Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo - a clinico-pathological case reporT.

BACKGROUND AND PURPOSE: Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose - Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. METHODS: A 56-year-old male patient's interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. RESULTS: During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion - It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the "seed and soil" theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. CONCLUSION: Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical aspects of otosclerotic ossicular chain fixations. / Az otoscleroticus eredetu hallócsontláncolati fixatiók klinikuma.

Otosclerosis is a human-specific ear disease characterised by complex bone-remodelling with multifactorial aetiology. It affects the bony labyrinth capsule and consequently fixates the stapes to the oval window rim. The fixation of the ossicular chain leads to a decrease in the middle ear's acoustic impedance-fitting and amplifier function that leads to conductive hearing loss. The process is progressive and when it involves the inner ear structures, it deteriorates the sensorineural function as well. The course of the illness can be prevented or delayed if hearing reconstructive surgery is performed on time. The development of stapes surgery spans the 20th century, and despite the major surgical steps - laid down by Shea and Marquet in the 1960s - are quite conservative, fine adjustments are still being made mainly due to technical progress. Several studies confirm that stapedotomy remained the first-to-offer therapeutic option in otosclerosis. With an adequate surgical technique, significant improvement can be achieved in the air conduction threshold, the air-bone gap may be minimalized or ceased over the speech frequencies, which significantly improves the quality of life of the patients. In this quest, we reviewed the Hungarian and the international literature as well in context with otosclerosis, with special attention to the newest methods in diagnostics and treatment management. Orv Hetil. 2020; 161(19): 780-788.

Review of electrode placement with the Slim Modiolar Electrode: identification and management.

Background - Several cochlear implant recipients experience functionality loss due to electrode array mal-positioning. The application of delicate perimodiolar electrodes has many electrophysiological advantages, however, these profiles may be more susceptible to tip fold-over. Purpose - The prompt realization of such complication following electrode insertion would be auspicious, thus the electrode could be possibly repositioned during the same surgical procedure. Methods - The authors present three tip fold-over cases, experienced throughout their work with Slim Modiolar Electrode implants. Implantations were performed through the round window approach, by a skilled surgeon. Standard intraoperative measurements (electric integrity, neural response telemetry, and electrical stapedial reflex threshold tests) were successfully completed. The electrode position was controlled by conventional radiography on the first postoperative day. Results - Tip fold-over was not tactilely sensated by the surgeon. Our subjects revealed normal intraoperative telemetry measurements, only the postoperative imaging showed the tip fold-over. Due to the emerging adverse perception of constant beeping noise, the device was replaced by a CI512 implant after 6 months in one case. In the two remaining cases, the electrode array was reloaded into a back-up sheath, and reinserted into the scala tympani successfully through an extended round window approach. Discussion - Future additional studies using the spread of excitation or electric field imaging may improve test reliability. As all of these measurements are still carried out following electrode insertion, real-time identification, unfortunately, remains questionable. Conclusion - Tip fold-over could be reliably identified by conventional X-ray imaging. By contrast, intraoperative electrophysiology was not sufficiently sensitive to reveal it.

[Possibilities for residual hearing preservation with Nucleus CI532 Slim Modiolar electrode array. Case report]. / A maradványhallás megorzésének lehetoségei cochlearis implantáció során Nucleus CI532 Slim Modiolar elektródasorral.

During the rehabilitation of hearing-impaired patients, the preservation of residual acoustic hearing following cochlear implantation by minimizing the implantation trauma allows for improved hearing performance. To achieve this, minimally invasive, soft surgery methods and thinner, atraumatic electrodes were required. In our present study, we reported a case where Cochlear® Nucleus CI532 Slim Modiolar electrode was implanted in a patient with residual hearing. Our aim was to study the possible preservation of postoperative acoustic residual hearing by audiological monitoring. Since childhood, due to her congenital hearing loss, she has been wearing a conventional, airborne hearing correction device on both ears. Six months before cochlear implantation, we measured the progression on both sides of the hearing loss, so we decided to perform cochlear implantation. The patient had residual hearing on both ears prior to surgery thus the Cochlear® Nucleus CI532 Slim Modiolar Implant was used. The minimally invasive surgery was performed on the patient's right ear through the round window approach. Compared to the preoperative hearing threshold (average 85 dBHL) in the 4th postoperative week, an initial hearing threshold progression of 20-25 dBHL was observed between 0.25 and 1.0 kHz, while of 5-10 dBHL between 2.0-4.0 kHz. Hearing threshold measured in the 6th month showed a slight progression in the range above 1 kHz, but improved by the 12th month, to the results achieved at the 4th week. The effects of cochlear implantation on residual hearing have been studied in numerous studies, in which several key surgical and technical factors have been identified. Nucleus CI532 is a Slim Modiolar electrode profile that is close to the modiolus, so it is expected to have a lower endocochlear hydrodynamic load since it lies in the covering of the osseus spiral lamina, thus less influencing the dynamics of the basilar membrane. However, the perimodiolar location of the electrode array allows the adjacent nerve elements of the spiral ganglion to be stimulated with a lower electrical intensity and a reduced surface that may be neuroprotective. Preservation of acoustic residual hearing following cochlear implantation improves the patient's speech perception and the sound localization skills, particularly in difficult circumstances. Long-term residual hearing preservation may also be of great importance in the subsequent feasibility for regenerative procedures and drug treatments. Orv Hetil. 2018; 159(41): 1680-1688.

[Pediatric hearing rehabilitation with the Baha® Attract implant system]. / Fiatalkori hallásrehabilitáció Baha® Attract implantátumrendszerrel.

INTRODUCTION: Baha® Attract is a new transcutaneous bone-conduction hearing aid, which is more preferable in childhood than the conventional percutaneous systems. AIM: Our aim was to demonstrate the possibilities of application in childhood. METHOD: Eight children have undergone surgeries (mean age of 13.2 ± 3.2 years; "posterosuperior" incision technique, 5 mm implants). The thickness of the skull bone was determined in 72 children (1-8 years old) at the recommended implant site, based on CT scans. RESULTS: The average duration of surgeries was 30 minutes. There were no intra- and postoperative complications observed. Sound processors were fitted at the postoperative 4th week. Hearing measurements proved 51.58±11.22SD dBHL gain in warble tone thresholds, and 43.3 ± 16.02 SD dB in speech discrimination thresholds. The skull bone thickness was measured as 3.39 ± 1.05 SD mm. CONCLUSION: The Baha Attract system is a new tool for hearing rehabilitation in pediatric population. Preoperative CT provides valuable knowledge about skull bone thickness. Orv. Hetil., 2017, 158(8), 304-310.

Vascular mapping of the retroauricular skin - proposal for a posterior superior surgical incision for transcutaneous bone-conduction hearing implants.

BACKGROUND: Passive transcutaneous osseointegrated hearing implant systems have become increasingly popular more recently. The area over the implant is vulnerable due to vibration and pressure from the externally worn sound processor. Good perfusion and neural integrity has the potential to reduce complications. The authors' objective was to determine the ideal surgical exposure to maintain perfusion and neural integrity and decrease surgical time as a result of reduced bleeding. METHODS: The vascular anatomy of the temporal-parietal soft tissue was examined in a total of 50 subjects. Imaging diagnostics included magnetic resonance angiography in 12 and Doppler ultrasound in 25 healthy subjects to reveal the arterial network. Cadaver dissection of 13 subjects formed the control group. The prevalence of the arteries were statistically analyzed with sector analysis in the surgically relevant area. RESULTS: The main arterial branches of this region could be well identified with each method. Statistical analysis showed that the arterial pattern was similar in all subjects. The prevalence of major arteries is low in the upper posterior area though large in proximity to the auricle region. CONCLUSIONS: Diverse methods indicate the advantages of a posterior superior incision because the major arteries and nerves are at less risk of damage and best preserved. Although injury to these structures is rare, when it occurs, the distal flow is compromised and the peri-implant area is left intact. Hand-held Doppler is efficient and cost-effective in finding the best position for incision, if necessary, in subjects with a history of surgical stress to the retroauricular skin. TRIAL REGISTRATION: This was a non-interventional study.

Laser-Doppler microvascular measurements in the peri-implant areas of different osseointegrated bone conductor implant systems.

The objective of this study was to evaluate the impact of hydroxyapatite coating of newly designed osseointegrated fixtures' abutments on the postoperative complication rates. The integrity of peri-implant microcirculation was used as a marker to compare tissue viability after different surgical techniques. Laser-Doppler Flowmetry (LDF) measures alone, and coupled with heat provocation tests were applied to test the different microcircular patterns. Measures for 17 consecutively implanted patients (8 women, 9 men, ages ranged from 18 to 77 years) were recruited; seven with soft tissue reduction (STR); and 10 with soft tissue preservation (STP).Thirteen non-operated retro-auricular areas were examined as naive controls. In isotherm conditions the baseline blood flow remained stable in all groups. The naive control patients demonstrated significant changes of blood flux in the intact skin. The non-implanted yet previously operated contralateral sides of the patients demonstrated marginally lower (p = 0.09) blood flux index. The STR sides however, showed significantly lower (average 217 %) provoked blood flux compared to controls (p < 0.001). At the STP sides a maladaptation could be observed (average 316 %) compared to the contralateral sides (p = 0.53). STP sides demonstrated a significantly better blood flow improvement compared to the STR sides (p = 0.02). These results suggest a favorable postoperative condition of vascular microcirculation after STP, than after STR surgery. The possibly faster wound healing and lower potential complication rate may widen the inclusion criteria and maybe beneficial for the patient compliance with a better quality-of-life.

Recurrent bacterial meningitis after cochlear implantation in a patient with a newly described labyrinthine malformation.

Authors report on a so far undescribed bilateral inner ear malformation with congenital deafness where a defect of both the medial and lateral bony labyrinthine wall allowed the herniation of a cerebrospinal fluid-filled endosteum sac into the tympanic cavity. The story of cochlear implantation in this ear and the series of following meningitis demonstrates the dilemma of indicating implantation in labyrinthine dysplasia and the difficulties of treating postimplantation meningitis. Routes of bacterial invasion from inner ear to intracranium is discussed regarding normal, dysplastic and surgically "disturbed" inner ear anatomy.

Neural response telemetry in cochlear implant users.

Programming of multichannel cochlear implants requires subjective responses to a series of sophisticated psychophysical percepts. It is often difficult for cochlear implant patients (especially young prelinguistically deaf children) to provide adequate responses for device fitting. However, the neural response telemetry (NRT) system renders possible the measurement of the compound action potential threshold. We performed NRT examinations in 27 cochlear implant users with Nucleus 24-channel cochlear implants. Measurements were obtained from five electrodes (3, 5, 10, 15, and 20) in each patient. Our goal was to look for correlation between behavioral subjective thresholds and compound action potentials. The action potentials could be elicited in 23 patients in all measured electrodes. The NRT threshold values were highly correlated with electrical threshold levels obtained through subjective responses. Our results suggest that the electrically elicited neural responses may yield very important information for device fitting in patients with cochlear implants.