[Audiological evaluation of a child with Klippel-Feil syndrome]

A 6-year-old boy with formerly diagnosed Klippel-Feil syndrome (KFS) presented with complaints of hearing loss, speech disorder, and problems related to his hearing aid. Clinical examination and computed tomography showed bilateral external and middle ear anomalies and audiological examination revealed bilateral severe conductive hearing impairment. The patient was prescribed a bone conduction hearing aid and, with necessary consultations, was examined for additional physical anomalies. All children with a diagnosis of KFS should be evaluated with audiologic and otologic examinations, consultations should be implemented with other disciplines concerning the presenting problems, a regular follow-up should be scheduled, and the parents should be informed on possible complications.

[Treacher-Collins syndrome: clinical and genetic aspects apropos of 4 cases of which 1 is familial]

Treacher Collins syndrome was first mentioned by Thompson in 1847, and described by Treacher Collins in 1900, then it was called mandibulo-facial dysostosis and well defined by Franceschetti in 1949. It is a very rare affection occurring lin 50.000 live births, which includes facial and auricular anomalies leading to functional, morphological and psychological difficulties due to related handicaps. Treacher Collins syndrome is inherited as autosomal dominant pattern with a variable expressivity and incomplete penetrance of "TCOF1" gene localized at 5q31.3q32. Today the gene is well identified and several mutations have been reported. In this paper we report the case of 4 Tunisian unrelated girls with Treacher Collins syndrome. One of them was born from an affected father. Clinical diagnostic was performed between age 12 days and 2 years demonstrating the large dysmorphic expression. Main clinical features were present in all reported cases. Family at risk might have genetic counselling and probably prenatal diagnostic in some situations. Out of our observations, we gave genetic counselling and proposed ultrasound prenatal diagnosis for two families without molecular study.

Beneficial auditory and cognitive effects of auditory brainstem implantation in children

CONCLUSION

This preliminary study demonstrates the development of hearing ability and shows that there is a significant improvement in some cognitive parameters related to selective visual/spatial attention and to fluid or multisensory reasoning, in children fitted with auditory brainstem implantation (ABI). The improvement in cognitive paramenters is due to several factors, among which there is certainly, as demonstrated in the literature on a cochlear implants (CIs), the activation of the auditory sensory canal, which was previously absent. The findings of the present study indicate that children with cochlear or cochlear nerve abnormalities with associated cognitive deficits should not be excluded from ABI implantation.

OBJECTIVES

The indications for ABI have been extended over the last 10 years to adults with non-tumoral (NT) cochlear or cochlear nerve abnormalities that cannot benefit from CI. We demonstrated that the ABI with surface electrodes may provide sufficient stimulation of the central auditory system in adults for open set speech recognition. These favourable results motivated us to extend ABI indications to children with profound hearing loss who were not candidates for a CI. This study investigated the performances of young deaf children undergoing ABI, in terms of their auditory perceptual development and their non-verbal cognitive abilities.

PATIENTS AND METHODS

In our department from 2000 to 2006, 24 children aged 14 months to 16 years received an ABI for different tumour and non-tumour diseases. Two children had NF2 tumours. Eighteen children had bilateral cochlear nerve aplasia. In this group, nine children had associated cochlear malformations, two had unilateral facial nerve agenesia and two had combined microtia, aural atresia and middle ear malformations. Four of these children had previously been fitted elsewhere with a CI with no auditory results. One child had bilateral incomplete cochlear partition (type II); one child, who had previously been fitted unsuccessfully elsewhere with a CI, had auditory neuropathy; one child showed total cochlear ossification bilaterally due to meningitis; and one child had profound hearing loss with cochlear fractures after a head injury. Twelve of these children had multiple associated psychomotor handicaps. The retrosigmoid approach was used in all children. Intraoperative electrical auditory brainstem responses (EABRs) and postoperative EABRs and electrical middle latency responses (EMLRs) were performed. Perceptual auditory abilities were evaluated with the Evaluation of Auditory Responses to Speech (EARS) battery - the Listening Progress Profile (LIP), the Meaningful Auditory Integration Scale (MAIS), the Meaningful Use of Speech Scale (MUSS) - and the Category of Auditory Performance (CAP). Cognitive evaluation was performed on seven children using the Leiter International Performance Scale - Revised (LIPS-R) test with the following subtests: Figure ground, Form completion, Sequential order and Repeated pattern.

RESULTS

No postoperative complications were observed. All children consistently used their devices for >75% of waking hours and had environmental sound awareness and utterance of words and simple sentences. Their CAP scores ranged from 1 to 7 (average =4); with MAIS they scored 2-97.5% (average =38%); MUSS scores ranged from 5 to 100% (average =49%) and LIP scores from 5 to 100% (average =45%). Owing to associated disabilities, 12 children were given other therapies (e.g. physical therapy and counselling) in addition to speech and aural rehabilitation therapy. Scores for two of the four subtests of LIPS-R in this study increased significantly during the first year of auditory brainstem implant use in all seven children selected for cognitive evaluation.

Rubinstein-Taybi syndrome and mixed bilateral hypoacousia case report

OBJECTIVE

To describe a case of Rubinstein-Taybi syndrome (RTS) in association with mixed bilateral hypoacousia.

PATIENT

A 10-year-old boy presented at a private otology practice center in Bogotá, Colombia, with signs and symptoms of RTS. In addition, the patient presented with mixed bilateral conductive hypoacousia, predominantly in the left ear with a 40- to 50-dB conductive component, caused by middle ear malformations and fixation of the ossicular chain and stapes footplate.

INTERVENTION

The patient underwent a left exploratory tympanotomy and then a stapedotomy.

MAIN OUTCOME MEASURES

Computed tomography, genetic evaluation, and audiologic testing.

RESULTS

Postoperative recovery was normal. There was closure of the conductive gap (< or =10 dB) with improvement of subjective hearing.

CONCLUSION

We presented a case of a patient with RTS and bilateral mixed hypoacousia who underwent a stapedotomy with a final improvement in his hearing performance. We consider it important to report and describe the simultaneous presence of these pathologic findings and to be able to analyzeif these otologic findings are coincidental or truly associated with RTS.

Satisfactory surgical option for congenital microtia with defects of external auditory meatus (EAM) and middle ear

CONCLUSIONS

Improved appearance and hearing and increased efficiency are achievable for congenital microbia with defects of external auditory meatus (EAM) and middle ear. First the site of the external auditory meatus (EAM) orifice must be located according to the results of the temporal CT scan, then the auricle can be reconstructed employing the three-stage method. At the third stage, the EAM and middle ear can be reconstructed at the same time.

OBJECTIVE

To select the best approach for reconstruction of congenital microtia with defects of the EAM and middle ear.

PATIENTS AND METHODS

This study analyzed 498 cases (528 ears) of auricle reconstruction by the three-stage method and 77 cases (91 ears operation/120 ears) of EAM and middle ear reconstruction.

RESULTS

For auricular reconstructions, the effects of reconstructed auricles were classified into four grades according to their structure verisimilitude and the bilateral symmetry. The majority of patients/families were satisfied. For 52 ears with normal movement of stapes, reconstructions of EAM and middle ear improved hearing by 15-50 dB, but long-term improvement was not ideal. In bilateral patients, 20 of 24 ears with reconstructed EAMs exhibited relapse of stenosis or atresia. For patients whose EAMs were reconstructed first, scar developed around the orifice and affected the skin flap and later auricle reconstruction, while reconstructing the auricle first sometimes resulted in the location of the EAM orifice deviating from an ideal position.

Tshz1 is required for axial skeleton, soft palate and middle ear development in mice

Members of the Tshz gene family encode putative zinc fingers transcription factors that are broadly expressed during mouse embryogenesis. Tshz1 is detected from E9.5 in the somites, the spinal cord, the limb buds and the branchial arches. In order to assess the function of Tshz1 during mouse development, we generated Tshz1-deficient mice. Tshz1 inactivation leads to neonatal lethality and causes multiple developmental defects. In the craniofacial region, loss of Tshz1 function leads to specific malformations of middle ear components, including the malleus and the tympanic ring. Tshz1(-/-) mice exhibited Hox-like vertebral malformations and homeotic transformations in the cervical and thoracic regions, suggesting that Tshz1 and Hox genes are involved in common pathways to control skeletal morphogenesis. Finally, we demonstrate that Tshz1 is required for the development of the soft palate.

Integration des aktiven Mittelohrimplantates in die plastische Ohrmuschelrekonstruktion

BACKGROUND

Patients with high-grade microtia and atresia require a sophisticated and specific treatment. Apart from the plastic reconstruction of the auricle, in some cases hearing rehabilitation is medically indicated or is desired by the patients. The long-term results of simultaneous middle ear reconstruction with tympanoplasty are often inadequate owing to a persisting air-bone gap, and new techniques in hearing rehabilitation are needed for these patients.

METHODS

We present three cases of unilateral atresia to illustrate a combined approach integrating hearing rehabilitation using the active middle ear implant Vibrant Soundbridge (VSB) into plastic auricular reconstruction. The VSB was attached to the stapes suprastructure via the titanium clip in two of these cases and in the third case a subfacial approach was used to attach it directly to the membrane of the round window.

RESULTS

The air-bone gap was reduced to 17 dB, 14 dB and 0.25 dB HL. In free-field speech recognition tests at 65 dB SPL the patients achieved 100%, 90% and 100% recognition with the activated implant. No postoperative complications such as facial nerve paresis, vertigo or inner ear damage were found.

CONCLUSIONS

The integration of active middle ear implants in auricular reconstruction opens up a new approach in complete hearing rehabilitation. The additional implantation of the VSB does not have any negative effect on the healing process or the cosmetic outcome of the auricular reconstruction.

Preoperative evaluation of the congenital aural atresia on computed tomography; an analysis of the severity of the deformity of the middle ear and mastoid

OBJECTIVE

To compare the development of temporal bone in normal and atretic ears and to assess some radiological landmarks that could be important in the hearing restoration interventions in such patients.

MATERIAL AND METHODS

Thirty-five patients with 40 atretic external ears were evaluated with temporal bone CT and compared to a control group of 40 normal ears retrospectively. Using comparable slice levels in all patients, the course and the caliper of the facial canal, the surface area of the incus and malleus, the level of mastoid aeration, the location and anteroposterior diameters of the jugular bulb and sigmoid sinus, the direction and the caliber of the tympanic bony part of the Eustachian tube, area of the middle ear cavity, distance from facial nerve to incudomalleolar joint, to the vestibule and to the jugular bulb were included in the assessment. Non-parametric and parametric statistical tests were used for comparison.

RESULTS

In atretic ears middle ear sectional area was found to be smaller at the equivalent plane as compared to control subjects (mean area index: 19.3mm(2) versus 47.4mm(2)). Mastoid aeration was low in general and the ossicles in the atretic ears were hypoplastic (mean ossicular sectional area: 8.3mm(2) versus 11 mm(2)). The distance from the jugular bulb to the facial nerve was significantly lower (mean: 6.2mm versus 6.8mm) (p<0.05) in the atretic ears. Facial canal caliber, distance from the facial canal to the incudomalleolar joint and distance from the facial canal to the vestibule in the atretic ears (means: 1.49, 2.93 and 1.82, respectively) did not show statistically significant difference from the control subjects (means: 1.44, 2.91 and 1.83, respectively) (p>0.05 for all).

CONCLUSION

External ear atresia is significantly associated with middle ear and mastoid abnormalities. The ossicles were underdeveloped which always have to be considered during reconstructive surgery. Radiologically, in the atretic ears anterior-posterior length of the temporal bone was more influenced as compared to superior-inferior portion, which justifies abnormal route of the facial nerve canal. However, there is no abnormality in the development of the facial nerve as the caliper is similar to the control subjects.

[Virtual endoscopy view of ossicular chain in the congenital aural atresia]

OBJECTIVE

To investigate the function of virtual endoscopy in assessing ossicular chain deformity in the congenital ear malformation.

METHOD

In 23 cases 28 ears with congenital atresia of external auditory meatus. A high resolution spiral CT is used to display the temporal bone by axial and direct coronal planes. Perspective virtual endoscopy was processed using the virtual endoscopy software. To compare the views of the operative exploration and the virtual endoscopy then draw the responding conclusions.

RESULT

Twenty-eight ears with congenital microtia were showed ossicular deformity in 25 ears, while flache pauke in 3 ears. Twenty-four ears treated by canaloplasty of external auditory meatus and tympanoplasty, hammer and incus hypoplasia in 19 ears, stapes abnormity were demonstrated in 11 ears, ossicles absence in 3 ears, vestibular window clausura in 1 ears. The coincidence between Virtual endoscopy and operating view were 100% in cases with congenital ear deformity.

CONCLUSION

Virtual endoscopy can provide reliable information on the ossicles pathological conditions in congenital congenital aural atresia.

External auditory canal atresia of probable congenital origin in a dog

A nine-month-old Labrador retriever was referred to the Clinica Veterinaria Privata San Marco because of frequent headshaking and downward turning of the right ear. Clinical examination revealed that there was no external acoustic meatus in the right ear. Computed tomography confirmed that the vertical part of the right auditory canal ended blindly, providing a diagnosis of external auditory canal atresia. Cytological examination and culture of fluid from the canal and the bulla revealed only aseptic cerumen; for this reason, it was assumed that the dog was probably affected by a congenital developmental deformity of the external auditory canal. Reconstructive surgery was performed using a "pull-through" technique. Four months after surgery the cosmetic and functional results were satisfactory.

Fully Implantable Hearing Aids in Patients With Congenital Auricular Atresia

INTRODUCTION

Patients with congenital auricular atresia suffer from a conductive hearing loss (HL) with an air-bone gap of 50 to 60 dB. Conventional bone conducting or bone anchored hearing aids are treatment options with several disadvantages and a biophysical limitation of almost no sound attenuation in the skull bone. Surgical construction of the sound conducting apparatus has been performed by others and modified by us into a three-step procedure with in vivo prefabrication of the external ear canal and the tympanic membrane. Although the results improved after inauguration of our modifications, there still remains an air-bone gap that makes air conducting hearing aids necessary in many patients. Implantable hearing aids have been developed for patients with perceptional HL and normal middle ear function but not for patients with middle ear disease or malformation.

OBJECTIVES

Our objectives were to improve the hearing results of auricular atresia.

STUDY DESIGN

Prospective.

METHODS

The surgical instruments, the transducer, and the operative technique of the only fully implantable hearing aid (Otologics Fully Implantable Middle Ear Transducer) clinically available were modified. They were implanted in five patients with congenital auricular atresia and their audiologic outcome evaluated.

RESULTS

After activation and fitting of the devices, patients experienced an improvement of sound-field thresholds up to 50 dB HL. The mean functional gain in a three frequency pure-tone average was approximately 35 dB HL.

CONCLUSIONS

This technique appears to provide a completely new dimension for the audiologic rehabilitation of patients with severe malformation of the middle ear.

Anomalies of the Middle and Inner Ear

The development of the middle and inner ear highlights the intricacy of embryology. As early as 3 weeks after fertilization, the inner ear begins taking form. This process, along with development of the middle ear, continues throughout gestation. At birth, the middle ear, inner ear, and associated structures are almost adult size. An understanding of the embryologic development of the ear serves as a foundation for evaluating and managing congenital malformations of these structures. The focus of this article is the normal, abnormal, and arrested development of the middle and inner ear, with a clinical emphasis on malformed middle and inner ear structures and a discussion of associated syndromes.

[Diagnosis and treatment of congenital abnormality in external and middle ear]

OBJECTIVE

To investigate the clinical characters, methods of evaluation before surgery and effects of treatment of congenital abnormality in external and middle ear.

METHOD

The data of 21 cases (22 ears) with congenital abnormalities in external and middle ear who received operation in ENT Department of the First Affiliated Hospital of Zhengzhou University during 5 years from June 2000 to June 2005 were analyzed.

RESULT

Malformations of middle ear were presented in all cases. These mainly consisted of small tympanic cavities in 16 ears (72.7%), ossicular chain anomalies in 20 ears (90.9%) and facial nerve abnormalities in 8 ears (36.4%). The hearing improvement was observed in 15 ears (68.2%) after surgery, of which 9 ears had hearing improvement greater than 30 dB. Long term (0.5 to approximately 5 years) follow-up demonstrated that the hearing in 17 ears were kept unchanged after surgery. The postoperative complications were external auditory canal stenosis in 4 ears and lateralization of the tympanic membrane in 2 ears.

CONCLUSION

Careful evaluation of the hearing and CT of congenital abnormalities of external and middle ear before operation are important. Maintenance of width of the external acoustic meatus and prevention of infection are crucial in the treatment of congenital abnormalities of external and middle ear.

Large vestibular aqueduct syndrome: a human temporal bone study

OBJECTIVES/HYPOTHESIS

Large vestibular aqueduct syndrome (LVAS) is one of the common causes of hearing loss (HL). All prior studies have reported some anomalies associated with LVAS by imaging techniques. This study was undertaken to determine prevalence of LVAS in our temporal bone (TB) collection and its relationship to other systemic or otologic anomalies.

STUDY DESIGN

Retrospective, TB histopathologic study.

METHODS

Anteroposterior diameters of internal (IA) and external (EA) apertures were measured in 40 normal TBs (40 cases). TBs were considered as large vestibular aqueduct (LVA) if width of apertures was 95% greater than "normals." Systemic and otologic anomalies and histopathology of ears with LVAS were noted.

RESULT

Of 1,608 non-"normal" TBs, 63 had LVA. There was negative correlation between IA and EA in 48 TBs with only enlarged IA. Fifteen TBs with enlarged EA always had enlarged IA and were therefore considered as LVAS. The most common pathologic condition was congenital heart anomaly. The most common syndrome or dysplasia was Mondini's. The most common anomalies of external and middle ears were dehiscent facial nerves, low set auricles, and ossicular deformities. Inner ear anomalies included modiolar deficiencies, hair cell loss, interscalar septum defects, and strial atrophy. There was no record of family history of HL, head injury, or craniofacial, branchial, or thyroidal abnormalities.

CONCLUSION

Because HL associated with LVAS may be attributed to other ear anomalies, it is important to investigate other inner ear problems and system diagnoses that may indicate a syndrome in patients with radiologically diagnosed LVAS.

Absent semicircular canals in CHARGE syndrome: radiologic spectrum of findings

BACKGROUND AND PURPOSE

This paper describes the CT findings that characterize the middle and inner ear anomalies in coloboma, heart defects, choanal atresia, mental retardation, genitourinary, and ear anomalies (CHARGE) syndrome. With this information, neuroradiologists will be better prepared to provide clinically relevant information to their referring physicians regarding this rare syndrome.

MATERIALS AND METHODS

CT studies from 13 patients were reviewed by 2 neuroradiologists with Certificate of Additional Qualification. Each ear was counted separately for a total of 26 ears. Middle and inner ear anomalies associated with CHARGE syndrome were categorized. Investigational review board approval was obtained.

RESULTS

Twenty of 26 (77%) ears demonstrated cochlear aperture atresia. Four of these ears were evaluated with MR imaging and were found to lack a cochlear nerve. Twenty-one of 26 (81%) cochlea had some form of dysplasia. Six of 26 (23%) round windows were aplastic. Three of 26 (12%) round windows were hypoplastic. Twenty-one of 26 (81%) oval windows were atretic or aplastic. Fifteen of 26 (58%) vestibules were hypoplastic or dysplastic. There were 5 of 26 (19%) enlarged vestibular aqueducts. Twelve of 26 (46%) vestibular aqueducts had an anomalous course. All cases demonstrated absent semicircular canals. Twenty-three of 26 (88%) facial nerve canals had an anomalous course. Four of 26 (15%) tympanic segments were prolapsed. Three of 26 (12%) temporal bones had an anomalous emissary vein referred to as a petrosquamosal sinus. Twenty-one of 26 (81%) middle ear cavities were small. Twenty-three of 26 (93%) ossicles were dysplastic with ankylosis. Three of 26 (12%) internal auditory canals were small.

CONCLUSION

The CT findings that correlate to the anomalies of CHARGE syndrome affect conductive as well as sensorineural hearing. Stenosis of the aperture for the cochlear nerve aperture on CT is suggestive of hypoplasia or absence of the cochlear nerve, which has been demonstrated in some cases by MR. Absence of the cochlear nerve would be a contraindication to cochlear implantation.

Tissue-specific roles of Tbx1 in the development of the outer, middle and inner ear, defective in 22q11DS patients

Most 22q11.2 deletion syndrome (22q11DS) patients have middle and outer ear anomalies, whereas some have inner ear malformations. Tbx1, a gene hemizygously deleted in 22q11DS patients and required for ear development, is expressed in multiple tissues during embryogenesis. To determine the role of Tbx1 in the first pharyngeal pouch (PPI) in forming outer and middle ears, we tissue-specifically inactivated the gene using Foxg1-Cre. In the conditional mutants, PPI failed to outgrow, preventing the middle ear bone condensations from forming. Tbx1 was also inactivated in the otic vesicle (OV), resulting in the failure of inner ear sensory organ formation, and in duplication of the cochleovestibular ganglion (CVG). Consistent with the anatomical defects, the sensory genes, Otx1 and Bmp4 were downregulated, whereas the CVG genes, Fgf3 and NeuroD, were upregulated. To delineate Tbx1 cell-autonomous roles, a more selective ablation, exclusively in the OV, was performed using Pax2-Cre. In contrast to the Foxg1-Cre mutants, Pax2-Cre conditional mutant mice survived to adulthood and had normal outer and middle ears but had the same inner ear defects as the Tbx1 null mice, with the same gene expression changes. These results demonstrate that Tbx1 has non-cell autonomous roles in PPI in the formation of outer and middle ears and cell-autonomous roles in the OV. Periotic mesenchymal markers, Prx2 and Brn4 were normal in both conditional mutants, whereas they were diminished in Tbx1-/- embryos. Thus, Tbx1 in the surrounding mesenchyme in both sets of conditional mutants cannot suppress the defects in the OV that occur in the null mutants.

[Multi-channel cochlear implantation in patients with congenital inner ear malformation accompanied middle ear malformation]

OBJECTIVE

To report the multi-channel cochlear implantation in three patients with congenital inner ear malformation accompanied middle ear malformation, including CI surgery and postoperative outcomes of hearing and speech recovery.

METHOD

Multi-channel cochlear implantation surgeries have been performed in three cases with congenital inner ear malformation accompanied middle ear malformation in our hospital from May 1995 to May 2002. The transmastoid approach was performed to the cases with congenital inner ear malformation accompanied middle ear malformation. The postoperative sound field hearing tests were taken to the cases three months after the cochlear implantation.

RESULT

Multi-channel cochlear implantation was successfully performed in three cases with congenital inner ear malformation accompanied middle ear malformation. The 27, 28, 32 electrodes were inserted respectively in three cases. The intraoperative "Ozze" occurred in three patients. No severe intraoperative and postoperative complications occurred in three cases. All postoperative hearing thresholds were at 35-40 dBHL. CONCLUSION Multi-channel cochlear implantation could be performed in the cases with congenital inner ear malformation accompanied middle ear malformation through the transmastoid approach. The postoperative outcomes were satisfied.