ORL 2013;75:357–360 DOI: 10.1159/000357475 Received: May 8, 2013 Accepted after revision: November 18, 2013 Published online: January 24, 2014
© 2014 S. Karger AG, Basel 0301–1569/14/0756–0357$39.50/0 www.karger.com/orl
Original Paper
Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media Badr Eldin Mostafa a Amr Gouda Shafik a Aly M.N. El Makhzangy a Hesham Taha b Heba Mahmoud Abdel Mageed a Departments of a Otorhinolaryngology and b Audiology, Ain Shams University, Cairo, Egypt
Key Words Chronic suppurative otitis media · Vertigo · Vestibular testing · Vestibular function · Videonystagmography · Rotatory chair
Prof. Badr Eldin Mostafa Professor of ENT-HNS, Faculty of Medicine, Ain Shams University 34 a El Higaz Street Heliopolis, Cairo 11351 (Egypt) E-Mail bemostafa @ med.asu.edu.eg
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Abstract Objective: The objective of this study was to assess vestibular functions in patients with chronic suppurative otitis media (CSOM) with and without sensorineural hearing loss. Study Design: This was a prospective case study performed at a tertiary referral university hospital. Sixty patients with CSOM were included, and patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae were excluded. Patients and Methods: The patients underwent basic audiological evaluation, and clinical and instrumental vestibular evaluation. The incidence and extent of vestibular dysfunction in patients with CSOM were analyzed. Results: A total of 42 males and 16 females with a mean age of 29.5 years were included in this study. Forty ears had tubotympanic disease and 19 had cholesteatoma. There were 14 ears with sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the cases. Rotatory chair abnormalities were found in 70% of the cases, caloric hypofunction was found in 61.6%, and vestibular myogenic evoked potentials were abnormal in 25%. The only positive correlation with vestibular dysfunction was the duration of disease. Conclusions: The vestibular system is significantly affected in cases with CSOM. Both semicircular canals and the saccule are affected. All patients with long-standing CSOM should be evaluated for vestibular dysfunction irrespective © 2014 S. Karger AG, Basel of their hearing levels.
358
ORL 2013;75:357–360 DOI: 10.1159/000357475
© 2014 S. Karger AG, Basel www.karger.com/orl
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Introduction
Chronic suppurative otitis media (CSOM) can be associated with functional damage to the inner ear resulting in sensorineural hearing loss (SNHL) and dizziness. The same pathological factor diffusing through the round window can lead to an altered expression of proteins causing cochlear and vestibular damage [1–5]. The clinical effects of such damage are not widely reported and are extremely variable [6–8]. As vertigo and instability can negatively affect patients’ quality of life, assessment of vestibular function should be part of the functional evaluation of patients with CSOM. However, vestibular test abnormalities correlate poorly with a history of dizziness and vertigo [9, 10]. The objective of this work was to assess vestibular functions in patients with CSOM with and without SNHL. Patients and Methods This study included 60 patients with CSOM presenting at the Vestibular Unit of the El Demerdash Hospital, Ain Shams University, Cairo, Egypt, between April 2009 and August 2011. The study design and intervention were approved by the Institutional Review Board. We excluded patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae. All patients underwent the following examinations: Audiological examination: In pure tone audiometry and speech audiometry, SNHL was considered if the averaged bone conduction threshold (500–4,000 Hz) was more than 25 dB in more than two frequencies and/or a deterioration in the SD score was found. Office vestibular tests: Spontaneous nystagmus, head impulse test (HIT), head shake test (HST), positional and positioning tests as well as examination of stance and gait were performed. Instrumental vestibular tests: (1) Infra-red videonystagmography (Charter v1.30, water caloric stimulator NCI 480): smooth pursuit, random saccade, gaze nystagmus, optokinetic nystagmus, and positional as well as positioning tests were conducted. A standard water bithermal caloric test (30–44 ° C, 60 s each) was performed after microscopic application of a polyethylene patch. A difference of >20% determined unilateral weakness. (2) Rotatory chair (controller model 300; Micromedical Technologies): gain, phase and symmetry were recorded for six different frequencies (0.01–0.64 Hz). The test was considered abnormal if the result of at least two frequencies fell outside the range of the normative data. (3) Computed dynamic posturography: sensory organization tests were performed in the six standard conditions (Neurocom Smart Equitest). (4) Vestibular evoked myogenic potential (MEB-530 4K, Neuropack; Nihon Kohden). Statistical Analysis We used the Sofastat software version 1.1.0. Numerical data were analyzed according to normality (Fisher’s exact test, χ2 test, Mann-Whitney test, Spearman’s rank test).
Of the included patients, 42 were males (67.4%) and 16 females (32.6%). The age of the patients ranged from 12 to 75 years (mean age 29.56 years). Forty-one ears had tubotympanic disease (68.3%), and 19 had atticoantral disease (31.7%). Vestibular symptoms were reported in 32 patients (53.5%) with no statistical difference between ears with and without cholesteatoma (Fisher’s exact test, p = 1.0, n.s.). There was a statistically significant correlation between the duration of the disease and the presence of vestibular symptoms (table 1). All office tests including HST and HIT were normal. There were 46 ears without SNHL (76.7%) and 14 with SNHL (23.3%). There was no statistically significant difference between ears with and without cholesteatoma (Fisher’s exact test, p = 0.163, n.s.). Vestibular ocular reflex tests were normal in all patients. Caloric
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Results
359
ORL 2013;75:357–360 © 2014 S. Karger AG, Basel www.karger.com/orl
DOI: 10.1159/000357475
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Table 1. Duration of disease vs. positive history of vertigo
Group
Median
Average rank
Min.
Max.
Negative (n = 20) Positive (n = 23)
2.0 6.0
18.6 24.957
0.0833333333333 0.0833333333333
40.0 33.0
The Mann-Whitney U test was used. A two-tailed p value of 0.097 was considered as statistical trend.
Table 2. Distribution of rotatory chair results in relation to chair frequencies
Phase shift
Normal Positive
Frequency 0.01
0.02
0.04
0.08
0.16
0.32
0.64
20 40
20 40
22 38
25 35
30 30
36 24
40 20
Pearson’s test of linear correlation was used. A two-tailed p value of 0.002 was considered significant.
weakness was reported in 37 patients (61.6%) but was statistically unrelated to vertigo or SNHL. The rotatory chair testing revealed a phase defect in 42 patients (70%). The rotatory chair results were statistically related to vertigo but not to SNHL. Furthermore, there was a reverse correlation between chair frequency and phase defect (table 2). There were 15 ears (25%) with delayed p13 and 12 (20%) with delayed n23 on cervical VEMP. The relationship between VEMP and vertigo or SNHL was statistically insignificant. All patients had normal response patterns on computed dynamic posturography. Of the 42 cases with chair abnormalities, 36 (60%) had caloric weakness and 27 (64.2%) had associated VEMP abnormalities. Fifteen patients had abnormalities in all three (35.7%). Of the 37 patients with caloric weakness, 27 (72.9%) had rotatory chair abnormalities. Of the patients with SNHL (14), 13 (92.8%) had chair abnormalities, 8 (57.1%) had caloric abnormalities, 7 (50%) all three abnormalities and 3 (21.4%) had VEMP abnormalities.
The same pathologic factors affecting neural hearing in CSOM can affect the vestibular system due to anatomical proximity [1–3]. Alterations in the endolymphatic duct and sac structure were found to correspond to time-dependent changes in the middle ear mucosa due to exposure to bacterial toxin [11]. The current study was performed in 60 patients with CSOM to determine the incidence of vestibular symptoms and vestibular test abnormalities. A positive history of dizziness was reported in 32 patients (53.5%). Only the duration of disease was associated with a complaint of vertigo and was close to statistical significance. On the contrary, testing revealed abnormalities in a much higher number. This may be due to gradual vestibular compensation [9]. Rotatory chair abnormalities were reported in 70.1% of the patients, caloric weakness was found in 61.6% and VEMPs were abnormal in 23.3% [9, 10, 12, 13]. Moreover, the relationship between vertigo and SNHL (57.1%) was just close to statistical significance [1, 3].
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Discussion
360
ORL 2013;75:357–360 DOI: 10.1159/000357475
© 2014 S. Karger AG, Basel www.karger.com/orl
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Test results suggest involvement of the semicircular canals in the low frequency range as documented by the high-pass filter results on rotatory chair and the abnormal calorics. A higher frequency is apparently spared as evidenced by the normal HIT and HST results. The saccule may also be involved as documented by the VEMP abnormalities. These results are consistent with some form of hydrops affecting primarily the vestibular system [11]. Conclusion
Patients with long-standing otorrhea are more vulnerable to develop semicircular canals and saccular dysfunction independent of cochlear damage. Vestibular function must be assessed in such patients as they may suffer additional vestibular damage during surgery leading to decompensation and deterioration of their quality of life as a result of vertigo and instability.
References
2 3 4 5 6 7 8 9 10 11 12 13
Pajor A, Gryczynski M, Lukomski M, Jozefowicz-Korczynska M: Vestibular system in patients with sensorineural hearing loss. Otolaryngol Pol 2002;56:707–712. Papp Z, Rezes S, Jokay I, Sziklai I: Sensorineural hearing loss in chronic otitis media. Otol Neurotol 2003;24: 141–144. Redaelli de Zinis LO, Campovecchi C, Parrinello G, Antonelli AR: Predisposing factors for inner ear hearing loss association with chronic otitis media. Int J Audiol 2005;44:593–598. Takumida M, Anniko M: Localization of endotoxin in the inner ear following inoculation into the middle ear. Acta Otolaryngol 2004;124:772–777. Juhn S, Tsuprun V, Lee Y-W, Hunter B, Schachern P: Interaction between middle and inner ear in otitis media. Audiolog Med 2004;3:158–161. Pal’chun VT, Kunel’skaia NL, Petlinov AP: The vestibular function in patients with various forms of chronic purulent otitis media. Vestn Otorinolaringol 2004;6:13–17. Pal’chun VT, Kunel’skaia NL, Mironov AA, Ganichkina Iia, Petlinov AP: Myringoplasty and its effects on a vestibular function in patients with otitis media purulenta chronica. Vestn Otorinolaringol 2005;2:19–21. Siampara L, Mann SBS, Panda NK, Mehra YN: Audiovestibular profile in unilateral chronic suppurative otitis media. Ind J Otolaryngol Head Neck Surg 1997;49:107–111. Gianoli GJ, Soileau JS: Preoperative vestibular testing in chronic suppurative otitis media. Otolaryngol Head Neck Surg 2005;2:75–76. Gianoli GJ, Soileau JS: Chronic suppurative otitis media, caloric testing, and rotational chair testing. Otol Neurotol 2007;29:13–15. Nordang L, Anniko M: Hearing loss in relation to the round window membrane morphology in experimental chronic otitis media. ORL J Otorhinolaryngol Relat Spec 2001;63:333–340. Lee I-S, Park HJ, Shin JE, Jeong YS, Kwak HB, Lee YJ: Results of air caloric and other vestibular tests in patients with chronic otitis media. Clinical Exper Otolaryngol 2009;3:145–150. Wang MC, Liu C-Y, Yu EC, Wu H-J, Lee G-S: Vestibular evoked myogenic potentials in chronic otitis media before and after surgery. Acta Otolaryngol 2009;129:1206–1211.
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
1
© 2014 S. Karger AG, Basel 0301–1569/14/0756–0357$39.50/0 www.karger.com/orl
Original Paper
Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media Badr Eldin Mostafa a Amr Gouda Shafik a Aly M.N. El Makhzangy a Hesham Taha b Heba Mahmoud Abdel Mageed a Departments of a Otorhinolaryngology and b Audiology, Ain Shams University, Cairo, Egypt
Key Words Chronic suppurative otitis media · Vertigo · Vestibular testing · Vestibular function · Videonystagmography · Rotatory chair
Prof. Badr Eldin Mostafa Professor of ENT-HNS, Faculty of Medicine, Ain Shams University 34 a El Higaz Street Heliopolis, Cairo 11351 (Egypt) E-Mail bemostafa @ med.asu.edu.eg
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Abstract Objective: The objective of this study was to assess vestibular functions in patients with chronic suppurative otitis media (CSOM) with and without sensorineural hearing loss. Study Design: This was a prospective case study performed at a tertiary referral university hospital. Sixty patients with CSOM were included, and patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae were excluded. Patients and Methods: The patients underwent basic audiological evaluation, and clinical and instrumental vestibular evaluation. The incidence and extent of vestibular dysfunction in patients with CSOM were analyzed. Results: A total of 42 males and 16 females with a mean age of 29.5 years were included in this study. Forty ears had tubotympanic disease and 19 had cholesteatoma. There were 14 ears with sensorineural hearing loss. A positive history of vertigo was reported in 53.5% of the cases. Rotatory chair abnormalities were found in 70% of the cases, caloric hypofunction was found in 61.6%, and vestibular myogenic evoked potentials were abnormal in 25%. The only positive correlation with vestibular dysfunction was the duration of disease. Conclusions: The vestibular system is significantly affected in cases with CSOM. Both semicircular canals and the saccule are affected. All patients with long-standing CSOM should be evaluated for vestibular dysfunction irrespective © 2014 S. Karger AG, Basel of their hearing levels.
358
ORL 2013;75:357–360 DOI: 10.1159/000357475
© 2014 S. Karger AG, Basel www.karger.com/orl
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Introduction
Chronic suppurative otitis media (CSOM) can be associated with functional damage to the inner ear resulting in sensorineural hearing loss (SNHL) and dizziness. The same pathological factor diffusing through the round window can lead to an altered expression of proteins causing cochlear and vestibular damage [1–5]. The clinical effects of such damage are not widely reported and are extremely variable [6–8]. As vertigo and instability can negatively affect patients’ quality of life, assessment of vestibular function should be part of the functional evaluation of patients with CSOM. However, vestibular test abnormalities correlate poorly with a history of dizziness and vertigo [9, 10]. The objective of this work was to assess vestibular functions in patients with CSOM with and without SNHL. Patients and Methods This study included 60 patients with CSOM presenting at the Vestibular Unit of the El Demerdash Hospital, Ain Shams University, Cairo, Egypt, between April 2009 and August 2011. The study design and intervention were approved by the Institutional Review Board. We excluded patients with a history of head trauma, diabetes, hypertension, previous ear surgery, use of ototoxic drugs, neurological deficits and suspected fistulae. All patients underwent the following examinations: Audiological examination: In pure tone audiometry and speech audiometry, SNHL was considered if the averaged bone conduction threshold (500–4,000 Hz) was more than 25 dB in more than two frequencies and/or a deterioration in the SD score was found. Office vestibular tests: Spontaneous nystagmus, head impulse test (HIT), head shake test (HST), positional and positioning tests as well as examination of stance and gait were performed. Instrumental vestibular tests: (1) Infra-red videonystagmography (Charter v1.30, water caloric stimulator NCI 480): smooth pursuit, random saccade, gaze nystagmus, optokinetic nystagmus, and positional as well as positioning tests were conducted. A standard water bithermal caloric test (30–44 ° C, 60 s each) was performed after microscopic application of a polyethylene patch. A difference of >20% determined unilateral weakness. (2) Rotatory chair (controller model 300; Micromedical Technologies): gain, phase and symmetry were recorded for six different frequencies (0.01–0.64 Hz). The test was considered abnormal if the result of at least two frequencies fell outside the range of the normative data. (3) Computed dynamic posturography: sensory organization tests were performed in the six standard conditions (Neurocom Smart Equitest). (4) Vestibular evoked myogenic potential (MEB-530 4K, Neuropack; Nihon Kohden). Statistical Analysis We used the Sofastat software version 1.1.0. Numerical data were analyzed according to normality (Fisher’s exact test, χ2 test, Mann-Whitney test, Spearman’s rank test).
Of the included patients, 42 were males (67.4%) and 16 females (32.6%). The age of the patients ranged from 12 to 75 years (mean age 29.56 years). Forty-one ears had tubotympanic disease (68.3%), and 19 had atticoantral disease (31.7%). Vestibular symptoms were reported in 32 patients (53.5%) with no statistical difference between ears with and without cholesteatoma (Fisher’s exact test, p = 1.0, n.s.). There was a statistically significant correlation between the duration of the disease and the presence of vestibular symptoms (table 1). All office tests including HST and HIT were normal. There were 46 ears without SNHL (76.7%) and 14 with SNHL (23.3%). There was no statistically significant difference between ears with and without cholesteatoma (Fisher’s exact test, p = 0.163, n.s.). Vestibular ocular reflex tests were normal in all patients. Caloric
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Results
359
ORL 2013;75:357–360 © 2014 S. Karger AG, Basel www.karger.com/orl
DOI: 10.1159/000357475
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Table 1. Duration of disease vs. positive history of vertigo
Group
Median
Average rank
Min.
Max.
Negative (n = 20) Positive (n = 23)
2.0 6.0
18.6 24.957
0.0833333333333 0.0833333333333
40.0 33.0
The Mann-Whitney U test was used. A two-tailed p value of 0.097 was considered as statistical trend.
Table 2. Distribution of rotatory chair results in relation to chair frequencies
Phase shift
Normal Positive
Frequency 0.01
0.02
0.04
0.08
0.16
0.32
0.64
20 40
20 40
22 38
25 35
30 30
36 24
40 20
Pearson’s test of linear correlation was used. A two-tailed p value of 0.002 was considered significant.
weakness was reported in 37 patients (61.6%) but was statistically unrelated to vertigo or SNHL. The rotatory chair testing revealed a phase defect in 42 patients (70%). The rotatory chair results were statistically related to vertigo but not to SNHL. Furthermore, there was a reverse correlation between chair frequency and phase defect (table 2). There were 15 ears (25%) with delayed p13 and 12 (20%) with delayed n23 on cervical VEMP. The relationship between VEMP and vertigo or SNHL was statistically insignificant. All patients had normal response patterns on computed dynamic posturography. Of the 42 cases with chair abnormalities, 36 (60%) had caloric weakness and 27 (64.2%) had associated VEMP abnormalities. Fifteen patients had abnormalities in all three (35.7%). Of the 37 patients with caloric weakness, 27 (72.9%) had rotatory chair abnormalities. Of the patients with SNHL (14), 13 (92.8%) had chair abnormalities, 8 (57.1%) had caloric abnormalities, 7 (50%) all three abnormalities and 3 (21.4%) had VEMP abnormalities.
The same pathologic factors affecting neural hearing in CSOM can affect the vestibular system due to anatomical proximity [1–3]. Alterations in the endolymphatic duct and sac structure were found to correspond to time-dependent changes in the middle ear mucosa due to exposure to bacterial toxin [11]. The current study was performed in 60 patients with CSOM to determine the incidence of vestibular symptoms and vestibular test abnormalities. A positive history of dizziness was reported in 32 patients (53.5%). Only the duration of disease was associated with a complaint of vertigo and was close to statistical significance. On the contrary, testing revealed abnormalities in a much higher number. This may be due to gradual vestibular compensation [9]. Rotatory chair abnormalities were reported in 70.1% of the patients, caloric weakness was found in 61.6% and VEMPs were abnormal in 23.3% [9, 10, 12, 13]. Moreover, the relationship between vertigo and SNHL (57.1%) was just close to statistical significance [1, 3].
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
Discussion
360
ORL 2013;75:357–360 DOI: 10.1159/000357475
© 2014 S. Karger AG, Basel www.karger.com/orl
Mostafa et al.: Evaluation of Vestibular Function in Patients with Chronic Suppurative Otitis Media
Test results suggest involvement of the semicircular canals in the low frequency range as documented by the high-pass filter results on rotatory chair and the abnormal calorics. A higher frequency is apparently spared as evidenced by the normal HIT and HST results. The saccule may also be involved as documented by the VEMP abnormalities. These results are consistent with some form of hydrops affecting primarily the vestibular system [11]. Conclusion
Patients with long-standing otorrhea are more vulnerable to develop semicircular canals and saccular dysfunction independent of cochlear damage. Vestibular function must be assessed in such patients as they may suffer additional vestibular damage during surgery leading to decompensation and deterioration of their quality of life as a result of vertigo and instability.
References
2 3 4 5 6 7 8 9 10 11 12 13
Pajor A, Gryczynski M, Lukomski M, Jozefowicz-Korczynska M: Vestibular system in patients with sensorineural hearing loss. Otolaryngol Pol 2002;56:707–712. Papp Z, Rezes S, Jokay I, Sziklai I: Sensorineural hearing loss in chronic otitis media. Otol Neurotol 2003;24: 141–144. Redaelli de Zinis LO, Campovecchi C, Parrinello G, Antonelli AR: Predisposing factors for inner ear hearing loss association with chronic otitis media. Int J Audiol 2005;44:593–598. Takumida M, Anniko M: Localization of endotoxin in the inner ear following inoculation into the middle ear. Acta Otolaryngol 2004;124:772–777. Juhn S, Tsuprun V, Lee Y-W, Hunter B, Schachern P: Interaction between middle and inner ear in otitis media. Audiolog Med 2004;3:158–161. Pal’chun VT, Kunel’skaia NL, Petlinov AP: The vestibular function in patients with various forms of chronic purulent otitis media. Vestn Otorinolaringol 2004;6:13–17. Pal’chun VT, Kunel’skaia NL, Mironov AA, Ganichkina Iia, Petlinov AP: Myringoplasty and its effects on a vestibular function in patients with otitis media purulenta chronica. Vestn Otorinolaringol 2005;2:19–21. Siampara L, Mann SBS, Panda NK, Mehra YN: Audiovestibular profile in unilateral chronic suppurative otitis media. Ind J Otolaryngol Head Neck Surg 1997;49:107–111. Gianoli GJ, Soileau JS: Preoperative vestibular testing in chronic suppurative otitis media. Otolaryngol Head Neck Surg 2005;2:75–76. Gianoli GJ, Soileau JS: Chronic suppurative otitis media, caloric testing, and rotational chair testing. Otol Neurotol 2007;29:13–15. Nordang L, Anniko M: Hearing loss in relation to the round window membrane morphology in experimental chronic otitis media. ORL J Otorhinolaryngol Relat Spec 2001;63:333–340. Lee I-S, Park HJ, Shin JE, Jeong YS, Kwak HB, Lee YJ: Results of air caloric and other vestibular tests in patients with chronic otitis media. Clinical Exper Otolaryngol 2009;3:145–150. Wang MC, Liu C-Y, Yu EC, Wu H-J, Lee G-S: Vestibular evoked myogenic potentials in chronic otitis media before and after surgery. Acta Otolaryngol 2009;129:1206–1211.
Downloaded by: Selçuk Universitesi 193.255.248.150 - 1/27/2015 5:16:19 AM
1
