Abstract
Objective
The diagnosis and management of Superior Canal Dehiscence Syndrome (SCDS) with concomitant otosclerosis can be a challenge. Otosclerosis can mask SCDS symptoms and stapes surgery may reveal or exacerbate vestibular symptoms. Our aim is to present four cases of SCDS with concomitant otosclerosis and thereby informing the reader about the possibility of this dual occurrence and its implications for treatment.
Cases
Four patients with SCDS and concomitant otosclerosis are presented. Two patients underwent surgical treatment for both SCDS and otosclerosis and two patients opted for conservative management.
Outcomes
The main differences between surgically and non-surgically treated cases are the presence of autophony and pressure-induced vertigo and a more severe experience of symptoms in surgically treated cases. Surgically treated cases achieved a sizeable reduction in postoperative air–bone gap and resolution of vestibular symptoms.
Conclusion
The subjective severity of symptoms in combination with shared decision-making is key in determining the appropriate treatment plan for SCDS and concomitant otosclerosis.
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Introduction
Superior semicircular canal dehiscence syndrome (SCDS) is an otovestibular condition involving a dehiscence of the superior semicircular canal [1]. It can cause a variety of audiological and vestibular symptoms, including hearing loss, autophony, pulsatile tinnitus, vertigo and hyperacusis [2,3,4]. Possible clinical signs include Tullio’s sign and Hennebert’s sign, which describe the occurrence of vertigo or nystagmus after exposure to loud sounds or pressure, respectively [2, 3, 5,6,7]. The superior semicircular canal dehiscence (SCD) is detected using a high-resolution (HR) CT-scan of the mastoid, with reconstructions in the Pöschl plane [8, 9]. The diagnosis of SCDS also requires appropriate symptomatology and instrumental findings (e.g. VEMP, video head impulse test (vHIT)) [10,11,12,13,14,15]. There is a positive correlation between the size of SCD and air-conduction (AC) thresholds and air–bone gap (ABG) [3, 16,17,18,19]. A location closer to the ampulla or a larger dehiscence is associated with a lower cervical vestibular-evoked myogenic potential (VEMP) threshold and presence of auditory symptoms [3, 16, 19,20,21]. Surgical treatment is only indicated in a minority of patients and may consist of resurfacing or plugging the dehiscence via a middle cranial fossa approach (MCFA) or transmastoid approach (TMA) [1, 22].
The distinction between SCD and SCDS is an important one. In the latter case, the SCD is associated with appropriate symptoms which may require treatment. Current literature frequently reports the presence of SCD, which may be asymptomatic, and therefore clinically irrelevant [23,24,25]. Using these cases as a basis for the management of SCDS and otosclerosis may understate the risk of exacerbation or unmasking of vestibular symptoms after stapedotomy [26, 27]. This is further complicated by a relatively large variation in symptomatology and degrees of SCDS [28, 29].
Otosclerosis is an osseous dysplasia of the otic capsule in the temporal bone which predominantly leads to hearing loss [30, 31]. It typically presents with progressive conductive hearing loss without evidence for middle ear inflammation [30]. It can be detected using a CT-scan of the middle ear [32, 33], however, the additional value of CT is limited [34]. The diagnosis can be confirmed by testing the mobility of the stapes during middle ear inspection. Treatment may consist of stapedotomy or hearing aid(s) [35].
SCDS can mimic otosclerotic symptoms and stapes fixation can eliminate the third window effect and thereby mask SCDS symptoms [36]. In these patients, stapes surgery can reveal or exacerbate SCDS-related symptoms (e.g. sound/pressure induced vertigo, hyperacusis, autophony, pulsatile tinnitus and conductive/mixed hearing loss) [23,24,25, 37,38,39,40]. In patients with otosclerosis, AC VEMP may be less reliable than bone-conduction (BC) VEMP due to impedance of sounds transmission through the ossicular chain [41, 42].
Furthermore, in patients with SCDS and concomitant otosclerosis, the success rate of stapes surgery in reducing the ABG may be impaired, as a postoperative ABG of less than 10 dB SPL is only achieved in 60% of cases [23, 24]. In case of failed stapes surgery, the presence of SCD should be investigated as a possible cause [24, 25, 29, 39, 40, 43,44,45,46].
Appropriate indications for and a comparison of surgical treatment options for SCDS with concomitant otosclerosis cannot be determined due to the limited number of cases and heterogeneous reported outcome measures [22, 38].
The goal of this case series is to review four patient cases regarding the presentation and treatment of SCDS with concomitant otosclerosis, and thereby informing the reader about the possibility of this dual occurrence and its implications with regards to treatment.
Case one
A 42-year-old woman presented with a history of aural fullness of the left ear since two years, autophony, asymmetric hearing loss and vertigo following loud noises. She underwent ossicular chain reconstruction of the right ear prior to the occurrence of the aforementioned complaints. Otoscopic examination of the left ear showed no abnormalities. Hennebert’s sign was positive. Tone audiometry (see Table 1) showed supranormal BC and subnormal low-frequency AC thresholds in the left ear. Stapes reflexes could not be evoked ipsi- and contralaterally. BC ocular VEMP (oVEMP) revealed a lowered threshold of 95 dB SPL in both ears. CT imaging of the mastoid bone confirmed a short interruption of the bony coverage of the left SSC (see Fig. 1.1). The dehiscence was plugged using bone wax via MCFA. After surgery, the autophony and vertigo resolved and the BC oVEMP thresholds were normalized. The BC threshold normalised, but AC hearing loss persisted. Stapes reflexes could still not be evoked in the left ear. In a second surgery, otosclerosis was confirmed and a stapedotomy was performed in the left ear. Postoperative audiometry revealed a sizeable reduction of the ABG. The only remaining complaint after the two surgeries was persistent tinnitus in the left ear.
Case two
A 58-year-old woman presented with a history of hyperacusis, autophony, and hearing loss of the left ear, and an unstable sensation when walking. Tullio’s and Hennebert’s signs were both positive. Otoscopic examination revealed no abnormalities. Tone audiometry revealed increased AC thresholds in the left ear (see Table 1) and normal hearing in the right ear. CT imaging of the mastoid revealed a bilateral dehiscence of the SCCs (see Fig. 1.2). BC oVEMP and electronystagmography (ENG) revealed no abnormalities. The patient underwent middle ear inspection revealing a fixed stapes, which confirmed otosclerosis in the left ear. First, a stapedotomy was performed, and subsequently the left SSC was covered via TMA using auricular cartilage, during the same surgery. After surgery, the patient reported resolution of vertiginous symptoms and improved hearing in the left ear. Tone audiometry revealed a reduced ABG (see Table 1).
Case three
A 28-year-old woman presented with a history of pressure sensation in the right ear since one year, hyperacusis, and pulsatile tinnitus (not synchronous to the heart rate). Otoscopic examination and audiometry (see Table 1) revealed no abnormalities. Oscillopsia was present and Tullio’s sign was positive. CT imaging confirmed a dehiscence of the right SSC and ipsilateral fenestral otosclerosis (see Fig. 1.3). BC oVEMP revealed lowered thresholds and increased amplitudes in the right ear. ENG showed no abnormalities. The patient preferred not to undergo surgery due to the relatively limited and mild symptoms.
Case four
A 25-year-old man presented with a history of progressive hearing loss mainly affecting the left ear, tinnitus, hyperacusis and the sensation of pressure in the left ear. He previously underwent grommet placement and stapedotomy of the left ear. Otoscopic examination showed a grommet in situ in the left ear and no abnormalities in the right ear. Tullio's sign was positive. Tone audiometry revealed a bilateral mixed hearing loss (see Table 1). CT imaging of the mastoid showed a dehiscence of the left SCC in combination with bilateral otosclerosis (see Fig. 1.4). BC oVEMP revealed an asymmetric response threshold of 120 dB SPL in the right ear and 110 dB SPL in the left ear. The patient opted not to have surgery due to the relatively mild symptoms.
Discussion
This study was conducted at the University Medical Centre (UMC) Utrecht The Netherlands, in compliance with the principles of the Declaration of Helsinki. This study was exempt from approval of an ethics committee under Dutch law.
Case discussion
The strength of our approach in these cases was appropriate use of shared decision making, thereby omitting surgery in two cases. A limitation is not combining the treatment of otosclerosis in the first case along with SCD repair. This would have made the treatment for both conditions possible in one operation.
The only discernible difference in complaints between patients who did and did not receive surgical treatment is the presence of autophony and pressure-induced vertigo in surgically treated cases (see Table 2). The tipping point in opting for surgical treatment apparently lies in the subjective severity of symptoms, which underlines the importance of shared decision making.
Overview of literature
In our surgical cases, a larger reduction in ABG was achieved (− 44 dB SPL and − 25 dB SPL) compared to the average reduction reported in literature (− 14 dB SPL; see Table 1). One possible explanation for this difference could be that almost all literature reports the presence of SCD, not of SCDS. It could be that SCDS is accompanied by worse hearing loss compared to SCD and therefore facilitates a larger improvement after surgical intervention.
Current literature fails to reveal evidence-based prognostic factors for the outcome of stapedotomy in patients with SCDS and comorbid otosclerosis. Caution is therefore advised when considering treating otosclerosis with stapedotomy in these patients, as it may not achieve the desired result and may even unmask vestibular symptoms [23,24,25, 37,38,39,40]. However, stapedotomy is not necessarily contra-indicated in these cases. It can lead to adequate closure of the ABG without unmasking vertiginous symptoms [39, 44, 45, 47] (Table 3).
We created a strategic decision-making flowchart (see Fig. 2) based on current literature, our cases and previous discussion points. This flowchart displays a compact overview of the suggested diagnostic and decision-making process, which may prove beneficial for clinicians in the future. The presence of concomitant SCDS should be considered and investigated using HRCT of the mastoid in cases of atypical otosclerosis (i.e. otosclerosis does not explain all present symptoms). In cases with SCD, a vestibular workup (consisting of vHIT, BC VEMP and ENG) is recommended. This can aid in determining whether the SCD may be a likely cause of the patients' complaints and may therefore lead to different treatment strategies. If the vestibular workup is normal, a more conservative approach may be appropriate.
Conclusion
It remains unclear from literature and our presented cases what the best treatment strategy is in cases with both otosclerosis and SCDS. The decision-making process in terms of management strategies should be principally influenced by the subjective severity of symptoms experienced by the patient.
Data availability
Study data are readily available for the coming 15 years. These can be provided on request at the corresponding author.
References
Minor LB, Solomon D, Zinreich JS, Zee DS (1998) Sound- and/or pressure-induced vertigo due to bone dehiscence of the superior semicircular canal. Arch Otolaryngol Head Neck Surg 124(3):249–258
Minor LB (2005) Clinical manifestations of superior semicircular canal dehiscence. Laryngoscope 115(10):1717–1727
Niesten M. Evaluation and management of superior canal dehiscence syndrome [Dissertation]. Utrecht: Utrecht University; 2014.
Bertholon P, Karkas A (2016) Otologic disorders causing dizziness, including surgery for vestibular disorders. Handb Clin Neurol 137:279–293
Rohrmeier C, Hilber H, Strutz J (2010) Superior semicircular canal dehiscence syndrome: a case of Tullio phenomenon. HNO 58(10):1057–1060
Shuman AG, Rizvi SS, Pirouet CW, Heidenreich KD (2012) Hennebert’s sign in superior semicircular canal dehiscence syndrome: a video case report. Laryngoscope 122(2):412–414
Dumas G, Curthoys IS, Castellucci A, Dumas L, Perrin P, Schmerber S (2023) A bone-conducted Tullio phenomenon-A bridge to understand skull vibration induced nystagmus in superior canal dehiscence. Front Neurol 14:1183040
Duman IS, Dogan SN (2020) Contribution of reformatted multislice temporal computed tomography images in the planes of Stenvers and Pöschl to the diagnosis of superior semicircular canal dehiscence. J Comput Assist Tomogr 44(1):53–58
Mau C, Kamal N, Badeti S, Reddy R, Ying YM, Jyung RW et al (2018) Superior semicircular canal dehiscence: diagnosis and management. J Clin Neurosci 48:58–65
Ward BK, van de Berg R, van Rompaey V, Bisdorff A, Hullar TE, Welgampola MS et al (2021) Superior semicircular canal dehiscence syndrome: diagnostic criteria consensus document of the committee for the classification of vestibular disorders of the Bárány Society. J Vestib Res 31(3):131–141
Re M, Gioacchini FM, Salvolini U, Totaro AM, Santarelli A, Mallardi V et al (2013) Multislice computed tomography overestimates superior semicircular canal dehiscence syndrome. Ann Otol Rhinol Laryngol 122(10):625–631
Tavassolie TS, Penninger RT, Zuñiga MG, Minor LB, Carey JP (2012) Multislice computed tomography in the diagnosis of superior canal dehiscence: how much error, and how to minimize it? Otol Neurotol 33(2):215–222
Castellucci A, Malara P, Martellucci S, Alfarghal M, Brandolini C, Piras G et al (2023) Impaired vestibulo-ocular reflex on video head impulse test in superior canal dehiscence: “spontaneous plugging” or endolymphatic flow dissipation? Audiol Res 13(5):802–820
Mukherjee P, Chiarovano E, Cheng K, Manzari L, McGarvie LA, MacDougall HG (2021) Video-head impulse test in superior canal dehiscence. Acta Otolaryngol 141(5):471–475
Dumas G, Lion A, Karkas A, Perrin P, Perottino F, Schmerber S (2014) Skull vibration-induced nystagmus test in unilateral superior canal dehiscence and otosclerosis: a vestibular Weber test. Acta Otolaryngol 134(6):588–600
Hunter JB, O’Connell BP, Wang J, Chakravorti S, Makowiec K, Carlson ML et al (2016) Correlation of superior canal dehiscence surface area with vestibular evoked myogenic potentials, audiometric thresholds, and dizziness handicap. Otol Neurotol 37(8):1104–1110
Chien WW, Janky K, Minor LB, Carey JP (2012) Superior canal dehiscence size: multivariate assessment of clinical impact. Otol Neurotol 33(5):810–815
Saliba I, Maniakas A, Benamira LZ, Nehme J, Benoit M, Montreuil-Jacques V (2014) Superior canal dehiscence syndrome: clinical manifestations and radiologic correlations. Eur Arch Otorhinolaryngol 271(11):2905–2914
Castellucci A, Piras G, Del Vecchio V, Crocetta FM, Maiolo V, Ferri GG et al (2021) The effect of superior canal dehiscence size and location on audiometric measurements, vestibular-evoked myogenic potentials and video-head impulse testing. Eur Arch Otorhinolaryngol 278(4):997–1015
Pfammatter A, Darrouzet V, Gärtner M, Somers T, Van Dinther J, Trabalzini F et al (2010) A superior semicircular canal dehiscence syndrome multicenter study: is there an association between size and symptoms? Otol Neurotol 31(3):447–454
Maheu M, Elblidi A, Saliba I (2021) Investigating performance of cVEMP and oVEMP in the identification of superior canal dehiscence in relation to dehiscence location and size. Audiol Res 11(3):452–462
Ossen ME, Stokroos R, Kingma H, van Tongeren J, Van Rompaey V, Temel Y et al (2017) Heterogeneity in reported outcome measures after surgery in superior canal dehiscence syndrome—a systematic literature review. Front Neurol 8:347
McClellan J, Nguyen A, Hamilton B, Jethanamest D, Hullar TE, Gupta S (2020) Stapes surgery outcomes in patients with concurrent otosclerosis and superior semicircular canal dehiscence. Otol Neurotol 41(7):912–915
Sioshansi PC, Drury EE, Tu NC, Babu SC, Schutt CA (2022) Outcomes of stapedotomy in patients with concomitant otosclerosis and superior semicircular canal dehiscence: should a radiographic third-window be a contraindication to stapes surgery? Otol Neurotol 43(2):165–169
Dewyer NA, Quesnel AM, Santos F (2020) A case series of patients with concurrent otosclerosis and superior semicircular canal dehiscence. Otol Neurotol 41(2):e172–e181
Guimaraes GC, RodriguesdaSilva VA, Castilho AM (2022) To the editor: “outcomes of stapedotomy in patients with concomitant otosclerosis and superior semicircular canal dehiscence: should a radiographic third-window be a contraindication to stapes surgery?” Otol Neurotol. 43(7):e792
Sioshansi PC, Tu NC, Babu SC, Schutt CA (2022) Response to letter to the editor: “outcomes of stapedotomy in patients with concomitant otosclerosis and superior semicircular canal dehiscence: should a radiographic third-window be a contraindication to stapes surgery?” Otol Neurotol 43(7):e792–e793
Van Rompaey V, Van de Heyning P. Response to "Michael Yong, Erica Zaia, Brian Westerberg, and Jane Lea. Diagnosis of superior semicircular canal dehiscence in the presence of concomitant otosclerosis". Otol Neurotol 2017;38: 1071–1075. Otol Neurotol. 2018;39(4):517–8.
Mikulec AA, McKenna MJ, Ramsey MJ, Rosowski JJ, Herrmann BS, Rauch SD et al (2004) Superior semicircular canal dehiscence presenting as conductive hearing loss without vertigo. Otol Neurotol 25(2):121–129
Rudic M, Keogh I, Wagner R, Wilkinson E, Kiros N, Ferrary E et al (2015) The pathophysiology of otosclerosis: review of current research. Hear Res 330(Pt A):51–56
Siddiq MA (2006) Otosclerosis: a review of aetiology, management and outcomes. Br J Hosp Med (Lond) 67(9):470, 2–6
Lee TC, Aviv RI, Chen JM, Nedzelski JM, Fox AJ, Symons SP (2009) CT grading of otosclerosis. AJNR Am J Neuroradiol 30(7):1435–1439
Lagleyre S, Sorrentino T, Calmels MN, Shin YJ, Escudé B, Deguine O et al (2009) Reliability of high-resolution CT scan in diagnosis of otosclerosis. Otol Neurotol 30(8):1152–1159
Wegner I, van Waes AMA, Bittermann AJ, Buitinck SH, Dekker CF, Kurk SA et al (2016) A systematic review of the diagnostic value of CT imaging in diagnosing otosclerosis. Otol Neurotol 37(1):9–15
Gjuric M, Rukavina L (2007) Evolution of stapedectomy prostheses over time. Adv Otorhinolaryngol 65:174–178
Yong M, Zaia E, Westerberg B, Lea J (2017) Diagnosis of superior semicircular canal dehiscence in the presence of concomitant otosclerosis. Otol Neurotol 38(8):1071–1075
Hope A, Fagan P (2010) Latent superior canal dehiscence syndrome unmasked by stapedotomy for otosclerosis. J Laryngol Otol 124(4):428–430
Fernandez IJ, Molinari G, Presutti L (2021) Decision making in patients with concomitant otosclerosis and superior semicircular canal dehiscence: a systematic review of the literature. Otol Neurotol 42(1):e1–e9
Maxwell AK, Slattery WH 3rd, Gopen QS, Miller ME (2020) Failure to close the gap: concomitant superior canal dehiscence in otosclerosis patients. Laryngoscope 130(4):1023–1027
Ungar OJ, Handzel O, Cavel O, Oron Y (2018) Superior semicircular canal dehiscence with concomitant otosclerosis—a literature review and case discussion. Clin Case Rep 6(12):2364–2370
Zhou G, Poe D, Gopen Q (2012) Clinical use of vestibular evoked myogenic potentials in the evaluation of patients with air-bone gaps. Otol Neurotol 33(8):1368–1374
Govender S, Fernando T, Dennis DL, Welgampola MS, Colebatch JG (2016) Properties of 500Hz air- and bone-conducted vestibular evoked myogenic potentials (VEMPs) in superior canal dehiscence. Clin Neurophysiol 127(6):2522–2531
Picavet V, Govaere E, Forton G (2009) Superior semicircular canal dehiscence: prevalence in a population with clinical suspected otosclerosis-type hearing loss. B-ENT 5(2):83–88
Lehmann M, Ebmeyer J, Upile T, Sudhoff HH (2011) Superior canal dehiscence in a patient with three failed stapedectomy operations for otosclerosis: a case report. J Med Case Rep 5:47
Halmagyi GM, Aw ST, McGarvie LA, Todd MJ, Bradshaw A, Yavor RA et al (2003) Superior semicircular canal dehiscence simulating otosclerosis. J Laryngol Otol 117(7):553–557
Whetstone J, Nguyen A, Nguyen-Huynh A, Hamilton BE (2014) Surgical and clinical confirmation of temporal bone CT findings in patients with otosclerosis with failed stapes surgery. AJNR Am J Neuroradiol 35(6):1195–1201
Pritchett CV, Spector ME, Kileny PR, Heidenreich KD, El-Kashlan HK (2014) Surgical treatment of hearing loss when otosclerosis coexists with superior semicircular canal dehiscence syndrome. Otol Neurotol 35(7):1163–1167
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Van Dijk, S.W., Peters, J.P.M., Stokroos, R.J. et al. Surgical decision-making in superior canal dehiscence syndrome with concomitant otosclerosis. Eur Arch Otorhinolaryngol 281, 3859–3865 (2024). https://doi.org/10.1007/s00405-024-08679-w
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DOI: https://doi.org/10.1007/s00405-024-08679-w