Electrocochleographic changes after intranasal allergen challenge: A possible diagnostic tool in patients with Meniere's disease.

Numerous observers have suggested a relationship between allergy and Meniere's disease, but objective proof has heretofore been limited. Using standard criteria, we studied a group of 7 patients with previously diagnosed Meniere's disease in whom significant allergy to 1 or more inhalants had also been diagnosed. Patients underwent a baseline electrocochleographic study followed by intranasal challenge with a carefully quantified amount of the allergen to which they were most sensitive. This was followed by a second electrocochleogram. Four of the 7 patients demonstrated at least a 15% increase in the summating potential/action potential ratio in 1 ear, associated with the production of subjective inner ear symptoms. We present this protocol as a potentially useful tool to further study whether inhalant allergy may be a causative factor in patients with Meniere's disease.     

Allergic management of Meniere's disease: an outcome study.

The effect of allergy immunotherapy and elimination of suspected food allergens was evaluated in patients with Meniere's disease. A total of 137 patients with Meniere's disease for whom allergy treatment had been recommended were identified and were mailed and returned a symptoms questionnaire. One hundred thirteen had received allergy treatment; 24 did not have treatment and served as a control group. Information regarding history, signs and symptoms, allergy test results, and audiologic data were obtained by chart review. The 113 patients treated with desensitization and diet showed a significant improvement from pretreatment to posttreatment in both allergy and Meniere's symptoms. Ratings of frequency, severity, and interference with everyday activities of their Meniere's symptoms also appeared better after allergy treatment than ratings from the control group of untreated patients. Vertigo control results, by use of the American Academy of Otolaryngology-Head and Neck Surgery classification, categorized 47.9% as class A or B. Hearing was stable or improved in 61.4%. Patients with Meniere's disease can show improvement in their symptoms of tinnitus and vertigo when receiving specific allergy therapy. The inner ear may be the target, directly or indirectly, of an allergic reaction.     

The role of vestibular rehabilitation in the treatment of Meniere's disease.

OBJECTIVE: To study the role of vestibular rehabilitation is treating patients with Meniere's disease. METHODS: We examined all Meniere's patients presenting to our tertiary care specialized vestibular clinic during a 1-year period. All patients underwent a standardized history and physical examination, a complete auditory-vestibular test battery, and a set of physical therapy tools to measure balance function. RESULTS: A subset of patients suffered from disequilibrium or unsteadiness between attacks. Once the acute fluctuating symptoms of Meniere's were controlled in this group of individuals, all of them underwent vestibular physical therapy and demonstrated significant improvement in balance function on both objective and self-report tests. CONCLUSIONS: Due to the fluctuating nature of the disorder, vestibular physical therapy has had a limited role in the treatment of Meniere's disease. In general, rehabilitation has been used only as a postoperative treatment for the acute vertigo seen after vestibular neurectomy or labyrinthectomy. This is the first report advocating the role of vestibular physical therapy in a group of patients receiving medical therapy of intraear medicines (other that gentamicin).     

Electrocochleography in retrosigmoid vestibular nerve section for intractable vertigo caused by Meniere’s disease

Interest in electrocochleography has increased in recent years because of the discovery of an elevated summating potential to action potential amplitude ratio (SP/AP ratio) in patients with endolymphatic hydrops caused by Meniere’s disease or perilymph fistula. It was the purpose of this investigation to determine whether the intraoperative SP/AP ratio will decrease after vestibular nerve section in patients with intractable Meniere’s disease. Fourteen patients with medically intractable classic Meniere’s disease underwent retrosigmoid vestibular nerve section. Intraoperative transtympanic electrocochleography was performed with alternating click stimuli presented at 95 dB HL. In all patients the SP/AP ratio was recorded before the skin incision (“baseline” condition) and after the dura was closed (“closing” condition). Statistical analysis was applied to the recorded data. In 11 (79%) patients, the SP/AP ratio was found to be elevated above 0.30 in the baseline state. In 13 (93%) patients, the SP/AP ratio decreased more than 25% after the nerve was sectioned. These results were highly statistically significant ( p < 0.001). We conclude that the SP/AP ratio does decrease in patients with Meniere’s disease after undergoing retrosigmoid vestibular nerve section and offer a possible explanation. (Otolaryngol Head Neck Surg 1997;116:593-6.)     

Intratympanic gentamicin therapy for persistent vertigo after endolymphatic sac surgery.

OBJECTIVES: To evaluate the role of intratympanic gentamycin therapy (ITGM) in controlling vertigo in patients with refractory Meniere's who have recurrent or persistent vertigo after endolymphatic sac surgery. STUDY DESIGN AND SETTING: A retrospective review of 491 patients seen in a university balance clinic between July 1999 and July 2000. Of these, 68 patients had Meniere's disease; 4 patients had recurrent vertigo after endolymphatic sac surgery and were followed for at least 1 year. These 4 patients received a series of ITGM injections. Outcome measures included control of vertigo and audiometric results. RESULTS: Three of 4 (75%) patients had control of their vertigo with ITGM therapy. The 1 patient who failed ITGM therapy underwent a successful vestibular neurectomy with ultimate control of his vertigo. No patients had progression of their sensorineural hearing loss. CONCLUSION: ITGM therapy can be used to control vertigo in selected patients with Meniere's disease who have persistent vertigo after unsuccessful endolymphatic sac surgery. SIGNIFICANCE: ITGM therapy may reduce the need for vestibular neurectomy in patients with refractory Meniere's disease after endolymphatic sac surgery.     

Prevalence of heat shock protein in patients with Meniere''s disease and allergy

OBJECTIVE: The study purpose was to investigate the prevalence of elevated heat shock protein 70 (HSP-70) in patients with Meniere's disease who have milk allergy compared with those who are not allergic to milk. METHODS: Fifty-five patients with Meniere's disease and allergy in whom milk allergy had been confirmed by intradermal progressive dilutional food testing or skin testing to milk antigen were included. Blood serum was tested for HSP-70 elevation with a Western blot assay using bovine renal extract. The 29 women and 26 men ranged in age from 29 to 76 years (mean age 52.8 years). Forty percent of the patients had bilateral Meniere's disease. RESULTS: Overall prevalence of HSP-70 elevation was 29.1%. This was higher in bilateral patients (50%) than unilateral patients (15%) (P 相似文献   

Allergy testing and immunotherapy in an academic otolaryngology practice: a 20-year review.

OBJECTIVE: Allergic disease plays a central role in the clinical practice of otolaryngology. The purpose of this study was to review the 20-year experience of an allergy clinic integrated within an otolaryngology practice at a major academic institution. STUDY DESIGN: We performed a retrospective database review of over 3300 otolaryngology patients referred for allergy skin testing between 1979 and 1999. RESULTS: Approximately 80% of patients referred for allergy testing in our clinic had positive test results, of which 75.7% went on to undergo desensitization. The most common allergen was house dust, with allergies to mites, ragweed, and grass also prevalent. Among current allergy immunotherapy patients, 30.8% have undergone nasal septal, turbinate, and/or endoscopic sinus procedures in addition to allergy management. Nasal obstruction was the symptom most frequently persistent despite immunotherapy and the one most frequently reported to be improved by surgery. CONCLUSIONS: The otolaryngologist-head and neck surgeon is uniquely qualified to perform comprehensive medical and surgical management for patients with complex disease processes involving a component of allergy. We believe that an integrated approach to allergy within an otolaryngology practice optimizes the treatment of such patients.     

Safety and efficacy of radioallergosorbent test-based allergen immunotherapy in treatment of perennial allergic rhinitis and asthma.

OBJECTIVE: This study was undertaken to demonstrate the safety and efficacy of in vitro, radioallergosorbent test (RAST)-based inhalant allergen immunotherapy. STUDY DESIGN AND SETTING: Prospective 22 year single site clinical study, with outcome evaluations of 480 perennial allergic rhinitis patients, including 96 with concomitant asthma. RESULTS: Rhinitis symptom control after 2 years of immunotherapy was excellent in 32.5% of patients, good in 45.6%, and fair in 14.2%. There was no improvement in 7.7%. For patients with asthma, 81% had good or excellent pulmonary symptom improvement, and no patient failed to improve. No severe reactions occurred, but there were 5 limited systemic reactions, or 0.008% of injections, during a 2.5-year mean immunotherapy treatment course. CONCLUSION: RAST-based immunotherapy is safe and effective for patients with perennial allergic rhinitis, with or without concomitant asthma. Significance This is the first large, multiyear study of safety and efficacy of RAST-based immunotherapy for treatment of perennial allergic rhinitis and asthma. EBM rating: C.     

ECoG results in perilymphatic fistula: clinical and experimental studies

Patients with perilymphatic fistula have been described as having symptoms similar to Meniere's disease and endolymphatic hydrops. Direct clinical or experimental evidence linking the two inner ear disorders has been lacking. An enhancement of the summating potential observed with electrocochleography suggests a diagnosis of ELH in both of these inner ear disorders. In this study, ECoG results of 27 patients with surgically confirmed PLF are reported. Fourteen patients with surgically confirmed spontaneous PLF had abnormal ECoG. Six of these 14 patients had normal hearing. The ECoG changes in patients with Meniere's disease and those with surgically confirmed PLF are identical, indicating the underlying pathologic change in both is hydrops. But there is no specific diagnostic abnormality on ECoG that differentiates these two inner ear disorders. Also, an experimental model of PLF was developed and studied in guinea pigs. "Inactive" PLF is defined as "an opening was made into the cochlea, but if no perilymph moved out through the fistula, it was defined as inactive" An "active" PLF occurs when perilymph actually moves from the inner ear out to the middle ear. ECoGs were recorded before and after creation of an "active" PLF. ECoG abnormalities were seen in "active" PLF and correlated with histologic data demonstrating ELH. An abnormally enhanced summating potential was demonstrated after active removal of perilymph through the experimentally created fistula. Cochlear duct histology showed hydropic distention of Reissner's membrane in the experimental ears and no changes in the membranous labyrinths of the unoperated, control ears.(ABSTRACT TRUNCATED AT 250 WORDS)     

Retrosigmoid approach for vestibular neurectomy in Meniere's disease

BACKGROUND: Vestibular nerve section is considered to be the most effective surgical procedure to control intractable symptoms secondary to Meniere's disease (MD). This study was developed to analyze the adequacy of retrosigmoid vestibular neurectomy in terms of vertigo control, hearing preservation and clinical complications of this procedure. METHODS: A retrospective review was carried out on 14 patients affected by definite unilateral MD who underwent vestibular neurectomy via the retrosigmoid approach. FINDINGS: One patient was lost from follow-up; another one had only a short postoperative observation. At follow-up performed on 12 cases, no patients reported any crisis of acute vertigo. Four patients were free from any vestibular symptoms, while 8 reported some slight gait disturbances. Hearing function was preserved in 10 patients and improved in 2. 1 year postoperative vestibular function was absent at the side operated on and unchanged on the other side in all the cases. CONCLUSIONS: Vestibular neurectomy via the retrosigmoid approach can be considered a safe and effective procedure in relieving medically refractory vertigo in Meniere's disease, while preserving hearing.     

Surgical management of Meniere's disease in the era of gentamicin.

OBJECTIVE: For many years, surgery was the mainstay of therapy for medically refractory patients, but recently, transtympanic gentamicin perfusion has attracted increasing interest and is a method frequently used for treating Meniere's disease. Many otologists question the relevance of surgical treatments, and traditional options are rarely discussed or offered to patients. The purpose of this study is to describe results of labyrinthectomy, vestibular nerve section, and endolymphatic mastoid shunt surgery for patients with Meniere's disease and to compare them with published results for gentamicin perfusion. STUDY DESIGN AND SETTING: Retrospective chart review. Two hundred twenty-nine patients underwent surgery for management of Meniere's disease between January 1, 1995 and December 31, 2001. One hundred eighty-nine patients' charts had sufficient data for review. Thirty-two patients had translabyrinthine labyrinthectomies, 83 underwent suboccipital vestibular nerve sections, and 74 elected for an endolymphatic mastoid shunt. Hearing results, dizziness classification, and functional level score were determined from patient charts and telephone conversations. All results were in accordance with the guidelines of the AAO-HNS Committee on Hearing and Equilibrium for evaluation of Meniere's disease therapy. RESULTS: Audiologic results, functional level score, and dizziness classification are reported for the preoperative period and for the 18- to 24-month postoperative period for all surgical patients. These data are also reported individually for each of the 3 surgical procedures. Early postoperative data and most recent follow-up data are presented if available. CONCLUSIONS: Surgical management of Meniere's disease is a safe and viable option for patients with medically refractory disease. EBM rating: C.     

Chronic rhinosinusitis: Allergy and sinus computed tomography relationships

The management of chronic or recurrent rhinosinusitis problems is multifaceted and should include consideration of contributory and potentially correctable medical and anatomic factors. To date, the relationship between allergy and rhinosinusitis has not been clearly defined. The purpose of this study is to improve understanding of the relative roles of perennial and seasonal allergens in the cause of chronic rhinosinusitis. A retrospective review of 200 consecutive patients was carried out on patients who had chronic rhinosinusitis refractory to medical therapy and who subsequently underwent functional endoscopic sinus surgery. All of these patients had allergy testing for common perennial and seasonal inhalant allergens before surgery. Each patient had sinus CT imaging before undergoing the surgery. The CT scans of each patient were staged according to a validated, standardized grading system by investigators blinded to allergic profile. Allergy testing indicated that 84% of all patients tested positive for allergies. Moreover, 60% of all patients had significant allergic sensitivity; 52% of all patients had multiple allergen sensitivities. Furthermore, there was a predominance of perennial allergens, especially house dust mite over seasonal allergens. The vast majority of our patients undergoing functional endoscopic sinus surgery had concomitant allergy. This study highlights the potential contribution of perennial allergies to the development of rhinosinusitis. Given this direction, future studies may reveal that in the care of patients with perennial allergic rhinitis, early intervention with identification of the offending allergen(s), and subsequent treatment through avoidance, pharmacotherapy, and/or immunotherapy may help in the prevention of recurrent and chronic rhinosinusitis.     

Retrolabyrinthine vestibular neurectomy with simultaneous monitoring of eighth nerve and brain stem auditory evoked potentials

We have used retrolabyrinthine vestibular neurectomy in 36 of 49 cases as the primary surgical procedure to relieve vertigo. Most of the patients (46 of 49) had Meniere's disease. Results indicate that 71% (35 of 49) of the patients had no vertigo after the operation, while 22% (11 of 49) had much improvement. Hearing was maintained within 20 dB of the preoperative level in 78% (38 of 49) of the patients. During surgery in the last 23 patients, direct nerve potentials were recorded from the middle ear promontory and the intracranial cochlear nerve. Brain stem auditory evoked responses were simultaneously recorded in the last 10 patients. It appears that the intraoperative direct cochlear nerve potentials can be used as a sensitive monitor of trauma to the cochlear nerve during and after vestibular neurectomy. If the latency of the eighth nerve action potential changes less than 0.3 msec and the waveform does not change after vestibular neurectomy, there is an excellent chance that hearing at 1 month after surgery will be within 15 dB of the level before surgery. The retrolabyrinthine vestibular neurectomy has replaced the middle fossa vestibular neurectomy and the endolymphatic subarachnoid shunt procedure in our clinic.     

Extratympanic electrocochleographic changes on noise-induced temporary threshold shift.

OBJECTIVE: Electrocochleography (ECoG) is a sensitive evoked-response test for evaluating changes in cochlear function. We investigated the extratympanic ECoG in a noise-induced temporary threshold shift (TTS) to evaluate the usefulness of ECoG in the early detection of noise-induced hearing loss (NIHL). STUDY DESIGN AND METHODS: In a prospective analysis, 15 healthy ears were exposed to 90.3- to 105.0-dB noise for 3 hours in the same computer-game arcade. Pure-tone audiometry and ECoG were performed before, immediately after, and 24 hours after the exposure. RESULTS: Before the exposure, the average hearing level was 5.8 +/- 2.7 dB, which increased significantly to 12.8 +/- 2.8 dB immediately after exposure. A marked increment in the SP/AP (summating potential/action potential) ratio was observed with the TTS. The mean ratio was 0.22 +/- 0.11 before the exposure, 0.46 +/- 0.18 in the TTS phase, and 0.20 +/- 0.11 after resolution. CONCLUSION: The results of this study suggest that the SP/AP ratio is useful for the early detection and monitoring of NIHL.     

Use of streptomycin sulfate in the treatment of Meniere's disease

Streptomycin sulfate has been known to be ototoxic since its use in the treatment of tuberculosis. This report describes 10 years of experience in the treatment of Meniere's disease with streptomycin. Streptomycin has been used in classical Schuknecht ablation of the vestibular system in bilateral Meniere's disease; classical Schuknecht ablation of the vestibular system in unilateral Meniere's disease in the only hearing ear; intratympanic streptomycin in the treatment of unilateral Meniere's disease; and low-dose intramuscular streptomycin as outpatient treatment in unilateral Meniere's disease. The results of bilateral vestibular ablation were similar to Schuknecht's and others. Patients developed profound ataxia with a wide-based gait and oscillopsia, which improved rapidly over a period of months. Approximately 30% experienced significant improvement in hearing, which usually deteriorated again after several months. All patients were relieved of vertigo. Patients with unilateral Meniere's disease in the only hearing ear responded as did the bilateral cases. Hearing in the only hearing ear was preserved in all cases. Low-dose subototoxic streptomycin as outpatient treatment offers promise in some cases for relieving attacks of Meniere's disease while improving hearing without producing the temporary disabling effects of ataxia and oscillopsia. Streptomycin and similar drugs that may reduce the production of endolymph may eventually be the treatment of choice in Meniere's disease.     

Efficacy of immunotherapy based on skin end-point titration.

OBJECTIVE: The purpose of this study is to examine the efficacy of skin end-point titration (SET) as a method of assessing skin responsiveness, selecting antigens, and initiating treatment for successful inhalant immunotherapy. Study Design: This study is a prospective, randomized, controlled, double-blind investigation. Eighteen patients were randomly assigned to 1 of 2 groups: an experimental group treated for all positive antigens, and a control group treated for all positive antigens, with the exception of the study antigens. Quality of life was assessed with 3 dependent measures, and response to nasal challenge and nasal endoscopic evaluations were conducted. Ten patients completed the 6-month study. RESULTS: There were significant improvements in the emotional component of sinus-related disability, in response to nasal challenge, and in the endoscopic appearance of the mucosa, regardless of patient group. There was a trend toward improved quality of life among experimental subjects. CONCLUSIONS: SET-based immunotherapy reduces self-rated disability over time. In addition, SET-based immunotherapy allows decrease in nasal reactivity and normalizes the endoscopic appearance of the nose.     

Retrolabyrinthine section of the vestibular nerve

When symptoms of dizziness and episodic vertigo cannot be controlled through medical management or drainage procedures such as endolymphatic subarachnoid shunt operations, selective vestibular nerve section may be necessary. In the 1920s eighth cranial nerve sections were performed by neurosurgeons through the suboccipital approach but were frequently associated with hearing loss and facial paralysis. The middle fossa approach has been popularized by Dr. William House and others as a method of selectively sectioning the vestibular nerve and preserving facial and cochlear function. More recently the suboccipital retrolabyrinthine approach has been described as a method of selectively sectioning the vestibular nerve. We have reviewed 42 cases of suboccipital retrolabyrinthine selective section of the vestibular nerve performed at the Otologic Medical Group over the past 2 years. The shortest follow-up on these patients has been 6 months. Thirty-two patients had preoperative diagnosis of Meniere's disease, and of these patients 25 had had previous endolymphatic subarachnoid shunt surgery. Eighty-five percent (27 patients) experienced complete relief of vertigo following surgery, while 6% (two patients) stated they were improved. Three patients reported no relief. There were 10 patients with dizziness who had a diagnosis other than Meniere's disease. In this diverse group three experienced complete relief of vertigo, five were improved, and two reported no improvement of vertigo following surgery. None of the patients lost his hearing as a result of the surgery and there was no facial weakness. One patient had postoperative CSF rhinorrhea and another had meningitis.     

Long-term hearing results following middle fossa vestibular nerve section

Hearing stabilization following middle fossa vestibular nerve section (MFVNS) has been observed to occur in a large percentage of patients (71% to 86%) after short-term followup. This study looks at the long-term audiological followup (5 to 15 years) of 46 patients who underwent a MFVNS for intractable Meniere's disease. Although the percentage of patients with stabilized hearing was relatively high within the first 2 years postoperatively (61%), it dropped to 41% after a longer followup of 5 to 15 years. When this patient population is divided into two groups based on their preoperative PTA, those patients in whom hearing had bottomed out to greater than or equal to 50 dB PTA preoperatively lost only 5 dB PTA over the course of the follow-up period. The patients with better preoperative hearing (less than 50 dB PTA) lost 30 dB PTA over the same follow-up period. As this pattern is similar to what has been observed in nonsurgically treated Meniere's patients, we conclude that the MFVNS has no beneficial effect on the hearing loss associated with Meniere's disease.     

Latex allergy in subjects who had undergone multiple surgical procedures for bladder exstrophy: relationship with clinical intervention and atopic diseases

OBJECTIVE: To evaluate the prevalence of latex sensitization in a group of patients with bladder exstrophy, and to determine the role of associated risk factors, e.g. atopy, and the number and duration of surgical and anaesthetic procedures. PATIENTS AND METHODS: The study comprised 17 patients (15 children and two young adults) affected by bladder exstrophy who had undergone multiple surgical procedures. Skin-prick tests and specific immunoglobulin-E (IgE) assays against latex, food allergens cross-reacting with latex and inhalant allergens were carried out. RESULTS: Twelve patients showed latex sensitization and five showed symptoms related to latex exposure, the most common of which was contact urticaria (four of the symptomatic patients). Intraoperative anaphylactic reaction had led to life-threatening events in only one child. Latex-specific IgE determined both by the prick test and assay was positive in all those with symptoms. Specific IgEs against inhalant allergens and foods were present in four of five symptomatic patients. In the seven sensitized patients with no clinical symptoms, the assay was positive in all, while the skin-prick test was positive only in four; specific IgEs against inhalant allergens were present in three of the seven. In the five patients not allergic and not latex-sensitized, only one showed allergic sensitization against grass pollen and mite allergen. None of the children without latex antibodies had symptoms of latex allergy. Symptomatic patients had a undergone significantly more hours of surgery, more cystography and had used intermittent catheterization for longer than those with no symptoms. CONCLUSION: A third of patients with bladder exstrophy showed latex symptoms and another third had latex sensitization. Multiple surgical procedures and atopy play a major role in the development of latex hypersensitivity     

Nitric oxide is a mediator of the late-phase response in an animal model of nasal allergy.

The presence of nitric oxide (NO) in the nose is well documented; however, the role of this molecule in nasal physiology is still poorly understood. Our laboratory has previously demonstrated that NO is a mediator of the immediate secretory response to an intranasal histamine challenge in a rat model of nasal allergy. Histamine challenge, however, does not elicit a late-phase response (LPR). To study the role of NO in the LPR, we developed a model of nasal allergy in which brown Norway rats are actively sensitized to the allergen ovalbumin and later challenged intranasally with either phosphate-buffered saline solution (vehicle), ovalbumin in vehicle, or ovalbumin and the NO synthase inhibitor N -nitro-l -arginine methyl ester. In each experiment, nasal lavage samples were collected 30, 120, 240, and 360 minutes after challenge. Lavage samples were analyzed for albumin content by ELISA, inflammatory cell concentration with a hemocytometer, and evidence of inflammation by light microscopy. Blocking NO synthesis with N -nitro-l -arginine methyl ester significantly inhibited both albumin exudation and inflammatory cell influx into the nasal cavity during the LPR. These data suggest that NO plays a role in the LPR of nasal allergy.