI, Visual Analogue Scale [VAS] on tinnitus loudness), hearing (Speech, Spatial, and Qualities of Hearing Scale- [SSQ]), and hyperacusis (Test de Hipersensibilidad al Sonido [THS]) up to 12 months after the initial CI fitting. RESULTS: Group data showed significant subjective benefit from CI treatment: the preoperative HUI3 total utility score of 0.45 went up to 0.57 at 6 months and 0.63 at 12 months; the preoperative THI total score of 75 decreased to 40 at 6 months and 35 at 12 months. The preoperative tinnitus loudness VAS score of 8.2 decreased to 2.4 at 6 months and 2.2 at 12 months with the implant "On" and to 6.7 at 6 months and 6.5 at 12 months with the implant "Off." The preoperative THS total score of 26 decreased to 17 at 12 months. The preoperative SSQ total score of 4.2 increased to 5.1 at 6 months and 6.3 at 12 months. No unanticipated adverse events were reported during the study period. At 12 months after CI activation all subjects (except 1 subject who used the device 6 days a week) wore their devices all day and every day. The primary reason for CI use was split evenly between tinnitus suppression (n = 6) and both hearing and tinnitus (n = 6). CONCLUSION: A CI should be considered as a treatment option in patients with UHL and a concomitant severe tinnitus handicap. However, appropriate counselling of candidates on the anticipated risks, benefits, and limitations that are inherent to cochlear implantation is imperative.

Contemporary non-echo-planar diffusion-weighted imaging of middle ear cholesteatomas.

Middle ear cholesteatoma is a common inflammatory disease that requires surgery due to potentially serious intracranial complications. Diagnosis of cholesteatoma is mainly clinical, with computed tomography (CT) used to evaluate disease extension before surgery. Certain patterns of bone erosion are specific, but CT attenuation does not allow differentiation from other inflammatory middle ear diseases. With its high tissue discrimination and contrast resolution, magnetic resonance imaging is valuable in diagnosis of cholesteatomas. Absent enhancement at delayed postcontrast imaging has been used for diagnosis. Diffusion-weighted imaging (DWI) is highly specific due to the high keratin content of cholesteatomas. New non-echo-planar DWI sequences, such as periodically rotated overlapping parallel lines with enhanced reconstruction, are superior to conventional echo-planar DWI, since they minimize susceptibility artifacts at the skull base and increase sensitivity for detection of lesions as small as 2 mm. This technique is indicated when clinical diagnosis is difficult and high tissue specificity is necessary, as in congenital, temporal bone, or atypical acquired middle ear cholesteatomas and residual or recurrent disease after surgery. Non-echo-planar DWI has been proposed for screening of postsurgical (residual or recurrent) cholesteatomas, thus obviating many second-look revision surgeries, especially after more conservative canal wall up surgery.

[Clinical symptoms of equilibrium disorders in patients with whiplash syndrome]. / Expresión clínica de las alteraciones del equilibrio en pacientes con síndrome de latigazo cervical.

INTRODUCTION AND OBJECTIVE: There are many entities that cause equilibrium disorders. Whiplash syndrome is becoming an important entity as a trigger of equilibrium disorders because of an increase in traffic accidents. There are many hypotheses on the generation of vertigo and dizziness in whiplash syndrome. The objective of this study is to describe and analyze the clinical symptoms of patients who suffered whiplash. MATERIAL AND METHOD: Thirty six patients with equilibrium disorders who suffered whiplash syndrome were studied prospectively. None of these subjects had cranial trauma or a history of vestibular pathology prior to the traffic accident. We conducted an exhaustive anamnesis, videonystagmography and cervical magnetic resonance. Patients were classified by type of equilibrium symptom and degree of cervical lesion. RESULTS: 55.5 % of patients had a sensation of dizziness associated with postural and cephalic movements, 38.8 % had disequilibrium continuously, and 16.7 % (6 cases) had vertigo. Three of this last group had a diagnosis compatible with benign positional vertigo but this diagnosis was confirmed in only 2 patients; two patients had labyrinth commotion and one patient had vertigo of unknown origin. CONCLUSIONS: In patients with whiplash, the most frequent equilibrium symptom is the sensation of fleeting dizziness associated with head movements, while only a small group suffer from vertigo. Although vestibular tests are normal in most patients, we cannot rule out the existence of otolithic lesions.

[Contribution of the vestibular evoked myogenic potentials to the study of the vestibular neuritis]. / Aportación del potencial vestibular miogénico evocado al estudio de la neuritis vestibular.

INTRODUCTION: Until recently, the only tests available to provide information about vestibular function were caloric and kinetic tests, which only give us information about the external semicircular canal and the superior vestibular nerve. In recent years the development of vestibular evoked myogenic potentials has allowed us to assess the saccule and the inferior vestibular nerve. Our aim is, by studying the caloric test results as well as the vestibular evoked myogenic potentials in patients with Vestibular Neuritis, to determine whether they have involvement of the superior, inferior or both vestibular nerves. MATERIAL AND METHODS: Retrospective study of 9 patients with Vestibular Neuritis admitted to a tertiary care hospital. We studied them by means of anamnesis, otoneurological clinical examination, caloric test and vestibular evoked myogenic potentials. Their clinical progress after admission and any residual instability were also studied. RESULTS: Women were more affected (66.6 %) than males. The mean age for presentation of the disease was 53.8 +/- 14.0 years. Hospital stays lasted for 5.7 +/- 3.2 days. After their crises, they suffered from instability for 122 +/- 114 days. Four cases were diagnosed as Complete Vestibular Neuritis and five as Superior Vestibular Neuritis. P13 wave latency was normal in all cases. There were no differences between the groups in terms of the length of hospital stay nor residual instability. CONCLUSIONS: Nowadays, vestibular evoked myogenic potentials make it possible to advance further in the study of Vestibular Neuritis. Complete and superior vestibular neuritis are much more frequent than inferior vestibular neuritis. Clinical behaviour is similar in the sub-types found.

[How middle-ear implants work]. / Mecanismo de funcionamiento de los implantes de oído medio.

Middle-ear implants consist of a microphone, an audioprocessor, a battery, a receiver and a transducer. Transducers can be classified in three groups: piezoelectric, electromagnetic, and electromechanical. The middle ear transducer (MET) system (Otologics) is composed of an outer part that uses a multichannel digital acoustic signal processing system that transforms this acoustic signal into an electromagnetic stimulus. This system has fully implantable devices. The Vibrant Med El Soundbrige uses an electromagnetic design in which a floating mass transducer is crimped around the long process of the incus by a titanium strap, transmitting vibration to the ossicular chain.

Response Over Time of Vertigo Spells to Intratympanic Dexamethasone Treatment in Meniere's Disease Patients.

OBJECTIVE: To assess the effectiveness and response over time of intratympanic dexamethasone on the symptoms of Meniere's disease. MATERIALS AND METHODS: We performed a matched cohort study of 24 patients with Meniere's disease who were unresponsive to initial treatment and underwent 3 sessions of weekly intratympanic dexamethasone injections using a concentration of 16 mg/mL and 24 matched controls with the same characteristics with regard to vertigo spells. RESULTS: Compared with control subjects, intratympanic dexamethasone injections resulted in a decrease in the frequency of vertigo spells in the first 6-month period. In the dexamethasone-treated group, a ≥60% decrease in vertigo spells was achieved by 70.8% of patients in the first 6 months. Total remission was achieved by 20.8% of patients in the first 8 months, but after this, the effect tapered. A slight improvement in Tinnitus loudness and no changes in hearing levels were found. The stage of Meniere's disease, years from disease onset, and mean number of vertigo spells per month did not have any effects on the percentage of decrease in vertigo spells. CONCLUSION: Intratympanic dexamethasone temporarily reduces the frequency of vertigo spells during the initial months but does not remove the probability of having further spells in the future. This therapy provides a valuable tool to accomplish a rapid decrease in vertigo spells in subjects with Meniere's disease, and it is considered an alternative to chemical or surgical labyrinthectomy.

Increased Velocity Storage in Subjects with Meniere's Disease.

OBJECTIVE: Velocity storage mechanism is a multisensory rotation estimator; it compensates for errors in the information provided by the peripheral vestibular organs by means of an adjustment in the duration of the vestibular signal. The aim of this study was to determine the activity of the velocity storage mechanism in the presence of a labyrinthine disorder, using galvanic vestibular stimulation to cause direct activation of the vestibular afferent neurons. MATERIALS AND METHODS: Forty-one subjects with definite Meniere's disease (MD) and 36 healthy volunteers were evaluated using a 20-s galvanic vestibular stimulation. RESULTS: We found a post-stimulus nystagmus overshoot exclusively in subjects with MD (47% in subjects with unilateral disease and 82% in subjects with bilateral disease), but no overshoot in healthy subjects. CONCLUSION: Because post-stimulus nystagmus overshoot is caused by the velocity storage mechanism, this finding suggests an increase in the velocity storage in subjects with a labyrinthine disease.

Malformation of the eighth cranial nerve in children. / Malformaciones del octavo par en niños.

INTRODUCTION AND OBJECTIVES: Prevalence of congenital sensorineural hearing loss (SNHL) is approximately 1.5-6 in every 1,000 newborns. Dysfunction of the auditory nerve (auditory neuropathy) may be involved in up to 1%-10% of cases; hearing losses because of vestibulocochlear nerve (VCN) aplasia are less frequent. The objectives of this study were to describe clinical manifestations, hearing thresholds and aetiology of children with SNHL and VCN aplasia. METHODOLOGY: We present 34 children (mean age 20 months) with auditory nerve malformation and profound HL taken from a sample of 385 children implanted in a 10-year period. We studied demographic characteristics, hearing, genetics, risk factors and associated malformations (Casselman's and Sennaroglu's classifications). Data were processed using a bivariate descriptive statistical analysis (P<.05). RESULTS: Of all the cases, 58.8% were bilateral (IIa/IIa and I/I were the most common). Of the unilateral cases, IIb was the most frequent. Auditory screening showed a sensitivity of 77.4%. A relationship among bilateral cases and systemic pathology was observed. We found a statistically significant difference when comparing hearing loss impairment and patients with different types of aplasia as defined by Casselman's classification. Computed tomography (CT) scan yielded a sensitivity of 46.3% and a specificity of 85.7%. However, magnetic resonance imaging (MRI) was the most sensitive imaging test. CONCLUSIONS: Ten percent of the children in a cochlear implant study had aplasia or hypoplasia of the auditory nerve. The degree of auditory loss was directly related to the different types of aplasia (Casselman's classification) Although CT scan and MRI are complementary, the MRI is the test of choice for detecting auditory nerve malformation.

The role of diffusion-weighted magnetic resonance imaging in cholesteatoma diagnosis and follow-up. Study with the diffusion PROPELLER technique.

INTRODUCTION AND OBJECTIVES: The diagnosis of cholesteatoma is based on clinical evaluation and computed tomography. New non-echo-planar diffusion-weighted magnetic resonance imaging (MRI) techniques, without intravenous contrast, are capable of differentiating cholesteatoma from inflammatory tissue, cholesterol granuloma and granulation tissues. The technique is very helpful in differential diagnosis of cholesteatoma, mainly after canal wall-up tympanoplasty surgery, to avoid routine second-look surgery in these patients. Congenital cholesteatoma and difficult cases can be detected and correctly diagnosed as well. The aim of this study was to evaluate sensitivity, specificity, positive predictive value and negative predictive value of the diffusion-weighted PROPELLER MRI in cholesteatoma diagnosis. METHODS: A prospective study was performed on 52 patients. Clinical and surgical findings were correlated with diffusion-weighted PROPELLER MRI results. RESULTS: Sensitivity, specificity and positive and negative predictive values were 92.85%, 92.30, 92.85 and 92.30%, respectively. CONCLUSIONS: Diffusion-weighted PROPELLER imaging is an effective technique in cholesteatoma diagnosis. It is capable of detecting lesions larger than 2mm.

Recurrent meningitis associated with Duane syndrome type I.

We present the case of a 17-month-old male patient with a bilateral Duane syndrome type 1 associated to unilateral cochleovestibular dysplasia, perilymphatic fistula and recurrent meningitis. Diagnosis was carried out by MRI and CT scan. His management and treatment are described, as well as the postoperative evolution. We believe this is an exceptional case due to the low frequency of this syndrome, as well as to the otoneurological complications.

[Peripheral vertigo classification of the Otoneurology Committee of the Spanish Otorhinolaryngology Society: diagnostic agreement and update (version 2-2011)]. / Clasificación de los vértigos periféricos de la Comisión de Otoneurología de la Sociedad Española de Otorrinolaringología: concordancia diagnóstica y actualización (versión 2, año 2011).

INTRODUCTION: In 2008, the Otoneurology committee of the SEORL-PCF published a classification of peripheral vertigo, based on clinical criteria. The objective of this study was to validate this classification through analysing the diagnostic agreement among several medical assessors. METHODS: Seven medical assessors, all with clinical experience, from 6 different hospitals, participated in the study. One of them selected the clinical histories of 50 consecutive patients who had consulted as a result of balance disorders (24 men and 26 women) with an average age of 53.5 years. These clinical histories -without any information that would identify the patient, the diagnosis established and the treatment- were sent to another 6 assessors. Each of these investigators established their own diagnosis, trying to adjust it to the epigraphs of the classification. RESULTS: Of the 50 patients, there was substantial agreement as to the diagnosis (4 or more evaluators indicated the same one) in 31 cases (26 with a positive diagnosis and 5 with a negative one, which could not be included in any epigraph). The kappa index, which measures the level of accordance between 2 or more assessors, was 0.4198 (moderate level of agreement). Unanimity was achieved in only 7 cases (4 BPPV, 2 Ménière's disease and 1 vertigo associated with migraine). CONCLUSIONS: The current classification, with the criteria it includes, allows labelling with an acceptable consensus to only 62% of the patients. Therefore, a modification in the classification is proposed in relation with the probable BPPV epigraph, as well a revision of the entries for vertigo-migraine and vertigo associated with migraine.