John Patrick Carey

Superior semicircular canal dehiscence is a relatively new diagnosis for otologic surgeons. Over time, a variety of different approaches have been described for the management of this condition, including observation, middle cranial fossa surgery, and transmastoid surgery. As with all surgeries, patient selection for surgical intervention is a critically important consideration.

The living human inner ear is challenging to study because it is encased within dense otic capsule bone that limits access to biological tissue. Traditional temporal bone histopathology methods rely on lengthy, expensive decalcification protocols that take 9-10 months and reduce the types of tissue analysis possible due to RNA degradation. There is a critical need to develop methods to access fresh human inner ear tissue to better understand otologic diseases, such as Ménière's disease, at the cellular and molecular level. This paper describes a technique for the harvest of human vestibular end organs from a living donor under physiologic conditions. An individual with Ménière's disease and 'drops attacks' that were refractory to intratympanic gentamicin injection underwent labyrinthectomy. A traditional mastoidectomy was first performed, and the horizontal and superior semicircular canals (SCC) were identified. The mastoid cavity was filled with a balanced salt solution so that the labyrinth could be opened under more physiologic conditions to preserve cellular integrity. A zero-degree endoscope fit with a lens-cleaning sheath irrigation system was used to visualize the submerged mastoid cavity, and a 2 mm diamond burr was used to skeletonize and open the horizontal and superior SCCs, followed by the vestibule. The ampullae and portion of the canal ducts for the superior and lateral SCCs were harvested. The utricle was similarly harvested. Harvested tissue was immediately placed in an ice-cold buffer and then fixed for one hour in 4% paraformaldehyde in phosphate-buffered saline (PBS). The tissue was rinsed several times in 1x PBS and stored for 48 h at 4 °C. The tissue samples underwent immunostaining with a combination of primary antibodies against tenascin-C (Calyx), oncomodulin (streolar hair cells), calretinin (Calyx and Type II hair cells), synaptic vesicle protein 2 (efferent fibers and boutons), β-tubulin 1 (Calyx and afferent boutons), followed by incubation with fluorophore-conjugated secondary antibodies. The tissue samples were then rinsed and mounted for confocal microscopy examination. Images revealed the presence of ampullar and macular hair cells and neural structures. This protocol demonstrates that it is possible to harvest intact, high-quality human inner ear tissue from living donors and may provide an important tool for the study of otologic disease.

The living human inner ear is challenging to study because it is encased within dense otic capsule bone that limits access to biological tissue. Traditional temporal bone histopathology methods rely on lengthy, expensive decalcification protocols that take 9-10 months and reduce the types of tissue analysis possible due to RNA degradation. There is a critical need to develop methods to access fresh human inner ear tissue to better understand otologic diseases, such as Ménière's disease, at the cellular and molecular level. This paper describes a technique for the harvest of human vestibular end organs from a living donor under physiologic conditions. An individual with Ménière's disease and 'drops attacks' that were refractory to intratympanic gentamicin injection underwent labyrinthectomy. A traditional mastoidectomy was first performed, and the horizontal and superior semicircular canals (SCC) were identified. The mastoid cavity was filled with a balanced salt solution so that the labyrinth could be opened under more physiologic conditions to preserve cellular integrity. A zero-degree endoscope fit with a lens-cleaning sheath irrigation system was used to visualize the submerged mastoid cavity, and a 2 mm diamond burr was used to skeletonize and open the horizontal and superior SCCs, followed by the vestibule. The ampullae and portion of the canal ducts for the superior and lateral SCCs were harvested. The utricle was similarly harvested. Harvested tissue was immediately placed in an ice-cold buffer and then fixed for one hour in 4% paraformaldehyde in phosphate-buffered saline (PBS). The tissue was rinsed several times in 1x PBS and stored for 48 h at 4 °C. The tissue samples underwent immunostaining with a combination of primary antibodies against tenascin-C (Calyx), oncomodulin (streolar hair cells), calretinin (Calyx and Type II hair cells), synaptic vesicle protein 2 (efferent fibers and boutons), β-tubulin 1 (Calyx and afferent boutons), followed by incubation with fluorophore-conjugated secondary antibodies. The tissue samples were then rinsed and mounted for confocal microscopy examination. Images revealed the presence of ampullar and macular hair cells and neural structures. This protocol demonstrates that it is possible to harvest intact, high-quality human inner ear tissue from living donors and may provide an important tool for the study of otologic disease.

Calcitonin gene-related peptide (CGRP) is a vasoactive neuropeptide that plays a putative role in the pathophysiology of migraine headaches and may be a candidate for biomarker status. CGRP is released from neuronal fibers upon activation and induces sterile neurogenic inflammation and arterial vasodilation in the vasculature that receives trigeminal efferent innervation. The presence of CGRP in the peripheral vasculature has spurred investigations to detect and quantify this neuropeptide in human plasma using proteomic assays, such as the enzyme-linked immunosorbent assay (ELISA). However, its half-life of 6.9 min and the variability in technical details of assay protocols, which are often not fully described, have yielded inconsistent CGRP ELISA data in the literature. Here, a modified ELISA protocol for the purification and quantification of CGRP in human plasma is presented. The procedural steps involve sample collection and preparation, extraction using a polar sorbent as a means of purification, additional steps to block non-specific binding, and quantification via ELISA. Further, the protocol has been validated with spike and recovery and linearity of dilution experiments. This validated protocol can theoretically be used to quantify CGRP concentrations in the plasma of individuals not only with migraine, but also with other diseases in which CGRP may play a role.

The cochlear aqueduct (CA) connects the scala tympani to the subarachnoid space and is thought to assist in pressure regulation of perilymph in normal ears, however, its role and variation in inner ear pathology, such as in superior canal dehiscence syndrome (SCDS), is unknown. This retrospective radiographic investigation compared CA measurements and classification, as measured on flat-panel computerized tomography, among three groups of ears: controls, n = 64; anatomic superior canal dehiscence without symptoms (SCD), n = 28; and SCDS, n = 64. We found that in a multinomial logistic regression adjusted for age, sex, and BMI, an increase in CA length by 1 mm was associated with a lower odds for being in the SCDS group vs. control (Odds ratio 0.760 p = 0.005). Hierarchical clustering of continuous CA measures revealed a cluster with small CAs and a cluster with large CAs. Another multinomial logistic regression adjusted for the aforementioned clinical covariates showed an odds ratio of 2.97 for SCDS in the small CA cluster as compared to the large (p = 0.004). Further, no significant association was observed between SCDS symptomatology—vestibular and/or auditory symptoms—and CA structure in SCDS ears. The findings of this study lend support to the hypothesis that SCDS has a congenital etiology.

Recently, Bächinger et al. developed a software that measures the angle between the vestibular aqueduct proximal to the vestibule and the distal vestibular aqueduct on computed tomography (CT) scans and found differences in the vestibular aqueduct angle between the hypoplastic and degenerative categories of Meniere’s disease (MD). Hypoplastic radiological findings were associated with the development of bilateral MD and hypoplastic changes were not found outside of fetal temporal bones and individuals with MD. The purpose of this study is to examine how the software developed by Bächinger et al. performs when applied to a large dataset of adult patients with varied otologic diagnoses. Adult patients who underwent high resolution flat panel CT scans without intravenous contrast (n = 301) were retrospectively reviewed. Measurements of the angle of the vestibular aqueduct were made using the previously developed software tool. The tool could be applied to measure the vestibular aqueduct angle in most CT scans of the temporal bones (n = 572 ears, 95%). While the majority of ears fell within the normal range of 140 degrees). Only one of the 13 patients had a diagnosis of MD and not in the ear in the hypoplastic category. An inconsistent pattern of other otologic diagnoses were found among the 13 individuals meeting criteria for hypoplastic MD. Although prior reports indicate the software has prognostic value in individuals with MD, these results suggest that the software may have lower positive predictive value when applied to a large population of individuals with varied otologic diagnoses.

Objectives: To describe factors predictive of tegmen dehiscence in subjects with superior semicircular canal dehiscence syndrome (SCDS). Study Design: Retrospective case series. Setting: Tertiary referral center. Patients: Subjects with SCDS who underwent middle fossa craniotomy (MFC) for plugging/resurfacing. Main Outcome Measures: Operative and radiographic findings of tegmen dehiscences, preoperative low frequency air-bone gaps (LF-ABGs), ocular vestibular evoked myogenic potential (oVEMP) amplitudes, size of superior semicircular canal dehiscence (SCD), and history of obesity or obstructive sleep apnea (OSA). Results: One hundred thirty six patients (avg. age, 50.6 yr, 55.1% female) underwent MFC for repair of SCDS. Tegmen dehiscences were commonly found intraoperatively (tegmen tympani dehiscence [TTD] in 19.9% [11% with dural contact of ossicles], tegmen mastoideum dehiscence [TMD] in 28.7%). There were no differences in preoperative LF-ABGs and preoperative oVEMP amplitudes with respect to tegmen status. The sensitivity and specificity of computed tomography (CT) for predicting an intraoperatively confirmed TTD was 85 and 74%, respectively, and 44 and 79% for TMD. History of obesity and OSA did not differ between those with and without tegmen dehiscences. The presence of contralateral SCD and increasing cross-sectional area of SCD were both significantly associated with concurrent tegmen defects. Conclusions: Obesity, OSA, preoperative oVEMP, and LF-ABG do not differ between those with SCD alone and those with SCD and concurrent tegmen dehiscences. Likewise, CT scans have relatively low sensitivity for identifying tegmen dehiscences. The presence of concurrent tegmen defects is more common in subjects with larger SCD cross-sectional areas and contralateral SCD.

Objective: To determine which clinical factors have the strongest impact on determining diagnosis and decision for surgical repair for superior semicircular canal dehiscence syndrome (SCDS). Patients: A total of 81 patients presented with a suspicion for SCDS between October 2017 and October 2018. 38 patients ultimately were diagnosed with SCDS, and 28 chose surgical repair. Methods: Clinical factors of subjective patient symptoms (autophony, sensitivity to loud sounds, vertigo induced by loud sounds, dizziness, hearing their own heartbeats or other visceral organs) and audiogram findings (low frequency conductive hearing loss [CHL], bone-conduction hyperacusis, low cVEMP threshold [17 μV] amplitudes) were analyzed with logistic regression to identify factors that predicted those who would ultimately be diagnosed with SCDS and those who would have surgical repair. Preoperative high-resolution CT imaging was performed on all patients. Results: Significant predictors of presence of SCDS from logistic regression included low frequency CHL and increased oVEMP amplitude (p = 0.002 [OR 40, 95%CI 3.8-413], p = 0.001 [OR 93, 95%CI 6.8-1267], respectively). These were also significant predictors of individuals who chose to have surgical repair (p = 0.004 [OR 47, 95%CI 3.5-620], p = 0.001 [OR 126, 95%CI 8.2-1941], respectively). Area under the receiver operating characteristic curve (ROC curve) for these two variables are 93% for diagnosing SCDS and 94% for predicting choice for surgical repair. Conclusions: Low frequency CHL and increased oVEMP amplitude are the strongest predictive factors for making a diagnosis of SCDS and for choosing surgical repair.