Double challenge:cochlear implantation in the only hearing ear with progressive hearing loss following meningitis and vestibular dysfunction after implantation

Objective:Vestibular dysfunction associated with cochlear implantation is rare.It is usually seen in patients with otosclerosis due to spread of electrical activity throughout the demineralized bone.A 17-year old female with progressive hearing loss 2 years after meningitis and vestibular dysfunction in the implanted ear is presented in this study.Findings:The patient had mild hearing loss in the right ear and total hearing loss on the left side because of complete ossification of the cochlea following meningitis.She had to have cochlear implantation in the right ear because of progression of hearing loss.She had successful implantation but she experienced vestibular dysfunction following activation of cochlear electrodes.Closure of two electrodes caused disruption of auditory programming.Then the patient was subjected to long term vestibular rehabilitation program.Conclusion:Timing for implantation before the completion of cochlear ossification is crucial not to miss the chance for hearing restoration.However,difficulties in hearing rehabilitation due to extensive ossification can be doubled by vestibular problems triggered by stimulation of the vestibular nerve by cochlear electrodes.Attempts to reduce the balance problem will complicate auditory programming.Vestibular rehabilitation for long term helps to carry on hearing progress.

Acute thrombosis of the carotid artery associated with positional nystagmus at multiple planes

Objective:An acute onset central pathology without any clear neurological symptoms may mimic peripheral vestibular problem in an emergency setting.A 54-year-old man suddenly developed dizziness without any cranial nerve symptoms,paresis,cerebellar signs or sensory disturbances except upbeat positional nystagmus at multiple provoked positions which alerted for a possible acute central pathology.Findings:An instantaneous magnetic resonance imaging and angiography studies further showed obstruction of the left internal carotid artery above the bifurcation.The patient’s subsequent prognosis was consistent with good recovery following anti-coagulant therapy.A follow-up MRI and angiography showed resolution of thrombosis.Conclusion:It should be kept in mind that positional nystagmus is likely to occur in central pathologies.Differentiation between benign paroxysmal positional vertigo and central positioning nystagmus is critical.

Analysis of persistent geotropic and apogeotropic positional nystagmus of the lateral canal benign paroxysmal positional vertigo

Objective:This study aims to analyze the clinical characteristics of persistent geotropic and apogeotropic positional nystagmus of LC-BPPV in view of light and heavy cupula discussion.Material and method:The study group includes 184 patients with LC BPPV(98 apogeotropic,86 geotropic type)who have been examined between 2009 and 2020.Ninety-nine females and 85 males,aged between 16 and 92 years were included(Ageotropic 49.32±14.12,geotropic 44.49±13.90 years).Average slow phase velocity(SPV)of positional nystagmus was documented and those with persistent directionchanging positional nystagmus lasting more than a minute were grouped separately.Age,gender difference,side of involvement,and recurrence pattern were particularly reviewed.Chi-square and One way ANOVA tests were used to compare the difference between groups.Statistical significance was set at P<0.05.Results:Thirty-seven patients with apogeotropic nystagmus(30.7%;37/98)and 18 patients with geotropic nystagmus(20.9%;18/86)had persistent nystagmus(p?0.05).Comparison of slow phase velocity(SPV)of persistent and non-persistent geotropic and apogeotropic positional nystagmus of the affected side was significant(p?0.05).Comparison of average age,male to female ratio,side of involvement,and the recurrence rate in patients with persistent and non-persistent geotropic and apogeotropic type positional nystagmus groups were not significant(p=0.177,p=0.521,p=0.891,p=0.702).Conclusion:Persistent geotropic and apogeotropic positional nystagmus is mostly correlated with the size,amount,and position of otoconial debris.It is difficult to justify the light cupula as a new geotropic variant of cupular pathology.Patients with persistent positional nystagmus present similar therapeutic outcomes and recurrence rates.

Direction-fixed positional nystagmus following head-roll testing:how is it related with a vestibular pathology?

Objective:The goal of this study is to analyze the clinical view of patients with direction-fixed positional nystagmus(DFPN)following head-roll maneuver.Methods:Sixty patients with DFPN were reviewed retrospectively.Patients were categorized into 3 groups according to the direction of nystagmus based on rotation side.Associated problems were documented,and cumulative data were compared between groups.One-way analysis of variance(ANOVA test)was used for statistical analysis(P<0.05).Results:Thirty-three patients(55%)had stronger nystagmus beating towards the direction of head-roll(Group-A).Three patients developed geotropic LC-BPPV.Fourteen patients had inner ear disease.Sixteen patients(27%)had stronger nystagmus beating against the direction of head roll(Group-B).Nine patients had inner ear disease.None of the patients tested with head-shaking had change of direction of nystagmus.Eleven patients(18%)had DFPN with equal velocity during right or left head-roll maneuver(Group-C).Of those,nine patients had inner ear disease.None of the patients had change of direction of nystagmus.Comparison of the incidence of associated problems(migraine,vestibular neuronitis,Meniere’s disease etc.)in each group was not statistically significant(P˃0.05).Conclusion:Patients with DFPN should be followed for a possibility of vestibular pathology since vestibular problem was documented for more than half of the patients in the follow-up.On the other hand,DFPN could be related with a temporary reason(thermal,physical or drug effect etc.)in some patients who do not exhibit any associated disease.Head-shaking testing is recommended to expose the lateral canal BPPV.But the incidence is low.

Revision surgery for otosclerosis:An overview

Stapes surgery for otosclerosis has been proved to be a very satisfying procedure. However, the condition is difficult for the patients with no or little hearing gain after surgery and for those who had sudden or gradual hearing loss after a successful air-bone gap closure in the follow-up period. The issue of re-exploring the middle ear is challenging. A general review of this subject from several points of view remains lacking. In this study, articles related with the revision surgery for otosclerosis have been reviewed after a Pub Med research and common and/or contradictory points were documented. The aim of this study is to give an insight to diagnostic and therapeutic approaches forthe clinicians in patients who need a revision surgery. In conclusion, prosthesis problems, loose prosthesis in stapedotomy and migrated prosthesis in stapedectomy are the most common causes for revision surgery. Most important indicators which effect better hearing outcome following revision surgery are those ears with the presence of incus, with no obliteration of oval window, with small fenestra stapedotomy and the experience of surgeon. The risk of neurosensorial hearing loss in revision cases is not high but the hearing gain is limited as compared to primary cases. The rate of 10 d B air-bone gap closure is around 60%-70% at most and even less promising results have been reported. Patient's demands and expectations have to be clarified in a realistic way.