Diagnostic approaches to and management options for patulous eustachian tube

Objectives:

To systematically review the literature and to summarize all evidence related to the diagnosis and management of patulous eustachian tube.

Methods:

The present study was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Results:

Overall, 59 articles were retrieved and included in the analysis. Studies investigating treatments enrolled 1279 patients collectively, with follow-up duration varying from few days and up to 2 years. Eight studies reported medical treatments with intranasal saline instillation as the most frequently studied option. Other studies reported various surgical treatments varying from simple tympanostomy to invasive procedures targeting the orifice of the ET or the anatomical features surrounding it. In addition, 10 studies including 367 subjects investigated different diagnostic methods.

Conclusion:

Currently, there is a wide spectrum of diagnostic and therapeutic interventions with minimal clinical efficacy, a persistent lack of systematic guidelines, and several gaps in previous research endeavours.

PROSPERO REG. NO. CRD: 1644000

Orthotropic nystagmus in predicting the efficacy of treatment in posterior canal benign paroxysmal positional vertigo

OBJECTIVE

To observe the type of nystagmus in each position of posterior semicircular canal benign paroxysmal positional vertigo (BPPV) after treatment with the Epley maneuver and analyze the relationship between the type of nystagmus in the second and third positions of the Epley maneuver and the effect of treatment. Then, the role of orthotropic nystagmus in predicting the success of posterior semicircular canal BPPV treatment was explored.

METHODS

Two hundred seventy-six patients diagnosed with posterior semicircular canal BPPV who were admitted from September 2018 to October 2019 to Zhejiang Hospital were included. All patients were treated with BPPV diagnosis and treatment system (Epley maneuver). During the treatment, we observed and recorded the type of nystagmus in the second and third positions, including the direction and duration of nystagmus. One hour after the first treatment, all patients were evaluated by both the Dix-Hallpike and Roll tests to determine whether the treatment was successful. The difference in the success rate of treatment between different types of nystagmus was compared, and the differences in sensitivity and specificity of orthotropic nystagmus in the second and third positions in predicting the effect of treatment were compared.

RESULTS

Among the 234 patients who had successful repositioning for the first time, the proportion of orthotropic nystagmus during the third position of the Epley maneuver was 88.9%, which was significantly higher than 23% in the unsuccessful group (42 cases) (P < 0.05) The proportion of patients with reversed nystagmus (4.7% vs 33.3%, P < 0.05) and no nystagmus (6.4% vs 42.9%, P < 0.05) was lower in the successful group than in the unsuccessful group. The proportion of orthotropic nystagmus during the second position of the Epley maneuver was 50.9%, which was also higher than the 19% in the unsuccessful group (P < 0.05). The proportion of reversed nystagmus (13.7% vs 31%, P < 0.05) was lower in the successful group than in the unsuccessful group. Additionally, the proportion of no nystagmus (35.5% vs 50%, P = 0.074) was lower in the successful group than in the unsuccessful group, but the difference was not statistically significant. The sensitivity of orthotropic nystagmus in the third position (88.9%) of the Epley maneuver in predicting the efficacy of treatment was higher than that of orthotropic nystagmus in the second position (50.9%), but there was no significant difference in specificity between the two.

CONCLUSION

Orthotropic nystagmus during the Epley maneuver, especially in the third position, has certain value in predicting the efficacy of posterior semicircular canal BPPV repositioning, which is better than its predictive effect in the second position, whereas reversed nystagmus or no nystagmus in the third position is suggestive of unsuccessful repositioning. Therefore, clinicians can carry out individualized treatments based on nystagmus types during repositioning to improve the effect of treatment.

Digital diaphanoscopy of the maxillary sinuses: A revival of optical diagnosis for rhinosinusitis

PURPOSE

The non-invasive diagnosis of acute rhinosinusitis (ARS) remains an unresolved problem of modern otolaryngology. Analog diaphanoscopy of reduced transillumination (shading) could be enhanced by a digital image processing of the maxillary sinuses. By this means, the limited ergonomics of this safe and low-cost method can be overcome, and merits renewed the investigation. Here, we compared the diagnostic sensitivity and specificity of digital diaphanoscopy and computed tomography (CT) in detecting shading in the maxillary sinus.

MATERIALS AND METHODS

We examined 103 adults using both digital diaphanoscopy of the maxillary sinus and native-phase cranial CT. We developed a scoring system for investigation of shading in the maxillary sinus using diaphanoscopy and compared the sensitivity and specificity with that of CT. Also, we documented a follow-up of acute rhinosinusitis.

RESULTS

In diagnosing shading in the maxillary sinus, digital diaphanoscopy had a sensitivity of 86% and a specificity of 88%. Digital diaphanoscopy can be used not only in the screening of ARS but also for documentation of its course.

CONCLUSION

This study supports the role of modern digital diaphanoscopy in the diagnosis of shading in the maxillary sinus, especially in patients with ARS when CT imaging is not recommended. The ergonomics of analog diaphanoscopy could be significantly improved for physicians and patients by the implementation of modern hardware and software components. Further development of the technique and the use of several discrete wavelengths will improve this method's sensitivity and specificity.

Comparison of sonotubometry, impedance, tubo-tympano-aerography, and tubomanometry to test eustachian tube function

PURPOSE

There is currently no gold standard for the diagnosis of eustachian tube (ET) dysfunction. To provide an objective basis for the clinical diagnosis of ET dysfunction, we explored the characteristics of sonotubometry, impedance, tubo-tympano-aerography (TTAG), and tubomanometry (TMM) in volunteers with healthy ETs.

MATERIALS AND METHODS

Sonotubometry, impedance, TTAG, and TMM tests were performed in 110 healthy ears of 55 volunteers, and the characteristics of each ET test were compared and discussed.

RESULTS

The ET opening rate was compared between sonotubometry with dry swallowing, impedance with the Valsalva maneuver, TTAG with the Valsalva maneuver, and TMM with a nasopharyngeal pressure of 50 mbar in 100 (90.9%), 102 (92.7%), 99 (90.0%), and 104 (94.5%) ears, respectively; there was no significant difference among the four methods (P = 0.575). In sonotubometry, both dry swallowing and the Valsalva maneuver were superior to wet swallowing in terms of detecting ET opening (P = 0.000). In TMM, both the opening rate and the external auditory canal pressure were positively correlated with the nasopharyngeal pressure. Specifically, the opening rate and external auditory canal pressure increased with an increase in the nasopharyngeal pressure (r = 0.271, P = 0.000; r = 0.315, P = 0.000, respectively).

CONCLUSIONS

Sonotubometry, impedance, TTAG, and TMM have their own advantages and disadvantages. In clinical practice, the appropriate ET function test should be chosen on the basis of the patient's specific condition.

Quantitative analysis tool for clinical functional MRI in mild traumatic brain injury

Functional magnetic resonance imaging (fMRI) has been available commercially for clinical diagnostic use for many years. However, both clinical interpretation of fMRI by a neuroradiologist and quantitative analysis of fMRI data can require significant personnel resources that exceed reimbursement. In this report, a fully automated computer-based quantification methodology (Enumerated Auditory Response, EAR) has been developed to provide an auditory fMRI assessment of patients who have suffered a mild traumatic brain injury. Fifty-five study participants with interpretable auditory fMRI sequence data were assessed by EAR analysis, as well as both clinical radiologist fMRI interpretation and voxelwise general linear model (GLM) analysis. Comparison between the clinical interpretation and the two computer analysis methods resulted in 67% concordance (identical), 32% nearconcordance (one level difference), and 1% discordant. Comparison between the clinical computer-based quantification (EAR) and GLM analysis yielded significant correlations in right and left ear responses (p⟨0.05) for the full subject group. Automated fMRI quantification analysis equivalent to EAR might be appropriate for both future research projects with constrained resources, as well as possible routine clinical use.

Ear Pain: Diagnosing Common and Uncommon Causes

Otalgia (ear pain) is a common presentation in the primary care setting with many diverse causes. Pain that originates from the ear is called primary otalgia, and the most common causes are otitis media and otitis externa. Examination of the ear usually reveals abnormal findings in patients with primary otalgia. Pain that originates outside the ear is called secondary otalgia, and the etiology can be difficult to establish because of the complex innervation of the ear. The most common causes of secondary otalgia include temporomandibular joint syndrome and dental infections. Primary otalgia is more common in children, whereas secondary otalgia is more common in adults. History and physical examination usually lead to the underlying cause; however, if the diagnosis is not immediately clear, a trial of symptomatic treatment, imaging studies, and consultation may be reasonable options. Otalgia may be the only presenting symptom in several serious conditions, such as temporal arteritis and malignant neoplasms. When risk factors for malignancy are present (e.g., smoking, alcohol use, diabetes mellitus, age 50 years or older), computed tomography, magnetic resonance imaging, or otolaryngology consultation may be warranted.

[Otomycosis: the modern view of etiology and management]

This article deals with the modern approaches to the diagnostics and treatment of fungal ear infection depending on the localization of the inflammatory process and the species of the causative fungal agent with special reference to the factors underlying the development of otomycosis under the present-day conditions based on the results of the analysis of the studies carried out during the period from 2010 to 2014. The materials of the examination of 2152 patients who applied for the medical care to various clinical departments of the Institute and were found to present with chronic inflammatory ear pathology were available for the analysis. Fungal lesions were diagnosed in 495 (23%) patients with this condition. Fungal lesions of the external ear were the predominant form of pathology; they were documented in 331 (67%) patients. Fungal otitis media was diagnosed in 85 (17%) patients and fungal lesions of the postoperative cavity in 79 (16%) patients suffering from otomycosis. 65% of the patients presenting with external fungal otitis, 20% of those with fungal otitis media, and 95% of the patients with inflammation of the postoperative cavity were infected with mold fungi dominated by the genus Aspergillus spp. 79 (16%) patients suffering from otomycosis. In 35% of the patients presenting with fungal external otitis, 80% of those with fungal otitis media, and 5% of the patients with inflammation of the postoperative cavity of the middle ear, the causative agents of the disease were the fungi Candida spp. The authors describe the modern schemes for the treatment of otomycosis elaborated at the L.I. Sverzhevskiy Research Institute of Clinical Otorhinolaryngology.

Auditory and otologic profile of Alström syndrome: Comprehensive single center data on 38 patients

Alström syndrome (AS) is a rare autosomal recessive ciliopathy caused by mutations in the ALMS1 gene. Hallmark characteristics include childhood onset of severe retinal degeneration, sensorineural hearing loss, obesity, insulin-resistant diabetes, and cardiomyopathy. Here we comprehensively characterize the auditory and otologic manifestations in a prospective case series of 38 individuals, aged 1.7-37.9 years, with genetically confirmed AS. Hearing loss was preceded by retinal dystrophy in all cases, and had an average age of detection of 7.45 years (range 1.5-15). Audiometric assessments showed mean pure tone averages (0.5, 1, 2, 4 kHz) of 48.6 and 47.5 dB HL in the right and left ears, respectively. Hearing was within normal limits for only 8/74 ears (11%). For the 66 ears with hearing loss, the degree was mild (12%), moderate (54%), or severe (8%). Type of hearing loss was predominantly sensorineural (77%), while three ears had mixed loss, no ears had conductive loss, and type of hearing loss was indeterminate for the remaining 12 ears. Serial audiograms available for 33 patients showed hearing loss progression of approximately 10-15 dB/decade. Our data show that hearing loss associated with AS begins in childhood and is a predominantly symmetric, sensory hearing loss that may progress to a severe degree. Absent otoacoustic emissions, intact speech discrimination, and disproportionately normal auditory brainstem responses suggest an outer hair cell site of lesion. These findings indicate that individuals with AS would benefit from sound amplification and if necessary, cochlear implantation.

Medial olivocochlear reflex in ankylosing spondylitis patients

OBJECTIVE

Ankylosing spondylitis (AS) is a chronic systemic inflammatory disease. Via autoimmune mediators, AS can damage the auditory system similar to other systems. Otoacoustic emission studies in AS patients showed that the damage that causes hearing loss was in the outer hair cells. The medial olivocochlear (MOC) reflex is used to evaluate the MOC efferent system (MOES), which includes the outer hair cells. The aim of this study was to evaluate the presence of subclinical damage in the inner ear with the aid of the MOC reflex test in AS patients with no hearing complaints.

PATIENTS AND METHODS

Thirty-four patients with AS and a control group of 30 healthy volunteers with similar demographic characteristics were evaluated in the study. Otoacoustic emission responses, MOC reflex results, and frequency-specific and total suppression findings were compared between the groups. The relationship between clinical and laboratory findings for the AS patients, and the MOC reflex data were also investigated.

RESULTS

Reduced MOC reflex response (p = 0.04) and suppression (p = 0.019) were detected in AS patients. When the clinical and laboratory findings for the AS patients and the MOC reflex test results were compared, a significant correlation was found only between the MOC reflex and the erythrocyte sedimentation rate.

CONCLUSION

The results showed that AS can damage the inner ear, especially the MOES, and can reduce the MOC reflex response without clinical hearing loss.

[The specific features of the clinical course of acute suppurative otitis media of viral and mixed viral-bacterial etiology in the children of the preschool age]

The objective of the present study was to elucidate the spectrum of the pathogenic agents responsible for the development of acute suppurative otitis media in the children of the preschool age and to reveal the specific clinical features of this disease depending on its etiological factors. The study involved 138 patients (186 ears) of either sex at the age from 1 year to 84 months who presented with acute suppurative otitis media. The following methods were employed for the purpose of the study: analysis of the patients' complaints and the past medical histories, examination of the ENT organs, microbiological (bacteriological and virological) studies of secretion from the tympanic cavity, diagnostic endoscopy of the nasal cavity and nasopharynx, laboratory investigations. The study allowed to reveal the characteristic clinical manifestations of the pathology of interest depending on its etiology.

[Atypical inflammation of the middle ear]

The objective of the present study was to characterize the patients presenting with atypical inflammation of the middle ear and consider the currently available methods for their examination. A total of 20 patients at the age from 16 to 66 years were admitted to the Department of Ear Microsurgery during the period from 2008 and 2016 for the treatment of atypical inflammation of the middle ear. Eleven of them (18 ears) were found to have tuberculous lesions (TL) of the middle ear while the remaining 9 patients (11 ears) suffered giant cell vasculitis (GCV). All the patients underwent the general clinical and otorhinolaryngological examination, computed tomography of the temporal bones and the thoracic cavity organs, cytological, bacteriological, pathomorphological, and molecular-genetic studies including PCR diagnostics, rheumatological tests, as well as counseling by a phthisiotherapist and rheumatologist. The primary localization of TL in the middle ear was documented in 6 patients including its association with lung lesions in 5 cases. The clinical picture of the disease in 5 patients was that of smoldering exudative pathology and in 6 ones was accompanied by suppurative perforative otitis media. According to the laboratory analyses, bacteriological diagnostics proved efficient in 9% of the patients, pathomorphological and cytological diagnostics in 18% and 27.3% of the cases respectively while the effectiveness of PCR diagnostics was estimated at 55%. The diagnosis in individual patients was established within the period from 1 month to 1.5 years after they first sought medical advice in connection with complaints of the ear disease. Tuberculosis of the middle ear began to develop as exudative middle otitis that acquired the form of bilateral pathology in 4 patients. Three patients had a concomitant pulmonary disease. In 4 patuents, the diagnois of middle ear tuberculosis was established based on the presence of the specific antibodies and in 5 ones based on the results of the pathomorphological study. All the studies were carried out in duplicate. The period between the beginning of the disease and the establishment of the definitive diagnosis varied from 1 month to 1 year.

Effect of Contralateral Medial Olivocochlear Feedback on Perceptual Estimates of Cochlear Gain and Compression

The active cochlear mechanism amplifies responses to low-intensity sounds, compresses the range of input sound intensities to a smaller output range, and increases cochlear frequency selectivity. The gain of the active mechanism can be modulated by the medial olivocochlear (MOC) efferent system, creating the possibility of top-down control at the earliest level of auditory processing. In humans, MOC function has mostly been measured by the suppression of otoacoustic emissions (OAEs), typically as a result of MOC activation by a contralateral elicitor sound. The exact relationship between OAE suppression and cochlear gain reduction, however, remains unclear. Here, we measured the effect of a contralateral MOC elicitor on perceptual estimates of cochlear gain and compression, obtained using the established temporal masking curve (TMC) method. The measurements were taken at a signal frequency of 2 kHz and compared with measurements of click-evoked OAE suppression. The elicitor was a broadband noise, set to a sound pressure level of 54 dB to avoid triggering the middle ear muscle reflex. Despite its low level, the elicitor had a significant effect on the TMCs, consistent with a reduction in cochlear gain. The amount of gain reduction was estimated as 4.4 dB on average, corresponding to around 18 % of the without-elicitor gain. As a result, the compression exponent increased from 0.18 to 0.27.

Cochlin-tomoprotein test and hearing outcomes in surgically treated true idiopathic perilymph fistula

CONCLUSION

Approximately 50% of patients with sPLF based on the clinical diagnosis criteria were definitively diagnosed with CTP-positive sPLF. These results suggest that early surgery within 7 days of the disease onset contributes to improvements in the therapeutic response of hearing loss.

OBJECTIVES/HYPOTHESIS

Idiopathic spontaneous perilymph fistula (sPLF) cannot be diagnosed reliably. It is speculated that this condition occurs in patients with vertigo-accompanied acute sensorineural hearing loss that progresses rapidly in spite of steroid therapy. This study herein evaluated cochlin-tomoprotein (CTP) test results in patients with sPLF who underwent exploratory tympanotomy and considered surgical outcomes with true sPLF.

STUDY DESIGN

Retrospective study.

METHODS

Twenty-three patients diagnosed with sPLF based on the clinical diagnosis criteria who underwent exploratory tympanotomy were included.

RESULTS

CTP test results were positive in 11 cases. In CTP-positive cases, the mean hearing level was 66.5 dB pre-operatively and 42.3 dB post-operatively. The hearing level post-operatively completely recovered in four cases, markedly recovered in three cases, slightly recovered in one case and showed no response in three cases. Hearing level improvements were significantly better in CTP-positive patients who underwent surgery within 7 days of the disease onset than in those treated 8 or more days after the disease onset.

The Vestibulo-Collic Reflex is Abnormal in Migraine

Interictal evoked central nervous system responses are characterized in migraineurs by a deficit of habituation, at both cortical and subcortical levels. The click-evoked vestibulo-collic reflex (VCR) allows the assessment of otolith function and an oligosynaptic pathway linking receptors in the saccular macula to motoneurons of neck muscles. Three blocks of 75 averaged responses to monaural 95-dB normal hearing level 3-Hz clicks were recorded over the contracted ipsilateral sternocleidomastoid muscle in 25 migraineurs between attacks and 20 healthy subjects, without vestibular symptoms. Amplitudes, raw and corrected for baseline electromyography, were significantly smaller in migraine patients. Whereas in healthy volunteers the VCR habituated during stimulus repetition (-4.96% ± 14.3), potentiation was found in migraineurs (4.34% ± 15.3; P = 0.04). The combination with a reduced mean amplitude does not favour vestibular hyperexcitability as an explanation for the habituation deficit in migraine, but rather an abnormal processing of repeated stimuli in the reflex circuit.

[A survey of the otoacoustic emissions (OAEs) of workers exposed to noise in manufacturing factories]

OBJECTIVES

Otoacoustic emission (OAE) testing is not widespread in Japanese industrial health. This study examined the association between hearing thresholds (HTs) and OAEs among workers exposed to noise in actual workplaces.

METHODS

In two metal products manufacturing factories, 34 workers with noise exposure in the workplace (exposure group, mean age 40.6 ± 9.4 years), and 9 workers with no noise exposure (control group, 49.0 ± 14.3 years) were surveyed. The time-weighted average (LAeq) and maximum (LAMAX) of environmental noise monitoring (ENM), and the time-weighted average (LTWA) and sound exposure level (LAE) of personal noise monitoring (PNM) were measured for each subject at the same time. As hearing effect indicators of noise exposure levels, HTs (0.5, 1, 2, 4 and 8 kHz) and distortion product OAEs (DPOAEs) (2, 3 and 4 kHz) were performed before and after 5 days of work. The results of the ENM, PNM, HTs and OAEs were compared between the groups using Student's t test, and their correlations were investigated using Pearson correlation coefficients.

RESULTS

Noise exposure levels of the exposure group were significantly higher than those of the control group. In the exposure group, LAeq, LAMAX, LTWA and LAE were respectively 84.5 ± 4.1 dB(A),89.5 ± 6.3 dB(A), 83.4 ± 4.7 dB(A) and 153.1 ± 15.7 dB(A), and in the control group, they were 53.2 ± 2.6 dB(A), 56.4 ± 2.4 dB(A), 67.8 ± 5.6 dB(A) and 119.5 ± 5.6 dB(A). There was no difference between hearing effect indicators (HTs and OAEs) before and after work in either group. There was no correlation between the noise exposure level (LAeq, LTWA, LTWA and LAE) and HTs or OAEs, but there was a significant correlation between the HTs and OAEs at most of frequencies. The HTs and OAEs of subjects with noise-induced hearing loss (NIHL) were significantly lower than those of subjects without NIHL.

CONCLUSIONS

This study revealed there is a significant correlation of the HTs and OAEs before and after 5 days of work. In the future, OAE is expected to be used as a screening test of hearing management of noise-exposed workers in Japan.

Is it important to repeat the positioning maneuver after the treatment for benign paroxysmal positional vertigo?

Introduction

Benign paroxysmal positional vertigo (BPPV) is the most common cause of peripheral vestibular dysfunction.

Objective

To assess whether the performance of the Dix–Hallpike maneuver after the Epley positioning maneuver has prognostic value in the evolution of unilateral ductolithiasis of posterior semicircular canal.

Methods

A prospective cohort study in monitored patients at otoneurology ambulatory with a diagnosis of BPPV; they were submitted to the therapeutic maneuver and then to a retest in order to evaluate the treatment effectiveness; all cases were reassessed one week later and the retest prognostic value was evaluated.

Results

A sample of 64 patients which 47 belonging to negative retest group and 17 belonging to positive retest. Performed the maneuver in all patients, the retest presented 51.85% sensitivity, 91.89% specificity, 82.35% positive predictive value and 72.34% negative predictive value.

Conclusion

The study shows that doing the retest after repositioning maneuver of particles in BPPV is effectual, since it has high specificity.

Eustachian tube opening measured by sonotubometry is poorer in adults with a history of past middle ear disease

OBJECTIVE

Test the hypothesis that active Eustachian tube opening efficiency as measured by sonotubometry is higher in adults with no extant middle-ear disease and no history of previous otitis media (Group-1) when compared to adults with no middle-ear disease but a positive history for otitis media (Group-2).

METHODS

Eustachian tube function for 1 ear of 33 otherwise healthy adult subjects, 16 assigned to Group-1 and 17 to Group-2, was tested by sonotubometry using a standard protocol. For each test, the sound envelopes for 3 swallows were abstracted independently by 2 observers from the data stream and 7 descriptive parameters related to sound envelope "shape" were calculated. Inter-relatedness among the values for the parameters was explored using correlation analysis. The contributions of swallow, observer and group to the variance in each parameter were evaluated for significance using a General Linear Model.

RESULTS

The shape parameters reflecting envelope height, area and rise and fall rates were highly inter-correlated, but those reflecting envelope widths were not. There was no effect of "swallow" on any of the parameters; but there was a significant "observer" effect on all measures of envelope width, greater for observer-2, and a significant "group" effect for 5 of the 7 shape parameters, all greater in Group-1.

CONCLUSIONS

Quantifiable measures of the sound signal "shape" recorded by sonotubometry during swallowing were significantly different between the 2 groups of subjects. This is interpretable as evidencing a more efficient Eustachian tube opening-function in adults with healthy middle ears who do not have a previous history of otitis media when compared to similar adults with a history of prior otitis media. Inefficient Eustachian tube function as children may not be completely resolved by adulthood increasing adult otitis media risk when Eustachian tube function is down-graded by extant upper respiratory diseases that provoke nasopharyngeal inflammation.

[Subjective tympanophonia. The current concepts of therapy]

The authors overview the current concepts of the management of the patients complaining of subjective tympanophonia with special reference to the medicamental and medicamental treatment of this condition and rehabilitation. Bearing in mind a great variety of approaches to addressing this problem, only the most important, widely applied, and clinically verified methods for this purpose are considered.

[Tinnitus management in 2013]

Tinnitus is a common symptom, affecting nearly 10% of the adult population. Even if most of the patients support it, it can be particularly disabling in some cases. Recent advances in neuroscience have greatly improved the understanding of its pathophysiology, resulting in development of new therapeutic strategies. The management of tinnitus requires a systematic and rational approach to avoid incomplete diagnosis procedures and unnecessary exams. The diagnostic approach will be held to identify the causal pathology. Etiological treatment, if it is possible, will be the first therapeutic step. Various symptomatic treatments, such as tinnitus retraining therapy, cognitive behavioral therapy, or neuromodulation will promote habituation to the tinnitus, to ensure that the latter won't cause discomfort anymore.

[Vertigoes in E.N.T]

Vertigoes represent 5% of GP consultations. We thus often deal with complaints from vestibular origin. The starting point of this text is the word "vertigo or instability" as well as a targeted anamnesis allowing a general approach leading to a precise clinical examination and thus to a diagnosis of most commonly encountered E.N.T. pathologies. The anamnesis, the oto-neurological test and the treatment(s) will be further developed. Willingly the complementary tests performed in the E.N.T. unit have been skipped and we will keep the focus on the anamnesis and the clinical examination that can be can performed in your practice or at patient's house. The main overviewed pathologies will be: paroxysmal positional vertigo, vestibular hypofunction, Meniere's disease and dizziness in the elderly. This paper will allow to identify the many vestibular pathologies more easily.

[The role of MRI in the preoperative examination and postoperative follow up of the patients presenting with a combination of chronic otitis media and cholesteatoma]

The objective of the present work was to estimate the possibilities of application of different MRI modalities for the diagnostics of cholesteatoma and to develop the criteria for the verification of the proposed protocols. The study was carried out in the standard T1 and T2 regimes as well as in the non-EPI DWI regime. The patients available for the examination presented with both primary cholesteatoma and with residual and recurrent cholesteatoma. The principal radiodiagnostic algorithm for cholesteatoma included the use of a signal of low-intensity in the T1 regime and a high-intensity signal in the T2 and non-EPI DWI regimes. Three clinical observations are reported in this paper. All the patients were examined by MRI in the T1, T2, and non-EPI DWI modalities. The presence of cholesteatoma was confirmed in 2 patients; this finding was verified during surgery. In one case, the use of the proposed method allowed cholesteatoma to be excluded.

[Criteria for the objective assessment of the dynamic state of the retraction pockets in the children presenting with excudative otitis media]

This publication continues the preceding paper entitled "Early diagnostics of the retraction pockets in the tympanic membrane of the children". The objective of the present work was to develop the criteria for the objective estimation of the dynamic state of the retraction pockets (RP) in the children at different stages of excudative otitis media. The secondary objective was to develop an approach to the early diagnostics of cholesteatoma of the middle ear. A group of 138 children at the age varying from 1 to 17 years was placed under dynamic observation for the purpose of drawing up the individual "photo-roentgenological passport of the retraction pockets". Special attention was given to RP-semiotics of different forms of the syndrome and its severity in accordance with the classification universally accepted by foreign researchers. The results of the dynamic observations were used to develop the indications for the early preserving surgical treatment. It was given to 16 children six of which presented with cholesteatoma. The original illustrative materials for all variants of the retraction pockets are presented.

A pilot study of the ability of the forced response test to discriminate between 3-year-old children with chronic otitis media with effusion or with recurrent acute otitis media

CONCLUSIONS

When used to test 3-year-old children within 3 months of tympanostomy tube placement for recurrent acute otitis media (rAOM) or chronic otitis media with effusion (cOME) the forced response test (FRT) showed relatively minor differences in the active and passive functions of the eustachian tube. While the sample size was small, the high variability in all test parameters suggests that the FRT alone is not capable of distinguishing between children with different expressions of otitis media.

OBJECTIVE

The FRT was designed to measure the passive and active properties of the eustachian tube. We evaluated the ability of that test to discriminate groups of children with rAOM or cOME.

METHODS

Twenty-two ears (15 children) with a confirmed history of rAOM and 24 ears (17 children) with a confirmed history of cOME were tested at 3 years of age within 3 months of ventilation tube placement. The parameters of the FRT were compared between these groups using a two-tailed Student's t test and the frequencies of ears evidencing eustachian tube dilation with swallowing were compared between groups using a χ(2) test.

RESULTS

Passive resistance and one measure of active function were significantly higher in the rAOM group. The frequency of tubal dilation was not significantly different between groups. There were no differences in any of the FRT measures between cOME ears that did and did not have acute otitis media by history.

[An oto-neurological approach to the acutely dizzy patient]

Benign paroxysmal positional vertigo, vestibular neuronitis and Menière's disease cause most cases of acute vertigo. However, doctors must consider central neurological reasons to vertigo. If it is determined that a patient has oto-neurological vertigo, the next task is to determine whether the patient has a peripheral or a central cause of vertigo, if the condition is potentially lethal and if there is a need for acute radiological imaging and/or medical intervention. This review highlights the oto-neurological approach to the dizzy patient with particular focus on the patient's history, clinical tests and treatment.

A clinical study of the subjective visual vertical during unilateral centrifugation and static tilt

CONCLUSION

The present study demonstrates that various response patterns of subjective visual vertical (SVV) can be identified during unilateral centrifugation (UC). It is proposed that these response types correspond to different degrees of compensation after disease. This is advantageous for monitoring the effect of rehabilitative measures and is useful in medico-legal issues. It also emerges that diagnosis of unilateral utricle function requires the determination not only of asymmetry ratio but also offset of SVV estimates.

OBJECTIVES

A retrospective clinical study of SVV test results was performed to establish a classification and model of response types in patients with suspected otolith disorder.

METHODS

SVV measurements were made in 473 patients recruited from the dizziness clinic. A control group of healthy subjects (n = 43) was tested with the same protocol. Testing with bilateral stimulation (stationary upright, 15°, 30° tilt) and UC was performed. A mathematical model for the UC results was developed.

RESULTS

During UC testing 61% of the patients showed an asymmetric response indicating a unilateral utricular hypofunction/dysfunction. These results could be classified into three subgroups, indicating different degrees of compensation. The model parameters can be adapted to reflect this classification.

[Peculiarities of ENT diseases in young subjects]

The results of outpatient medical examination of the applicants and students of the Moscow State Institute of International Relations carried out by otorhinolaryngologists during the past 12 years are reported. A total of 32,238 subjects aged from 15 to 25 years were recruited into the project. When appropriate, it was supplemented by a combination of audiological studies and microbiological analysis of naso- and oropharyngeal secretion. Protocols of preventive medical examination and treatment of young subjects presenting with acute and chronic inflammatory ENT diseases are proposed.

[Somatosensorial disorders. Alterations in the quality of life in patients presenting with peripheral vestibular dysfunction]

The authors undertook the assessment of the available methods for the analysis of the sensations of patients suffering pathology of the vestibular analyzer. The fact that such conditions as dizziness and disequilibrium have great influence on the social status of a patient and his (her) position in society accounts for the use of functional stabilometry in the clinical practice along with the evaluation of quality of life. It is emphasized that the timely diagnosis of these disorders and elucidation of their primary causes are as important for the successful treatment of this pathology as the choice of an adequate course of medicamental and rehabilitative therapy.

Test-retest reliability of low-level evoked distortion product otoacoustic emissions

PURPOSE

The purpose of this study was to examine test-retest reliability of low-level evoked distortion product otoacoustic emissions (DPOAEs) as a function of L(1), L(2) level; f(2) frequency; and test condition. A predictive relationship between these variables and the presence/absence of DPOAE responses was also examined.

METHOD

Sixteen normal-hearing young adults participated. DPOAEs were evoked to 12 tones with f(2) frequencies ranging from 1500 Hz to 7546 Hz at 4 L(2) levels between 45 dB SPL and 30 dB SPL. Four test conditions were employed: (a) initial test, (b) retest without probe removal, (c) retest with probe reinsertion, and (d) retest with probe reinsertion by a second tester.

RESULTS

L(1), L(2) level and f(2) frequency were statistically significant (p < .0001) predictors of a DPOAE response (i.e., the presence of a DPOAE response was more likely to be observed at higher L(1), L(2) levels and lower f(2) frequencies regardless of test condition). DPOAE levels were significantly affected by L(1), L(2) level and f(2) frequency (p < .0001) but not by test condition. Intra- and intertester test-retest differences were not significantly different.

CONCLUSIONS

The prevalence of missing responses coupled with large intersubject variability and intrasubject test-retest variability are a detriment to the clinical utility of DPOAEs evoked with low-level stimuli.

[Algorithm of early diagnosis and treatment of nasal cavity and accessory sinuses of the nose in students of educational establishments of the water-borne transport system]

An algorithm of early diagnosis and treatment of nasal cavity and accessory sinuses of the nose in students of educational establishments of the water-borne transport system has been developed. Inclusion of such methods as screening diagnosis of inflammatory diseases of paranasal sinuses, original roentgenologic and zonographic imaging of paranasal and frontal sinuses made it possible to substantially improve the quality of diagnosis, shorten duration of the examination, and reduce radiation exposure of the patients. The proposed algorithm was used to provide therapeutic and rehabilitation services to 260 patients admitted to the Clinical Hospital No 1 of the federal state institution <<Medical Centre of the Southern Federal District>>, Russian Agency for Health Care.

[Principal mistakes in expert and diagnostic evaluation of the relationship between noise exposure and ear diseases]

The problem of hearing impairment is considered with special reference to subjects exposed to intense occupational noise. The place of this clinical condition in the overall structure of occupational diseases is discussed with special reference to physical factors of the technological environment responsible for its development. The current untoward situation is underlain not only by imperfections of modern technological processes, inadequate labour protection and industrial hygiene policies, and poor organization of <<noisy>> manufacturing activities. It is also attributable to the low quality of medicinal-prophylactic examination at the stage of acceptance for employment and the lack of adequate periodic medical monitoring during the subsequent period. This, in turn, is a result of insufficient knowledge of health professionals about methods of prevention, diagnosis, and assessment of occupational loss of hearing. The main mistakes in the analysis of the relationship between the prevalence of ear diseases and the exposure to occupational noise are divided into organizational, diagnostic, expert, and deontological ones. Characteristics of these mistakes and their causes are described.

[Potential of acureflexotherapy for the diagnosis and treatment of occupational loss of hearing]

The present in-depth clinical and audiologic study with the use of the Nakatani reflexodiagnostic technique included 240 subjects employed in mechanical engineering, coal and ore mining industries exposed to occupational noise and vibration in excess of the maximally permissible level (MPL). Results of the study confirm the effectiveness of Nakatani's express-method for the vocational selection and designation of groups at risk of occupational neurosensory loss of hearing. The study was also designed to evaluate results of combined treatment of bilateral neurosensory deafness by reflexotherapy. It is concluded based on the results of audiometry that such treatment resulted in improved hearing of frequencies from 500 to 8000 Hz (by 10-15 dB) in more than half of the treated subjects.

[Examination of dynamic body balance using the body tracking test in cases of vestibular neuronitis]

Body Tracking Test (BTT) is a testing method of the dynamic body balance function wherein movement of the center of gravity in accordance with a moving visual target stimulus is examined to evaluate the tracking function of the body. The objects were the patients who were diagnosed as having vestibular neuronitis at the Department of Otolaryngology in Toho University medical center Sakura hospital, and were undergoing hospital treatment. Lateral BTT was performed in 31 subjects, and antero-posterior (A-P) BTT in 45 subjects. Although gaze nystagmus was noted, inspection was enforced when a standing position posture was possible. In lateral BTT, the average (cm/second) horizontal direction body sway speed was compared, however, no clear lateral difference was noted. In the antero-posterior (A-P) BTT, it inquired using the direction body sway average center displacement (cm) of X. Deviation was seen by the affected side in stabilometry. Deviation was seen by the unaffected side in the antero-posterior (A-P) BTT. This phenomenon differs from the deviation pattern until now and is considered to involve participation of the higher centers.

[Static posturography versus clinical tests in elderly people with vestibular pathology]

INTRODUCTION AND OBJECTIVES

Balance can be quantified by clinical tests and through instrumental studies. The objective of this paper is to determine the correlation between static posturography and 4 clinical tests of balance in elderly people with vestibular disorders and to identify its capability to discriminate the groups studied.

METHODS

60 patients with vestibular disorders and 60 healthy subjects performed 4 clinical tests (one leg standing with opened eyes, Timed Up and Go, Tinetti and Berg tests) and a static posturography analysis (NedSVE/IBV system) under 4 conditions: Romberg Test, Eyes Open (REO), Romberg Test, Eyes Closed (REC), Romberg Test on Foam with Eyes Open (RFEO), and Romberg Test on Foam with Eyes Closed (RFEC).

RESULTS

RFEO correlated best with the clinical tests and RFEC was the worst. RFEO distinguished between healthy individuals and decompensated patients.

CONCLUSIONS

RFEO gave the best information about postural balance in the elderly. RFEC was not useful. Static posturography can be useful to distinguish vestibular compensation status.

Machine learning method for knowledge discovery experimented with otoneurological data

We have been interested in developing an otoneurological decision support system that supports diagnostics of vertigo diseases. In this study, we concentrate on testing its inference mechanism and knowledge discovery method. Knowledge is presented as patterns of classes. Each pattern includes attributes with weight and fitness values concerning the class. With the knowledge discovery method it is possible to form fitness values from data. Knowledge formation is based on frequency distributions of attributes. Knowledge formed by the knowledge discovery method is tested with two vertigo data sets and compared to experts' knowledge. The experts' and machine learnt knowledge are also combined in various ways in order to examine effects of weights on classification accuracy. The classification accuracy of knowledge discovery method is compared to 1- and 5-nearest neighbour method and Naive-Bayes classifier. The results showed that knowledge bases combining machine learnt knowledge with the experts' knowledge yielded the best classification accuracies. Further, attribute weighting had an important effect on the classification capability of the system. When considering different diseases in the used data sets, the performance of the knowledge discovery method and the inference method is comparable to other methods employed in this study.

[Sudden deafness due to cochlear ischemia in a patient with anterior inferior cerebellar artery occlusion]

Sudden deafness is a less-known symptom in patients with anterior inferior cerebellar artery (AICA) infarction, and its underlying mechanism is still unclear. In this report, the authors describe a case of a 63-year-old male who suddenly developed right deafness and vertigo. MR imaging on admission revealed cerebral infarction in the right AICA territory infarction. Precise neuro-otological examinations, including auditory brainstem response (ABR) and oto-acoustic emissions (OAE), Caloric test, first demonstrated that his deafness resulted from cochlear dysfunction. The authors emphasize that hearing impairment can be one of the neurological sequelae due to AICA infarction, and that precise neuro-otological examination may be important to clarify its underlying mechanisms.

Diagnosis of ear pain

Many patients in primary care present with ear pain (otalgia). When the ear is the source of the pain (primary otalgia), the ear examination is usually abnormal. When the ear is not the source of the pain (secondary otalgia), the ear examination is typically normal. The cause of primary otalgia is usually apparent on examination; the most common causes are otitis media and otitis externa. The cause of secondary otalgia is often difficult to determine because the innervation of the ear is complex and there are many potential sources of referred pain. The most common causes are temporomandibular joint syndrome, pharyngitis, dental disease, and cervical spine arthritis. If the diagnosis is not clear from the history and physical examination, options include a trial of symptomatic treatment without a clear diagnosis; imaging studies; and consultation with an otolaryngologist. Patients who smoke, drink alcohol, are older than 50 years, or have diabetes are at higher risk of a cause of ear pain that needs further evaluation. Patients whose history or physical examination increases suspicion for a serious occult cause of ear pain or whose symptoms persist after symptomatic treatment should be considered for further evaluation, such as magnetic resonance imaging, fiberoptic nasolaryngoscopy, or an erythrocyte sedimentation rate measurement.

A critical analysis of tinnitus measuring methods

One of the main factors that make tinnitus treatment so difficult is the subjectivity of measuring methods and therapeutic monitoring. Database: Our aim, in this study, is to make a critical analysis of tinnitus measuring methods. Conclusion: There is no consensus about tinnitus measuring methods, causing criticism in the methodology used in many papers. In Brazil, the simplest methods are the most used.

Audiologic evaluation of infants and preschoolers: a practical approach

Many children suspected of having hearing loss are referred for audiologic evaluation every day. Cross-checking the results from more than one audiologic tests is considered crucial in pediatric audiology, preferably combining subjective and objective methods. The current recommended approach for hearing assessment of infants and preschoolers is based on physiologic tests, immittance measurements, and behavioral responses. As a consequence, a full examination usually takes more than 90 minutes. Because the number of referrals may be much greater than the actual performance of a modern audiologic department, it would be desirable to shorten the evaluation time without reducing its validity. The largest part of the population referred to our department for hearing evaluation consists of children 1(1/2) to 4 to 5 years old suspected of having hearing loss. The proposed triad history/otoscopy --> speech evaluation --> otoacoustic emissions (OAEs) has been proven very effective in sorting out all those children with normal hearing bilaterally. The suggested algorithm shows several advantages compared to the conventional approach. It is safe, inexpensive, noninvasive, and gives reliable results in a significantly faster way, thus increasing compliance and applicability in very young children. In this way, we can save time, "money," and "diagnostic energy," which could be used for those children who really need them.

Expanding the differential diagnosis of chronic dizziness

OBJECTIVE

To improve treatment outcomes for patients with chronic dizziness by identifying clinical conditions associated with persistent symptoms and delineating key diagnostic features that differentiate its causes and direct attention to specific treatments.

DESIGN

Prospective cohort study from 1998 to 2004.

SETTING

Tertiary care balance center.

PATIENTS

A total of 345 men and women, aged 15 to 89 years, referred for evaluation of chronic dizziness (duration of > or =3 months) of uncertain cause.

INTERVENTIONS

Patients were systematically directed through multiple specialty examinations until definitive diagnoses were made.

MAIN OUTCOME MEASURE

Final diagnoses associated with dizziness.

RESULTS

Nearly all patients with chronic subjective dizziness were diagnosed with psychiatric or neurologic illnesses. These included primary and secondary anxiety disorders (n = 206 [59.7%]) and central nervous system conditions (n = 133 [38.6%]), specifically migraine headaches, mild traumatic brain injuries, and neurally mediated dysautonomias. A small number of patients (6 [1.7%]) had dysrhythmias. Four of 5 patients with migraine or dysrhythmias had comorbid anxiety.

CONCLUSIONS

Chronic dizziness has several common causes, including anxiety disorders, migraine, traumatic brain injuries, and dysautonomia, that require different treatments. Key features of the clinical history distinguish these illnesses from one another and from active neurotologic conditions. The high prevalence of secondary anxiety may give a false impression of psychogenicity.

Origin of sound-evoked EMG responses in human masseter muscles

Sound is a natural stimulus for both cochlear and saccular receptors. At high intensities it evokes in active masseter muscles of healthy subjects two overlapping reflexes: p11/n15 and p16/n21 waves, whose origin has not yet been demonstrated. Our purpose was to test which receptor in the inner ear is responsible for these reflexes. We compared masseter EMG responses induced in normal subjects (n = 9) by loud clicks (70-100 dB normal hearing level (NHL), 0.1 ms, 3 Hz) to those evoked in subjects with a selective lesion of the cochlea (n = 5), of the vestibule (n = 1) or with mixed cochlear-vestibular failure (n = 5). In controls, 100 dB clicks induced bilaterally, in the unrectified mean EMG (unrEMG), a clear p11 wave followed by a less clear n15 wave and a subsequent n21 wave. Lowering the intensity to 70 dB clicks abolished the p11/n15 wave, while a p16 wave appeared. Rectified mean EMG (rectEMG) showed, at all intensities, an inhibitory deflection corresponding to the p16/n21 wave in the unrEMG. Compared to controls, all deaf subjects had a normal p11 wave, together with more prominent n15 wave; however, the p16/n21 waves, and their corresponding inhibition in the rectEMG, were absent. The vestibular patient had bilaterally clear p11 waves only when 100 dB clicks were delivered bilaterally or to the unaffected ear. Stimulation of the affected ear induced only p16/n21 waves. Data from mixed patients were consistent with those of deaf and vestibular patients. We conclude that click-induced masseter p11/n15 waves are vestibular dependent, while p16/n21 waves depend on cochlear integrity.

[Topical problems of occupational deafness]

The article covers up-to-date state of occupational deafness problem, its importance in occupational therapy. The authors defined topical directions of research in contemporary diagnosis, prognosis and treatment of "noise-related" deafness.

Tinnitus: a multidisciplinary clinical approach

This article provides a clinical step-by-step approach for assessing a patient with tinnitus as primary complaint. The medical diagnosis of the disease provoking the tinnitus has to be made first in a comprehensive evaluation, including imaging. The psycho-acoustic characteristics and the influence on health-related quality of life is a compulsory complementary assessment to establish a complete picture of the patient.

Eustachian tube function in patients with eosinophilic otitis media associated with bronchial asthma evaluated by sonotubometry

OBJECTIVE

To determine eustachian tube function in patients with asthma and with or without eosinophilic otitis media (EOM), a new middle ear disease entity with a highly viscous middle ear effusion containing many eosinophils and usually associated with bronchial asthma. One of the most important causes of otitis media (OM) is eustachian tube dysfunction.

DESIGN

Retrospective case review.

SETTING

A referral center.

PATIENTS

Twenty patients with EOM and patients with asthma but without OM.

MAIN OUTCOME MEASURES

We studied eustachian tube function using sonotubometry and a questionnaire. Sonotubometry was also performed on 13 control patients with chronic otitis media (COM) and 7 normal controls.

RESULTS

The tubal opening duration was significantly longer in patients with EOM than in patients with asthma but without OM, controls with COM, and normal controls, indicating the presence of patulous eustachian tubes in patients with EOM. Responses to the questionnaire also supported the presence of patulous eustachian tubes in the patients with EOM.

CONCLUSIONS

The presence of a patulous eustachian tube may be a major cause of EOM in patients with bronchial asthma. In patients with asthma who have a helper T-cell 2-dominant predisposition, a patulous eustachian tube easily allows the entry of antigenic materials into the middle ear, causing eosinophil-dominant inflammation.

???Bow and Lean Test??? to Determine the Affected Ear of Horizontal Canal Benign Paroxysmal Positional Vertigo

OBJECTIVE

One of the problems in the management of horizontal semicircular canal benign paroxysmal positional vertigo (HSC-BPPV) is the difficulty in determining the affected ear using Ewald's second law. The purpose of this study is to develop the new "bow and lean test (BLT)" to easily determine the affected ear of HSC-BPPV and evaluate its efficiency.

METHODS

We compared the efficiency between the classic method and BLT in 26 patients with HSC-BPPV. The classic method is based on Ewald's second law comparing the intensity of nystagmus or symptoms in the head roll test. BLT is based on the direction of both "bowing nystagmus" and "leaning nystagmus" at the head's bowing and leaning state in a sitting position. The affected ear is the same direction of bowing nystagmus in canalolithiasis and the same direction of leaning nystagmus in cupulolithiasis.

RESULTS

In 26 patents (15 canalolithiasis, 11 cupulolithiasis), 3 (11.5%) patients did not show a prominent affected ear in the classic method, and 7 (26.9%) patients showed the different affected ear between the two methods. All 10 patients were successfully treated with just one trial of barbecue rotation based on the affected ear in BLT. Three patients did not show any bowing or leaning nystagmus. The side with canal paresis in all four patients, who showed significant canal paresis in bithermal caloric tests, was equal to the affected ear based on BLT.

CONCLUSIONS

The "bow and lean test" (also called "Choung's test") is a new method that can easily determine the affected ear of HC-BPPV.