Tullio phenomenon with dehiscence of the superior semicircular canal.

HYPOTHESIS: The goal of the investigation was to determine if vector analysis of nystagmus in a patient with the Tullio phenomenon could determine the source of the nystagmus. BACKGROUND: The Tullio phenomenon consists of the combination of vertigo and abnormal eye and/or head movements provoked by sound. Dehiscence of the superior semicircular canal can be found in certain patients with the Tullio phenomenon. METHODS: The patient was tested with pure tones ranging from 250 to 3,000 Hz at 95dB HL. The time course of the three-dimensional vector of eye movement, including torsion and vertical and horizontal displacement angles was determined by individual stop-frame analysis of digitized video. RESULTS: Torsion amplitude varied from 1 to 7 degrees; vertical amplitude varied from 1 to 5 degrees; and horizontal amplitude varied less than 1.5 degrees. The maximal response occurred on stimulation of the right ear with a 1,250-Hz 95-dB HL tone. This elicited a reliable counterclockwise torsional and down-beating fast phase nystagmus as seen from the examiner's point of view. Comparison of the nystagmus with known canal vectors identified the right superior semicircular canal as the source of stimulation. High-resolution computed tomography scan of the temporal bone showed a definite right superior canal dehiscence. CONCLUSION: The origin of nystagmus from the Tullio phenomenon can be identified by calculating the three-dimensional vector of the observed nystagmus. We show that vector analysis of the observed eye movement can be used to infer the source of nystagmus in these patients. The development of real-time, three-dimensional vector analysis of nystagmus is desirable.

A meta-analysis review of revision stapes surgery with argon laser: effectiveness and safety.

OBJECTIVE: To determine whether there is an advantage in safety and outcome efficacy with the use of argon laser in revision stapes surgery as compared with conventional instruments. DATA SOURCES: A search of the published English-language literature, 1970-1995, was conducted using the following key words: revision, surgery, stapes, laser, stapedotomy, and argon laser. STUDY SELECTION: The following inclusion criteria were used to select articles for the meta-analysis: revision cases only, a comprehensive review of intraoperative pathological findings that led to the failure, and accurate documentation by the author, confirmed by our statisticians using a modified chi 2 test. Eleven studies without the use of the laser (n = 1,147 patients) and four studies with the use of the laser (n = 170 patients) including our own patients (n = 23) were entered into the model. DATA EXTRACTION: The data had to meet strict audiometric criteria, including preoperative and postoperative audiogram pure tone average air-bone gap; postoperative audiograms had to include five classifications, and these audiograms had to be obtained a minimum of 6 months after revision surgery. DATA SYNTHESIS: A log-linear model was developed for this meta-analysis study, with each study analyzed individually and collectively. CONCLUSION: Revision stapes surgery using the laser demonstrated statistically significant (p = 0.002) advantage in both safety and efficacy over revision procedures using conventional instruments.

Estrogen and progesterone receptor concordance between primary and recurrent breast cancer.

Estrogen and progesterone receptor status in breast cancer can determine therapeutic options and may provide prognostic information. The purpose of this study is to compare the concordance of the primary breast cancer steroid hormone receptor status to that of the recurrent breast cancer and to determine whether the type of second lesion (local recurrence, second primary, or metastatic lesion) and adjuvant therapy received changed the receptor concordance. The records of eighty-three patients with estrogen receptor (ER) analysis available for primary (p) and recurrent (r) breast cancer for 1976-1990 were reviewed. In addition, 32 of these patients also had available progesterone receptor (PR) values for primary and recurrent breast cancers. Statistical evaluation was performed by chi-square, Student's t-test, and Wilcoxon signed-rank test. ER concordance (primary/recurrent, p/r) was identified in 59/83 (71%) patients; PR concordance was identified in 18/32 (56%) patients. Whether the second lesion was a local recurrence, second primary, or a metastatic lesion did not affect ER concordance or PR concordance. Adjuvant chemotherapy, hormonal therapy, or radiation therapy, either alone or in combination, did not affect ER or PR concordance. The disease-free survival (DFS) for patients with ER (p+)/(r-) (primary receptor positive/recurrent receptor negative) was significantly shorter than those with ER (p-)/(r+)(27.6 +/- 7.4 months versus 50.6 +/- 7.6 mo, P = 0.04). The DFS for PR (p+)/(r-) patients was 28.8 +/- 7.9 months compared to the DFS of 46.8 +/- 11.8 months for PR (p-)/(r+) patients (P = NS). A significantly shorter DFS for ER (p+)/(r-) patients compared to ER (p-)/(r+) patients and a trend towards a shorter DFS for PR (p+)/(r-) patients compared to PR (p-)/(r+) patients may reflect a loss of hormonal regulation or an increase in cancer aggressiveness.

Localizing value of optokinetic afternystagmus.

Previous reports have indicated that optokinetic afternystagmus (OKAN) becomes asymmetric after the occurrence of unilateral peripheral vestibular lesions, and suggested that OKAN may be used for localizing the side of the lesion. These studies did not take into account spontaneous nystagmus. We compared OKAN in 12 subjects with unilateral vestibular loss after resection of acoustic neuroma to OKAN in 30 normal subjects. After offsetting the data for spontaneous nystagmus, we calculated the initial amplitude, the time constant, and the slow-phase cumulative eye position (SCEP) parameters of OKAN. The directional asymmetry of parameters to rightward and leftward stimulation were also calculated. The mean SCEP, initial amplitude, and time constant parameters were reduced significantly in the patients, and each also showed a directional asymmetry, such that they were greater for stimulation toward the side of the lesion. The directional preponderance of the SCEP parameter had the highest sensitivity for the side of the lesion, being abnormally elevated in 58.3% of patients with unilateral loss. We conclude that OKAN might be useful in combination with other subtests of a battery, but that by itself OKAN is only moderately sensitive to unilateral peripheral vestibular loss.