Effectiveness of vestibular rehabilitation therapy in patients with idiopathic Cerebellar Ataxia with Bilateral Vestibulopathy (iCABV)

OBJECTIVE

To evaluate the benefit of vestibular rehabilitation therapy (VRT) in the management of patients with idiopathic cerebellar ataxia with bilateral vestibulopathy (iCABV).

BACKGROUND

iCABV is a hindbrain degenerative disorder with impairment of both central and peripheral vestibular pathways. There is combined failure of four compensatory eye movement systems including the vestibulo-ocular reflex (VOR), optokinetic reflex, smooth pursuit and the visually enhanced vestibulo-ocular reflex (VVOR). Phenotypic presentation includes postural and gait instability, oscillopsia and dizziness with active head movement. The benefit of VRT in iCABV patients has not been established.

METHODS

A retrospective review was performed on a cohort of twelve patients diagnosed with iCABV in a multidisciplinary neuro-otology clinic. All participated in VRT and completed their suggested course of VRT. The following clinical measures were assessed before starting and after finishing VRT: 1) Dizziness Handicap Inventory (DHI), 2) Activities-Specific Balance Confidence (ABC) Scale, 3) Catastrophization scale, 4) Positive Affective Negative Affective Score (PANAS), 5) Dynamic Gait Index (DGI) and 6) Modified Clinical Test of Sensory Interaction in Balance (mCTSIB). The number of falls historically was recorded in addition to gait speed (ft./sec).

RESULTS

Following VRT, patients were found to have improved balance on mCTSIB (condition 4 : 7 vs 18 seconds, P = 0.04) and a better postural stability with a reduced number of falls (p = 0.01). No statistically significant improvement was seen in the DHI, ABC, Catastrophization scale, DGI, PANAS and gait speed (p > 0.05).

CONCLUSIONS

iCABV patients who underwent VRT were found to have a better postural stability and reduced risk of falls. VRT was not found to significantly improve patients' overall subjective perception of their symptoms or their psychological status.

Post-traumatic peripheral vestibular disorders (excluding positional vertigo) in workers following head injury

Benign paroxysmal positional vertigo has typically been reported to be the most common cause of post-traumatic dizziness. There is however paucity in the literature about other peripheral vestibular disorders post-head injury. This article provides an overview of other causes of non-positional dizziness post-head trauma from our large institutional experience. The UHN WSIB Neurotology database (n = 4291) between 1998 and 2018 was retrospectively studied for those head-injured workers presenting with non-positional peripheral vestibular disorders. All subjects had a detailed neurotological history and examination and vestibular testing including video nystagmography, video head impulse testing (or a magnetic scleral search coil study), vestibular-evoked myogenic potentials, and audiometry. Imaging studies included routine brain and high-resolution temporal bone CT scans and/or brain MRI. Based on a database of 4291 head-injured workers with dizziness, 244 were diagnosed with non-positional peripheral vertigo. Recurrent vestibulopathy (RV) was the most common cause of non-positional post-traumatic vertigo. The incidence of Meniere's disease in the post-traumatic setting did not appear greater than found in the general population. The clinical spectrum pertaining to recurrent vestibulopathy, Meniere's disease, delayed endolymphatic hydrops, drop attacks, superior semicircular canal dehiscence syndrome, and uncompensated peripheral vestibular loss are discussed.

Contralesional High-Acceleration Vestibulo-Ocular Reflex Function in Vestibular Schwannoma

Impairment of ipsilesional vestibulo-ocular reflex (VOR) function is well described in vestibular schwannoma (VS) and a correlation between gain of the VOR and tumor size has been suggested. Bilateral VOR impairment may also occur in VS patients, but its mechanisms are poorly understood. We sought to explore the effect of unilateral VS on ipsilesional and contralesional high-acceleration VOR function using video head impulse testing, and evaluate potential factors responsible for contralesional VOR impairment.

MATERIALS AND METHODS

Chart review in tertiary referral center of patients with unilateral VS, who completed neurotological examination and vestibular function testing.

RESULTS

One hundred one patients (mean age 57.4 yrs) were included. Maximal tumor diameter ranged from 0.3 to 5.0 cm. Forty one patients had evidence of brainstem compression from VS on magnetic resonance imaging (MRI). Ipsilesional and contralesional VOR impairment was present in 81 (80%) and 44 (43%) patients, respectively. Bilateral VOR impairment was seen in 42 (42%) patients. Bilateral VOR impairment correlated with tumor size. Presence of brainstem compression was associated with reduced ipsilesional VOR gain, but not contralesional VOR gain.

Long-Term Outcomes from Blind Sac Closure of the External Auditory Canal: Our Institutional Experience in Different Pathologies

OBJECTIVES

This study reports long-term results of blind sac closure of the external auditory canal performed for various pathologies, compares the complication rates and the need for revision surgery.

MATERIALS AND METHODS

This study is a retrospective review. Ninety-six cases of blind sac closure performed for various pathologies were included in this study. The primary pathologies included extensive mucosal disease in an open mastoid cavity, cholesteatoma, skull base lesion, cerebrospinal fluid leak, and osteoradionecrosis of the temporal bone. Preoperative history, postoperative complications, and the need for revision surgery were evaluated.

RESULTS

The most common indication for blind sac closure in our series involved skull base lesions (62.5%). The mean follow-up period was 46 months (4 months - 20 years). The total complication rate related to blind sac closure was 10.4%. The median time between surgery and long-term complications was 5.5 years. Patients with chronic mucosal disease had the highest rate of complications.

CONCLUSION

Blind sac closure of external meatus can be effectively performed for different pathologies. Long-term follow-up with patients is necessary. Patients with chronic mucosal disease have the highest complication rates.

Management of invasive intralabyrinthine cholesteatoma: Can one realistically preserve hearing when disease is medial to the otic capsule?

PURPOSE

To report our long-term results in surgical management of invasive intralabyrinthine cholesteatoma.

MATERIAL AND METHODS

The study is a case series in a tertiary referral center. Retrospective chart review of all mastoid operations performed for chronic ear disease between 1994 and 2019 at University Health Network, Toronto. The type of surgery, intraoperative findings, hearing outcome, recurrence of disease and the need for revision surgery were evaluated.

RESULTS

10 cases of extensive petrous bone cholesteatoma medial to the otic capsule were identified in 616 mastoid surgeries. All but one patient with extensive petrous bone cholesteatoma who underwent an exteriorizing procedure to preserve cochlear function failed the first surgery. A second procedure was needed in all cases due to complications which included facial palsy, recurrent cholesteatoma or internal auditory canal (IAC) abscess. Hearing was not preserved in any patient. In contrast, 57 ears with cholesteatomatous labyrinthine fistula lateral to the otic capsule had matrix exteriorized and had very good long-term results.

CONCLUSION

We were rarely able to preserve hearing in massive petrous bone cholesteatoma. There should be no hesitation to remove the otic capsule to exteriorize diseases even under circumstances where residual cochlear and vestibular function is present if required to provide a safe ear.

Transient Vertigo with Horizontal Nystagmus to Loud Noise and Pressure: Utricular Hydrops or Vestibular Atelectasis?

We present an unusual case of a patient with a positive Tullio phenomenon, brief Valsalva-induced transient horizontal nystagmus, reduced left caloric response, and bilateral vestibulo-ocular reflex loss. This study discusses the pathophysiology and differential diagnosis concerning the suspected pathology for the phenomenon of utricular hydrops or vestibular atelectasis and presents a literature review.

Occult Laryngeal Foreign Body Mimicking Normal Thyroid Cartilage

Introduction:

Foreign body aspiration is common especially in children. The absence of history of choking does not rule out the diagnosis. Diagnosis required high index of suspicion.

Case Presentation:

Undiagnosed foreign body aspiration mostly occurs in bronchial airway rather than larynx and can cause severe complications. In this article, we report a silent laryngeal foreign body aspiration to show that careful history taking and accurate evaluation of radiography are important factors for diagnosis.

Conclusions:

The single most significant factor leading to detect of tracheobronchial foreign body aspiration is a high index of suspicion; this case highlights the possibility of a foreign body in the airway in patients who presents with a recent onset of chronic respiratory complaints.

Surgical Outcomes of Cerebellopontine angle Tumors in 50 Cases

INTRODUCTION

To report our experience with a large series of surgical procedures for removal of cerebellopontine angle (CPA) tumors using different approaches.

MATERIALS AND METHODS

This was a retrospective analysis of 50 patients (mean age, 49 years) with CPA tumors (predominantly acoustic neuroma) who underwent surgical removal using appropriate techniques (principally a translabyrinthine approach) during a 4-year period.

RESULTS

One death occurred during this study. There were nine cases (18%) of cerebrospinal fluid leak, and five patients (10%) were diagnosed as having bacterial meningitis. Complete gross tumor removal was not achieved in four patients (8%). Facial nerve function as measured by the House Brackmann system was recorded in all patients 1 year following surgery: 32% had a score of 1 or 2; 26% had a score of 3 or 4; and 8% had a score of 5 or 6. Other complications included four cases of wound infection.

CONCLUSION

The translabyrinthine approach was predominantly used in our series of CPA tumors, and complication rates were comparable with other large case series.

Effect of Intratympanic Dexamethasone on Controlling Tinnitus and Hearing loss in Meniere's Disease [corrected]

INTRODUCTION

We investigated the effect of intratympanic dexamethasone on control of tinnitus and hearing loss in patients with Menier's disease.

MATERIALS AND METHODS

100 consecutive patients with a diagnosis of Menier's disease according to the 1995 criteria of The American Academy of Otolaryngology - Head and Neck Surgery (AAO-HNS) who remained symptomatic despite medical therapy were assigned to receive intratympanic dexamethasone. The results were assessed with respect to changes in hearing symptoms and tinnitus.

RESULTS

Hearing improvement and improvement in SDS was observed in 52% and 35% of patients, respectively. Tinnitus score was improved in 57% of patients. There was no relationship between age, sex, duration of disease, unilaterality of disease, or response to therapy.

CONCLUSION

Intratympanic dexamethasone may be effective in the symptomatic control of hearing loss and tinnitus in Menier's disease.

Value of fine-needle aspiration cytology in the evaluation of parotid tumors

Fine needle aspiration cytology (FNAC) is commonly used in the study of parotid masses; however controversy exists regarding its diagnostic accuracy. The objective of this study was to evaluate the effectiveness of FNAC as a preoperative diagnostic tool of parotid tumors. Sixty-five patients had satisfactory preoperative FNAC and underwent subsequent surgery to the parotid between March 2002 and July 2009 at our institution. The results of the FNAC were compared to the permanent histopathological diagnosis. The sensitivity, specificity, positive predictive value, negative predictive value, and the overall accuracy of FNAC for parotid masses were 57.9, 97.8, 91.7, 84.9, and 86%, respectively. FNAC is useful in the preoperative assessment of parotid tumors and surgical planning. The non-diagnostic and false-negative results are the limitations of FNAC that should be reduced to improve its usefulness in the evaluation of parotid tumors.

Repair of large nasal septal perforation with titanium membrane: report of 10 cases

OBJECTIVE

The aim of the study was to study a new treatment to repair large nasal septal perforation with medical titanium membrane.

METHOD

Ten patients with septal perforation underwent repair with open rhinoplasty approach using titanium membrane.

RESULTS

The perforation of nasal septum in 10 patients was closed satisfactorily. During our followup period (mean, 1 year), the titanium membrane was mucosalized, and this technique led to persistent closing of perforation.

CONCLUSION

Repair of septal perforation with titanium membrane yields excellent results.

Delayed laryngotracheal reconstruction with titanium plate: report of 10 cases

BACKGROUND

Subglottic stenosis is congenital or acquired narrowing of subglottic area. The management of subglottic stenosis is still a serious surgical challenge. Although different surgical techniques are accomplished to manage the condition, no standard treatment has been presented yet.

STUDY DESIGN

Titanium mesh was used in the reconstruction of the anterior laryngotracheal wall in 10 tracheostomized patients with laryngotracheal stenosis because of prolonged intubation. The anterior laryngotracheal wall was split, followed by excision of scar tissue. After several weeks, in a second-stage performance, the titanium plate was fixed at the split edges.

RESULTS

Finally, all the patients were decanulated. However, one patient developed respiratory distress because of granulation tissue and underwent a second trial of decanulation. In one patient, the titanium plate extruded.

Giant cell reparative granuloma of nasal cavity, a case report

Giant cell reparative granuloma (GCRG) is an unusual, nonneoplastic lesion affecting maxillary and mandibular bones. GCRG of the nasal cavity is exceedingly rare. To the best of our knowledge only few of such cases have been previously reported. Being a soft fleshy lesion of bone, it tends to have a benign course, not aggressive and it often recurs following incomplete excision. We report the case of a man with a GCRG of nasal cavity. We discuss the clinical presentation, differential diagnosis, histological evaluation and appearance on computed tomography and MRI.