Treatment Efficacy of Various Maneuvers for Lateral Canal Benign Paroxysmal Positional Vertigo With Apogeotropic Nystagmus: A Randomized Controlled Trial

Objectives@#The aim of this study was to determine the most effective treatment approach by comparing the impacts of various otolith reduction techniques in patients with apogeotropic lateral semicircular canal benign paroxysmal positional vertigo (LC-BPPV). @*Methods@#We performed a multicenter randomized prospective study from January to December 2015, involving 72 consecutive patients with apogeotropic LC-BPPV. The patients were divided into three treatment groups: therapeutic head-shaking (group A), the Gufoni-Appiani maneuver (group B), and the cupulolith repositioning maneuver (CuRM; group C). Each group underwent evaluation and treatment up to the fourth week. Treatment success was defined as the disappearance of positional vertigo and nystagmus. @*Results@#This study included 72 patients (49 male and 23 female), with a mean (±standard deviation) age of 55.4±13.5 years. The mean duration of vertigo experienced prior to treatment was 3.9±4.4 days. The mean latency and duration of nystagmus were 2.7±3.0 seconds and 47.9±15.8 seconds, respectively. The overall treatment frequency was 2.0±0.9. The number of treatments differed significantly among the three groups (P0.05). However, CuRM was the only method with a 100% treatment success rate. @*Conclusion@#While no clear difference was observed among the three treatments for LC-BPPV, CuRM was found to be superior to the other approaches in the long term.

Glossopharyngeal Neuralgia and Somatic Tinnitus Caused by a Small Tonsillolith / 대한이비인후과학회지

A 66 years old male presented with severe right-sided otalgia and throat pain, which persisted more than a year. He also complained of bilateral tinnitus. Tinnitus was continuous and high-pitched. Severe pain usually followed swallowing food. Pressing his right tonsil aggravated such symptoms. Pure tone audiogram showed both high frequencies hearing loss. Neck CT image revealed a small tonsillolith in his right tonsil. Gabapentin and non-steroidal anti-inflammatory drugs reduced the intensity of pain, but could not eradicate the pain. Finally, we performed radiofrequency tonsil ablation to eliminate right side tonsillolith. After ablation, pain immediately subsided and his tinnitus also disappeared. Tiny impacted tonsillolith may induce glossopharyngeal neuralgia and somatic tinnitus.

Dissociated Results between Caloric and Video Head Impulse Tests in Dizziness: Prevalence, Pattern, Lesion Location, and Etiology

Background@#and PurposeThis study was designed to determine the prevalence, pattern, lesion location, and etiology of dissociation in the results of the bithermal caloric test and the horizontal video head impulse test (vHIT) in dizzy patients with various etiologies and disease durations. @*Methods@#We analyzed the results of bithermal caloric tests and vHITs performed over 26 months in 893 consecutive patients who underwent both tests within a 10-day period. @*Results@#Dissociation in the results of the two tests was found in 162 (18.1%) patients. Among them, 123 (75.9%) had abnormal caloric tests (unilateral paresis in 118 and bilateral paresis in 5) but normal vHITs. Peripheral lesions were identified in 105 (85.4%) of these patients, with the main underlying diseases being Meniere's disease (62/105, 59%) and vestibular neuritis/labyrinthitis (29/105, 27.6%). In contrast, central pathologies of diverse etiologies were found only in 18 (14.6%) patients. Abnormal vHIT (bilaterally positive in 18, unilaterally positive in 19, and hyperactive in 2) and normal caloric responses were found in 39 patients, with an equal prevalence of central (n=19) and peripheral (n=20) lesions. The peripheral lesions included vestibular neuritis/labyrinthitis in seven patients and Meniere's disease in another seven. The central lesions had diverse etiologies. @*Conclusions@#Dissociation in the results between caloric tests and horizontal vHITs is not uncommon. The present patients with abnormal caloric tests and normal vHITs mostly had peripheral lesions, while central lesions were likely to underlie those with abnormal vHITs and normal caloric tests.

Vestibulocochlear Symptoms Caused by Vertebrobasilar Dolichoectasia

Objectives@#. Vertebrobasilar dolichoectasia (VBD), an elongation and distension of vertebrobasilar artery, may present with cranial nerve symptoms due to nerve root compression. The objectives of this study are to summarize vestibulocochlear manifestations in subjects with VBD through a case series and to discuss the needs of thorough oto-neurotologic evaluation in VBD subjects before selecting treatment modalities. @*Methods@#. Four VBD subjects with vestibulocochlear manifestations were reviewed retrospectively. VBD was confirmed by either brain or internal auditory canal magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA). Patient information, medical history, MRI/MRA findings, and audiometry or vestibular function tests were reviewed according to patient’s specific symptom. @*Results@#. Of the four subjects, three presented with ipsilesional sensorineural hearing loss (SNHL), three with paroxysmal recurrent vertigo, and two with typewriter tinnitus. The MRI/MRA of the four subjects revealed unilateral VBD with neurovascular compression of cisternal segment or the brainstem causing displacement, angulation, or deformity of the cranial nerve VII or VIII that corresponded to the symptoms. @*Conclusion@#. Vestibulocochlear symptoms such as SNHL, recurrent paroxysmal vertigo, or typewriter tinnitus can be precipitated from a neurovascular compression of the vestibulocochlear nerve by VBD. Because proper medical or surgical treatments may stop the disease progression or improve audio-vestibular symptoms in subjects with VBD, a high index of suspicion and meticulous radiologic evaluation are needed when vestibulocochlear symptoms are not otherwise explainable, and if VBD is confirmed to cause audiovestibular manifestation, a thorough oto-neurotologic evaluation should be performed before initial treatment.

Feasibility of Eye Tracking Assisted Vestibular Rehabilitation Strategy Using Immersive Virtual Reality

OBJECTIVES: Even though vestibular rehabilitation therapy (VRT) using head-mounted display (HMD) has been highlighted recently as a popular virtual reality platform, we should consider that HMD itself do not provide interactive environment for VRT. This study aimed to test the feasibility of interactive components using eye tracking assisted strategy through neurophysiologic evidence. METHODS: HMD implemented with an infrared-based eye tracker was used to generate a virtual environment for VRT. Eighteen healthy subjects participated in our experiment, wherein they performed a saccadic eye exercise (SEE) under two conditions of feedback-on (F-on, visualization of eye position) and feedback-off (F-off, non-visualization of eye position). Eye position was continuously monitored in real time on those two conditions, but this information was not provided to the participants. Electroencephalogram recordings were used to estimate neural dynamics and attention during SEE, in which only valid trials (correct responses) were included in electroencephalogram analysis. RESULTS: SEE accuracy was higher in the F-on than F-off condition (P=0.039). The power spectral density of beta band was higher in the F-on condition on the frontal (P=0.047), central (P=0.042), and occipital areas (P=0.045). Beta–event-related desynchronization was significantly more pronounced in the F-on (–0.19 on frontal and –0.22 on central clusters) than in the F-off condition (0.23 on frontal and 0.05 on central) on preparatory phase (P=0.005 for frontal and P=0.024 for central). In addition, more abundant functional connectivity was revealed under the F-on condition. CONCLUSION: Considering substantial gain may come from goal directed attention and activation of brain-network while performing VRT, our preclinical study from SEE suggests that eye tracking algorithms may work efficiently in vestibular rehabilitation using HMD.

Comparison of Free-Beam- and Fiber-Type CO₂ Laser Delivery Systems in Stapes Surgery

BACKGROUND AND OBJECTIVES: A free-beam-type CO₂ laser, which use a micromanipulator mounted on a microscope as the delivery system, has the merit of not being affected by hand tremor at the time of shooting. However, this delivery system has several disadvantages, including a restricted operation range and a risk of incorrect focusing. A fiber-type CO₂ laser uses a hand-held delivery system and has the opposite merits and demerits. We compared the results of stapes surgery with free-beam and fiber type delivery systems. SUBJECTS AND METHODS: The study enrolled 36 patients who underwent stapedotomy with free-beam- (n=26) or fiber- (n=10) type CO₂ lasers. The air-bone (AB) gap closure, bone conduction (BC) change, and operating time were evaluated. The AB gap closure was calculated by subtracting the preoperative BC thresholds from the postoperative air conduction thresholds. The BC change was calculated by subtracting the postoperative BC thresholds from the preoperative BC thresholds. RESULTS: The mean operating time was significantly (p=0.035) shorter in the fiber-type group (72.5±8.2 min) than in the free-beam-type group (80.5±11.4 min). The mean AB gap closure did not differ significantly (p=0.297) between the free-beamand fiber-type groups (5.8±10.1 and 1.4±6.8 dB, respectively). The mean BC change did not differ significantly (p=0.873) between the free-beam- and fiber-type groups (2.4±6.9 and 2.8±5.3 dB, respectively). The hearing outcomes did not differ significantly between the two groups. CONCLUSIONS: Operating times were significantly shorter using the fiber-type CO₂ laser, while hearing outcomes did not differ significantly between the two groups.

Bilaterally Abnormal Head Impulse Tests Indicate a Large Cerebellopontine Angle Tumor

BACKGROUND AND PURPOSE: Tumors involving the cerebellopontine angle (CPA) pose a diagnostic challenge due to their diverse manifestations. Head impulse tests (HITs) have been used to evaluate vestibular function, but few studies have explored the head impulse gain of the vestibulo-ocular reflex (VOR) in patients with a vestibular schwannoma. This study tested whether the head impulse gain of the VOR is an indicator of the size of a unilateral CPA tumor. METHODS: Twenty-eight patients (21 women; age=64+/-12 years, mean+/-SD) with a unilateral CPA tumor underwent a recording of the HITs using a magnetic search coil technique. Patients were classified into non-compressing (T1-T3) and compressing (T4) groups according to the Hannover classification. RESULTS: Most (23/28, 82%) of the patients showed abnormal HITs for the semicircular canals on the lesion side. The bilateral abnormality in HITs was more common in the compressing group than the non-compressing group (80% vs. 8%, Pearson's chi-square test: p<0.001). The tumor size was inversely correlated with the head impulse gain of the VOR in either direction. CONCLUSIONS: Bilaterally abnormal HITs indicate that a patient has a large unilateral CPA tumor. The abnormal HITs in the contralesional direction may be explained either by adaptation or by compression and resultant dysfunction of the cerebellar and brainstem structures. The serial evaluation of HITs may provide information on tumor growth, and thereby reduce the number of costly brain scans required when following up patients with CPA tumors.

Multicenter Randomized Study on the Efficacy of Isosorbide in Patients with Mèniére's Disease / 대한평형의학회지

OBJECTIVES: Mèniére's disease is one of the most common causes of episodic vestibular syndrome that shows symptom complexes of recurrent vertigo, hearing loss, tinnitus and ear fullness. Isosorbide (Isobide) is a osmotic diuretics which has been used for Meniere's disease to reduce the endolymphatic pressure. The purpose of this study was to evaluate the efficacy of isosorbide in the treatment of Mèniére's disease by comparing the combined therapy of isosorbide and betahistine (Meniace) to betahistine only. METHODS: Among 220 patients enrolled with Mèniére's disease from 9 centers, 187 patients completed this clinical study. Patients were randomly subjected either to betahistine alone therapy at dose of 6 mg three times a day (n=97) or to combined therapy with isosorbide (dose of 30 mL three times a day) and betahistine (n=90) for 12 weeks. Two groups were compared at 4 and 12 weeks after treatment on frequency of vertigo, hearing level (pure tone audiometry, speech audiometry), electocochleography (ECoG), tinnitus (Tinnitus Handicap Inventory, THI) and quality of life (Korean functional level scale, Korean dizziness handicap inventory). RESULTS: During first 4 weeks after treatment, the frequency of vertigo was not reduced in either betahistine alone therapy group or combined therapy group. However, between 8 and 12 weeks, the frequency of vertigo was significantly reduced in either group, and in the combined group frequency of vertigo was more significantly reduced than in the betahistine alone therapy group (p=0.041). The hearing level, ECoG, tinnitus and quality of life was not significantly different between two groups. CONCLUSION: Isosorbide and betahistine combined therapy were more effective for vertigo control than betahistine alone therapy. Isosorbide is an effective diuretic in vertigo control in definite Mèniére's disease.

Acute Phlegmonous Gastritis Developing after Endoscopic Submucosal Dissection That Was Successfully Treated by Antibiotics Alone / 대한내과학회지

Endoscopic submucosal dissection (ESD) is widely used to treat a variety of gastric lesions including early gastric cancer and gastric adenoma. Bleeding and perforation are the most common complications of ESD. However, a rare and fatal bacterial stomach infection, termed acute phlegmonous gastritis, can also develop after ESD. We treated a patient with a high fever who complained of severe abdominal pain after ESD. Abdominal computed tomography (CT) revealed a diffuse, submucosal, minimally attenuated lesion and mucosal irregularity. The clincial presentation and the CT findings were compatible with acute phlegmonous gastritis and the patient was successfully treated with antibiotics alone. The case is worth reporting because acute phlegmonous gastritis is a very rare complication of ESD.

Normal Caloric Responses during Acute Phase of Vestibular Neuritis

BACKGROUND AND PURPOSE: We report a novel finding of caloric conversion from normal responses into unilateral paresis during the acute phase of vestibular neuritis (VN). METHODS: We recruited 893 patients with a diagnosis of VN at Dizziness Clinic of Seoul National University Bundang Hospital from 2003 to 2014 after excluding 28 patients with isolated inferior divisional VN (n=14) and those without follow-up tests despite normal caloric responses initially (n=14). We retrospectively analyzed the neurotological findings in four (0.5%) of the patients who showed a conversion from initially normal caloric responses into unilateral paresis during the acute phase. RESULTS: In those four patients, the initial caloric tests were performed within 2 days of symptom onset, and conversion into unilateral caloric paresis was documented 1-4 days later. The clinical and laboratory findings during the initial evaluation were consistent with VN in all four patients except for normal findings in bedside head impulse tests in one of them. CONCLUSIONS: Normal findings in caloric tests should be interpreted with caution during the acute phase of suspected VN. Follow-up evaluation should be considered when the findings of the initial caloric test are normal, but VN remains the most plausible diagnosis.

Normal Caloric Responses during Acute Phase of Vestibular Neuritis

BACKGROUND AND PURPOSE: We report a novel finding of caloric conversion from normal responses into unilateral paresis during the acute phase of vestibular neuritis (VN). METHODS: We recruited 893 patients with a diagnosis of VN at Dizziness Clinic of Seoul National University Bundang Hospital from 2003 to 2014 after excluding 28 patients with isolated inferior divisional VN (n=14) and those without follow-up tests despite normal caloric responses initially (n=14). We retrospectively analyzed the neurotological findings in four (0.5%) of the patients who showed a conversion from initially normal caloric responses into unilateral paresis during the acute phase. RESULTS: In those four patients, the initial caloric tests were performed within 2 days of symptom onset, and conversion into unilateral caloric paresis was documented 1-4 days later. The clinical and laboratory findings during the initial evaluation were consistent with VN in all four patients except for normal findings in bedside head impulse tests in one of them. CONCLUSIONS: Normal findings in caloric tests should be interpreted with caution during the acute phase of suspected VN. Follow-up evaluation should be considered when the findings of the initial caloric test are normal, but VN remains the most plausible diagnosis.

Preoperative Vestibular Function in Adults with Cochlear Implantation: Comparison between Prelingual and Poslingual Deafness / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Cochlear system and vestibular system have close relationship anatomically and developmentally. According to previous literatures, there are high incidences of vestibular dysfunction in subjects with severe hearing loss. The aim of this study is to validate the status of vestibular function in adults with profound hearing loss, and to compare the status of vestibular function between pre-lingual and post-lingual deaf. SUBJECTS AND METHOD: Vestibular function of 59 patients who had profound hearing loss was reviewed retrospectively. Patient's information and audiometry, Korean version Central Institute for the Deaf (KCID) scores, caloric test, rotation chair test and vestibular evoked myogenic potential (VEMP) were analyzed. The subjects were divided into two groups, prelingual deaf (pre-LD, n=12) and postlingual deaf (post-LD, n=47). We analyzed the difference between two groups. RESULTS: Fifty nine point six percent of patients showed hypo-function in caloric test. In the rotational chair test, abnormality of step velocity gain (43.1%), time constant (51.8%), sinusoidal harmonic acceleration (SHA)-gain (53.4%), SHA-phase lead (29.1%) and SHA-asymmetry (23.6%) were found. There was unilateral (20.0%) and bilateral (37.5%) hypo-function when VEMP was tested. Between pre-LD and post-LD groups, VEMP test revealed statistically significant difference between two groups (p=0.020). Post-LD groups had more patients of unilateral or bilateral hypofunction in VEMP test. The KCID score showed no significant correlation with vestibular functions. CONCLUSION: The patients of bilateral profound hearing loss showed unilateral or bilateral vestibular functional abnormality despite of no dizziness. Prevalence of lateral canal dysfunction does not seem to be different between pre-LD group and post-LD group. And post-LD groups have higher probability of saccular dysfunction than pre-LD.

Profound Hearing Loss after Endolymphatic Sac Decompression in Intractable Meniere's Disease / 대한평형의학회지

Endolymphatic sac decompression (ESD) is indicated in intractable Meniere's disease patients with serviceable hearing. A 43-year-old man presented with recurrent vertigo and fluctuating right hearing loss that had been intractable to medical treatment. ESD was performed for the purpose of vertigo control with hearing preservation. Positional vertigo with profound hearing loss developed immediate after surgery and positional vertigo was resolved within days. Following paralytic vestibulopathy with positive sign on head thrust test also resolved after 2 weeks, while sensorineural hearing loss was not recovered to preoperative level during 1 year of follow up. Recurrent vertigo attacks were developed again 1 year after the operation. Hearing preservation was not always guaranteed in ESD. Furthermore, chance of hearing loss should be included in informed consent though the procedure is purposed for hearing preservation.

Surgical Treatments of Benign Paroxysmal Positional Vertigo / 대한평형의학회지

Benign paroxysmal positional vertigo (BPPV) is the most frequent vestibular disorder. Although it is easily cured with canal repositioning maneuvers for the majority of patients, it can be disabling in rare cases. For these patients, surgical treatments may be proposed. The aim of this article is to discuss their indication in intractable BPPV and review the surgical treatments used, the reported cases in the literature. All the articles from 1972 to 2013 that discussed specific surgical treatments in BPPV were reviewed. Many of them reported cases of operated patients and described original techniques. Some others are studies that discussed the three techniques used: singular neurectomy, posterior semicircular canal occlusion and intratympanic injection of gentamicin. Singular neurectomy and posterior semicircular canal occlusion are the two specific techniques used in intractable BPPV. A very small population of patients requires surgical treatments of BPPV. These procedures are difficult and risk compromising hearing. The intratympanic injection of gentamicin can be useful procedure in BPPV associated with Meniere disease. The surgical treatments of BPPV appear to be limited to exceptional cases. When good examination and appropriate treatment fail to cure patients with intractable BPPV, central positional vertigo should be ruled out before irreversible surgical procedures.

In Reply: IgG4 Related Disease and Sensorineural Hearing Loss

No abstract available.

A Case of Biliary Cast Developed in a Patient with Long-Standing Biliary Sludge

Development of biliary casts is very unusual, especially in patients who have not undergone liver transplantation. Variable causes of biliary cast formation in nonliver transplantation patients have been suggested. However, stasis of bile flow and/or gallbladder hypocontractility is known to eventually result in the promotion of biliary sludge and subsequent cast formation. Here we present one case of biliary cast syndrome, which developed in a nonliver transplant patient who had biliary sludge for a long period of time, providing evidence that long-standing biliary sludge may lead to cast formation.

Subjective and Audiologic Results of Bone Anchored Hearing Aids (BAHA) / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: This study aims to evaluate audiologic results and subjective satisfaction of bone anchored hearing aids (BAHA) patients. SUBJECTS AND METHOD: Preoperative air-conduction and bone-conduction thresholds, postoperative aided thresholds were measured for 14 patients. To evaluate patient satisfaction, two questionnaires derived from single sided deafness (SSD) questionnaire and Bern Benefit in SSD questionnaire were used. RESULTS: The mean age of patients, consisting of 8 males and 6 females, was 40.0+/-5.9 year. Ten patients (71%) received implantations for conductive or mixed hearing loss and 4 (29%) for SSD. The mean follow-up period was 27.8+/-5.6 months. The mean preoperative bone-conduction threshold of conductive or mixed hearing loss group was 21.4 dB and the mean air-conduction threshold was 65.4 dB. The mean bone-conduction threshold of SSD group was 60.0 dB and the mean air-conduction threshold was 105.9 dB. The postoperative aided threshold was significantly improved in conductive or mixed hearing loss group (p=0.005). The patients in the conductive or mixed hearing loss group showed more satisfaction with BAHA than those in the SSD group did, but the degree of satisfaction was not statistically significant (p=0.08 for questionnaire 1, p=0.12 for questionnaire 2). Patients with better preoperative bone-conduction threshold and patients with better preoperative speech discrimination score showed more satisfaction with BAHA in the questionnaire 1 (p=0.045, p=0.036). CONCLUSION: BAHA can be considered effective and beneficial for patients with conductive or mixed hearing loss and SSD. Further studies will be needed to choose the appropriate indications for BAHA, especially in SSD group in Korea.

Superior Semicircular Canal Dehiscence Syndrome Presenting with Sudden Deafness and Vertigo after Trauma / 대한평형의학회지

Superior semicircular canal dehiscence syndrome (SCDS) is characterized by cochleovestibular hyper-responsiveness symptoms including sound- and pressure-evoked vertigo and oscillopsia, autophony, hyperacusis and ear fullness. The typical audiometric feature of SCDS is known as conductive hearing loss at low frequency. A 43-year-old man presented with unilateral sudden deafness after several events of heading during soccer game. High-resolution temporal bone computed tomography revealed a dehiscence of superior canal encased by superior petrous sinus. We reviewed audio-vestibular findings in this patient and speculated potential pathogenic mechanisms of sudden deafness in SCDS with literature review.

Multicenter Study on the Clinician's Diagnostic and Therapeutic Approaches for Benign Paroxysmal Positional Vertigo in Korea / 대한평형의학회지

BACKGROUND AND OBJECTIVES: It is necessary to establish the most efficient diagnostic and therapeutic method for benign paroxysmal positional vertigo (BPPV), which is appropriate for Korean healthcare system. We aimed to evaluate current state of Korean clinician's diagnostic and therapeutic approaches for BPPV. MATERIALS AND METHODS: A 16-item survey was emailed to the members of dizziness department of Otology Research Interest Group in the Korean Otologic Society (n=68). 43 were returned and analyzed. RESULTS: All respondents (100%) used Dix-Hallpike test as a diagnostic tool for vertical canal-BPPV. Supine roll test was used for diagnosing lateral canal BPPV in nearly all the respondents (97.7%). Epley maneuver was chosen as otolith repositioning maneuver (ORM) for posterior canal BPPV in all respondents and barbecue rotation (BBQ) was used for treating lateral canal BPPV with geotropic nystagmus in 95.3% of respondents. Extreme variation was noted for therapeutic approach of lateral canal BPPV with ageotropic nystagmus BBQ, with 4 kinds of ORM and adjunctive measures to liberate otolith from cupula, while BBQ was again the most commonly used ORM (76.7%). CONCLUSION: The development of practical and efficient ORM for lateral canal BPPV with ageotropic nystagmus is necessary.

Asymmetric Audiovestibular Dysfunction in Patients With Systemic Aminoglycoside Treatment / 대한평형의학회지

Since the characteristics of aminoglycoside ototoxicity is typically bilaterally symmetric progression of cochlea-vestibular dysfunction, a unilateral involvement has rarely been reported. However, ototoxicity can be asymmetric or focal after systemic aminoglycoside treatment. The authors report 2 cases of asymmetric or focal audiovestibular deficits in patients treated with systemic aminoglycoside. In such cases, further investigations are also necessary to rule out other possible causes of unilateral sensorineural hearing loss such as cerebellopontine angle tumors.