Vol 44, No 7 (2016)


The role of temporomandibular joint dysfunction and occlusal disorders in the pathophysiology of somatogenic cochlear and vestibular syndrome

Boldin A.V., Agasarov L.G., Tardov M.V., Kunelskaya N.L.


Rationale: Temporomandibular joint (TMJ) dysfunction and occlusion abnormalities can cause cochlear and vestibular disorders. This issue is at the crossroads of several disciplines: otoneurology, physiotherapy, dentistry, medical rehabilitation and posturology, which often makes it difficult to timely diagnose them and delays the onset of treatment. Aim: To assess the role of abnormal dental occlusion and TMJ disorders in the pathophysiology and clinical manifestation of cochleovestibular syndrome. Materials and methods: We examined 300 subjects with clinical signs of cochleovestibular syndrome, asymmetry of occlusion and/or TMJ dysfunction (the main group), 55 patients with signs of TMJ structural and functional disorders and occlusal disorders without a cochleovestibular syndrome (the reference group), and 35 healthy volunteers (the control group). All patients were examined by a neurologist, an ENT specialist, a dentist and a physiotherapist. A series of additional investigations of the brachiocephalic vessels, cervical spine, TMJ, auditory and vestibular function, premature tooth contacts were performed. Results: The main group patients had high values of TMJ dysfunction in the Hamburg test (5.85 vs 2.2 in the reference group) and higher proportions of patients with moderate and severe TMJ dysfunction (n = 243, 81% and n = 13, 23.7%, respectively). The functional muscle test parameters and the results of manual muscle testing in the main group patients were significantly different from those in the control group (р < 0.05), whereas most values obtained in the reference group did not differ significantly (р > 0.05). Patients with cochleoves-tibular syndrome had 2 to 3-fold higher rates of vertebrogenic dysfunctions than those from the reference group. The video nystamography technique detected the positional cervical nystagmus in 100% (n = 300) of patients from the main group, whereas there were no nystagmus in those from the reference group. Voluntary dental occlusion in the main group patients was associated with a deterioration of postural tests in 61.8% (n = 185) of patients; in the reference group patients these parameters deteriorated in 38.2% (n = 21) of cases. According to T-SCAN assessment, 300 (100%) patients from the main group had in imbalance of total distribution of the occlusion force (р < 0.05 compared to the control group). The biggest number of patients from the main group (73.7%, n = 221) had an imbalance of occlusion force within 20 to 40%, and in most patients from the reference group this parameter was in the range of 10 to 30% (85.5%, n = 47), with 14.5% (n = 8) of this group having a normal balance of the occlusion force. Cerebrovascular reactivity parameters measured by ultrasound Doppler technique demonstrated a moderately significant (р < 0.05) strain of the cerebral hemodynamic reserve in the posterior arterial system in patients with cochleovestibular syndrome. Conclusion: Cochleovestibular disorders can be caused by a dysfunction of the dentoman-dibular system and/or cervical / masticatory myofascial syndrome. After exclusion of any otogenic pathology in patients with cochleovestibular syndrome, their neurological examination should include a visual assessment of the occlusion and mandibular movements, as well as testing of the cervical and masticatory muscles. If any abnormalities of occlusion and/or TMJ and local muscle dysfunction are revealed, then a dentist and a physiotherapist consultation should be performed.

Almanac of Clinical Medicine. 2016;44(7):798-808
pages 798-808 views

Endoscopic surgery of the paranasal sinuses and skull base neoplasms with the use of the computerassisted navigation system (CANS) in pediatric practice

Vorozhtsov I.N., Grachev N.S., Nasedkin A.N.


Background: In the last 10 years, the use of computer-assisted navigation systems (CANS) in endo-nasal endoscopic surgery of the paranasal sinuses and skull base in adults has been well studied. In pediatric practice, isolated cases of the use of this method have been described, with most of patients suffering from various types of sinusitis. Aim: To improve efficacy of the transnasal surgery for sinonasal, nasopharyngeal and skull base neoplasms in pediatric patients. Materials and methods: 77 patients aged from 22 days to 18 years with various nasal, nasopharyngeal, paranasal and skull base neoplasms were divided into two groups depending on the surgical technique. The main group included 40 patients in whom CANS guided surgery was used and the control group comprised 37 patients operated without CANS. Each group was divided into two subgroups based upon the complexity of the intervention (in subgroup 1, it was a biopsy and in subgroup 2, tumor excision). Results: There were no significant differences between 1st subgroups of both groups in the intervention duration, intra-operative blood loss, number of post-operative days in the hospital. Compared to the patients from the subgroup 2 of the control group, in those from the subgroup 2 of the main group the duration of intervention decreased by 60 minutes (p = 0.038, Mann-Whitney U-test), intra-operative blood loss decreased by half (p = 0.044, Mann-Whitney U-test), duration of hospital stay, by 2 days (p = 0.02, Student's t-test). The rates of radical excision was higher in the main group (p = 0.02, Fischer's exact test). Conclusion: The use of CANS in endonasal surgery allows for reduction of the intervention time and anesthesia duration, minimizes blood loss, is associated with earlier post-operative rehabilitation of children.

Almanac of Clinical Medicine. 2016;44(7):809-813
pages 809-813 views

Management and surgical outcomes in patients with chronic suppurative otitis media

Daikhes N.A., Diab K.M., Korvyakov V.S., Kondratchikov D.S., Pashchinina O.A., Umarov P.U., Mikhalevich А.E., Medeulova A.R.


Background: Reconstruction of the ossicular chain is performed in 70-90% of tympanoplastic interventions. A cholesteatoma in chronic suppurative otitis media is diagnosed in 24-63% cases, irrespective of localization of the eardrum perforation. Persistently good outcomes after radical mastoidectomy is obtained only in 65 to 66% of patients, and the proportion of unsatisfactory results remains to be rather high (10 to 15%). Aim: To analyze the effectiveness of surgical treatment of patients with chronic suppurative otitis media, operated in a single clinical center from 2014 to 2016. Materials and methods: A total of 212 patients (233 ears) with chronic suppurative otitis media patients, who underwent surgery, were included in this study. The effectiveness of surgical interventions were assessed as short-term (up to 3 months post-operatively) and long-term (6 to 12 months) anatomical and functional outcomes. The anatomical results were considered satisfactory if there was a well-formed mobile neotympanic membrane, air tympanic cavity and dry postoperative cavity. Pure tone audiograms were analyzed to evaluate the functional results. Results: Satisfactory anatomical results were obtained in 93.5% of patients with the safe type suppurative otitis, 88.9% of patients with the unsafe type and 91.2% of patients after a revision surgery. Displacement of total ossicular prosthe-ses was the main cause of poor functional results. The most common causes of unsatisfactory anatomical results were perforation (14 cases), cholesteatoma recurrence (2 cases) and lateralization of the neotympanic membrane (2 cases). Discussion and conclusion: Formation of a reliable sound conducting system with ossicular prostheses allows for persistent improvement of hearing. Various surgical techniques, such as extended posterior tympanotomy, endoscopic assistance, provide a good effect with the removal of non-aggressive cholesteatoma while preserving the bone structures, which are not involved in the disease. A complete removal of an advanced aggressive cholesteatoma with the opening of the temporal bone cell system ensures good functional and anatomical outcomes, makes it possible to prevent the spread of the pathological process and development of intracranial complications.

Almanac of Clinical Medicine. 2016;44(7):814-820
pages 814-820 views

Difficult cases of cochlear implantation

Daikhes N.A., Diab K.M., Pashchinina O.A., Kondratchikov D.S., Yusifov K.D., Umarov P.U., Siraeva А.R.


Background: In the recent  years, there  is a tendency to extend  the  indications  to cochlear implantation in patients  with inner and middle ear malformations, cochlea  ossificans and  Meniere's disease. In otosurgical practice, the cases are not uncommon when  cochlear  implantation is difficult after previous canal wall down mastoidectomy due to chronic suppurative otitis media. Aim: To improve postoperative auditory performance of patients  with profound  sensorineural  hearing loss (deafness), complicated  by the inner or middle ear disorders, through the optimization of cochlear implantation surgical technique. Materials and methods: We analyzed 42 patients  with profound  sensorineural  hearing  loss who underwent  cochlear  implantation, 12 of them  having cochlea  ossification  after  meningitis  (group  1), 19,  with  inner  ear  malformations   (group  2),  9, had underwent canal wall down mastoidectomy (group 3) and 2, with Meniere's disease (group 4). Surgical  techniques  varied  depending  on  the type of disorder. In all patients, implant  telemetry and  evoked  stapes  reflex registration  (if stapedium muscle was present) were performed. Postoperatively the mastoid cavity was controlled by  otomicroscopy. Results: Stapes  reflex were obtained in 8 patients  from group  1. Number of from group 3 in whom of the proposed cochlear implantation technique was used, no long-term relapses of chronic suppurative otitis media were observed, the mastoid cavity could be visualized very well and graft survival was excellent. No cases of electrode array extrusion or protrusion were registered. Patients  with  Meniere's  disease  and bilateral  sensorineural  hearing  loss who  underwent  simultaneous  operations  (endolymphatic sac drainage  and cochlear implantation)  showed satisfactory results of audioverbal  rehabilitation and a marked reduction  of vestibular symptoms. Conclusion: Surgical techniques proposed in this study  allow for insertion  of maximal  electrode numbers  into the spiral canal of a malformed and ossified cochlea. Formation  of bone  tunnels  for the active electrode  in the burred  cavity and its covering with autocartilage helps to prevent  any protrusion  and displacement of the electrode  in patients   who  had  previously  underwent canal wall down mastoidectomy. Simultaneous cochlear implantation and endolymphatic sac drainage is also considered  to be an adequate approach  to treatment of patients  with late  stage  Meniere's disease with profound bilateral sensorineural hearing loss.

Almanac of Clinical Medicine. 2016;44(7):821-827
pages 821-827 views

Obstructive sleep apnea: the state of cerebral hemodynamic reserve

Kunelskaya N.L., Tardov M.V., Klyasov A.V., Zaoeva Z.O., Burchakov D.I.


Background: Individuals with obstructive  sleep apnea syndrome (OSAS) have an increased risk of disabling disorders of the cardiovascular system, including  stroke.  The  mechanisms   of OSAS effects on cerebral blood flow and cerebral vascular autoregulation have not been clear enough. Aim: To study characteristics of cerebral blood flow in patients  with OSAS and the effect of CPAP therapy on cerebral hemodynamic reserve. Materials and  methods: One  hundred and  two  patients with various OSAS severity (61 male  and  41 female) and  20 healthy  volunteers  participated in the study. We performed  ultrasound assessment of cerebral  blood  flow with functional  tests  and calculated  reactivity indices. Results: With more severe OSAS, no significant differences in cerebral vascular reactivity compared to the control group were  registered. However, there  was a trend  to some  decrease  in the  index of constriction  and dilation  in the  vertebral  arteries  and  the  basilar artery, as well as to its increase in the middle cerebral artery in severe and moderate OSAS. The index of vasomotor  reactivity of cerebral  arteries was significantly (р < 0.05) lower in patients with  severe  OSAS:  for vertebral  arteries,  up  to 38.9 ± 8.5 and for basilar artery, up to 36.8 ± 15.7, compared to  the  control  group  (52.1 ± 9.8 and 50.1 ± 11.2, respectively). In patients who initiated CPAP therapy, there were no changes  in velosity, resistance  and  reactivity parameters of cerebral vessels after 2 months. Conclusion: We were able to  confirm a significant  impairment  of cerebral vascular autoregulation  in patients  with severe OSAS, predominantly in the posterior circulatory region. CPAP-therapy of 2 months'  duration  did not lead to restoration  of cerebral hemodynamic reserve.

Almanac of Clinical Medicine. 2016;44(7):828-834
pages 828-834 views

Fusion of computed tomography and diffusionweighted magnetic resonance images for detection of primary, residual and recurrent cholesteatoma of the middle ear

Stepanova E.A., Vishnyakova M.V., Abramenko A.S., Sambulov V.I.


Background:  At present,  computed  tomography  (CT)  is recognized  as  method for primary diagnosis of middle ear disorders. More accurate diagnosis  of  cholesteatoma  is based  on  a  sequence  of non-echo   planar  diffusion-weighted magnetic  resonance imaging. The choice of the type  of surgery depends on cholesteatoma size and location. Aim: To assess the possibility of fusion of CT and magnetic  resonance images (MRI) to determine the  precise location of the  middle ear cholesteatoma. Materials and methods: The CT and diffusion-weighted (DW) images of 24 patients  with chronic suppurative otitis media, including 12 with newly diagnosed and 12 with relapsing cholesteatoma were fused. The patients underwent the  standard  CT and  MRI, including DW-MRI.  CT  and  DW-MRI  images  were  fused with determination of exact size and location of cholesteatoma in the middle ear cavity. Results: The exact location and size of the cholesteatoma were identified. The study results were compared with intraoperative data. The use of fused CT and DW images  had  the  sensitivity in determination of cholesteatoma location and size of 96%, specificity of 100%, positive predictive value of 100%, and negative  of 96%, which all were higher than the corresponding values for CT and MRI assessments. Conclusion: Fusion of CT and DW-MRI allows for determination of the precise localization of cholesteatoma, partial exclusion of false-positive  results   correlate   and   for  comparison   of the  lesion with important bone  landmarks. The method may be  useful for the  surgeon  both  in planning of primary surgery, as well as for repeated revision of the postoperative cavity.

Almanac of Clinical Medicine. 2016;44(7):835-840
pages 835-840 views


Structures of non-cellular tissues of the body and their importance in otorhinolaryngology

Shatokhina S.N., Sambulov V.I.


We present  the  results of our studies  in various pathological   conditions   in  otorhinolaryngology performed  with  a diagnostic  technology  of functional morphology  of non-cellular tissue structures  (mouth  fluid, surgical wound  exudation, blood  serum, and  others). With the  use of methods of cuniform and  marginal dehydration of biological fluids, the possibility of developing essentially novel criteria was shown, such as:

• prediction  of complicated  course of post-operative wound  healing in subjects with a lamellar morphotype in the  wound  exudation  resulting from cholesterol residues due to massive cell death;

• prediction  of a polypous  rhinosinusitis  relapse in subjects with an increase in the proliferation marker, anisotropic  parallels lines in the  dehydrated  serum  obtained from the  blood  taken from the inferior nasal turbinate;

• diagnostics   of  the  middle  ear  cholesteatoma in children by combination of cuniform and marginal  dehydration of the  mouth  fluid. The singularity of the  technique  is based  on triple sampling  of the  fluid:  first sample  was  taken immediately  after awakening, the  second  one, after a few minutes  of active swallowing movements  and  the  third one,  after trans-tympanicair pumping.  Detection  of the  structural  signs of congestive effusion and the lamellar morphotype as a destruction marker in the third sample suggested the presence  of cholesteatoma;

• assessment  of  treatment  efficacy  in  patients with chronic tonsillitis and of the indications to tonsillectomy in patients  with persisting pathological  characteristics   of  the  exudation   from the palatal tonsil lacunes throughout the whole course of conservative treatment;

• determination of the grade of activity / absence of activity of laryngeal cancer by identification of a basic spherolith with various degrees  of anisotropy, abnormally  aggregated with a granular microspherolith;

• detection of the  signs of progression  in laryngeal  cancer  by  the  presence   of wave-shaped structures  in the  microspherolith during  radiation therapy.

Almanac of Clinical Medicine. 2016;44(7):857-865
pages 857-865 views


Diagnosis and treatment of combat injuries of the ear

Egorov V.I., Kozarenko A.V.


The authors  discuss specifics of the  wound  process in modern  combat  injury of the  ear, significance  and  specifics of diagnosis  of gunshot ear injury related to individual characteristics of gunshot  wounds  with consideration of the  accepted anatomical classification of the injured zones. Typical complications of ear injuries are described that  can result in death. The authors  analyze an approach  to  surgical treatment of traumatic  ear injuries based on their own experience, including non-conventional choice  of the  type  of surgery. They proposed an algorithm to assess the auditory and  vestibular  analyzers in the  injured based  on their analysis of date obtained from 772 patients, determine types of pure-tone audiograms  typical for acoustic  and  barotrauma,  and  underline  the informative  value  of optokinetic  nystagmus   assessment. Various types of conservative  management of the sequelae of the mine-blast ear trauma are discussed  aimed at potential  minimization of the  post-traumatic reactions  of the  auditory  and vestibular  analyzers.  The  authors  draw attention to the importance of early treatment, the highest effectiveness of combination therapy and plasmapheresis. They propose  their  experience  of care for the above mentioned traumatic injuries to improve treatment efficacy.

Almanac of Clinical Medicine. 2016;44(7):841-849
pages 841-849 views

The role of innate immunity in the development of chronic rhinosinusitis and perspectives of its conservative management

Egorov V.I., Savlevich E.L.


Chronic rhinosinusitis (CRS) is a heterogeneous, multifactorial disease of unknown etiology, with an underlying deficient immune response to infectious and other triggers, leading to their incomplete elimination and persistence of inflammation. Development of CRS is made possible by a deficient response of the innate immunity of nasal and paranasal sinus mucosa. The main factors of non-specific defense system of nasal and paranasal mucosa are the function of cell junctions between epithelial cells, mucociliary clearance, pattern recognition receptors (PRRs), antigen presenting cells, and phagocytosis. The multirowed ciliate epithelium of nasal and paranasal sinus mucosa is covered by a thick layer of mucus containing more than 200 proteins. Changes in the qualitative composition of the nasal mucus in CRS manifests in overexpression of the main mucins MUC5AC and MUC5B and decreased synthesis of lactoferrin and lyzocin. Ciliary dyskinesia or abnormalities in their microstructure lead to decreased efficacy of mucociliary clearance. Diminished expression of proteins of tight junctions (TJ) ZO-1 and occluding results in decreased density of intercellular contacts and increased permeability of epithelial barrier. In addition, CRS is characterized by deficient Tolllike receptors (TLR) 9, 2 and 4, as well as increased counts of M2 macrophages in the mucosa. This results in suppressed phagocytosis and antimicrobial mucosal defense. Lower levels of STAT3 protein causes an imbalanced reaction of innate and adaptive immune response and disordered reparation processes. With abnormal functioning of all the above mentioned mechanisms, no immune elimination of infectious agents can take place, with increased susceptibility to viral and bacterial infections of the upper respiratory tract. This opens the door to development of CRS, including that with polyps. Investigation of the innate immunity factors would allow for predicting of inflammation in a given patient, as well as for development of new approaches to its conservative management.
Almanac of Clinical Medicine. 2016;44(7):850-856
pages 850-856 views

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