Contralateral sensorineural hearing loss after vestibular schwannoma surgery

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Gómez" "autores" => array:6 [ 0 => array:4 [ "nombre" => "Patricia" "apellidos" => "García-Cabo" "email" => array:1 [ 0 => "patriciagcabo@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn1" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Fernando" "apellidos" => "Rivas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "1" "identificador" => "fn1" ] ] ] 2 => array:2 [ "nombre" => "Fernando" "apellidos" => "López" ] 3 => array:2 [ "nombre" => "Andrés" "apellidos" => "Coca" ] 4 => array:2 [ "nombre" => "José Luis" "apellidos" => "Llorente" ] 5 => array:2 [ "nombre" => "Justo R." "apellidos" => "Gómez" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Hipoacusia neurosensorial contralateral tras cirugía de schwannoma vestibular" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1611 "Ancho" => 2560 "Tamanyo" => 243716 ] ] "descripcion" => array:1 [ "en" => "Contralateral sensorineural hearing loss noted in a median time of eleven months following surgery. All patients had an ipsilateral severe-profound SNHL after de surgery." ] ] ] "textoCompleto" => "IntroductionMost of the cerebellopontine angle (CPA) tumours are vestibular schwannoma (VS) (80%).<a class="elsevierStyleCrossRef" href="#bib0055">1</a> There are different treatment options for managing these tumours. Microsurgical resection of VS is one of them, which has potential complications such as cerebrospinal fluid (CSF) leak, meningitis, cranial nerve damage, or intracranial haemorrhage.<a class="elsevierStyleCrossRef" href="#bib0065">3</a> Recently, CSHL after VS resection has been described<a class="elsevierStyleCrossRefs" href="#bib0065">3–5</a> resulting in a severe complication, especially if hearing preservation in the operated side was not a reachable outcome.Material and methodsWe performed a retrospective review of the VS operated in our institution between 2004 and 2015. Of the 185 cases of VS treated with surgery, 4 patients (2.2%) developed a CSNHL after VS surgery. We described our experience of these 4 patients who developed a CSNHL after VS surgery.ResultsCase 1: A 52-year-old woman presented with a 3-year history of a right progressive hearing loss. The otoscopy was normal on both sides and the electronystagmography testing presented with signs consistent with peripheral right vestibular hypofunction. Pure-tone audiometry (PTA) revealed a mild SNHL at high frequencies on the right side. Magnetic resonance imaging (MRI) showed a right CPA lesion consistent with a VS, the tumour protruded to the CPA by 22mm×2mm×21mm. A retrosigmoid approach was performed with total resection of the tumour. Two months after surgery the patient complained of worsening hearing loss on the non-operated ear. PTA demonstrated a moderate-severe (>70dB) left side SNHL (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>Case 2: A 53-year-old male patient presented with a 6-month history of dizziness and tinnitus and right sudden hearing loss. MRI depicted a 7.8mm×5.4mm×4.2mm right intracanalicular (IC) VS. The otoscopy was normal and the PTA showed a mild SNHL on the left side and a moderate SNHL on the right side. The tumour was totally removed by a translaberynthine approach with preservation of all left facial and cochlear nerves. Two months after surgery the patient noted a worsening hearing on the non-operated ear. PTA demonstrated a moderate-severe (75dB) left side SNHL. After 12 months, an improvement of the hearing level was observed (moderate SNHL – 50dB) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).Case 3: A 46-year-old male patient with a history of dizziness, tinnitus and right progressive hearing loss. The otoscopy was unremarkable and the PTA revealed a bilateral mild neurosensorial hearing loss. MRI demonstrated a right VS with a 18mm×10mm×16mm tumour extension to the CPA. The patient underwent a translaberynthine approach with total resection of the lesion. Eighteen months after surgery the patient experienced a worsening of hearing function on left side and the PTA showed a severe SNHL (90dB) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).Case 4: A 46-year-old male patient presented with a chief complaint of progressive bilateral hearing loss and an episode of dizziness 6 years ago. Otoscopy was normal and the electronystagmography testing demonstrated a left vestibular hypofunction with brain stem compromise. MRI demonstrated a left CPA lesion consistent with a VS, the tumour protruded to the CPA by 2mm×3mm×2.5mm. A retrosigmoid approach was performed with total resection of the tumour. Twelve months after surgery the patient had a worsening of hearing on the right ear. A PTA demonstrated a moderate-severe right side SNHL (75dB) (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).To sum up, they were 3 men and 1 woman, with an average tumour size of 12.5mm (range 7.8–22mm). The median time of appearance of the contralateral SNHL was 10 months (range 2–24 months) with an average of hearing loss in the contralateral ear at the moment of diagnosis of 50dB (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>).<elsevierMultimedia ident="tbl0005"></elsevierMultimedia>In all cases a complete neurological examination and otoscopy were performed. No patient reported a history of meningeal symptoms and the analysis of CSF was normal. To rule out infectious or autoimmune disease a routine battery of blood test was performed, including a full blood count, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibodies, anticardiolipin antibodies, lupus anticoagulant, antineutrophil cytoplasmic antibodies, clotting factors and syphilis serology. In all cases the study was negative.All patients were treated with oral corticosteroids (prednisone 1mg/kg/day for one month with dose reduction every five days) and with intratympanic corticosteroids (dexamethasone 4mg/ml one injection weekly for 3 weeks).After the treatment, partial recovery of hearing occurred, in 1 patient (moderate SNHL with PTA of 50dB). A severe SNHL (75–90dB) was developed in the other 3 patients.DiscussionCSNHL after VS removal is an extremely rare surgical complication, being described also in other posterior fossa procedures for other CPA tumours; in large clinical series, SNHL following surgery has been demonstrated in 1.2–4.5% of patients<a class="elsevierStyleCrossRefs" href="#bib0065">3–5</a>; in the present study, we reported 4 of 185 patients (2.2%) who developed a CSNHL. The mechanism of CSNHL remains unclear, including meningitis, ototoxicity, acoustic trauma due to drill noise, vascular compromise, autoimmune reaction, sympathetic cochleolabyrinthitis and compensatory endolymphatic hydrops.<a class="elsevierStyleCrossRef" href="#bib0070">4</a>Meningitis is the second most common complication after VS surgery. The presence of CSF leak increases the risk of meningitis with an incidence of 14% in patients with CSF leaks when compared with those without CSF leaks (2.5%). The mechanism of damage is a direct spread infection from the subarachnoid space to the cochlea with the cell damage mediated by endotoxins. None of our patients had any signs or symptoms consistent in meningitis and CSF analysis discarded an CSF infection.<a class="elsevierStyleCrossRefs" href="#bib0060">2,4</a>Tos et al. examined the effects of drill noise after a translabyrintine approach in the contralateral ear in 50 consecutive cases, being unable to detect one single case of CSNHL.<a class="elsevierStyleCrossRef" href="#bib0075">5</a>Vascular compromise is another possible cause of CSNHL, which has been described principally in relation to cardiac surgery. In this scenario, the hearing loss develops early (less than 1 week) and it mainly affects high frequencies, probably due to blood distribution or embolic events.<a class="elsevierStyleCrossRefs" href="#bib0080">6,7</a> In our cases the hearing loss appeared several months after surgery and it affected all the frequencies in the audiogram, making this cause improbable.Ototoxicity is another theoretically cause of a postoperative SNHL, operative exposure may be systemic (diuretics or prophylactic antibiotics) or topical (bacitracin irrigation).<a class="elsevierStyleCrossRef" href="#bib0070">4</a> None of our patients had received ototoxic agents during the stay.Loss of CSF is another possible reason of contralateral hearing loss, especially during the acoustic neuroma surgery.<a class="elsevierStyleCrossRef" href="#bib0085">7</a> During the surgery, the loss of CSF pressure is transmitted to the perilymph via the cochlear aqueduct, generating a compensatory expansion of the endolymph, similar to an endolymphatic hydrops. Lusting et al.<a class="elsevierStyleCrossRef" href="#bib0070">4</a> supports this theory being based in 2 facts; the first was the result of a electrocochleography made to one of his patients, that showed an increase of the SP/AP potential, highly indicative of endolymphatic hydrops; the second one is the fact that 3 of his patients presented a postoperative CSF fistula. They reported a 3 months recovery for the hearing loss. This theory could explain our results considering the type of surgical approach, but in our cases, none of our patients presented a postoperative fistula and our hearing results were comparatively worse.The autoimmunity, sympathetic cochleolabyrinthitis (SC), is another theory that might explain the CSNHL. The surgical injury could result, in a release of sequestered antigens to the systemic circulation, which would be capable of damaging to the contralateral ear, what has been named in ophthalmology as sympathetic ophthalmia, in which an immunologic response following eye trauma or surgery injuries the contralateral eye.<a class="elsevierStyleCrossRefs" href="#bib0090">8,9</a> This has been studied in animal models in which sensitized lymphocytes were able to transfer autoimmune inner disease, resulting in cellular infiltration by neutrophil granulocytes and lymphocytes in the scala tympani, loss of outer hair cells in the apical turn and loss of detection of TEOAE in the studied animals.<a class="elsevierStyleCrossRef" href="#bib0100">10</a>SC represents an explanation considering the time of onset of hearing loss of our patients, 80% of patients develop a lesion in the contralateral eye in the first three months due to a sympathetic ophthalmia.<a class="elsevierStyleCrossRef" href="#bib0090">8</a> The hearing loss of all frequencies, the association with vertigo and the good response to the steroids treatment of one of our patient could be explain with the SC theory.With regard to the treatment, the optimal treatment is also uncertain, steroids therapy has been used in some patients but there is no supportive evidence, and often the results are very poor.<a class="elsevierStyleCrossRef" href="#bib0065">3</a> Only one of our patients showed a good response after steroids treatment with a severe to moderate hearing level improvement.ConclusionsCSNHL after VS surgery is a rare but catastrophic complication that should be keep in mind by the surgeon.The mechanism behind this process remains unclear but the hearing loss of all frequencies and the association with vertigo and tinnitus could be explain by a SC.Established treatment guidelines do not exist, but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful.Conflicts of interestThe authors declare that they have no financial or other conflicts of interest in relation to this research and its publication." "textoCompletoSecciones" => array:1 [ "secciones" => array:11 [ 0 => array:3 [ "identificador" => "xres1184997" "titulo" => "Abstract" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec1105062" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1184996" "titulo" => "Resumen" "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec1105061" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Material and methods" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Discussion" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Conclusions" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 10 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-02-14" "fechaAceptado" => "2018-03-06" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1105062" "palabras" => array:4 [ 0 => "Contralateral hearing loss" 1 => "Vestibular schwannoma" 2 => "Surgery" 3 => "Complication" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1105061" "palabras" => array:4 [ 0 => "Hipoacusia contralateral" 1 => "Schwannoma vestibular" 2 => "Cirugía" 3 => "Complicación" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "IntroductionContralateral sensorineural hearing loss (CSNHL) after vestibular schwannoma (VS) is a severe complication, especially in those cases in which hearing preservation in the operated side was not possible. There are several theories that attempt to explain this issue, but there is no established guideline of treatment. Material and methodsWe report 4 patients treated in our institution who developed a severe CSNHL after surgery. ResultsOf the 185 cases of VS treated with surgery, 4 patients (2.2%) developed a CSNHL after VS surgery. After medical treatment, partial recovery of hearing occurred in one patient the other 3 patients presented a well-established severe SNHL. ConclusionsEstablished treatment guidelines do not exist, but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0005" "titulo" => "Introduction" ] 1 => array:2 [ "identificador" => "abst0010" "titulo" => "Material and methods" ] 2 => array:2 [ "identificador" => "abst0015" "titulo" => "Results" ] 3 => array:2 [ "identificador" => "abst0020" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "IntroducciónLa hipoacusia neurosensorial contralateral (HNSC) tras cirugía de schwannoma vestibular (SV) es una complicación grave, especialmente en aquellos casos en los que la preservación de la audición del lado intervenido no fue posible. Existen varias teorías que intentan explicar este problema, pero no existe una guía de tratamiento en estos casos. Material y métodosPresentamos los casos de 4 pacientes tratados en nuestro hospital que desarrollaron una HNSC severa tras cirugía de SV. ResultadosDe los 185 casos de SV tratados con cirugía, 4 pacientes (2,2%) desarrollaron una HNSC después de la cirugía. Tras el tratamiento médico se produjo recuperación parcial de la audición en un paciente, los otros 3 pacientes presentaron una HNS severa. ConclusionesNo existen guías de tratamiento, pero se recomienda el uso de altas dosis de corticosteroides y el implante coclear en casos sin recuperación y pérdida completa de la audición." "secciones" => array:4 [ 0 => array:2 [ "identificador" => "abst0025" "titulo" => "Introducción" ] 1 => array:2 [ "identificador" => "abst0030" "titulo" => "Material y métodos" ] 2 => array:2 [ "identificador" => "abst0035" "titulo" => "Resultados" ] 3 => array:2 [ "identificador" => "abst0040" "titulo" => "Conclusiones" ] ] ] ] "NotaPie" => array:1 [ 0 => array:3 [ "etiqueta" => "1" "nota" => "These authors contributed equally to this work." "identificador" => "fn1" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1611 "Ancho" => 2560 "Tamanyo" => 243716 ] ] "descripcion" => array:1 [ "en" => "Contralateral sensorineural hearing loss noted in a median time of eleven months following surgery. All patients had an ipsilateral severe-profound SNHL after de surgery." ] ] 1 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "F: female; M: male; R: right; L: left; IC: intracanalicular; RS: retrosigmoid approach; TL: translaberynthine approach." 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style="border-bottom: 2px solid black">Surgical approach \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contralateral preop HL (dB) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contralateral postop HL (dB) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Onset (months) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associate symptoms \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry " align="char" 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Contralateral sensorineural hearing loss after vestibular schwannoma surgery

Hipoacusia neurosensorial contralateral tras cirugía de schwannoma vestibular

Patricia García-Cabo1,

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patriciagcabo@gmail.com

Corresponding author.

, Fernando Rivas1, Fernando López, Andrés Coca, José Luis Llorente, Justo R. Gómez

Department of Otorhinolaryngology and Head and Neck Surgery, Hospital Universitario Central de Asturias, Oviedo, Spain

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      "titulo" => "Oral benign neoplasms&#58; A retrospective study of 790 patients over a 14-year period"
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          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Contralateral sensorineural hearing loss noted in a median time of eleven months following surgery&#46; All patients had an ipsilateral severe-profound SNHL after de surgery&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Most of the cerebellopontine angle &#40;CPA&#41; tumours are vestibular schwannoma &#40;VS&#41; &#40;80&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> There are different treatment options for managing these tumours&#46; Microsurgical resection of VS is one of them&#44; which has potential complications such as cerebrospinal fluid &#40;CSF&#41; leak&#44; meningitis&#44; cranial nerve damage&#44; or intracranial haemorrhage&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Recently&#44; CSHL after VS resection has been described<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a> resulting in a severe complication&#44; especially if hearing preservation in the operated side was not a reachable outcome&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Material and methods</span><p id="par0010" class="elsevierStylePara elsevierViewall">We performed a retrospective review of the VS operated in our institution between 2004 and 2015&#46; Of the 185 cases of VS treated with surgery&#44; 4 patients &#40;2&#46;2&#37;&#41; developed a CSNHL after VS surgery&#46; We described our experience of these 4 patients who developed a CSNHL after VS surgery&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Results</span><p id="par0015" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Case 1</span>&#58; A 52-year-old woman presented with a 3-year history of a right progressive hearing loss&#46; The otoscopy was normal on both sides and the electronystagmography testing presented with signs consistent with peripheral right vestibular hypofunction&#46; Pure-tone audiometry &#40;PTA&#41; revealed a mild SNHL at high frequencies on the right side&#46; Magnetic resonance imaging &#40;MRI&#41; showed a right CPA lesion consistent with a VS&#44; the tumour protruded to the CPA by 22<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>21<span class="elsevierStyleHsp" style=""></span>mm&#46; A retrosigmoid approach was performed with total resection of the tumour&#46; Two months after surgery the patient complained of worsening hearing loss on the non-operated ear&#46; PTA demonstrated a moderate-severe &#40;&#62;70<span class="elsevierStyleHsp" style=""></span>dB&#41; left side SNHL &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Case 2</span>&#58; A 53-year-old male patient presented with a 6-month history of dizziness and tinnitus and right sudden hearing loss&#46; MRI depicted a 7&#46;8<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>5&#46;4<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>4&#46;2<span class="elsevierStyleHsp" style=""></span>mm right intracanalicular &#40;IC&#41; VS&#46; The otoscopy was normal and the PTA showed a mild SNHL on the left side and a moderate SNHL on the right side&#46; The tumour was totally removed by a translaberynthine approach with preservation of all left facial and cochlear nerves&#46; Two months after surgery the patient noted a worsening hearing on the non-operated ear&#46; PTA demonstrated a moderate-severe &#40;75<span class="elsevierStyleHsp" style=""></span>dB&#41; left side SNHL&#46; After 12 months&#44; an improvement of the hearing level was observed &#40;moderate SNHL &#8211; 50<span class="elsevierStyleHsp" style=""></span>dB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Case 3</span>&#58; A 46-year-old male patient with a history of dizziness&#44; tinnitus and right progressive hearing loss&#46; The otoscopy was unremarkable and the PTA revealed a bilateral mild neurosensorial hearing loss&#46; MRI demonstrated a right VS with a 18<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>10<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>16<span class="elsevierStyleHsp" style=""></span>mm tumour extension to the CPA&#46; The patient underwent a translaberynthine approach with total resection of the lesion&#46; Eighteen months after surgery the patient experienced a worsening of hearing function on left side and the PTA showed a severe SNHL &#40;90<span class="elsevierStyleHsp" style=""></span>dB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall"><span class="elsevierStyleBold">Case 4</span>&#58; A 46-year-old male patient presented with a chief complaint of progressive bilateral hearing loss and an episode of dizziness 6 years ago&#46; Otoscopy was normal and the electronystagmography testing demonstrated a left vestibular hypofunction with brain stem compromise&#46; MRI demonstrated a left CPA lesion consistent with a VS&#44; the tumour protruded to the CPA by 2<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>mm<span class="elsevierStyleHsp" style=""></span>&#215;<span class="elsevierStyleHsp" style=""></span>2&#46;5<span class="elsevierStyleHsp" style=""></span>mm&#46; A retrosigmoid approach was performed with total resection of the tumour&#46; Twelve months after surgery the patient had a worsening of hearing on the right ear&#46; A PTA demonstrated a moderate-severe right side SNHL &#40;75<span class="elsevierStyleHsp" style=""></span>dB&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">To sum up&#44; they were 3 men and 1 woman&#44; with an average tumour size of 12&#46;5<span class="elsevierStyleHsp" style=""></span>mm &#40;range 7&#46;8&#8211;22<span class="elsevierStyleHsp" style=""></span>mm&#41;&#46; The median time of appearance of the contralateral SNHL was 10 months &#40;range 2&#8211;24 months&#41; with an average of hearing loss in the contralateral ear at the moment of diagnosis of 50<span class="elsevierStyleHsp" style=""></span>dB &#40;<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0040" class="elsevierStylePara elsevierViewall">In all cases a complete neurological examination and otoscopy were performed&#46; No patient reported a history of meningeal symptoms and the analysis of CSF was normal&#46; To rule out infectious or autoimmune disease a routine battery of blood test was performed&#44; including a full blood count&#44; erythrocyte sedimentation rate&#44; C-reactive protein&#44; antinuclear antibodies&#44; anticardiolipin antibodies&#44; lupus anticoagulant&#44; antineutrophil cytoplasmic antibodies&#44; clotting factors and syphilis serology&#46; In all cases the study was negative&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">All patients were treated with oral corticosteroids &#40;prednisone 1<span class="elsevierStyleHsp" style=""></span>mg&#47;kg&#47;day for one month with dose reduction every five days&#41; and with intratympanic corticosteroids &#40;dexamethasone 4<span class="elsevierStyleHsp" style=""></span>mg&#47;ml one injection weekly for 3 weeks&#41;&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">After the treatment&#44; partial recovery of hearing occurred&#44; in 1 patient &#40;moderate SNHL with PTA of 50<span class="elsevierStyleHsp" style=""></span>dB&#41;&#46; A severe SNHL &#40;75&#8211;90<span class="elsevierStyleHsp" style=""></span>dB&#41; was developed in the other 3 patients&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Discussion</span><p id="par0055" class="elsevierStylePara elsevierViewall">CSNHL after VS removal is an extremely rare surgical complication&#44; being described also in other posterior fossa procedures for other CPA tumours&#59; in large clinical series&#44; SNHL following surgery has been demonstrated in 1&#46;2&#8211;4&#46;5&#37; of patients<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3&#8211;5</span></a>&#59; in the present study&#44; we reported 4 of 185 patients &#40;2&#46;2&#37;&#41; who developed a CSNHL&#46; The mechanism of CSNHL remains unclear&#44; including meningitis&#44; ototoxicity&#44; acoustic trauma due to drill noise&#44; vascular compromise&#44; autoimmune reaction&#44; sympathetic cochleolabyrinthitis and compensatory endolymphatic hydrops&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Meningitis is the second most common complication after VS surgery&#46; The presence of CSF leak increases the risk of meningitis with an incidence of 14&#37; in patients with CSF leaks when compared with those without CSF leaks &#40;2&#46;5&#37;&#41;&#46; The mechanism of damage is a direct spread infection from the subarachnoid space to the cochlea with the cell damage mediated by endotoxins&#46; None of our patients had any signs or symptoms consistent in meningitis and CSF analysis discarded an CSF infection&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">2&#44;4</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Tos et al&#46; examined the effects of drill noise after a translabyrintine approach in the contralateral ear in 50 consecutive cases&#44; being unable to detect one single case of CSNHL&#46;<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a></p><p id="par0070" class="elsevierStylePara elsevierViewall">Vascular compromise is another possible cause of CSNHL&#44; which has been described principally in relation to cardiac surgery&#46; In this scenario&#44; the hearing loss develops early &#40;less than 1 week&#41; and it mainly affects high frequencies&#44; probably due to blood distribution or embolic events&#46;<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6&#44;7</span></a> In our cases the hearing loss appeared several months after surgery and it affected all the frequencies in the audiogram&#44; making this cause improbable&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Ototoxicity is another theoretically cause of a postoperative SNHL&#44; operative exposure may be systemic &#40;diuretics or prophylactic antibiotics&#41; or topical &#40;bacitracin irrigation&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> None of our patients had received ototoxic agents during the stay&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">Loss of CSF is another possible reason of contralateral hearing loss&#44; especially during the acoustic neuroma surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a> During the surgery&#44; the loss of CSF pressure is transmitted to the perilymph via the cochlear aqueduct&#44; generating a compensatory expansion of the endolymph&#44; similar to an endolymphatic hydrops&#46; Lusting et al&#46;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> supports this theory being based in 2 facts&#59; the first was the result of a electrocochleography made to one of his patients&#44; that showed an increase of the SP&#47;AP potential&#44; highly indicative of endolymphatic hydrops&#59; the second one is the fact that 3 of his patients presented a postoperative CSF fistula&#46; They reported a 3 months recovery for the hearing loss&#46; This theory could explain our results considering the type of surgical approach&#44; but in our cases&#44; none of our patients presented a postoperative fistula and our hearing results were comparatively worse&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The autoimmunity&#44; sympathetic cochleolabyrinthitis &#40;SC&#41;&#44; is another theory that might explain the CSNHL&#46; The surgical injury could result&#44; in a release of sequestered antigens to the systemic circulation&#44; which would be capable of damaging to the contralateral ear&#44; what has been named in ophthalmology as <span class="elsevierStyleItalic">sympathetic ophthalmia</span>&#44; in which an immunologic response following eye trauma or surgery injuries the contralateral eye&#46;<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">8&#44;9</span></a> This has been studied in animal models in which sensitized lymphocytes were able to transfer autoimmune inner disease&#44; resulting in cellular infiltration by neutrophil granulocytes and lymphocytes in the scala tympani&#44; loss of outer hair cells in the apical turn and loss of detection of TEOAE in the studied animals&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a></p><p id="par0090" class="elsevierStylePara elsevierViewall">SC represents an explanation considering the time of onset of hearing loss of our patients&#44; 80&#37; of patients develop a lesion in the contralateral eye in the first three months due to a sympathetic ophthalmia&#46;<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The hearing loss of all frequencies&#44; the association with vertigo and the good response to the steroids treatment of one of our patient could be explain with the SC theory&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">With regard to the treatment&#44; the optimal treatment is also uncertain&#44; steroids therapy has been used in some patients but there is no supportive evidence&#44; and often the results are very poor&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Only one of our patients showed a good response after steroids treatment with a severe to moderate hearing level improvement&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Conclusions</span><p id="par0100" class="elsevierStylePara elsevierViewall">CSNHL after VS surgery is a rare but catastrophic complication that should be keep in mind by the surgeon&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">The mechanism behind this process remains unclear but the hearing loss of all frequencies and the association with vertigo and tinnitus could be explain by a SC&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">Established treatment guidelines do not exist&#44; but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors declare that they have no financial or other conflicts of interest in relation to this research and its publication&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Introduction</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Contralateral sensorineural hearing loss &#40;CSNHL&#41; after vestibular schwannoma &#40;VS&#41; is a severe complication&#44; especially in those cases in which hearing preservation in the operated side was not possible&#46; There are several theories that attempt to explain this issue&#44; but there is no established guideline of treatment&#46;</p></span> <span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Material and methods</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We report 4 patients treated in our institution who developed a severe CSNHL after surgery&#46;</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Results</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Of the 185 cases of VS treated with surgery&#44; 4 patients &#40;2&#46;2&#37;&#41; developed a CSNHL after VS surgery&#46; After medical treatment&#44; partial recovery of hearing occurred in one patient the other 3 patients presented a well-established severe SNHL&#46;</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Conclusions</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Established treatment guidelines do not exist&#44; but the use of high doses of corticosteroids has been recommended and cochlear implant in cases with no recovery and complete hearing loss may be useful&#46;</p></span>"
        "secciones" => array:4 [
          0 => array:2 [
            "identificador" => "abst0005"
            "titulo" => "Introduction"
          ]
          1 => array:2 [
            "identificador" => "abst0010"
            "titulo" => "Material and methods"
          ]
          2 => array:2 [
            "identificador" => "abst0015"
            "titulo" => "Results"
          ]
          3 => array:2 [
            "identificador" => "abst0020"
            "titulo" => "Conclusions"
          ]
        ]
      ]
      "es" => array:3 [
        "titulo" => "Resumen"
        "resumen" => "<span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Introducci&#243;n</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">La hipoacusia neurosensorial contralateral &#40;HNSC&#41; tras cirug&#237;a de schwannoma vestibular &#40;SV&#41; es una complicaci&#243;n grave&#44; especialmente en aquellos casos en los que la preservaci&#243;n de la audici&#243;n del lado intervenido no fue posible&#46; Existen varias teor&#237;as que intentan explicar este problema&#44; pero no existe una gu&#237;a de tratamiento en estos casos&#46;</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Material y m&#233;todos</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Presentamos los casos de 4 pacientes tratados en nuestro hospital que desarrollaron una HNSC severa tras cirug&#237;a de SV&#46;</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Resultados</span><p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">De los 185 casos de SV tratados con cirug&#237;a&#44; 4 pacientes &#40;2&#44;2&#37;&#41; desarrollaron una HNSC despu&#233;s de la cirug&#237;a&#46; Tras el tratamiento m&#233;dico se produjo recuperaci&#243;n parcial de la audici&#243;n en un paciente&#44; los otros 3 pacientes presentaron una HNS severa&#46;</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusiones</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">No existen gu&#237;as de tratamiento&#44; pero se recomienda el uso de altas dosis de corticosteroides y el implante coclear en casos sin recuperaci&#243;n y p&#233;rdida completa de la audici&#243;n&#46;</p></span>"
        "secciones" => array:4 [
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            "identificador" => "abst0025"
            "titulo" => "Introducci&#243;n"
          ]
          1 => array:2 [
            "identificador" => "abst0030"
            "titulo" => "Material y m&#233;todos"
          ]
          2 => array:2 [
            "identificador" => "abst0035"
            "titulo" => "Resultados"
          ]
          3 => array:2 [
            "identificador" => "abst0040"
            "titulo" => "Conclusiones"
          ]
        ]
      ]
    ]
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        "etiqueta" => "1"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0010">These authors contributed equally to this work&#46;</p>"
        "identificador" => "fn1"
      ]
    ]
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        "descripcion" => array:1 [
          "en" => "<p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Contralateral sensorineural hearing loss noted in a median time of eleven months following surgery&#46; All patients had an ipsilateral severe-profound SNHL after de surgery&#46;</p>"
        ]
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      1 => array:8 [
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        "detalles" => array:1 [
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            "identificador" => "at1"
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        "tabla" => array:3 [
          "leyenda" => "<p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">F&#58; female&#59; M&#58; male&#59; R&#58; right&#59; L&#58; left&#59; IC&#58; intracanalicular&#59; RS&#58; retrosigmoid approach&#59; TL&#58; translaberynthine approach&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Case&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Age&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Sex&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Side&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Size &#40;mm&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Surgical approach&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contralateral preop HL &#40;dB&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Contralateral postop HL &#40;dB&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Onset &#40;months&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Associate symptoms&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Outcome&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">F&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">22&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">70&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vertigo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe SNHL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;8 &#40;IC&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vertigo&#47;tinnitus&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Moderate SNHL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">R&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">TL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">25&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">24<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Tinnitus&#47;joint pain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe SNHL<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="char" valign="top">4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">46&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">M&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">L&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">RS&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">75&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12<span class="elsevierStyleHsp" style=""></span>m&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Vertigo&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Severe SNHL&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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            0 => array:3 [
              "identificador" => "tblfn0005"
              "etiqueta" => "a"
              "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Gait disturbance&#46;</p>"
            ]
          ]
        ]
        "descripcion" => array:1 [
          "en" => "<p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Patients with contralateral hearing loss after acoustic neuroma surgery&#46;</p>"
        ]
      ]
    ]
    "bibliografia" => array:2 [
      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:10 [
            0 => array:3 [
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              "referencia" => array:1 [
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                  "contribucion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
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                            0 => "A&#46;P&#46; Calzada"
                            1 => "J&#46;L&#46; Go"
                            2 => "D&#46;L&#46; Tschirhart"
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                            4 => "M&#46;S&#46; Schwartz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
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                      "Revista" => array:5 [
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              ]
            ]
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                            0 => "M&#46; Tos"
                            1 => "N&#46; Trojaborg"
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                          ]
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                          "etal" => false
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                            1 => "U&#46;K&#46; Andreassen"
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                          ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Contralateral hearing loss after acoustic neuroma surgery"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:6 [
                            0 => "S&#46; Togashi"
                            1 => "J&#46; Maruya"
                            2 => "C&#46; Nerome"
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Article information

ISSN: 00016519
Original language: English

DOI:10.1016/j.otorri.2018.03.007

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Year/Month	Html	Pdf	Total

2023 March	2	3	5
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