Tinnitus as a prognostic factor of sudden deafness.

CONCLUSIONS: The 'tinnitus-rare' group had a poorer prognosis for hearing than the 'tinnitus-often' group in all sudden sensorineural hearing loss (SSNHL), although the 'shorter duration' group had better prognosis than the 'longer duration' when restricted to SSNHL accompanied by tinnitus. This indicates that tinnitus itself may not be a sign for poor hearing prognosis but might be an essential sound for the initiation of repair of a damaged auditory system. OBJECTIVES: We examined the hearing improvement rate (HIR) and tinnitus at the onset of SSNHL to elucidate the prognostic value of tinnitus accompanying SSNHL. PATIENTS AND METHODS: Fifty patients with SSNHL were treated with systemic administration of steroids. Hearing recovery was determined by comparing the hearing levels before and after treatment. Tinnitus was subjectively evaluated by the tinnitus scoring questionnaire. The score for the five-step evaluation of the subjective tinnitus feelings 'loudness', 'duration' and 'annoyance' was obtained at the onset. RESULTS: In terms of 'duration', when we divided all the cases into 'tinnitus-rare' group and 'tinnitus-often' group, HIR in the 'tinnitus-rare' group was significantly lower than that in 'tinnitus-often' group. When restricted to the 'tinnitus-often' group, HIR for 'shorter duration' was significantly higher than that for 'longer duration'.

[A case of advanced adenocarcinoma of the ethmoid sinus treated by chemoradiation with S-1].

We report a case of advanced adenocarcinoma in the left ethmoid sinus invading the frontal sinus, the frontal skull base and the orbits(T4bN0M0 and Stage IVB). With the goal of functional preservation, we carried out radiation therapy with total 60 Gy irradiation and chemotherapy with S-1 80 mg/body/day before a radical operation. The tumor clinically disappeared without surgical treatment, and there was no sign of recurrence for 2.5 years. When we decide the treatment policy for advanced adenocarcinoma of the ethmoid sinus, chemoradiotherapy wit S-1 might be one of the effective treatments before radical operation to control the disease with preservation of functions.

Changes in caloric responses after temporal bone surgery with posterior tympanotomy.

OBJECTIVE: To elucidate the role of facial recess bony plate in the thermal transmission route from external auditory canal to lateral semicircular canal during caloric stimulation test, we performed the test on patients before and after removal of the plate, i.e. posterior tympanotomy. In the present study, we adopted facial nerve decompression (FND) as posterior tympanotomy without surgery-induced inner ear damages and cochlear implantation (CI) as posterior tympanotomy with surgery-induced inner ear damages. METHODS: Between 1999 and 2003, we performed FND on 19 patients with unilateral facial nerve paresis due to Bell's palsy (n=7), Ramsay-Hunt syndrome (n=7) or facial nerve trauma (n=5) at Osaka Rosai Hospital. We also performed CI on 34 patients with bilateral deafness at Osaka University Hospital. To examine effects of FND or CI on caloric responses in vestibular periphery, caloric stimulation (30 degrees C cold water and 44 degrees C hot water) with ENG was performed twice, just before and 6 months after surgery in each subject. The caloric-induced nystagmus was recorded by using ENG under dark and open-eyes situation to calculate the maximum slow phase eye velocity. RESULTS: In cases of FND (n=19), there were significant decreases between pre- and post-operative 30 degrees C responses (t-test: p=0.049<0.05). There were no significant differences between pre- and post-operative 44 degrees C responses (t-test: p=0.467>0.05). In cases of CI (n=34), there were significant changes between pre and post-operative responses in both temperatures (t-test: p<0.0001 in 30 degrees C; p=0.011<0.05 in 44 degrees C). CONCLUSION: The insertion of electrodes during CI did some damages to vestibular peripheral function and reduced both hot and cold caloric responses according to the results of CI. However, the procedure during posterior tympanotomy could also decrease caloric responses especially in cold stimulation according to the results of FND. Therefore, we should consider the effect of structural change in temporal bone on the thermal transmission in case of evaluation of vestibular peripheral function by using caloric stimulation test.

The investigation of the recurrence rate of cholesteatoma using Kaplan-Meier survival analysis.

OBJECTIVES: To investigate the recurrence rate of cholesteatoma using Kaplan-Meier survival analysis. STUDY DESIGN: Retrospective study. SETTING: Tertiary referral center. PATIENTS: Three hundred forty-five patients with middle ear cholesteatoma operated on by the same surgeon between 1987 and 2002. METHODS: The cumulative recurrence rate of cholesteatoma during a 5-year follow-up period was calculated using Kaplan-Meier survival analysis. RESULTS: The overall 5-year recurrence rate was 11.8%. The recurrence rate increased with the follow-up time. The 5-year recurrence rate was 3.9% in patients treated with canal wall down tympanoplasty (CWDT) and 16.7% in patients treated with intact canal wall tympanoplasty (ICWT) or canal wall reconstruction (CWR) after CWDT with a significant difference (p < 0.01). The 5-year recurrence rate was 26.0% in patients operated on between 1987 and 1996 and 0.7% in patients operated on between 1997 and 2002, again with a significant difference (p < 0.001). CONCLUSION: Kaplan-Meier survival analysis should be used for calculating the recurrence rate of cholesteatoma. Although this analytic method further demonstrates that CWDT is a more reliable surgical method than ICWT/CWR in reducing cholesteatoma recurrence, clinical judgment should be exercised, and we continue to recommend that a flexible approach should be adopted in deciding whether to perform CWDT or ICWT/CWR for individual cases.

Effects of endolymphatic sac drainage with steroids for intractable Meniere's disease: a long-term follow-up and randomized controlled study.

OBJECTIVE: Meniere's disease is a common inner ear disease with an incidence of 15 to 50 per 100,000 population. Since Meniere's disease is thought to be triggered by an immune insult to the inner ear, we examined intraendolymphatic sac application of steroids as a new therapeutic strategy for intractable Meniere's disease. STUDY DESIGN: Prospective randomized controlled study. METHODS: Between 1996 and 2005, we enrolled and assigned 197 intractable Meniere's patients to three groups in a randomized controlled trial: Group I (G-I)- patients who underwent endolymphatic sac drainage and steroid-instillation; Group II (G-II)-those who underwent endolymphatic sac drainage without steroid-instillation; and Group III (G-III)-those who declined endolymphatic sac drainage. Definitive spells and hearing in all three groups were determined for 2 to 7 years after treatment. RESULTS: According to the 1995 American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) criteria, 2-year results demonstrated that vertigo was completely controlled in 88.0% of patients in G-I (n = 100), 85.1% of patients in G-II (n = 47), and 8.0% in G-III (n = 50). Statistically, G-I = G-II>G-III. Hearing was improved in 49.0% of patients in G-I, 31.9% in G-II, and 6.0% in G-III (G-I>G-II>G-III). Results after 7 years showed that vertigo was completely controlled in 78.8% of patients in G-I, 79.2% in G-II, and 25.0% in G-III (G-I = G-II>G-III). Hearing improved in 36.5% of patients in G-I, 8.3% in G-II, and 0.0% in G-III (G-I>G-II = G-III). CONCLUSIONS: From non-surgical observation in G-III for at least 7 years after treatment, steroids instilled into endolymphatic sac in G-I patients significantly improved hearing in intractable Meniere's patients, more so than endolymphatic sac drainage without steroids in G-II patients.

[Dynamic vestibular compensation in vestibular peripheral diseases].

Vestibular compensation, or neuronal plasticity in the central vestibular system, is quite an important process in patients with acute unilateral peripheral vestibular disease, allowing them to lead a comfortable daily life when medical treatments fail to cure the peripheral vestibular function. Is the residual unilateral vestibular input from damaged vestibular endo-organs a positive or negative factor for the development of dynamic vestibular compensation in the central nervous system? To elucidate the true mechanism of vestibular compensation, we examined the ENG findings and dizziness handicap inventory questionnaire in patients with vestibular neuronitis (VN), sudden deafness with vertigo (SDV), Meniere's disease (MD) and acoustic tumor (AT) during remission of the vertigo attacks. We obtained neuro-otological findings from caloric tests and head shaking after nystagmus using ENG and information on motion-evoked dizziness in daily life using the questionnaire. There were no significant differences in the sex, age or canal paresis % (CP%) among the four groups. The results of the present study showed that dynamic vestibular compensation processes developed progressively in the order of patients with SDV, VN, MD and AT (Kruskal-Wallis : p < 0.05). This finding suggests that processes of dynamic vestibular compensation could be accelerated in patients with fixed vestibular lesions caused by SDV and VN more than in those with fluctuating vestibular functions caused by MD and AT. In patients with fixed vestibular lesions caused by SDV and VN, patients with lower CP% showed dynamic vestibular compensation (i.e. disappearance of head shaking after nystagmus (chi-square: p < 0.05) and motion-evoked dizziness (Mann-Whitney: p < 0.0005)) more rapidly than those with higher CP%. In patients with fluctuating vestibular functions caused by MD and AT, patients with lower CP% did not always develop dynamic vestibular compensation more smoothly than those with higher CP%.

[Delayed facial nerve palsy after otologic surgery].

Delayed facial nerve palsy (DFP) is rarely experienced after otologic surgeries that do not directly touch the facial nerves, such as tympano-mastoidectomy, cochlear implants, and stapes surgery, and is troublesome to both surgeons and patients if it happens. Here, we report 7 cases of DFP, including one case that developed DFP after endolymphatic sac surgery. The ratios of occurrence were as follows: 0.7% (2/305) for tympano-mastoidectomy, 0.8% (3/354) for cochlear implant, 0.4% (1/260) for stapes surgery and 1.0% (1/98) for endolymphatic sac surgery. All otologic surgeries, except for endolymphatic sac surgery, exposed the chorda tympani, and all surgeries, except for stapes surgery, underwent drilling for a mastoidectomy. Furthermore, DFP was always observed ipsilaterally to the operated ear after otologic surgeries and was never seen after benign parotid tumor surgery or total laryngectomy. Therefore, there may be a strong relationship between DFP and the procedures, used during otologic surgeries.

Prognosis of inner ear periphery and central vestibular plasticity in sudden deafness with vertigo.

OBJECTIVES: We sought to elucidate the clinical problems and otopathology of patients with sudden deafness with vertigo (SDV). METHODS: In 24 patients with SDV who had significant canal paresis (CP) at their first visit to our hospital between 1997 and 2001, we examined pure tone audiograms, caloric tests, and several questionnaires twice, at the first visit within 5 days after the onset and around 2 years after steroid therapy. RESULTS: These examinations revealed that improvements of auditory and vestibular function in patients with SDV tended to be correlated with one another. Sixteen of the 24 patients (66.7%) still had CP. This rate in SDV was significantly worse than that reported previously for vestibular neuritis (VN). On the other hand, patients with SDV with long-lasting CP had a faster reduction of head-shaking afternystagmus and of handicaps in their everyday life due to dizziness than did patients with VN and CP. CONCLUSIONS: These findings suggest that SDV may deteriorate the inner ear function more severely but accelerate the central vestibular compensation more effectively than VN after the lesion. It is well known that vestibular neurectomy causes much more severe motion-induced dizziness after surgery than does labyrinthectomy. Taken together, these findings suggest different regions of damage in SDV (mainly the labyrinth, as in labyrinthectomy) and VN (mainly the ganglion, as in vestibular neurectomy).

Surgical management of special cases of intractable Meniere's disease: unilateral cases with intact canals and bilateral cases.

If a clinician seeks to allow patients with vertigo to return to work as soon as possible, it is very important to determine the appearance of vestibular symptoms during convalescence just after treatment, as well as the long-term results. Apprehensive patients with vertigo may undergo severe psychological torment if treatment requires long-term rest in bed before they can return to daily life. In this paper, we observed postoperative vestibular symptoms (subjective sensation and objective nystagmus) in 50 patients with intractable Meniere's disease, including cases from our previous preliminary report, during the period of convalescence just after endolymphatic sac drainage and steroid instillation surgery (EDSS). All symptoms were eliminated within 8 days after EDSS. There was no significant difference in the duration of any vestibular symptoms between bilateral (n = 8) and unilateral cases (n = 42). This result indicates that EDSS could be as safe a treatment for bilateral Meniere's disease as for unilateral disease. In unilateral cases with intact semicircular canal function (n = 17), postoperative evoked vestibular sensation, positional, and positioning (Dix-Hallpike) nystagmus disappeared significantly earlier than in those with canal paresis (n = 25). This result indicates that EDSS could keep the vestibular peripheral function of patients with unilateral Meniere's disease with intact canals quite stable after surgery. Therefore, EDSS could be recommended as an initial, less-invasive surgical treatment for intractable Meniere's disease, especially in unilateral cases with intact canals and in bilateral cases.

Management of hemorrhagic high jugular bulb with adhesive otitis media in an only hearing ear: transcatheter endovascular embolization using detachable coils.

A 51-year-old woman had a hemorrhagic high jugular bulb protruding into the posterosuperior part of the tympanic cavity in her left ear. This (only hearing) ear had severe adhesive otitis media resulting in repetitive hemorrhage from the jugular bulb. Therefore, treatment to stop the bleeding was required. Since invasive middle ear surgery in an only hearing ear would involve a high risk of hearing loss and massive bleeding, transcatheter endovascular embolization using detachable coils was selected for this special case; it safely blocked the blood flow and preserved the patient's hearing level. This is the first such report in the otosurgical field, showing that transcatheter endovascular embolization using detachable coils was quite effective in a difficult case of a hemorrhagic high jugular bulb with severe adhesive otitis media in an only hearing ear.

Steroid effects on vestibular compensation in human.

Vestibular neuritis (VN) rapidly damages unilateral vestibular periphery, inducing severe balance disorders. In most cases, such vestibular imbalance is gradually restored to within the normal level after clinical therapies. This successive clinical recovery occurs due to regeneration of vestibular periphery and/or accomplishment of central vestibular compensation. We experienced 36 patients with VN treated at our hospital, including cases in our previous preliminary report. To elucidate effects of steroid therapy both on the recovery of peripheral function and on the adaptation of central vestibular compensation, we examined caloric test and several questionnaires with two randomly divided groups, 18 steroid-treated and 18 nonsteroid-treated patients, over two years after the onset. These examinations revealed that steroid-treated patients had a tendency of better canal improvements (13/18, 72%) than nonsteroid-treated ones (10/18, 55.6%). However, there was no significant difference between these two groups. In cases with persistent canal paresis, steroid-treated patients (n = 5) reduced handicaps in their everyday life due to the dizziness induced by head and/or body movements and the disturbance of their mood, more effectively than those with nonsteroid therapy (n = 8). These findings suggest that steroid therapy with VN could be effective on not only vestibular periphery but central vestibular system, to restore the balance.

[A rare case of the high jugular bulb associated with only hearing ear].

The jugular bulb may be present in different positions and dimensions within the temporal bone. In general, high jugular bulbs were classified into 2 types: lateral in which the jugular bulb protrudes into the middle ear and up into the tympanic cavity and medial in which the jugular bulb is abnormally placed more superiorly and medial to the cochlea. We report, a unique case of a high jugular bulb which came round from behind of the internal auditory canal and the cochlea protruding into the posterosuperior part of the mesotympanum. It was a very rare pattern of a high jugular bulb which varies in position. The occurrence of adhesive otitis media caused the high jugular bulb to bleed easily in the only hearing ear. There would be risks of making the patient suffer severe bilateral healing impairment due to only one hearing ear and excessive hemorrhage in surgical treatment. With only one hearing ear, we should therefore select transcatheter interventional angiography when the quantity and frequency of bleeding from the jugular bulb increase so.

[Changes in plasma inner ear hormones after endolymphatic sac drainage and steroid-instillation surgery (EDSS)].

We treated 33 cases of intractable Meniere's disease with endolymphatic sac drainage and steroid-instillation surgery (EDSS), attaining good long-term results in vertigo and hearing. To elucidate how EDSS affects the diseased inner ear, we examined changes in plasma inner ear hormones after EDSS. Among inner ear hormones, plasma vasopressin was significantly decreased after EDSS compared to after mastoidectomy. In cases with good long-term results in vertigo and hearing, postoperative plasma vasopressin remained lower over the long term than in cases with poor results. In cases with negative glycerol test results one year after surgery, postoperative plasma vasopressin also remained significantly lower over the long term than in cases with positive results. Previous studies reported that vestibular neurons projected into hypothalamic supraoptic and paraventricular nuclei and that changes in the inner ear pressure were related to plasma vasopressin. Taken together with present findings, this suggests that EDSS may reduce plasma vasopressin through modification of the diseased inner ear environment, resulting in improved inner ear function.