Dispersed DNA variants underlie hearing loss in South Florida's minority population

BACKGROUND

We analyzed the genetic causes of sensorineural hearing loss in racial and ethnic minorities of South Florida by reviewing demographic, phenotypic, and genetic data on 136 patients presenting to the Hereditary Hearing Loss Clinic at the University of Miami. In our retrospective chart review, of these patients, half self-identified as Hispanic, and the self-identified racial distribution was 115 (86%) White, 15 (11%) Black, and 6 (4%) Asian. Our analysis helps to reduce the gap in understanding the prevalence, impact, and genetic factors related to hearing loss among diverse populations.

RESULTS

The causative gene variant or variants were identified in 54 (40%) patients, with no significant difference in the molecular diagnostic rate between Hispanics and Non-Hispanics. However, the total solve rate based on race was 40%, 47%, and 17% in Whites, Blacks, and Asians, respectively. In Non-Hispanic Whites, 16 different variants were identified in 13 genes, with GJB2 (32%), MYO7A (11%), and SLC26A4 (11%) being the most frequently implicated genes. In White Hispanics, 34 variants were identified in 20 genes, with GJB2 (22%), MYO7A (7%), and STRC-CATSPER2 (7%) being the most common. In the Non-Hispanic Black cohort, the gene distribution was evenly dispersed, with 11 variants occurring in 7 genes, and no variant was identified in 3 Hispanic Black probands. For the Asian cohort, only one gene variant was found out of 6 patients.

CONCLUSION

This study demonstrates that the diagnostic rate of genetic studies in hearing loss varies according to race in South Florida, with more heterogeneity in racial and ethnic minorities. Further studies to delineate deafness gene variants in underrepresented populations, such as African Americans/Blacks from Hispanic groups, are much needed to reduce racial and ethnic disparities in genetic diagnoses.

Genotype-phenotype associations in paragangliomas of the temporal bone in a multi-ethnic cohort

BACKGROUND

Temporal bone paragangliomas are rare tumours with variable presentation that can be hereditary. Identification of clinical and genetic factors of aggressive tumour behaviour is important.

OBJECTIVE

To determine the underlying genetic mutations and genotype/phenotype correlations in a multi-ethnic population of South Florida with sporadic temporal bone paragangliomas.

METHODS

In a cohort of glomus tympanicum (GT) and glomus jugulare (GJ) cases, we assessed the frequency of pathogenic single nucleotide variants, insertions, deletions, and duplications in coding exons of genes that have been associated with paragangliomas (SDHB, SDHC, SDHD, SDHA, SDHAF2, RET, NF1, VHL, TMEM127, and MAX).

RESULTS

None of the 12 GT cases had mutations. Among 13 GJ cases, we identified four mutation carriers (31%); two in SDHC, one in SDHB, and one in SDHD. All patients with pathogenic mutations were of Hispanic ethnicity, presented at a younger age (mean 27.5 versus 52.11 years), and with more advanced disease when compared to mutation-negative GJ cases.Conclusions and Significance: Mutations in the SDH genes are found in 31% of sporadic GJ. SDH-associated GJ had advanced disease and a 50% risk of metastasis. Our data supports emerging recommendations for genetic screening in all populations with GJ tumours as the genetic status informs management.

Title: Microsurgical Management of Vestibular Schwannoma (Acoustic Neuroma): Facial Nerve Outcomes, Radiographic Analysis, Complications, and Long Term Follow up in a Series of 420 surgeries

INTRODUCTION

The purpose of this study is to retrospectively evaluate the clinical and surgical outcomes of a large surgical series of vestibular schwannoma from North America over 20 years.

METHODS

After institutional review board approval a retrospective review of the senior author's personal case logs to identify patients who had operations for vestibular schwannoma was performed. The clinical notes, operative record, pre-operative, and post-operative imaging and long-term clinical follow up notes were evaluated.

RESULTS

A total of 415 patients who underwent 420 surgeries were identified from the years 1998-2021. The average length of follow up was 3 years and 9 months. Overall, at last follow up the rate of "good" facial nerve outcomes (HB I and II) was 86% and "poor" facial nerve outcomes (HB III-VI) was 14%. The amount of CPA extension (p=0.023), tumor volume (p=0.015), facial nerve consistency (p<0.001), preoperative HB score (p<0.001), and FN stimulation threshold at the end of the procedure (p<0.001) were correlated to facial nerve function at last follow up.

CONCLUSION

This study represents one of the largest recently reported surgical series of vestibular schwannoma in North American literature with available long term follow up. Facial nerve outcomes correlated with CPA extension, tumor volume, facial nerve stimulation threshold, facial nerve consistency, preoperative facial nerve function, and history of a prior resection. Tumor recurrence remains significantly higher after subtotal resection. We believe the data supports a continuation of a strategy of general intent of gross total resection, greatly modifiable by intraoperative findings and judgement.

Catchment Profile of Large Cochlear Implant Centers in the United States

OBJECTIVE

To characterize the catchment area and patient profile of large cochlear implant (CI) centers in the United States.

STUDY DESIGN

Multi-institutional retrospective case series.

SETTING

Tertiary referral CI centers.

METHODS

Patients who underwent CI surgery at 7 participating CI centers between 2015 and 2020 were identified. Patients' residential zip codes were used to approximate travel distances and urban vs rural residential areas.

RESULTS

Over the 6-year study period (2015-2020), 6313 unique CI surgical procedures occurred (4529 adult, 1784 pediatric). Between 2015 and 2019, CI procedures increased by 43%. Patients traveled a median 52 miles (interquartile range, 21-110) each way; patients treated at rural CI centers traveled greater distances vs those treated at urban centers (72 vs 46 miles, P < .001). Rural residents represented 61% of the patient population and traveled farther than urban residents (73 vs 24 miles, P < .001). Overall, 91% of patients lived within a 200-mile radius of the institution, while 71% lived within a 100-mile radius. In adults, multiple regression analysis redemonstrated an association between greater travel distances and (1) older age at the time of CI and (2) residential rural setting (both P < .001, r2 = 0.2).

CONCLUSIONS

While large CI centers serve geographically dispersed populations, most patients reside within a 200-mile radius. Strategies to expand CI utilization may leverage remote programming, telemedicine, and strategic placement of new centers and satellite clinics to ameliorate travel burden.

The Epidemiological and Financial Effects of Pneumococcal Vaccination on Otitis Media Related Admissions in the United States

OBJECTIVE

To quantify the prevalence of hospital admissions, the financial impact, and the trends in surgical procedure rates for AOM and CAOM for all ages before and after 13-valent pneumococcal conjugate vaccine (PCV13) introduction.

METHODS

Retrospective analysis of the National Inpatient Sample (NIS) from 1998 to 2013 to determine the prevalence of AOM/CAOM related admissions and weighted frequencies of AOM/CAOM related International Classification of Diseases, ninth revision (ICD-9) hospital diagnoses. Prevalence of surgical procedures to treat CAOM, cost of admission, length of stay, and cost per day of admission were tabulated. Trend analysis of this data was performed.

RESULTS

A total of 46 580 patients were hospitalized with AOM in the designated time period, of which 37 366 had CAOM. The prevalence of hospital admission due to AOM had the most pronounced decrease from pre-vaccine era (1998) to post-PCV13 implementation (2013) in age group 0 to 4 (32%) followed by age group 5 to 19 (7%). Age groups 20-64 and 65+ showed slight increases in prevalence. The trend in prevalence of admissions due to CAOM mirrors that of overall admissions with an 18% and 5.8% decrease in age groups 0-4 and 5-19, respectively, and a 1% increase in ages 20+. The inflation adjusted mean cost of admission did not significantly increase between 2001 and 2013. The total cost per admission was $4428 and $7546 for those with AOM and CAOM, respectively. Mastoidectomy rates increased by 17% in hospitalized children during the post-vaccine era but decreased in the elderly population.

CONCLUSION

The prevalence of AOM/CAOM hospital admissions decreased from the pre-vaccine era (1998) to post-PCV13 implementation (2013) in pediatric patients. Surgical procedure utilization and cost of hospital admission for AOM/CAOM did not increase throughout the study period.

Cervical VEMP tuning changes by Meniere's disease stages

Objective

To determine if changes in cervical vestibular-evoked myogenic potential (cVEMP) testing reflect the different stages of cochlea-saccular hydrops in Meniere's disease (MD).

Methods

This is a case-control retrospective series. Forty-seven patients with unilateral MD by American Academy of Otolaryngology-Head and Neck Surgery diagnostic and staging criteria, and 30 with non-MD vertigo as control. Meniere patients were further classified based on symptoms at the time of testing as active or stable. Subsequently, patients underwent cVEMP testing by tone-burst stimuli at 500 and 1,000 Hz. The main outcome measure was to compare the cVEMP 1,000 and 500 Hz amplitude ratio in ears with MD and non-MD vertigo, and in active versus stable MD.

Results

The cVEMP 1,000/500 Hz amplitude ratio was higher in Meniere's ears (mean = 1.14 μV, SD = 0.25) than in non-Meniere's ears (mean = 0.96 μV, SD = 0.2) (Student's t test, P = .001), and higher in active (mean = 1.22 μV, SD = 0.25) than in stable MD (mean = 1.00 μV, SD = 0.18) (P = .0035). The diagnostic value of cVEMP 1,000/500 Hz amplitude ratio to differentiate MD versus non-MD vertigo was evaluated with a receiver-operating characteristics (ROC) curve and the area under the curve (AUC) was 0.716 (95% confidence interval [CI] [0.591, 0.829]). The ideal cutoff point was 0.9435 with sensitivity and specificity values of 83% and 53%, respectively. The sensitivity and specificity values for this test to differentiate active versus stable MD were 68% and 81%, respectively, with AUC 0.746 (95% CI [0.607, 0.885]) and cutoff value of 1.048. In all ears, the 1,000/500 Hz amplitude ratio increased by a decrease of the 500 Hz amplitude with increasing age.

Conclusion

The cVEMP 1,000/500 Hz amplitude ratio is elevated in ears with MD but not in those with non-MD vertigo. After corrected by age, this ratio is higher in active but not in stable MD, probably reflecting dynamic changes in saccular membrane motion mechanics in hydrops, and may be a useful marker of disease progression and the effect of therapy.

Level of Evidence

IV.

Animal Model of Chronic Tympanic Membrane Perforation

Chronic tympanic membrane perforations (TMP) can be a source of significant morbidity from hearing loss, recurrent middle ear infections, changes in lifestyle, and risk of cholesteatoma formation. Laboratory experiments of TMP have been fraught by the rapid and high rate of spontaneous healing observed in animal models. There is controversy on the minimal time that perforations in animal models must have in order to be considered chronic TMP and thus have clinical relevance, with authors suggesting time periods of perforation patency of 8-12 weeks. In this article, we sought to create a clinically significant experimental model that could yield a high rate of perforation patency for at least 8 weeks. Animals undergoing acute TMP were exposed to three different experimental situations to delay the healing of the perforation: fractionated radiation, topical lipopolysaccharide application, and a combined dexamethasone and mitomycin C (DXM/MC) solution. In our study, the use of DXM/MC reliably produced TMP lasting at least 8 weeks in 86.48% of the cases without the need to reopen the perforation, infolding the edges of the membrane, or using physical barriers to prevent TMP closure. Histologically, the resulting perforated tympanum showed hyaline changes of the remnant tympanum and hyperkeratosis of the squamous epithelia of the external auditory canal. We believe that this model is reproducible and has potential use in experiments of delayed healing of TMP. Anat Rec, 303:619-625, 2020. © 2019 American Association for Anatomy.

The pattern of hearing outcome following surgery of the semicircular canals

OBJECTIVE

To analyze demographic, clinical, surgical, and audiometric factors that may affect hearing outcome following surgery for the semicircular canals (SCC).

METHOD

This is a retrospective case review of adults who underwent surgeries for superior SCC (SSCC), lateral SCC (LSCC), or posterior SCC (PSCC) and whose data were extracted and analyzed for factors affecting the hearing outcome in these procedures.

RESULTS

Thirteen patients underwent surgery for SSCC, seven cases for the LSCC, one for the PSCC, and one case of combined PSCC/SSCC surgery. The mean age was 49.8 ± 12 years (21-66). There was no difference between the preoperative and postoperative pure tone average (PTA) thresholds at 0.5-3 kHz. Higher thresholds were noted at 4, 6, and 8 kHz postoperatively. Deterioration (>10 dB) in the bone-conduction (BC) PTA was demonstrated in 3 of 22 (13.6%) cases with no significant difference in the demographic, clinical, surgical, and preoperative audiometric parameters relative to the cases without PTA BC change. A significantly larger difference in PTA BC (pre- vs. postoperative) was seen for males. Small effect size was noted for Air conduction (AC) PTA in males, and moderate effect size for Word Recognition Score (WRS) in surgery for the LSCC compare to SSCC.

CONCLUSIONS

SCC surgeries carry a relatively low risk of deterioration in PTA BC. High frequency thresholds should also be included in postoperative hearing outcome assessment. Cases of LSCC for intractable Meniere's disease and surgery in males carry higher risk of poor postoperative hearing outcomes. Level of Evidence: 4.

A new technique to find the facial nerve and recess by using the short process of the incus and the spine of Henle as landmarks: incus-spine angle

BACKGROUND

Precise techniques to find the facial nerve (FN) and recess are lacking.

OBJECTIVES

We aimed to define incus-spine and incus-FN angles which can be used to localize the FN and recess during mastoidectomy.

MATERIAL AND METHODS

Thirty adult cadaveric temporal bones were studied. Canal-wall up mastoidectomy with a facial recess approach was performed. The temporal bones and microscope were positioned differently to change the visual angle. The following distances were measured: (1) Short process of the incus (SPI)-FN; (2) Body of the incus-FN. Photographs were taken. Three lines were drawn on the photographs between the SPI, FN, and the spine of Henle. The angles were created and measured.

RESULTS

Three of the temporal bones were excluded due to the absence of the spine of Henle and two of them due to the displacement of the SPI. The mean of the incus-spine angle in 25 temporal bones was 90.12° and the mean of the Incus-FN angle was 135.96°. The mean distances of the SPI-FN and body of incus-FN were 4.85 and 9.26 mm, respectively.

CONCLUSIONS AND SIGNIFICANCE

The incus-spine and the incus-FN angles along with the distances can help localize the FN and recess.

Middle Ear Packing: Comparison Between Merogel and Gelfoam

Problem

Gelfoam has been used for decades in otologic surgery to support grafts and prostheses despite causing fibrosis and adhesions. More biocompatible packing materials could avoid these complications. This study compares Gelfoam with an injectable esterified hyaluronic acid, Merogel, as middle ear packing material after mucosal trauma.

Methods

A randomized, blinded, controlled study was performed in 17 juvenile guinea pigs. Middle ear surgery with mucosal trauma was performed and middle ears were packed with Merogel or Gelfoam; unpacked contralateral ears were used as controls. Auditory brainstem response (ABR) thresholds were measured in 4 frequencies pre-operatively, and repeated at 1, 2, and 6 weeks postoperatively. Gross analysis measured inflammatory reaction in each group. Statistical analysis was performed using ANOVA followed by post-hoc analysis for ABR thresholds and packing remaining at 6 weeks. Non-prametric tests were used for presence of mucosal inflammation, effusion and tympanic membrane perforation.

Results

ABR threshold changes from baseline were minor and comparable between the Merogel group and the control group. Threshold change was higher in the Gelfoam group. This difference was seen in each frequency tested at each time interval (all p<0.05). Gross analysis showed 1) Mucosal inflammation higher in the Gelfoam group (p<0.05), 2) Effusions were higher in the Gelfoam group but the difference was not significant (p=0.07), 3) Tympanic membrane perforation was equally rare between groups (p>0.05), 4) Unabsorbed packing was higher in the Gelfoam group (p<0.05); little Merogel was detectable at time of sacrifice.

Conclusion

Middle ear healing after surgery occurred similarly in the control group and the Merogel group. In contrast, the Gelfoam group demonstrated greater perturbation of hearing and a greater inflammatory reaction.

Significance

These results support Merogel as an alternative to Gelfoam in middle ear packing after otologic surgery.

Support

Research grant from Medtronic ENT.

The effect of n-acetyl-cysteine on recovery of the facial nerve after crush injury

Objective

Facial nerve dysfunction can vary in severity and recovery is dependent on the character of the injury. N‐acetyl‐cysteine prevents oxidative stress and cellular damage, and its use in the setting of nerve dysfunction from crush injury has not yet been established. In this study, rats with facial nerve crush injury will be treated with n‐acetyl‐cysteine or control and functional recovery and electrophysiologic outcome will be compared.

Study Design

Prospective, randomized animal study

Methods

Twenty‐four Wistar rats underwent unilateral facial nerve crush injury. Rats were implanted with a subcutaneous osmotic pump filled with saline (n = 12) or n‐acetyl‐cysteine 50 mg/kg/day (n = 12). Functional and electromyographic recovery was recorded at two and four weeks postoperatively.

Results

When compared to untreated rats, n‐acetyl‐cysteine treated rats had a greater electromyography amplitude recovery at 2 weeks with regard to eye blink (p=0.006) but not vibrissae function. At four weeks, the electromyography amplitude recovery of the vibrissae function was greater in n‐acetyl‐cysteine treated rats (P=0.001), but the amplitude recovery difference in eye blink was only marginally significant between groups (p=0.07). The functional score was higher in n‐acetyl‐cysteine‐treated rats than in untreated rats at all of the time points.

Conclusion

This study demonstrated that n‐acetyl‐cysteine facilitated facial nerve recovery with improved functional and electromyography outcomes in the setting of crush injury.

Level of Evidence

NA

Comparison of packing material in an animal model of middle ear trauma

PURPOSE

To compare the performance of absorbable gelatin sponge (AGS) with polyurethane foam (PUF) as middle ear packing material after mucosal trauma.

MATERIALS AND METHODS

Using a randomized, controlled and blinded study design fifteen guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears. One ear was packed with either PUF or AGS while the contralateral ear remained untreated and used as non-packed paired controls. Auditory brainstem response (ABR) thresholds were measured pre-operatively and repeated at 1, 2, and 6weeks postoperatively. Histological analysis of middle ear mucosa was done in each group to evaluate the inflammatory reaction and wound healing. Another eighteen animals underwent middle ear wounding and packing in one ear while the contralateral ear was left undisturbed as control. Twelve guinea pigs were euthanized at 2weeks postoperatively, and six were euthanized at 3days post-operatively. Mucosal samples were collected for analysis of TGF-β1 levels by enzyme-linked immunosorbent assay.

RESULTS

ABR recordings demonstrate that threshold level changes from baseline were minor in PUF packed and control ears. Threshold levels were higher in the AGS packed ears compared with both control and PUF packed ears for low frequency stimuli. Histological analysis showed persistence of packing material at 6weeks postoperatively, inflammation, granulation tissue formation, foreign body reaction and neo-osteogenesis in both AGS and PUF groups. TGF-β1 protein levels did not differ between groups.

CONCLUSION

PUF and AGS packing cause inflammation and neo-osteogenesis in the middle ear following wounding of the mucosa and packing.

Performance after cochlear implantation in DFNB1 patients

Objective

To evaluate the speech perception and language development with cochlear implants (CI) of DFNB1 children in comparison with non-DFNB1 deaf children.

Study Design

Retrospective case series.

Setting

Academic tertiary center.

Results

Thirty-one congenitally deafened children, screened for GJB2 allele variants, were followed for an average 32 months after CI. With the use of age-appropriate testing, 75% of DFNB1 and 53% of non-DFNB1 children achieved open set word recognition (speech perception category [SPC] level 6). Multivariate analysis showed that SPC was primarily dependent on duration of CI use, but not on the cause of hearing loss. In Reynell language tests, DFNB1 children showed more consistent and quicker gains than non-DFNB1 children.

Conclusion

Although children with CI with DFNB1 show faster gains in Reynell scores, duration of CI use appears to have a greater effect on speech perception than DFNB1 status. SIGNIFICANCE: Identification of DFNB1 children is useful in counseling of CI outcomes.

Etiologic diagnosis of sensorineural hearing loss in adults

OBJECTIVE: To determine the etiology of adult-onset sensorineural hearing loss.

STUDY DESIGN AND SETTING: This is a prospective cohort study of 60 adult subjects with bilateral sensorineural hearing loss of no obvious etiology by medical history and physical examination. These patients were evaluated at an academic medical center and underwent evaluation by high-resolution computed tomography of the temporal bone, autoimmune panel, and DNA testing for mutations of both the GJB2 gene and the mitochondrial DNA (1555A>G and 7445A>G).

RESULTS: An etiologic diagnosis was achieved in 6 patients: cochlear otosclerosis, 1 case; dilated vestibular aqueduct, 1 case; a mitochondrial DNA 7445A>G mutation, 3 cases; and a mitochondrial DNA 1555A>G mutation, 1 case.

CONCLUSION: This result underscores the importance of a search for the etiology of a hearing deficit in adult patients. There are specific interventions now available for the management of hearing-impaired patients with cochlear otosclerosis and mitochondrial DNA mutations.

Hyaluronate Gel Stapedotomy

OBJECTIVE: To evaluate hearing results and postoperative dizziness after stapedotomy with application of sodium hyaluronate gel (HG) to the oval window niche during fenestration of the footplate.

STUDY DESIGN: Case-control study comparing 27 stapedotomies with HG and 32 stapedotomies without HG.

OUTCOME MEASURE: Preoperative and postoperative audiometric data, postoperative dizziness (vertigo or dysequilibrium), and nystagmus.

RESULTS: Postoperative hearing results were not statistically different for the 2 groups. There were no cases of postoperative sensorineural hearing loss greater than 10 dB. Early postoperative dizziness (χ2 = 4.08, P = 0.043) and nystagmus (χ2 = 5.05, P = 0.024) were reduced in the HG group.

CONCLUSIONS: HG stapedotomy is safe and effective and results in less early postoperative dizziness and nystagmus when compared with the standard technique of stapedotomy. The application of HG to the oval window niche to prevent blood from entering or perilymph from escaping the vestibule during fenestration of the stapes footplate may contribute to a quicker recovery in outpatient otosclerosis surgery.

EBM rating: B-3b

Current concepts in the pathogenesis and treatment of chronic suppurative otitis media

Otitis media (OM) is an inflammation of the middle ear associated with infection. Despite appropriate therapy, acute OM (AOM) can progress to chronic suppurative OM (CSOM) associated with ear drum perforation and purulent discharge. The effusion prevents the middle ear ossicles from properly relaying sound vibrations from the ear drum to the oval window of the inner ear, causing conductive hearing loss. In addition, the inflammatory mediators generated during CSOM can penetrate into the inner ear through the round window. This can cause the loss of hair cells in the cochlea, leading to sensorineural hearing loss. Pseudomonas aeruginosa and Staphylococcus aureus are the most predominant pathogens that cause CSOM. Although the pathogenesis of AOM is well studied, very limited research is available in relation to CSOM. With the emergence of antibiotic resistance as well as the ototoxicity of antibiotics and the potential risks of surgery, there is an urgent need to develop effective therapeutic strategies against CSOM. This warrants understanding the role of host immunity in CSOM and how the bacteria evade these potent immune responses. Understanding the molecular mechanisms leading to CSOM will help in designing novel treatment modalities against the disease and hence preventing the hearing loss.

Utricular paresis and semicircular canal hyperactivity: a distinct otolith syndrome

CONCLUSIONS

Although combined utricular and canal paresis has been described previously, this is the first report of canal hyperactivity associated with utricular hypofunction. Unsteadiness and swaying were the most common symptoms, and patients with shorter duration of symptoms also had positional vertigo. We propose that this syndrome is a variant of utricular dysfunction and should be considered in the differential diagnosis of peripheral vestibular disorders.

OBJECTIVE

To describe a syndrome of instability associated with utricular dysfunction and hyperactive caloric responses.

METHODS

The study comprised 11 consecutive patients exhibiting abnormalities of the eccentric subjective visual vertical test (e-SVV) and high responses during the caloric test of the videonystagmography (VNG). We carried out a review of symptoms, physical examination, and vestibular tests.

RESULTS

There was no gender predilection or obvious etiology. The patients' main complaint included instability with linear symptoms (i.e., tilting, rocking, and swaying), with positional vertigo as a secondary symptom. Oculomotor testing, visual fixation index, and brain MRI were normal, excluding a central nervous system disorder. VNG was essentially normal except for hyperactive responses during the caloric testing in all patients. Abnormal e-SVV was found in 10 patients unilaterally and bilaterally in 1 patient. Abnormal oVEMP was found in seven of seven patients, further supporting a utricular site of lesion.

Body Mass Index and Imaging Abnormalities in Spontaneous Cerebrospinal Fluid Leaks of the Temporal Bone

Objectives:

Determine if (1) increased body mass index (BMI) is associated with spontaneous cerebrospinal fluid leak (SCSFL) of the temporal bone when compared with NSCSFL; (2) if body mass index (BMI) is a prognostic factor in the management of SCSFL; (3) if aberrant arachnoid granulations and empty sella are associated with SCSFL when compared to NSCSFL.

Methods:

Retrospective chart review of patients from 2002 to 2013 of all patients treated for CSFL.

Results:

Eighteen patients were treated for SCSFL and 17 for NSCSFL between 2002 and 2013. The mean BMI of the SCSFL group was 32.86 (median 33.53). The mean BMI of the NSCSFL group was 28.54 (median 29) ( P = .0683). The average BMI of patients requiring revision surgery was 37.88 compared to patients who only required a single intervention 30.35 ( P = .012). 100% of patients with SCSFL had ectopic arachnoid granulations identified on CT temporal bone while none of the patients with NSCSFL had these ( P < .001). 66% (8/12) of patients with SCSFL had empty sella on MRI compared to 16 % (2/12) of those with NSCSFL ( P = .04).

Conclusions:

Patients with SCSFL of the temporal bone have an elevated BMI when compared with NSCSFL. The presence of arachnoid granulations and empty sella on diagnostic imaging is associated with SCSFL when compared to NSCSFL. Patients with SCSFL requiring multiple interventions demonstrated a higher BMI than those treated successfully with a single intervention, indicating that this may be a poor prognostic factor.

Aural Full and Otogenic Pain Redux

Program Description:

Otogenic pain and aural fullness can be some of the more frustrating chief complaints to work up and address. Many patients with this complaint are frustrated with lack of diagnosis and treatment. This leads to multiple visits in search of the answer to their affliction. In this miniseminar, our panel of experts will continue their discussion on how to evaluate and treat these difficult patients. Paradigms for management of these patients will be discussed. Case presentations will highlight proper workup and management of these confusing cases. Sponsored by the Otology and Neurotology Education Committee.

Educational Objectives:

(1) Describe pathologies that may cause otogenic pain or aural fullness. (2) Conduct workup paradigms to avoid missing potentially dangerous processes. (3) Examine possible treatments for the various pathologies.

Efficacy of L-N-Acetyl Cysteine in the Prevention of Gentamicin Vestibulotoxicity in Rats

Objectives:

Determine the effect of L-N-acetylcysteine (LNAC) on gentamicin (GM) initiated vestibulotoxicity.

Methods:

Wistar rats were divided into 4 groups: Group A (n = 7) had intratympanic (IT) GM (20 mg in 40 µL); group B (n = 6) had IT GM and intraperitoneal (IP) LNAC (350 mg/kg) at 24 hours and 1 hour before GM administration; group C (n = 6) had IT GM and IT LNAC (5 mg in 40 µL); and group D (n = 6) had only IT saline (40 µL). Rats were tested by ABR and cervical vestibular evoked myogenic potentials (VEMP) pretreatment, and at 1 week and 1 month posttreatment. Morphological analysis of the inner ears was performed at 1 month. Main outcome measures were the mean change in VEMP P1 latency at sound stimulation from 80 to 110 dB SPL, and hair cell count in the saccule.

Results:

Rats treated with IT LNAC exhibited the least change in mean VEMP latencies, although the intergroup differences were not statistically significant except for 80 dB stimulation at 1 week posttreatment. IP and IT LNAC resulted in preservation of the VEMP response in all rats, whereas 42% of rats not receiving LNAC had absent responses. Morphological analysis of the saccule revealed lower mean hair cell counts in rats not receiving LNAC.

Conclusions:

Systemic and IT administration of LNAC of rats treated with GM resulted in minimal variations in VEMP latencies and greater preservation of vestibular hair cells. The protective effect of LNAC in GM-initiated vestibulotoxicity is promising and warrants further research.

Middle fossa vestibular neurectomy for refractory vertigo: less is more

OBJECTIVE

This study aimed to evaluate outcomes of the middle fossa (MF) superior vestibular neurectomy in unilateral Ménière's disease.

PATIENTS AND METHODS

Case series with preoperative and postoperative analysis of the 1995 American Academy of Otolaryngology hearing stage and vertigo class, gait instability, and results of vestibular-evoked myogenic potentials (VEMP).

RESULTS

Four out of the 5 patients had total vertigo control (class A) and 1 had near total control (class B) by the last visit (mean follow-up, 23.6 months). There were no changes in hearing thresholds and hearing stage. Four patients had resolution of their gait instability by 2 months after surgery. Postoperative VEMP responses were preserved in all 3 patients with positive VEMP preoperatively.

CONCLUSION

This is the first report of the anatomical and functional preservation of the inferior vestibular nerve in vestibular neurectomy for the treatment of refractory vertigo in unilateral Ménière's disease, with VEMP testing before and after vestibular neurectomy. The modified technique limits the surgical dissection and may help avoid complications such as postoperative hearing loss and persistent gait instability. This approach is indicated when other more conservative measures have failed, and patient selection is paramount to avoid long-term complications.

Utricular Dysfunction in Refractory Benign Paroxysmal Positional Vertigo

Objective

To determine the prevalence of otolith dysfunction in patients with refractory benign paroxysmal positional vertigo (BPPV).

Study Design

Unmatched case control.

Setting

Tertiary care institution.

Subjects and Methods

Patients included were diagnosed with BPPV, failed initial in-office canalith repositioning maneuvers (CRMs), and completed vestibular testing and vestibular rehabilitation (n = 40). Refractory BPPV (n = 19) was defined in patients whose symptoms did not resolve despite vestibular rehabilitation. These patients were compared with a control group of those with nonrefractory BPPV (n = 21) for results of a caloric test, cervical vestibular evoked myogenic potential (cVEMP), and subjective visual vertical (SVV).

Results

Forty-six of 251 patients failed initial treatment with in-office CRM. Forty patients met inclusion criteria. There was no significant difference between the cases (refractory BPPV) (n = 19) and controls (nonrefractory BPPV) (n = 21) in terms of age, duration of symptoms, laterality of BPPV, and BPPV symptoms. There was no difference in the prevalence of caloric weakness and cVEMP abnormalities ( P > .05), with odds ratios (ORs [95% confidence interval (CI)]) of having abnormal results among cases vs controls of 1.1818 (0.3329-4.1954) and 4.3846 (0.7627-25.2048), for caloric and cVEMP, respectively. Abnormal eccentric SVV was more prevalent in refractory BPPV cases (58%) than in controls (14%) ( P < .0072). The OR (95% CI) of having abnormal SVV was 8.25 (1.7967-37.8822) higher among patients with refractory BPPV than those with nonrefractory BPPV.

Conclusion

Patients with refractory BPPV are more likely to have abnormal eccentric SVV and thus underlying utricular dysfunction. This finding is important to take into account when designing rehabilitation strategies for patients with BPPV who fail CRM.

Incidence of cranial nerve palsy after preoperative embolization of glomus jugulare tumors using Onyx

OBJECT

The resection of glomus jugulare tumors can be challenging because of their inherent vascularity. Preoperative embolization has been advocated as a means of reducing operative times, blood loss, and surgical complications. However, the incidence of cranial neuropathy associated with the embolization of these tumors has not been established. The authors of this study describe their experience with cranial neuropathy following transarterial embolization of glomus jugulare tumors using ethylene vinyl alcohol (Onyx, eV3 Inc.).

METHODS

The authors retrospectively reviewed all cases of glomus jugulare tumors that had been treated with preoperative embolization using Onyx at their institution in the period from 2006 to 2012. Patient demographics, clinical presentation, grade and amount of Onyx used, degree of angiographic devascularization, and procedural complications were recorded.

RESULTS

Over a 6-year period, 11 patients with glomus jugulare tumors underwent preoperative embolization with Onyx. All embolization procedures were completed in one session. The overall mean percent of tumor devascularization was 90.7%. No evidence of nontarget embolization was seen on postembolization angiograms. There were 2 cases (18%) of permanent cranial neuropathy attributed to the embolization procedures (facial nerve paralysis and lower cranial nerve dysfunction).

CONCLUSION

Embolizing glomus jugulare tumors with Onyx can produce a dramatic reduction in tumor vascularity. However, the intimate anatomical relationship and overlapping blood supply between these tumors and cranial nerves may contribute to a high incidence of cranial neuropathy following Onyx embolization.

A schwannoma of the greater petrosal nerve located within the petrous apex and treated with stereotactic radiotherapy

A 26 year-old female experienced progressive left sided pulsatile tinnitus and conductive hearing loss for two years, which following an extensive clinical workup, was diagnosed as a left greater petrosal nerve schwannoma located within the petrous apex of the temporal bone. Between neurosurgical management and radiation therapy, multiple therapeutic options were presented to the patient, who ultimately chose stereotactic radiotherapy as an alternative to surgical resection due to the potential morbidity associated with surgery. The patient received three fractions of 600 cGy without subsequent worsening of her symptoms, new onset neurologic symptoms or radiation induced side effects reported at a 3, 6 and 12 month clinic visits. A follow-up MRI at 6 and 12 months post radiation administration demonstrated no further tumor growth.

Implementing Genomic Medicine in Care of Patients with Impaired Hearing

Objectives:

The Miami Otogenetic Program has provided a unique platform to carry out translational research on delivering genetic services to deafness patient care. Using target-enrichment/NGS, we will 1) determine the overall frequencies of different forms of genetic deafness, 2) identify new genes for ARSNHL and ADNSHL, and 3) create a Genomic Deafness Database (GDD) and Personalized Sequence Profile (PSP) for the clinical care of deaf patients.

Methods:

We collected a unique cohort of multiplex families derived from three unique sources from the U.S., China, and Turkey, suitable for determination of molecular epidemiology of hereditary deafness and for new gene identification using “target-enrichment,” methods and next generation sequencing (NGS). Our interdisciplinary and collaborative team will conduct outcomes evaluation of genetic service on deaf patient care in our diverse populations.

Results:

The infrastructure of our multidisciplinary otogenetics team is presented along with our use of testing algorithms when evaluating patients with sensorineural hearing loss (SNHL). A total of 60% of small multiplex families are identified to have mutations in the known deafness genes in a pilot study and the remaining 40% have mutations in other yet-unidentified deafness-causing genes. We have identified several new genes for SNHL.

Conclusions:

The combined target-enrichment/NGS is a powerful tool in the identification of new deafness genes in small multiplex families and large multi-generational families. The multidisciplinary team approach is an effective way to bring the sequencing data to clinical practice for the clinical diagnosis and management of deaf and hard-of-hearing families.

Otolith Dysfunction Is Prevalent in Refractory Benign Paroxysmal Positional Vertigo

Objectives:

Determine the prevalence of otolith dysfunction in patients who have failed treatment for benign paroxysmal positional vertigo (BPPV).

Methods:

Case-control study of patients with BPPV who failed standard treatment and subsequently underwent vestibular testing and supervised vestibular rehabilitation. Interventions included videonystagmography, rotary chair, subjective visual vertical test (SVV), and cervical vestibular evoked myogenic potentials (VEMP). We compared the prevalence of abnormalities in tests of otolith dysfunction (SVV and VEMP) in patients who responded or failed vestibular rehabilitation.

Results:

In 2012, 46 of 251 patients with BPPV failed initial treatment with canalith repositioning maneuvers performed in the office; of these 46 patients, 28 patients had posterior semicircular canal BPPV and 18 cases had atypical presentations (multicanal BPPV, anterior canal BPPV, or signs of uncompensated unilateral peripheral vestibulopathy). Vestibular testing followed by customized vestibular rehabilitation was completed in 40 patients: 21 patients had resolution of their positional vertigo and nystagmus, and 19 patients did not respond to therapy. Abnormal otolith tests (SVV and/or VEMP) were more common in patients who failed therapy (Pearson Chi square, P = 0.002). Conversely, abnormalities of caloric testing did not predict response to therapy.

Conclusions:

Abnormalities of utricle and saccular function are prevalent in patients with refractory BPPV. This fact is important to take into account when designing rehabilitation strategies for BPPV patients who fail canalith repositioning maneuvers.

Otogenic Pain and Aural Fullness: Mystery Diagnosis

Program Description:

Otogenic pain and aural fullness can be some of the more frustrating chief complaints to work up and address. Many patients with this complaint are frustrated with a lack of diagnosis and treatment. This leads to multiple visits in search of the answer to their affliction. In this miniseminar, a panel of experts will discuss an appropriate evaluation and workup for these issues. Discussions will highlight appropriate examinations, testing, and imaging, as well as a thorough discussion of the differential diagnoses. Also, recommendations for treatment will be discussed. Case presentations will highlight proper workup and management of these confusing cases.

Educational Objectives:

1) Recite likely etiologies of aural fullness and otogenic pain. 2) Recognize potentially serious etiologies of these symptoms. 3) Use appropriate workup and treatment of these symptoms and their causes.

Ethnic disparity in skin complications following bone-anchored hearing aid implantation

OBJECTIVES

Sound processor loading after implantation of a bone-anchored hearing aid is often delayed by skin-site complications. This study examined the frequency of skin-site complications in various ethnic groups and determined factors that may lead to higher rates of skin-site complications resulting in delayed processor loading.

METHODS

Adult, English-speaking patients who underwent implantation of a bone-anchored hearing aid between 2007 and 2010 were reviewed. Demographic data including ethnicity, tobacco use, diabetes mellitus, immunosuppression, and long-term steroid use were determined. Major and minor skin-site complications and the time to processor loading were recorded.

RESULTS

The mean time to processor loading was 9.5 weeks, and the mean follow-up time was 23 months. There were no cases of osseointegration failure. African American patients had a significantly higher rate of major skin-site complications (p < 0.005) and a longer time to processor loading (mean, 17.6 weeks; p < 0.05) than the other ethnic groups. There was no significant difference in minor skin complication rates. There was no correlation between diabetes mellitus, long-term immunosuppression, or tobacco use and skin-site complications.

CONCLUSIONS

Skin complications can delay processor loading following implantation of a bone-anchored hearing aid. There is a higher rate of major skin-site complications in African American patients, and these often delay processor loading. The risk of skin-site complications is not correlated with smoking, diabetes mellitus, or immunosuppression. An increased risk of skin-site complications is an important consideration for preoperative counseling.

Audioprofiles and antioxidant enzyme genotypes in presbycusis

OBJECTIVES/HYPOTHESIS

Audiometric patterns have been shown to indirectly provide information regarding the pathophysiology of presbycusis and be useful in the phenotyping of hereditary deafness.

STUDY DESIGN AND METHODS

Hospital-based cohort study of adults with presbycusis, comparing the association of audiometric patterns and polymorphisms of antioxidant enzymes that have been linked to presbycusis: GSTT1, GSTM1 and NAT2. All subjects underwent a clinical evaluation and completed questionnaires regarding ototoxicity and noise exposure. Pure-tone threshold audiometry was obtained and subjects' audiograms were classified into specific patterns. DNA was extracted from blood and the polymorphisms of GSTT1, GSTM1, and the NAT2 variants (NAT2* 5A; NAT2* 6A,B) were analyzed by PCR.

RESULTS

The audiometric patterns that were more prevalent in our cohort were "High-Frequency Steeply Sloping" or HFSS (33%), "High-Frequency Gently Sloping" or HFGS (31%), and "Flat" (27%), with other patterns being rare. We did not find a statistical significant effect of gender, age, hearing level, and ear side on the audiometric pattern. Subjects with mutant alleles for GSTT1 were more likely to have a HFSS audiogram than subjects with the wild type genotype.

CONCLUSIONS

In this cohort, there was a similar prevalence for the three audiometric configurations HFSS, HFGS, and Flat, with other configurations being rare. Subjects with mutant alleles for GSTT1 were more likely to have a HFSS audiogram than subjects with the wild type genotype, suggesting that the basal turn of the cochlea is susceptible to GSTT1 regulated oxidative stress. However, further studies of audioprofiles with larger sample sizes may be needed to establish phenotype-genotype correlations in presbycusis.

Outcomes after surgical resection of head and neck paragangliomas: a review of 61 patients

We reviewed the postoperative functional outcome following surgical resection of paragangliomas in patients with and without preoperative cranial nerve dysfunction. Patients who underwent surgical resections of head and neck paragangliomas were reviewed with functional outcomes defined as feeding tube and/or tracheostomy dependence, need for vocal cord medialization, and incidence of cerebral vascular accidents as primary end points. Secondary end points included pre- and postoperative function of lower cranial nerves and the impact of this dysfunction on long-term functional status. Sixty-one patients were identified: 27 with carotid paraganglioma (CP), 21 with jugular paraganglioma (JP), 8 with tympanic paragangliomas, 4 with vagal paragangliomas (VPs), and 1 with aortopulmonary paraganglioma. Following resection, 8 patients were feeding tube dependent, 14 patients required vocal cord medialization, 2 patients suffered strokes, but no patients required tracheostomy tubes. Twenty percent of patients (4/20) with JP and postoperative cranial neuropathies were feeding tube dependent, and 80% of patients (4/5) with CP and postoperative cranial nerve dysfunction were feeding tube dependent. Cranial nerve deficits were more common in patients with JP relative to those with CP. However, when cranial nerve dysfunction was present, our patients with CP had a higher incidence of temporary feeding tube dependence. Overall, 98% of patients were able to resume oral nutrition.

Comparison of Packing Material in Middle Ear Mucosal Trauma

Objective: To compare absorbable gelatin sponge (AGS) with polyurethane foam (PUF) as middle ear packing material after mucosal trauma.

Method: Controlled animal experiment. Thirty-six guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears. One ear was packed with either PUF or AGS. Contralateral ears were used as nonpacked paired controls. Auditory brainstem response (ABR) thresholds were measured preoperatively and repeated at 1, 2, and 6 weeks postoperatively. Histological analysis was done by a pathologist blinded to the type of packing using hematoxylin and eosin staining to measure inflammatory reaction and trichome staining to measure fibrosis in each group.

Results: ABR recordings demonstrates that threshold level changes from baseline were minor in the PUF and the control groups. Threshold levels were higher in the AGS group compared with both control groups and the PUF group for the 1 KHz and 0.5 KHz frequencies. Macoscopic analysis showed no tympanic membrane perforation and packing material was absorbed in all groups at 6 weeks postoperatiely. The histological analysis showed normal mucosal healing in the PUF and control groups. There was more packing retention, inflammation, and osteoneogenesis in the AGS group than the PUF or either control group.

Conclusion: Following surgical trauma, the middle ear mucosa healed well without packing or with PUF packing material, and hearing was not affected. In contrast AGS packing material showed hearing loss at low frequencies and osteogenesis.

Mitochondrial DNA mutation screening in an ethnically diverse nonsyndromic deafness cohort

Deafness is a heterogeneous trait with many known genetic and environmental causes. Hereditary hearing loss is an extremely common disorder in the general population. Mutations in mitochondrial DNA (mtDNA) are known to be associated with nonsyndromic deafness (NSD) and syndromic deafness. The objective of this article is to investigate the frequency of common mitochondrial mutations (A1555G, G7444A, and A3243G) in an ethnically diverse cohort of probands with NSD from South Florida. These patients were ascertained at the University of Miami. Polymerase chain reaction-restriction fragment length polymorphism analysis and direct sequencing methods were used for mutation screening in a cohort of 217 patients with NSD. The frequency of common mitochondrial mutations is 1.84% (4/217) in this cohort. A1555G and G7444A accounted for four patients with NSD. Our mutation frequencies are comparable with those previously reported in other populations, indicating that mutations in mtDNA are an important cause of NSD in our patient cohort.

Etiologic diagnosis of nonsyndromic genetic hearing loss in adult vs pediatric populations

OBJECTIVES

Determine the diagnostic yield of a shared genetic testing algorithm in adult and pediatric populations with sensorineural hearing loss (SNHL) and recommend effective testing strategies to evaluate for genetic causes of deafness in patients presenting with idiopathic sensorineural hearing loss.

STUDY DESIGN

Hospital-based cohort study.

SETTING

University of Miami outpatient otology clinics between 2001 and 2010.

SUBJECTS

Two hundred twenty-one adult and 163 pediatric patients with nonsyndromic sensorineural hearing loss.

METHODS

Peripheral blood samples were screened for mutations in GJB2 and GJB6 and mitochondrial DNA mutations 1555A>G, 7444G>A, and 3243A>G. Audiometric data and family history were also collected.

RESULTS

GJB2/GJB6-related deafness was diagnosed in 23 of 163 pediatric patients (14%) compared with only 3 of 221 adults (1%). All adults had a family history of hearing loss, and 2 patients noted deafness onset at birth. Nineteen GJB2 mutations were identified with 35delG the most common mutation. The 35delG homozygous state was the most common pathogenic genotype (54%). Mitochondrial DNA (mtDNA) mutations were found in 6 adult probands (3%). No mtDNA mutations were found in pediatric patients.

CONCLUSION

Testing for common GJB2/GJB6 mutations in pediatric patients has considerable value in establishing an etiologic diagnosis for SNHL. Similar testing in adults is of very low yield except perhaps in cases of early-onset SNHL or strong family history. Mitochondrial DNA testing should be considered in adults with idiopathic SNHL.

Prophylactic valacyclovir in a patient with recurrent vestibular disturbances secondary to vestibular neuritis

A 57-year-old woman with herpes labialis and previously diagnosed with vestibular neuritis experienced recurrences of vertigo and disequilibrium. Initially preceded by oral herpes outbreaks or upper respiratory infections, these recurrences became spontaneous and more frequent. Vestibular function demonstrated a 25% decrease in energy function in the right and the patient had left beating nystagmus on positional maneuver. Her reoccurrences of vestibular disturbances were followed up. Concurrently, she was prescribed daily valacyclovir (500 mg, 1 per day) given for the prevention of herpes labialis outbreaks by her primary care physician. Recurrences of disequilibrium stopped completely as well as oral herpes outbreaks.

Management Outcomes of Facial Nerve Tumors

Objectives

Primary facial nerve tumors (FNTs) present in varying ways. In this study, the authors present their institutional experience with the management of facial nerve tumors, including their recommendations for available therapies such as observation, microsurgical decompression or removal, and stereotactic radiation. They emphasize the auditory and facial nerve function outcomes.

Study Design

Retrospective case review.

Setting

Tertiary referral center.

Subjects and Methods

Retrospective review of all cases of FNT seen at the authors’ tertiary care academic medical center over a 10-year period (2002-2011). The clinical presentation, treatment modality, and outcome parameters of cochlear and facial nerve function were assessed.

Results

Twelve patients were identified. House-Brackmann grades on presentation were 4 grade I, 2 grade II, 2 grade III, 1 grade IV, and 3 grade V, with 2 grade V patients declining to grade VI shortly after presentation. Seven patients presented with serviceable hearing and 4 with nonserviceable hearing. Treatment options/arms included observation with serial clinicoradiological review (2 cases), stereotactic radiation with the CyberKnife (3 cases), wide fallopian canal decompression (3 cases), microsurgical excision and repair (3 cases), and biopsy followed by observation (1 case). At the end of the review period, facial nerve function was stable in 8 patients, improved in 3, and declined in 1, and none had documented worsening of hearing based on American Academy of Otolaryngology—Head and Neck Surgery Foundation classification.

Conclusions

Management of FNT is largely based on the clinicoradiological picture. Each treatment arm is different, but overall auditory and facial function can be maintained.

L-N-Acetylcysteine treatment is associated with improved hearing outcome in sudden idiopathic sensorineural hearing loss

CONCLUSION

Combination therapy corticosteroids plus an oral antioxidant L-N-acetylcysteine (LNAC) was associated with improved hearing over corticosteroids alone, particularly at the 6-month follow-up and at high frequencies (i.e. 4000 Hz). This is the first report of a beneficial effect of LNAC in sudden idiopathic sensorineural hearing loss (SISNHL).

OBJECTIVE

To determine the association between antioxidant treatment and functional outcomes in SISNHL.

METHODS

This was a case-control study of adult patients with SISNHL, treated with oral prednisone plus intratympanic dexamethasone either alone or in combination with LNAC. The outcome measure was change in pure-tone thresholds at 500-4000 Hz. Hearing recovery was also recorded as the percentage of subjects with final pure-tone threshold average (PTA) within 50% of the difference between the initial value of the affected ear and the value of the unaffected ear. Comparisons were made between combination (corticosteroids plus LNAC) and single (no LNAC use) therapy groups.

RESULTS

At 6 months, the mean PTA improvements were 26.1 dB and 15.1 dB for the combination and single therapy groups, respectively (p = 0.046). Higher gains at 4000 Hz were noted with LNAC use. The percentage of patients with at least 50% recovery was 63% and 35% for the combination and single therapy groups, respectively (p = 0.0319).

Bone-Anchored Implantation for Single-Sided Deafness in Patients with Less Than Profound Hearing Loss

Objective

The benefit of bone-anchored implantation (BAI) for the treatment of single-sided deafness (SSD) is well established. In this study, the authors sought to evaluate objective hearing outcomes and subjective benefits in patients undergoing BAI for SSD with residual hearing in the implanted ear.

Study Design

Case series with chart review.

Setting

Academic tertiary referral center.

Subjects and Methods

All adult, English-speaking patients undergoing BAI for SSD from 2004 to 2010 were included. Patients were divided into 2 groups: (1) residual hearing in the affected ear (≤90 db hearing level [HL] pure-tone average [PTA]) and (2) profound hearing loss in the affected ear (>90 dB HL PTA). Patients underwent pre- and postoperative objective hearing outcomes testing including speech-in-noise and monosyllabic word tests. Subjective outcomes were measured pre- and postoperatively using the Glasgow Hearing Aid Benefit Profile (GHABP).

Results

Patients in both groups showed significant improvement in all objective hearing measures following implantation ( P < .0001), and there were no significant differences in objective hearing outcomes between groups. Subjective benefits from BAI varied across patients according to GHABP results, but patients with residual hearing in the affected ear trended toward improved satisfaction with their device postoperatively.

Conclusion

Individuals with SSD and residual cochlear reserve can be successfully implanted with BAI, achieving significant improvements in objective hearing measures. Postoperative improvements do not seem to correlate with the preoperative audiometric testing scores. Although subjective benefit varies across patients, BAI is clearly a viable rehabilitation option for patients with SSD and less than profound hearing loss.

Head-shaking nystagmus predicts greater disability in unilateral peripheral vestibulopathy

OBJECTIVES

The objective of this study was to determine the association of the bedside test of head-shaking nystagmus (HSN) with patients' self-perceived dizziness handicap as well as this test's sensitivity and specificity in unilateral peripheral vestibular hypofunction.

STUDY DESIGN

A retrospective case-control study was performed.

SETTING

The study was held at an academic, tertiary referral center.

METHODS

Fifty-three adult patients with unilateral peripheral hypofunction defined by the caloric test of the videonystagmography with documented bedside HSN and who had completed questionnaires of self-perceived dizziness handicap were included. The sensitivity and specificity of the bedside HSN in patients and 10 healthy controls in diagnosing unilateral vestibular hypofunction defined by videonystagmographic caloric testing and by abnormal gain and symmetry of the vestibular-ocular reflex by rotary chair testing were determined. Scores of the screening test of the Dizziness Handicap Index and Functional Level Scale questionnaires were taken.

RESULTS

When using the caloric irrigation test as the reference standard for unilateral vestibular hypofunction, the sensitivity, specificity, and positive predictive value of the bedside HSN were 31%, 96%, and 97%, respectively. When comparing with results of rotational chair testing (vestibular-ocular reflex gain and symmetry), the sensitivity of the HSN test increases to 71%. Patients with positive bedside HSN had higher scores (greater self-perceived dizziness handicap) of the Dizziness Handicap Index (P = .049) and higher (worse) scores of the Functional Level Scale (P = .0377) than those with negative bedside HSN (Wilcoxon rank test).

CONCLUSIONS

Greater perceived handicap was correlated with a positive bedside HSN in patients with unilateral peripheral vestibulopathy. The HSN has sufficient sensitivity to be used as screening test of uncompensated vestibulopathy in this series. However, a negative HSN alone does not rule out the diagnosis of peripheral vestibular dysfunction.

Facial Schwannoma Treatment via Cyberknife or Decompression

Objective: Microsurgical excision of facial nerve schwannomas frequently results in facial paresis or paralysis of House-Brackmann Grade III or higher. This study’s objectives are: 1) describe alternatives to microsurgical excision of facial nerve schwannomas, specifically wide fallopian canal decompression and Cyberknife radiosurgery; and 2) describe clinical outcomes of these alternative therapies.

Method: This is a case-control study of all patients undergoing excision, wide fallopian canal decompression, or Cyberknife radiosurgery at a tertiary academic referral center between 2002 and 2011. Main outcome measures were pre- and posttreatment facial nerve function, tumor control, and speech reception thresholds.

Results: Eleven patients were identified (3 wide decompression, 2 Cyberknife treated, 4 observation, and 2 microsurgical excision), and mean posttreatment follow-up was 35 months. When compared with excision, all of the cases undergoing nonexcision treatments resulted in facial nerve function stable or improved, no tumor growth, and no changes in speech reception thresholds.

Conclusion: While surgical excision of facial nerve schwannomas may be indicated in cases of poor facial function and impending complications, wide bony decompression, observation, and Cyberknife radiosurgery should be considered as alternative treatments to excision for patients with normal or good facial function who wish to maintain preoperative hearing thresholds.

Middle ear packing: comparison of materials in an animal model of mucosal trauma

OBJECTIVE

To compare absorbable gelatin sponge (AGS) with an injectable esterified hyaluronic acid (EHA) as middle ear packing material after mucosal trauma.

STUDY DESIGN

Randomized, blinded, and controlled study.

SETTING

Tertiary university-based hospital.

SUBJECTS AND METHODS

Twenty-three guinea pigs underwent middle ear surgery with mucosal trauma performed on both ears and one ear packed with either EHA or AGS. Contralateral ears were used as nonpacked paired controls. Auditory brainstem response (ABR) thresholds were measured preoperatively and repeated at 1, 2, and 6 weeks postoperatively. Macroscopic and microscopic analysis measured inflammatory reaction in each group.

RESULTS

ABR threshold changes from baseline in the EHA and both control groups were minor. Threshold levels were higher in the AGS group compared with the AGS control group. This trend was seen in each frequency tested at each time interval. Macroscopic analysis showed tympanic membrane perforation was rare, effusions were common in the AGS group, mucosal edema was most frequent in the AGS group, and unabsorbed packing was usually detected in the AGS group with little EHA detectable at 6 weeks. Microscopic analysis showed normal mucosal healing in all groups. Two AGS ears demonstrated excessive middle ear packing with exuberant osteoneogenesis.

CONCLUSIONS

Middle ear function and mucosal healing after surgery occurred similarly between the EHA control group and the EHA group. In contrast, the AGS group demonstrated worse hearing and a greater level of osteoneogenesis compared with the AGS control group. These results support EHA as an alternative middle ear packing material in otologic surgery.

Middle Ear Irrigations Decrease the Density of Mucosal Biofilms in an Animal Model of Acute Otitis Media

Objective: Bacteria in biofilms are extremely resistant to antibiotics. Recurrent acute otitis media appears to be a disease related to biofilm formation. The goal of this study is to determine if middle ear irrigations with saline or baby shampoo could eradicate mucosal biofilms in a chinchilla model of acute otitis media.

Method: After a baseline ABR, middle ears of 10 chinchillas were inoculated with Haemophilus influenzae. On day 5, the ears were irrigated with saline or 1% baby shampoo using a syringe or hydrodebrider. A final ABR was obtained before the animals were euthanized and middle ear mucosa were harvested for SEM analysis.

Results: Biofilm formation on middle ear mucosa in chinchillas was in nonuniform distribution. SEM analysis by a blinded microscopist showed a statistically significant decrease in biofilm densities of middle ear mucosa after normal saline or 1% baby shampoo irrigations when compared with nonirrigated ears using Wilcoxon/Kruskal-Wallis Tests ( P < .01). No statistically significant difference in biofilm densities between normal saline and 1% baby shampoo irrigations was seen. The hearing thresholds on auditory brainstem responses (ABR) at frequencies 16 kHz, 4 kHz, 1 kHz, and 500 Hz were unchanged two days after normal saline or 1% baby shampoo irrigations.

Conclusion: Middle ear irrigations with 1% baby shampoo or normal saline lead to a statistically significant decrease in biofilm densities. One percent baby shampoo or normal saline are non-ototoxic and can be safely used for middle ear irrigations. Future work in our laboratory will study the effect of a hydrodebrider prototype.

Histopathological Differences between Polyvinyl Alcohol and Ethylene Vinyl Alcohol Copolymer in Preoperative Glomus Jugulare Embolization

Objective: 1) Histopathologically characterize glomus jugulare paragangliomas preoperatively embolized with ethylene vinyl alcohol copolymer (EVAC). 2) Describe histopathological differences between glomus jugulare paragangliomas preoperatively embolized with polyvinyl alcohol (PVA) and EVAC.

Method: Case series of glomus jugulare paragangliomas preoperatively embolized with EVAC. The tumors were subsequently resected at a tertiary care center between 2003 and 2010. Patient demographic and clinical data were collected, and histopathological analysis of the preoperatively embolized tumors was performed.

Results: Glomus jugulare paragangliomas embolized with EVAC demonstrated 100% or near 100% occlusion of arterial vessels by histopathological analysis, whereas in previous studies PVA demonstrated a significantly lower percentage of embolization. Even when resection was performed several months after embolization, there was no revascularization of EVAC embolized vessels, whereas PVA embolized vessels have demonstrated partial revascularization. In one patient whose tumor was not completely resected after embolization with EVAC, there was no evidence of subsequent growth of the remnant disease.

Conclusion: Histopathological analysis of preoperatively embolized glomus jugulare paragangliomas indicates that EVAC provides a more thorough and longer lasting embolic profile than PVA.

A clinical protocol for predicting outcomes with an implantable prosthetic device (Baha) in patients with single-sided deafness

BACKGROUND

The Baha implant is increasingly becoming a common form of treatment for individuals with single-sided deafness (SSD). However, evidence-based guidelines for determining candidacy in these patients are not yet established.

PURPOSE

The purpose of this study was to investigate the clinical utility of speech-in-noise testing as a part of the preoperative evaluation of the Baha device in patients with SSD.

RESEARCH DESIGN

The study design was a prospective cohort of 24 English-speaking adults comparing preoperative results on speech-in-noise measures using the Baha Cordelle II headband stimulator to postoperative results using the patient's external Baha processor.

INTERVENTION

Outcome measures included signal-to-noise ratio (SNR) loss as measured by the QuickSIN™ and scores of self-reported disability questionnaires.

RESULTS

Wilcoxon signed-rank test resulted in no significant difference between the preoperative and postoperative methods for measuring benefit on listening in noise tasks. Passing Bablok regression analysis showed the preoperative and postoperative results to be statistically equivalent, which suggests that postoperative results can be predicted during preoperative testing. Wilcoxon signed-rank test showed significant improvements in self-reported disability postoperatively.

CONCLUSIONS

The results support the use of speech-in-noise measures as an accurate predictor of overall benefit in patients with SSD prior to implantation.

Malleus handle: determinant of success in ossiculoplasty

OBJECTIVE

The purpose of this study is to identify prognostic factors affecting outcome in ossicular chain reconstruction (OCR).

STUDY DESIGN AND SETTING

This study is a retrospective case series of electronic database at an academic institution.

MATERIALS AND METHODS

We reviewed 209 cases of chronic supportive otitis media performed from January 2000 through December 2007 and collected demographic, clinical, audiologic, and outcome information. Univariate analyses of group differences in terms of postoperative air-bone gap (ABG) changes were evaluated by analysis of variance. Multiple regression analyses were used to examine the relationship between postoperative ABG and the independent variables.

RESULTS

There were 105 cases of OCR the met the inclusion criteria (44 primary and 61 revision tympanoplasties), with an average follow-up of 19 months. The diagnoses were chronic suppurative otitis media without cholesteatoma in 36 cases and cholesteatoma in 69 cases. The mean preoperative ABG was 34 +/- 15 dB, and the mean postoperative ABG was 20 +/- 14 dB (P < 0.001). Of the independent variables analyzed, the type of procedure (ie, OCR performed during second-look tympanoplasty vs canal wall up vs canal wall down), preoperative ABG, and status of malleus handle were predictive of the success of OCR.

CONCLUSIONS

Favorable prognostic factors in OCR include smaller preoperative ABG and the presence of an intact malleus handle.

Imaging correlation of children with DFNB1 vs non-DFNB1 hearing loss

OBJECTIVES

To evaluate temporal bone CT findings in GJB2-related deafness (DFNB1) hearing loss and non-DFNB1 hearing loss children.

STUDY DESIGN

Case-control series.

SUBJECTS AND METHODS

Children with nonsyndromic hearing loss diagnosed as DFNB1 or non-DFNB1 after screening GJB2 allele variants and the large GJB6 deletion. Temporal bone CT images compared in a cohort of nine DFNB1 children with 10 non-DFNB1 children. Visual criteria and absolute measurements were compared against established normative values.

RESULTS

Visual inspection failed to identify two patients with abnormalities identified by using absolute measurements. Only one of nine DFNB1 children had an ear anomaly versus seven of 10 non-DFNB1 (odds ratio 16.33; 95% CI, 1.35, 197.78; P = 0.050). The non-DFNB1 group had a mean vestibule width that was significantly larger, and a mean lateral semicircular canal island width and vestibular aqueduct that were significantly smaller than the DFNB1 group.

CONCLUSIONS

Visual inspection of temporal bone CT images alone may not identify all anomalies and should be used with absolute CT measurements. Abnormal temporal bone CT findings are significantly less likely in children with DFNB1 compared with non-DFNB1 children despite similar age and degree of hearing loss.