Injury Mechanism to Induce Traumatic Balance Disorder / 대한평형의학회지

Many of the dizziness patients annually visit ENT (ear, nose, throat) clinics because the vestibular function is the major organ to keep body balance and belongs to the Otorhinolaryngology. Nevertheless, many otolaryngologists feel that it is not easy to access the dizziness patients. The reason is that dizziness is not a final diagnosis and it is necessary to start the diagnosis of dizziness and find out the cause. Also, the causes of dizziness belong to multiple medical departments. That is why we need to pay more attention. Among them, traumatic vertigo can be manifested in various ways depending on the injury site and mechanism, and it is often difficult to predict the medical prognosis. Therefore, this review article focuses on traumatic vertigo. In this paper, we discussed its epidemiology and mechanism to help clinicians to treat patients with traumatic vertigo.

The Study of Standardization for a Korean Dizziness Handicap Inventory for Patient Caregivers / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES@#Several questionnaires had been developed to assess the handicap due to dizziness. The questionnaires for adults were used and these had been translated into Korean with validity and reliability. However, there is no Korean translation of dizziness inquiry form owing to the little concern of the pediatric dizziness. The objective of this study was to determine the reliability and validity of a Korean Dizziness Handicap Index for Patient Caregivers (KDHI-PC), and revealed the factor analysis of this index.SUBJECTS AND METHOD: We sampled the 24 pediatric patients who had dizziness-related symptoms and visited the hospitals. The patients completed a questionnaire (DHI-PC) that had been translated and reverse translated into Korean. The results of this investigation were analyzed using exploratory factor analysis, Cronbach's α coefficient and internal consistency reliability.@*RESULTS@#By exploratory factor analysis, KDHI-PC was divided into two scales. This questionnaire showed a good internal consistency (Cronbach's α=0.945). All items had good item-total correlations.@*CONCLUSION@#The KDHI-PC is a reliable tool for evaluating the dizziness of pediatric patients.

Changes in the Laterality of Functional Connectivity Associated with Tinnitus: Resting-State fMRI Study

PURPOSE: One of the suggested potential mechanisms of tinnitus is an alteration in perception in the neural auditory pathway. The aim of this study was to investigate the difference in laterality in functional connectivity between tinnitus patients and healthy controls using resting state functional MRI (rs-fMRI). MATERIALS AND METHODS: Thirty-eight chronic tinnitus subjects and 45 age-matched healthy controls were enrolled in this study. Connectivity was investigated using independent component analysis, and the laterality index map was calculated based on auditory (AN) and dorsal attention (DAN), default mode (DMN), sensorimotor, salience (SalN), and visual networks (VNs). The laterality index (LI) of tinnitus subjects was compared with that of normal controls using region-of-interest (ROI) and voxel-based methods and a two-sample unpaired t-test. Pearson correlation was conducted to assess the associations between the LI in each network and clinical variables. RESULTS: The AN and VN showed significant differences in LI between the two groups in ROI analysis (P < 0.05), and the tinnitus group had clusters with significantly decreased laterality of AN, SalN, and VN in voxel-based comparisons. The AN was positively correlated with tinnitus distress (tinnitus handicap inventory), and the SalN was negatively correlated with symptom duration (P < 0.05). CONCLUSION: The results of this study suggest that various functional networks related to psychological distress can be modified by tinnitus, and that this interrelation can present differently on the right and left sides, according to the dominance of the network.

The Study of Standardization for a Korean Dizziness Handicap Inventory for Patient Caregivers / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Several questionnaires had been developed to assess the handicap due to dizziness. The questionnaires for adults were used and these had been translated into Korean with validity and reliability. However, there is no Korean translation of dizziness inquiry form owing to the little concern of the pediatric dizziness. The objective of this study was to determine the reliability and validity of a Korean Dizziness Handicap Index for Patient Caregivers (KDHI-PC), and revealed the factor analysis of this index. SUBJECTS AND METHOD: We sampled the 24 pediatric patients who had dizziness-related symptoms and visited the hospitals. The patients completed a questionnaire (DHI-PC) that had been translated and reverse translated into Korean. The results of this investigation were analyzed using exploratory factor analysis, Cronbach's α coefficient and internal consistency reliability. RESULTS: By exploratory factor analysis, KDHI-PC was divided into two scales. This questionnaire showed a good internal consistency (Cronbach's α=0.945). All items had good item-total correlations. CONCLUSION: The KDHI-PC is a reliable tool for evaluating the dizziness of pediatric patients.

Superficial Siderosis with Peripheral Dizziness: Report of 2 Cases / 대한평형의학회지

Superficial siderosis (SS) of the central nervous system is a rare disease, which is caused by the accumulation of iron from the hemoglobin in the superficial layer of the brain, spinal cord, and central parts of cranial nerves. The etiology of SS is the accumulation of hemosiderin in the subarachnoid space due to chronic or repeated hemorrhage resulting in progressive and irreversible neurological dysfunction. The cause of the disease is aneurysm, trauma, tumor, and vascular malformation. In most cases, the cause of bleeding is unknown. Clinical features include sensorineural hearing loss, cerebellar ataxia, and myelopathy. Until now, magnetic resonance imaging (MRI) has only been diagnosed and there is no standardized treatment. We will investigate clinical features and MRI findings of SS disease in the central nervous system using 2 patient cases.

Clinical Characteristics of the Patients with Dizziness after Car Accidents / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: With increasing frequency of car accidents, patients of dizziness caused by car accidents are also increasing. Various types of dizziness or vertigo can occur from car accidents depending on different injury mechanisms. Since accurate diagnosis is important for providing proper treatments, we evaluated clinical characteristics related to vestibular function of patients with dizziness caused car accidents. SUBJECTS AND METHOD: In this retrospective case review study that runs from January 2011 to March 2013, a total of 82 patients with dizziness following car accident were enrolled consecutively. We analyzed the final diagnosis of dizziness according to different mechanisms of injury during car accident through clinical record review. Patients who developed dizziness within one month of car accident were included, excluding those who had temporal bone fracture and previous history of dizziness. RESULTS: Of the different types observed, 36.6% was head injury, 24.4% whiplash injury, 3.7% complex injury, 2.4% others and the rest was unknown. In the final diagnosis, the different types included 36.6% benign paroxysmal positional vertigo (BPPV), 23.2% unclassifiable dizziness, 18.3% cervical vertigo, 7.3% labyrinthine concussion, 3.7% BPPV with labyrinthine concussion and the rest was others. Of the different types of dizziness symptoms, 58.5% was headache, 45.1% was audiologic symptoms, and others included earfullness, tinnitus and hearing disturbance. Tinitogram and pure tone audiogram results show that 2.9% (27 people) of patients have tinnitus and 7.3% (6 people) have hearing disturbance. CONCLUSION: An accurate diagnosis and timely management would be very important in forming a proper approach for post traumatic vertigo patients.

Bacterial Species and Antibiotic Sensitivity in Korean Patients Diagnosed with Acute Otitis Media and Otitis Media with Effusion

Changes over time in pathogens and their antibiotic sensitivity resulting from the recent overuse and misuse of antibiotics in otitis media (OM) have complicated treatment. This study evaluated changes over 5 years in principal pathogens and their antibiotic sensitivity in patients in Korea diagnosed with acute OM (AOM) and OM with effusion (OME). The study population consisted of 683 patients who visited the outpatient department of otorhinolaryngology in 7 tertiary hospitals in Korea between January 2010 and May 2015 and were diagnosed with acute AOM or OME. Aural discharge or middle ear fluid were collected from patients in the operating room or outpatient department and subjected to tests of bacterial identification and antibiotic sensitivity. The overall bacteria detection rate of AOM was 62.3% and OME was 40.9%. The most frequently isolated Gram-positive bacterial species was coagulase negative Staphylococcus aureus (CNS) followed by methicillin-susceptible S. aureus (MSSA), methicillin-resistant S. aureus (MRSA), and Streptococcus pneumonia (SP), whereas the most frequently isolated Gram-negative bacterium was Pseudomonas aeruginosa (PA). Regardless of OM subtype, ≥ 80% of CNS and MRSA strains were resistant to penicillin (PC) and tetracycline (TC); isolated MRSA strains showed low sensitivity to other antibiotics, with 100% resistant to PC, TC, cefoxitin (CFT), and erythromycin (EM); and isolated PA showed low sensitivity to quinolone antibiotics, including ciprofloxacin (CIP) and levofloxacin (LFX), and to aminoglycosides. Bacterial species and antibiotic sensitivity did not change significantly over 5 years. The rate of detection of MRSA was higher in OME than in previous studies. As bacterial predominance and antibiotic sensitivity could change over time, continuous and periodic surveillance is necessary in guiding appropriate antibacterial therapy.

Tinnitus Assessment / 한양의대학술지

Tinnitus is a common medical condition where patients perceive unwanted noise in the absence of environmental stimuli. However, it is very difficult to find out definite causes of each patient's tinnitus. According to tinnitus classification systems, there are many different diagnostic tools. Representatively, tinnitus can be divided into objective and subjective tinnitus. Also, there are many etiologic factors for each classified tinnitus. Tinnitus assessment is defined as finding out the exact cause of tinnitus and prediction of treatment effect. It starts from history taking and physical examination to audiologic evaluations. Also, it is an important part in the relationship with the patient, as well as tinnitus objectification in the treatment process. And, it affects the consequent management of tinnitus. Otherwise, assessment of tinnitus is a challenging task due its subjective nature. Therefore, a multidimensional diagnostic approach to tinnitus is very important in appropriate treatment of tinnitus and in predicting the effect of the management.

Clinical Differences in Types of Otalgia

BACKGROUND AND OBJECTIVES: Although otalgia is usually associated with ear problems, it may also originate outside the ear. We therefore assessed the clinical characteristics of patients with otalgia. SUBJECTS AND METHODS: We analyzed 294 patients who presented with otalgia. We assessed differences in otalgia between adults and children, differences in otogenic vs. referred otalgia between adults and children, differences between men and women. RESULTS: Of the 294 patients, 208 (70.7%) had otogenic otalgia and 86 (29.3%) had referred otalgia. Hearing disturbance and otorrhea were significantly more common in otogenic otalgia, whereas rhinorrhea, sore throat, and postnasal drip were significantly more common in referred otalgia. Children were more likely to have otogenic otalgia than adults. The proportion of patients with referred otalgia was significantly higher in adults than in children (p<0.05). Otogenic otalgia was more common in men, whereas referred otalgia was more common in women. Among patients with referred otalgia, neuralgia was significantly more frequent in women than in men (p<0.05). CONCLUSIONS: Otogenic otalgia was more frequent in men than in women and in children than in adults, whereas referred otalgia was more frequent in women and adults, indicating that types of otalgia were dependent on age and gender.

Association between Insomnia and Depression in Tinnitus Patients / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: About one third of all people experience tinnitus in their life. And insomnia is the second most common symptom in tinnitus patients, following hearing disturbance. The aim of this study was to define the influence of insomnia on the clinical features of tinnitus patients and to assess the relation of tinnitus to insomnia and depression. SUBJECTS AND METHOD: The consecutive 197 patients with tinnitus were enrolled from May 2012 to May 2013 for this study. All patients with tinnitus filled out the following questionnaire, Visual Analogue Scale, Tinnitus Handicap Inventory (THI), Beck Depression Inventory (BDI), and Pittsburgh Sleep Quality Index (PSQI) for evaluating clinical features of tinnitus patients. Also we examined pure tone audiometry and tinnitogram for evaluating audiologic characteristics. RESULTS: When the insomnia was defined as more than five scores in PSQI, 46 of 197 patients had insomnia. Loudness of tinnitus was significantly higher in the tinnitus patients with insomnia group when compared to those of the tinnitus without insomnia group (p=0.018). The score of THI and BDI were significantly higher in the tinnitus with insomnia group, too (p=0.003, <0.001, respectively). A strong correlation (r=0.616, p<0.001) was shown between THI score and BDI score in both groups. CONCLUSION: It appears, due to the high possibility that depression and insomnia are related in tinnitus patients with insomnia, that proper evaluations about sleep disturbance and depression of tinnitus patients are necessary to produce better therapeutic results.

Electrical Stimulation for the Treatment of Tinnitus / 대한이비인후과학회지

Tinnitus is a phantom sensation of sound in the absence of external stimulation. Since the mechanism of tinnitus is not clearly discovered, no currently available treatments are ideal. There have been many published studies which report that electrical stimulation has a suppressive effect on tinnitus. Although there is no consensus stimulation method and regimen, electrical stimulation has emerged as an interesting and promising modality for tinnitus relief. In this review, authors collected and analyzed articles on electrical stimulation and outlined various methods of noninvasive and invasive stimulation.

Changing Patterns of Bacterial Strains in Adults and Children With Otitis Media in Korean Tertiary Care Centers

OBJECTIVES: Otitis media (OM) is an infectious disease that affects all age brackets. Aural discharge is a typical symptom, occurring in all subtypes of OM. We have compared the identity and antibiotic sensitivity of bacteria isolated from aural discharges of adults and children with various types of OM, including acute OM (AOM), OM with effusion (OME), chronic OM (COM), and cholesteatomatous OM (CSOM). METHODS: The study involved 2,833 patients who visited five tertiary hospitals between January 2001 and December 2010 and were diagnosed with AOM, OME, COM, or CSOM. The patients were divided into a pediatric group and an adult group, and the distribution of cultured bacteria and their antibiotic sensitivity were compared in the two groups. RESULTS: Bacterial detection rates were higher in adults than in children with OME and COM (P=0.000 each). The majority of the bacteria cultured from patients with AOM and OME bacteria were methicillin-susceptible Staphylococcus aureus (MSSA) and Streptococcus pneumoniae. Bacteria cultured from children were more susceptible to antibiotics (P=0.002) and had higher antibiotic sensitivity (P=0.001) than were bacteria cultured from adults. The majority of bacteria culture from patients with COM and CSOM were MSSA and pathogenic Pseudomonas aeruginosa. The frequency of methicillin-resistant Staphylococcus aureus was significantly higher in adults than in children, and more strains of bacteria isolated from adults were sensitive to the antibiotics septrin, vancomycin, and teicoplanin. CONCLUSION: Bacteria cultured from children were more susceptible to antibiotics and had higher antibiotic sensitivity than did bacteria cultured from adults.

Influence of Head and Neck Muscle Contraction on Tinnitus / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Tinnitus can be classified into two types, otogenic and somatic tinnitus. Somatic tinnitus can occur even when the ear is normal, as it is known that tinnitus can occur after there is movement in the muscles of the head and neck. This study aims to characterize tinnitus and clarify the nature of tinnitus when it occurs from the contraction of the head and neck muscle. SUBJECTS AND METHOD: Thirty-five people with normal hearing, who had no history of otitis media or inner ear disease, were taken as subjects. First, we investigated whether the natural tinnitus occurred or not in the silent environment and checked its characteristics for five minutes. We then implemented eight different kinds of muscle contractions maneuver and measured whether the tinnitus occurred and the recorded the onset time, duration and location of the occurrence of the tinnitus. RESULTS: Among the total of 35 subjects inspected, 15 (42.9%) people felt the natural tinnitus. In terms of natural tinnitus, ringing was the most common characteristic and heard most often from both sides. Twenty (57.1%) subjects out of total 35 subjects inspected felt tinnitus after the contraction of the head and neck muscles. Tinnitus after the resistance to a force applied by the people to the occiput was the most common for 14 (40.0%) people, followed by parietal and right temporal area. The most common location was the left side for 6 (17.1%) subjects followed by right side and both sides. For the type of tinnitus after the contraction of muscles, ringing was observed the most by 6 (17.1%) subjects, followed by high frequency and pulsatile sound. The average onset time of the tinnitus was 8.8 seconds and the average duration was 29.6 seconds. CONCLUSION: The study showed that the muscle contraction of head and neck affects the occurrence of tinnitus for people who had no tinnitus. By clarifying the occurrence of tinnitus due to the contraction of muscles, the study identified the basic features of hearing and the role of the somatic tinnitus.

Ocular Vestibular Evoked Myogenic Potential in Vestibular Neuritis Patients: Comparative Study with Cervical Vestibular Evoked Myogenic Potential and Subjective Visual Vertical / 대한평형의학회지

BACKGROUND AND OBJECTIVES: Subjective visual vertical (SVV) reflects utricle and superior vestibular neural functions, and cervical vestibular evoked myogenic potentials (cVEMP) reflect saccule and inferior vestibular neural functions. But, origin and characteristics of ocular VEMP (oVEMP) remain controversial, especially in case of evoked by air conducted sound (ACS). Thus, the aim of this study was to identify the origin and characteristics of oVEMP by comparing with various otolith function tests. MATERIALS AND METHODS: Forty vestibular neuritis patients were enrolled from September 2012 to January 2013 in this study. We examined cVEMP, oVEMP using 500 Hz air-counducted sounds. And, we measured static and dynamic SVV. RESULTS: Abnormal cVEMP responses were observed in 6 (15%) patients, and abnormal oVEMP responses were observed in 28 (70%) patients. Abnormal static and dynamic SVV were observed in 18 (45%), 35 (87.5%) patients, respectively. There was strong correlation between oVEMP and dynamic SVV (p=0.009). CONCLUSION: ACS oVEMP responses showed different tendency from cVEMP responses in vestibular neuritis patients, but similar tendency with results of dynamic SVV. The results suggest that origin of oVEMP is different from that of cVEMP and maybe utricle and superior vestibular neuron.

Decreased Expression of TLR-9 and Cytokines in the Presence of Bacteria in Patients with Otitis Media with Effusion

OBJECTIVES: Toll-like receptor (TLR)-9 recognizes unmethylated cytidine-phosphate-guanosine (CpG) motifs in bacteria. Therefore, the expression of TLR-9 may differ according to the results of bacterial culture, and thus a change in proinflammatory cytokine induction can also be expected. The authors aimed to assess the differences and relationships between the expression of TLR-9, cytokines, and nitric oxide synthase (NOS) in otitis media with effusion (OME) based on bacterial culture results. METHODS: Sixty-eight patients with OME were divided into culture-positive and culture-negative groups based on middle ear culture results. mRNA expression of TLR-9, NOS, and cytokines was measured and analyzed. RESULTS: Bacteria were detected in 38.2% of patients, and the distribution was as follows: coagulase negative Staphylococcus (10.3%), Staphylococcus aureus (8.8%), Streptococcus pneumonia (5.9%), and Bacillus spp. and Haemophilus influenza combined (2.9%). There were no significant differences in epidemiologic characteristics according to the culture results. Down-regulation of TLR-9 was observed in the culture-positive group (P=0.019). Cytokines including interleukin (IL)-12 (r=-0.582), tumor necrosis factor (TNF)-alpha (r=-0.569), interferon (IFN)-gamma (r=-0.442), IL-6 (r=-0.395) and inducible NOS (r=-0.256) tended to decrease with the detection of bacteria. CONCLUSION: The expression of TLR-9 significantly decreased in OME with confirmed bacterial pathogens. IL-12, TNF-alpha, IFN-beta, IL-6 expression tended to decrease with the detection of bacteria. The presence of bacterial pathogens in OME may be related to abnormalities in the innate immune system.

Agreement between the Facial Nerve Grading System 2.0 and the House-Brackmann Grading System in Patients with Bell Palsy

OBJECTIVES: We have analyzed the correlation between the House-Brackmann (HB) scale and Facial Nerve Grading System 2.0 (FNGS 2.0) in patients with Bell palsy, and evaluated the usefulness of the new grading system. METHODS: Sixty patients diagnosed with Bell palsy from May 2009 to December 2010 were evaluated using the HB scale and FNGS 2.0 scale during their initial visit, and after 3 and 6 weeks and 3 months. RESULTS: The overall intraclass correlation coefficient (ICC) was 0.908 (P=0.000) and the Spearman correlation coefficient (SCC) was 0.912 (P<0.05). ICC and SCC displayed differences over time, being 0.604 and 0.626, respectively, at first visit; 0.834 and 0.843, respectively, after 3 weeks; 0.844 and 0.848, respectively, after 6 weeks; and 0.808 and 0.793, respectively, after 3 months. There was a significant difference in full recovery, depending on the scale used (HB, P=0.000; FNGS 2.0, P<0.05). The exact agreements between regional assessment and FNGS 2.0 for the mouth, eyes, and brow were 72%, 63%, and 52%, respectively. CONCLUSION: FNGS 2.0 shows moderate agreement with HB grading. Regional assessment, rather than HB grading, yields stricter evaluation, resulting in better prognosis and determination of grade.

A Case of Spontaneous Temporomandibular Joint Herniation into the External Auditory Canal with Clicking Sound

A bony defect of the external auditory canal (EAC) and herniation of the temporomandibular joint (TMJ) can be caused by tumorous conditions, inflammation, trauma, and otologic procedures. Spontaneous TMJ herniation into the EAC can be caused by a congenital bony defect known as patent Huschke's foramen, which is a very rare condition. In our case, an objective clicking sound was produced when the patient opened his mouth. A protruding mass was found in the anterior wall of the EAC during mouth closing, and herniation of the TMJ was confirmed with computed tomography. Therefore, we thought the clicking sound of our case could have resulted from spontaneous TMJ herniation through the patent foramen of Huschke.

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.

Herpes Simplex Encephalitis Suffered Rotatory Dizziness as a Primary Symptom / 대한평형의학회지

Herpes simplex encephalitis (HSE) is rare, serious sporadic encephalitis associated with high mortality in untreated cases. Although cognitive impairment with fever could be the clue of diagnosis, various symptoms can make it difficult to be diagnosed. Dizziness is one of the most frequent symptoms ENT doctors can encounter. Authors experienced the HSE patient suffered rotatory sense of dizziness as a primary symptom and treated the patient successfully without major complication. We reported our experience and findings of vestibular function test of patient. It could be helpful to other ENT doctors who encounter similar patients.

The Diagnosis Criteria of Meniere's Disease and Related Objective Tests / 대한이비인후과학회지

The etiology and pathophysiology of Meniere's disease (MD) remain controversial and incompletely understood. Diagnosis of MD is decided according to the diagnostic criteria proposed by the American Academy of Otolaryngology-Head and Neck Surgery (AAO) (1995), which is based on clinical symptoms. It would be of great value to have an objective clinical test for the diagnosis of endolymphatic hydrops. Various tests like electrocochleography, vestibular evoke myogenic potential and cochlear hydrops analysis masking procedures have been applied for detecting endolymphatic hydrops. Any of single objective tests is not perfect for the diagnosis of MD. However, considering AAO guideline is not enough for the diagnosis, additive objective tests for MD become essential. We evaluated the objective tests for MD and also surveyed preferred tests among Korean otologic society members.