[Clinical observations of acute low-tone sensorineural hearing loss considered as cochlear hydrops].

Acute low-tone sensorineural hearing loss (ALHL) has the following three criteria; obscure origin, acute onset and sensorineural hearing loss limited to low frequencies. Sixteen cases of ALHL which were considered as cochlear hydrops using glycerol test and electrocochleogram were studied. All patients visited our department within two weeks after onset and were followed up for one year or more after initial examination. The subjective symptoms, the character of vestibular and hearing impairment and prognosis of 16 cases with ALHL were also investigated. The results were as follows. 1. Patients complained of ear fullness rather than hearing impairment. Four patients were unaware of hearing loss. 2. Recruitment phenomenon was found in all of 15 cases examined. Vestibular findings were mostly normal, except that spontaneous nystagmus was found in two cases and head-shaking nystagmus in one. 3. Recurrence and fluctuation of hearing impairment occurred in 14 cases. Three cases had an attack of rotatory vertigo once and two has diagnosed as Meniere's disease later. 4. During three months prior to last examination, hearing was stabilized in nine cases and continued to fluctuate in seven cases. In the former, hearing was improved in four cases, unchanged in three, and worsened in two. 5. Two patients underwent an endolymphatic sac operation and have had a good prognosis. 6. The authors suggest that most of ALHL should be considered as transient cochlear hydrops because the subjective symptom and audiological and vestibular findings of our cases are similar to those of cases which were reported as ALHL by other investigators. According to the findings of glycerol test and electrocochleogram, endolymphatic hydrops in ALHL is considered to exist in all turns of cochlea.

Fluctuating hearing loss in lipoma of the cerebellopontine angle.

Two cases of lipoma of the cerebellopontine angle are presented. Both of them showed fluctuating hearing loss, and one case exhibited Menière-like symptoms. In one of the cases, continued clinical surveillance is considered in view of a high chance of postoperative morbidity.

The Auto-Tilt Test in patients with positional vertigo and Menière's disease.

As a new method of testing the righting reflex, which has been considered to be closely related to the otolith function, we used the Auto-Tilt Test (ATT) on 24 patients with positional vertigo, on 5 patients with Meniere's disease before and after cochlearendolymphatic shunt, and on 10 normal subjects. The subject is required to stand on an electrically driven tilt board with an autoregulating switch in hand, and to perform bilateral tilt swings of 5 degrees and 10 degrees wearing a helmet with a Head Inclinometer or tilt sensor. The result of this test in patients with positional vertigo revealed the patients had an abnormal labyrinthine reflex and significantly excessive tilt in the return swing from the side of the lesion. In addition, we consistently observed an inaccurate righting reflex, coupled with a diminished sensation of tilt, on the side of the lesion. The results in Meniere's disease patients, followed up before and after surgery, showed that the depressed righting reflex toward the affected side and the tendency to list to the healthy side before surgery, improved after surgery.

The surgical procedures and evaluation of two modifications of endolymphatic sac surgery: the epidural shunt and vein graft drainage.

A method of ELS surgery was originally described in 1926 by George Portmann. However, the risk of adhesive closure of an incision on the lateral wall of the ELS in his technique has been a matter of dispute ever since. A number of modifications have been advocated in order to improve the patency of the ELS, such as Yamakawa-Naito's subarachnoid shunt (1954), House's endolymphatic-subarachnoid shunt (1962), Shea's Teflon film drainage of the sac (1966), the T-tube shunt of Paparella & Hanson (1976), the valve implant by Arenberg (1979), the epidural drainage by an L-shaped incision in the lateral wall of the sac with insertion of gelatin film, developed by Kitahara & Futaki (1974), and vein graft drainage of the ELS by Futaki & Nomura (1988). During the period July 1980 to February 1986, 142 patients with endolymphatic hydrops were followed postoperatively according to the AAO-HNS (1985) guidelines. Of these 142 cases, 122 patients were operated on by Kitahara & Futaki's procedure and 20 by the vein graft drainage procedure. The incidence of vertigo was cured in over 90% of the cases and hearing impairment was improved in over 30%. In this paper, the surgical procedures are described in detail, using illustrations.

Vein graft drainage of the endolymphatic sac in patients with Menière's disease. A preliminary report.

The blood supply of the endolymphatic sac, which has a role in the absorption of endolymph, is connected to the meningeal artery separate from the branch of the cerebellar artery of the inner ear. Therefore, avoiding damage to the small vessels of the lateral wall of the sac should be important for restoring the absorptive function. To prevent adhesive closure of the drainage incision and restore the absorption function of the sac, we developed a new technique that restricts the drainage incision to a simple straight one on the rostral edge of the sac and in which a drainage vein from the back of the patient's foot is grafted with a gelatin-film core to the incised sac. Our procedure was performed on 20 patients with Menière's disease, who were followed over 24 months. The results were favorable: recovery from vertigo was "complete" in 7 cases (35%), "substantial" in 12 (60%), and "limited" in 1 case (5%) according to the new formula developed by the American Academy of Otolaryngology and Head and Neck Surgery (AAO-HNS) (Miami, 1985).

Treatment of hydropic patients by immunoglobulin with methyl B12.

Recently several investigations have been reported suggesting that the cause of endolymphatic hydrops might be an immunologic disorder of the endolymphatic space, including the endolymphatic sac. As the first choice in a conservative treatment by medication, the authors have used a combination of prednisolone and furosemide per os, which is rather safe and effective for hydrops patients in a subacute stage. However, some patients do not respond to this treatment or gradually become immune to this medication. With these patients, we have tried an intravenous administration of immunoglobulin G with methyl B12, expecting a curative effect on immunologic deficiency in the endolymphatic space. Compared with a group of patients without this treatment, the group receiving it showed rather good scores in hearing improvement; however, vertigo and tinnitus remained almost unchanged.

Development of pressure monitoring and controlling system for quantitative analysis of experimentally induced perilymph fistula.

The cause of perilymph fistula, a subgroup of sudden deafness, has not been clearly understood. To study its etiology quantitatively, the inner ear pressure monitoring system with a computer controlled pressurizing device and three types of low-pressure monitoring sensors was constructed and utilized in ex vivo experiments using white guinea pigs. Hypothesizing that cerebrospinal pressure increases cause rupture of the round window membrane, direct and indirect pressurization to cerebrospinal region and simultaneous measurement of inner ear and cerebrospinal pressures were carried out. Ruptures of the round window membranes were seen in the experiments with direct saline infusion into the cochlea when the increment of inner ear pressure exceeded 500 mmH2O. There was no sign of rupture when squeezing abdomen was employed as an indirect pressurization, although cerebrospinal pressure increased.

Immunological analysis of IgG and other protein fractions in endolymph obtained from endolymphatic sac of Meniere patients and a control.

During endolymphatic sac surgery on patients with Meniere's disease, very small amounts (1 microliter) of the intra-sac endolymph were obtained with micro-glass pipets. An immunological assay of microanalysis of the protein by the single radial immunodiffusion (SRID) method was applied to 2 patients, one with bilateral involvement and the other unilateral. Among the protein fractions Alb, IgG, IgM, IgA, C3, C4, transferrin and alpha 2M, the concentrations of IgG were relatively higher, especially in the Meniere patient in the active stage. From 2 other patients and a control deaf patient with temporal bone fracture, the same amounts of endolymph were obtained, accompanied by a tiny specimen of the outer wall of the sac. When a radio-immunological procedure was applied to the endolymph and the homogenized sac, the specific concentration of IgG was higher in the Meniere patients than in the control.

Detection of delayed endolymphatic hydrops by the furosemide test.

Delayed endolymphatic hydrops, an entity which can be differentiated from Meniere's disease, was first reported simultaneously by Nadol et al. (1975) and Wolfson & Leiberman (1975) and specified by Schuknecht (1978). They diagnosed it from the anamnesis of patients and confirmed the hydropic condition of the labyrinth solely by evidence obtained from surgical procedures such as labyrinthectomy. The aim of the present study was to emphasize the usefulness of the furosemide test for distinguishing this entity before surgery by detecting the hydropic condition in the labyrinth. In these 3 years, we encountered 11 cases of endolymphatic hydrops, 9 ipsilateral and 2 contralateral, in our clinic (Univ. of Tokyo Hospital). Among the ipsilateral cases, the estimated genesis of pre-existing hearing loss was most frequent in mumps (44%). The result of the furosemide test in this group was 89% positive. On the basis of this result, we have been able to choose the method of treatment, i.e. 4 cases treated by epidural shunt operation on the endolymphatic sac, 2 by labyrinthectomy, one by cochleosacculotomy and 2 by medication with steroids and diuretics. In the 2 contralateral cases, one was treated by epidural shunt and the other by medication. The authors are therefore able to confirm the usefulness of the furosemide test for detecting delayed endolymphatic hydrops.

[Clinical experience with cefotiam infusions in chronic sinusitis and otitis media].

Clinical efficacy and safety of cefotiam were studied. Twelve patients with chronic sinusitis and 14 patients with chronic otitis media were intravenously given cefotiam in daily doses of 2 g for 7 to 10 days. In chronic sinusitis, clinical responses were excellent in 6 patients, good in 3 and fair in 3, the rate of satisfactory clinical responses (excellent and good) being 75%. In chronic otitis media, the responses were excellent in 5, good in 4 and fair in 5, the rate of satisfactory clinical responses being 65%. As for side effects, eruption and abdominal pain were observed in 1 patient.

[Topical administration of cefsulodin in postoperative Pseudomonas aeruginosa infection of the middle ears].

The clinical evaluation for cefsulodin (CFS) against P. aeruginosa was studied in postoperative infections of chronic otitis media by means of washing the middle ear with the drug, and the following results were obtained; CFS treatment was given to 5 cases, and the clinical responses were excellent in 4 and good in 1 case. P. aeruginosa in otorrhea was eradicated within several days, and otorrhea disappeared in all the cases. No side effect was observed in all cases.

Measurement of eye deviation under the nonfixative condition in patients with peripheral labyrinthine disorders, especially Meniere's disease.

Among 232 Japanese patients with peripheral disorders, 98 had a unilateral Meniere's disease. In these patients and 20 healthy adults, recordings of eye deviation were made utilizing DC-ENG under two conditions, i.e. eyes closed (EC) and eyes open in the absolute darkness (AD). (1) 90 % tolerance interval of AD. was significantly smaller than that of EC in controls. (2) Appearance of nystagmus in 5 groups with labyrinthine lesions was compared with the direction of deviation toward and against the affected side in both conditions. (3) Concerning unilateral Meniere's, the relationship among deviation, nystagmus and caloric response was analyzed statistically and the clinical application discussed.

A comparison of the furosemide and glycerol tests for Meniere's disease. With special reference to the bilateral lesion.

The feasibility of furosemide test for the detection of endolymphatic hydrops has previously been discussed (Authors, 1973, 1975). The glycerol test also has been reported as being effective for the same purpose but only in Meniere patients with fluctuating hearing loss (Klockhoff & Lindblom, 1966). In 48 patients with Meniere's disease, both the furosemide test (F-test) and the glycerol test (G-test) were performed on 51 ears including 3 cases of bilateral involvement. The average value of urine volume in the F-test was significantly greater than that for the G-test. The decrease in tinnitus was 40% in the former, 45% in the latter. The F-test yielded a positive rate of 73%, and the G-test, 45%. The results were thus: positive in the both tests, i.e., F+: G+ were 17 (33%); F+: G-, 20 (39%); F-: G+, 6 (12%), and both negative, F-: G-, only (16%). The side effects of the F-test were nil, but those of the G-test were as follows: headache (29%), nausea (4%), and increase in tinnitus (9%). The response increase of the hydropic labyrinth caused by the two kinds of systemic dehydration over-lapped in part and differed in part, as a result of the differing diuretic mechanisms and their respective affinities to the cochlea and the vestibulum. The furosemide test may be based on the action of the vestibular response type, which is caused by natriuretic dehydration accompanying the more sensitive response increase in caloric-induced nystagmus, while the glycerol test may be based on the action of the cochlear response type, owing to osmotic diuresis manifested as hearing shift. The correlation between labyrinthine hydrops and dehydration was discussed and it was concluded that these double test were quite adequate methods for choice of treatment of not only unilateral Meniere's disease in its various stages but also in bilateral involvements.