Biomedical subjects

Michael J Ruckenstein

Publications and source records attributed to Michael J Ruckenstein.

11 recordsLinked to original sources

PubMed2006

Ossiculoplasty.

Contemporary surgical techniques for treating various pathologies affecting the middle ear address not only eradication of the underlying disease process but also restoration of normal auditory function. Trauma, neoplasms, inflammatory processes, and cholesteatomas can erode and alter normal middle ear components and relationships vital for the transmission of auditory energy to the inner ear. Over the last five decades, various ossiculoplasty techniques and prostheses have been studied and reported in the literature. Unfortunately, the multitude of reconstructive techniques attests to the fact that none of the currently available methods are ideal.

Biomechanical Phenomena↗

PubMed2005

Chronic dizziness and anxiety: effect of course of illness on treatment outcome.

OBJECTIVE: To investigate the hypothesis that the efficacy of selective serotonin reuptake inhibitors (SSRIs) for chronic subjective dizziness (CSD) and anxiety depends on the longitudinal pattern of the patients' symptoms. DESIGN: Prospective cohort study. SETTING: Tertiary care, multidisciplinary, balance center. PATIENTS: Eighty-eight consecutive patients treated with an SSRI for CSD and anxiety between 1998 and 2003. All patients were referred for evaluation of unremitting dizziness. They entered SSRI treatment after comprehensive neurotologic and psychiatric evaluations revealed a syndrome of CSD with accompanying anxiety. Patients were separated into 3 groups according to their longitudinal patterns of illness: (1) otogenic, defined as primary neurotologic conditions triggering secondary anxiety disorders; (2) psychogenic, defined as anxiety disorders alone causing dizziness; and (3) interactive, defined neurotologic conditions exacerbating preexisting anxiety. INTERVENTIONS: Patients with CSD were treated with an SSRI according to an established protocol for at least 8 weeks or until they proved intolerant to medication. MAIN OUTCOME MEASURES: Changes in dizziness and anxiety as measured by the Clinical Global Impressions-Improvement scale. RESULTS: Patients with the otogenic and psychogenic patterns of illness had a more complete response to SSRI treatment than did patients in the interactive group (P<.01). Rates of SSRI intolerance were similar for all 3 groups. CONCLUSIONS: Selective serotonin reuptake inhibitors are effective for patients with CSD and anxiety. However, patients with clinically significant anxiety predating neurotologic illness may require more intensive interventions.

Adolescent↗

PubMed2005

Antiphospholipid inner ear syndrome.

OBJECTIVE: This study was initiated to clarify the possible association between antiphospholipid antibodies, mediators of microthrombus formation, and sensorineural hearing loss (SNHL) of unknown origin in a large cohort of patients. STUDY DESIGN: Prospective study. METHODS: The study cohort consists of 168 adult patients (>/=18 yr) referred to the University of Pennsylvania's Division of Neurotology and Balance Center for diagnosis and treatment of progressive hearing loss with or without vertigo. A comprehensive screening panel of blood tests for autoimmune and infectious diseases was applied to all patients, including testing for anticardiolipin antibodies, anti-B2 glycoprotein, and lupus anticoagulant. RESULTS: Forty-two patients (25%) had at least one elevated antiphospholipid antibody marker. Twenty patients had two or more positive test results. Of the 42 patients, 64% (n = 27) met the diagnostic criteria for Meniere disease, and the remainder were diagnosed with idiopathic SNHL. Within this group of patients, 24 patients (57%) had unilateral hearing loss, and 18 (44%) had bilateral hearing loss. CONCLUSIONS: These data support the hypothesis that antiphospholipid antibodies are involved in the pathogenesis of some forms of inner ear dysfunction, presumably by causing microthrombus formation in the labyrinthine vasculature. Basic science studies are required to better understand the mechanisms by which antiphospholipid antibodies mediate inner ear dysfunction. Clinical studies to evaluate the efficacy of anticoagulation in this group of patients are also required.

Antibodies, Anticardiolipin↗

PubMed2004

A prospective trial of sertraline for chronic subjective dizziness.

OBJECTIVES/HYPOTHESIS: The authors previously reported that selective serotonin reuptake inhibitors (SSRIs) reduce chronic subjective dizziness in patients with and without psychiatric illnesses. To extend those preliminary findings and test the hypothesis that SSRIs may offer a novel treatment for chronic subjective dizziness, the authors conducted a prospective study of sertraline in patients with dizziness for more than 6 months, in the absence of active physical neurotologic illness. STUDY DESIGN: Sixteen-week, prospective, open-label, flexible-dose clinical trial. METHODS: Twenty-four patients with subjective dizziness for more than 6 months and no active physical neurotologic illness were studied. Eighteen patients had major anxiety disorders. Six had minor frustration or worry that did not warrant a psychiatric diagnosis. Sertraline was administered at a daily dose of 25 mg, which was increased to a maximum daily dose of 200 mg. Dizziness, functional impairment, and psychological distress were measured using the Dizziness Handicap Inventory (DHI) and Brief Symptom Inventory-53 (BSI-53). Treatment outcomes were analyzed using repeated-measures multivariate analyses of variance, with last observations carried forward. RESULTS: Three patients were excluded from data analysis for disqualifying medical conditions, one for protocol violations. Fifteen (75%) patients completed treatment. Five (25%) withdrew for adverse effects or lack of efficacy. The median daily dose of sertraline was 100 mg. Sertraline significantly reduced scores on all three DHI subscales and the BSI-53. Eleven of 15 (73%) patients who completed treatment had a positive response, including 8 of 11 (73%) with major anxiety disorders and 3 of 4 (75%) with no psychopathological conditions. Six patients enjoyed a full remission of symptoms. CONCLUSION: Sertraline significantly reduced chronic subjective dizziness in patients without active physical neurotologic illness, including those with and without psychiatric comorbidity.

Adult↗

PubMed2004

Autoimmune inner ear disease.

PURPOSE OF REVIEW: The role of the immune system in mediating inner ear pathology has received considerable attention over the past two decades. The purpose of this paper is to summarize recent basic science research into the pathogenesis of autoimmune inner ear disease (AIED), review the current diagnostic work-up for patients with suspected AIED, and delineate treatment strategies. RECENT FINDINGS: Basic science and clinical studies have been performed to delineate the mechanisms by which autoimmune processes may affect the ear and to develop treatment strategies to reverse this pathology. AIED refers to a rapidly progressive (over a course of weeks to months) sensorineural hearing loss that responds to the administration of corticosteroids. In addition, systemic autoimmune diseases (eg, vasculitides, lupus, Wegener granulomatosis) can secondarily affect the inner ear. Although a number of diagnostic tests for AIED have been advocated, the diagnosis of this entity is still predicated on a positive therapeutic response to corticosteroid administration. Alternate immunosuppressive regimens, designed to be used in patients who cannot be weaned off corticosteroids or whose disease becomes refractory to treatment, have proven to be difficult to develop. Methotrexate, which initially showed promise, has recently been shown to be ineffective in preventing progression of hearing loss. Further research is required to better delineate the pathophysiologic mechanisms involved in AIED and to establish more effective and better tolerated treatment regimens. SUMMARY: The original enthusiasm that was generated by the concept that immune-mediated mechanisms may mediate reversible forms of inner ear pathology has been tempered by the realities conveyed by scientific research. The pathophysiology of AIED is still not well understood. Multiple potential mechanisms have been identified that can result in immune-mediated inner ear pathology. The diagnosis of AIED is based on clinical presentation and response to the administration of corticosteroids. Diagnostic testing may support the diagnosis, and the results of a recent multicenter study should clarify the role of immunologic testing in the diagnosis of this entity. Treatment options are limited, with corticosteroids being the only validated treatment option, and methotrexate offering no significant benefit to patients. The role of cyclophosphamide is restricted to patients willing to endure the attendant risks. With the advent of cochlear implants, the administration of toxic medications to preserve hearing at all costs is a less desirable option.

Adrenal Cortex Hormones↗

PubMed2003

Which comes first? Psychogenic dizziness versus otogenic anxiety.

SUMMARY: OBJECTIVE To investigate the hypotheses that physical neurotologic conditions may trigger anxiety disorders (otogenic pattern of illness), that psychiatric disorders may produce dizziness (psychogenic pattern), and that risk factors for these syndromes may be identified. STUDY DESIGN Retrospective review of all patients (N = 132) treated at a tertiary care balance center from 1998 to 2002 for psychogenic dizziness with or without physical neurotologic illnesses. METHODS All patients underwent comprehensive neurotologic and psychiatric evaluations with attention to the longitudinal course of symptoms and risk factors for psychopathology. Patients were grouped according to the condition first causing dizziness. Risk factors were compared across groups. RESULTS Three equally prevalent patterns of illness were found: anxiety disorders as the sole cause of dizziness (33% of cases), neurotologic conditions exacerbating preexisting psychiatric disorders (34%), and neurotologic conditions triggering new anxiety or depressive disorders (33%). Panic disorder and agoraphobia were significantly more prevalent than less severe phobias in the first two groups, whereas the opposite pattern existed in the third group (P <.0001). More patients in the first two groups had risk factors for anxiety disorders (P <.05). Depression was not a primary cause of dizziness in any patient. Vestibular neuronitis, benign paroxysmal positional vertigo, and migraine were the most common neurotologic conditions. CONCLUSIONS These data support the hypothesis that physical neurotologic conditions may trigger psychopathology as often as primary anxiety disorders cause dizziness. A third pattern appears to be equally common wherein physical neurotologic conditions exacerbate preexisting psychiatric illnesses. Individuals at risk for anxiety disorders may be more likely to have primary psychopathology.

Adolescent↗

PubMed2003

Dehiscence of bone overlying the superior canal as a cause of apparent conductive hearing loss.

OBJECTIVE: To identify patients with superior semicircular canal dehiscence and apparent conductive hearing loss and to define the cause of the air-bone gap. STUDY DESIGN: Prospective study of patients with superior canal dehiscence. SETTING Tertiary referral center. PATIENTS: Vestibular and/or auditory findings indicative of canal dehiscence and demonstration of superior canal dehiscence on computed tomography of the temporal bone. INTERVENTION: Vestibular-evoked myogenic potentials, three-dimensional eye movement recordings, and surgical resurfacing of the superior canal. OUTCOME MEASURE: Association of superior canal dehiscence with an air-bone gap on audiometry. RESULTS: Four patients with dehiscence of bone overlying the superior canal were found to have air-bone gaps in the affected ears that were greatest at lower frequencies and averaged 24 +/- 7 dB over the frequency range of 250 to 4,000 Hz. Three of these patients had undergone stapedectomy before the identification of superior canal dehiscence. The air-bone gap was unchanged postoperatively. Each patient had an intact vestibular-evoked myogenic potential (VEMP) response from the affected ear, a finding that would not have been expected based on a middle ear cause of conductive hearing loss. One patient underwent resurfacing of the superior canal through a middle fossa approach. Postoperatively, his vestibular symptoms were relieved, and his air conduction thresholds were improved by 20 dB. CONCLUSIONS: Superior canal dehiscence can result in apparent conductive hearing loss. The third mobile window created by the dehiscent superior canal results in dissipation of acoustic energy and is a cause of inner ear conductive hearing loss.

Adult↗

PubMed2003

The efficacy of corticosteroids in restoring hearing in patients undergoing conservative management of acoustic neuromas.

OBJECTIVE: To evaluate the role of corticosteroids in restoring hearing in patients undergoing conservative management of acoustic neuromas. STUDY DESIGN: Prospective cohort. SETTING: Tertiary referral center. PATIENTS: Seven patients with acute hearing loss secondary to an acoustic neuroma. INTERVENTION: Oral prednisone (1 mg/kg for 1 to 2 weeks) within a week of onset of hearing loss. MAIN OUTCOME MEASURES: Audiometric assessment at the time of presentation and after corticosteroid therapy. RESULTS: All seven patients had pure tone reception threshold improvements ranging from 10 to 50 dB in at least two frequencies or more. Speech discrimination thresholds improved after therapy in all seven patients, with gains of 4 to 38% points. CONCLUSIONS: Patients with acoustic neuromas who are being treated with a "watchful waiting" approach should receive corticosteroid treatment at the first signs of hearing deterioration. An evaluation to rule out a retrocochlear lesion is mandated in patients with sudden hearing loss, regardless of whether the hearing loss responds to corticosteroid treatment. Older data documenting the efficacy of corticosteroids in the treatment of sudden hearing loss may need to be reevaluated, given that many of these studies were conducted before MRI was available.

Adult↗

PubMed2002

Serotonin reuptake inhibitors for dizziness with psychiatric symptoms.

OBJECTIVE: To investigate the efficacy and tolerability of selective serotonin reuptake inhibitors (SSRIs) for the treatment of patients with dizziness and major or minor psychiatric symptoms, with or without neurotologic illnesses. DESIGN: Review of 60 consecutive cases of patients with dizziness who were treated with an SSRI for at least 20 weeks during the 30-month period from July 1998 to December 2000. SETTING: Tertiary care, multidisciplinary referral center. PATIENTS: Sixty men and women, aged 13 to 81 years, with (1) psychogenic dizziness, (2) dizziness due to a neurotologic condition, as well as significant psychiatric symptoms, or (3) idiopathic dizziness. INTERVENTIONS: Open-label treatment with an SSRI titrated to 1 of 3 end points: optimal clinical benefit, intolerable adverse effects, or no therapeutic response. MAIN OUTCOME MEASURE: Change in dizziness and psychiatric symptoms measured by the 7-point, clinician-rated, Clinical Global Impressions-Improvement Scale. RESULTS: Thirty-eight (63%) of 60 patients in the intent-to-treat sample and 32 (84%) of 38 patients who completed treatment improved substantially. The response rates did not differ between patients with major psychiatric disorders and those with lesser psychiatric symptoms. Patients whose only diagnosis was a psychiatric disorder and those with coexisting peripheral vestibular conditions or migraine headaches fared better than patients with central nervous system deficits. Before being treated with an SSRI, two thirds of the study patients took meclizine hydrochloride and/or benzodiazepines, with minimal benefit. CONCLUSIONS: Treatment with SSRIs relieved dizziness in patients with major or minor psychiatric symptoms, including those with peripheral vestibular conditions and migraine headaches. Patients fared far better with SSRI treatment than with treatment with vestibular suppressants or benzodiazepines.

Adolescent↗

PubMed2002

Exertional dizziness and autonomic dysregulation.

OBJECTIVES: To define the clinical characteristics and treatment of dizziness induced by physical exertion and to investigate autonomic nervous system function in exertional dizziness. STUDY DESIGN: Retrospective case series from a review of 1400 patients evaluated for dizziness at a neurotology referral center, identifying those with predominantly exertional symptoms. METHODS: Records of patients with exertional dizziness were screened to eliminate those with known vestibular deficits, cardiopulmonary illnesses, and psychiatric disorders. The clinical characteristics, evaluation results, and treatment of nine patients with purely exertional dizziness were described. RESULTS: The cohort included 4 male and 5 female patients (age range, 13-53 y) with symptoms for 1 to 8 years. Only one patient had a history of autonomic symptoms: phlebotomy-induced syncope in childhood. No patient was taking medications that caused dizziness or orthostasis. All patients experienced "spacey" or "foggy" head sensations without vertigo during exertion. Provocative activities ranged from standing upright for extended periods to running and swimming. On examination, voluntary hyperventilation provoked moderate symptoms in all patients (without nystagmus or anxiety), although no patient had spontaneously occurring, hyperventilation-related complaints. Seven patients underwent autonomic testing. Tilt table tests (n = 5) produced severe symptoms in one patient and mild symptoms in two patients. Sodium lactate infusions (n = 6) provoked marked symptoms in four patients and moderate symptoms in one patient. All were treated for autonomic dysregulation. Seven patients improved substantially and resumed all of their premorbid activities. Two improved slightly. CONCLUSIONS: In nine patients with exertional dizziness, autonomic challenges were provocative, and medications for autonomic dysregulation were effective. Exertional dizziness may be a clinical manifestation of autonomic nervous system dysregulation.

Adolescent↗

PubMed2002

Immunologic and serologic testing in patients with Ménière's disease.

OBJECTIVE: To establish the value of immunologic and serologic testing in patients with Ménière's disease. STUDY DESIGN: Prospective cohort. SETTING: University-based, tertiary care balance center. INTERVENTION: Patients with active unilateral or bilateral Ménière's disease underwent testing, including antinuclear antibodies, anti-DNA antibodies, rheumatoid factor, complement levels, anti-Sjögren syndrome A and B antibodies, sedimentation rate, antiphospholipid antibodies, Western blot for anticochlear antibodies (anti-heat shock protein 70), microhemagglutination test for Treponema pallidum, and Lyme titers. OUTCOME MEASURES: Results of laboratory tests. RESULTS: In patients with unilateral Ménière's disease (n = 40), 27% demonstrated elevated antiphospholipid antibody titers (population norm, 6-9%). The majority of these patients manifested negative assays on the other tests listed above. In patients with bilateral Ménière's disease (n = 18), elevations in antinuclear antibody titers (38%) were the most notable finding. As part of a broader study of patients with progressive hearing loss, four patients with positive syphilis titers were identified; however, none of these patients complained of vertigo. CONCLUSION: In general, the results of this study do not support the hypothesis that immune or infectious pathologies are involved in the pathogenesis of unilateral Ménière's disease. In particular, Lyme disease does not seem to cause labyrinthine disease. However, the potential role of the thrombogenic antiphospholipid antibodies must be further investigated. Patients with bilateral Ménière's disease may be more likely to have a systemic autoimmune process.

Antibodies, Antinuclear↗