Comparison of Video Head Impulse Test with Posterior Semicircular Canal Plane and Cervical Vestibular Evoked Myogenic Potential / 대한평형의학회지

OBJECTIVE: Cervical vestibular evoked myogenic potential (cVEMP) is thought to be assessing the function of the saccule and inferior vestibular nerve. Therefore, cVEMP indirectly reflects the function of the posterior semicircular canal. Recently, the video head impulse test (vHIT) is considered as useful clinical tool to detect each semicircular canal dysfunction. Goal of this study was to evaluate and compare the results of cVEMP with posterior canal plane of vHIT (p-vHIT). METHODS: Retrospectively, we compared the results of cVEMP with p-vHIT in 43 patients who visited with dizziness. We analyzed the inter-test agreement of cVEMP with p-vHIT. RESULTS: Positive asymmetry of cVEMP was present in 37.2% (16/43), and no responses of both ears were identified in 16.3% (7/43). In p-vHIT analysis, unilateral positive was 27.9% (12/43), bilateral positive was 11.6% (5/43) and negative in both sides was 60.5% (26/43). The inter-test agreement between cVEMP and p-vHIT was 75.8% (25/33) as we considered even in lesion side. And, Fleiss's kappa value showed a fair to good agreement (kappa value=0.559). In bilateral no response group (7 patients) in cVEMP, variable additional information could be obtained using p-vHIT. CONCLUSION: cVEMP and p-vHIT showed relatively lower inter-test agreement than expected. But, p-vHIT could be easily performed, and give additional information for differential diagnosis.

A Case of Vestibular Schwannoma with Acute Spontaneous Vertigo / 대한이비인후과학회지

Vestibular schwannoma (VS) is a rare benign tumor arising from the vestibular portion of the 8th cranial nerve. Patients with VS complain of diverse symptoms, such as asymmetrical hearing loss, tinnitus, vertigo, and unsteadiness. The most common symptom of VS is unilateral and gradual loss of hearing, which may also be associated with tinnitus. We experienced an unusual case of 62-year-old woman, who presented with acute vertigo without any typical otologic symptoms of hearing loss and tinnitus. Because of the unusual symptom, the patient was initially diagnosed with vestibular neuronitis. However, atypical nystagmus was presented after head shaking test. Internal auditory canal MRI scanning confirmed the diagnosis of VS. We removed the patient's VS by middle cranial fossa approach. We present this case with a review of relevant peer-reviewed medical articles and literature.

Tumarkin Otolithic Crisis Controlled by Endolymphatic Sac Surgery / 대한평형의학회지

Turmarkin otolithic crisis is a rare feature of Meniere's disease. It shows sudden falling to the ground with no warning sign. It is an otologic emergency because of the risk of falling, and it has traditionally been treated with labyrinthectomy or vestibular neurectomy. We experienced a 49-year-old male suffering from recurrent drop attack, and found that he had hearing loss, tinnitus or recurrent vertigo on his left ear, and could make a diagnosis him as Tumarkin otolithic crisis. We have performed the endolymphatic sac decompression, considering the hearing preservation and therapeutic opinion of patients. Two years after surgery, he showed intermittent, mild dizzy symptoms, without further drop attack. Therefore, we report our clinical experience with a brief review of literature.

A Case of Foreign Bodies in Middle Ear and Eustachian Tube When Making Impression of Hearing Aid / 대한이비인후과학회지

Making impression is the first step of making hearing aid. Because it needs silicon injection on external auditory canal and lateral side of tympanic membrane, careful evaluation is required regarding the presence of any tympanic perforation or problems of external auditory canal prior to making ear impression. Recently, we experienced encountering one case of foreign body in ear while making impression of hearing aid by a local hearing aid seller. Silicone mold material, impacted into the middle ear, had perforated the tympanic membrane; a metallic foreign body was also found in the eustachian tube. Reporting this case, we suggest that special attention be paid to tympanic membrane and external auditory canal conditions when making an ear impression for hearing aids. Therefore, physical examination by otolaryngologist should precede any application of hearing aid.

A Case of Multiple Sclerosis with Isolated Vertigo / 대한이비인후과학회지

Multiple sclerosis (MS) is a chronic disease characterized by multiple areas of demyelination, inflammation, and glial scarring in the central nervous system. MS is the most common chronic and usually progressive neurologic disease whose clinical course varies from a benign and symptom-free disease to a rapidly progressive and disabling disorder. MS can be presented with various symptoms, but isolated vertigo, represented in only 5%, is very rare. Nevertheless, in such a case, differential diagnosis of peripheral vestibular disease is very important for neuro-otologist. We recently experienced a 39 year-old female patient of multiple sclerosis with isolated vertigo mimicking vestibular neuritis. We report our case with a review of literature.

Acute Central Vertigo / 대한이비인후과학회지

Acute vertigo is a common symptom at the otolaryngology clinics or the Emergency Department. Also, many otolaryngologists see these patients first or they are referred from the Emergency Department. Although the stroke incidence in all dizzy patients is relatively low, the misdiagnosis of central vertigo may lead to serious morbidity and even mortality. Nevertheless, it is difficult to diagnose in vertigo patients whether the origin is central or not, especially at the initial visit. The purpose of this clinical review was to investigate clinical findings of acute central vertigo and to suggest the recent advance of differential diagnosis in these patients from peripheral vestibulopathy. We also suggest an appropriate practice for the radiologic investigation in these patients.

Two Cases of Central Vertigo Presenting as Apogeotropic Direction Changing Positional Nystagmus / 대한평형의학회지

Positional vertigo and nystagmus without focal neurological symptoms and signs are characteristic features of benign paroxysmal positional vertigo (BPPV). And the apogeotropic positional nystagmus can be diagnosed as cupulolithiasis of the horizontal semicircular canal. However, cerebellar lesion involving especially nodulus could be initially presented as positional vertigo like a BPPV without other neurologic signs. In most of the patients with cerebellar involvement, initial presentation shows dysarthria, ataxia, headache, nausea, vomiting and unsteadiness. But in some central lesions, positional nystagmus might be observed in head roll test as if BPPV was presented. It is very important for clinicians of dizziness care unit to differentiate central positional vertigo (CPV) from BPPV. But it is difficult to diagnose CPV at initial visit by history and physical exam only. Therefore, we introduce two cases with cerebellar infarction and hemorrhage initially presenting isolated positional vertigo mimicking BPPV.

Two Cases of Cerebellar Hemangioblastoma with Isolated Vertigo / 대한평형의학회지

Hemangioblastoma is solid or cystic benign vascular tumor that may arise anywhere in the body. It is rarely presented tumor accounting for only 1% to 2.5% of all intracranial neoplasms. Usually, hemangioblastoma is located in the cerebellum and posterior cranial fossa and it occurs in a variety of symptoms depending on where the tumor is located. The initial symptoms in 80% to 90% of hemangioblastoma patients are headache and vomiting due to elevated intracranial pressure, and also dizziness and balance problems are initially presented in about half of the patients. We experienced 2 cases of hemangioblastoma who presented with isolated vertigo. All of them initially showed unidirectional spontaneous nystagmus during head impulse test. Finally, hemangioblastoma of the cerebellum has been diagnosed on magnetic resonance imaging scan. In one case, the tumor was successfully removed by retrosigmoid approach and the other case was treated conservatively due to pregnancy.

The Efficiency of Simultaneous Binaural Ocular Vestibular Evoked Myogenic Potentials: A Comparative Study with Monaural Acoustic Stimulation in Healthy Subjects

OBJECTIVES: To evaluate the test-retest reliability and convenience of simultaneous binaural acoustic-evoked ocular vestibular evoked myogenic potentials (oVEMP). METHODS: Thirteen healthy subjects with no history of ear diseases participated in this study. All subjects underwent oVEMP test with both separated monaural acoustic stimulation and simultaneous binaural acoustic stimulation. For evaluating test-retest reliability, three repetitive sessions were performed in each ear for calculating the intraclass correlation coefficient (ICC) for both monaural and binaural tests. We analyzed data from the biphasic n1-p1 complex, such as latency of peak, inter-peak amplitude, and asymmetric ratio of amplitude in both ears. Finally, we checked the total time required to complete each test for evaluating test convenience. RESULTS: No significant difference was observed in amplitude and asymmetric ratio in comparison between monaural and binaural oVEMP. However, latency was slightly delayed in binaural oVEMP. In test-retest reliability analysis, binaural oVEMP showed excellent ICC values ranging from 0.68 to 0.98 in latency, asymmetric ratio, and inter-peak amplitude. Additionally, the test time was shorter in binaural than monaural oVEMP. CONCLUSION: oVEMP elicited from binaural acoustic stimulation yields similar satisfactory results as monaural stimulation. Further, excellent test-retest reliability and shorter test time were achieved in binaural than in monaural oVEMP.

Is BPPV a Prognostic Factor in Idiopathic Sudden Sensory Hearing Loss?

OBJECTIVES: The prognostic significance of vertigo in patients with idiopathic sudden sensorineural hearing loss (SSNHL) remains a matter of debate because vertigo is associated with many different vestibular disorders. The purpose of this study is to determine the role of benign paroxysmal positional vertigo (BPPV) as a prognostic factor in patients with SSNHL. METHODS: We conducted a retrospective study of 298 patients with SSNHL. Hearing outcomes were evaluated by assessments of pre-treatment hearing and hearing gain. Comparative multivariate analyses between prognostic factors and hearing outcome were conducted. RESULTS: Thirty-eight (12.7%) SSNHL patients were found to also have BPPV. BPPV showed significant negative prognostic factors in hearing outcome on multivariate analysis (odds ratio, 0.15). In comparison to average pure tone audiometry (PTA), patients diagnosed with SSNHL with BPPV exhibited poorer hearing in pre- and post-treatment PTA compared to SSNHL without BPPV. Old age (>60 years), pre-treatment hearing, and canal paresis were significant outcome predictors. CONCLUSION: BPPV in SSNHL patients, representing definitive vestibular damage, was closely related to poor prognosis.

Electrophysiologic Response of the Vestibular Afferents and Efferents / 대한평형의학회지

No abstract available.

A Case of Vestibular Neuronitis Followed by Mumps Parotitis in a Pediatric Patient / 대한이비인후과학회지

Vestibular neuronitis is characterized by sudden onset of vertigo, horizonto-rotatory spontaneous nystagmus, loss of caloric response on the affected side with normal otoscopic findings, normal hearing and no other neurological deficit. The pathogenesis of the disease is still unproven, though the viral origin is strongly considered. Herpes simplex virus-type 1, Mumps virus, Rubella virus, Cytomegalovirus, Ebstein-Barr virus may have a role in the disease. Mumps virus is among the other rare causes, so we introduce a case of 13-year old girl who developed sudden vertigo with spontaneous nystagmus, nausea, and vomiting preceded by mumps in her left parotid one week ago. She was diagnosed as a vestibular neuronitis clinically, and serum IgM Ab of mumps virus was detected positive. This case supports the possible role of mumps virus in the etiology of vestibular neuronitis.

Assessment of Residual Subjective Symptoms after Canalith Repositioning Procedure in Benign Paroxysmal Positional Vertigo / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Canalith repositioning procedure (CRP) provides rapid and long-lasting relief of symptoms in most patients with benign paroxysmal positional vertigo (BPPV). However, some patients express nonspecific symptoms such as anxiety or discomfort after CRP, even after the disappearance of nystagmus and vertigo. The purpose of this study is to assess the residual symptoms after CRP in patients with BPPV using questionnaire. SUBJECTS AND METHOD: CRP was performed in 135 patients until nystagmus and vertigo disappeared, and the patients were asked to complete the Dizziness Handicap Inventory (DHI) before and five to seven days after treatment. For the control group, 135 normal volunteers were selected, and cross matched according to the age and sex with the patient group. The DHI were compared among pre CRP, post CRP and control group. RESULTS: There were statistically significant differences between the pre-CRP and post-CRP DHI scores and also between the post-CRP and control group. Comparison between the pre and post-CRP DHI scores, and post-CRP and control group both showed incomplete improvement with respect to some items. CONCLUSION: Even after the successful CRP, DHI scores indicated incomplete recovery and residual subjective symptoms was presented. Thus, additional follow up and management may be needed.

A Case of Cerebellar Hemangioma Mimicking Peripheral Vestibulopathy

Central vertigo of cerebellar origin may present the syndromes similar to those of peripheral vertigo such as vestibular neuronitis. The character of those vertigo syndrome depend on the location, extent, and the etiology of the lesion such as stroke, inflammation, mass. Cavernous hemangioma may be clinically silent, but can cause variable neurologic manifestations including central vertigo if it affects the vestibular system. We report a rare case of cerebellar cavernous hemangioma with the vertigo syndrome closely mimicked vestibular neuronitis.

Vocal Analysis Related to Changes in Frequency of Pure Tone Auditory Feedback

PURPOSE: Many studies have shown that subjects show a change of vocal fundamental frequency (F0) when phonating subjects hear their vocal pitch feedback shifted upward or downward. This study was performed to demonstrate whether vocal parameters [F0, intensity, jitter, shimmer, and noise to harmonic ratio (NHR)] in normal males respond to changes in frequency of pure tone masking. MATERIALS and METHODS: Twenty healthy male subjects participated in this study. Subjects vocalized /a/ vowel sounds while listening to a pitch- shift pure tone through headphones (upward pitch-shift in succession: 1kHz to 2kHz and 1kHz to 4kHz at 50dB or 80dB, respectively, downward pitch-shift in succession: 1kHz to 250Hz and 1kH to 500Hz at 50dB or 80dB, respectively). RESULTS: Vocal intensity, F0, was increased, whereas jitter was decreased as the pitch of pure tone was shifted upward. However, there was no correlation between shimmer and NHR with pitch-shift feedback for pure tones. Unlike vocal pitch- shift feedback in other studies, upward pitch-shift feedback of pure tones caused the vocal F0 and intensity to change in the same direction as pitch-shift. CONCLUSION: The results of this study demonstrated that auditory kinesthetic feedback is affected by pitch-shift in pure tone.

Surgical Treatment Using an Allograft Dermal Matrix for Nasal Septal Perforation

PURPOSE: Numerous methods have been utilized to repair nasal septal perforation with varying degrees of success; however, no consensus has been reached on nasoseptal perforation repair. Here, the authors describe a surgical method based on human dermal allograft (Surederm(TM), Hans Biomed Corp. Korea) for the repair of nasal septal perforations. MATERIALS AND METHODS: Eleven patients with a nasal septal perforation were included in this study. The causes of these septal perforations included previous nasal surgery, trauma, foreign body (button battery), and idiopathy. There were several sites of perforation: 9 in the central area, 1 in the posterior-central area, and 1 in the anterior area. An interpositional graft incorporating Surederm(TM) was positioned between bilateral mucoperichondrial flaps using an intranasal approach. A silastic sheet was then left in the nasal septum bilaterally until complete healing had occurred through new nasal mucosa, which took a mean duration of 6 weeks. RESULTS: Outcomes in ten of the eleven patients were successful, with complete septal perforation closure. The remaining perforation, which was caused by a button battery, closed incompletely; however, its initial size of 2cm was reduced to 5mm. CONCLUSION: The described technique has a high success rate and can be performed under local anesthesia without external scarring. In the absence of donor site morbidity, this technique can also be utilized to repair posterior or multiple septal perforations without difficulty.

A Case of Familial Otosclerosis / 대한이비인후과학회지

Otosclerosis is a primary metabolic bone disease of the otic capsule and ossicles. It is one of the causes of acquired hearing loss, with clinical manifestations occurring in approximately 1% of individuals in some populations in the Western countries. Although the cause of otosclerosis is undetermined, the disease has a well established hereditary predisposition, with approximately half of all affected individuals having family members known to be affected. Many genetic studies of otosclerosis support an autosomal dominant mode of inheritance with penetrance in the range of 20-40%. There have been a few reports of the clinically suspicious otosclerosis cases in Korea, but otosclerosis having familial forms have not been reported. We report one case of familial otosclerosis.

Results of Ossiculoplasty with Kurz Titanium Prosthesis / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Various materials have been used for ossicular reconstruction, but there have been no reports for titanium prosthesis in South Korea. The purpose of this study was to assess the hearing results of Kurz titanium prosthesis in chronic ear diseases. SUBJECTS AND METHOD: A retrospective review was made of 62 cases who underwent ossicular reconstruction using either titanium (TTP(R)-VARIO System) or plastipore (Polycel(R)) prosthesis from January 2003 to July 2005. Postoperative hearing results were analyzed taking in several prognostic factors such as the condition of middle ear mucosa and ossicle, or surgical method. RESULTS: A postoperative air-bone gap of E20 dB was obtained in 75.6% of the titanium and 56% of plastipore ossiculoplasty. The Postoperative ABG (air bone gap) show better results in healthy middle ear mucosa and in those cases which contain stapes superstructure. CONCLUSION: Titanium have a good biocompatibility and low extrusion rates with excellent hearing results. Besides, good visualization and accurate placement were easy to achieve.

Clinical Manifestations of Headache in Meniere's Disease

BACKGROUND AND OBJECTIVES: A possible link between Meniere's disease (MD) and headache was originally suggested by Prosper Meniere. We aimed to analyze the clinical manifestation of headache in definite MD compared with benign paroxysmal positional vertigo (BPPV) as a control group. MATERIALS AND METHODS:We examined headache in 67 patients with definite MD according to the criteria of the American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS). Sex- and age-matched 67 patients with BPPV served as a control group. Information was obtained concerning the prevalence, localization, severity, character, sequence of headache and response to therapy. RESULTS: Altogether 60 MD patients (90%) and 47 BPPV patients (70%) was reply the questionnaire. 46 MD patients (69%) and 15 BPPV patients (22%) reported headache. Headache was moderate to severe in 39 MD patients (85%) and as a whole more severe than that of the BPPV patients (P<0.05). Temporal area was the most frequently involved region in MD group, whereas posterior neck area was most frequent in BPPV group. The sequence of headache and vertigo attack was pre-(23%), intra-(33%), after-(44%). The 39 patients (89%) of headache in MD was response to the vestibular suppressants, diuretics, calcium channel blocker. CONCLUSION: It is concluded that high incidence of headache and migraine in combination with MD seems to common pathophysiology with migraine. Therefore, our results could provide predictive value in the treatment and follow up of MD patients with headache.

Clinical Characteristics of Secondary BPPV

BACKGROUND AND OBJECTIVE: The purpose of this study was to identify clinical characteristics of secondary form of BPPV. MATERIALS AND METHODS:Of 384 patients with BPPV, 82 patients have a ipsilateral inner ear disease to the BPPV. We reviewed the site of lesion, duration of treatment in secondary BPPV and compared with idiopathic BPPV. RESULTS: The site of canal affected by idiopathic BPPV (M=119, F=183) showed that 138 (Lt=62, Rt=76) had a lateral canal, 157 (Lt=63, Rt=94) had a posterior canal, 7 had a multicanal. The involved canal by secondary BPPV (M=45, F=37) showed that 34 had a lateral canal, 43 in posterior canal, 1 in anterior canal and 4 in multicanal. 28 patients with idiopathic sudden sensory hearing loss developed BPPV within a few days (posterior=17, lateral=7, multicanal=4). 12 patients had a unilateral peripheral vestibulopathy and ipsilateral BPPV (posterior=11, lateral=1, anterior canal=1). 14 patients with meniere's disease developed ipsilateral BPPV (Lateral=9, posterior=5). 28 patients with BPPV had a history of headtrauma which is considered to be cause of BPPV. The mean duration of treatment is 2.68 on idiopathic BPPV, 6.27 on BPPV with ISSHL, 6.75 on BPPV with unilateral vestibulopathy, 2.28 on BPPV with meniere's disease and 2.4 on posttraumatic BPPV. There was no significant difference of recurrence among groups. CONCLUSION: Secondary BPPV showed different prevalence of involved canal from idiopathic BPPV. The duration of treatment for BPPV with ISSHL or unilateral vestibulopathy take longer time than for other groups.