Variation among pre-surgical CT assessments of chronic otitis media

OBJECTIVE

To investigate the reliability of preoperative computed tomography (CT) in patients with chronic otitis media (COM) as assessed by otologist-ENT surgeons, compared with surgical findings and respective radiological assessments, and to identify areas of the middle ear that are difficult to evaluate reliably with preoperative CT.

MATERIALS AND METHODS

Fifty patients with COM underwent preoperative temporal bone CT reported by a qualified radiologist. Each operating surgeon completed a standardized questionnaire regarding the status of 10 middle-ear structures after the operation. Two otologists blindly reviewed the scans. AC1-statistics between the radiology/otology report and the intra-operative findings were calculated.

RESULTS

In the attic, malleus-incus complex, tympanic cavity, and round window niche, the otologists' assessments of CT scans corresponded better to intra-operative findings than did the respective radiology report. In the lateral semicircular canal and sigmoid sinus, the otologists' assessments also outperformed those of the radiologists in cases of erosion. Radiological assessments outperformed those of otologists in only one of 10 studied areas: confirmation of an unexposed dura in the tegmen area. The scutum and oval window represent difficult areas for which to obtain a reliable preoperative CT scan report.

CONCLUSION

Otologists' assessments regarding the pre-surgical status of the temporal bone in COM appear more reliable than those of radiologists. This finding has serious implications in current clinical practice, and should be considered when designing strategies for Radiology Head & Neck training. The inherent limitations of CT may necessitate modifications to imaging and operating strategies.

Glottic and supraglottic laryngeal cancer: epidemiology, treatment patterns and survival in 164 patients

PURPOSE

To evaluate the effectiveness of different therapeutic managements in relation to clinical disease stage, the location of the lesion and to register the rate of disease recurrence of patients with glottic and supraglottic laryngeal cancer, and to also study some specific epidemiologic characteristics.

METHODS

A series of 164 patients with laryngeal glottic and supraglottic squamous cell cancer (SCC) treated surgically, with radiation therapy (RT), chemotherapy or combination of these was analysed. After treatment, all patients were followed up for an average of 58 months. All data concerning the primary lesion, therapeutic management, recurrence, staging, 5-year overall survival and epidemiological characteristics such as smoking and alcohol abuse were recorded and analysed in combination with the follow up data.

RESULTS

The therapeutic approach most commonly used was RT for stage I tumors and surgery for stages II, III and IV. Stage I and II patients treated with RT had high recurrence rate (60%). Patients with recurrence had 45.3% 5-year overall survival rate and average survival time 80 months, whereas patients with no recurrence had 77.4% 5-year overall survival rate and average survival time 173 months (p=0.0001). There was significant difference in survival between stage I and III (p=0.035), stage I and IV (p=0.0038) and stage II and IV (0.0156). The average overall survival time for non smokers was 195 months (median 1707rpar;, while for smokers it was 99 months (median 100; p=0.0047). The average overall survival time for alcohol abusers was 79 months (median 54), while for those who did not use alcohol it was 153 months (median 150; p=0.016).

CONCLUSION

The 5-year overall survival rate was 61.3%. RT alone in stages I and II proved inferior in decreasing re-currences compared with surgery. Smokers had significantly shorter overall survival.

Laryngeal cancer: smoking is not the only risk factor

AIM

To investigate the role of smoking, alcohol, coffee consumption, demographic factors, toxic agents, and occupation in laryngeal carcinogenesis.

MATERIALS/METHODS

A case-control study included 70 patients with histologically confirmed laryngeal cancer and 70 controls with non-neoplastic conditions unrelated to diet/smoking/alcohol. Relative risk, odds ratio (OR), and 95% confidence intervals were estimated using multiple logistic regression.

RESULTS

Current smokers had 19.46 OR of laryngeal cancer compared to non-smokers (p = 0.006). The respective OR for alcohol consumption was 3.94 (p = 0.006). While the risk increased in heavy drinkers, there was no difference in duration of alcohol consumption. There was a strong and consistent relation between laryngeal cancer and the consumption of Greek/Turkish coffee cups/day (p = 0.002, OR = 1.77). Diesel exhaust fumes also seemed to increase the risk of laryngeal cancer, although the association was found to be no longer significant after analysis with logistic regression.

CONCLUSION

The present study confirmed the relation of smoking and alcohol with laryngeal cancer. However, other factors such as coffee and diesel exhaust fumes may play an important role in laryngeal carcinogenesis.

Quantifying the bystander-effect of 2.5G mobile telephones on the speech perception of digital hearing aid users

OBJECTIVE

To quantify the bystander-effect of 2.5G mobile telephones (2.5G-MTs) on the speech perception of digital hearing-aid (dHA) users. Differences in the susceptibility of behind-the-ear (BTE) compared to in-to-the-ear (ITE) dHAs were also assessed.

MATERIALS/METHODS

Prospective-comparative study conducted at a tertiary referral centre (ENT Department) and a HA-fitting laboratory. Key-word recognition scores from open-sentence lists were calculated. Power-analysis determined that a minimum of 60 subjects with SNHL (30 in each group), using either BTE or ITE dHAs, were required for reliable study outcomes. Sixty-four adults were tested with a functioning 2.5G-MT at almost physical contact with their ear; thirty subjects used BTE and 34 ITE dHAs.

MAIN OUTCOME MEASURES

Aided word recognition score differences between studied groups and within each group, while a 2.5G-MT was activated. Cut-off inclusion criterion regarding baseline aided word recognition score was 75%.

RESULTS

Baseline aided word recognition scores for ITE dHAs were better compared to BTE ones (p < 0.01). Following the 2.5G-MT activation, this difference disappeared. No statistically significant difference in word recognition was observed between the examined groups, or within the BTE group, from the bystander-effect of the 2.5G-MT. ITE dHAs proved more susceptible to electromagnetic interference (p < 0.05).

CONCLUSION

The bystander-effect of 2.5G-MTs on the speech perception of dHA users is either minimal, or not significant. The observed compatibility has a positive impact on the lives of millions of people worldwide. The long-standing theory of more interference in BTE compared to ITE HAs is not confirmed by the results of the present study. EBM level of evidence: 2c.

Meniere's disease: Still a mystery disease with difficult differential diagnosis

One hundred and forty-six years after its first description, the differential diagnosis of Meniere’s disease remains very challenging. The aim of the present study is to review the current knowledge on the advantages and disadvantages of the new diagnostic methods for Meniere’s disease. The importance of accurate diagnosis for primary healthcare systems is also discussed. An extensive search of the literature was performed in Medline and other available database sources. Information from electronic links and related books were also included. Controlled clinical studies, prospective cohort studies, retrospective cohort studies, cross-sectional studies, case reports, written guidelines, systematic reviews, and books were selected. The typical clinical triad of symptoms from the vestibular and cochlear systems (recurrent vertigo, fluctuating sensorineural hearing loss and tinnitus) is usually the key for clinical diagnosis. Glycerol dehydration test and electrocochleography are the main diagnostic tests in current practice, while vestibular evoked myogenic potentials may be used in disease staging. Imagine techniques are not specific enough to set alone the diagnosis of Meniere’s disease, although they may be necessary to exclude other pathologies. Recently developed 3D MRI protocols can delineate the perilymphatic/endolymphatic spaces of the inner ear and aid diagnosis. Meniere’s disease is a continuous problem for the patients and affects their quality of life. Taking into account the frequent nature of the disease in certain countries, efforts for reliable diagnosis, prompt referral, and successful management are undoubtedly cost-effective for healthcare systems.

Bilateral versus unilateral cochlear implantation in young children

OBJECTIVES

To compare the preverbal communication skills of two groups of young implanted children: those with unilateral implantation and those with bilateral implantation.

MATERIAL AND METHODS

The study assessed 69 children: 42 unilaterally and 27 bilaterally implanted with age at implantation less than 3 years. The preverbal skills of these children were measured before and 1 year after implantation, using Tait Video Analysis that has been found able to predict later speech outcomes in young implanted children.

RESULTS

Before implantation there was no significant difference between the unilateral group and the bilateral group. There was still no difference at 12 months following implantation where vocal autonomy is concerned, but a strongly significant difference between the groups for vocal turn-taking and non-looking vocal turns, the bilateral group outperforming the unilateral group. Regarding gestural turn-taking and gestural autonomy, there was a strongly significant difference between the two groups at the 12 month interval, and also a difference before implantation for gestural autonomy, the unilateral group having the higher scores. Multiple regression of non-looking vocal turns revealed that 1 year following implantation, bilateral implantation contributed to 51% of the variance (p<0.0001), after controlling for the influence of age at implantation and length of deafness which did not reach statistical significance.

CONCLUSIONS

Profoundly deaf bilaterally implanted children are significantly more likely to use vocalisation to communicate, and to use audition when interacting vocally with an adult, compared with unilaterally implanted children. These results are independent of age at implantation and length of deafness.

Surgical management of cholesteatoma: the two main options and the third way--atticotomy/limited mastoidectomy

Chronic otitis media with cholesteatoma is considered an "unsafe" ear and generally requires surgical management. This is particularly challenging in children due to anatomical, pathophysiological and social reasons. There are different approaches for this objective. The two main options are the canal wall up and canal wall down mastoidectomy. The aim of this article is to compare the advantages and disadvantages of canal wall up and canal wall down method and present the third way of surgical management: the inside-outside approach through an endaural incision. This technique includes atticotomy, atticoantrostomy or mastoidectomy (mostly very limited) according to the size and location of the cholesteatoma. This technique contributes to the successful surgical management of cholesteatoma, eradicating the disease with the creation of small, dry, self-cleaning cavities and no pinna protrusion. Moreover, there is no need for meatoplasty or obliteration. However, we should never forget that in ear surgery the choice of the operative procedure should take into account the needs of the patient, the extent of the disease, and the surgeon's experience.

Laryngeal paragangliomas - controversies in diagnosis and management

Paragangliomas of the larynx are rare neuroendocrine tumors with difficulties in diagnosis and management. A review of the literature was carried out, using Medline and other available databases. Electronic links and related books were also included. The most reliable diagnostic imaging procedures are MRI, CT scan, and octreotide scintigraphy. Complete surgical excision with the maximal possible preservation of the laryngeal function is the treatment of choice. Many different surgical techniques have been reported but open surgical procedures seem to provide better results with lower recurrence rates, although endoscopic approaches and laser surgery have also been used with variable results. The use of long-acting depot octreotide has been used for the relief of symptoms and stabilization of the disease, especially in inoperable lesions with positive initial octreotide scintigraphy imaging. Detailed preoperative assessment and treatment planning in individual basis are essential in the management of these tumors.

Deaf children with cochlear implants before the age of 1 year: comparison of preverbal communication with normally hearing children

OBJECTIVES

To compare preverbal behaviors of deaf children implanted under 1 year of age with age-matched hearing children.

METHODS

The study assessed 20 children; 10 deaf children implanted under 1 year of age and 10 normally hearing children of the same age. Preverbal skills were measured before, 6 months, and 1 year after implantation, using Tait Video Analysis that is able to predict later speech outcomes in young implanted children.

RESULTS

Regarding vocal turns, the normally hearing group outperformed the implanted group although the latter children became quite vocal, nearly 60% of their turns being taken in this way. The mean vocal autonomy in implanted children, 1 year after implantation, was very close to the respective of hearing children (38.5 versus 43.5). Regarding the non-looking vocal turns, by the 12-month interval, hearing children had somewhat higher scores than implanted children, but the difference was not significant and the increase in implanted children was much higher (40-fold increase versus 4-fold increase). However, implanted children were more likely to use silent communication than hearing children, although gestural turns were decreasing with time.

CONCLUSIONS

The small numbers in this study, although two of the largest European cochlear implant centers were combined to recruit such young implantees, led us to be cautious in interpreting the results. However, it seems that in deaf implanted children under 1 year of age, some preverbal communication behaviors are developing to an extent (although at a somewhat lower level) not significantly different from those of age-matched normally hearing children.

The use and reliability of Tait video analysis in assessing preverbal language skills in profoundly deaf and normally hearing children under 12 months of age

BACKGROUND

Assessment measures in evaluating preverbal skills and their progress in very young deaf children are lacking. However, their importance is highlighted by the recent trend of implanting children under 1 year of age. Tait video analysis is a technique for assessing preverbal communication behaviours in very young children with hearing impairment and has been found to be strongly related to speech discrimination and intelligibility outcomes post-implantation.

AIM

To assess feasibility and inter-user reliability of Tait video analysis in assessing preverbal communication skills in children under 1 year of age.

MATERIAL AND METHODS

Ten children (five profoundly deaf and five normally hearing) under 1 year of age were assessed by Tait video analysis. Three observers analysed the samples independently, according to the established protocol.

RESULTS

There was complete agreement on 305 judgements and 8 discrepancies between observers over all the measures. Four of the discrepancies occurred in the samples of deaf children and four in the normally hearing samples. Statistical analysis revealed that the correlation coefficients between the different observers were extremely high ranging from 0.94 to 1 (perfect agreement). All of them were found to be statistically significant (p<0.01).

CONCLUSION

The very high rate of inter-observer reliability suggests that the video recordings of children under 12 months can be scored consistently, and Tait video analysis is therefore a valid method of monitoring the development of vocal and auditory preverbal skills in very young deaf children, either following cochlear implantation or using acoustic hearing aids.

Surgical correction of pinna malformations

BACKGROUND

Auricle reconstruction is a surgical procedure described in the medical literature as early as 600 BC. The aim of the present paper is to review these attempts and their results.

METHODS

Literature search and medical history books were used as scientific sources.

RESULTS

More than 40 different cartilagenous, osseous or other alloplastic frame materials (autogenous tibial bone, iliac bone, mastoid bone, maternal auricular cartilage, autogenous nasoseptal cartilage, allogenous meniscus, autogenous meniscus and many more) have been used since 1891. From approximately 40 reconstruction procedures that had been proposed, only eight were still in use in the 1980s. The reason for abandoning the majority of these surgical techniques was the unacceptable aesthetic result. However, at the end of the 20th Century two new techniques were introduced. These techniques were designed by Satoru Nagata and Burt Brent. Both techniques provide cosmetic and functional results that are acceptable both to the patient and to the surgeon.

CONCLUSIONS

Although the outcome of surgical auricle reconstruction was in general disappointing through the centuries, at the end of the 20th Century new surgical methods were established and at the present time auricle reconstruction can be attempted with acceptable results.

Age at implantation and development of vocal and auditory preverbal skills in implanted deaf children

BACKGROUND

Preverbal vocal and auditory skills are essential precursors of spoken language development and they have been shown previously to predict later speech perception and production outcomes in young implanted deaf children.

OBJECTIVES

To assess the effect of age at implantation on the development of vocal and auditory preverbal skills in implanted children.

METHODS

The study assessed 99 children, 33 in each of three groups (those implanted between 1 and 2 years; 2 and 3 years; and 3 and 4 years). Preverbal skills were measured in three areas: turn taking, autonomy and auditory awareness of spoken language, using the Tait video analysis method.

RESULTS

The youngest implanted group made an exceptional progress outperforming in all measures the two other groups (p<0.01), 6 and 12 months post-implantation, whereas there was no such difference before implantation. In the youngest group there was also significantly greater use of an auditory/oral style of communication: 85% of the group by 12 months post-implantation compared with 30% and 18% of the two older groups.

CONCLUSIONS

Vocal and auditory preverbal skills develop much more rapidly in children implanted between 1 and 2 years in comparison with older implanted children and reach a significantly higher level by 6 and 12 months post-implantation. In addition, younger implanted children are significantly more likely by 12 months post-implantation to adopt an auditory/oral mode of communication. These findings favour cochlear implantation as early as between 1 and 2 years, provided that correct diagnosis and adequate hearing-aid trial have been achieved.

Tissue detection of natural killer cells in laryngeal carcinoma

Natural Killer (NK) cells have gained much attention as potential cells in antitumor immune defense mechanisms. In a group of 31 patients with surgically treated squamous cell laryngeal carcinoma, NK cell presence was semiquantitatively assessed by means of immunohistochemistry. A panel of three monoclonal antibodies including anti-CD16, was applied on frozen tissue sections. High CD 16+ cell presence was more frequently detected in poorly differentiated carcinomas (in 6 out of 14 cases) by comparison to carcinomas of high to moderate degrees of differentiation (in 1 out of 16 cases, p=0.031). No other clinicopathological variable appeared to influence NK cell presence in the examined specimens. No relation between NK cell detection and relapse-free survival emerged. Poorly differentiated laryngeal cancer cells appear to trigger off a greater NK cell tissue response than well and moderately differentiated cancer cells; however, the potential prognostic impact of this observation remains to be established.

Laryngeal pemphigus without skin manifestations and review of the literature

Pemphigus is an uncommon chronic disease with dermatologic and mucosal manifestations. Primary laryngeal involvement without skin lesions is extremely rare. The present paper describes a 72-year old man who presented with a 2-month history of hoarseness, haemoptisis and dysphagia. Clinical examination revealed an erythematous oral mucosa without ulcerations. Indirect laryngoscopy revealed supraglottic ulcerations mainly in the laryngeal surface of the epiglottis and in the right arytenoid. The lesions had characteristic gray color membranes. The patient underwent microlaryngoscopy under general anesthesia and biopsies were taken for histology that revealed inflammatory and granular lesions with necrosis. The diagnosis of pemphigus was based on immunohistopathology and the clinical examination. The patient underwent intravenous treatment with high doses of corticosteroids (prezolon 75 mg/24 h) for 10 days and gradually the dose was reduced to 10 mg/24 h. The patient had a very good response to the treatment and after a week approximately 80% of the lesions disappeared. However, the dose of 10 mg prednisolone per day was sustained for 3 months because any attempt of prednisolone discontinuation was related with reappearance of the clinical symptoms. After 3 months, finally the treatment was discontinued without problems. Now, 15 months later, the patient is well and without symptoms. He is under long-term follow-up. ENT surgeons should be aware of pemphigus as primary laryngeal manifestation in order to investigate and manage patients accordingly.

Topical antibiotic ear drops: are they safe?

A discharging ear is a very common condition for the general practitioner and the ENT surgeon. Oral and intravenous antibiotics have potential complications, are costly, and exhibit increasing resistance. This study explores the advantages and disadvantages of all common otic preparations and compares effectiveness, safety, cost and complication rates. In chronic otitis media (chronic discharging ears), topical antibiotics seem to be the treatment of choice by comparison with oral or intravenous antibiotics. Cultures and antibiograms do not correspond directly to clinical efficacy, as laboratory determination of resistance does not take into account the high concentration of antibiotics in local preparations. It is safer to use quinolone drops as a first-line treatment, but it is still possible to use short courses of other drops if quinolones are either unavailable or contraindicated (e.g. allergy), or when bacteria are resistant to them. However, in such a situation, a round window membrane involved in an established inflammatory process and therefore less permeable to the passage of topical preparations is the preferred setting, as ototoxicity is a potential complication, especially in the case of gentamicin, in which case patients should be warned accordingly.

Should We Use Ossicular Remnants in Ossicular Reconstruction following Cholesteatoma Removal?

The remnants of the acoustic ossicles have been used in ossicular reconstruction during mastoid surgery for many decades. The present study assessed the status of the acoustic ossicles in 114 patients (57 with cholesteatoma and 57 without) during surgery for chronic otitis media using the operating microscope. In 52 cases, the ossicles (malleus and/or incus) were assessed using both the surgical and scanning electron microscope in order to reveal any erosions and compare the findings. From the 57 operated ears with cholesteatoma, 45 (79%) had ossicular erosion whereas 12 (21%) did not. In the group of 57 operated ears with chronic otitis media without cholesteatoma, 33 (58%) had ossicular erosion whereas 24 (42%) did not. This difference was statistically significant (p = 0.02). With regard to the 52 operated cases who were studied with both microscopes, in the cholesteatoma patients the surgical microscope was not able to reveal any ossicular erosions in 39% of the cases, whereas the scanning electron microscope revealed moderate or severe erosions in the same ears. This suggests that the operating microscope is not reliable enough to determine if ossicular remnants can be used in ossicular reconstruction following cholesteatoma surgery. There is a considerable risk that epithelia or other cholesteatoma particles remain in the areas of erosions that cannot be seen with the operating microscope. The use of such ossicular remnants may lead to cholesteatoma recurrence and failures in mastoid surgery. Therefore, autoclaving or alternative prosthesis may be considered in such cases.

Evidence-based overview of ophthalmic disorders in deaf children: a literature update

BACKGROUND

Deaf children are heavily reliant on the sense of vision in order to develop efficient communication skills and explore the world around them. Any ophthalmic disorder may thus negatively impact on this process, especially if it is unrecognised in the early years of life. These disorders may be correctable (such as myopia) or treatable (such as cataract), and their early identification is of the utmost importance to optimise language development (spoken or sign, or both) and develop social cognition. Those children with non-correctable and non-treatable visual disorders, like retinitis pigmentosa in Usher syndrome, require multiple environmental adaptations and appropriate support services and information.

AIM

: To review the accumulated scientific knowledge on ophthalmic disorders in deaf children and assess the quality of evidence published in the literature in order to contribute to better diagnosis and management of these conditions.

MATERIAL AND METHODS

The project reviewed more than 1000 published papers and other sources. 191 papers complied with the aims of the study and were used in the project. From these studies, 95% were based on type III or IV evidence (mainly descriptive studies or case reports). Only 3% were based on type II evidence and 2% on type I evidence.

RESULTS-CONCLUSIONS

The main conclusions of this project are: a) the overall quality of evidence in the literature concerning deaf children and their ophthalmic problems is very low, b) the prevalence of ophthalmic problems in deaf children is very high (approximately 40% to 60%) and these problems may remain undetected for years although they may have a serious impact on children's acquisition of communication skills, c) screening for ophthalmic problems in deaf children should be encouraged and specialist ophthalmic examination should be carried out as soon as the diagnosis of deafness is confirmed irrespective of age, and may need to be repeated at intervals following diagnosis, d) families should be informed about the nature of the screening process in discussion with the relevant professionals and appropriate information should be available in a range of formats and in different community languages, e) professionals administering the tests should be familiar with the needs of deaf children with ophthalmic problems and should be sensitive to the communication needs of the child, especially undertaking behavioural testing where their collaboration is needed, f) while orthoptists can perform the majority of psychophysical tests (visual and stereo acuity tests, ocular motility tests, etc.) a comprehensive opthalmologic assessment by slit lamp biomicroscopy, streak retinoscopy, direct and indirect ophthalmoscopy, intraocular pressure measurement etc is required. Electrophysiologic testing to help identification of Usher syndrome may also be required, and finally g) serial hearing assessments of children with dual sensory deficits are needed to monitor hearing thresholds, to optimise hearing aid use and to ensure timely referral for cochlear implantation for those who need it.

Newborn Hearing Screening: Effectiveness, Importance of High-Risk Factors, and Characteristics of Infants in the Neonatal Intensive Care Unit and Well-Baby Nursery

BACKGROUND

In contrast to the recommendations of the Joint Committee on Infant Hearing, neonatal hearing screening programs are still not universally available, and many countries implement elective screening in high-risk newborns.

OBJECTIVE

To assess the failure rates of neonates in hearing screening and the relative importance of risk factors for hearing impairment, both in neonatal intensive care units and in well-baby nursery neonates. The impact on cost-effectiveness is also evaluated.

SUBJECTS

In the current study, 25,288 newborns were assessed; 23,574 were full-term newborns in the well-baby nursery and 1,714 neonates were in neonatal intensive care units.

METHODS

All neonates had a general examination (including assessment for congenital anomalies and related history) and were assessed using transient evoked otoacoustic emissions. All newborns were older than 36 weeks at examination and thus had reliable transient evoked otoacoustic emissions.

RESULTS

From the 23,574 full-term neonates in the well-baby nursery, 23,123 (98.1%) passed the test and 451 failed (1.9%). Fifty-three of the 23,574 neonates (0.2%) had a risk factor for hearing impairment; 44 (83%) passed the test and 9 failed (17%). Family history of congenital hearing loss and congenital anomalies were the most frequent risk factors for hearing loss. From the 1,714 neonates in neonatal intensive care units, 1,590 (93%) passed the test and 124 failed (7%). Two hundred thirty-two of the 1,714 neonates (14%) had a risk factor for hearing impairment; 205 (88%) passed the test and 27 failed (12%). In neonatal intensive care unit neonates, toxic levels of ototoxic drugs, mechanical ventilation for more than 24 hours, prematurity, and low birth weight were the most frequent risk factors for hearing loss. Congenital anomalies/syndromes were the most important risk factors for failing screening in both the neonatal intensive care unit and the well-baby nursery, as they showed the highest risk of failing hearing screening. The second most important factor in neonatal intensive care unit newborns was low birth weight, and the third was prematurity in relation to the possibility of failing hearing screening.

CONCLUSION

The present study found 575 neonates failing hearing screening of 25,288 tested newborns (2.3%). The fact that 78% of newborns who failed hearing screening were in the well-baby nurseries further supports the necessity of universal hearing screening instead of selective screening in neonatal intensive care units, even with the obvious impact on cost-effectiveness. Even if limited funding lead to selective screening in neonatal intensive care units, this should not be applied to high-risk newborns but to all neonatal intensive care unit neonates. Continuous assessment of risk factors and the related possibility of failing hearing screening are of paramount importance in designing hearing screening programs and refining the respective criteria.

Cochlear implants: 100 pediatric case conversions from the body worn to the nucleus esprit 22 ear level speech processor

OBJECTIVE

To assess performance of Nucleus 22 mini system pediatric users converted from the Spectra 22 body-worn to the ESPrit 22 ear-level speech processor using aided thresholds and speech discrimination measures before and after the conversion.

STUDY DESIGN

Spectra 22 body-worn speech processor users were chosen using preselection criteria (stable map, ability to report on the quality of the signal, no device problems). The subjects underwent tuning, map conversion, fitting of the ESPrit 22, and aided soundfield threshold and speech discrimination testing.

SUBJECTS

The first 100 consecutive conversions are analyzed in this study. Fifty children (50%) were female, and 50 (50%) were male. The average age at implantation was 4.6 years (median 4.3 years, range 1.7 to 11 years). The average age of fitting the ear level speech processor was 11.1 years (median 11 years, range 6.2 to 18.2 years).

SETTING

Tertiary referral pediatric cochlear implant center in the United Kingdom.

RESULTS

Of the 100 fittings attempted, all Spectra 22 maps could to be converted for use in the ESPrit 22. Of these 100 fittings, 44 were straightforward with no adjustment to map parameters being required, and 56 needed rate reductions and other map adjustments to achieve the conversion. The difference of the mean thresholds before and after the conversion did not exceed 2 dB across the frequencies studied (0.5-4 kHz). In 95% of the cases, the differences were less than 9 dB(A). With regard to speech discrimination testing, the mean threshold before the conversion was 53.4 dB and after the conversion 52.7 dB. Of the 100 conversions, only five children stopped using the ESPrit 22 despite fitting being achieved.

CONCLUSION

Conversion from the Spectra 22 body worn to the ESPrit 22 ear level speech processor was found to be feasible in all the 100 cases studied. Only a minority (5%) of children chose not to use the ear level speech processor suggesting that children and parents were satisfied from the conversion.

Burkitt's lymphoma in the base of the tongue: differential diagnosis and management

Burkitt's lymphoma is the most common malignancy in African children but can occur sporadically in every country. It is one of the most aggressive malignancies in the human body, and in the past the prognosis was very poor. However, complex chemotherapy regimens can now cure approximately 50-80% of adult patients with Burkitt's lymphoma or small noncleaved lymphoma, and in pediatric populations the cure rate is even higher. Although the African type has a preference to the head and neck region (whereas the sporadic type to the abdomen), involvement of the base of the tongue is extremely rare as only 1 case has ever been reported in the English literature. The present study describes a patient with Burkitt's lymphoma presenting as a single mass in the base of the tongue without any abdominal or other extra-abdominal involvement. The patient was submitted to chemotherapy (intravenous and intrathecal) and skull radiotherapy. Today, 17 months after the diagnosis, the patient is disease free. Physicians should be aware of the extranodal manifestations of Burkitt's lymphoma and their differential diagnosis in order to achieve early diagnosis and treatment.

Variations in gains in auditory performance from pediatric cochlear implantation

OBJECTIVE

To investigate variations in gains in auditory performance in children with cochlear implants.

STUDY DESIGN

The auditory performance of 98 children was measured with the Category of Auditory Performance survey instrument. All data were collected prospectively. Variables used to explain gain in Category of Auditory Performance were age at implantation, sex, the duration of "untreated" deafness, the year in which implantation occurred, health care inputs, and cause of hearing impairment. The data were analyzed by ordered probabilistic regression analysis.

RESULTS

Gain in Category of Auditory Performance was observed to be negatively related to age at implantation, the year in which implantation took place, and the number of medical consultations the child received. None of the other variables were significant determinants of gain in Category of Auditory Performance.

CONCLUSION

This study demonstrates the value of examining incremental gain from implantation rather than simply examining outcome levels. It was found that pediatric implantation is subject to diminishing returns. This suggests that further relaxation of entry criteria to implant programs should be undertaken only after careful consideration. The study also confirmed that age at implantation is an important determinant of outcomes. Greater gain in Category of Auditory Performance was experienced by those who underwent implantation at a younger age. This finding has implications for screening, as well as for purchasers and providers of implant services, highlighting the importance of responding in a timely fashion to identified need.

Communication development in young deaf children: review of the video analysis method

It is widely recognised that preverbal communication skills underpin development of spoken language. This historical review outlines the establishment of a quantitative methodology for assessing preverbal communication skills in children with hearing aids and cochlear implants. The method is shown to be reliable and free from observer bias. The review also summarises findings from a series of cross-sectional and longitudinal observational studies utilising the methodology. Profoundly deaf young children, either with cochlear implants or successful users of hearing aids, show similar patterns of preverbal communication development that contrast with those of unsuccessful hearing-aid users. Preverbal measures obtained 12 months after implantation are predictive of late performance on speech perception tasks. Moreover, there is a significant association between the preverbal measure of 'autonomy' obtained before implantation and later speech perception performance. This latter finding has important theoretical implications for understanding of language development and suggests that intervention that promotes autonomy in adult-child interaction may lead to improved outcomes. Such intervention could be commenced as soon as deafness is discovered.

Reliability of a rating scale for measuring speech intelligibility after pediatric cochlear implantation

OBJECTIVE

To evaluate the reliability of the Speech Intelligibility Rating scale to monitor the speech intelligibility of deaf children who have received cochlear implants.

STUDY DESIGN

A prospective study assessing the speech intelligibility of deaf children with cochlear implants by local and cochlear implant program speech and language therapists.

SETTING

Pediatric tertiary referral center for cochlear implantation.

PATIENTS AND METHODS

Fifty-four children were each rated by two speech and language therapists, one working with the child locally and the other working with the child at the cochlear implant program. All children were between 1.2 and 10.9 years of age at the time of implantation (median, 4.0 years). The follow-up intervals ranged from before implantation to 9 years after implantation.

MAIN OUTCOME MEASURE

Correlation coefficient, intraclass correlation coefficient, and kappa statistics were used to assess the interobserver reliability of the Speech Intelligibility Rating scale.

RESULTS

Spearman rank correlation coefficient and intraclass correlation coefficient were 0.82 with high statistical significance (p < 0.00001). Kappa statistical analysis revealed a moderate to substantial agreement between the ratings. This agreement also reached a high statistical significance (overall kappa = 0.53, p < 0.000001). The Speech Intelligibility Rating scale was found to be able to discriminate speech intelligibility among subjects, and the ratings covaried with high consistency.

CONCLUSION

The study found a high rate of agreement between observers when they used the Speech Intelligibility Rating scale to assess the speech intelligibility of deaf children after cochlear implantation. Because the scale presents information in a format that is understood by parents, local professionals, and health care purchasers, it will be useful to provide them with accessible information on speech intelligibility outcomes of deaf children who have received cochlear implants.

Cochlear implantation in children with large vestibular aqueduct syndrome and a review of the syndrome

OBJECTIVE

Children with Large Vestibular Aqueduct Syndrome (LVAS) frequently develop speech and language skills prior to deterioration of their hearing. Operations designed to halt the progression of hearing loss have largely failed so the question of Cochlear Implantation in these children has arisen. It had been suggested that there would be technical difficulties in implanting these patients and, therefore, there had been an initial reluctance to proceed to implantation. The aim of the present paper is to assess surgical and functional outcomes in implanted children with LVAS and review the related literature.

MATERIAL AND METHODS

From the 170 children assessed by MRI in the Nottingham Paediatric Cochlear Implant Programme, seven (4%) were identified as having LVAS. Four of these children were implanted and had at least 12 months follow up. Two of the children are on the waiting list for implantation and one child was not implanted because of absence of the cochlear nerve. Operative findings, complications and outcome measures were recorded. The auditory skills of the children were assessed before implantation and 1 year following implantation. A literature search was done to identify other series with experience in implanting children with LVAS.

RESULTS

Full insertion of the electrode array was achieved in all our cases. After cochleostomy two patients experienced a mild CSF leak that was easily controlled by the muscle graft. On the first day post-operation two patients were nauseous and one had an episode of vomiting, however, all were discharged within 24 h of surgery. Initial outcome measures at 12 months post-implantation were encouraging showing significant progress in children's auditory skills.

CONCLUSIONS

The results of the present study and the review of the literature suggest that LVAS is not a contraindication to implantation as initial concerns about severe perilymph leaks and surgical complications have proved to be unfounded. The post-operative progress of these children in listening skills also suggest that these children are suitable for cochlear implantation

Hearing evaluation with distortion-product otoacoustic emissions in young patients undergoing haemodialysis

Sensorineural hearing loss is frequently reported in young patients with chronic renal failure having haemodialysis. The effect of a single session of haemodialysis on hearing acuity was assessed prospectively in nine children with end-stage renal disease using pure-tone audiometry (PTA) and distortion-product otoacoustic emissions (DPOAEs). Results were compared with those obtained from nine audiologically normal healthy children also tested with PTA and DPOAEs twice during a 4-h interval. Sensorineural hearing loss of unknown aetiology was found in 55.5% of renal patients, mainly in the higher frequencies. Patients on HD had mean PTA thresholds significantly poorer than those of the control group in the frequency range 1000-12 000Hz (P < 0.05). Their mean DPOAE amplitudes were significantly lower in all frequencies > 1184 Hz (P < 0.05). Furthermore, patients' ears with normal PTA thresholds between 250 and 4000 Hz also had decreased DPOAE amplitudes. No significant changes in PTA thresholds or DPOAE amplitudes were encountered in renal patients before and after a HD session (P > 0.05). Changes in PTA thresholds or DPOAE amplitudes were not significantly different than those in the control group (P > 0.05). In conclusion, sensorineural hearing loss of unknown origin, especially in high frequencies, is frequent in young renal patients under HD and single HD sessions do not seem to alter the hearing acuity of these patients. DPOAEs seem to be more sensitive to incipient cochlear damage than behaviour thresholds in monitoring renal patients.

Indirect costs, cost-utility variations and the funding of paediatric cochlear implantation

OBJECTIVE

To demonstrate the existence of variations in cost-utility associated with indirect costs in paediatric cochlear implantation; to illustrate the implications of this for purchasing decisions and; to posit a potential solution to anomalies in purchasing that may otherwise result when services are publicly funded.

METHODS

Data was taken from published sources on the cost of implantation, outcomes measured in terms of quality adjusted life years (QALY) and in savings in education costs associated with paediatric cochlear implantation. Cost-utility ratios across education authorities were calculated using a single centre's implantation costs.

RESULTS

Variations in savings across education authorities show that the cost per QALY gain associated with paediatric cochlear implantation can vary between approximately $12,000 and $18,000 assuming an exchange rate of $1.45 = 1 pound sterling for the same implant centre. These variations have the potential to produce situations in which less efficient implant centres are preferred by purchasers over more efficient ones or in which candidates with poorer outcomes are selected for funding over candidates with superior outcomes. It is important that savings associated with education be taken into consideration in evaluations intended to inform purchasing decisions regarding implantation. Equally it is important that potentially anomalous decisions be avoided if evaluations are to remain credible. It is argued that this may be achievable if public funding for implantation is determined at a national level and ring-fenced i.e. devoted exclusively to use in cochlear implantation.

Pediatric cochlear implantation: the parents' perspective

OBJECTIVE

To analyze parental views on cochlear implantation, before and in the years following implantation, to determine whether the results from the intervention met their expectations.

DESIGN

Prospective longitudinal study to assess parental perspectives of an unselected group of children with cochlear implantation.

SETTING

Tertiary referral pediatric cochlear implant center in the United Kingdom.

SUBJECTS

Forty-three parents of children with cochlear implantation.

INTERVENTION

A specifically designed questionnaire was administered to assess preimplant expectations and observed changes and concerns at 1, 2, and 3 years following implantation. Three key domains were evaluated: (1) communication with others, (2) listening to speech without lipreading, and (3) the development of speech and language.

RESULTS

Preoperative expectations were met or surpassed at each of the follow-up intervals. In the area of communication, 35 (81%) parents expected a definite improvement preoperatively, and 3 years following implantation, 42 (98%) actually saw such an improvement. The respective numbers in the area of listening to speech were 15 (35%) and 38 (88%), and for speech development, 37 (86%) and 37 (86%). Speech development was the major area of concern at all intervals.

CONCLUSION

This study demonstrates the ability of cochlear implantation to meet or surpass parental expectations in 3 important outcome domains: communication, listening to speech, and the development of speech and language.

Use of the telephone in prelingually deaf children with a multichannel cochlear implant

OBJECTIVE

To assess progress in the use of the telephone in a group of prelingually deaf children after cochlear implantation.

SETTING

Tertiary referral pediatric cochlear implant center in the U. K.

STUDY DESIGN

A prospective study was undertaken on a consecutive group of 150 congenital and prelingually deaf children up to 5 years after implantation. The study group was confined to prelingually deaf children aged less than 7 years at the time of implantation. No child was lost to follow-up, and there were no exclusions from the study. At the time of the study, 129 children had reached the 1-year stage, and 91, 68, 40, and 23 had reached the 2-, 3-, 4-, and 5-year intervals, respectively.

METHODS

A specifically designed profile was used to assess the telephone use of the implanted children. Regression analysis was used to assess the correlation between the results of the telephone profile with the outcomes of the Iowa sentence test and connected discourse tracking.

RESULTS

After implantation, prelingually deaf children showed significant progress in telephone use over time, not reaching a plateau at the 5-year interval (median score 27 with maximum score available 34). The results of the telephone profile showed significant correlations with the other tests of speech perception (correlation coefficients from 0.47 to 0.79, all statistically significant p < 0.0001).

CONCLUSION

The telephone profile provided a useful method of monitoring children's telephone use. The profile was easily administered, and it was sensitive in assessing the progress of prelingually deaf children with cochlear implants. Outcomes from the profile were highly correlated with results from other widely used closed- and open-set tests.

Impact of facial paralysis on patients with acoustic neuroma

OBJECTIVE

To assess the psychological distress, the ways of coping with that stress, and the self-esteem of patients with facial paralysis after acoustic neuroma surgery. Possible predictors and associations between these measures were also explored.

STUDY DESIGN

Four validated questionnaires were completed by patients with facial paralysis after acoustic neuroma surgery: 1) the Derriford Appearance Scale (DAS) to measure psychological distress, 2) the COPE questionnaire to measure how patients cope with facial paralysis, 3) the Personal Report questionnaire to measure the self-esteem of patients, and 4) the Facial Paralysis Questionnaire (FPQ) to measure the severity of facial paralysis.

PATIENTS

One hundred three patients with facial paralysis after surgical removal of acoustic tumors.

RESULTS

Distress spanned a wide range in these patients. There was no statistically significant association between the level of distress and the grade of facial paralysis or between time since operation and levels of distress. Women had higher levels of distress (P = .02) and a significant negative correlation was found between levels of distress and age (r = -0.28, P = .005). High levels of distress were associated with low levels of self-esteem, as shown by the significant negative correlation between level of distress and self-esteem (r = -0.59, P = .01). A significant correlation between distress and maladaptive coping (r = 0.31, P = .002) was also found. Stepwise multiple regression of the distress scores revealed that self-esteem was the most important contributing factor (standardized coefficient beta -0.60, P = .0001), followed by age (beta -0.24, P = .006) and sex (beta -0.21, P = .04). This model explained 44% of the distress variance.

CONCLUSION

Clinicians must be aware of the distress felt by some patients experiencing facial palsy after acoustic neuroma surgery and that the level of distress may not be related to the clinical grade of the facial nerve paralysis. People with low self-esteem, young people, and women suffer from more distress due to the facial palsy. Clinicians should thoroughly counsel patients before and after surgery and should implement measures that increase patients' self-esteem and decrease their distress, especially in these high-risk groups.

Determinants of speech perception in children after cochlear implantation

BACKGROUND

Cochlear implants provide access to the speech signal in those profoundly deaf children who derive no material benefit from acoustic hearing aids. Speech perception after implantation can vary widely--we have analysed the contribution of several factors.

METHODS

We examined 40 children with mean age at implantation of 52 months who were either born deaf or became deaf before 3 years. All patients received the same multichannel implant system and were followed up for 5 years. We used connected discourse tracking (CDT) as the measure of speech perception. The effect of five potential predictors (age at implantation, number of inserted electrodes, origin of deafness, mode of communication, and socioeconomic group) on speech perception was analysed.

FINDINGS

The mean number of words per minute perceived increased from 0 before implantation to 44.8 (SD 24.3) 5 years after implantation. Repeated-measures ANOVA showed that children significantly progressed over time (p=0.001). Age at implantation was a significant covariate (p=0.01) and mode of communication was a significant between-individuals factor (p=0.04).

INTERPRETATION

Young age at intervention and oral communication mode are the most important known determinants of later speech perception in young children after cochlear implantation. Early identification of candidate children necessitates implementation of universal neonatal screening programmes for hearing impairment.

Approach to communication, speech perception and intelligibility after paediatric cochlear implantation

The aim of this study was to explore the relationship between approach to communication, speech perception and speech intelligibility after cochlear implantation of young children with profound early deafness. A prospective speech perception and speech intelligibility assessment was undertaken on a consecutive group of implanted children. There were 46 children at the three-year, 26 at the four-year and 20 at the five-year intervals. All had been born deaf or deafened before the age of three and received cochlear implants before the age of seven. Their speech perception ability and the intelligibility of their speech were measured before cochlear implantation and annually thereafter. The children's communication had been classified by their teachers of the deaf at each interval into one of two categories: those using an oral approach and those using a signing approach. Results revealed that at all intervals, those children classified as using oral communication significantly exceeded those using signed communication on measures of speech perception and intelligibility (p<0.05). When those children who had changed from signed to oral communication were compared at the three-year interval with those who used oral communication throughout, there was no significant difference in their results. However, it remains to be explored whether children use oral communication after cochlear implantation because they are doing well, or whether they do well because they are using oral communication.

The prognostic value of promontory electric auditory brain stem response in pediatric cochlear implantation

OBJECTIVE

To test the hypothesis that children with clear promontory electrically evoked auditory brain stem responses (prom-EABRs) would outperform, after cochlear implantation, children who had no prom-EABR preoperatively.

DESIGN

A prospective study was undertaken on 47 implanted children assigning them to two groups (group A: 35 children with a clear wave e-V in the preoperative prom-EABR and group B: 12 children with no prom-EABR). Speech perception and speech intelligibility were assessed annually up to 3 yr after implantation with the IOWA sentence test (level A and level B), Connected Discourse Tracking, Categories of Auditory Performance, and Speech Intelligibility Rating. t-test and Mann-Whitney U test were used to compare the above outcome measures in the two groups.

RESULTS

There was no statistically significant difference between the two groups on any of the outcome measures at any interval. Moreover, the small differences observed showed no consistent trend toward either group of children. Further analysis revealed that the outcomes have not been affected by possible confounding factors (age at implantation, duration of deafness, preoperative unaided pure-tone thresholds, and number of inserted electrodes).

CONCLUSIONS

The results suggest that children with no prom-EABR performed at levels comparable with children who had clear promontory responses preoperatively. The prognostic value of prom-EABR is limited and absence of a prom-EABR is not, by itself, a contraindication for cochlear implantation. However, in selected cases (congenital malformations, cochlear nerve dysplasia or suspected aplasia, narrow internal auditory canal, etc.) the presence of a prom-EABR is a positive finding in the assessment of candidates for cochlear implantation as it confirms the existence of intact auditory neurones.

Impairments, disabilities, and handicaps after acoustic neuroma surgery

The measurement of a patient's health-related quality of life following acoustic neuroma surgery is important because the surgery itself can impose significant symptoms postoperatively. This study describes the most common problems experienced by the patients, using an open-ended questionnaire mailed to a series of 70 patients who had undergone acoustic neuroma surgery. Patient responses were classified by impairment, disability and handicap, according to the World Health Organization (WHO) classification. Results showed that this group of patients had a wide variety of symptoms and concerns, and particularly highlighted the relative importance of visual (49% of the patients) and psychosocial problems (34% of the patients) associated with surgery in contrast to tinnitus that seemed to be of minor importance. Open-ended questionnaires are useful in assessing outcomes from a quality of life perspective.

The development of auditory perception in children following cochlear implantation

The time course for the development of auditory perception in prelingually deaf children following cochlear implantation may extend over many years, thus making long-term studies necessary to evaluate any such outcome. However, few such studies exist in the literature. We prospectively followed-up a consecutive group of 133 prelingually deaf children up to 6 years following implantation. All children were prelingually deaf with age at onset of deafness < 3 years and age at implantation < 8 years. The aetiology of deafness was meningitis for 45 children (34%), congenital deafness for 77 children (58%) and other causes for 11 children (8%). All were implanted with a Nucleus-22 multi-channel cochlear implant and followed the same rehabilitation programme. No child was lost to follow-up and there were no exclusions from the study. Prelingually deaf children showed significant improvement in the auditory perception with implant experience. 82% of children who reached the 6-year interval could understand conversation without lip-reading. The respective percentage in the 4-year interval was 70%. The long-term results of cochlear implantation reveal that the majority of prelingually deaf children, when implanted before the age of 8 years, will develop significant auditory perception.

Cochlear implants in young children: the relationship between speech perception and speech intelligibility

OBJECTIVE

To determine the relationship between measures of speech perception and speech production after cochlear implantation of young children with profound congenital and prelingual deafness.

DESIGN

A prospective study was undertaken on a consecutive group of children with profound deafness. There were 126 children at the preimplantation interval and 71, 50, 26, and 20 children, respectively, at the 2, 3, 4, and 5 yr follow-up after implantation. Speech perception and speech intelligibility were assessed using hierarchical rating scales. Spearman rank correlation coefficients were used to determine the statistical correlations. All patients were either congenitally deaf or deafened before the age of 3 yr and were implanted before age 7 yr. The patients all received the Nucleus multichannel cochlear implant system with the most appropriate speech encoding strategy.

RESULTS

Speech intelligibility at 5 yr was strongly correlated with speech perception at the 2, 3, 4, and 5 yr intervals after implantation (Spearman coefficients 0.77, 0.81, 0.58, 0.58; p < or = 0.01). Speech intelligibility at the 2, 3, and 4 yr intervals also correlated in a similar manner with earlier speech perception abilities (p < or = 0.01).

CONCLUSIONS

The results suggest that speech intelligibility between 2 and 5 yr after implantation in young children with congenital and prelingual profound deafness can be predicted by measures of earlier speech perception.

Integrity of the auditory pathway in young children with congenital and postmeningitic deafness

This study compares the functional integrity of the auditory pathways of congenitally deaf and postmeningitically deaf children. We used the electrical auditory brain stem response evoked by promontory stimulation to assess 49 profoundly deaf children before cochlear implantation. The age at implantation ranged from 21 months to 15 years (mean 4.5 years). The onset of deafness was either congenital or up to the age of 2 years (mean 5 months). The cause of deafness was meningitis in 19 children (39%) and congenital in 30 (61%). The number of children with identifiable waveform components (eV, eIII, and eII) was significantly greater in the congenitally deaf group. We also analyzed the amplitudes, the latencies, and 4 parameters of the amplitude input-output functions. All the statistically significant differences were in favor of better responses in the congenitally deaf children. These results suggest that the functional status of the peripheral neurons of the auditory pathways may be more intact in congenitally deaf children than in postmeningitic children.

Age at implantation: its importance in pediatric cochlear implantation

OBJECTIVE

To assess the influence of age at implantation on speech perception and speech intelligibility following pediatric cochlear implantation.

STUDY DESIGN

A prospective study was undertaken on a consecutive group of 126 congenital and prelingually deaf children up to 4 years after implantation. The study group was confined to prelingually deaf children less than 7 years of age at the time of implantation. All had implantation with the same multichannel cochlear implant system. No child was lost to follow-up, and there were no exclusions from the study.

METHODS

The Iowa Matrix Closed Set Sentence test, connected discourse tracking, categories of auditory performance, and speech intelligibility rating were used to assess the speech perception (closed and open set) and speech intelligibility of the children with implants. Regression analysis and Spearman rank correlation coefficients were used to assess the correlation between the outcome measures with age at implantation. The setting was a tertiary referral pediatric cochlear implant center in the United Kingdom.

RESULTS

Age at implantation positively correlated with preimplantation assessment performance and with most of the outcome measures up to 24 months following implantation. However, at the 3-and 4-year intervals following implantation, age at implantation was found to be a strong negative predictor of all the outcomes studied (correlation coefficients ranging from -0.44 to -0.58, all statistically significant [P<.05]).

CONCLUSIONS

The results of the present study provide strong evidence that prelingually deaf children should receive implants as early as possible to facilitate the later development of speech perception skills and speech intelligibility and thus maximize the health gain from the intervention. However, because of the wide variation in individual outcomes, age alone should not be used as a criterion to decide implant candidacy.

Speech perception in children after cochlear implantation

OBJECTIVE

This study aimed to determine the speech perception ability of congenitally and prelingually deaf children after cochlear implantation.

STUDY DESIGN

A prospective study was undertaken on a consecutive group of 119 congenitally and prelingually deaf children up to 5 years after implantation. The study group was confined to children between 2 and 7 years of age at the time of implantation. All were implanted with multichannel cochlear implant systems. No child was lost to follow-up, and there were no exclusions from the study other than one child with auditory nerve aplasia.

METHODS

The Iowa Matrix Closed Set Sentence Test and Connected Discourse Tracking were used to assess closed- and open-set speech perception, respectively, without lip reading.

SETTING

The study was conducted at a tertiary referral pediatric cochlear implant center in the United Kingdom.

RESULTS

It was possible to formally test closed-set speech discrimination on 83, 55, 32, 21, and 15 children at 12, 24, 36, 48, and 60 months, respectively. On the Iowa Matrix Test, the median score was 0% at 12 months, reaching a plateau of 99% at 36 months. On Connected Discourse Tracking, the median scores at 12, 24, 36, 48, and 60 months were 0, 0, 21, 40, and 53 words per minute, respectively.

CONCLUSION

Congenitally and prelingually deaf children who receive cochlear implants before the age of 7 years have significant closed-set speech perception abilities develop in <3 years after implantation. Their ability to perform open-set tasks without lip reading is limited in the first 2 years but shows significant improvement, not reaching a plateau, at the 4-5-year interval after implantation.

Is there a correlation between vascular loops and unilateral auditory symptoms?

OBJECTIVES

To assess whether contact of a vascular loop formed by the anterior inferior cerebellar artery (AICA) with the eighth cranial nerve correlated with unilateral auditory symptoms so as to produce a "vascular compression syndrome."

STUDY DESIGN

Prospective evaluation of patients with unilateral auditory symptoms using magnetic resonance imaging (MRI) scans to identify contact of a vascular loop with the eighth cranial nerve.

METHODS

One hundred twelve patients with idiopathic unilateral auditory symptoms (42 women and 70 men, mean age of 51 years) were evaluated with MRI. Location of the vascular loop and contact with the eighth cranial nerve were assessed in each case. The asymptomatic contralateral ears of the patients were used as controls. A power analysis had determined the size of the sample to be studied.

RESULTS

The arterial loop was found to be in contact with the eighth cranial nerve in 28 (25%) of the 112 symptomatic ears and in 24 (21.4%) of the asymptomatic (control) ears. The statistical analysis revealed that the difference was not statistically significant.

CONCLUSION

The results suggest that radiologic demonstration of contact between a vascular loop formed by the AICA and the eighth cranial nerve on MRI scans should be considered a normal anatomic finding and should not, on its own, be used to support the diagnosis of a "vascular compression syndrome."

Speech intelligibility in children after cochlear implantation

OBJECTIVE

This study aimed to evaluate the long-term speech intelligibility of young deaf children after cochlear implantation.

STUDY DESIGN

The study design was a prospective study following a large group of consecutively implanted deaf children with up to 5 years' cochlear implant use.

SETTING

The study was conducted at a pediatric tertiary referral center for cochlear implantation.

PATIENTS

All children in the study were congenitally deaf or deafened before 3 years of age. They each received a Nucleus multichannel cochlear implant before the age of 7 years. Eighty-four subjects were evaluated up to 5 years after cochlear implantation.

INTERVENTION

Cochlear implantation followed by an intensive program of local and center-based assessment and rehabilitation was performed.

MAIN OUTCOME MEASURES

A speech intelligibility rating scale evaluated the spontaneous speech of each child before and at yearly intervals for 5 years after implantation.

RESULTS

After cochlear implantation, the difference between the speech intelligibility ratings increased significantly each year for 4 years (Mann-Whitney U-test). For the first 2 years, the average rating remained "prerecognizable words" or "unintelligible speech." It was not until the 3-year interval that the average intelligibility rating became category 3 (intelligible speech if someone concentrates and lip-reads). At the 4-year interval, 85% of children had some intelligible connected speech. This improvement continued, and at the 5-year interval, the median speech intelligibility was category 4 (intelligible speech to a listener with a little experience of deaf speech) and the mode was category 5 (intelligible speech to all listeners).

CONCLUSION

Congenital and prelingually deaf children gradually develop intelligible speech that does not plateau 5 years after implantation.

Educational placement of deaf children following cochlear implantation

This study examined the educational placements, before cochlear implantation, of 121 deaf children, and the educational placements, two years after implantation, of the 48 children who had reached that stage, looking at the influence of age at implantation and duration of deafness on the placement of these children. In addition, it compared the educational placements of those given implants prior to schooling, and those given implants when already in an educational setting. Categories used were pre-school, school for the deaf, unit or resource base within a mainstream school and full-time mainstream provision. Age at implantation and duration of deafness were found to be significant predictors of placement two years after implantation. The duration of deafness of children in schools for the deaf or units was twice that of children in mainstream education. Fifty-three per cent of children who were in pre-school at the time of implantation were in mainstream schools two years after implantation, whereas only 6% of those who were already in educational placements at the time of implantation were in mainstream education. This difference was statistically significant. The results indicate that children who are given implants early, before an educational decision has been made, are more likely to go to mainstream schools than those given implants when already in an educational setting.

Quality of life after acoustic neuroma surgery

OBJECTIVE

To assess how surgery affected the quality of life of patients with acoustic neuromas and to investigate possible predictors of the functional outcome following surgery.

STUDY DESIGN

A questionnaire based on the Glasgow Benefit Inventory was completed by patients randomly selected following acoustic neuroma surgery.

SETTING

Skull base surgery unit of a university teaching hospital (tertiary referral center).

PATIENTS

Fifty-three patients with acoustic tumors (follow-up, 1 to 3 y).

RESULTS

With regard to overall quality of life, nine patients (17.4%) reported that it became better, 28 patients (53.8%) worse, and 15 patients (28.8%) that it remained the same. Four patients (7.8%) became better off financially, 15 patients (29.4%) worse, and 32 (62.8%) remained unchanged. Forty-one patients (78.8%) did not change their occupation, and 11 (21.2%) had to change their occupation, mainly because of the adverse effects of the operation. With regard to the age at operation, older patients were found to have better overall quality of life. Moreover, younger patients had worse postoperative financial status and they were more likely to change their occupation after the operation. The tumor size did not significantly affect the overall postoperative quality, but it did affect the postoperative financial status (patients with larger tumors were more likely to have worse postoperative financial status).

CONCLUSION

Acoustic neuroma surgery has a significant impact on patients' overall quality of life. Surgeons proposing to operate on small tumors should not assume that the impact on patients' life will be necessarily less than that following the removal of larger tumors. All patients, especially in the younger age group, should be prepared and thoroughly informed about the consequences of the operation on their quality of life.

Cochlear implantation in adults and children

Cochlear implants are electronic devices that are introduced surgically into the inner ear and directly stimulate the auditory nerve in response to sound. They are of benefit to profoundly or totally deaf patients who derive no material benefit from optimally fitted hearing aids.

Multichannel cochlear implantation in postmeningitic and congenitally deaf children

OBJECTIVE

To test the view that prelinguistic postmeningitic deaf (PMD) children outperform congenitally deaf children (CD) in the first year following cochlear implantation.

STUDY DESIGN AND PATIENTS

We evaluated 85 children with ages (at implantation) ranging from 1.9 years to 13.5 years (mean age 5.4 years). The Listening Progress scale was used to assess the developing use of audition 3, 6, and 12 months after implantation.

RESULTS

In contrast to previous reports, the PMD children achieved statistically significantly lower scores than CD children.

Preoperative radiologic evaluation in cochlear implantation

AIM OF STUDY

Assess the value of computed tomography (CT) in the evaluation of abnormalities in the cochlea and auditory pathways.

MATERIAL AND METHODS

We used CT to evaluate 108 children before cochlear implantation surgery. Children's ages at implantation ranged from 21 months to 16 years (mean age, 5.4 years). The etiology of deafness was meningitis in 44 children (40.8%), congenital in 51 (47.2%), and other in 13 children (12%).

RESULTS

Eighteen of the 108 (16.6%) children and 34% of the postmeningitic children were found to have at least partial obliteration of the cochlea. Two (2%) children had congenital malformations of the cochlea and 12 children (11.1%) had abnormalities in the brain CT-scan. CT diagnostic values in postmeningitic children regarding cochlear obliteration were accuracy, 75%; sensitivity, 62%; specificity, 82%; positive predictive value, 66.6%; and negative predictive value, 79.3%. In six (20.6%) of postmeningitic children with normal CT-scans, some scala tympani drillout was required.

CONCLUSION

CT-scan is capable neither of predicting with certainty the presence of minor degrees of cochlear obliteration nor of specifically imaging either the auditory nerve or its central connections.

Electric auditory brain stem response in pediatric patients with cochlear implants

OBJECTIVE

To introduce four comprehensive electrical auditory brain stem response (EABR) parameters that objectively measure the input-output function and may be the base of comparison in related studies.

MATERIALS AND METHODS

In 53 children (106 ears), recordings of the EABR evoked by electrical stimulation at the promontory were made at the time of surgery after the child was anesthetized and before cochlear implantation.

RESULTS

Of the 106 ears studied, 81 (76.4%) produced clearly defined responses. These responses were used to develop a package of four comprehensive EABR parameters (slope, maximal slope, relative growth rate, and maximal relative growth rate) that measure objectively the input-output function. The methods of calculation are described in detail.

CONCLUSION

These parameters may help us to refine and make more consistent the subjective EABR evaluation. They will also enable a comparison of the results from different cochlear implant centers and promote the progress of related research.

Laryngeal tuberculosis at the end of the 20th century

Despite the dramatic reduction in the incidence of laryngeal tuberculosis after the 1950s, the topic has now gained new interest due to claims that the disease has changed its clinical pattern. In the past, the typical patient was 20-40 years old with ulcerated laryngeal lesions, perichondritis, and advanced cavitary lung disease. We studied nine cases of laryngeal tuberculosis confirmed by histological examination. The microlaryngoscopy revealed tumour-like lesions and/or chronic non-specific laryngitis. There were no significant ulcerations or signs of perichondritis. The patients' ages ranged from 48.5 years to 69.3 years (mean, 59.4 years). In three of our patients (33 per cent) we did not find any pulmonary involvement, thus suggesting primary laryngeal tuberculosis or haematogenous spread. In conclusion, the numerous physicians who deal with the various laryngeal symptoms and diseases should be aware of the existence of laryngeal tuberculosis and the changing patterns of the disease (at least in the developed countries).

Auditory function in young patients with chronic renal failure

Debate on the relationship between renal insufficiency and hearing loss continues mainly due to the advanced age and the possible accelerated presbycusis of the patients that have been studied in surveys. Hearing acuity was studied in 46 children and adolescents suffering from renal insufficiency. Sensorineural hearing loss (mainly high-frequency) of unknown cause was found in 14 patients (30.4%). Hearing loss was not influenced by the various haematological, biochemical and clinical parameter (type of renal disease, blood pressure, history of ototoxic drugs administration). However, hearing loss seemed to be affected by the method of management of the renal insufficiency (more in the haemodialysis group than in the peritoneal dialysis group). There were no significant changes in audiometric findings before and after haemodialysis.

Effect of subclinical lead intoxication on laryngeal cancer

In this study we investigated the possible relationship of laryngeal cancer and subclinical lead intoxication, using the depression of aminolevulinic acid dehydratase (ALAD) activity in blood as indicator. Twenty-six patients with laryngeal cancer and 53 normal controls met the criteria to enter the study. Blood ALAD activity values in the patients with laryngeal cancer ranged from 27.1 to 75.3 U/l with a mean of 50.79 U/l. The respective values in the control group ranged from 36.2 to 98 U/l with a mean of 59.76 U/l. There was a statistically significant difference between the two means (0.001 < p < 0.01), whereas blood lead concentrations in all patients were within normal limits. These findings support the hypothesis that low level lead intoxication (subclinical blood lead levels), from cars, industries and products, may contribute to the risk of laryngeal cancer. Further investigation is needed to clarify the exact relationship between lead and cancer of the larynx.