MONDINI DEFORMITY / DYSPLASIA

Background
Mondini deformity refers to the absence of the apical modiolus and interscalar septum, resulting in an incomplete partitioning of the cochlea together with an enlarged vestibular aqueduct (EVA) and dilated vestibule.It was first described in 1791 by Carlo Mondini after dissecting the inner ear of an 8-year-old deaf boy. Unfortunately, Mondini dysplasia has been used as an all-encompassing term to describe multiple variants of inner-ear anatomy. Malformations including cochlear hypoplasia, cochlear aplasia, and complete labyrinthine aplasia have at times been incorrectly placed into this larger category.However, the original article by Mondini is clear in its description of a cochlear deformity that contains (1) a normal basal turn and cystic apex, (2) a minimally dilated vestibule, and (3) an enlarged vestibular aqueduct.

Anatomy
Embryology

Typically, the membranous labyrinth achieves its usual shape around the eighth week of development, and ossification of the otic capsule around the membranous labyrinth is complete by birth. Traditionally, pathogenesis of cochlear malformations was believed to be related to different stages of developmental arrest during inner-ear formation. Based on this rationale, developmental arrest at the seventh week of gestation produces a cochlea that is smaller and incompletely partitioned with only 1.5 turns.However, recent evidence demonstrates that not all inner-ear anomalies result from developmental arrest at a specific date.
Classification

In 1987, Jackler et al proposed a classification system of inner-ear malformations that was based on specific dates of cessation of cochlear development. Cessation of development at the fifth week caused cochlear agenesis, cessation at the sixth week produced cochlear hypoplasia, and developmental cessation at the seventh week produced a small cochlea that was incompletely partitioned with resultant 1.5 turns.This classification system was created using polytomography, a form of imaging that has now been discarded and since replaced with high-resolution CT imaging, which is superior in its resolution to polytomography. In 2004, Sennaroglu and Saatci created a modified classification system for incomplete partition of the cochlea to help differentiate different forms of incomplete partitioning.Using a retrospective review of temporal bone CT scans from patients with sensorineural hearing loss, the researchers were able to ascertain two variants in the their study population.

The first variant, termed incomplete partition type I (IP-I), demonstrated a cochlea that was without the entire interscalar septum and the modiolus, resulting in a cystic appearance. While the vestibule was found to be dilated when compared to a normal temporal bone, enlargement of the vestibular aqueduct was rare. Incomplete partition type II (IP-II) demonstrated a cochlea that had a normal basal turn; however, the apex was cystic in appearance owing to absence of the modiolus and the corresponding interscalar septum. Additionally, the vestibule was mildly dilated and the vestibular aqueduct was enlarged. The IP-II malformation is the deformity described by Carlo Mondini and is the basis for the title Mondini deformity. A third type of incomplete partition (IP-III) has been recently described and is found in individuals with X-linked deafness. Morphologically IP-III demonstrates the presence of the interscalar septa; however, the modiolus is absent. In all three variants of incomplete partitioning, the cochleas are of normal size, which differs from the findings of Jackler et al in 1987. Additionally, Sennaroglu and Saatci state that using the term 1.5 turns for Mondini deformity is inaccurate and should be discontinued. The reasoning is that, if the cochlea has 1.5 turns, then it would technically be smaller than a normal cochlea, which would place it into the category of cochlear hypoplasia rather than incomplete partitioning.

Schematic representation of the normal cochlea and cochlear malformations. A: normal cochlea, mid-modiolar section; Mo = modiolus, CA = cochlear aperture, B = basal turn, M = middle turn, A = apical turn, arrowheads = interscalar septa. B: Normal cochlea, inferior section passing through the round window niche (RWN); arrowhead = interscalar septum between middle and apical turns. C: Cochlear aplasia with normal vestibule. D: Cochlear aplasia with enlarged vestibule. E: Common cavity. F: Incomplete partition type I. G: Incomplete partition type II. H: Incomplete partition type III. I: Cochlear hypoplasia, bud type (type I). J: Cochlear hypoplasia, cystic cochlea type (type II). K: Cochlear hypoplasia, with less than 2 turns (type III).

Etiology
Genetics

Mutation of the SLC26A4 gene, which codes for the membrane transport protein pendrin and functions as an iodide/chloride transporter, has been implicated in congenital hearing loss. Mutation of the SCL26A4 gene is very heterogeneic, with more than 100 different mutations identified, including missense, nonsense, and splice-site mutations. The SCL26A4 mutation has been associated with Pendred syndrome and DFNB4, both of which share sensorineural hearing loss associated with Mondini deformity or an enlarged vestibular aqueduct. Typically, individuals with Pendred syndrome are homozygous for the SCL26A4 mutation and display incomplete partition type II or an enlarged vestibular aqueduct. Not all congenital malformations of the inner ear result from SCL26A4 gene mutation.This is an interesting finding because the various types of cochlear malformation have always been thought of as a continuum of defects, all due to developmental arrest at some embryological stage. In persons with IP-III, X-linked deafness has been found to be related to the pathogenesis. Males with X-linked deafness are expected to suffer from severe hearing loss, while females are expected to experience more mild-to-moderate hearing loss.

Epidemiology
Current estimates of the prevalence of congenital SNHL are between 1 and 6 newborns per 1,000. 20-30% of patients with congenital hearing loss demonstrate some sort of radiographically anomalous inner ear. A study of 63 patients with SNHL and radiographically documented abnormalities found that 55% of these patients had incomplete partitioning of the cochlea

Prognosis
The prognosis of Mondini deformity varies. Depending on the degree of malformation of the cochlea, sensorineural hearing loss can range from nonexistent to profound.

History
Most newborns with congenital sensorineural hearing loss have impaired hearing at birth and are usually identified with infant hearing screening. In persons with Mondini deformity, the variability of hearing acuity in individuals is wide, ranging from normal hearing to profound sensorineural hearing loss. Of the 25 patients studied in their 1987 study, Jackler et al found that the average hearing level in patients with incomplete partition was 75 dB with a speech discrimination score of 44%.

Physical Examination
In patients with congenital cochlear malformation, otoscopy findings are normal with intact middle ear structures present behind the tympanic membrane.
Hearing evaluation

Using a 512-MHz tuning form, the Weber test can be performed to access gross hearing. In patients with Mondini deformity, sound should localize to the ear opposite to the congenitally malformed ear.

Diagnostic Considerations
The diagnosis of Mondini deformity is confirmed with radiographs that demonstrate a cystic cochlear apex, minimal dilation of the vestibule, and an enlarged vestibular aqueduct. While most patients with congenital sensorineural hearing loss have incomplete partitioning, other etiologies to consider include the following:

Labyrinthine aplasia Cochlear aplasia Common cavity Other types of Incomplete partitioning Cochlear hypoplasia

Approach Considerations
In patients with congenitally acquired anomalous inner ears, high-resolution CT and MRI scan of the temporal bone are the diagnostic tools of choice in diagnosing the disorder.

CT Scanning
High-resolution CT scanning of the temporal bone should be obtained to assist in diagnosis and can be particularly useful in classification of the cochlear malformation. Assessing the width of the internal auditory canal and course of the facial nerve is easily performed using highresolution CT scanning.

MRI
MRI is useful in assessing soft tissues of the temporal region, specifically the presence or absence of the eighth cranial nerve in the internal auditory canal.

Incomplete partition anomalies of the cochlea. A and B: Incomplete partitions. Cochlea (C), without the modiolus and interscalar septa, resembles an empty cystic structure (A) and is accompanied by dilated vestibule (v) (B). C and D: Incomplete partition type II. The apical part of the modiolus and the corresponding interscalar septa are defective (black arrow), giving the apex of the cochlea a cystic appearance due to the confluence of middle and apical turns (C). This is accompanied by minimally dilated vestibule (v) and large vestibular aqueduct (white arrow). E: Incomplete partition type III. Cochlea has interscalar septa (black arrow), but the modiolus is completely absent. Published by Cochlear Implants International.

Treatment & Management

Approach Considerations
Because of the root cause of the sensorineural hearing loss in patients with Mondini deformity, surgical therapy is the only treatment consideration.

Cochlear Implantation
Cochlear implantation has been described as an effective tool for treating sensorineural hearing loss due to incomplete partitioning. Prior to surgery, imaging (specifically MRI) of the affected temporal bone is important to ascertain the presence of sufficient cochlear lumen for electrode placement and to assess for hypoplasia/aplasia of the eighth cranial nerve. Another concern for surgery is whether there is any aberrancy in the course of the facial nerve. Sixteen percent of individuals with inner-ear malformations were found to have an aberrant facial nerve.Gushers, or oozing of cerebrospinal fluid (CSF) due to bony abnormalities found in the cribriform plate separating the internal auditory canal and the cochlea, have also been described in patients with incomplete partitioning. Oozing CSF more seems to be more common in patients with Mondini deformity. As for electrode selection for patients with Mondini deformity, because the basal turn is normal and research has shown that the majority of spiral ganglion cells reside in the basal turn, all types of electrodes should theoretically provide sufficient stimulation.

Consultations
Patients diagnosed with Mondini deformity should consult with a neurootologist to ascertain whether cochlear implantation is warranted. Additionally, an audiologist and speech/language pathologist should be consulted.

Long-Term Monitoring
Oozing of CSF due to the abnormal bony architecture of the inner ear has been reported among patients with Mondini deformity who have undergone cochlear implantation. Because these patients now have an inner ear in which CSF is exposed to perilymph, meningitis is an increased risk, so these patients should receive routine vaccinations. References 1. Mondini C. Anatomica surdi nati sectio. De Bononiensi Scientiarum et Artium Instituto atque Academia Commentarii. 1791;7:289:41931. 2. Lo WW. What is a 'Mondini' and what difference does a name make?. AJNR Am J Neuroradiol. Sep 1999;20(8):1442-4. [Medline]. 3. Hartley, G. The Minor Works of Carlo Mondini (Carlo Mondini). The American Journal of Otology. 1996;18:288293. 4. Jackler RK, Luxford WM, House WF. Congenital malformations of the inner ear: a classification based on embryogenesis. Laryngoscope. Mar 1987;97(3 Pt 2 Suppl 40):214. [Medline]. 5. Sennaroglu L, Saatci I. Unpartitioned versus incompletely partitioned cochleae: radiologic differentiation. Otol Neurotol. Jul 2004;25(4):520-9; discussion 529. [Medline]. 6. Sennaroglu L, Sarac S, Ergin T. Surgical results of cochlear implantation in malformed cochlea. Otol Neurotol. Aug 2006;27(5):615-23. [Medline]. 7. Everett LA, Glaser B, Beck JC, Idol JR, Buchs A, Heyman M. Pendred syndrome is caused by mutations in a putative sulphate transporter gene (PDS). Nat Genet. Dec 1997;17(4):411-22. [Medline]. 8. Molecular Otolaryngology Research Labs. Pendred/BOR Homepage. Available at http://www.healthcare.uiowa.edu/labs/pendredandbor. Accessed Oct 12, 2011. 9. Azaiez H, Yang T, Prasad S, Sorensen JL, Nishimura CJ, Kimberling WJ. Genotypephenotype correlations for SLC26A4-related deafness. Hum Genet. Dec 2007;122(5):451-7. [Medline]. 10. Wu CC, Yeh TH, Chen PJ, Hsu CJ. Prevalent SLC26A4 mutations in patients with enlarged vestibular aqueduct and/or Mondini dysplasia: a unique spectrum of mutations in Taiwan, including a frequent founder mutation. Laryngoscope. Jun 2005;115(6):10604. [Medline]. 11. Campbell C, Cucci RA, Prasad S, Green GE, Edeal JB, Galer CE. Pendred syndrome, DFNB4, and PDS/SLC26A4 identification of eight novel mutations and possible genotype-phenotype correlations. Hum Mutat. May 2001;17(5):403-11. [Medline].

12. Wang QJ, Zhao YL, Rao SQ, Guo YF, Yuan H, Zong L. A distinct spectrum of SLC26A4 mutations in patients with enlarged vestibular aqueduct in China. Clin Genet. Sep 2007;72(3):245-54. [Medline]. 13. Fitoz S, Sennaroglu L, Incesulu A, Cengiz FB, Koc Y, Tekin M. SLC26A4 mutations are associated with a specific inner ear malformation. Int J Pediatr Otorhinolaryngol. Mar 2007;71(3):479-86. [Medline]. 14. Wu CC, Chen PJ, Hsu CJ. Specificity of SLC26A4 mutations in the pathogenesis of inner ear malformations. Audiol Neurootol. Jul-Aug 2005;10(4):234-42. [Medline]. 15. Incesulu A, Adapinar B, Kecik C. Cochlear implantation in cases with incomplete partition type III (X-linked anomaly). Eur Arch Otorhinolaryngol. Nov 2008;265(11):1425-30. [Medline]. 16. Mylanus EA, Rotteveel LJ, Leeuw RL. Congenital malformation of the inner ear and pediatric cochlear implantation. Otol Neurotol. May 2004;25(3):308-17. [Medline]. 17. Sennaroglu L. Cochlear implantation in inner ear malformations--a review article. Cochlear Implants Int. Mar 2010;11(1):4-41. [Medline].

KUNNAMPALLIL GEJO JOHN / MASLP .