Otologic management in children with the CHARGE association

Co-Occurrence of Sensorineural Hearing Loss and Congenital Heart Disease: Etiologies and Management

OBJECTIVES/HYPOTHESIS

The co-occurrence of sensorineural hearing loss (SNHL) and congenital heart disease (CHD) is a rare condition with complex etiologies. The purpose of this study is to assess the etiologies, clinical features, and outcomes of cochlear implant (CI) in this patient population.

STUDY DESIGN

Case series and literature review.

METHODS

Clinical data of children who were diagnosed with SNHL and CHD and received CIs at a tertiary hospital from 2016 to 2021 were retrospectively analyzed. A literature review was performed to identify patients with SNHL and CHD.

FINDINGS

Of the 382 children who underwent cochlear implantation at our center, eight (2.1%) were diagnosed with SNHL and CHD. A literature review identified 1525 patients from 254 studies; the database therefore consisted of 1533 patients. The most common genetic etiologies of co-occurring SNHL and CHD were CHARGE syndrome (36.3%), Turner syndrome (8.4%), 22q11.2 deletion (3.0%), Noonan syndrome (2.9%), and Down syndrome (2.5%), whereas the most common non-genetic etiologies were congenital rubella syndrome (22.9%) and SNHL after early cardiac surgery (5.5%). Most of the patients presented with congenital, bilateral, severe-profound SNHL requiring early rehabilitation. Of the 126 children who received CIs at a median age of 2.5 years, half showed delayed speech development at last follow-up.

CONCLUSIONS

Co-occurring SNHL and CHD is a rare condition with complex etiologies. Timely hearing intervention with long-term follow-up and proper timing of heart surgery is essential for these children.

LEVEL OF EVIDENCE

4, case series Laryngoscope, 134:400-409, 2024.

Neural crest contributions to the ear: Implications for congenital hearing disorders

Congenital hearing disorders affect millions of children worldwide and can significantly impact acquisition of speech and language. Efforts to identify the developmental genetic etiologies of conductive and sensorineural hearing losses have revealed critical roles for cranial neural crest cells (NCCs) in ear development. Cranial NCCs contribute to all portions of the ear, and defects in neural crest development can lead to neurocristopathies associated with profound hearing loss. The molecular mechanisms governing the development of neural crest derivatives within the ear are partially understood, but many questions remain. In this review, we describe recent advancements in determining neural crest contributions to the ear, how they inform our understanding of neurocristopathies, and highlight new avenues for further research using bioinformatic approaches.

Suprameatal Cochlear Implantation in a CHARGE Patient With a Novel CHD7 Variant and KALLMANN Syndrome Phenotype: A Case Report

OBJECTIVE

We present the clinical findings, technique of the suprameatal cochlear implantation, postoperative auditory results, and genetic analysis of the CHD7 gene.

PATIENT

A 19-year-old Japanese woman was referred because of progressive hearing loss since early childhood. She had used verbal language for the main mode of communication until the age of 17. Examination revealed coloboma, heart defect, choanal atresia, genital hypoplasia, and deafness, which was diagnosed as CHARGE syndrome. Examination also revealed features of Kallmann syndrome.

INTERVENTIONS

Cochlear implantation was performed in the left ear at age 20. Targeted resequencing of the CHD7 gene was performed by next-generation sequencing.

RESULTS

Cochlear implantation was performed using a suprameatal approach (SMA) with cartilage protection because of a venous malformation of the temporal bone. The electrode introduced into the scala tympani through the cochleostomy could be fully inserted. The electrode was covered with cartilage to avoid contact with the skin of the external auditory canal. No intra- or postoperative complications have occurred up to 4 years postoperatively, and the patient uses verbal language again as the main mode of communication. A novel variant c.6405_6406delAG,p.(Ala2137Argfs*2) in CHD7 was identified by next-generation and Sanger sequencing analyses, resulting in a 2137-amino-acid truncated polypeptide. Parental genetic screening confirmed the sporadic origin of the mutation.

CONCLUSION

Cochlear implantation surgery using the SMA with cartilage protection technique appears to be a feasible and effective option for patients with ear anomalies that obstruct the usual approach. A novel frameshift variant c.6405_6406delAG,p.(Ala2137Argfs*2) in CHD7 was also identified in this patient.

Influence of hearing loss and cognitive abilities on language development in CHARGE Syndrome

Hearing loss and cognitive delay are frequently occurring features in CHARGE syndrome that may contribute to impaired language development. However, not much is known about language development in patients with CHARGE syndrome. In this retrospective study, hearing loss, cognitive abilities, and language development are described in 50 patients with CHARGE syndrome. After informed consent was given, data were collected from local medical files. Most patients (38.3%; 18/47 patients) had moderate hearing loss (41-70 dB) and 58.5% (24/41 patients) had an IQ below 70. The mean language quotients of the receptive and expressive language were more than one standard deviation below the norm. Both hearing loss and cognitive delay had an influence on language development. Language and cognitive data were not available for all patients, which may have resulted in a pre-selection of patients with a delay. In conclusion, while hearing thresholds, cognitive abilities and language development vary widely in CHARGE syndrome, they are mostly below average. Hearing loss and cognitive delay have a significant influence on language development in children with CHARGE syndrome. To improve our knowledge about and the quality of care we can provide to CHARGE patients, hearing and developmental tests should be performed regularly in order to differentiate between the contributions of hearing loss and cognitive delay to delays in language development, and to provide adequate hearing amplification in the case of hearing loss. © 2016 Wiley Periodicals, Inc.

Congenital incudostapedial anomalies in adult stapes surgery: a case-series review

OBJECTIVES

The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. We review our experience in managing various incudostapedial developmental anomalies discovered during middle ear exploration for suspected otosclerosis in adult patients.

DESIGN

A retrospective case-series review was used.

SETTING

The study was set at a military tertiary referral center.

PATIENTS AND OTHER PARTICIPANTS

A review of 185 stapes procedures yielded 8 cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory.

INTERVENTIONS

The developmental anatomy and surgical technique in each case were reviewed. The surgical technique used in each case varied depending on the specific ossicular abnormality found and whether both the stapes and incus were affected.

MAIN OUTCOME MEASURES

Comparison of preoperative and postoperative audiometric testing results was performed.

RESULTS

All 8 ears (7 patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome, with 7 ears improving to within 10-dB and 1 ear to within 13-dB air-bone gap on postoperative audiometry.

CONCLUSIONS

Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

Mature middle and inner ears express Chd7 and exhibit distinctive pathologies in a mouse model of CHARGE syndrome

Heterozygous mutations in the gene encoding chromodomain-DNA-binding-protein 7 (CHD7) cause CHARGE syndrome, a multiple anomaly condition which includes vestibular dysfunction and hearing loss. Mice with heterozygous Chd7 mutations exhibit semicircular canal dysgenesis and abnormal inner ear neurogenesis, and are an excellent model of CHARGE syndrome. Here we characterized Chd7 expression in mature middle and inner ears, analyzed morphological features of mutant ears and tested whether Chd7 mutant mice have altered responses to noise exposure and correlated those responses to inner and middle ear structure. We found that Chd7 is highly expressed in mature inner and outer hair cells, spiral ganglion neurons, vestibular sensory epithelia and middle ear ossicles. There were no obvious defects in individual hair cell morphology by prestin immunostaining or scanning electron microscopy, and cochlear innervation appeared normal in Chd7(Gt)(/+) mice. Hearing thresholds by auditory brainstem response (ABR) testing were elevated at 4 and 16 kHz in Chd7(Gt)(/+) mice, and there were reduced distortion product otoacoustic emissions (DPOAE). Exposure of Chd7(Gt)(/+) mice to broadband noise resulted in variable degrees of hair cell loss which inversely correlated with severity of stapedial defects. The degrees of hair cell loss and threshold shifts after noise exposure were more severe in wild type mice than in mutants. Together, these data indicate that Chd7(Gt)(/+) mice have combined conductive and sensorineural hearing loss, correlating with changes in both middle and inner ears.

Spectrum of hearing disorders and their management in children with CHARGE syndrome

OBJECTIVE

The CHARGE syndrome is associated with ear anomalies and deafness in addition to other malformations. Deformations of the ossicles or aplasia of the semicircular canals, cochlear hypoplasia, hypoplasia or aplasia of the VIIIth cranial nerve and abnormal routing of the VIIth cranial nerve, sigmoid sinus, and emissaries are typical findings. The aim of this study is to explore the feasibility and procedure of cochlear implantation in patients with CHARGE syndrome and to assess the outcome.

STUDY DESIGN

Retrospective case review.

SETTING

Tertiary referral center; cochlear implant program.

PATIENTS

Ten patients with CHARGE syndrome and 3 patients with CHARGE-like syndrome treated in our center due to hearing impairment. Eleven patients were congenitally deaf, 1 patient had progressive hearing loss, and 1 patient had mixed hearing loss.

INTERVENTION

Computed tomography of temporal bones and magnetic resonance imaging of the brain; bone-anchored hearing aid surgery, cochlear implantation, rehabilitation results.

MAIN OUTCOME MEASURES

Surgical suitability and hearing rehabilitation.

RESULTS

We illustrate the management of preoperative diagnostics, surgical planning, and hearing rehabilitation. One patient with mixed hearing loss underwent bilateral bone-anchored hearing aid surgery. Because 2 patients had bilateral aplasia of the auditory nerves, we recommended an auditory brainstem implant. The unilateral cochlear implantation was performed in 9 patients and bilateral in 1 patient. In selected cases, it was helpful to plan the operation using a simulator for temporal bone surgery. Complex malformations, such as in CHARGE syndrome, with an increased intraoperative risk for complications should be facilitated by using intraoperative digital volume tomography-assisted navigation and intraoperative digital volume tomography control of electrode position. The results after CI surgery vary due to the differing extent of additional disabilities such as developmental delay, intellectual delay, and visual impairment. Nine of our patients showed improved responsiveness with the cochlear implant. Open speech comprehension could not be observed in 8 patients, whereas the follow-up period was less than 1 year in 4 patients. The relatively high age of our patients at implantation might be an important factor.

CONCLUSION

Careful planning of the treatment of CHARGE syndrome patients with sensorineural hearing loss can, to a limited extent, lead to auditory benefit without increasing surgical complications. Cochlear implantation is therefore indicated after critical assessment.

Factors related to the development of communication in CHARGE syndrome

Parents of 28 children and a young adult with CHARGE syndrome participated in a survey on factors related to communication development. Information was obtained using a questionnaire and a follow-up interview. Parents were asked to (1) specify their child's primary mode of communication, (2) judge the significance of the effects of physical disorders, sensory deficits, and behavior on development and communication, (3) provide lists of their child's conditions and disorders, and (4) provide information about intervention related to communication and education. Thirty-nine percent of the participants (11/28) did not use symbolic language to communicate. The results suggest that factors affecting the majority of participants--physical disorders, vision loss, and hearing loss--may adversely affect communication ability. However, these factors did not preclude the development of symbolic language. Factors that were related to the development of symbolic language were success in the treatment of hearing loss with amplification, the ability to walk independently, and communication training initiated by 3 years of age. Other factors that may be related to the development of symbolic language are also discussed.

CHARGE syndrome: a window of opportunity for audiologic intervention

OBJECTIVE

To detail the clinical features of 22 new patients with a syndrome characterized by ocular coloboma, heart defects, atretic choanae, retarded growth or development, genital hypoplasia, and ear anomalies or hearing loss (CHARGE) seen in a tertiary academic medical center; compare auditory brainstem response (ABR) thresholds and behavioral hearing test results; identify a "window of opportunity" for audiologic intervention; review the literature regarding hearing results in CHARGE syndrome; and review the relationship between facial palsy and sensorineural hearing loss.

METHODS

Clinical data were gathered to examine 1) the variety of hearing results, 2) the average age at the time of hearing loss identification in 22 children with CHARGE using electrophysiologic and behavioral test methods, 3) the usefulness of the ABR as an early indicator of hearing sensitivity for a select group composed of children from the present study and from an earlier report from the same institution, and 4) the value of congenital facial paralysis as a predictor of sensorineural hearing loss in CHARGE children seen in the authors' institution since 1983.

RESULTS

All children had 4 or more acronymic features, including colobomatous defects or choanal atresia. Ear anomalies/hearing loss occurred at least as frequently as other primary features. A total of 81% of patients had hearing loss; in this subset, 1 child had a mild degree of loss, and the remaining children had moderate or greater losses. The average age at which ABR confirmed hearing status was 3.8 months, whereas for behavioral testing, that age was 24.7 months, a statistically significant difference. In a select group of 16 children, no statistical differences existed when comparing threshold results of early electrophysiologic testing with behavioral test findings obtained at a later date. Contingency analysis suggests that congenital facial paralysis and sensorineural hearing loss are related.

CONCLUSIONS

Hearing loss is prevalent in children with CHARGE syndrome. Within a wide range of results exists a propensity for moderate or greater hearing loss in children with sensorineural or mixed impairments. Congenital facial palsy seems to be a valid statistical predictor of sensorineural hearing loss and can be a useful device in audiologic decision making. A "window of opportunity" for audiologic intervention exists in the first few months of life. Primary care providers are encouraged to recognize the need for immediate, early audiologic referral of their patients suspected to have CHARGE. Evaluation of hearing sensitivity during infancy and, when appropriate, provision of amplification are important components in the process of auditory habilitation. These efforts are in keeping with various professional guidelines that call for early detection of hearing loss and subsequent prompt intervention to minimize effects on infant development.