Association between superior semicircular canal dehiscence and other dehiscences in temporal bone

Folia Mo phol. Vol. 79, No. 4, pp. 823–828 DOI: 10.5603/FM.a2019.0138 Copy igh © 2020 Via Medica ISSN 0015–5659 jou nals. iamedica.pl O R I G I N A L A R T I C L E 823 Add ess o co espondence: D . A.I. Cisne os, Ana omy and His ology Depa men , School o Medicine, Za agoza Uni e si y, Spain, e-mail: aicisne @uniza .es Associa ion be ween supe io semici cula canal dehiscence and o he dehiscences in empo al bone J. Why e1, A.I. Cisne os1, A. Ga cia-Ba ios1, J. F aile2, A. Why e3, R. C o e o4, M. Lahoz1 1Ana omy and His ology Depa men , School o Medicine, Za agoza Uni e si y, Spain 2Pa hology Depa men , Miguel Se e Hospi al, Spain 3Pa hology Depa men , School o Ve e ina y, Za agoza Uni e si y, Spain 4Bilbao Clinic, Spain [Recei ed: 14 Oc obe 2019; Accep ed: 3 Decembe 2019] Backg ound: The s udy o he associa ion be ween supe io semici cula canal and o he dehiscences in he empo al bone. Ma e ials and me hods: We ha e s udied compu ed omog aphy o adiologically diagnosed people wi h supe io o pos e io semici cula canal dehiscences, in ou heal h cen es. In addi ion, we ha e s udied one isola ed human empo al bone, one skull and one cada e head belonging o he collec ion o he Depa men o Human Ana omy and His ology o he Uni e si y o Za agoza ha had dehiscence in he supe io semici cula canal. Resul s: The mos equen associa ion ha we obse ed was be ween supe io semici cula canal dehiscence and egmen ympani dehiscence (37.33%). Th ee cases ( wo clinical cases and one isola ed empo al bone) showed mul iple associ- a ed dehiscences ( egmen ympani, mas oid an um, pos e io semici cula canal, in e nal audi o y canal, glenoid ca i y, ympanum bone and genicula e ganglion) associa ed wi h supe io semici cula canal dehiscence Conclusions: When he supe io semici cula canal dehiscence is associa ed o o he in he pe ous bone ( egmen ympani, mas oid an um, pos e io semici cula canal, in e nal audi o y canal) could be g ouped in o he same synd ome called “o ic capsule synd ome”, since hey ha e he same o igin and common ae iology (o ic capsule). (Folia Mo phol 2020; 79, 4: 823–828) Key wo ds: bony laby in h, o ic capsule, bony de ec s g oup, hi d window INTRODUCTION A miles one in he s udy o supe io semici cu- la canal (SSC) pa hology was he manusc ip by Mino [22] in 1998, who i s desc ibed he p es- ence o dehiscence in he canal. This dehiscence is a a e and uncommon pe iphe al es ibulopa hy, which is cha ac e ised by a lack o bone co e age o he SSC in he a ea closes o he du a o he middle ce eb al ossa. Since ha da e, s udies ha e been conduc ed o in es iga e i s p e alence, pa hophysiology, clinical a iables, diagnosis and su gical p ocedu es. The e a e cu en ly wo heo ies abou he gen- esis o dehiscence: congeni al (s op o delay in he ossi ica ion o he canal du ing i s de elopmen ) and acqui ed (bone laye up u e co e ing he canal as 824 Folia Mo phol., 2020, Vol. 79, No. 4 a esul o ano he e en , as inc eased in ac anial p essu e, auma, e en a e childbi h o coi us). The associa ion o SSC dehiscence wi h o he ea diseases [4, 9, 27] and o he dehiscences p oduced in he bone laby in h is cu en ly being in es iga ed. In his line, associa ions be ween dehiscence o he SSC and dehiscence o he pos e io semici cu- la canal ha e been desc ibed [6, 15, 18, 20, 21]. Bo h dehiscences show a simila , nonspeci ic clini- cal p esen a ion, some imes he audi o y symp oms (hypoacusis, inni us) and some imes he es ibula ones (dizziness, nys agmus, Tullio phenomenon) p e- domina e; hey may no e en p esen any. The e may also be cases whe e he e a e dehis- cences in o he s uc u es such as he egmen ym- pani [1, 5, 24], genicula e ganglion [10, 13, 17] and in e nal audi o y canal [19]. The objec i e o his s udy is o de e mine adio- logically on he one hand, he possible associa ions be ween dehiscence in he supe io and pos e io semici cula canal, and on he o he , bo h dehiscences wi h o he mo phological al e a ions in he empo al bone (glenoid ca i y and in e nal audi o y canal). MATERIALS AND METHODS We ha e s udied compu ed omog aphy (CT) o adiologically diagnosed people wi h supe io o pos- e io semici cula canal dehiscences, in ou heal h cen es: Basu o and C uces Hospi al, Gene al Hos- pi al o he De ence and Miguel Se e Hospi al in Za agoza. An in o med consen o m was signed by e e y pa icipa ing pa ien . All he pa ien s ac- knowledged ha hey canno be iden i ied ia he pape ; he esea che s ully anonymised hem. The e hics commi ee o each cen e app o ed his s udy in acco dance wi h he guidelines o he Helsinki Decla a ion o 1983. The s udies ha e been pe o med wi h mul i-splice helical CT equipmen (Philips B illiance 6), ob aining he images on he axial plane and wi h he pa ien ’s neck in hype ex ension o a oid di ec adia ion dam- age o c ys alline. La e , co onal econs uc ions ha e been ca ied ou in all he cases, in he plane o he SSC o each ea (Pöschl plane) and in axial planes o he pos e io semici cula canals. The oo o he glenoid ca i y has been s udied wi h sagi al plane econs uc ions. The “ aw da a” ha e been econs uc ed using a bone algo i hm. The ollowing adiological p o ocols o he acqui- si ion and o ma ing o he images ha e been used: 2 × 0.6 mm collima ion, 0.65 mm splice hickness, 0.32 mm splice inc ease, 0.75 s o a ion ime, 0.38 pi ch, 120 CV, 300 mAs, 1024 × 1024 ma ix, 180 mm ield o ision, 0.5 mm econs uc ion hickness and 0.5 mm econs uc ion inc ease. The CT scans we e upda ed by 3 adiologis s wi h mo e han 10 yea s o expe ience in neu o adiology and e iewed by he signa o ies o he manusc ip , all o hem wi h ex ensi e expe ience in dehiscence o semici cula canals. RESULTS We ha e pe o med a adiological s udy on a o al o 61 pa ien s (20 men, 41 women) wi h an a e age age o 55.98 yea s ( anging 2–89), in e ms o he possible associa ions be ween (supe io and pos e i- o ) e ical semici cula canal dehiscence, and o he dehiscences loca ed in he empo al bone. Two o he pa ien s, who p esen ed unila e al SSC dehiscence, we e sis e s. Se en y one cases o SSC dehiscence and 4 o pos- e io semici cula canal dehiscence we e de ec ed. Thi y-one dehiscences we e de ec ed on he igh side in he SSC, 20 on he le side, and bila e al dehiscences (28.16%) we e obse ed in 10 pa ien s (20 cases) (Table 1). Two dehiscences we e de ec ed on he igh side in he pos e io semici cula canal, and ano he wo on he le side, and he e was one bila e al case. The mos equen associa ion ha we obse ed was be ween SSC dehiscence and egmen ympa- ni dehiscence, which was e i ied in a o al o 28 (39.44%) cases. Two cases p esen ed mul iple associa ed dehis- cences (Fig. 1). Thus, he i s case p esen ed bila e al supe io semici cula dehiscences (Fig. 1A), bila e al egmen ympani dehiscences, and dehiscence in he glenoid ca i y o he empo omandibula join on he Table 1. Dis ibu ion o supe io semici cula canal (SSC) dehiscence and pos e io semici cula canal (PSC) dehiscence Righ side Le side Bila e al SSC 31/71 (43.67%) 20/71 (28.17%) 20/71 (28.16%) PSC 1/4 (25%) 1/4 (25%) 2/4 (50%) 825 J. Why e e al., Associa ion be ween SSC dehiscence and o he s igh side (Fig. 1B). The o he cases showed bila e al supe io and pos e io semici cula canal dehiscences (Fig. 1D), bila e al egmen ympani dehiscences, and dehiscence o he oo o he in e nal audi o y canal (Fig. 1C) on he igh side (Table 2). DISCUSSION Supe io semici cula canal dehiscence, as a s u- c u al cause o dizziness and hypoacusis, is only 20 yea s old [22], so he e a e s ill knowledge gaps ela ed o his pa hology. Fi e yea s la e i would be K ombach e al. [14] who desc ibed pos e io semi- ci cula canal dehiscence. The i s au ho s who desc ibed associa ions be- ween de ec s o he bony co e age o he SSC and o he pa s o he bony laby in h was Mino [23] who obse ed an associa ion be ween egmen dehiscence and he SSC. One yea la e , Gianoli [10] unde lined he high incidence o pa ien s who also p esen ed a- diog aphic supe io canal dehiscence wi h genicula e ganglion dehiscence. La e , Manza i and Modugno [18] and Chen e al. [3] desc ibed isola ed cases o SSC dehiscences associa ed wi h pos e io canal dehis- cences, he o me in adul s, and he la e in child en. In la ge se ies o pe sons wi h SSC dehiscence, he a ec a ion was ound o be bila e al, in pe cen ages ha a ied be ween 16% and 37%. These da a a e e y simila o hose obse ed by us, as we ha e eg- is e ed an incidence o 34.48%. Figu e 1. Di e en associa ions be ween supe io semici cula canal dehiscence wi h o he s in he empo al bone; A. Supe io semici cula canal dehiscence (black a ow); B. Tegmen ympani (black a ow), glenoid ca i y (whi e a ow); C. Tegmen ympani (black a ow), in e nal audi o y canal (IAC; whi e a ow); D. Pos e io semici cula canal dehiscence (PSCD; whi e a ow). Table 2. Associa ion o empo al bone dehiscences TTD IACD GFD SSCD 28/71 (39.44%) 1/71 (1.41%) 1/71 (1.41%) PSCD 2/4 (50%) 1/4 (25%) 0/4 (0%) SSCD — supe io semici cula canal dehiscence; PSCD — pos e io semici cula canal dehiscence; TTD — egmen ympani dehiscence; IACD — in e nal audi o y canal dehi- scence; GFD — glenoid ca i y dehiscence A B C D 826 Folia Mo phol., 2020, Vol. 79, No. 4 The p esence o bila e al pos e io semici cula ca- nal dehiscences is no e y equen , and hey a e lim- i ed o isola ed cases such as hose desc ibed by Saxby e al. [30] and Bea e al. [2]. We ha e also obse ed one single isola ed case o bila e al dehiscence, bu we mus conside ha pos e io semici cula dehis- cence is much less equen han supe io semici cula dehiscence, being 3.6% and 0.6%, espec i ely [5]. The associa ion be ween supe io and pos e io ca- nal dehiscence has been desc ibed by K ombach e al. [14], who obse ed 8 pa ien s wi h pos e io and SSC dehiscences. Chen e al. [3] also ob ained 1 case wi h bo h dehiscences. Gopen e al. [11] obse ed ha 2 o he 12 pa ien s wi h pos e io semici cula canal dehiscences also p esen ed SSC dehiscences. Russo e al. [29] desc ibed ha in 3 o he 5 cases wi h pos- e io semici cula canal dehiscence we e associa ed o dehiscences in he supe io canal. Saxby e al. [30] communica ed 1 case o a child wi h bila e al supe io unila e al and pos e io canal dehiscence. Kundaga i e al. [15] also p esen ed a case o a pa ien wi h bila - e al pos e io semici cula canal dehiscence, oge he wi h igh supe io canal dehiscence. We ound only 1 case in which he 2 dehiscences we e associa ed, among he 61 pa ien s s udied, which deno es he low equency o his associa ion since hey we e selec ed pa ien s. The mos equen associa ion ound, which has clinical epe cussion, was wi h he egmen ympani. C o e o e al. [5] ound a 36.4% incidence o dehis- cen egmens associa ed wi h SSC dehiscence, and Nada aja e al. [24] ound 76%. In he e e se s udy, El Hadi e al. [7] ound a 56.5% incidence o dehis- cen semici cula canals in pa ien s who p esen ed e i ied dehiscence o he egmen ympani. We ha e obse ed his associa ion in 28 o he cases s udies (37.33%) and we hink ha he explana ion would be, as p oposed by F aile Rod igo e al. [8], ha bo h s uc u es ha e a common o igin, he o ic capsule, and ha he p ima y cen es o he ex e nal o la e al SSCs, which, when hey g ow, ex end o he base o he egmen al p olonga ion, collabo a e in he ossi ica ion o he egmen ympani. In addi ion o his, he ex e nal pe ios ium laye , which sepa a es he egmen om he middle c anial ossa, is a con inua ion o he laye ha co e s he SSC. We ha e no ound in he li e a u e any manusc ip ha ela es he pos e io semici cula canal dehiscence wi h he absence o egmen ympani, while we ha e ound i in in 2 o he 4 cases o pos e io semici cula canal dehiscence (50%). The associa ion o SSC dehiscences wi h in e nal audi o y canal dehiscences has only been desc ibed in li e a u e by Manza i and Scagnelli [19]. We ha e obse ed 1 case in which SSC dehiscences we e as- socia ed wi h in e nal audi o y canal and pos e io canal dehiscence. In he li e a u e consul ed, we ha e no obse ed any associa ion be ween SSC dehiscence and glenoid ca i y dehiscence o he empo omandibula join o o he ympanic bone, and only Ku e al. [16] associa es SSC dehiscence wi h symp oms in he empo omandibula join , desc ibing he la ening o he condyle, i egu- la i ies on he su ace and o ma ion o os eophy es, as adiological indings. We ha e seen hese associa ions in a adiological s udy which leads us o conside ha one same cause could ac du ing de elopmen , bo h in he squamous po ion o he empo al bone and in he o ic capsule, al hough he o igin is no ye clea . The e o e, we ha e obse ed ha he cases o SSC dehiscence associa ed wi h o he empo al bone dehiscences a e ew and a be ween, ei he loca ed in he pe ous apophysis, in he squamous po ion o he empo al bone o in he ympanic bone. To unde s and he ae iology o mul iple dehiscenc- es, an emb yological cause ha ac s upon he o ic cap- sule mus be sough . Thus, Isaacson and V abec [13] and Pa k e al. [26] obse ed ha he bony o ic cap- sule was signi ican ly hinne in pa ien s wi h associ- a ed SSC dehiscence. G acia-Tello e al. [12] concludes ha he exis ence o supe io semici cula dehiscence is associa ed wi h he hinning o he bone o he ca- nal on he opposi e side, and Manza i and Modugno [18] hink ha he associa ion be ween wo bone s uc u es ha p esen dehiscences, and de i e om he o ic capsule, is p esen ed as suppo o he idea ha i is a congeni al ype diso de . Nies en e al. [25] in o m o h ee amilies in which he i s -deg ee ela i es show SSC dehiscences, and El Hadi e al. [7] egis e ed wo wins in he se ies ha hey s udied, wi h bo h SSC dehiscence and egmen ympani dehiscence. These e en s sugges gene ic ae iology. In ou s udy, we ha e ound SSC dehiscence in 2 sis e s, which sugges s, in ha case, a gene ic componen . Howe e , in ou s udies abou COACH synd ome and in he s udies conduc ed by Roknic e al. [28], demons a ing a cons an gene ic diso de associa ed wi h hese dehiscences has no been possible. Wackym e al. [31] coins a new e m, “o ic capsule synd ome”, o de ine he exis ence o associa ed de- 827 J. Why e e al., Associa ion be ween SSC dehiscence and o he s hiscences be ween he di e en semici cula canals, and he bases his on he ac ha hese pa hologies ha e e y simila symp oms, whe he implan ed in (supe io and pos e io ) e ical canals o in he (la e - al) ho izon al canal. We would use his e m o when in he CT scans ind mul iple dehiscences o s uc u es de i ed om he o ic capsule ( egmen ympani, mas- oid an um, pos e io semici cula conduc , in e nal audi o y canal). We ha e no ound clinical ea u es o dis inguish pa ien s wi h SSC dehiscence om he pos e io , and bo h wi h o he empo al bone dehiscences. CONCLUSIONS The e o e, and in conclusion, we hink ha SSC dehiscence may ha e a congeni al cause and be as- socia ed wi h o he dehiscences, and in ou clinical p ac ice, we mus seek hese associa ions whene e we encoun e a diso de in he bony co e age o he empo al bone, as al eady ecommended when a egmen ympani o SSC dehiscence is diagnosed. In ag eemen wi h ou obse a ions, e iews and a e analysing he emb yological de elopmen , we conside ha he exis ence o mal o ma ion syn- d omes in which he e is an associa ion o mul iple s uc u e dehiscences, bo h o he o ic capsule and o he empo al bone, is e y likely. REFERENCES 1. Allen KP, Pe ez CL, Isaacson B, e al. Supe io semici cula canal dehiscence in pa ien s wi h spon aneous ce eb o- spinal luid o o hea. O ola yngol Head Neck Su g. 2012; 147(6): 1120–1124, doi: 10.1177/0194599812457545, indexed in Pubmed: 22886079. 2. Bea ZW, McE oy TP, Mikulec AA. Quan i ica ion o hea ing loss in pa ien s wi h pos e io semici cula canal dehis- cence. Ac a O ola yngol. 2015; 135(10): 974–977, doi: 10.3109/00016489.2015.1060630, indexed in Pubmed: 26107020. 3. Chen EY, Paladin A, Phillips G, e al. Semici cula canal dehiscence in he pedia ic popula ion. In J Pedia O o hinola yngol. 2009; 73(2): 321–327, doi: 10.1016/j. ijpo l.2008.10.027, indexed in Pubmed: 19091428. 4. Cho YW, Shim BS, Kim JiW, e al. P e alence o adio- logic supe io canal dehiscence in no mal ea s and ea s wi h ch onic o i is media. La yngoscope. 2014; 124(3): 746–750, doi: 10.1002/la y.24281, indexed in Pubmed: 23794324. 5. C o e o M, Why e J, Rod iguez OM, e al. Ana omo- adio- logical s udy o he supe io semici cula canal dehiscence adiological conside a ions o supe io and pos e io semici cula canals. Eu J Radiol. 2010; 76(2): 167–172, doi: 10.1016/j.ej ad.2009.05.038, indexed in Pubmed: 19540691. 6. Dang PT, Kennedy TA, Gubbels SP. Simul aneous, uni- la e al plugging o supe io and pos e io semici cula canal dehiscences o ea debili a ing hype acusis. J La yngol O ol. 2014; 128(2): 174–178, doi: 10.1017/ S0022215113003605, indexed in Pubmed: 24480590. 7. El Hadi T, So en ino T, Calmels MN, e al. Spon aneous egmen de ec and semici cula canal dehiscence: same e iopa hogenic en i y? O ol Neu o ol. 2012; 33(4): 591– –595, doi: 10.1097/MAO.0b013e31824bae10, indexed in Pubmed: 22429945. 8. F aile Rod igo JJ, Cisne os AI, Obón J, e al. On ogene ic explana ion o egmen ympani dehiscence and supe io semici cula canal dehiscence associa ion. Ac a O o - inola ingol Esp. 2016; 67(4): 226–232, doi: 10.1016/j. o o i.2015.09.006, indexed in Pubmed: 26738982. 9. Ga ell BC, Gen y LR, Kennedy TA, e al. Radiog aphic ea u es o supe io semici cula canal dehiscence in he se ing o ch onic ea disease. O ol Neu o ol. 2014; 35(1): 91–96, doi: 10.1097/MAO.0b013e3182a03522, indexed in Pubmed: 24136312. 10. Gianoli G. De iciency o he supe io semici cula canal. Cu Opin O ola yngol Head Neck Su g. 2001; 9(5): 336–341, doi: 10.1097/00020840-200110000-00016. 11. Gopen Q, Zhou G, Poe D, e al. Pos e io semici cula canal dehiscence: i s epo ed case se ies. O ol Neu o ol. 2010; 31(2): 339–344, doi: 10.1097/MAO.0b013e3181be65a4, indexed in Pubmed: 19841602. 12. G acia-Tello B, Cisne os A, C o e o R, e al. E ec o semici cula canal dehiscence on con ala e al canal bone hickness. Ac a O o inola ingol Esp. 2013; 64(2): 97–101, doi: 10.1016/j.o o i.2012.10.004, indexed in Pubmed: 23298437. 13. Isaacson B, V abec JT. The adiog aphic p e alence o genicula e ganglion dehiscence in no mal and congeni ally hin empo al bones. O ol Neu o ol. 2007; 28(1): 107–110, doi: 10.1097/01.mao.0000235968.53474.77, indexed in Pubmed: 17031323. 14. K ombach GA, DiMa ino E, Schmi z-Rode T, e al. Pos e io semici cula canal dehiscence: a mo phologic cause o e igo simila o supe io semici cula canal dehiscence. Eu Radiol. 2003; 13(6): 1444–1450, doi: 10.1007/s00330- 003-1828-5, indexed in Pubmed: 12764665. 15. Kunda agi NG, Mudali S, Ka pagam B, e al. In ac anially p o uded bila e al pos e io and supe io SCCs wi h mul- iple dehiscences in a pa ien wi h posi ional e igo: CT and MR imaging indings and e iew o li e a u e. Indian J Radiol Imaging. 2014; 24(4): 406–409, doi: 10.4103/0971- 3026.143904, indexed in Pubmed: 25489134. 16. Ku H, O han K, Aksoy S, e al. E alua ion o he supe io semici cula canal mo phology using cone beam compu - ed omog aphy: a possible co ela ion o empo oman- dibula join symp oms. O al Su g O al Med O al Pa hol O al Radiol. 2014; 117(3): e280–e288, doi: 10.1016/j. oooo.2014.01.011, indexed in Pubmed: 24528799. 17. Lookabaugh S, Kelly HR, Ca e MS, e al. Radiologic classi i- ca ion o supe io canal dehiscence: implica ions o su gical epai . O ol Neu o ol. 2014; 36(1): 118–125, doi: 10.1097/ MAO.0000000000000523, indexed in Pubmed: 25122602. 18. Manza i L, Modugno GC. Bila e al dehiscence o bo h supe- io and pos e io semici cula canals. O ol Neu o ol. 2009; 828 Folia Mo phol., 2020, Vol. 79, No. 4 30(3): 423–425, doi: 10.1097/MAO.0b013e3181684048, indexed in Pubmed: 18997636. 19. Manza i L, Scagnelli P. La ge bila e al in e nal audi o y mea us associa ed wi h bila e al supe io semici cula canal dehiscence. Ea Nose Th oa J. 2013; 92(1): 25–33, doi: 10.1177/014556131309200109, indexed in Pubmed: 23354888. 20. Manza i L. Mul iple dehiscences o bony laby in hine capsule. A a e case epo and e iew o he li e a u e. Ac a O o hinola yngol I al. 2010; 30(6): 317–320, indexed in Pubmed: 21808455. 21. Meehan T, Noguei a C, Rajende kuma D, e al. Dehiscence o he pos e io and supe io semici cula canal p esen - ing in p egnancy. B-ENT. 2013; 9(2): 165–168, indexed in Pubmed: 23909125. 22. Mino LB, Solomon D, Zin eich JS, e al. Sound- and/ /o p essu e-induced e igo due o bone dehiscence o he supe io semici cula canal. A ch O ola yngol Head Neck Su g. 1998; 124(3): 249–258, doi: 10.1001/ a cho ol.124.3.249, indexed in Pubmed: 9525507. 23. Mino L. Supe io canal dehiscence synd ome. Am J O ola yngol. 2000; 21(1): 9–19, doi: 10.1016/s0196- 0709(00)80068-x. 24. Nada aja GS, Gu gel RK, Fischbein NJ, e al. Radiog aphic e alua ion o he egmen in pa ien s wi h supe io sem- ici cula canal dehiscence. O ol Neu o ol. 2012; 33(7): 1245–1250, doi: 10.1097/MAO.0b013e3182634e27, indexed in Pubmed: 22872173. 25. Nies en MEF, Lookabaugh S, Cu in H, e al. Familial supe io canal dehiscence synd ome. JAMA O ola yngol Head Neck Su g. 2014; 140(4): 363–368, doi: 10.1001/ jamao o.2013.6718, indexed in Pubmed: 24526223. 26. Pa k JH, Kang SIl, Choi HS, e al. Thickness o he bony o ic capsule: e iopa hogene ic pe spec i es on supe io canal dehiscence synd ome. Audiol Neu oo ol. 2015; 20(4): 243–250, doi: 10.1159/000371810, indexed in Pubmed: 25998441. 27. Pu am SV, Robe s DS, Nies en MEF, e al. Cochlea implan ou comes in pa ien s wi h supe io canal dehis- cence. Cochlea Implan s In . 2015; 16(4): 213–221, doi: 10.1179/1754762813Y.0000000044, indexed in Pubmed: 24074366. 28. Roknic N, Hube A, Hegemann SCA, e al. Mu a ion analysis o Ne in 1 and HMX3 genes in pa ien s wi h supe io semici cula canal dehiscence synd ome. Ac a O ola yngol. 2012; 132(10): 1061–1065, doi: 10.3109/00016489.2012.681797, indexed in Pubmed: 22779713. 29. Russo JE, C owson MG, DeAngelo EJ, e al. Pos e io semici cula canal dehiscence: CT p e alence and clinical symp oms. O ol Neu o ol. 2014; 35(2): 310–314, doi: 10.1097/MAO.0000000000000183, indexed in Pubmed: 24366470. 30. Saxby AJ, Gowdy C, Fandiño M, e al. Radiological p e alence o supe io and pos e io semici cula canal dehiscence in child en. In J Pedia O o hinola yngol. 2015; 79(3): 411–418, doi: 10.1016/j.ijpo l.2015.01.001, indexed in Pubmed: 25636666. 31. Wackym PA, Wood SJ, Sike DA, e al. O ic capsule dehiscence synd ome: Supe io semici cula canal de- hiscence synd ome wi h no adiog aphically isible de- hiscence. Ea Nose Th oa J. 2015; 94(8): E8–EE24, doi: 10.1177/014556131509400802, indexed in Pubmed: 26322461.