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.

Vestibular Rehabilitation after Traumatic Head Injury with Dizziness / 대한평형의학회지

The vestibular symptoms such as dizziness and imbalance that occurred after traumatic head/brain injury were caused by a combination of central factors such as abnormalities of white matter, diffuse axonal injury and microhemorrhage, and peripheral factors like decreased vestibulo-ocular reflex caused by the energy transmitted to the semicircular canal and otolith organs. These symptoms can affect on the patient's overall physical, cognitive, emotional, and quality of life. There have been reports that vestibular rehabilitation for the treatment of dizziness and imbalance after head trauma can promote vestibular compensation, stabilize of the gaze movements, and also affect the treatment outcomes of the associated injuries. The frequency, duration, and number of people participating in vestibular rehabilitation varied with each study, and physical therapy, occupational therapy, cognitive counseling, medication treatment, duration of treatment for associated injuries were also variable. Most studies have shown that many patients who get the vestibular rehabilitation have a significantly reduced time to return to work and sports activities, and may be able to speed up the recovery of vestibular symptoms. However, further research is needed on its long-term effects. In addition, patients with traumatic head/brain injuries are more susceptible to injuries of other organs as well as vestibular disorders, therefore consideration of treatment planning for associated injuries including precise evaluation mental support, and cognitive therapy is expected to be more effective with vestibular rehabilitation therapy.

The Light Cupula: An Emerging New Concept for Positional Vertigo

Benign paroxysmal positional vertigo (BPPV) is the most common type of positional vertigo. A canalolithiasis-type of BPPV involving the lateral semicircular canal (LSCC) shows a characteristic direction-changing positional nystagmus (DCPN) which beats towards the lower ear (geotropic) on turning the head to either side in a supine position. Because geotropic DCPN in LSCC canalolithiasis is transient with a latency of a few seconds, the diagnosis can be challenging if geotropic DCPN is persistent without latency. The concept of “light cupula” has been introduced to explain persistent geotropic DCPN, although the mechanism behind it requires further elucidation. In this review, we describe the characteristics of the nystagmic pattern in light cupula and discuss the current evidence for possible mechanisms explaining the phenomenon.

Outcome of Canalith Repositioning Procedure in Patients with Persistent and Transient Geotropic Direction-Changing Positional Nystagmus: Short-term Follow-up Evaluation / 대한평형의학회지

OBJECTIVES: Patients, who showed persistent geotropic-direction changing positional nystagmus (p-DCPN) tend to have different clinical manifestations from those who showed transient geotropic DCPN (t-DCPN). We investigated the clinical characteristics between p-DCPN and t-DCPN patients, and its recovery rate after canalith repositioning procedure (CRP). METHODS: Based on the duration of nystagmus, 117 geotropic DCPN patients were classified to 2 groups, p-DCPN and t-DCPN. Barbeque maneuver had been introduced towards the opposite direction of null plane for the p-DCPN patients, and to the opposite direction of stronger nystagmus for the t-DCPN patients. RESULTS: Seventy-four patients showed t-DCPN and 43 patients were classified to the p-DCPN cases. No p-DCPN patient showed prompt improvement after the 1st canalolith reposition therapy. Among the t-DCPN patients, 18 canal switch cases were found , but, there was no canal switch cases found among the p-DCPN The CRP has showed less effective for the p-DCPN patients than the t-DCPN patients (after the 1st CRP, 37 in 74 improved, p < 0.001). CONCLUSIONS: Due to its distinguishing clinical manifestation, p-DCPN may have different pathogenesis and clinical mechanisms from t-DCPN. And for the p-DCPN patients, the CRP seems not an efficient treatment compared to the t-DCPN patients. Further study with larger number of enrolled subjects is necessary.

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.

Dizzy and Psychological Scales in Benign Paroxysmal Positional Vertigo: Suspicious Patients without Characteristic Nystagmus / 대한평형의학회지

OBJECTIVES: Patients, who have had a history of benign paroxysmal positional vertigo (BPPV)-like symptoms, but no characteristic nystagmus, were often present. They are diagnosed as having a resolved state from BPPV or normal, and tend to be overlooked. We investigated the dizzy and psychological scales in BPPV-suspicious patients. METHODS: Thirty-nine patients, which they had vertigo of a short duration at the specific head position, and clinically suspicious BPPV, but no nystagmus in positional tests, were enrolled. We compared dizzy and psychological scales of suspicious BPPV patients with 138 BPPV patients, using dizziness handicap inventory (DHI), the beck depression inventory (BDI), and the Spielberger state-trait anxiety inventory. Additionally, among the BPPV-suspicious group, patients with a BPPV history were compared with those with no previous BPPV. RESULTS: No differences in the all scales were found between the two groups. However, DHI scores of patients with a previous BPPV attack were significantly higher than those of patients with no BPPV-like symptoms; in particular, there was a significant difference in emotional scores. CONCLUSION: Although the patients had no characteristic nystagmus, if they have a BPPV-like history and symptoms, emotional support and periodic follow up are needed. In particular, careful observation should be performed in patients with previous BPPV attack.

Clinical Analysis of Dizzy Patients with High Levels of Depression and Anxiety

BACKGROUND AND OBJECTIVES: Some patients experiencing dizziness also report psychological distress. However, the association between vestibular deficits and psychological symptoms remains controversial. Thus, the aim of this paper is to report the proportion of patients who complained of dizziness who also had high depression and anxiety indices. Also we investigated the severity of their dizziness and the distribution of the diseases underlying this symptom. SUBJECTS AND METHODS: We assessed the dizziness and psychological distress of 544 patients experiencing dizziness using the Korean versions of the Dizziness Handicap Inventory (DHI), the Beck Depression Inventory (BDI), and the Spielberger State-Trait Anxiety Inventory (STAI). We also reviewed the audio-vestibular symtoms of patients with high levels of depression and anxiety. RESULTS: The incidences of high depression and anxiety scores were 11% (60/544) and 18% (98/544), respectively. Patients with vestibular migraine were most likely to have high depression and anxiety indices. Patients in the high-BDI or high-STAI groups (117/544) obtained significantly higher DHI scores than those in neither the high-BDI nor the high-STAI group (427/544). We noticed that about 20% of the patients experiencing dizziness had high levels of psychological distress in this study; this group also suffered from various vestibular diseases and more symptoms of dizziness. CONCLUSIONS: The results of the study suggest that psychological evaluation should be considered when assessing patients with vertigo.

Analysis of Voice and Swallowing Symptoms after Thyroidectomy in Patients without Recurrent Laryngeal Nerve Injury in Early Postoperative Period

BACKGROUND AND OBJECTIVES: After thyroidectomy, many patients experience problems report such things as reduced voice range and vocal fatigue, swallowing problems without superior and recurrent laryngeal nerve injury. The purpose of this study was to evaluate voice and swallowing problems before and after thyroid surgery without laryngeal nerve injury. MATERIALS AND METHODS: Ninety-three patients who underwent thyroidectomy without laryngeal nerve injury and completed the follow-up evaluations were studied between June 2013 and December 2015. Each evaluation was performed preoperatively, as well as 1 week, 1 month postoperatively. Analysis was performed including voice handicap index (VHI), dysphagia handicap index (DHI), and acoustic voice analysis. RESULTS: Patients show significant variation of parameters in the fundamental frequency (F), maximal phonation time (MPT), shimmer, jitter and soft phonation index (SPI) early after operation, and most of them showed recovery of parameters after 1month of operation. Perceptive complaint of voice and swallowing also showed significant decreased after operation (p<0.005). After 1 month of operation, MPT, highest frequency and frequency ranges still showed significant decreased parameters. Comparing acoustic and perceptive parameters of total thyroidectomy and lobectomy, there was no significant changes between them except highest frequency (p=0.042). CONCLUSION: The results from both subjective and objective evaluations show voice and swallowing disturbance after thyroidectomy even in the absence of laryngeal nerve and provide patients information about the recovery process after surgery. Highest frequency parameter showed most significant changes after operation.

A Case of Endolymphatic Sac Decompression of Intractable Meniere's Disease in Children / 대한이비인후과학회지

Meniere's disease in children is characterised with a hard and long-term diagnostic course, for which there is no accurate classification and treatment plan. A patient may undergo severe discomfort and long-term contraction of the disease. We experienced a 13-year-old female suffering from recurrent dizziness, and found that she had hearing loss, and tinnitus on her right ear. We diagnosed it as possible meniere's disease, but the disease progressed despite a trial of medication. The patient then underwent an endolymphatic sac decompression. During 6 months after the operation, she has shown only mild, intermittent dizzy symptoms, without severe vertigo. We report this clinical experience with a brief review of 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.

Warthin's Tumor with Skin Ulceration Mimicking Parotid Malignancy / 대한이비인후과학회지

Warthin's tumor with skin ulceration is extremely uncommon. We report on a 64-year-old man with Warthin's tumor with skin ulceration in the right parotid gland. The ulceration may have resulted from malignant transformation of either the epithelial or lymphoid component, or, as in very rare cases, an inflammatory process crossing the capsule of the tumor into the adjacent parotid parenchyma and overlying skin. Although Warthin's tumor is a common benign tumor of the parotid area, once ulcerated, it is difficult to make a clinical diagnosis. The gross finding of the case reported herein was close to the malignant form, but because an fine needle aspiration biopsy history existed, the possibility of whether more inflammatory changes might have occurred was considered. Therefore, since complications such as facial nerve injury may arise, extensive surgeries should be avoided.

Clinical Characteristics and Microbiology of Acute Otitis Media of Children: Multicenter Studies / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Acute otitis media (AOM) is one of the most common forms of bacterial infection in children. The aim of this study was to investigate the clinical characteristics and the common pathogens of AOM children who visited three different centers. SUBJECTS AND METHOD: We have conducted a retrospective study of 133 children under 15 years with the diagnosis of AOM that had been seen between January 2010 and January 2011. We examined of AOM children's symptoms, signs and culture results. RESULTS: The most common symptoms were in the order of crying or irritability, otalgia and fever. Otorrhea was significantly higher under 2 years old and drum injection was over 2 years old. The most common pathogens were Streptococcus pneumoniae (26.6%), followed by Moraxella catarrhalis (19.0%), Haemophilus influenzae (11.4%) and Staphylococcus aureus (11.4%). Among the total pathogens, about 71% of pathogens were resistant to amoxicillin, 78% to macroride, and 55.2% to clindamycin. About 58.3% of H. influenza and M. catarrhalis were positive to beta-lactamase. CONCLUSION: More than half of pathogens were resistant to standard dose amoxicillin. For the appropriate treatment of AOM, decisions were made based on the common symptoms, signs and antibiotic resistances of pathogens.

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.

Comparison of Sudden Deafness in Adults and Children

OBJECTIVES: Although many studies have assessed sudden deafness in adults, sudden deafness has not been evaluated in children. We therefore evaluated the differences in sudden deafness between children and adults. METHODS: We compared clinical manifestations, including gender, audiogram pattern of initial hearing loss, and recovery rate after treatment in 87 children and 707 adults diagnosed with sudden deafness from September 2003 and August 2012. RESULTS: There were no differences in sex, side, or audiogram between children and adults (P>0.05 each). Hearing recovery rates in children and adults were 72.4% and 70.6%, respectively (P>0.05). Both children and adults with mild hearing loss showed significantly greater hearing recovery rates than individuals with profound hearing loss (P<0.05 each). The percentage with initially mild and moderate hearing loss was higher in children than in adults, as were the recovery rates of children compared to adults with initially mild, moderate-severe, and profound hearing loss (P<0.05 each). In regard to final hearing outcome after treatment, a low percentage of children showed no improvement whereas a high percentage showed complete recovery; a higher percentage of children than of adults showed complete recovery (P<0.05). Recovery rate from profound hearing loss was significantly higher in children than in adults (60.0% vs. 45.4%, P<0.05). CONCLUSION: Degree of hearing loss, gender, side, and recovery rate were similar in children and adults, but the rate of complete recovery was higher in children.

Congenital Cholesteatoma Localized to the Tip of the Mastoid Bone: A Case Report and Possible Etiology

Congenital cholesteatomas of mastoid origin are extremely rare. We reported one in 2007 and experienced an additional case. A male presented with a 5-month history of right-sided ear discharge. Computed tomography of the temporal bone showed a soft tissue density occupying the mastoid tip. At surgery, the cholesteatoma sac was completely isolated from the mastoid antrum and lateral air cell in the mastoid tip area. We now doubt the rarity of this entity. With a brief literature review, we consider how the cholesteatoma localizes to the tip of the mastoid bone.

Unusual Presentation of a Metastatic Tumor to the Temporal Bone: Severe Otalgia and Facial Paralysis

Metastatic temporal bone tumors are rare diseases and they are usually clinically asymptomatic, so it is difficult to diagnose them. Breasts are the most common sites of temporal bone metastasis. Tumors of lung, kidney, gastrointestinal tract, prostate gland, larynx and thyroid gland are the other sites. The pathogenesis of the temporal bone is most commonly related to the hematogenous route. We present the case of a 78-year-old man with facial paralysis combined with severe otalgia. This patient was initially diagnosed with Bell's palsy. However, based on the radiologic findings, the patient was diagnosed with lung cancer with temporal bone metastasis.

Vestibular Paroxysmia in a 7-Year-Old Child / 대한평형의학회지

Neurovascular cross-compression of the eighth cranial nerve is characterized by brief attacks of vertigo, unilateral audiologic symptoms such as tinnitus, ear fullness and hearing disturbance and relatively rare disease, in particular, in children. We report a 7-year-old female patient who presented with recurrent spontaneous vertigo, lasting 15 seconds and occuring up to 40 times per day and often associated with physical activity. Her symptoms were developed by hyperventilation. Associated aural symptoms are not founded. Magnetic resonance image showed the eighth cranial nerve compression caused by the vascular loop. She was treated with oxcarbazepine and showed improving symptoms. Therefore we report our clinical experience with a brief review of literature.

Transverse Fracture of the Stapes Anterior Crus Caused by the Blast Pressure from a Land Mine Explosion

Stapes fractures without other ossicle problems are rare and ossicle problems due to explosion pressure are also rare. We describe a very rare case of stapes anterior crural fracture resulting from a land mine explosion. As this case suggests, a close examination of the ossicles is necessary during an exploration tympanotomy.

Development of Bell's Palsy after Influenza Vaccination / 대한이비인후과학회지

Bell's palsy, also known as idiopathic facial palsy, is one of the most common causes of peripheral facial nerve palsy. Many studies of the cause and treatment of Bell's palsy have been performed, but the results are still controversial. Clinical cases of other forms of cranial nerve paralysis after influenza vaccination have also been reported. We herein report a review of literature and a case of a 95-year-old female patient who developed left facial paralysis following influenza vaccination.

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.