Short Term Effects of Repetitive Transcranial Magnetic Stimulation in Patients with Catastrophic Intractable Tinnitus: Preliminary Report

OBJECTIVES: The short-term effects of low-frequency repetitive transcranial magnetic stimulation (rTMS) in the patients with catastrophic and intractable tinnitus were investigated. METHODS: Fifteen participants were recruited among patients with catastrophic intractable tinnitus to receive 1 Hz rTMS treatment. Tinnitus severity was assessed before rTMS and directly after sham or real rTMS using the tinnitus handicap inventory (THI) and visual analog scale (VAS). RESULTS: There was no statistical difference in the THI score before and after sham stimulation. However, after 5 replications of real rTMS there was statistically significant reduction in THI score. Eight patients showed a decrease of more than 10 in THI score. Patients who showed a vast change in THI score after rTMS also showed a large decrease in their VAS score (r=0.879, P<0.001). Duration of tinnitus and change of THI score showed statistically significant moderate negative correlation (r=-0.637, P=0.011). But in case of VAS, there was no significant difference between VAS and duration of tinnitus. CONCLUSION: Among total 15 patients with catastrophic intractable chronic tinnitus, eight patients showed some improvement in symptoms after 1 Hz rTMS. rTMS can be considered management modality for intractable tinnitus even with distress as severe as catastrophic stage.

Clinical Manifestations of Aural Fullness

PURPOSE: Even though aural fullness is ubiquitous among patients presenting to otolaryngology clinics, the association between aural fullness and disease development has not yet been clearly determined. MATERIALS AND METHODS: Our study was performed on outpatients from June 2006 to February 2010 whose major complaint was "ear fullness", "aural fullness", or "ear pressure". We assessed their demographic and clinical characteristics, including sex, associated diseases, symptoms, otoscopic findings, audiology test results, and final diagnoses. RESULTS: Among 432 patients, 165 (38.2%) were males and 267 (61.8%) were females, with mean ages of 42+/-19 years and 47+/-17 years, respectively. Tinnitus, hearing disturbance, autophony (p<0.01) as well as nasal obstruction and sore throat (p<0.05) showed a statistically significant correlation with aural fullness. Among patients who complained of hearing fullness, tests and measures such as impedance audiometry, speech reception threshold, and pure tone audiometry generated statistically significant results (p<0.05). Ear fullness was most frequently diagnosed as Eustachian tube dysfunction (28.9%), followed by otitis media with effusion (13.4%) and chronic otitis media (7.2%). However, 13.4% of patients could not be definitively diagnosed. CONCLUSION: Among patients complaining of ear fullness, Eustachian tube dysfunction, otitis media with effusion, chronic otitis media were most commonly observed. Performance of otoscopy, nasal endoscopy, the Valsalva maneuver, and additional audiological tests is necessary to exclude other diseases.

Possibility of Discriminating the Presence of Tinnitus through Repeated Tinnitograms

BACKGROUND AND OBJECTIVES: The evaluation of tinnitus is becoming increasingly important in assessing the degree of disability. However, until now, there are no tools to verify the presence of tinnitus. The aim of this study was to identify the possibilities in discriminating the presence of tinnitus through tinnitus test, pitch match test and loudness balance test. MATERIALS AND METHODS: Typically, 50 patients who have suffered from continuous tinnitus and 20 subjects with normal hearing ability who did not suffer from tinnitus were selected for the present investigation. All the patients underwent the tests for pitch match and loudness balance, which were replicated thrice with 1-minute intervals with a TDH 49 headphone and an oribiter model 922, GN otometrics in a soundproof room. Non-tinnitus group that didn't have tinnitus chose virtual tinnitus based on their own discretion. RESULTS: The most similar sounds mimicking tinnitus were of pure tone in both the groups. However, subjects of the tinnitus group were exposed to a greater variety of sounds than those of the non-tinnitus group. Moreover, the most common frequency of tinnitus was 4 and 8 kHz in the tinnitus group, but 1 kHz in the non-tinnitus group. The mean loudness of tinnitus was 7.28 dBSL in the tinnitus group and 13.6 dBSL in the non-tinnitus group. The loudness of tinnitus in the tinnitus group was less than that in the non-tinnitus group in a statistically significant manner (p<0.05). Loudness in each repeated tinnitus tests was identical in tinnitus group, but significantly different in non-tinnitus group (p<0.05). CONCLUSIONS: We concluded that repeated tinnitus tests for loudness matching were helpful in identifying the presence of tinnitus.

Clinical Approaches for Understanding the Expression Levels of Pattern Recognition Receptors in Otitis Media with Effusion

OBJECTIVES: Bacterial infections in the normally sterile environment of the middle ear cavity usually trigger host immune response, whereby the innate immune system plays a dominant role as the host's first line of defense. We evaluated the expression levels of Toll-like receptors (TLRs) -2, -4, -5, -9, and nucleotide-binding oligomerization domain-containing proteins (NODs) -1 and -2, all of which are related to bacterial infection in pediatric patients with otitis media with effusion (OME). METHODS: The study sample consisted of 46 pediatric patients with OME, all of whom had ventilation tubes inserted. The expression levels of TLR-2, -4, -5, -9, NOD-1 and -2 mRNA in middle ear effusion were assessed by polymerase chain reaction (PCR). Difference of pattern recognition receptors (PRRs) expression level by presence of bacteria, ventilation tube insertion rate, and effusion fluid character was assessed. RESULTS: All effusion fluid samples collected from patients with OME showed expression of TLR-2, -4, -5, -9, NOD-1, and -2 mRNA by PCR. However, we found no differences among expression levels of PRRs in relation to characteristics of exudates, presence of bacteria, or frequencies of ventilation tube insertion (P>0.05). CONCLUSION: Our findings suggest that exudates of OME patients show PRR expressions that are related to the innate immune response regardless of the characteristics of effusion fluid, presence of bacteria in exudates, or frequency of ventilation tube insertion.

Analysis of Associated Symptoms of Bell's Palsy / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: We aimed to evaluate associated symptoms in patients with Bell's palsy and prognosis according to associated symptoms. SUBJECTS AND METHOD: Seventy-four patients with Bell's palsy were enrolled in this study. We evaluated the degree of facial palsy with Facial Nerve Grading System 2.0. The grade of facial palsy was determined as initial facial palsy at admission and as final facial palsy at visit after 3 months. Afterwards, we examined symptoms (such as otalgia, facial numbness, taste disturbance, eye problems, hyperacusis, and tinnitus) and co-morbid diseases (such as diabetes mellitus and hypertension) associated with facial palsy. After 3 months of the onset of facial palsy, we examined the changes in the associated symptoms. RESULTS: At admission, 71.6 percent of all patients had symptoms associated with facial palsy. Of the associated symptoms, facial numbness and taste disturbance were the most common, which were still found in 23% of the patients after 3 months of the onset of facial palsy. Patients with a high initial grade of facial palsy were accompanied by taste disturbance and hyperacusis more than by other symptoms. Also patients who had auricular pain during the recovery period of Bell's palsy showed poor prognosis. Compared to non-hypertension patients, for patients with hypertension, taste disturbance was more common during the early period whereas eye problems were more common during the recovery period. CONCLUSION: Patients with Bell's palsy had diverse symptoms associated with facial palsy. During the early period of Bell's palsy, we concluded that there was no correlation between the symptoms and the prognosis. However, patients with pain around the ear during the recovery period showed poor recovery of facial palsy.

Changes of Mastoid Gas Physiology in Virtual Mastoidectomy Model / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: It is essential to understand gas physiology of mastoid cavity to study the pathophysiology of middle ear diseases, and the surface area and volume of mastoid mucosa are important parameters for evaluating gas physiology. However, the surface area and mastoid volume of the mastoid cavity have not been practically measured yet. Therefore, we measured and compared surface area and volume of the mastoid cavity before and after mastoidectomy using a virtual mastoidectomy model. SUBJECTS AND METHOD: We performed a virtual mastoidectomy using 10 cases of temporal bone CT indicating pneumatic mastoid. First, we removed all air cells after outlining with irregular AOI function after loading axial CT images to Image-Pro Plus 4.0. Then we filled the removed area with equal planes using local equalization filter. Finally, we calculated and compared the total surface area, volume and area to volume (A/V) ratio by estimating their circumference and area. RESULTS: The mean surface area of pneumatized mastoid cavity was 127.8 cm2 (range: 94.2-165.3 cm2), and the mean volume was 7.1 cm3 (range: 5.2-11.0 cm3). The mean surface area and volume were altered to 42.8 cm2 (range: 35.9-55.0 cm2) and 12.6 cm3 (range: 10.3-18.7 cm3), respectively, after virtual mastoidectomy. As a result, the A/V ratio decreased from 18 to 3.4 after a virtual mastoidectomy in the pneumatic mastoid cavity. CONCLUSION: When a complete mastoidectomy is performed in the pneumatic mastoid, the surface area is decreased by one third compared to a relatively minor increase in volume. Therefore, the surface area per unit volume is expected to greatly decrease after mastoidectomy. Some physiologic problems occurring after mastoidectomy could be more accurately explained using a virtual mastoidectomy model.

Fine Needle Aspiration for Thyroid Nodule: Clinical Application of Bethesda Classification / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: To evaluate the usefulness of fine needle aspiration (FNA) for thyroid nodule using the new Bethesda classification. SUBJECTS AND METHOD: Patient cytology data were reviewed by retrospective search of thyroid FNA. Cytologic diagnoses were classified as unsatisfactory, benign/negative for malignancy, indeterminate (ID), follicular neoplasm (FN), suspicious for malignancy (SM), and positive for malignancy (PM) according to the proposing of The National Cancer Institute. We analyzed the follow-up FNA diagnoses and the cytologic-histologic correlations. RESULTS: Of 1983 patients, 16.8% was classified as unsatisfactory, 73.6% as benign, 1.1% as ID, 0.4% as FN, 1.4% as SM, and 6.8% as PM. After the cytologic follow-up, the groups designated as unsatisafactory (80.2%) and ID (50%) mainly showed significant change in diagnosis. Two hundred fifty patients had surgical follow-up. Sensitivity, specificity, and accuracy, positive predictive values and negative predictive values for malignancy of thyroid were 87.6%, 97.2%, 91%, 98.3% and 81.2%, respectively. The cytologic-histologic diagnostic discrepancy rate was 13.6%. CONCLUSION: FNA for thyroid nodule using the new Bethesda classification was an accurate and sensitive method for the diagnosis of thyroid nodule, and can provide useful information for the management of thyroid nodule.

A Human Immunodeficiency Virus-Positive Patient with Dizziness and Peripheral Facial Palsy / 대한평형의학회지

Various neurological complications occur in association with human immunodifiency virus (HIV) infection. These complications occur at all stages of infection and any level of central and peripheral nervous system. Neurological complications, such as aseptic meningitis, encephalopathy, neuropathy, myelopathy, and brachial neuritis, develop in association with primary HIV infection. We here in report a case of peripheral facial palsy with suspicious peripheral vertigo manifested as initial symptoms of primary HIV infection.