A Young Patient with Horizontal Semicircular Cupulolithiasis with Immediate Response to the Therapeutic Head-Shaking Maneuver (HSM)

The apogeotropic variant of horizontal semicircular canal benign paroxysmal positional vertigo is attributed to either short anterior ampullary arm canalolithiasis or to the cupulolithiasis with the otoconial debris adhering to the cupula on utricular (Cup-U) or canal side (Cup-C), rendering it heavy and gravity sensitive. The treatment options for horizontal semicircular cupulolithiasis are not very well defined. A 25-year-old female patient with 8 days history of vertigo on rolling to either of the lateral recumbent position presented in the first week of November 2019. The supine roll test (SRT) on yawing head maximally to the right as well as to the left elicited an apogeotropic horizontal positional nystagmus lasting more than 1 minute, which was stronger on the right side and indicated a diagnosis of left horizontal semicircular cupulolithiasis. Two short-term follow-ups at 1 and 24 hours after head-shaking maneuver (HSM), with verifying SRT, were undertaken. During either of the two follow-ups, neither the previously elicited horizontal positional nystagmus was observed, nor did the patient have vertigo on rolling to lateral recumbent positions. She was telephonically questioned weekly regarding the recurrence of rotational vertigo for the next 4 weeks, and it was confirmed that she remained symptom free till then. The therapeutic HSM, owing to the inertial forces generated, can detach the otoconial debris from the cupula that renders it heavy and gravity sensitive. Successful offloading of cupula by HSM brings immediate cure in the Cup-U variant of the horizontal semicircular cupulolithiasis.

Physical Therapy for the Horizontal Semicircular Cupulolithiasis: A Prospective Interventional Case Series from an Otoneurology Center in South Rajasthan, India

Objective This article aims to study the effect of physical therapy in patients of horizontal semicircular cupulolithiasis with results audited in the short term. Design Nonrandomized prospective interventional study. Study Sample Four patients with horizontal semicircular cupulolithiasis. Results All four patients in whom diagnostic supine roll test (carried at least thrice to look for the sustainability as well as the polarity of the nystagmus) elicited apogeotropic horizontal positional nystagmus lasting more than 1 minute were subjected to therapeutic head-shaking maneuver (HSM). The results were audited immediately after the physical therapy, and at 1 hour. Follow-up by telephonic interviews for 4 weeks was done in all patients. Three out of four patients responded to HSM alone. One patient who did not respond to HSM was successfully treated with four other sequent physical therapies. Conclusion The response of physical therapy for horizontal semicircular cupulolithiasis occasionally indicates the side of the cupula to which otoconial debris is adherent (Cup-U or Cup-C). Occasionally, Cup-C variant of horizontal semicircular cupulolithiasis can be transformed by physical therapy to long posterior arm horizontal semicircular canalolithiasis—a disorder with better established treatment options.

Unilateral Multicanalicular Vestibular Lithiasis of Right Horizontal and Posterior Semicircular Canals: An Unusual Case

Vestibular lithiasis (canalolithiasis as well as cupulolithiasis) commonly exists in monocanalicular forms involving one of the three semicircular canals, frequent posterior, less frequent horizontal, and very rarely anterior. It is treated with canal clearing maneuvers intended to reposition the otoconia from the semicircular canal (where they have inappropriately entered) through the utricular exit in the nonampullary arm of the semicircular canal to the utricle (where they normally remain as a part of utricular gelatinous matrix). The cases of multicanalicular vestibular lithiasis with the involvement of more than one semicircular canal require meticulous identification of the involved canals and multiple different canal-clearing maneuvers for effective treatment. A 70-year-old male patient with no significant history of previous medical or otologic illnesses or head trauma presented with a 1-day history of vertigo with positional aggravation. A one-time performed diagnostic supine head roll test elicited three different patterns of positional nystagmus, each with an accurate localizing and lateralizing value. Diagnosis of unilateral multicanalicular vestibular lithiasis of right horizontal and posterior semicircular canals was entertained based on the pattern of the elicited positional nystagmi on the supine roll test. The upbeating torsional nystagmus that localizes the involvement to the posterior semicircular canal was paradoxically elicited by supine head roll test and not by the Dix–Hallpike test. As horizontal semicircular canalolithiasis causes severe symptoms, its treatment preceded that of concurrent posterior semicircular canalolithiasis. The patient was successfully treated with multiple sessions of canalith repositioning maneuvers (CRMs) spread over 24 hours. It is important to perform both positional tests, namely Dix–Hallpike maneuver, and supine head roll test, in cases suspected to have multicanalicular vestibular lithiasis. The positionings may need to be repeated several times to unveil multiple nystagmi, each with different localizing and lateralizing values. Identifying treatment priorities with CRM for the individual semicircular canals is crucial, and the canal that is liable to cause severe symptoms needs early clearance of the otoconial debris. If a CRM fails to clear a semicircular canal, an alternative maneuver may need to be executed. Clinicians involved in the care of cases with multicanalicular vestibular lithiasis should be well versed with all possible backup maneuvers for clearing each of the three semicircular canals.

Primary Malignant Melanoma Limited to the External Auditory Canal: A Rare Presentation

Malignant melanoma limited to the external auditory canal is very rare. These patients present relatively late as compared with melanoma involving other subsites of external ear. However, the tumor is slow-growing but shows aggressive behavior with a poor prognosis when presented late. We have a 44-year-old female who presented with a blackish lesion, which was bleeding on and off from her left ear. She was managed with wide local excision, preserving maximum part of external auditory canal cartilage. The histopathology of the lesion was suggestive of malignant melanoma. After a thorough evaluation, she was kept under close follow-up. Malignant melanoma of external auditory canal shows poor prognosis usually, mainly because of late presentation. Thus, early diagnosis is crucial, as in our case, where wide local excision was sufficing, and the patient is disease-free after 4 years of follow-up.

Association of Passive Smoking with Otitis Media among School Children of Eastern Nepal

Introduction Otitis media (OM) and otitis media with effusion are commonly presenting conditions in an otolaryngology clinic. Exposure to passive smoking is thought to increase the risk of OM through an effect on mucociliary clearance, decreased ciliary beat frequency, or mucous hypersecretion. Awareness among parents plays a key role in the primary prevention of the disease. Objective We aimed to identify the association of passive smoking with OM among school-going children of the eastern region of Nepal. Methods A community-based cross-sectional study was done among 663 school-going children, selected by stratified random sampling using a questionnaire. Data regarding age, gender, type of school, otological symptoms, smoking status of parents and family members, otoscopic findings, pure tone audiometry, and impedance audiometry were recorded. Results Six-hundred and sixty-three students were included in the study. OM was confirmed in 103 students (15.5%). Smoking history was present in at least one of the family members in 177 out of 663 students (26.69%) and with positive smoking history in any member of the family, OM was seen in 65 (36.7%) students (p ≤ 0.001), which suggested significant association. OM was seen in 38 students (7.8%) when there was no exposure to passive smoking. Conclusions There is a high prevalence of OM (15.5%) in school-going children. The study shows significant association between passive smoking and OM in children.

Cochlear Model for the Evaluation of MRI Sequences and Cochlear Implant Electrode Pattern at 3T

Introduction Cochlear implant (CI) magnets and surgical techniques (e.g., positioning) have made an impact on the relationship between CI and magnetic resonance imaging (MRI) by solving the problem of pain and artifact. Recent investigations displayed the possibility to evaluate the CI electrode position by MRI in vivo. However, further improved perceptual quality is needed to allow an improved evaluation of the electrode. Aims The aim of this study was to assess a cochlear model for the examination of CI electrode pattern and MRI sequences in vitro. Materials and Methods We investigated CI electrodes in a fluid-filled three-dimensional artificial scala tympani model combined with a fluid package in a 3T MRI scanner. Different high-resolution T2 sequences (0.6–0.2 mm voxel size) were used for the visual electrode pattern evaluation for finding an optimized sequence. Results Artificial models can be used to evaluate MRI characteristics of CI electrodes. In our scanner configuration, a 0.3 mm voxel and 0.9 mm slice thickness sequence showed the best compromise between resolution and scanning time. Conclusion and Significance MRI model-based testing can be performed in vitro to evaluate CI electrodes’ pattern and to optimize sequences. An MRI model is a tool for in vitro testing of MRI sequences and might help for future in vivo applications.

Ramsay Hunt Syndrome: Viral Infection Coexisting with COVID-19

Severe acute respiratory syndrome coronavirus 2 presents with a multitude of different symptoms and signs, most described is respiratory compromise. Many viral and bacterial infections coexist with coronavirus disease 2019 (COVID-19). Many cranial neuropathies have also been reported, including facial nerve palsy and sudden sensorineural hearing loss individually. Ramsay Hunt Syndrome, which is conventionally described as acute peripheral facial neuropathy, associated with erythematous vesicular rash of pinna or external auditory canal can at times present with cochlear or vestibular symptoms along with it. We report the case of a 32-year-old male who presented with Ramsay Hunt syndrome with cochlear manifestation during his COVID-19 illness. Evaluation of the patient and further management have been described.

Mastoid Obliteration Using Bioactive Glass—Our Experience

Aims The aim of this study was to evaluate the surgical outcome of cavity obliteration with bioactive glass in patients with cholesteatoma undergoing canal wall down mastoidectomy with reconstruction of the canal wall. Materials and Methods A prospective study was conducted over a period of 3 years on 25 patients who underwent mastoid obliteration with bioactive glass following canal wall down mastoidectomy for cholesteatoma. The primary outcome measure was the presence of a dry, low-maintenance mastoid cavity that was free of infection, assessed, and graded according to the grading system by Merchant et al at the end of 1 and 6 months postoperatively. Secondary outcome measures included presence of postoperative complications like wound infection, posterior canal wall bulge, and residual perforation. Results Out of the 25 patients on whom this study was conducted, at the end of 1 month 60% had a completely dry ear, 28% of patients had grade 1, and 12% had grade 2 otorrhea at the end of the first month. At the end of 6 months, 72% had a completely dry ear, while 20% had grade 1 and 8% had grade 2 otorrhea. There were no cases with grade 3 otorrhea during the entire follow-up period. Postoperative complications of the posterior canal bulge were noted in two patients (8%), and one patient (4%) had a residual perforation. Conclusion Mastoid cavity obliteration with bioactive glass is an effective technique to avoid cavity problems.

MRI T2-Weighted Cochlear Intensity as a Predictor of Hearing Loss with Vestibular Schwannoma Patients

Objective It is difficult to predict how hearing loss will progress with vestibular schwannomas (VSs) and to determine the optimal time for hearing preservation interventions. This study investigated the relationship between cochlear intensity on T2-weighted magnetic resonance imaging and hearing loss in VS patients over time. Design Retrospective cohort study. Setting Single major academic center. Participants Patients with a diagnosis of VS from 2007 to 2018. Main Outcome Measures Pure tone average (PTA) and cochlear-to-pontine relative signal intensity (RSI) measured at two time points. Results Fifty patients were included in the final analysis. For both affected and unaffected ears, the trend in PTA increased from baseline to follow-up. For affected ears, the trend in RSI increased from baseline to follow-up, while for the unaffected ears RSI decreased. There was a significant positive correlation between the initial RSI value in the ipsilateral ear when compared with the change in PTA from baseline to follow-up (r = 0.28, p = 0.048). Conclusion There is a trend between initial RSI and how hearing changes in the affected ears of patients with VS. Additional studies are needed to explore how this relationship may be better used to predict hearing loss.

Effect of Epidermal Growth Factor with Silastic Scaffold on Tympanic Membrane Perforations of Chronic Otitis Media

Aims The burden of chronic otitis media continues to be high, especially in developing countries. The demand for corrective procedure of surgical myringoplasty, which is considered the gold standard for tympanic membrane perforations, is also growing. Hence, there is a need to innovate simpler alternative office procedures that could save effort, time, waiting period, and expenditure. Materials and Methods This prospective study of 84 patients with mucosal chronic otitis media was undertaken in a tertiary referral hospital. All patients underwent eustachian tube function test, diagnostic nasal endoscopy, and pure tone audiometry. The size of the perforation was assessed endoscopically. All perforations were freshened first with silver nitrate solution. Silastic pieces were placed medial and lateral to the perforation with epidermal growth factor gel in between. Patients were followed up for 3 months. Results The perforations were classified into three groups (healed, partially healed, and nonhealed) based on the treatment response at the end of the first and third follow-up months. Completely healed and partially healed perforations were considered as “success” and were found to be 79% in this study. Significant association was found between healing status and type of anesthesia. However, the disease stage, size of perforation, and the duration of procedure did not affect the healing status. Conclusion Silastic enhanced myringoplasty with epidermal growth factor is a simple, effective, and economical procedure that can become an alternative to surgical myringoplasty for chronic otitis media.