Congenital aural atresia

Diagnosis and Management of Unexplained Conductive Hearing Loss With Intact Tympanic Membrane: A Systematic Review

Objective: To analyze the etiology, diagnosis, and treatment of unexplained conductive hearing loss (UCHL) with intact tympanic membrane. Methods: A systematic review was conducted based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 642 articles were retrieved from databases such as PubMed, Embase, Web of Science, and Cochrane. Fifty-four research articles and 21 case reports were screened out according to the inclusion and exclusion criteria for analysis of the etiology of UCHL. Seven research articles with UCHL who underwent exploratory tympanotomy were selected for data extraction and analysis of clinical characteristics. Results: UCHL is a common manifestation of various diseases, including congenital ossicular anomalies (COA), otosclerosis (OTS), congenital middle ear cholesteatoma (CMEC), oval window atresia, superior semicircular-canal dehiscence, congenital stapedial footplate fixation, middle ear osteoma or adenoma, congenital ossification of stapedial tendon, and so on. A total of 522 patients were included in the 7 articles; among whom OTS showed a tendency to increase with age. The main symptoms were hearing loss, followed by tinnitus, dizziness, ear fullness, ear pain, facial paralysis. A total of 87.5% to 93.0% patients with COA manifested as nonprogressive deafness that occurred since childhood, with tinnitus incidence of 15.6% to 30.2%, and 86.4% to 96.4% patients with OTS presented with progressive hearing loss, with tinnitus incidence of 60.1% to 90.9%. The diagnosis positive rate of high-resolution computed tomography (HRCT) was 33.8% to 87.1%, and CMEC was higher than that of COA (83.3%-100% vs 28.6%-64%). All the articles reported good hearing recovery. The most common surgical complications included taste abnormalities, tinnitus, and dizziness. Conclusion: UCHL presents with similar clinical manifestations and poses challenges in preoperative diagnosis. Exploratory tympanotomy is the primary method for diagnosis and treatment, with good prognosis after removing the lesion and reconstructing hearing during the operation. Children can also safely undergo the surgery.

Efficacy of vibrant sound bridge in congenital aural atresia: an updated systematic review

PURPOSE

The indications of Vibrant Soundbridge (VSB) have been expanded to include patients with conductive and mixed hearing loss due to congenital aural atresia (CAA). However, the current evidence supporting the auditory outcomes of VSB is based mainly on case reports and retrospective chart reviews. Therefore, the present systematic review aims to summarize and critically appraise the current evidence regarding the safety and effectiveness of VSB in children and adult patients with CAA.

METHODS

A systematic literature search retrieved studies that evaluated the outcomes of unilateral or bilateral implantation of VSB in patients with CAA. The bibliographic search was conducted in PubMed, Scopus, EBSCO, and Cochrane Central Register of Controlled Trials (CENTRAL) databases from January 2000 to December 2022.

RESULTS

Twenty-seven studies were included in the present systematic review. Overall, the speech perception after VSB was good, with a mean word recognition score (WRS) score ranging from 60 to 96.7%. The mean postoperative speech recognition threshold (SRT) after implantation ranged from 20.8 to 50 dB. The effective gain was reported in 15 studies, ranging from 31.3 to 45.5 dB. In terms of user satisfaction with VSB, the included studies showed significant improvements in the patient-reported outcomes, such as the Speech Spatial and Qualities of Hearing scale and Glasgow Hearing Aid Benefit Profile. The VSB implantation was generally safe with low incidence of postoperative complications.

CONCLUSION

VSB provides significant benefits to individuals with hearing loss owing to CAA, with very good subjective outcomes and a low risk of complications.

Updated EUROCAT guidelines for classification of cases with congenital anomalies

BACKGROUND

Precise and correct classification of congenital anomalies is important in epidemiological studies, not only to classify according to etiology but also to group similar congenital anomalies together, to create homogeneous subgroups for surveillance and research. This paper presents the updated EUROCAT (European surveillance of congenital anomalies) subgroups of congenital anomalies and the updated multiple congenital anomaly (MCA) algorithm and provides the underlying arguments for the revisions.

METHODS

The EUROCAT methodology is described. In addition, we show how we validated the revised EUROCAT subgroups and MCA algorithm, which are both based on the International Classification of Diseases (ICD10/ICD9) codes.

RESULTS

The updated EUROCAT subgroups and the updated MCA algorithm are described in detail and the updated version is compared to the previous versions.

CONCLUSION

The EUROCAT subgroups and MCA algorithm provide a standardized and clear methodology for congenital anomaly research and epidemiological surveillance of congenital anomalies in order to facilitate the identification of teratogenic exposures and to assess the impact of primary prevention and prenatal screening policies. The EUROCAT subgroups and MCA algorithm are made freely available for other researchers via the EUROCAT Database Management Software.

Comparison of Transcutaneous and Percutaneous Implantable Hearing Devices for the Management of Congenital Aural Atresia: A Systematic Review and Meta-Analysis

OBJECTIVE

To compare audiometric outcomes, complications, and revisions required for percutaneous (pBCD) versus transcutaneous (tBCD) implantable bone-conduction devices for the treatment of hearing loss associated with congenital aural atresia (CAA).Databases Reviewed.PubMed, Scopus, CINAHL.

METHODS

A systematic review was performed searching for English language articles from inception to December 14, 2022. Studies reporting audiometric outcomes or complications for either pBCDs or tBCDs for the treatment of CAA were selected for inclusion. A meta-analysis of single means and meta-analysis of proportions with comparison (Δ) of weighted proportions was conducted.

RESULTS

A total of 56 articles with 756 patients were selected for inclusion. One hundred ninety patients were implanted with pBCDs, whereas the remaining 566 were implanted with tBCDs. Mean pure-tone audiometry improvement in the pBCD group (39.1 ± 1.1 dB) was significantly higher than in the tBCD group (34.6 ± 1.6 dB; Δ4.5 dB; 95% confidence interval, 4.2-4.7 dB; p < 0.0001). The average improvement in speech reception threshold was 38.6 ± 2.5 dB in the percutaneous group as compared with 32.7 ± 1.6 dB in the transcutaneous group (Δ5.9 dB [5.3-6.5 dB], p < 0.0001). Overall complication rates for patients implanted with pBCDs and tBCDs were 29.0% (15.7-44.4%) and 9.4% (6.5%-13.0%), respectively (Δ19.6% [12.0-27.7%], p < 0.0001).

CONCLUSIONS

Patients with CAA implanted with pBCDs had significantly better audiometric outcomes than those implanted with tBCDs. However, complication rates were significantly higher among the pBCD group.

Labyrinthine Bifurcation of the Facial Nerve

The labyrinthine bifurcation of the facial nerve is extremely rare. Diverse congenital temporal bone anomalies usually coexist, and a detailed preoperative evaluation is needed to detect them. We report a case of labyrinthine bifurcation of the facial nerve detected on the preoperative evaluation of a patient with congenital aural atresia.

Comparative Analysis of Cartilage Conduction Hearing Aid Users and Non-Users: An Investigative Study

Clinical findings on cartilage conduction hearing aids (CCHAs) have gradually become clear; however, few reports include a large number of cases. This study included 91 ears from 69 patients who underwent CCHA fitting in our hospital. Their ears were divided into six groups (i.e., bilateral aural atresia or severe canal stenosis, unilateral aural atresia or severe canal stenosis, chronic otitis media or chronic otitis externa with otorrhea, sensorineural hearing loss, mixed hearing loss, and conductive hearing loss) according to their clinical diagnosis and type of hearing loss. Most clinical diagnoses were aural atresia or meatal stenosis (bilateral, 21.8%; unilateral, 39.6%). The purchase rate of CCHAs was higher in the closed-ear group (bilateral, 77.3%; unilateral, 62.5%). In the bilateral closed-ear group, air conduction thresholds at 1000, 2000, and 4000 Hz and aided thresholds with CCHAs at 4000 Hz were significantly lower in the purchase group than the non-purchase group. No significant difference was observed between the purchase and non-purchase groups in the unilateral closed-ear group. In the bilateral closed-ear group, air conduction thresholds and aided thresholds were associated with the purchase rate of CCHAs. In the unilateral closed-ear group, factors other than hearing might have affected the purchase rate of CCHAs.

Long-term outcomes of retrospective case series of middle ear implantation with Vibrant Soundbridge in children with congenital aural atresia

PURPOSE

to assess audiological performance in quiet and noise, quality of life and side effects of Vibrant Soundbridge (VSB) in children with congenital aural atresia (CAA).

METHODS

A retrospective study including consecutive patients with unilateral or bilateral CAA implanted with VSB from 2009 to 2020 in a tertiary referral centre.

RESULTS

18 patients with CAA and a present stapes were included (3 simultaneous bilateral VSB implants) and 21 ears: 17 VSB were attached to the short incus process, and four to the stapes. Age at implantation ranged from 4.7 to 15.8 years. Average follow-up was 6.5 years (± 3.7 years). In unilateral VSB, air conduction pure tone average (ACPTA) thresholds increased from 75.3 ± 15.2 to 32.6 ± 8.3 dB post-operatively (VSB activated) (n = 15; p < 0.01). The speech reception threshold (SRT) and the word recognition score (WRS) were significantly improved from 81.5 ± 10.4 to 43.9 ± 7.6 dB and 0% to 84.8 ± 8.5% postoperatively (n = 15; p < 0.01). The signal to noise ratio (SNR) was significantly improved from 2.1 ± 2.9 dB VSB inactivated to 0.3 ± 2.7 dB VSB activated (n = 15; p < 0.01). There was no significant difference in performance according to floating mass transducer (FMT) placement. 5/15 children were non-users at last follow-up in unilateral VSB and 0/3 in bilateral.

CONCLUSIONS

CAA ears with VSB activated had a significant improvement of ACPTA, WRS, SRT and SNR. A third of patients with unilateral CAA became non-users at last follow-up. The main challenge is to target the indications for the implantation of the VSB to avoid its discontinuation.

Taste Changes after Atresioplasty in Patients with Congenital Aural Atresia

OBJECTIVE

We evaluated chorda tympani nerve (CTN) and postoperative taste dysfunction according to anomaly severity and intraoperative CTN status.

STUDY DESIGN

Prospective observational study.

SETTING

Tertiary referral center, Samsung medical center hospital.

PATIENTS

Thirty-one patients who underwent atresioplasty by a single surgeon in a tertiary referral center were enrolled.

INTERVENTIONS

Therapeutic surgery.

MAIN OUTCOME MEASURES

Preoperative Schuknecht type and Jahrsdoerfer score and intraoperative CTN status were recorded, and a postoperative questionnaire was administered to evaluate taste function.

RESULTS

A significant difference was found among intact, cut, and unidentified groups in terms of Schuknecht type ( p = 0.000) and Jahrsdoerfer score (9.28 ± 1.11, 8.80 ± 0.83, 8.10 ± 0.93, p = 0.028). CTN was observed in Schuknecht type B, and not in type C ( p = 0.000), and was more likely to be observed as Jahrsdoerfer score increased ( p = 0.012). Taste disturbance tended to last longer in adult patients than in children. A significant difference was observed in the incidence of taste change between cut and intact CTN groups ( p = 0.018).

CONCLUSION

CTN was not identified during surgery in patients with Schuknecht type C anomalies, and there was no change in taste after surgery. Meanwhile, CTN was observed in all patients with Schuknecht type B anomalies, and CTN injury occurred in 41.67%. Therefore, CTN presence can be predicted by severity of anomaly, and patients with type B anomalies should be informed of the risk of CTN injury before surgery.

Patient reported outcome measures in unilateral aural atresia treated using a transcutaneous bone conduction implant (The Cochlear Baha Attract®)

OBJECTIVES

Unilateral aural atresia (UAA) is a congenital condition that is associated with maximal conductive hearing loss. The primary objective of this study was to assess the long-term compliance, complications, and quality of life of pediatric patients with UAA who had transcutaneous bone conduction hearing implants (TCBI).

METHODS

Retrospective consecutive case series at a single centre between 2014 and 2018. Inclusion criteria consisted of UAA patients between 5 to 17 years-old receiving the Cochlear Baha Attract ® device. Demographic and audiologic data was extracted from charts. A prospective telephone survey was done, with patients and their families completing the Glasgow Children's Benefit Inventory (GCBI). Basic descriptive statistics, paired t-tests, and a univariate analysis were completed.

RESULTS

Data was successfully collected from all 9 eligible children who received the Cochlear Baha Attract ® device for UAA (100%). The mean follow-up duration was 33 months after TBCI (9-60 months). The mean daily use was 7.7 h/day. Pure tone average and mean speech in noise scores were both significantly improved when comparing the unaided condition to the aided condition with TCBI (p < 0.001). The majority (89%) of patients had an improvement in GCBI; the median GCBI score was +14.6, indicating overall positive benefit. A linear regression showed no demographic variables were significant for mean daily use or GCBI scores.

CONCLUSION

This preliminary study showed that patients with a TCBI for UAA had high long-term compliance and daily usage rates. TCBI improved the quality of life for the majority of patients and significantly improved hearing measures.

Development of an interdisciplinary microtia-atresia care model: A single-center 20-year experience

Objectives

Microtia and aural atresia are congenital ear anomalies with a wide-ranging spectrum of phenotypes and varied functional and psychosocial consequences for patients. This study seeks to analyze the management of microtia-atresia patients at our center over a 20-year period and to propose recommendations for advancing microtia-atresia care at a national level.

Methods

We performed a retrospective analysis of data from patients presenting to the Massachusetts Eye and Ear (Boston, MA) for initial otolaryngology consultation for congenital microtia and/or aural atresia between 1999 and 2018.

Results

Over the 20-year study period, 229 patients presented to our microtia-atresia center at a median age of 7 years. The severity of microtia was most commonly classified as grade III (n = 87, 38%), 61% (n = 140) of patients had complete atresia, the median Jahrsdoerfer grading scale score was 6 (range 0-10), and 81 patients (35%) underwent surgery for microtia repair. For hearing rehabilitation, 30 patients (64%) underwent bone conduction device implantation and 17 patients (36%) underwent atresiaplasty. The implementation of an interdisciplinary, longitudinal care model resulted in an increase in patient (r = 0.819, p < .001) and surgical volume (microtia surgeries, r = 0.521, p = .019; otologic surgeries, r = 0.767, p < .001) at our center over time.

Conclusion

An interdisciplinary team approach to microtia-atresia patient care may result in increased patient volume, which could improve aesthetic and hearing outcomes over time by concentrating care and surgical expertise. Future work should aim to establish standardized clinical consensus recommendations to guide the creation of high-quality microtia-atresia care programs.

Level of Evidence

4.

Facial Nerve Anomalies as an Obscure Co-occurrence With External Ear Malformations: A Case Report

This study reports an infant with a rare triad of congenital facial palsy, bilateral aural atresia, and middle ear malformations. We highlight the audiological test battery in detail that led to identifying this obscure co-occurrence in a 6-month-old infant. The challenges associated with identifying such rare conditions, especially in infants, can be overcome only by incorporating a meticulous and vigilant approach. The infant was subjected to a series of subjective and objective audiological evaluations, through which rare asymmetric facial grimaces were vigilantly observed. This observation warranted radiologic investigation, which confirmed the suspicion that the anomaly may not be restricted to auditory structures alone. As facial nerve anomalies were confirmed, diversified recommendations, including speech, language, and swallow evaluation, were made apart from the auditory management. Hence in cases of external ear anomalies, although rare, it is essential to rule out facial nerve abnormalities as they can be a concealed problem.

Early surgical and audiologic outcomes of active, transcutaneous, osseointegrated bone-conduction hearing device (Osia 2® system) placement

OBJECTIVE

To assess the outcomes of pediatric Osia 2® System placements.

METHODS

We performed a retrospective chart review of primary and revision Osia 2® System surgical cases at two tertiary academic children's hospitals. Operative details and post-operative surgical and audiologic outcomes were recorded.

RESULTS

18 cases were performed on 14 children (mean age: 11.5 years, range 7-16) and included 9 primary surgeries and 9 revisions from BAHA Attract®, Connect® and Sophono® implants. Surgical planning for revision surgeries was complex due to prior incisions, implants, and bony contour. Post-operative aided audiograms revealed pure tone average (0.5-4 kHz) of 26.2 ± 2.5 dB HL (mean ± SD), with no high frequency roll-off (8 kHz aided threshold: 23.8 ± 7.5 dB HL). Two minor post-operative complications were identified.

CONCLUSION

Bone-conduction hearing devices (BCHDs) are used to improve access to sound for children with conductive hearing loss, single-sided deafness, and aural atresia. Traditional passive, percutaneous abutment-based and transcutaneous magnet-based surgical BCHDs can be limited by skin complications and high-frequency acoustic attenuation. Recent availability of active, transcutaneous osseointegrated BCHD systems presents potential for improvement on both of these traditional limitations. Initial experience with the Osia 2® System demonstrates overall successful, uncomplicated placement with excellent audiologic outcomes. Revision cases require careful surgical planning. Further follow-up and comparative studies with other BCHDs are necessary to fully evaluate the effectiveness of the Osia 2® System.

OUP accepted manuscript

Congenital aural atresia refers to abnormal embryological development of the external auditory canal. The treatment of this anatomical malformation is only surgical repair. This article reports a case of unilateral congenital aural atresia, the surgical procedure performed and the post-operative findings.

Intraoperative navigation during atresiaplasty for congenital aural atresia

OBJECTIVE

The purpose of this study was to evaluate the feasibility of intraoperative navigation (ION) using adhesive fiducials and high-resolution computed tomography (HRCT) of the temporal bone in pediatric patients undergoing atresiaplasty for congenital aural atresia (CAA).

METHODS

From June 2018 to August 2019, a retrospective review was performed on pediatric patients with unilateral or bilateral CAA who underwent atresiaplasty with or without concurrent bone anchored implant (BAI) placement. Single stage atresiaplasty was performed at a tertiary referral center with ION linked to image-guidance compatible HRCT non-contrast temporal bone images. Up to six adhesive fiducials were placed for navigation. Patient demographics were collected including Schuknecht classification type and Jahrsdoerfer score. Main outcome measures included the number of useable adhesive fiducials for navigation, navigation system registration accuracy, operative time, intraoperative complications, and postoperative outcomes including facial nerve function, surgical site infection rate, restenosis rate, and audiometric data.

RESULTS

Five patients (3 male, 1 AU atresia, 2 AS atresia, all Schuknecht type C) with an average age of 9.2 years (range 6.8-11.8 years) underwent single sided atresiaplasty with ION. Two patients underwent concurrent BAI placement. Average Jahrsdoerfer score was 8.6 (range 7-10). Preoperative audiogram demonstrated a mean air-bone gap (ABG) of 45 dB (range 35-54 dB). The navigation system registration accuracy ranged from 0.08 to 1.80 mm (mean 1.00 mm). Mean operative time was 268 min (range 217-307 min). There were no intraoperative complications. At an average follow up of 7.2 months (range 2-15 months), postoperative facial nerve function was normal in all patients and no patients developed postoperative stenosis or surgical site infections. Four patients underwent postoperative audiogram at an average of 4 months after surgery (range 2-5 months) and all demonstrated an ABG of less than 30 dB (mean 20 dB, range 15-26 dB) with an average improvement in ABG of 23 dB (range 11-39 dB). The one patient who did not undergo postoperative pure tone audiometry underwent AzBio speech perception testing and demonstrated an improvement from 81% to 89%.

CONCLUSIONS

The use of ION in otologic surgery is uncommon. Inherent aberrant temporal bone anatomy in CAA makes this a unique population to study the value of this technology. The use of adhesive fiducials is feasible, with navigation registration accuracy and surgical outcomes comparable to those in the literature. More data is necessary regarding the impact of ION on long-term surgical and audiometric outcomes.

Anatomy and Development of the Mammalian External Auditory Canal: Implications for Understanding Canal Disease and Deformity

The mammalian ear is made up of three parts (the outer, middle, and inner ear), which work together to transmit sound waves into neuronal signals perceived by our auditory cortex as sound. This review focuses on the often-neglected outer ear, specifically the external auditory meatus (EAM), or ear canal. Within our complex hearing pathway, the ear canal is responsible for funneling sound waves toward the tympanic membrane (ear drum) and into the middle ear, and as such is a physical link between the tympanic membrane and the outside world. Unique anatomical adaptations, such as its migrating epithelium and cerumen glands, equip the ear canal for its function as both a conduit and a cul-de-sac. Defects in development, or later blockages in the canal, lead to congenital or acquired conductive hearing loss. Recent studies have built on decades-old knowledge of ear canal development and suggest a novel multi-stage, complex and integrated system of development, helping to explain the mechanisms underlying congenital canal atresia and stenosis. Here we review our current understanding of ear canal development; how this biological lumen is made; what determines its location; and how its structure is maintained throughout life. Together this knowledge allows clinical questions to be approached from a developmental biology perspective.

Epithelial dynamics shed light on the mechanisms underlying ear canal defects

Defects in ear canal development can cause severe hearing loss as sound waves fail to reach the middle ear. Here, we reveal new mechanisms that control human canal development and highlight for the first time the complex system of canal closure and reopening. These processes can be perturbed in mutant mice and in explant culture, mimicking the defects associated with canal atresia. The more superficial part of the canal forms from an open primary canal that closes and then reopens. In contrast, the deeper part of the canal forms from an extending solid meatal plate that opens later. Closure and fusion of the primary canal was linked to loss of periderm, with failure in periderm formation in Grhl3 mutant mice associated with premature closure of the canal. Conversely, inhibition of cell death in the periderm resulted in an arrest of closure. Once closed, re-opening of the canal occurred in a wave, triggered by terminal differentiation of the epithelium. Understanding these complex processes involved in canal development sheds light on the underlying causes of canal atresia.

Highlighted Article: We reveal new mechanisms that control development of the ear canal and highlight for the first time the complex system of canal closure and reopening.

Outcomes for School-Aged Children with Aural Atresia

This study compared the language, reading, classroom, and quality of life outcomes of primary school-aged children with aural atresia (AA) to matched controls. Participants included 10 children with AA (eight unilateral) and 10 children with typical hearing matched by chronological and mental age. All children with AA had been fitted with an amplification device. Outcome measures included standardized tests of language, reading, and functional communication questionnaires of children's classroom performance and hearing quality of life. The children with AA recorded significantly reduced hearing quality of life. The two groups did not differ on any other measures. The present preliminary findings suggest that children with AA who receive early amplification have similar language, communication, reading, and classroom outcomes as their typically hearing peers. Despite these promising outcomes, however, the children's quality of life is significantly reduced. Further research is needed to further elucidate these findings.

Long-term Outcomes of Clip Coupler Implantation in Patients with Unilateral Congenital Aural Atresia

OBJECTIVE

To evaluate the long-term safety and efficacy of the Clip coupler attached to the stapes head in patients with unilateral congenital aural atresia (CAA).

METHODS

This single-center retrospective study included 16 Mandarin-speaking patients who had unilateral microtia accompanied by CAA. All patients were divided into two groups: the short-term follow-up group (n = 9) and the long-term follow-up group (n = 7). The floating mass transducer of the Vibrant Soundbridge (VSB) was positioned in the stapes head by the Clip coupler. The safety of the VSB was investigated by comparing preoperative and postoperative bone-conduction (BC) thresholds as well as by complications. The effectiveness was evaluated by functional gain (FG), word recognition score (WRS), speech reception threshold (SRT) and signal-to-noise ratio (SNR).

RESULTS

Pre- and post-operative BC thresholds were no different in all patients. And no complications developed. VSB-aided thresholds in the free-field had improved significantly in both short- and long-term follow-up groups. The improvements of WRS were observed in two groups. The monosyllabic VSB-aided WRS in the long-term follow-up group was significantly higher than that in the short-term follow-up group. When speech was from the impaired ear and noise presented to the side of normal ear (S_VSBN_CL), lower SNRs were found in two groups after VSB implantation. However, there was no statistical difference in aided SNR between the two groups at S_VSBN_CL status.

CONCLUSIONS

Our results show that the FMT connected to the stapes head is a secure and useful device for patients with unilateral CHL/MHL, not only in terms of improved hearing thresholds, but also improved speech intelligibility in quiet and noisy environments.

Sound-localisation performance in patients with congenital unilateral microtia and atresia fitted with an active middle ear implant

OBJECTIVE

This study assessed the safety and sound-localisation ability of the Vibrant Soundbridge (VSB) (Med-EL, Innsbruck, Austria) in patients with unilateral microtia and atresia (MA).

METHODS

This was a single-centre retrospective research study. Twelve subjects with unilateral conductive hearing loss (UCHL) caused by ipsilateral MA were recruited, each of whom underwent VSB implantation and auricular reconstruction. The bone-conduction (BC) threshold was measured postoperatively, and the accuracy of sound localisation was evaluated at least 6 months after surgery. Horizontal sound-localisation performance was investigated with the VSB activated and inactivated, at varying sound stimuli levels (65, 70 and 75 dB SPL). Localisation benefit was analysed via the mean absolute error (MAE).

RESULTS

There was no statistical difference in mean BC threshold of impaired ears measured preoperatively and postoperatively. When compared with VSB-inactivated condition, the MAE increased significantly in unilateral MA patients in the VSB-activated condition. Besides, sound-localisation performance worsened remarkably when sound was presented at 70 dB SPL and 75 dB SPL. Regarding the side of signal location, the average MAE with the VSB device was much higher than that without the VSB when sound was from the normal-hearing ear. However, no significant difference was observed when sound was located from the impaired ear.

CONCLUSION

This study demonstrates that in patients with unilateral MA, the VSB device does not affect inner-ear function. Sound-localisation ability is not improved, but deteriorated at follow-up. Our results suggest that the VSB-aided localisation abilities may be related to the thresholds between the ears, plasticity of auditory system and duration of use of VSB.

Developmental aspects of the tympanic membrane: Shedding light on function and disease

The ear drum, or tympanic membrane (TM), is a key component in the intricate relay that transmits air-borne sound to our fluid-filled inner ear. Despite early belief that the mammalian ear drum evolved as a transformation of a reptilian drum, newer fossil data suggests a parallel and independent evolution of this structure in mammals. The term "drum" belies what is in fact a complex three-dimensional structure formed from multiple embryonic cell lineages. Intriguingly, disease affects the ear drum differently in its different parts, with the superior and posterior parts being much more frequently affected. This suggests a key role for the developmental details of TM formation in its final form and function, both in homeostasis and regeneration. Here we review recent studies in rodent models and humans that are beginning to address large knowledge gaps in TM cell dynamics from a developmental biologist's point of view. We outline the biological and clinical uncertainties that remain, with a view to guiding the indispensable contribution that developmental biology will be able to make to better understanding the TM.

Correlation among external auditory canal anomaly, temporal bone malformation, and hearing levels in patients with microtia

We conducted a retrospective study to evaluate the relationship between external auditory canal (EAC) anomaly, temporal bone abnormality, and hearing levels using objective scoring systems in Chinese patients with microtia. The study population consisted of 106 ears of 94 Chinese patients (67 male and 27 female) aged 5 to 45 years (mean: 12.6) with microtia. The EAC abnormalities were classified into 4 types according to Schuknecht's criteria: type A, type B, type C, and type D. Developmental anomalies of the temporal bone were evaluated by Jahrsdoerfer computed tomography (CT) scoring system using high-resolution CT scans of the temporal bone. Temporal bone malformation parameters were divided into 4 subgroups: ossicular chain development, windows connected to the cochlea, aeration development of the middle ear, and facial nerve aberration. Hearing levels (air conduction and bone conduction) were examined. Outcomes parameters included correlation coefficients (r) and a number of other variables. The total points (10 points) and subtotal points related to ossicles (4 points), windows (2 points), aeration (2 points), and facial nerve (1 point) correlated inversely with the EAC abnormalities. The hearing levels (air conduction, r = 0.396, p <0.01; bone conduction, r = 0.21, p = 0.03) correlated significantly with the EAC abnormalities of Schuknecht's classification. We conclude that the better developed the external auditory canal, the better developed the temporal bone and the better developed the external auditory canal, the better hearing level. The hearing level also can serve as an indicator to determine whether a patient will be suitable for reconstructive surgery.

External auditory exostoses and hearing loss in the Shanidar 1 Neandertal

The Late Pleistocene Shanidar 1 older adult male Neandertal is known for the crushing fracture of his left orbit with a probable reduction in vision, the loss of his right forearm and hand, and evidence of an abnormal gait, as well as probable diffuse idiopathic skeletal hyperostosis. He also exhibits advanced external auditory exostoses in his left auditory meatus and larger ones with complete bridging across the porus in the right meatus (both Grade 3). These growths indicate at least unilateral conductive hearing (CHL) loss, a serious sensory deprivation for a Pleistocene hunter-gatherer. This condition joins the meatal atresia of the Middle Pleistocene Atapuerca-SH Cr.4 in providing evidence of survival with conductive hearing loss (and hence serious sensory deprivation) among these Pleistocene humans. The presence of CHL in these fossils thereby reinforces the paleobiological and archeological evidence for supporting social matrices among these Pleistocene foraging peoples.

Otorhinolaryngologic manifestations of Hartsfield syndrome: Case series and review of literature

Diagnosis of Hartsfield syndrome includes recognition of three distinct clinical anomalies: holoprosencephaly, ectrodactyly, and bilateral cleft-lip and palate syndrome. A family including three male siblings all affected by Hartsfield syndrome presented to our institution for care. An autosomal dominant variant in Fibroblast Growth Factor Receptor 1 (FGFR1) was identified. This report focuses on otorhinolaryngologic manifestationsof Hartsfield syndrome, previously undescribed, including midline defects of holoprosencephaly, bilateral cleft-lip and palate, retrognathia, gastroesophageal reflux disease, external ear anomalies, eustachian tube dysfunction, and midface abnormalities, in addition to multidisciplinary, long-term management strategies. Multidisciplinary management is imperative in the care of these children with modification of approach based on their medical complexity.