Surgical decision-making in superior canal dehiscence syndrome with concomitant otosclerosis

OBJECTIVE

The diagnosis and management of Superior Canal Dehiscence Syndrome (SCDS) with concomitant otosclerosis can be a challenge. Otosclerosis can mask SCDS symptoms and stapes surgery may reveal or exacerbate vestibular symptoms. Our aim is to present four cases of SCDS with concomitant otosclerosis and thereby informing the reader about the possibility of this dual occurrence and its implications for treatment.

CASES

Four patients with SCDS and concomitant otosclerosis are presented. Two patients underwent surgical treatment for both SCDS and otosclerosis and two patients opted for conservative management.

OUTCOMES

The main differences between surgically and non-surgically treated cases are the presence of autophony and pressure-induced vertigo and a more severe experience of symptoms in surgically treated cases. Surgically treated cases achieved a sizeable reduction in postoperative air-bone gap and resolution of vestibular symptoms.

CONCLUSION

The subjective severity of symptoms in combination with shared decision-making is key in determining the appropriate treatment plan for SCDS and concomitant otosclerosis.

Treatment of a floppy epiglottis with upper airway stimulation therapy

PURPOSE

To evaluate the efficacy of upper airway stimulation therapy in patients with a floppy epiglottis who have experienced continuous positive airway pressure failure or intolerance.

METHODS

A retrospective single-center cohort study was conducted. Patients who received an Inspire Upper Airway Stimulation system and had a 1-year follow-up were included. Baseline and one-year in-laboratory polysomnography examinations were performed. Patient characteristics, Epworth Sleepiness Scale scores and upper airway stimulation device settings were collected.

RESULTS

A total of 75 patients were included, of whom 10 had a floppy epiglottis. Patients with a floppy epiglottis had a significant therapeutic response to upper airway stimulation therapy, similar to patients without a floppy epiglottis. According to the Sher's success criteria, 90% of patients with a floppy epiglottis and 68% of patients without a floppy epiglottis were responders to therapy (p = 0.149). In the floppy epiglottis group, the apnea-hypopnea index decreased from 35.1 ± 5.5 events/hour to 11.2 ± 11.3 events/hour (95% CI (15.0, 32.9), p < 0.001), similarly in the non-floppy epiglottis group, the decline was from 36.4 ± 8.3 events/hour to 14.4 ± 9.5 events/hour (95% CI (18.6, 25.2), p < 0.001, between groups p = 0.659). Comparable reductions were observed for the other respiratory parameters.

CONCLUSION

Treatment of patients with obstructive sleep apnea and a floppy epiglottis can be challenging. Continuous positive airway pressure may aggravate the epiglottis collapse. Upper airway stimulation therapy can be considered an effective alternative treatment option for patients with a floppy epiglottis who have encountered either continuous positive airway pressure failure or intolerance.

Aminoglycoside- and glycopeptide-induced ototoxicity in children: a systematic review

Background

Ototoxicity has been reported after administration of aminoglycosides and glycopeptides.

Objectives

To identify available evidence for the occurrence and determinants of aminoglycoside- and glycopeptide-related ototoxicity in children.

Materials and methods

Systematic electronic literature searches that combined ototoxicity (hearing loss, tinnitus and/or vertigo) with intravenous aminoglycoside and/or glycopeptide administration in children were performed in PubMed, EMBASE and Cochrane Library databases. Studies with sample sizes of ≥50 children were included. The QUIPS tool and Cochrane criteria were used to assess the quality and risk of bias of included studies.

Results

Twenty-nine aminoglycoside-ototoxicity studies met the selection criteria (including 7 randomized controlled trials). Overall study quality was medium/low. The frequency of hearing loss within these studies ranged from 0%–57%, whereas the frequency of tinnitus and vertigo ranged between 0%–53% and 0%–79%, respectively. Two studies met the criteria on glycopeptide-induced ototoxicity and reported hearing loss frequencies of 54% and 55%. Hearing loss frequencies were higher in gentamicin-treated children compared to those treated with other aminoglycosides. In available studies aminoglycosides had most often been administered concomitantly with platinum agents, diuretics and other co-medication.

Conclusions

In children the reported occurrence of aminoglycoside/glycopeptide ototoxicity highly varies and seems to depend on the diagnosis, aminoglycoside subtype and use of co-administered medication. More research is needed to investigate the prevalence and determinants of aminoglycoside/glycopeptide ototoxicity. Our results indicate that age-dependent audiological examination may be considered for children frequently treated with aminoglycosides/glycopeptides especially if combined with other ototoxic medication.

Tinnitus treatment by vagus nerve stimulation: A systematic review

Background

Tinnitus is a phantom sensation of sound, which can have a negative impact on quality of life of those affected. No curative treatments are currently known. Neuromodulation by vagus nerve stimulation has emerged as a new treatment option for tinnitus, though till date the effectiveness remains unclear. Therefore, we aim to review the effect of vagus nerve stimulation on tinnitus distress and tinnitus symptom severity in patients with chronic tinnitus.

Methods

We searched Pubmed, Embase and the Cochrane Library systematically for RCTs, observational studies and case studies on the effect of VNS treatment for tinnitus on October 29, 2019. Studies including adult patients with subjective tinnitus, comparing transcutaneous or implantable VNS to placebo or no treatment or before and after application of VNS treatment on tinnitus distress and tinnitus symptom severity measured with a validated questionnaire were eligible. The risk of bias was assessed with the appropriate tool for each type of study.

Results

Our search identified 9 primary studies of which 2 RCTs, 5 cohort studies and 2 case series or reports. 5 studies used transcutaneous VNS treatment and 4 used implanted VNS treatment. 6 studies combined VNS treatment with sound therapy. There was a serious risk of bias in all studies, especially on confounding. Most studies reported a small decrease in tinnitus distress or tinnitus symptom severity.

Conclusion

Due to methodological limitations and low reporting quality of the included studies, the effect of VNS on tinnitus remains unclear. To draw conclusions for which patient population and to what extent (t)VNS is beneficial in the treatment of tinnitus, a randomised controlled trial should be considered.

Clinical Outcomes of Soft Tissue Preservation Surgery With Hydroxyapatite-Coated Abutments Compared to Traditional Percutaneous Bone Conduction Hearing Implant Surgery-A Pragmatic Multi-Center Randomized Controlled Trial

Background: Soft tissue preservation using a hydroxyapatite-coated abutment in bone conduction hearing implant surgery may lead to improved clinical outcomes over the short (1 year) and long term (3 years).

Methods: In this open multi-center, randomized (1:1), controlled clinical trial, subjects with conductive, mixed hearing loss or single-sided sensorineural deafness were randomly assigned to receive the conventional intervention, a titanium abutment with soft tissue reduction surgery (control), or a new intervention, a hydroxyapatite-coated abutment with soft tissue preservation surgery (test). The primary efficacy outcome was the combined endpoint of numbness, pain, peri-abutment dermatitis, and soft tissue thickening/overgrowth after 1 and 3 years.

Results: The Intention-to-treat (ITT) population consisted of 52 control subjects and 51 test subjects. The difference between the groups after 1 year of follow-up as measured by the primary efficacy outcome was not statistically significant (p = 0.12) in the ITT population (n = 103), but did reach statistical significance (p = 0.03) in the per-protocol (PP) population (n = 96). It showed an advantage for the test group, with over twice as many subjects (29%) without these medical events during the first year compared to the control group (13%). After 3 years, the difference between the two groups had declined and did not reach statistical significance (24 vs. 10%, ITT p = 0.45). Secondary outcome measures which showed a statistical significant difference during the first year, such as surgical time (15 vs. 25 minutes, p < 0.0001), numbness (90 vs. 69% of subjects experienced no numbness at 1 year, p < 0.01), neuropathic pain at 3 months (p = 0.0087) and the overall opinion of the esthetic outcome (observer POSAS scale at 3 months, p < 0.01) were favorable for the test group. More soft tissue thickening/overgrowth was observed at 3 weeks for the test group (p = 0.016). Similar results were achieved for the long term follow up.

Conclusions: Soft tissue preservation with a hydroxyapatite-coated abutment leads to a reduction in the combined occurrence of complications over the first year which is not statistically significant in the ITT population but is in the PP population. This effect decreased for the long-term study follow up of 3 years and did also not reach statistical significance.

Investigating the race for the surface and skin integration in clinically retrieved abutments with two-photon microscopy

Bone conduction hearing implants can rehabilitate some types of hearing loss. A hydroxyapatite (HA)-coated skin-penetrating abutment was developed to allow for soft tissue preservation and increased skin-abutment adherence. Inflammation is thought to relate to bacterial infection of pockets around the abutment. Upon integration, the host's ability to cover the abutment surface ("race for the surface"), and thus control and prevent competitive bacteria from colonizing it, is improved. However, the attachment mechanisms behind it are not clear. In this study, we applied two-photon microscopy to visualize tissue attachment on abutments retrieved from patients. Skin integration markers were validated and applied to four HA-coated abutments. Evidence of skin integration was found, including the presence of hemidesmosomes, a basement membrane, dermal collagen and vascularization. Cases with clinical signs of severe inflammation and evident biofilm formation showed limited skin integration based on these indicators, confirming the applicability of the "race for the surface" model.

An Exploratory Study to Detect Ménière's Disease in Conventional MRI Scans Using Radiomics

OBJECTIVE

The purpose of this exploratory study was to investigate whether a quantitative image analysis of the labyrinth in conventional magnetic resonance imaging (MRI) scans using a radiomics approach showed differences between patients with Ménière's disease (MD) and the control group.

MATERIALS AND METHODS

In this retrospective study, MRI scans of the affected labyrinths of 24 patients with MD were compared to the MRI scans of labyrinths of 29 patients with an idiopathic asymmetrical sensorineural hearing loss. The 1.5- and 3-T MRI scans had been previously made in a clinical setting between 2008 and 2015. 3D Slicer 4.4 was used to extract several substructures of the labyrinth. A quantitative analysis of the normalized radiomic image features was performed in Mathematica 10. The image features of the two groups were statistically compared.

RESULTS

For numerous image features, there was a statistically significant difference (p-value <0.05) between the MD group and the control group. The statistically significant differences in image features were localized in all the substructures of the labyrinth: 43 in the anterior semicircular canal, 10 in the vestibule, 22 in the cochlea, 12 in the posterior semicircular canal, 24 in the horizontal semicircular canal, 11 in the common crus, and 44 in the volume containing the reuniting duct. Furthermore, some figures contain vertical or horizontal bands (three or more statistically significant image features in the same image feature). Several bands were seen: 9 bands in the anterior semicircular canal, 1 band in the vestibule, 3 bands in the cochlea, 0 bands in the posterior semicircular canal, 5 bands in the horizontal semicircular canal, 3 bands in the common crus, and 10 bands in the volume containing the reuniting duct.

CONCLUSION

In this exploratory study, several differences were found in image features between the MD group and the control group by using a quantitative radiomics approach on high resolution T2-weighted MRI scans of the labyrinth. Further research should be aimed at validating these results and translating them in a potential clinical diagnostic method to detect MD in MRI scans.

Honey and beehive products in otorhinolaryngology: a narrative review

BACKGROUND

Honey and beehive products were rediscovered as an alternative treatment in wounds. The medicinal properties also raised interest of their use in Otorhinolaryngology.

OBJECTIVE OF REVIEW

To give an overview of the effectiveness of beehive products in Otorhinolaryngology.

TYPE OF REVIEW

Narrative.

SEARCH STRATEGY AND EVALUATION

A literature search of the databases PubMed, EMBASE and Cochrane was performed from the last two decades till December 2014. The search terms 'honey', 'propolis' or 'royal jelly' were used. Articles, which evaluated the effectiveness of beehive products in Otorhinolaryngology, were included. The quality assessment of included studies was performed using the Cochrane Collaboration's risk of bias tool.

DISCUSSION AND CONCLUSION

A total of 36 studies were identified and evaluated. Eighteen studies investigated their effect in oral infections, seven in infection of the respiratory tract, six in rhino-sinusal diseases, four investigated the use in tonsillectomy and head and neck surgery and one study explored the preventive effect in otitis media. Honey can be considered as effective (additional) treatment in mucositis, childhood cough, persistent post-infectious cough and after tonsillectomy. Propolis may have a role in the treatment of (aphthous) stomatitis, mouth ulcer and prevention of acute otitis media. Royal jelly showed to reduce mucositis. In the presented studies, beehive products proved to be safe, with only minor adverse reactions. Studies showed to be diverse and had some methodological limitations.

Sclerosing bone dysplasias with involvement of the craniofacial skeleton

In this review we provide a complete overview of the existing sclerosing bone dysplasias with craniofacial involvement. Clinical presentation, disease course, the craniofacial symptoms, genetic transmission pattern and pathophysiology are discussed. There is an emphasis on radiologic features with a large collection of CT and MRI images. In previous reviews the craniofacial area of the sclerosing bone dysplasias was underexposed. However, craniofacial symptoms are often the first symptoms to address a physician. The embryology of the skull and skull base is explained and illustrated for a better understanding of the affected areas.

Localization of the gene for hyperostosis cranialis interna to chromosome 8p21 with analysis of three candidate genes

Hyperostosis cranialis interna (HCI) is a rare autosomal dominant disorder characterized by intracranial hyperostosis and osteosclerosis, which is confined to the skull, especially the calvarium and the skull base. The rest of the skeleton is not affected. Progressive bone overgrowth causes nerve entrapment that leads to recurrent facial nerve palsy, disturbance of the sense of smell, hearing and vision impairments, impairment of facial sensibility, and disturbance of balance due to vestibular areflexia. The treatment is symptomatic. Histomorphological investigations showed increased bone formation with a normal tissue structure. Biochemical parameters were normal. Until today the disease has been described in only three related Dutch families with common progenitors and which consist of 32 individuals over five generations. HCI was observed in 12 family members over four generations. Patients are mildly to severely affected. Besides HCI, several bone dysplasias with hyperostosis and sclerosis of the craniofacial bones are known. Examples are Van Buchem disease, sclerosteosis, craniometaphyseal dysplasia, and Camurati-Engelmann disease. However, in these cases the long bones are affected as well. Linkage analysis in a family with HCI resulted in the localization of the disease-causing gene to a region on chromosome 8p21 delineated by markers D8S282 and D8S382. Interesting candidate genes in this region are BMP1, LOXL2, and ADAM28. Sequence analysis of these genes did not reveal any putative mutations. This suggests that a gene not previously involved in a sclerosing bone dysplasia is responsible for the abnormal growth in the skull of these patients.

Neurophysiologic, audiometric and vestibular function tests in patients with hyperostosis cranialis interna

OBJECTIVE

Hyperostosis cranialis interna (HCI) is an autosomal dominant sclerosing bone dysplasia affecting the skull base and the calvaria, characterized by cranial nerve deficits due to stenosis of neuroforamina. The aim of this study is to describe the value of several neurophysiological, audiometric and vestibular tests related to the clinical course of the disorder.

METHODS

Ten affected subjects and 13 unaffected family members were recruited and tested with visual evoked potentials, masseter reflex, blink reflex, pure tone and speech audiometry, stapedial reflexes, otoacoustic emissions, brainstem evoked response audiometry and electronystagmography.

RESULTS

Due to the symmetrical bilateral nature of this disease, the sensitivity of visual evoked potentials (VEPs), masseter reflex and blink reflex is decreased (25-37.5%), therefore reducing the value of single registration. Increased hearing thresholds and increased BERA latency times were found in 60-70%. The inter-peak latency I-V parameter in BERA has the ability to determine nerve encroachment reliably. 50% of the patients had vestibular abnormalities. No patient had disease-related absence of otoacoustic emissions, because the cochlea is not affected.

CONCLUSION

In patients with HCI and similar craniofacial sclerosing bone dysplasias we advise monitoring of vestibulocochlear nerve function with tone and speech audiometry, BERA and vestibular tests. VEPs are important to monitor optic nerve function in combination with radiological and ophthalmologic examination. We do not advise the routine use of blink and masseter reflex.

Imaging features and progression of hyperostosis cranialis interna

BACKGROUND AND PURPOSE

HCI is a unique autosomal-dominant sclerosing bone dysplasia affecting the skull base and the calvaria, characterized by cranial nerve deficits due to stenosis of neuroforamina, whereby the mandible is affected to a lesser extent. The aim of this study is to describe the specific radiologic characteristics and course of the disorder.

MATERIALS AND METHODS

CT scans of affected individuals within 1 family were analyzed and compared with scans of their unaffected family members and with an age- and sex-matched control group. Linear measurements were performed of the inner table, the medulla, and the outer table of different skull locations, and attenuation (density) measurements of the same regions were recorded. Neuroforamina widths were recorded as well.

RESULTS

There was significant thickening of the skull in the frontal, parietal, temporal, and occipital regions, which was mainly due to thickening of the inner table of the skull. The attenuation of the deposited hyperostotic bone was lower than normal cortical bone.

CONCLUSIONS

HCI is the only genetic bone dysplasia known that is confined to the craniofacial area. The hyperostotic bone is less attenuated than normal cortical bone. The observed radiologic abnormalities explain the possible impairment of the olfactory, optic, trigeminal, facial, and vestibulocochlear nerves.

The diagnostic accuracy of non-echo-planar diffusion-weighted imaging in the detection of residual and/or recurrent cholesteatoma of the temporal bone

BACKGROUND AND PURPOSE

Non-EPI DWI is a promising alternative to second-look surgery for the detection of residual and/or recurrent cholesteatoma. We evaluated the diagnostic accuracy, expressed as a positive predictive value, of MR imaging for the detection of residual and/or recurrent cholesteatoma in our hospital.

MATERIALS AND METHODS

Fifty-six MR imaging studies were performed from 2005 to 2010 in patients having previously undergone surgery for cholesteatoma. Pre- and postgadolinium T1-weighted, T2-weighted, and non-EPI DWI sequences were performed and correlated with clinical and intraoperative findings. Twenty-seven patients underwent second-look surgery; 7 were under close clinical follow-up. Twenty-two patients without evidence of cholesteatoma were under regular follow-up (range, 14-44 months).

RESULTS

Non-EPI DWI sequences showed increased DW signal intensity in 36 patients. Of those, 27 had second-look surgery, confirming cholesteatoma in 25 patients; in 1 patient, an empyema was diagnosed, and in the other patient, no cholesteatoma was found at surgery. In 2 patients who had not undergone surgery, increased DW signal intensity was accompanied by hyperintense signal intensity on T1-weighted images, consistent with transplanted fat in the postoperative cavity. The positive predictive value for detection of cholesteatoma was 93% (25/27).

CONCLUSIONS

Residual and/or recurrent cholesteatomas after primary cholesteatoma surgery can be accurately detected by increased DW signal intensity on non-EPI DWI. However, DWI without conventional sequences increased the risk of misdiagnosis in our patient setting because transplanted fat within the postoperative cavity may show increased DW signal intensity.

Potential role for lipopolysaccharide in congenital sensorineural hearing loss

Congenital sensorineural hearing loss (SNHL) is common. In the Western world, the incidence is 1-3 per 1000 live births. The aetiology encompasses genetic and non-genetic factors accounting for 55 % and 45 % of cases, respectively. Reports that describe the contribution of intrauterine infection to the occurrence of congenital SNHL are limited, and comparative analysis of the different pathogens is lacking. Lipopolysaccharide (LPS), a product of bacteriolysis, has been demonstrated to be associated with inner ear damage in experimental studies. To elucidate the potential role of this toxin in congenital SNHL and to identify the pathogenesis and transmission routes, we reviewed the literature. We speculate that different routes of exposure to LPS in utero may result in congenital inner ear damage.

Post-operative complications of cochlear implantation in adults and children: five years' experience in Maastricht

Although cochlear implantation is considered a safe method of rehabilitation for profoundly deaf individuals, a number of these patients suffer complications after surgery. To evaluate post-operative complications after cochlear implantation, a retrospective chart review was performed for 112 patients who had undergone implantation in the Maastricht Academic Hospital. Minor complications were defined as those that could be overcome by medical or audiological management. These occurred in 36 patients (32 per cent) and all were managed successfully. Major complications were defined as device extrusion and those requiring further surgery, and these were identified in four patients (3.6 per cent). These complications included wound infection and device failure mediated by middle-ear pathology. In cases of chronic otitis media, we recommend performance of cochlear implantation as a staged procedure. In order to reduce the post-operative incidence of acute otitis media, we recommend adenoidectomy, placement of ventilation tubes and early antibiotic treatment.

Intratympanic steroid therapy for inner ear diseases, a review of the literature

To evaluate the value of clinical trials on intratympanic steroid therapy in Ménière's disease (MD), idiopathic sudden sensorineural hearing loss (ISSNHL) and rapidly progressive sensorineural hearing loss (RPSNHL). Medline and Pubmed databases from 1966 to present were searched for clinical studies on intra- or transtympanic (cortico)steroid therapy of MD, ISSNHL and RPSNHL. Results were cross-checked with additional databases to obtain a complete data set. Clinical trials were evaluated on the basis of comparability, internal and external validity. Articles were judged using the following questions: was a randomised double-blind controlled trial performed? Which criteria were used to confirm the diagnosis of MD, ISSNHL, RPSNHL? Which therapy was evaluated? How long was the follow-up? Which criteria were used to evaluate the results? Reliable evidence on the efficiency, optimum dosage and administration schedule of intratympanic steroid therapy in MD, ISSNHL and RPSNHL is lacking, therefore further investigation is required.

Cochlear implantation in a patient with deafness induced by Charcot–Marie–Tooth disease (hereditary motor and sensory neuropathies)

Charcot–Marie–Tooth disease (CMT), also named hereditary motor and sensory neuropathies (HMSN), comprises a clinically and genetically heterogeneous group of disorders affecting the peripheral nervous system. Deafness induced by CMT is clinically distinct among the genetically heterogeneous group of CMT disorders. Deafness in CMT patients is associated with point mutations or deletions in the transmembrane domain in the peripheral myelin gene (PMP) 22, which are in close proximity to the extracellular component of this gene. We present a patient with deafness induced by CMT type 1A, undergoing cochlear implantation. Prior investigations showed good results due to replacing a synchronous impulse by means of cochlear implantation in patients with auditory neuropathy.

Reanimation of the paralyzed face by indirect hypoglossal-facial nerve anastomosis

BACKGROUND

The results of indirect hypoglossal facial nerve anastomosis with interposition of a free nerve graft, end-to-end to the periferal facial nerve stump, and end-to-side to the hypoglossal nerve are prospectively evaluated. This technique is supposed to overcome loss of hypoglossal function.

METHODS

Tongue function in 39 consecutive patients and facial reanimation in 29 patients who completed 24 months follow-up were assessed. Facial nerve function was judged using the House-Brackmann (HB) grading system.

RESULTS

Tongue movements were normal in all operated on patients. Initial facial movements occurred on average 7.5 months postoperatively. The results were graded HB II in 6 (20.9%), HB III in 13 (44.6%), HB IV in 7 (24.1%), HB V in 2 (6.8%) patients, and HB VI in 1 (3.4%) patient. The results were significantly better in young patients and when a short time interval between paralysis and surgery existed.

CONCLUSIONS

Indirect hypoglossal-facial anastomosis is the preferred technique in most patients for whom the classical direct hypoglossofacial anastomosis is indicated.

[Successful reanimation of facial paralysis with an indirect anastomosis between hypoglossal nerve and facial nerve, without loss of function of the tongue]

OBJECTIVE

To describe the surgical procedure and the results of the indirect hypoglossal-facial nerve anastomosis using a free nerve graft in patients with facial nerve paralysis. This technique leaves the tongue function intact.

DESIGN

Prospective study.

METHODS

Tongue function was assessed in 39 consecutive patients who underwent this procedure and facial reanimation was assessed in 29 of these patients who had completed at least 24 months follow-up. Facial nerve function was judged using the House-Brackmann (HB) facial nerve grading system.

RESULTS

Tongue movements were normal in all operated patients; one patient had mild homolateral atrophy. Initial facial movements occurred on average 7.5 months postoperatively (range 4 to 18 months) in all but one patient. The results were graded HB II in 6 patients (20.9%), HB III in 13 (44.6%), HB IV in 7 (24.1%), HB V in 2 (6.8%) and HB VI in 1 patient (3.4%). Hemifacial synkineses were noticeable but no mass movements or gross hypertonia were observed (as are often present in direct hypoglossal-facial anastomosis). The results of facial reanimation were significantly better in young patients and when a short time interval between paralysis and surgery existed. HB grade II was achieved only if the duration of paralysis was less than 12 months.

CONCLUSION

Indirect hypoglossal-facial anastomosis with interposition of a nerve graft allows preservation of tongue function together with good overall facial reanimation, and is therefore to be preferred to the classical direct hypoglossal-facial anastomosis.

The double auditory meatus--a rare first branchial cleft anomaly: clinical presentation and treatment

OBJECTIVE

To discuss the embryology, classification, clinical experience with, and management of first branchial cleft anomalies.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center.

PATIENTS

Patients with a first branchial cleft anomaly.

INTERVENTION

Surgery or revision surgery.

MAIN OUTCOME MEASURES

Classifications according to Work, Olsen, Chilla; previous diagnostic and therapeutic pitfalls; outcome of intervention (including facial nerve function).

RESULTS

Between 1984 and 1999, first branchial cleft anomalies were diagnosed in 18 patients. Surgical treatment was the treatment of choice. The authors' approach in Work type I and type 2 lesions is described, and surgical aspects of revision surgery are discussed. The importance of early establishment of the relationship of the anomaly to the facial nerve is stressed. In 8 patients, previous surgical attempts had been undertaken without establishment of the diagnosis first. After intervention, the outcome was favorable.

CONCLUSIONS

First branchial cleft anomalies occur sporadically in ordinary clinical practice. They may go unrecognized or may be mistaken for tumors or other inflammatory lesions of in the periauricular region. However, the distinct clinical features, which can be derived from embryologic development, usually lead to the correct diagnosis. This avoids both treatment delay and eventual failure.

Lemierre syndrome and acute mastoiditis

Lemierre syndrome seldom follows an episode of pharyngotonsillitis. Characteristically, it is comprised of septic thrombosis of the internal jugular vein and bacteremia, leading to lung emboli and metastatic abscess formation. We describe Lemierre syndrome that complicates an acute mastoiditis, with considerations regarding its pathogenesis and management. Despite its sporadic occurrence, awareness of Lemierre syndrome is important, since early recognition reduces both the morbidity and mortality associated with it.

Therapy of idiopathic sudden sensorineural hearing loss: antiviral treatment of experimental herpes simplex virus infection of the inner ear

Experimental herpes simplex virus type 1 (HSV-1) labyrinthitis provides a model of idiopathic sudden sensorineural hearing loss (ISSHL). Corticosteroids improve the prognosis for hearing recovery in ISSHL, but the effects of acyclovir are unknown. To establish the therapeutic efficacy of acyclovir (Zovirax) and prednisolone in experimental HSV-1 viral labyrinthitis, we induced HSV-1 labyrinthitis in 12 guinea pigs. Three animals received no treatment, 3 received prednisolone, 3 received acyclovir, and 3 received both. Four other animals served as controls, receiving culture medium only. Hearing, HSV-1 antibody titers, and cochlear damage were evaluated. The HSV-1 labyrinthitis caused hearing loss within 24 hours. Combination treatment consisting of prednisolone and acyclovir resulted in earlier hearing recovery and less extensive cochlear destruction compared to prednisolone or acyclovir as a monotherapy. The beneficial effect of this treatment modality remains to be demonstrated in ISSHL.

Magnetic resonance imaging of the inner ear in patients with idiopathic sudden sensorineural hearing loss

Although gadolinium-enhanced magnetic resonance imaging (Gd-MRI) has been used to indicate the presence of a subclinical labyrinthitis in patients with idiopathic sudden sensorineural hearing loss (ISSHL), its sensitivity in daily clinical practice is unknown. We describe Gd-MRI findings in 27 ISSHL patients taking part in a prospective multicenter clinical trial. MRI findings were related to the severity of the hearing loss, vestibular involvement and the time interval between the occurrence of ISSHL and imaging. Pathological enhancement of the cochlea indicating a labyrinthitis was found in one patient with ISSHL. In 26 cases, no pathological enhancement could be established. Study results indicate that the present sensitivity of Gd-MRI is low for detecting subclinical viral labyrinthitis in patients with ISSHL. To improve the sensitivity of MRI in ISSHL, we recommend that imaging is performed as early as possible, preferably before treatment is started.

Antiviral treatment of idiopathic sudden sensorineural hearing loss: a prospective, randomized, double-blind clinical trial

A subclinical viral labyrinthitis has been postulated in the literature to elicit Idiopathic Sudden Sensorineural Hearing Loss. An etiological role for the herpes virus family is assumed. Corticosteroids possess a limited beneficial effect on hearing recovery in ISSHL. In this study, the therapeutic value of the antiherpetic drug aciclovir (Zovirax) on hearing recovery in 44 ISSHL patients receiving prednisolone is evaluated in a multicentre clinical trial. The study is designed prospectively, randomized, double-blind and placebo-controlled. Subjective parameters include hearing recovery, a pressure sensation on the affected ear, disequilibrium or vertigo and tinnitus. Audiometric parameters include pure tone and speech audiometry. A one-year follow up is obtained. Both the pressure sensation and disequilibrium or vertigo have a good prognosis, but tinnitus, occurring in most patients, has a poor prognosis. Hearing recovery prognosis depends on the severity of initial hearing loss, and not on vestibular involvement. No beneficial effect from combining aciclovir with prednisolone can be established in ISSHL.

The etiology of idiopathic sudden sensorineural hearing loss. Experimental herpes simplex virus infection of the inner ear

HYPOTHESIS

Experimentally induced herpes simplex virus type 1 (HSV-1) labyrinthitis provides a suitable model for idiopathic sudden sensorineural hearing loss (ISSHL).

BACKGROUND

Viral labyrinthitis has been postulated to play a role in the pathophysiology of ISSHL. Circumstantial evidence is pointing at members of the herpes virus family. Experimental viral labyrinthitis elicited by various virus families leaves a virus-specific pattern of cochlear damage. Herpes viruses provide the best matching pattern in the distribution of cochlear damage when compared with ISSHL postmortem cochlear histopathology.

METHODS

Herpetic viral labyrinthitis was induced in guinea pigs using perilymphatic inoculation with HSV-1. A control group was inoculated with the culture medium only. Infection was confirmed by the measurement of HSV antibodies. Hearing was monitored. Cochlear damage was evaluated by light and electron microscopy.

RESULTS

In all HSV-1 inoculated animals, rapid loss of hearing occurred. Seroconversion took place, but no systemic manifestations of herpetic infection were observed. The control group showed no cochlear or systemic symptoms. When comparing cochlear histopathology in ISSHL to experimental viral HSV-1 labyrinthitis, strong similarities were found: degeneration of the stria vascularis, destruction of the organ of Corti, loosening of the tectorial membrane, and inflammatory changes in neural structures.

CONCLUSIONS

Based on clinical and histopathologic characteristics, experimental HSV-1 labyrinthitis provides a suitable model of ISSHL.

Van Buchem disease (hyperostosis corticalis generalisata) maps to chromosome 17q12-q21

Van Buchem disease (hyperostosis corticalis generalisata; OMIM 239100 [http://www3.ncbi.nlm.nih. gov:80/htbin-post/Omim/dispmim?239100]) is an autosomal recessive disorder characterized by hyperostosis of the skull, mandible, clavicles, ribs, and diaphyseal cortices of the long bones. The most striking clinical features are the enlargement of the jaw and the thickness of the skull, which may lead to facial nerve palsy, hearing loss, and optic atrophy. Increased formation, by osteoblasts, of qualitatively normal bone has been proposed as the underlying pathological mechanism, but the molecular defect is unknown. We studied 11 van Buchem patients and their highly inbred family, who live in The Netherlands in a small ethnic isolate, that had a common ancestor approximately 9 generations ago. A genomewide search with highly polymorphic microsatellite markers showed linkage to marker D17S1299 on chromosome 17q12-21 (maximum LOD score of 8.82 at a recombination fraction [straight theta] of .01). Analysis of additional markers from that region delineated a candidate region of <1 cM, between markers D17S1787 and D17S934. Interestingly, the only marker not showing recombination with the disease locus was an intragenic marker of the thyroid-hormone receptor alpha1 (THRA1) gene, which generated a LOD score of 12.84 at straight theta=.00. Since thyroid hormones are known to stimulate bone resorption, the THRA1 gene might be involved in the etiology and pathogenesis of van Buchem disease. Unraveling the underlying mechanism for this disorder could contribute to the understanding of the regulatory processes conditioning bone density and the underlying pathological processes.