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  1. patients suffering from Pendred'·s Volume 2 Number 4 Zemestan 1367 lam.diol.wwal 1408 Medical lournal of the Islamic Republic of Iran 1 Case Reports PENDRED'S SYNDROME REVISITED Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 M.DJALILIAN, M.D.,M.S., M.FARHADI, M.D.,ANDF.NAZEM,M.D. From the Department of Otorhinolaryngology, Iran University of Medical Sciences, Tehran, Islamic Republic of Iran. ABSTRACT Pendred's syndrome is defined as a triad of congenital perceptive hearing loss, goiter, and abnormal perchlorate test. Three brothers with Pendred's syndrome [P.S.] are reported. The oldest brother has hearing loss (he has been deaf and mute since childhood) and has a large goiter. A thyroid scan revealed euthyroid multinodular goiter and a perchlorate test was performed, and reported abnormal. His brother had the same manifestations but with less severity and after subtotal thyroidectomy, the pathology report revealed follicular carcinoma. The youngest brother had hearing loss since childhood but a normal sized thyroid. We report three patients and compare the frequency of their symptoms with that reported in the literature. MJIRI, Vol. 2, No.4, 305-311, INTRODUCTION There is no apparent tendency in the male-female ratio of the syndrome. 1 The most important feature of the defect is that only the basal cochlea is retained while the apical cochlea turns from a common cavity. The defect is caused by a fault in the development of the modiolus in the seventh fetal week. The lesion in the ears of patients with Pendred's disease similar to the thyroid defect possibly results from a deficiency in the peroxidase enzyme system. Three brothers of seven siblings who are affected by Pendred's syndrome are reported. Pendred's syndrome is an autosomal recessive form of sensorineural deafness associated with goiter in that the perchlorate test shows an abnormal organification of non-organic iodine. Perchlorates when adminis­ tered to a healthy subject, bring about the immediate release of inorganic-bound iodine from the thyroid gland, while the organic-bound iodine remains affected. If perchlorate is given, following a tracer dose of iodine 131 , a slight fall, if any, in the activity of the gland will be the only reaction in normal subjects. This demonstrates the fact that inorganic iodine is very rapidly assimilated (perchlorate test). On the other hand, an abnormal fall in the activity will be seen in CASE REPORT CASE I: A 23 year old male was referred to the E.N. T. clinic for hearing loss evaluation. He has been deaf and mute since childhood. His parents are related and he has five brothers and two sisters. His father died at age 70 of hypertension, syndrome. This is presumed to result from a defect in the peroxidase system, possibly a reduction in the amount of perox­ idase enzyme; the greater the defect the greater the fall in activity. The disease is found throughout the world and may account for 1 to 7 percent of cases of deafness. 305

  2. M. Djalilian M.D., et al Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 Fig 1. Case one depicting large goiter. his mother is 60 years old and living. Two of his brothers have goiter associated with hearing loss (case II, III). One brother has hearing loss without goiter. The other brother is 32 years old and healthy without hearing loss and goiter. Of his two sisters, the older one has goiter without hearing loss, and the other is in good health without any hearing loss or goiter. The past history was unremark­ able. On physical examination, he was well developed, well nourished, and had a large goiter (Fig. 1). Blood chemistry and urine analysis were within normal limits. Pure tone audiometry showed total deafness. The eye examination was unremarkable. Thyroid scan (Fig.2) reported a euthyroid multi­ nodular goiter and perchlorate test showed abnormal organification of nonorganic iodine (about 45 %). Be­ cause of difficulty in breathing, thyroid extract was given for one year without any change in the size of the thyroid. Subtotal thyroidectomy was subsequently done without any problems, followed by thyroid ex­ tract. 55% abnormal organification of nonorganic iodine. Because of a sensation of pressure on his neck and difficulty in breathing, he was tre ated with thyroid extract for one year without any change in size of goiter, so he underwent subtotal thyroidectomy. The pathology report was follicular carcinoma (Fig.5). CASE II: A 22 year old male, brother of the first case had severe hearing loss since childhood accompanied with a large goiter (Fig.3). Blood tests and urine analysis was unremarkable; eye examination for retinitis pigmento­ sa was negative. Thyroid scan(Fig. 4) reported euthyroid multinodu­ lar goiter; the fall in the perchlorate test showed about Fig 2. Thyroid Scan of patient one. 306

  3. literature, and at the same time defined P,endred's Pendred's Syndrome r ' Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 Fig 3. Large goiter of the second patient. CASE III: A 15 year old male was brought to the E.N.T. clinic for hearing loss since childhood. On E.N.T. examina­ tion, thyroid was of normal size (Fig.6). Eye examina­ tion for retinitis pigmentosa was negative, blood tests and urine analysis were normal. Fall in perchlorate test was 60%. The patient was treated with thyroid extract. 1,000,000 and in England,7 8/100,000. Because the goiter develops slowly, the incidence in children is reported to be only 0.581100,000.5 The disease is clearly inherited as an autosomal recessive, with some variability of expressivity of the gene. In the homozygote the hearing loss is sensorineu­ ral and usually static, but there have been observations DISCUSSION Pendred's syndrome is an autosomal recessive form of sensorineural deafness with goiter. It has been known for some centuries that there is a relationship between endemic goiter and deafness. In 1824 Wood2 mentioned a relationship between sporadic goiter and deafness.However, as hisdescriptionwas not complete , the syndrome has been named after the English general practItioner Pendred3who in 1898,described two deaf­ mute sisters with pronounced goiter. The diagnosis of this disease was further advanced in 1958 by Morgan and Trotter4 by the use of the perchlorate test, which showed an abnormal organification of non-organic iodine. The disease is found throughout the world. In 1965, Fraserl was able to collect 233 cases from the syndrome as a triad of congenital perceptive hearing loss, goiter, and pathological perchlorate test. Thould5 and Scowen in 1964 reported that Pen­ dred's disease may account for 1 to 7 percent of severely to Plofoundly deaf children. The incidence, as stated in literature, varies considerably. In Swedenl it is 11 Fig 4. Thyroid scan of patient two. 307

  4. M. Djalilian M.D., et al Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 Fig 6. Thyroid scan of the third patient. (1972), and our second case was reported as follicular carcinoma. Our cases I and II because of having some difficulty in breathing, inspite of treatment with thyr­ oid hormone for one year, underwent surgery (subtotal thyroidectomy). Fraser feels that the frequency of the allele in this disease is approximately 0.008 and that the mutation rate may be 56/1,000,000 loci per gametes. It has also been noted! that heterozygotes may show a decrease in protein bound iodine. Statistically this decrease in P. B.1. is significant at the 2 % level. Initially, the goiter is diffuse and soft, but gradually it will develop a tendency to become nodular and hard, particularly in women, this is caused by the prolonged increased stimulation with thyroid stimulating hor­ mone (TSH), which is a result of the relative insuffi­ ciency. Fig 5. Photomicrograph of thyroid gland of second patient. of possible progression. The hearing loss is usually severe to profound, mainly affecting the hightones, but there may be some cases of unilateral hearing loss. 10 After reviewing the audiogram of23 patients with Pendred's syndrome one had no response, 12 out of23 were severely deaf, 80f23 were less severely deaf, and 2 of 23 had low levels of hearing loss. Vestibular responses were quite variable in these patients. The first histologic description was reported by Hvidberg-Hansen and Jorgensen ings were bilateral malformation of cochlea ofMondini type. In 1986 Torsten, Johnson and associates reported pathologic exams of six temporal bones from five patients with confirmed P. S. The characteristic Mondi­ ni cochlea9 was found in all preparations. They con­ cluded that the inner ear malformation in P.S. is more in accordance with Mondini's original description that in other syndromes in which a Mondini-like cochlea has been described. The most characteristic feature is that the basal turn is retained while the apical turn makes a large common cavity. Temporal bone histopathologic studies indicated that neuroepithelium of the cochlea of spiral ganglion cells was absent. The macula was normal with ossification of the endostium of the labyr­ inthine wall. Since the hearing loss is sensorineural type, patients can't get benefit out of any medications, except advise using hearing aid, in those patients who are deaf and mute .We are hoping cochlear implant to be useful for them in near future. The goiter will usually be apparent before the age of 8 and in some instances may be found at birth.7 The patients are usually euthyroid.7 It has been found that pathologic goiter in P.S. is not associated with cancer but case 7 of Peter Illum and associates in 1968;8 the find­ REFERENCES 1. Fraser GR: Association of congenital deafness with goiter(Pen­ dred's syndrome) Ann Hum genet 18: 207-249, 1965. 2. Wood K: Some observations upon local prevalence of iodine and its connections with goiter. Men Manchr Lit Phil Soc 4:88-103, 1824 .. 3. Pendred V: deaf-mutism and goiter. Lancet 1I:532, 1896. 4. Morgans ME. Trotter WR: Assocation of congenital deafness with goiter. Lancet 1:607-609, 1958. 5. Thould AK, Scowen EF: The syndrome of congenital deafness and simple goiter. In:Pitt-Rivers R (ed): Transactions of the Fourth International Goiter Conference, London 1960, Oxford, Eng­ land. Pergammon Press. p22, 1961. 6. Nilsson LR, Borgfors N, Gamstcirp I, et al: Nonendemic goiter and deafness. Acta Paediatr Scand 53: 117-131,.1964. 7. JensenJ: Malformations on inner ear in deaf children. Acta Radiol 8:1-95,1969. 8. Hvidberg-Hansen J, Jorgensen MB: The inner ear in Pendred's syndrome. Acta OtolaryngoI 66:129-153, 1968. 9. Mondini C: Anatomia surdi nati sectio: De Bononiensi scien­ tarium et artium instituto atque academia commentarii, Bono­ niae (opu scula), 7:419-431,.1791. 10. Torsten J, Jorgensen MB, Johnsen S: Mondini cochlea in Pendred's syndrome. A histological study. Acta Otolaryngol (Stockh) 102: 239-247, 1986. 11 IlIum P, et al: Fifteen cases of Pendred's syndrome. Arch Otolaryngol 96: 294-304, 1972. 308

  5. Pendred's Syndrome L.Ear R.Ear z 250 250 500 1000 2000 4000 8000 HZ 125 125 500 1000 2000 4000 80nO � -10 -10 o o 10 20 30 10 20 Q. 30 Cl (I) 40 � 50 60 Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 40 50 60 70 80 90 100 110 70 , \11' maski:9 � ... 1/ - 80 90 100 110 ���skeb c unmasked 0 < unmasked 0 < II' 1 , ---. I X > X ::> v " :l 5 Rinne test: Rinne test: WEBER 500 1000 2000 4000 I S.RJ -- dB S.DS - 250 S.R.T S.DS dB IL RI I I I Reflexometry Tympanogram ml 5 �f1ex Thresholds in dB Int. SOO Hz Contra latera I Probe Tone Ear Teat Tone Ear 1000 Hz 2000 11& 4000 Hz 4 R� Right Left 5- 3 L Cs= 2 Reflex Thresholds in dB Int. 0500 Hz Ipsih,\rral Probe Tone E.ar TC!st Ton� Ear 4000 Hz 2000 11& 1000 Hz 1 ---: ,:.: ....... . ... �� Right Left o -400 -300 -200 -100 Pressure in 0 m.m / water +100 +200 Right Left .......... =R. --=L. Fig. 7. Audiological evaluation of case 1. 309

  6. M. Djalilian M.D., et al L.Ear R.Ear _ 0 25 250 500 1000 2000 4000 8000 HI 500 125 125 1000 2000 4000 8000 � z -10 -10 o o 10 10 20 20 Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 Q. 30 CD $I) 40 � 50 60 30 40 50 • 60 70 70 t \V 80 .� 80 90 100 110 �skeb c mask1:9 unmasked 0 < unmasked 0 < Rinne test: I) 90 100 110 4 � I� X :> lP' X > \J \J , � � \" �� ::> :5 Rinne test: WEBER S.RJ _ dB 5.0.5 - 500 1000 2000 4000 RI I 250 S.RJ S.O.5 dB IL Tympanogram Reflexometry ml 5 aef1e� Thresholds ift dB HTL 500 Hz JJ �,.. . ",.(l.. 9 N.(L� Iv.� Rieht If·p.· /11 .(2. 1'1 ,tt #,ll Probe Tone Ear. Conualater.1 Teat Tone Eu 2000 Ha 4000 liz 1000 Hz 4 Rlcs= Ri,ht 1.eft L� 3 Left 2 Tone aef1ex Thresholds in dB HTL 500 Hz Probe Tone Ear lpsih,ttral Teat �v. .... . � � .. ' 4000 liz 1.000 Hz 2000 Ha Ear "' .. ' 1 /....... ' ... � Ri,ht 1.eft o -400 -3qo -200 -loo Pressure in 0 m.m / water ·····,;····=R. --=L-,- +100 +200 Left Rieht Fig.8. Audiological evaluation of case 2. 310

  7. Pendred's Syndrome L.Ear R.Ear 25 o 250 500 1000 2000 4000 8000 HZ. 1000 2000 4000 8000 rr 500 I 125 125 -10 -10 o o 10 10 20 20 Downloaded from mjiri.iums.ac.ir at 18:13 IRDT on Monday May 4th 2020 a. 30 OJ sn 40 � 50 60 30 40 50 • 60 70 70 \J1f maskt9 � 80 80 90 100 110 \ II zskeb .� �C unmasked 0 < unmasked 0 < Rinne test: 90 X > X :> 100 110 � \ 1/ til , .... �'I/ "'� ::l � 5 Rinne test: WEBER S.RT - dB 5.0.5 - 250 500 1000 2000 4000 RI I S.R:T S.D.S dB Il Retlexometry Tympanogram ml 5 Probe Tone .. � Reflex Thresholds iD dB tnt. 500 Hz Contralateral Teat Tvne Bu 1000 Hz 2000 Ha 4000 Hz 4 Rlcs= l� ti,ht Left 3 Left Ri,ht 2 Reflex Thresholds ill dB tnt. '00 Hz Probe Tone Bar 'psilllt�ral Teat Tone Bar 2000 Ha 1000 Hz 4000 Hz - �--.. :"- � . 1 .... . � --� ti,ht Left o :.-- -.. �r--- -400 -300 -200 -100 Pressure in 0 m.m / water +100 +200 Left Ri,ht · · · · · · · · · · · = R. --=L. Fig.9. Audiological evaluation of case 3. 311

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