Correlation of otosclerotic foci and degenerative changes in the organ of Corti and spiral ganglion

A comparison between endoscopic and microscopic approaches for stapes surgery: experience of a tertiary referral center

PURPOSE

Otosclerosis is a common ear disease causing ankylosis of the stapedio-vestibular joint and conductive hearing loss. Stapedoplasty is the most advisable surgical solution. The restoration of hearing depends on the condition of the patient and the surgery itself. The aim of our work was to compare the surgical and audiological results of stapedoplasty performed with endoscopic versus microscopic technique.

METHODS

This is a retrospective study of 254 patients treated with stapedoplasty with a microscopic approach (91/254) or with an endoscopic approach (163/254) between 2014 and 2021 at our tertiary referral center. Statistical significance of differences between the two methods was determined using the Mann-Whitney test for quantitative variables and the Wilcoxon matched-pairs signed-rank test for repeated measures. Categorical variables were assessed with Fisher's exact test.

RESULTS

Both techniques improved the hearing status of patients, with no statistically significant difference between them. There was also no statistically significant difference in reported complications between the two techniques. There is a statistical difference (p < 0.001) in operating time between the two techniques: the endoscopic technique had a mean operating time of 39 min versus 45 min for the microscopic technique.

CONCLUSIONS

The two techniques are comparable in terms of results and the choice depends on the surgeon's preferences and experience.

Brazilian Society of Otology task force - Otosclerosis: evaluation and treatment

OBJECTIVES

To review and provide evidence-based recommendations for the diagnosis and treatment of otosclerosis.

METHODS

Task force members were educated on knowledge synthesis methods, including electronic database search, review and selection of relevant citations, and critical appraisal of selected studies. Articles written in English or Portuguese on otosclerosis were eligible for inclusion. The American College of Physicians' guideline grading system and the American Thyroid Association's guideline criteria were used for critical appraisal of evidence and recommendations for therapeutic interventions.

RESULTS

The topics were divided into 2 parts: 1) Diagnosis - audiologic and radiologic; 2) Treatment - hearing AIDS, pharmacological therapy, stapes surgery, and implantable devices - bone-anchored devices, active middle ear implants, and Cochlear Implants (CI).

CONCLUSIONS

The pathophysiology of otosclerosis has not yet been fully elucidated, but environmental factors and unidentified genes are likely to play a significant role in it. Women with otosclerosis are not at increased risk of worsening clinical condition due to the use of contraceptives or during pregnancy. Drug treatment has shown little benefit. If the patient does not want to undergo stapedotomy, the use of hearing aids is well indicated. Implantable systems should be indicated only in rare cases, and the CI should be indicated in cases of profound deafness.

Radiological parameters and audiometric findings in otosclerosis: is there any relationship?

OBJECTIVE

The role of high-resolution computed tomography scans in otosclerosis remains uncertain. There is a debate over the relationship between radiological and audiometric findings among patients.

METHOD

Pre-operative audiometry and high-resolution computed tomography findings from 40 ears with surgically confirmed otosclerosis were compared. High-resolution computed tomography scan data regarding the characteristics of the disease foci, the endosteal extension and the occurrence of internal auditory canal diverticula were obtained. The influence of each radiological variable on the simple pure tone average, the high-frequency pure tone average and the bone-conduction pure tone average were investigated.

RESULTS

Cases with endosteal extension (p = 0.047) and a higher number of affected sites within the otic capsule had a worse bone-conduction pure tone average, although it was only significant for the latter (p = 0.006). Those without concomitant retrofenestral disease (p = 0.019) had better simple pure tone average.

CONCLUSION

The number of sites of involvement and concomitant retrofenestral disease seem to significantly impact audiometric findings in otosclerosis.

[A preliminary study on characteristics of wideband acoustic immittance in patients with Meniere's disease]

Objective:To explore the wideband absorbance characteristics of patients with Meniere's disease（MD）. Methods:Wideband acoustic immittance was performed in 52 patients with unilateral Meniere's disease（UMD） and 30 control subjects with normal hearing. All UMD patients underwent pure tone audiometry, 226 Hz acoustic immittance, wideband acoustic immittance, and gadolinium contrast MRI. Sixteen frequency points were chosen to analyze the wideband absorbance at ambient and peak pressure, and the subjects were grouped as UMD group vs. control group and asymptomatic group. The student's t-test was used to compare the absorbance difference between them. Results:Both at peak and ambient pressure, there was a significant difference between the MD group and control group at 1587 Hz, 2000 Hz, 2519 Hz, 3174 Hz, and 4000 Hz; the MD group was lower than the control group（P<0.05）; there were no differences between the asymptomatic group and the symptomatic group, there also was a significant difference between the asymptomatic group and control group at 1587-4000 Hz（P<0.05）. Conclusion:The wideband absorbance in MD patients was significantly reduced within the frequency range of 1587-4000 Hz, and wideband acoustic immittance seems to be cost-effective in predicting MD.

Wideband tympanometry as a diagnostic tool for Meniere's disease: a retrospective case-control study

PURPOSE

The main purpose of this study was to investigate the usefulness of wide band tympanometry (WBT) as a diagnostic tool for Ménière's disease (MD) by comparing differences in absorbance measures between normal hearing ears and patient diagnosed with MD.

METHODS

We conducted a retrospective case-control study. From a cohort of 116 patients diagnosed with Ménière disease, 52 MD patients and 99 normal hearing adults with no history of otological disease served as subjects. Wideband tympanometry was conducted using at Titan Impedance module and audiometry was performed with a MADSEN Astera². Mean energy absorbance curves with 95% confidence intervals were computed across cases with MD and controls in the frequency range 226-8000 Hz. An overall test for difference between curves of cases and controls was calculated by multivariate analysis of variance.

RESULTS

The MD group and the subpopulations of MD patients who fulfilled the International criteria for MD showed a statistically significant lower absorbance at tympanic peak pressure compared to the control group (p < 0.001). No overlap of confidence intervals between mean curves was found within the frequency range of 2000-4000 Hz.

CONCLUSION

Absorbance measures obtained by WBT were able to distinguish between MD ears and normal ears within the frequency range of 2000-4000 Hz. The results indicate that WBT potentially could be a useful and simple non-invasive diagnostic tool for MD. However, more research on the association between absorbance measures and inner ear pathologies is needed.

Effects of endolymphatic hydrops on acoustic energy absorbance

Background: The presence of endolymphatic hydrops (EH) may cause hearing loss and affect the transmission of acoustic energy to the inner ear.Objectives: Acoustic energy absorbance on wideband acoustic immittance (WAI) was evaluated, focusing especially on EH in the vestibule.Material and methods: A total of 32 ears from 16 patients who underwent 3-T magnetic resonance imaging (MRI) to evaluate the presence of EH were examined, retrospectively. The degree of EH in the vestibule was classified into three grades (no, mild, and significant), and pure tone audiometry (PTA) and WAI were measured before and after a glycerol drip.Results: Ears with significant EH showed significantly higher hearing levels and air-bone gaps (ABG), and higher absorbance values on WAI at low frequencies (560-600 Hz) than ears with mild or no EH. Changes in absorbance values were observed in some ears without threshold change on PTA.Conclusions and Significance: This study showed significantly higher absorbance values of acoustic energy with significant vestibular EH at low frequencies. Considering ABGs observed in ears with significant EH, the presence of EH in the vestibule might cause an obstacle to the transmission of acoustic energy to the inner ear.

Surgical considerations and audiological results of cochlear implantation in patients with otosclerosis

Background/aim

To emphasize the role of cochlear implantation (CI) in the auditory rehabilitation of patients with otosclerosis (OS) and share our surgical experiences on this rare group of patients.

Materials and methods

Retrospective analysis of the patients who have a diagnosis of otosclerosis and implanted between January 1998–May 2019 was performed. Preoperative and postoperative clinical, radiological, audiological and surgical findings are presented.

Results

Among 2195 patients who have been implanted in our institution, 12 (0.54%) met the diagnostic criteria of OS according to their preoperative (clinical, radiological, audiological) and peroperative (surgical) findings. Electrode insertion was performed via “round window membrane and cochleostomy” in 8 and 4 patients, respectively. No major complications occured. All patients showed satisfactory performances by means of audiometric scores postoperatively. Nonauditory stimulation (NAS) which manifested as “facial twitching” was a challenging problem in one patient during the surgery and subsided after the operation.

Conclusion

Our experience on CI in patients with OS revealed that the implantation was a relatively safe procedure and had satisfactory impact on audiological performances.

Contributions of Contemporary Human Temporal Bone Histopathology to Clinical Otology

Contemporary techniques have greatly enhanced the contributions of human temporal bone (HTB) histopathology to our understanding of the mechanisms of human otologic disease and disease treatment. Herein, we review some of the most salient contributions of this research to disease management. The field of HTB histopathology is challenged by limited resources as applies to trained investigators, infrastructure, and well-equipped laboratories. This research provides insights into clinical otology that cannot be obtained by any other means. Measures should be taken to preserve and extend the contributions of HTB research.

On the classification of hydropic ear disease (Menière's disease)

More than 150 years after its initial description by Prosper Menière, the disease named after him is still at the center of scientific debates. Two recent developments have specifically created a breeding ground for controversy: (1) Since its first description 10 years ago, magnetic resonance imaging diagnosis of endolymphatic hydrops in living patients has seen an increasing and worldwide application. (2) The Bárány Society Classification Committee published diagnostic criteria for Menière's disease in 2015 and proposed a concept of the disease that has elicited widespread criticism. In order to promote the understanding of the underlying controversies and arguments, this article gives an overview of and discusses relevant classification proposals for Menière's disease, including the new classification system of hydropic ear disease.

Cochlear implantation in far-advanced otosclerosis: hearing results and complications

Severe forms of otosclerosis known as far-advanced otosclerosis (FAO) can lead to severe to profound sensorineural hearing loss and can justify cochlear implantation. Because of the pathophysiology of otosclerosis, patients implanted for FAO may experience an increased rate of complications, such as facial nerve stimulation or electrode dislocation, and may have poorer hearing outcomes than expected. This retrospective study aimed to compare cochlear implantation hearing outcomes, surgical difficulties and complications in FAO patients versus non-FAO patients. Moreover, we evaluated whether high resolution computed tomography (CT scan) findings were predictive of perioperative problems, complications and hearing outcomes. FAO patients were diagnosed based on medical history, examination and CT scan. Thirty-five ears from FAO patients were compared to 38 control ears. Audiometric results were assessed at least 12 months after implantation by pure tone average, speech reception threshold, monosyllabic and disyllabic word recognition score (WRS) and Central Institute for the Deaf (CID) sentences test. Complications and surgical difficulties were compiled. CT scan findings were categorised within 3 grades of otosclerotic extension. No significant difference was found between FAO and non-FAO hearing outcomes, except that monosyllabic WRS were lower for FAO patients, especially those who underwent previous stapedotomy. Facial nerve symptomatology occurred in 8.6% of FAO patients; among these, one required explantation-reimplantation surgery. 86% of FAO implanted patients had retrofenestral extension on CT. These were associated with poorer disyllabic WRS (51% vs 68%, p < 0.05) than those with only fenestral involvement. Although not significant, high grade of severity on CT tended to be associated with surgical difficulties and complications. Cochlear implantation in FAO patients is an effective treatment technique. Though the overall complication rate is low, it tends to be higher in cases of severe extension on CT. Patient counselling should be adjusted accordingly.

MR Imaging in Menière Disease: Is the Contact between the Vestibular Endolymphatic Space and the Oval Window a Reliable Biomarker?

BACKGROUND AND PURPOSE

No reliable MR imaging marker for the diagnosis of Menière disease has been reported. Our aim was to investigate whether the obliteration of the inferior portion of the vestibule and the contact with the stapes footplate by the vestibular endolymphatic space are reliable MR imaging markers in the diagnosis of Menière disease.

MATERIALS AND METHODS

We retrospectively enrolled 49 patients, 24 affected by unilateral sudden hearing loss and 25 affected by definite Menière disease, who had undergone a 4-hour delayed 3D-FLAIR sequence. Two readers analyzed the MR images investigating whether the vestibular endolymphatic space bulged in the third inferior portion of the vestibule contacting the stapes footplate. This sign was defined as the vestibular endolymphatic space contacting the oval window.

RESULTS

We analyzed 98 ears: 27 affected by Menière disease, 24 affected by sudden sensorineural hearing loss, and 47 that were healthy. The vestibular endolymphatic space contacting the oval window showed an almost perfect interobserver agreement (Cohen κ = 0.87; 95% CI, 0.69-1). The vestibular endolymphatic space contacting oval window showed the following: sensitivity = 81%, specificity = 96%, positive predictive value = 88%, and negative predictive value = 93% in differentiating Menière disease ears from other ears. The vestibular endolymphatic space contacting the oval window showed the following: sensitivity = 81%, specificity = 96%, positive predictive value = 96%, negative predictive value = 82% in differentiating Menière disease ears from sudden sensorineural hearing loss ears.

CONCLUSIONS

The vestibular endolymphatic space contacting the oval window has high specificity and positive predictive value in differentiating Menière disease ears from other ears, thus resulting in a valid tool for ruling in Menière disease in patients with mimicking symptoms.

Controversies in the Evaluation and Management of Otosclerosis

Controversies have been associated with the etiology, diagnosis, evaluation, and management of otosclerosis since Valsalva first described stapes fixation as a cause of hearing loss. Although the exact mechanism of the bone remodeling associated with otosclerosis remains uncertain, stapedotomy has been accepted as the surgical treatment of most patients with stapedial otosclerosis. There remains a disparity of opinion, however, regarding the role of preoperative imaging, surgical technique, implant selection, and medical therapy for cochlear otosclerosis. In addition, opinions vary regarding the optimal postoperative care of patients undergoing stapedotomy and a patient's ability to participate in activities that may result in barotrauma.

Third-generation bisphosphonates for cochlear otosclerosis stabilizes sensorineural hearing loss in long-term follow-up

Objective

To assess long‐term hearing outcomes in patients treated with third‐generation bisphosphonates for otosclerosis‐related progressive sensorineural hearing loss (SNHL).

Study Design

Retrospective case series review

Methods

We performed a retrospective case series review of patients with otosclerosis and progressive SNHL. Patients were treated with either risedronate or zoledronate after a diagnosis of otosclerosis with a significant SNHL component. Bone conduction pure tone threshold averages (BC‐PTAs) and word recognition scores (WRS) before and after bisphosphonate administration in long‐term follow‐up was analyzed. Significant change in BC‐PTA was defined as greater than 10dB or between 4% and 18% in WRS based on binomial variance.

Results

Seven patients were identified and 14 ears met inclusion criteria. Three patients were female and the mean age was 48.3 ± 10.3 years. The mean duration between treatment with bisphosphonate administration and long‐term post‐treatment follow‐up audiometry was 87.6 ± 18.3 months, with a range of 61.6 to 109.1 months and median of 89.2 months. Analysis using BC‐PTA and WRS demonstrated that 11 ears remained stable while 2 improved and 1 worsened. No patient experienced any major complication as the result of bisphosphonate therapy.

Conclusion

Treatment with third‐generation bisphosphonates is associated with stability in otosclerosis‐related sensorineural hearing over 5‐ to 9‐year period. These results suggest that such medications may prevent the progression of SNHL in patients with otosclerosis.

Level of Evidence

4 (Case series).

Long-term Incidence and Degree of Sensorineural Hearing Loss in Otosclerosis

OBJECTIVES

1) To evaluate the long-term incidence and degree of the sensorineural component of hearing loss (SNHL) in patients with otosclerosis after accounting for expected age-related hearing loss. 2) To identify variables that might predict development of sensorineural hearing loss due to otosclerosis.

STUDY DESIGN

Retrospective audiometric database and chart review.

SETTING

Tertiary referral center.

PATIENTS

Consecutive patients with otosclerosis observed between 1994 and 2004, with ≥10 years follow-up, excluding patients with postoperative hearing loss or surgery before the initial audiogram.

INTERVENTION

Bone conduction (BC) thresholds at 0.5, 1, 2, and 4 kHz and Word Recognition.

MAIN OUTCOME MEASURE

BC threshold change (BCTC) over ≥10 years minus estimated age-related threshold change (ARTC) specific to age and sex for each patient (based on ISO 7029 reference population).

RESULTS

Three-hundred fifty-seven ears (290 patients) met study criteria, including 217 ears that had undergone stapedectomy during the study period. Mean follow-up was 14.0 years. The average BCTC after subtracting estimated ARTC was 4.6, 2.6, 3, and 2.7 dB for 0.5, 1, 2, and 4 kHz frequencies, respectively. However, 34% of ears (122 ears) had clinically significant progression of SNHL during the study period (>10 dB BCTC beyond expected ARTC at ≥2 frequencies). Multivariate analysis demonstrated that the probability of developing clinically significant SNHL was higher for women (odds ratio 1.86, p = 0.018) and lower for operated patients (odds ratio 0.46, p = 0.002).

CONCLUSION

The average long-term sensorineural hearing loss due to otosclerosis was statistically significantly more than for age alone at each frequency, but these average values (from 2.6 to 4.6 dB for tested frequencies) were clinically insignificant. Approximately one-third of patients with otosclerosis demonstrated a clinically significant progression of the sensorineural component of hearing loss, with the average BCTC above expected age-related changes ranging from 10.2 to 14.6 dB for tested frequencies among this subgroup.

The large vestibular aqueduct: A new definition based on audiologic and computed tomography correlation

Objective

The study goal was to determine the prevalence and clinical significance of a large vestibular aqueduct (LVA) in children with sensorineural hearing loss (SNHL).

Study Design and Setting

We conducted a retrospective review of a pediatric SNHL database. One hundred seven children with SNHL were selected and their radiographic and audiometric studies were evaluated. Radiographic comparisons were made to a group of children without SNHL.

Results

A vestibular aqueduct (VA) larger than the 95th percentile of controls was present in 32% of children with SNHL. Progressive SNHL was more likely to occur in ears with an LVA and the rate of progressive hearing loss was greater than in ears without an LVA. The risk of progressive SNHL increased with increasing VA size as determined by logistic regression analysis.

Conclusions

An LVA is defined as one that is ≥2mm at the operculum and/or ≥1 mm at the midpoint in children with nonsyndromic SNHL. An LVA appears to be more common than previously reported in children with SNHL. A linear relationship is observed between VA width and progressive SNHL.

Significance

The finding of an LVA in children with SNHL provides diagnostic as well as prognostic information. © 2007 American Academy of Otolaryngology-Head and Neck Surgery Foundation. All rights reserved.

Endoscopic approach for cochlear implantation in advanced otosclerosis: A case report

HYPOTHESIS

Ossification of the cochlea was once considered to be a contraindication for cochlear implantation. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. The endoscopic technique allows a direct approach to the round window and the cochlea, especially in remodeled labyrinth, allowing a better vision of scala tympani.

BACKGROUND

Tertiary referral ENT center.

METHODS

Between January 2011 and February 2015 three patients with far advanced otosclerosis with partial obliteration of the cochlea were selected and underwent endoscopic-assisted cochlear implantation.

RESULTS

In far advanced otosclerosis, endoscopy allowed a magnification of the anatomy of the round window, permitting the surrounding anatomical structures forming the anatomy of the niche to be identified, and avoiding a blind dissection. No postoperative complications were noted, in particular, no surgical site infection, no vertigo, and no facial nerve injuries. Implant activation was routinely performed 1 month after surgery. All monitoring till date has indicated that the external auditory ducts are well ventilated and there are no signs of extrusion.

CONCLUSIONS

Ossification may occur as a consequence of the pathology of meningitis, chronic otitis media, severe otosclerosis, autoimmune inner ear diseases, temporal bone traumas, and other diseases. Advances in cochlear implant technology and coding strategies have led to developments in different surgical procedures to manage cochlear ossification. Supported by a number of years of experience in the field of otoendoscopic surgery, we propose a technique for cochlear implantation under unfavorable conditions using endoscopic-assisted surgery, especially in advanced otosclerosis. This technique permits us to extend the indication for cochlear implantation, and in our opinion will reduce the morbidity associated with this surgical procedure.

Inner Ear Conductive Hearing Loss and Unilateral Pulsatile Tinnitus Associated with a Dural Arteriovenous Fistula: Case Based Review and Analysis of Relationship between Intracranial Vascular Abnormalities and Inner Ear Fluids

While pulsatile tinnitus (PT) and dural arteriovenous fistula (DAVF) are not rarely associated, the finding of a conductive hearing loss (CHL) in this clinical picture is unusual. Starting from a case of CHL and PT, diagnosed to be due to a DAVF, we analyzed relationship between intracranial vascular abnormalities and inner ear fluids. DAVF was treated with endovascular embolization. Following this, there was a dramatic recovery of PT and of CHL, confirming their cause-effect link with DAVF. We critically evaluated the papers reporting this association. This is the first case of CHL associated with PT and DAVF. We describe the most significant experiences and theories reported in literature, with a personal analysis about the possible relationship between vascular intracranial system and labyrinthine fluids. In conclusion, we believe that this association may be a challenge for otolaryngologists. So we suggest to consider the possibility of a DAVF or other AVMs when PT is associated with CHL, without alterations of tympanic membrane and middle ear tests.

Third-generation bisphosphonates for treatment of sensorineural hearing loss in otosclerosis

OBJECTIVE

To evaluate hearing outcomes in patients treated with third generation bisphosphonates for otosclerosis-related sensorineural hearing loss (SNHL).

HYPOTHESIS

Otosclerosis is a disease of abnormal bone remodeling in the otic capsule. In recent years, third generation bisphosphonates, with more powerful anti-resorptive properties and increased bone affinity, have demonstrated effectiveness in the treatment of osteoporosis and other metabolic bone diseases. We hypothesized that newer generation bisphosphonates, such as risedronate and zoledronate, would be effective in slowing the progression of SNHL in patients with otosclerosis.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary referral center, ambulatory care.

INTERVENTIONS

Risedronate or zoledronate administration.

MAIN OUTCOME MEASURES

Bone conduction pure tone threshold averages (PTAs) and word recognition (WR) scores were examined for each ear before and after bisphosphonate treatment. Criteria for significant change were defined as greater than 10 decibels in PTA or between 4% and 18% in WR based on binomial variance.

RESULTS

All 10 patients had audiometric progression of SNHL in the pretreatment monitoring interval and 12 ears met criteria for significant progression. All 10 patients (19 ears) showed at least no significant progression of SNHL (i.e., stabilization) at an average follow-up of 13 months. Two patients (3 ears) showed improvement by defined audiometric criteria. There were no major complications.

CONCLUSION

Treatment with zoledronate or risedronate stabilized progressive SNHL related to otosclerosis in this small group of patients. Further evaluation of third-generation bisphosphonate treatments is warranted.

Cochlear otosclerosis adjacent to round window and oval window: a histopathological temporal bone study

HYPOTHESIS

The purpose of this histopathological study is to examine temporal bones of patients with cochlear otosclerosis adjacent to the round window or adjacent to the oval window as compared with healthy controls.

BACKGROUND

It is unclear if the extent and site of otosclerosis affects the extent of damage to cochlear structures and hearing loss.

METHODS

Twelve temporal bones from 10 patients with cochlear otosclerosis adjacent to the round window, 11 temporal bones from 8 patients with cochlear otosclerosis adjacent to the oval window, and 12 bones of healthy age-matched controls were selected for study. We calculated the number of spiral ganglion cells, changes in cochlear structures, the extent and site of cochlear otosclerosis, and audiometric data.

RESULTS

The loss of spiral ganglion cells and the absence of outer hair cells in patients with cochlear otosclerosis adjacent to the round window were significantly higher than those in patients with cochlear otosclerosis adjacent to the oval window and healthy controls. The area of the spiral ligament in patients with cochlear otosclerosis adjacent to the oval window was significantly smaller than that in healthy controls. However, no significant difference was found in the spiral ligament of patients with cochlear otosclerosis adjacent to the round window and healthy controls. There was no significant difference between patients with cochlear otosclerosis and age-matched controls in audiometric data.

CONCLUSION

Cochlear otosclerosis adjacent to the round window caused significantly more damage to spiral ganglion cells and outer hair cells than cochlear otosclerosis adjacent to the oval window without loss of spiral ligament.

Distortion product otoacoustic emissions following stapedectomy versus stapedotomy

Objectives:

To evaluate distortion product otoacoustic emissions following stapes surgery in patients with otosclerosis, and to compare in this respect two surgical techniques used in our department.

Method:

This retrospective study included 17 stapedectomy and 23 stapedotomy patients aged 16–68 years who had been followed up for at least 12 months. Distortion product otoacoustic emission results at 2, 3, 4 and 5 kHz (i.e. =f2, with 2f1 − f2 = 0.6f2) were obtained pre-operatively and four weeks post-operatively. The control group included 13 volunteers aged 18–50 years with normal hearing and normal otoscopic findings.

Results:

Distortion product otoacoustic emissions were detected pre-operatively in 34.8 per cent of stapedotomy patients and 29.4 per cent of stapedectomy patients, and post-operatively in 91.3 per cent of stapedotomy patients and 88.2 per cent of stapedectomy patients. The differences between the stapedotomy and stapedectomy groups were statistically insignificant for each tested frequency, both pre- and post-operatively. The patients' post-operative distortion product otoacoustic emission amplitudes were less than those of normal hearing individuals, even in patients with complete air–bone gap closure and a significant improvement in hearing.

Conclusion:

Distortion product otoacoustic emissions were detected in most of our patients following successful stapes surgery, and appeared to be unaffected by the surgical technique or prosthesis used.

Selective activation of nuclear factor kappa B in the cochlea by sensory and inflammatory stress

Damage response pathways triggered by mechanical stress might reasonably be expected to be conserved throughout evolution. However, using a nuclear factor kappa B (NF-kappaB) reporter mouse we show here that this phylogenetically recent transcription factor plays a major role in the response to mechanosensory stress in the mammalian inner ear. The protective action of NF-kappaB is exerted in neither sensory nor non-sensory epithelial cells, but rather in connective tissue cells within the spiral ligament and spiral limbus. In the spiral ligament, predominantly type I fibrocytes are activated following noise exposure, whereas type II fibrocytes are activated following systemic inflammatory stress. Immune-mediated and acoustic trauma-mediated hearing loss syndromes in humans may in part result from the vulnerability of type II and type I fibrocytes to systemic inflammatory stress and acoustic trauma, respectively. Unexpected cell-specific and stress-specific NF-kappaB activation found in the inner ear in this in vivo study suggest that this approach may have wide applications in demonstrating similar specializations of stress responses in other tissues, including the brain.

Very far-advanced otosclerosis: stapedotomy or cochlear implantation

CONCLUSION

Every patient with severe or profound hearing loss must have a temporal bone high-resolution computed tomography (CT) scan. Stapedotomy is a simple, safe and low-cost procedure compared with cochlear implantation and can provide very good results. This can justify our decision to propose stapedotomy at the initial treatment in patients with very far-advanced otosclerosis. In cases of hearing failure after stapes surgery, cochlear implantation is an option.

OBJECTIVE

This study aimed to find the best first intention treatment of very far-advanced otosclerosis.

MATERIALS AND METHODS

This was a retrospective study and included 14 patients with non-measurable preoperative bone and air conduction thresholds and otosclerosis on temporal bone high-resolution CT scan. Stapes surgery followed by a well fitted hearing aid was the initial treatment in 11 patients and cochlear implantation in 7 patients, including 4 patients who had poor results after stapedotomy. Objective and subjective audiometric results were studied and compared between stapedotomy and cochlear implantation groups.

RESULTS

Objective and subjective results were statistically better in the cochlear implant group than in the stapedotomy group. However, four patients in the stapedotomy group had comparable results to the patients with cochlear implants.

Unbiased stereological estimation of the spiral ligament and stria vascularis volumes in aging and Ménière's disease using archival human temporal bones

The present study applies the unbiased stereological technique-Cavalieri principle to measure the volumes of the stria vascularis (SV) and the spiral ligament (SL) using postmortem archival human temporal bones from normal young and older subjects and subjects with Ménière's disease. Normative data was obtained from subjects without ages ranging from 15 to 84 years old who had no history of audiovestibular disease (N=25). For comparison purposes, the normative specimens were divided into three groups: group 1 (n=8) had ages ranging from 15 to 38 years old, average age=23.9; group 2 (n=8) had ages ranging from 51 to 59 years old, average age=55.1; group 3 (n=9) had ages ranging from 64 to 84 years old, average age=74.3. The average SV volume of group 3 (0.479 mm3) was significantly lower than that of group 1 (0.705 mm3) (p<0.0005) and was significantly lower than that of group 2 (0.603 mm3) (p=0.01). The average SL volume of group 3 (8.42 mm3) was significantly lower than that of group 1 (9.54 mm3) (p<0.05), but was not significantly lower than that of group 2 (8.58 mm3). Five subjects with Ménière's disease, confirmed by histopathological examination (ages ranging from 63 to 91 years old, average age=73.4), were studied. The average SV volume in Ménière's subjects (0.378 mm3) was significantly lower than age-matched controls (p<0.05). The average SL volume in Ménière's subjects (7.01 mm3) was also significantly lower than age-matched controls (p<0.05). The SV and SL volumes were unaffected by gender. The present study demonstrates for the first time the use of the unbiased stereological technique-Cavalieri principle-as a reliable and efficient method to obtain volumetric estimates of the SV and the SL by using archival human temporal bone specimens.

Late Failure of Cochlear Implantation Resulting From Advanced Cochlear Otosclerosis: Surgical and Programming Challenges

OBJECTIVE

The objective of this study was to discuss cochlear implantation in the setting of severe cochlear otosclerosis and review programming challenges in a patient whose performance is deteriorating as a result of advancing disease.

STUDY DESIGN

We conducted a case report and literature review.

SETTING

Tertiary care medical center. PATIENTS, INTERVENTION, AND RESULTS: A case is presented of a 66-year-old man with otosclerosis who initially had good benefit from a cochlear implant but gradually lost benefit even with reimplantation. Imaging studies demonstrated severely distorted otic capsule anatomy from cochlear otosclerosis.

CONCLUSIONS

Advancing cochlear otosclerosis can result in a severely thinned and distorted otic capsule. Although cochlear implantation is generally beneficial in cochlear otosclerosis, implantation in certain severe cases may be complicated as a result of difficulties with cerebrospinal fluid leak, programming challenges, and other potential hazards that can occur with a distorted anatomy.

Questioning the Relationship between Cochlear Otosclerosis and Sensorineural Hearing Loss: A Quantitative Evaluation of Cochlear Structures in Cases of Otosclerosis and Review of the Literature

BACKGROUND

The literature provides conflicting information regarding the prevalence and cause of sensorineural hearing loss (HL) in individuals with otosclerosis.

OBJECTIVE

The purpose of this study was to further evaluate the association between involvement of the cochlear endosteal layer with otosclerosis and sensorineural HL.

STUDY DESIGN

Retrospective case review.

METHODS

Temporal bones and audiograms from five individuals with otosclerosis were evaluated. The cochlear elements were quantified. The location and extent of the cochlear element loss was correlated with the location and extent of endosteal involvement with otosclerosis.

RESULTS

A reduction in the population of cochlear elements was observed in most individuals; however, the reduction was not proportional to the extent of endosteal involvement with otosclerosis. The cochlear elements remained normal adjacent to some areas of endosteal involvement with otosclerosis. One individual with extensive cochlear otosclerosis had normal hearing and predominantly normal cochlear elements.

CONCLUSION

This study demonstrates a variable amount of degeneration of the cochlear elements in individuals with otosclerotic involvement of the endosteum. The reduction in the population of cochlear elements was not related to the extent and location of endosteal involvement with otosclerosis. These findings suggest that factors that limit the effect of otosclerotic endosteal involvement on the cochlear elements or processes that effect the cochlear elements directly and are independent of bone involvement may be present.

Labyrinthine fistula as a late complication of middle ear surgery using the canal wall down technique

OBJECTIVES

To evaluate the clinical features of labyrinthine fistulae occurring as a late complication of middle ear surgery using the canal wall down technique.

STUDY DESIGN

This was a retrospective study of the past 23 years, conducted at a single tertiary care center. The authors evaluated the backgrounds, clinical features, and surgical findings in 25 patients with labyrinthine fistulae, who had a history of ear surgery using the canal down technique and who underwent a second operation at their hospital.

INTERVENTIONS

All the patients underwent revision surgery because of persistent or recurrent vertigo caused by labyrinthine fistulae, circumscribed labyrinthitis, or suppurative labyrinthitis.

MAIN OUTCOME MEASURES

The clinical features of this disease entity were assessed by history, surgical findings, and the results of audiovestibular testing.

RESULTS

The patients had a long history of repetitive postoperative aural discharge before experiencing vertigo, which initially occurred 4 to 64 years (average, 20.2 years) after the previous operation. At the first visit to the authors' clinic, the results of a fistula test conducted with a Politzer's bulb were positive in 14 patients and negative in 5 patients. In the remaining 6 ears, pressure loading of the ear canal induced the sensation of vertigo without accompanying nystagmus. Surgical intervention showed that the fistulae were located at the lateral semicircular canal in 19 ears, at the footplate of the stapes in 4 ears, and at the promontory in 2 ears. Labyrinthine fistulae were closed with conchal cartilage, bone paste (bone dust mixed with fibrin glue), and/or temporalis fascia. In some patients, the fistulae were further covered with pedicled temporalis muscle. In 2 cases complicated by acute suppurative labyrinthitis, the mastoid cavity was obliterated after completion of the labyrinthectomy. The postoperative courses in all patients were uneventful.

CONCLUSIONS

A labyrinthine fistula may be created by repeated and insidious infection of a mastoid cavity that has been exposed to the outside during canal wall down surgery. Intensive care of the opened mastoid cavity is essential to avoid this late complication.

Management of far advanced otosclerosis in the era of cochlear implantation

OBJECTIVE

To evaluate issues pertaining to cochlear implantation in patients with far advanced cochlear otosclerosis.

STUDY DESIGN

Prospective cohort.

SETTING

Tertiary care referral center.

PATIENTS

Eight adult patients (18 years of age or older) referred for management of profound hearing loss, the cause of which was determined to be otosclerosis.

INTERVENTION

Cochlear implantation with multichannel cochlear implant device.

MAIN OUTCOME MEASURES

Benefit from cochlear implant as measured by CID sentence scores, incidence and management of facial nerve stimulation, and technical issues pertaining to cochlear implantation in this patient population.

RESULTS

All patients demonstrated significant improvement in auditory function as measured by performance on CID sentence scores and ability to engage in telephone conversation. Facial nerve stimulation was present in two of eight patients and was managed with deactivation of the stimulating electrodes. Ossification in the basal turn of the cochlea, detected on preoperative computed tomography, necessitated placement of the electrode into the scala vestibuli in two patients and use of a thinner electrode (Nucleus 24) in a third patient.

CONCLUSION

Patients with profound hearing loss secondary to otosclerosis derive excellent benefits from cochlear implantation. Surgical implantation may be complicated by ossification of the cochlea, which can be detected on preoperative computed tomography. Electrode activation may be complicated by facial nerve stimulation, which can be addressed with programming strategies.

Sensorineural hearing loss and otosclerosis: a clinical and radiologic survey of 437 cases

The aim of this study was to determine if a relationship exists between bone level thresholds and the extension of otosclerotic foci within the otic capsule. The study consisted of a retrospective case review in a university hospital. We included patients who underwent surgery for otosclerosis in our department and who had a CT scan prior to surgery. We analyzed the data charts and CT scans of 437 cases (386 patients). On CT scan, we distinguished patients with fenestral otosclerosis and/or with a pericochlear focus. A pericochlear focus could be extended (Group 2) or not (Group 1) to the cochlear endosteum. Data for Groups 1 and 2 were compared with those for the control group of all patients for whom CT scan showed no cochlear focus (Group 3). Of the 437 CT scans, 399 were positive (91.3%). An anterior focus was reported in 305 cases (69.8%), a footplate thickening in 21 cases (4.8%) and both anomalies were encountered in 60 cases (13.7%). A pericochlear focus was reported in 53 examinations. This focus was extended to the endosteum in 14 cases (26.4% of the pericochlear foci). In Group 1, preoperative air conduction (AC) thresholds were significantly lower than in the control group (p < 0.05). The air--bone gap was also significantly larger in Group 1 (p < 0.05). Bone conduction (BC) thresholds were lower in Group 1 than in the control group but the difference was not significant. In Group 2, preoperative AC thresholds were significantly lower than in the control group (p < 0.05). BC thresholds were also lower in Group 2 than in the control group and the difference was significant (p < 0.05). As a result of this study, we assume that there may be a relationship between bone level thresholds and the radiological extension of otosclerosis within the otic capsule.

Fluoride therapy for cochlear otosclerosis? an audiometric and computerized tomography evaluation

The progress of sensorineural hearing loss (SNHL) in patients with cochlear otosclerosis was compared for 19 patients treated with fluoride for 1-5 years and 22 untreated controls. CT scans of eight patients before and after fluoride treatment were evaluated visually. Fluoride therapy arrested the progression of SNHL in the low (250, 500 and 1,000 Hz) (p < 0.001) and high (2 and 4 kHz) (p = 0.008) frequencies. It seemed to be more effective for the higher frequencies in cases with an initial SNHL of < 50 dB. Fluoride administration for 4 years did not seem to be superior to a shorter treatment period (1-2 years). For six patients followed up after discontinuing fluoride therapy there was minimal deterioration in SNHL. There was no clear relationship between the size and site of otospongiotic lesions on CT and the severity of SNHL. Follow-up with CT evaluation did not provide reliable information as to the efficacy of fluoride therapy.

Vertigo and dysequilibrium with associated hearing loss

There are numerous disorders that can present with hearing loss and vertigo or dysequilibrium. The combination of vertigo and imbalance associated with hearing loss are symptoms suggestive of a peripheral vestibular disorder. This article summarizes presentation, diagnosis, and treatment of the various common and rare peripheral vestibular disorders that can present with these symptoms.

Clinical observations on the on-off effect of the acoustic stapedius reflex

The on-off effect of the acoustic stapedius reflex was found in association with several kinds of ear disease: otosclerotic stapes fixation, incudostapedial dislocation and sensorineural hearing loss. One fifth (8/40) of the patient group with an on-off effect and sensorineural hearing loss showed the typical symptoms of Ménière's syndrome.