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Author: admin | 14.01.2016 | Category: Ginkgo Biloba Tinnitus

A much larger (and newer) temporal bone CT scan showing dehiscence of the R SCC, as pointed to by the green arrow. Roughly 2% of persons at autopsy are found to have thinning of bone, which is thought to predispose them to this syndrome (Carey et al, 2000; Hirvonen et al. Eye movements in this syndrome align with the superior canal (Ostrowski, Hain and Wiet, 1997; Cremer et al, 2000). Case example: a commercial airline pilot complained that on landing, the world would tilt 15 degrees to the side. Posterior canal dehiscence (PCD) is rarely reported compared to superior canal dehiscence, but nevertheless a few cases have been identified (Di Lella et al, 2007).
We have encountered a similar case in which there was both SCD and PCD on the same side, associated with exercise intolerance, conductive hyperacusis and an enlarged VEMP. A case of a fistula (air in labyrinth) was reported after cochlear implantation of the HiFocus II implant In this case, vertigo occurred after the patient blew his nose.
There are also patients who can indicate that their voice sounds louder than normal to them. Dehiscence, being a bone defect, is nearly always diagnosed using a high resolution temporal bone CT scan.
Case example: In the man shown in figures 3 and 4, 10 seconds of straining produced a very powerful torsional nystagmus (and a lot of dizziness).
A fistula test , which entails making a sensitive recording of eye movements while pressurizing each ear canal with a rubber bulb, is occasionally helpful.
A strong nystagmus (vertical and rotatory) may be produced by pressure in the external ear canal.
Simple observation of the patient's eyes with appropriate equipment (such as video frenzel goggle) may also provide the diagnosis, as in some cases, there is a pulse-synchronous oscillation (Rambold, 2001; Hain et al, 2008), see videos below and case 2. Figure 5 left: VEMP obtained in an individual shown in figure 3, who has left sided superior canal dehiscence, using a Bio-Logic Navigator Pro. Audiometry is generally done as a preliminary test, and an alert audiologist who knows about SCD may make the diagnosis on the spot. Figure 4: Coronal CT scan of the temporal bone clearly showing missing bone at the top of the left anterior (superior) semicircular bone. A CT scan of the temporal bone should generally be obtained in persons with sound or pressure sensitivity. Conventional CT scans of the brain are nearly always useless to diagnose SCD as their cut resolution is 8-10mm -- this is almost as big as the entire inner ear !
Reformatted sagittal views are essential for the situation where there is no direct coronal.
Because the posterior canal on each side is perpendicular to the ipsilateral superior canal, oblique reformats allow the clinician to check for dehiscence in all canals.
DO NOT PROCEED If you cannot perform a CT scan of the temporal bone with a resolution of 0.6 mm or less.
A properly done MRI can rule out SCD, as well as point strongly towards SCD (Browaeys et al, 2013). An example of a coronal with no SCD is here (T2, 4 mm cut size): Note that there is space between the loop of the canal and the brain. Basically, one can either do nothing and avoid things that make you dizzy, or you can get an operation.
Conservative approach: Dehiscence is not likely to resolve on it's own, so the real choice is between adjusting ones life, or having surgery done. Surgical treatment of Superior Canal Dehiscence (see next section on caution regarding otologic surgeons). Capping refers to closing of the opening made for the plugging with cement, or closing of the dehiscence with cement. The closing of the dehiscence using a bone or fibrous tissue graft (roofing, resurfacing) appears to be the riskier procedure -- sometimes dura is stuck to the membranes of the inner ear and an attempted repair results in deafness instead. In our own practice, Chicago Dizziness and Hearing in Chicago Illinois, we have accumulated 92 SCD patients in our database over the last few years. Patients who undergo surgery are unsteady for roughly 6 weeks after the repair (Janky et al, 2012).
Before you proceed surgical treatment for SCD, be sure you get an opinion from an expert who is not an otologic surgeon, preferably at another institution. You should pick otologic surgeons who are experienced, mature, trustworthy, and well trained. While the diagnosis of SCD has become much easier in recent years, treatment has lagged behind. Browaeys P, Larson TL, Wong ML, Patel U.Can MRI replace CT in evaluating semicircular canal dehiscence?

Van Haesendonck G1,2, Van de Heyning P1,2, Van Rompaey V1,2.Retrospective cohort study on hearing outcome after transmastoid plugging in superior semicircular canal dehiscence syndrome.
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Radiology studies show that the thickness of the SCC decreases with advancing age as well (Davey et al, 2015).
When asked, she said that ever since her fenestration surgery in the 1940's, she had gotten dizzy from loud noses.
It was suggested that the connective tissue seal between the electrode and positioner extends into the tympanic cavity and predisposes this type of implant to this type of fistula (Hempel et al, 2004). Other tests, not involving X-rays, may provide a clue that an temporal bone CT is indicated.
We are less enthused about technique as it is very hard to keep the sclera in view while the patient iDevices and Printers - Shortcut (2)s undergoing a maneuver. This sign is not unusual, but it usually requires either use of an ophthalmoscope or video frensel goggles to see it. This can easily be missed as audiologists just assume that one can't hear better than '0' dB, and don't always test the patient thoroughly. These sound evoked vestibulocollic evoked potentials have been described as useful in diagnosing Tullio's phenomenon (sound induced dizziness) from superior canal dehiscence (Brantberg et al, 1999; Watson et al, 2000). However, as VEMP's are present in SCD, but absent in conductive hearing loss, it is easy to tell these two apart. Also a downbeating nystagmus may be seen on positional testing, which resembles that of anterior canal BPPV.
Temporal bone CT scans need a lot of X-ray radiation to see through the hard bone of the temporal area. Event triggered averaging is used to detect electro-oculographic responses to loud clicks -- intensities ranging from 80 to 110 Db.
Avoid loud nose -- for example, if you play a musical instrument, better find another hobby or get used to being dizzy. Avoid pressure fluctuations between your ear and the rest of your body -- this isn't easy, as nearly any type of exertion has the potential for producing pressure fluctuation. Avoid pressure fluctuations between your middle ear and external ear -- in other words, avoid situations where your ear might pop.
This positive effect is due to reduced movement of the tympanic membrane, ossicular chain, and stapes footplate, and therebye reduction of pressure on the middle ear.
Medications are not terribly useful, but those in the benzodiazepine family are sometimes helpful. On examination he was noted to have both a positional nystagmus (downbeating) as well as pulse-synchronous nystagmus (see video above).
The treatment of a dehiscence generally involves either closing the dehiscence (resurfacing or capping) or plugging of the canal.
Results are claimed to be good (Mikulec et al, 2005), although in a condition like this without clear cut objective endpoints, it might be difficult to be sure.
It eliminates the stiumulation of the superior canal by pressure, and also eliminates the normal function of the superior canal on one side. This procedure is intermediate in effectiveness compared to plugging (Vlastarkos et al, 2009). Roofing however would seem to be the only truly logical approach to the hyperacusis of SCD. We diagnose a new patient based either on office exam (Valsalva) or VEMP results followed by a temporal-bone CT scan (see comments).
We have encountered a few patients who have had plugging done by very experienced surgeons, in which it appeared that more damage was done than intended. The basic idea is that pressure changes in the inner ear can cause fluid shifts only if there there is a place for the fluid to go.
Silverstein and Van Ess reported a single case in which this approach was successful (Silverstein and Van Ess, 2009). Subarcuate venous malformation causing audio-vestibular symptoms similar to those in superior canal dehiscence syndrome. Complete round window niche occlusion for superior semicircular canal dehiscence syndrome: a minimally invasive approach. Endolymphatic hydrops in superior canal dehiscence and large vestibular aqueduct syndromes. In superior canal dehiscence (SCD) bone is missing over the top (superior) semicircular canal, uncovering a membrane.
These conditions are generally recognized because pressure in the ear, changes in intrathoracic pressure, or loud noises can cause strong vertigo and jumping of the eyes (nystagmus).

It is thought that there is a failure of postnatal bone development, resulting in thin roofs of the superior canals.
This suggests that SCD is at least part an acquired condition, and also that it should get worse with age. PCD is identified using high-resolution CT scans, either with axial cuts, or with cuts in the plane of the PC. One would think instead that this highly unlikely jutaxposition of dehiscences in two different canals would be due to a congenital maldevelopment of the inner ear.
More commonly autophony is caused by a patulous eustachian tube, which is another subject entirely. One also has to think of it (: this is usually the hard part) The main confounding possibility is oculopalatal myoclonus, which causes a similar but non-pulse synchronous oscillation. The side with the larger VEMP (figure 5 left) or lower threshold (figure 5 right) is the abnormal side. One might argue that the tiny lesions that can be discovered with 0.1 mm cuts are not worth the radiation load.
Better are oblique reformats parallel to and perpendicular to the plane of the superior semicircular canals.
Again, there is no real danger (other than that of falling or driving off the road), but you might get pretty dizzy. A VEMP was abnormal and this was followed by a temporal-bone CT scan which documented clear superior canal dehiscence. Roofing (resurfacing) can also lead to recurrent symptoms due to shifting or resorption of the bone. It may be that plugging can sometimes lead to collateral damage and occlusion of more canals than anticipated.
The operative approach was do to a very thorough closure of the round window, using 3 layers. In the past, a somewhat similar condition to SCD (perilymph fistula), was associated with an immense surge in operations, many later determined to be inappropriate.
While similar to a perilymph fistula, these conditions are generally less bothersome than than the oval or round window fistulae, perhaps because fluid is generally not in direct communication with an air-filled cavity, but a membrane is present which maintains a seal.
The thin bone is worn down by age, and can be broken by minor trauma (Teixido et al, 2012). The image above shows an example of a person with dehiscence in both the AC and PC, and cuts in the plane of the canals.
The image above shows a man with SCD identified from his very large VEMP on the right side.
Weight lifting, straining to do things, strenuous sexual activity - -these are all things that might cause trouble. As the dehiscence may include the entire top of the superior canal, one would wonder how the surgeon can successfully plug the canal through this route.
This is essentially what is done in perilymph fistula surgery, but using a more vigorous approach.
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As it is known that about 2% of the population has thinning of the bone that can lead to SCD, our estimate is that a reasonable estimate of prevalence of symptomatic SCD is about 0.1% of the population. However, if a patient complains of dizziness during tympanometry, this is a clue that the patient has a positive pressure test. Although resolution is not quite as good as with direct coronal, the radiation load is half compared to the protocol that combines direct axials and coronals, and we think that this is a reasonable compromise.
While better exposure is attained through the middle fossa, it is riskier overall as it involves entering the cranial vault and lifting up the dura. This is an evolving situation as of 2013, and the surgeon's experience with the technique must also be considered.
This leads us to continue to be conservative regarding recommendations for surgical intervention.
When there is abnormal pressure presented to the opening in SCD, presumably the round window also moves back and forth and faciliates fluid movement. Several otolaryngologists have suggested that closing the round window, might be a successful treatment of SCD. The advantage of this method is that it is much less invasive than either the plugging or resurfacing approaches.

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