Endolymphatic hydrops magnetic resonance imaging in Ménière's disease.

This review is designed to help radiologists interested in developing a magnetic resonance imaging service for patients with symptoms of Ménière's disease. Examples are selected from our experience with delayed post-gadolinium three-dimensional (3D) fluid attenuated inversion recovery (FLAIR) inner ear imaging of endolymphatic hydrops. The imaging features of the normal and hydropic endolymphatic structures, semiquantitative grading systems, normal variations, and differential diagnoses will be illustrated, whilst appropriate clinical referrals, approaches to reporting and diagnostic pitfalls will be discussed.

'Black Bone' magnetic resonance imaging as a novel technique to aid the pre-operative planning of posterior tympanotomy for cochlear implantation.

Purpose: 'Black Bone' magnetic resonance imaging (BB MRI) is a novel sequence developed as an alternative to computed tomography (CT) for osseous imaging. We explored its potential utilisation in the pre-operative surgical planning of posterior tympanotomy for cochlear implantation through depiction of the mastoid facial nerve (mFN) canal and the posterior canaliculus of the chorda tympani (ChT), thus defining the facial recess. Methods: Twenty five adult patients were prospectively imaged with a dedicated BB MRI sequence. A consensus qualitative BB MRI 'visibility score' for the confidence of demonstration of the mFN canal and the posterior canaliculus of the ChT was recorded, as well as a 'corresponding score' to determine whether the neural structures on BB MRI corresponded to the paths of the nerves on a previous CT study. Results/discussion: The BB MRI sequence was able to clearly delineate the course of mFN in 100% of cases and that of ChT in 72%, with their courses corresponding to those depicted on CT in almost all cases. Maximum intensity projections with 7 mm slabs provided the optimal simultaneous demonstration of mFN, ChT and round window along the posterior tympanotomy surgical approach. Conclusion: The proposed BB MRI sequence reliably depicts mFN and ChT in the majority of cases, with a performance comparable to that of CT. It is proposed that it will be a useful adjunct to MRI protocols as part of cochlear implant assessment in those centres where CT is not routinely performed.

Diagnostic Yield and Therapeutic Impact of Face and Neck Imaging in Patients Referred with Otalgia without Clinically Overt Disease.

BACKGROUND AND PURPOSE: Otalgia may be secondary to serious pathology, such as upper aerodigestive tract malignancies, and CT or MR imaging of the skull base, face, and neck is often performed to detect clinically occult lesions. The diagnostic yield, management impact, and therapeutic impact of imaging in this clinical scenario, however, have yet to be elucidated. MATERIALS AND METHODS: CT and MR imaging in patients who presented with otalgia without clinically overt disease was retrospectively analyzed from a single center over a 9-year period. The cohort was subdivided into groups, depending on the presence of additional symptoms and a history of head and neck cancer. Relevant diagnostic outcome findings were categorized, and the diagnostic yield and impact of imaging on management and therapy were calculated for each group. RESULTS: In our study cohort of 235 patients, the diagnostic yield of imaging for otalgia, with or without other symptoms, in patients who lacked a history of head and neck cancer was negligible for upper aerodigestive tract malignancy (1%), abnormalities related to otalgia (2%), and other moderate or major findings (2%). Although equivocal or unimportant findings occasionally resulted in additional investigations, the therapeutic impact was also very low (2%). The diagnostic yield for upper aerodigestive tract malignancy (34%) and therapeutic impact increased (34%) when there was a history of head and neck cancer. CONCLUSIONS: The diagnostic yield and therapeutic impact of imaging for otalgia without clinically overt disease are very low, unless there is a history of head and neck cancer.

Magnetic resonance imaging of Ménière's disease: early clinical experience in a UK centre.

BACKGROUND: Recent developments in magnetic resonance imaging have enabled demonstration of endolymphatic hydrops, and the clinical application of these imaging studies in Ménière's disease is being explored. OBJECTIVE: To evaluate our centre's experience to date of hydrops magnetic resonance imaging in patients with episodic vertigo. METHODS: Magnetic resonance imaging was performed using a high-resolution three-dimensional fluid-attenuated inversion recovery sequence on a 3 Tesla scanner at 4 hours following double-dose gadolinium administration. RESULTS: The study included 31 patients, 28 of whom had a clinical diagnosis of Ménière's disease. In unilateral Ménière's disease, magnetic resonance imaging was able to lateralise endolymphatic hydrops to the clinically symptomatic ear in all cases. Mild hydrops was often seen in clinically asymptomatic ears. CONCLUSION: There is a good correlation between the clinical symptoms and lateralisation of hydropic changes on magnetic resonance imaging. Further refinements of imaging techniques and grading system will likely improve the diagnostic accuracy and clinical utilisation of hydrops magnetic resonance imaging.

Is CT or MRI the optimal imaging investigation for the diagnosis of large vestibular aqueduct syndrome and large endolymphatic sac anomaly?

BACKGROUND AND PURPOSE: We explored whether there was a difference between measurements obtained with CT and MRI for the diagnosis of large vestibular aqueduct syndrome or large endolymphatic sac anomaly, and whether this influenced diagnosis on the basis of previously published threshold values (Valvassori and Cincinnati). We also investigated whether isolated dilated extra-osseous endolymphatic sac occurred on MRI. Secondary objectives were to compare inter-observer reproducibility for the measurements, and to investigate any mismatch between the diagnoses using the different criteria. MATERIALS/METHODS: Subjects diagnosed with large vestibular aqueduct syndrome or large endolymphatic sac anomalies were retrospectively analysed. For subjects with both CT and MRI available (n = 58), two independent observers measured the midpoint and operculum widths. For subjects with MRI (± CT) available (n = 84), extra-osseous sac widths were also measured. Results There was no significant difference between the width measurements obtained with CT versus MRI. CT alone diagnosed large vestibular aqueduct syndrome or large endolymphatic sac anomalies in 2/58 (Valvassori) and 4/58 (Cincinnati), whilst MRI alone diagnosed them in 2/58 (Valvassori). There was 93% CT/MRI diagnostic agreement using both criteria. Only 1/84 demonstrated isolated extra-osseous endolymphatic sac dilatation. The MRI-based LVAS/LESA diagnosis was less dependent on which criteria were used. Midpoint measurements are more reproducible between observers and between CT/MR imaging modalities. CONCLUSION: Supplementing MRI with CT results in additional diagnoses using either criterion, however, there is no net increased diagnostic sensitivity for CT versus MRI when applying the Valvassori criteria. Isolated enlargement of the extra-osseous endolymphatic sac is rare.

A dural arteriovenous fistula associated with an encephalocele presenting as otitis media with effusion.

OBJECTIVE: This case report illustrates an unusual case of a dural arteriovenous fistula and an associated encephalocele presenting as otitis media with effusion.Case reportA 53-year-old man presented with right-sided hearing loss and aural fullness of 2 years' duration. Examination revealed ipsilateral post-auricular pulsatile tenderness. Computed tomography showed transcalvarial channels suggestive of dural arteriovenous fistula. Further magnetic resonance imaging demonstrated the presence of a temporal encephalocele herniating through the tegmen tympani defect, as well as the abnormal vascularity. Angiography confirmed a Cognard type I dural arteriovenous fistula, which is being managed conservatively. Surgical repair of the encephalocele was recommended but declined by the patient. CONCLUSION: Dural arteriovenous fistula is an uncommon intracranial vascular malformation rarely seen by otolaryngologists, with pulsatile tinnitus being the usual presentation. To our knowledge, this is the first reported case of dural arteriovenous fistula presenting with conductive hearing loss and otalgia.

An alternative approach to mixed hearing loss in otosclerosis: stapes surgery combined with an active middle-ear implant.

OBJECTIVE: To report a novel management strategy for mixed hearing loss in advanced otosclerosis. METHODS: A 50-year-old male was referred to St Thomas' Hearing Implant Centre with otosclerosis; he was no longer able to wear conventional hearing aids because of recurrent otitis externa. The patient underwent short process incus vibroplasty (using the Med-El Vibrant Soundbridge device), followed at a suitable interval (six weeks) by stapes surgery. The main outcome measures were: pure tone audiometry, functional gain and monosyllabic word recognition scores. RESULTS: Post-operative pure tone audiometry showed a reduction of the mean air-bone gap from 55 dB HL to 20 dB HL. The residual mixed hearing loss was rehabilitated with the Vibrant Soundbridge, with an average device gain of 32 dB. The monosyllabic word recognition scores in quiet at 65 dB improved from 37 to 100 per cent when using the Vibrant Soundbridge at six months after switch-on of the device. CONCLUSION: Stapedotomy in conjunction with incus short process vibroplasty (i.e. inner-ear vibroplasty) is a safe and promising procedure for managing advanced otosclerosis with mixed hearing loss in selected patients.

Discontinuity of the incudo-stapedial joint within a fully aerated middle ear and mastoid on computed tomography: A clinico-radiological study of its aetiology and clinical consequence.

AIM: To investigate the aetiology and clinical consequences of incudo-stapedial (IS) discontinuity when it is demonstrated on computed tomography (CT) within a fully aerated middle ear and mastoid. METHODS AND MATERIALS: Patients with CT evidence of IS discontinuity within a fully aerated middle ear and mastoid were prospectively identified. Clinical history, otoscopic findings, audiometry, and CT data were evaluated. Predefined criteria were used to determine the likely aetiology of IS discontinuity, whether it was diagnosed prior to the CT study, and the clinical consequences in terms of degree of conductive hearing loss and requirement for surgical correction. The range of CT appearances was evaluated. RESULTS: The IS discontinuity in 34/36 ears was felt to be due to incus erosion secondary to chronic otitis, on the basis of clinical history and otoscopic findings. The IS discontinuity was rarely evident prior to CT with long-process deficiency being identified in only 5/36 cases. The mean air bone gap was only 22.5 dB. The ossicular defect was surgically addressed in only four cases. The incus deficiency was confined to the lower-third on CT in 19/36 cases. CONCLUSION: When IS discontinuity is demonstrated within a fully aerated middle ear and mastoid, the most likely aetiology is of acquired incus erosion due to chronic otitis media. The IS discontinuity on CT is usually not evident otoscopically. It usually results in only mild conductive hearing loss and the ossicular discontinuity was rarely surgically addressed in the present series.

Tuberculosis presenting as bilateral vocal fold palsy: case report and review of otolaryngological manifestations of tuberculosis.

OBJECTIVE: We report a rare case of tuberculosis presenting with bilateral vocal fold palsy. METHOD: Case report and discussion of ENT manifestations of tuberculosis. CASE REPORT: A 39-year-old man presented with stridor and bilateral vocal fold palsies, and underwent an emergency tracheostomy. Intra-operatively, a mass was identified overlying the thyroid cartilage. Fine needle aspiration cytology of this mass showed well formed granulomas but negative Ziehl-Nielsen staining. Computed tomography showed the mass to be surrounding the thyroid cartilage, causing airway occlusion; pulmonary infiltrates were also seen. The patient was commenced on tuberculosis treatment. Subsequent sputum samples from the tracheostomy confirmed the diagnosis. The patient responded very well to treatment, and was successfully decannulated after one week. CONCLUSION: The incidence of tuberculosis in the UK is increasing, particularly in urban areas. The otolaryngologist may encounter a wide variety of presentations. Diagnosis requires a high index of clinical suspicion.

Monopolar suction diathermy adenoidectomy: technical note.

Monopolar suction diathermy allows controlled resection of the adenoids in a near bloodless field. In this article the author describes some technical points to make the procedure safe.

Blue-emitting Ir(III) phosphors with ancillary 4,6-difluorobenzyl diphenylphosphine based cyclometalate.

Treatment of difluorobenzyldiphenylphosphine with the Ir(III) dimer [(dfppy)2Ir(mu-Cl)]2 gives (N,N)-trans-[Ir(dfppy)2(dfbdpH)Cl], followed by skeletal isomerization to form its (N,N)-cis analogue, and then the fully cyclometalated complex [Ir(dfppy)2(dfbdp)]; the last complex and its derivative are suitable for fabrication of true-blue phosphorescent OLEDs.

Synthesis of 2,5-disubstituted thienosultines and their thermal reactions with dienophiles and nucleophiles.

The 2,5-disubstituted thienosultines (5,7-disubstituted 1,4-dihydro-1H-3lambda(4)-thieno[3,4-d][2,3]oxathiin-3-oxides) 5a-d were prepared from the corresponding dichlorides 4a-d with the commercially available Rongalite (sodium formaldehyde sulfoxylate) in 17-60% yields. When heated in the presence of electron-poor dienophiles, sultines 5a-d underwent elimination of SO(2), and the resulting non-Kekulé biradicals 7a-d were intercepted as the 1:1 adducts 8-12 in good to excellent yields. The pyrolysis of sultines and sulfolenes with different concentrations of dienophiles revealed that either a preequilibrium between starting reagents and biradical species or Diels-Alder and retro-Diels-Alder reaction mechanisms may be involved; however, more work is necessary to establish the proposed mechanisms. Reaction of sultine 5b with nBuLi was found to undergo a nucleophilic ring-opening reaction to give sulfinyl alcohol 17 after H(2)O workup. When sultine 5a was heated in benzene in a sealed tube in the presence of methanol, methanol-d(4), or 2-mercaptoethanol, the respective 1:1 trapping adducts 19-21 as well as the rearranged sulfolene 6a were isolated in similar amounts. The isolation of adducts 19-21 may be explained by the involvement of either biradical or ionic intermediates during the pyrolysis.