Bevacizumab for Hearing Preservation in Neurofibromatosis Type 2: Emphasis on Patient-Reported Outcomes and Toxicities

Objective

Bevacizumab for hearing preservation in patients with neurofibromatosis type 2 (NF2) is an emerging practice. We set out to characterize the effectiveness and toxicity of bevacizumab in our patient group.

Study Design

Case series with chart review.

Setting

Tertiary referral center.

Subjects and Methods

Seventeen consecutive patients with NF2 received bevacizumab treatment for vestibular schwannomas, including 2 patients treated to maintain cochlear implant performance. Volumetric analysis of serial magnetic resonance imaging scans was used to evaluate radiographic response, and hearing response was evaluated with serial audiograms. Patient-reported outcomes were also assessed, including subjective hearing improvement, changes in tinnitus, vertigo, headaches, ear pain, and improvement in ability to communicate via telephone.

Results

A positive radiographic response occurred in 8 of 17 (47%) patients and the median tumor volume change was a tumor decrease of 19%. A positive hearing response was recorded in 5 of 9 (56%) patients. Two patients had a word recognition score improvement over 40%. There was an approximately 40% improvement in patient-reported outcomes. Primary toxicities included hypertension, proteinuria, dysgeusia, and amenorrhea.

Conclusion

Bevacizumab treatment was followed by hearing improvement in 56% of patients, while decreased tumor volume was noted in 47%. These outcomes agree favorably with prior reported series. There were significant improvements in patient-reported outcomes that have not been described previously.

Randomized Controlled Pilot Study of Video Self-assessment for Resident Mastoidectomy Training

A prospective randomized controlled pilot study was performed to determine if video self-assessment improves competency in mastoidectomy and to assess interrater agreement between expert and resident evaluations of recorded mastoidectomy. Sixteen otolaryngology residents were recorded while performing cadaveric mastoidectomy and randomized into video self-assessment and control groups. All residents performed a second recorded mastoidectomy. Performance was evaluated by blinded experts with a validated assessment scale. Video self-assessment did not lead to greater skill improvement between the first and second mastoidectomy. Interrater agreement was fair to substantial between the expert evaluators and between resident self-evaluations by recall and video review. Agreement between experts and residents was only slight to fair; residents consistently rated their performance higher than experts (P < .05). In conclusion, 1 session of video self-review did not lead to improved competence in mastoidectomy over standard practice. While experts agree on assessments, residents may overestimate their competency in performing cadaveric mastoidectomy.

Peripheral Facial Nerve Regeneration Using Collagen Conduit Entubulation in a Cat Model

Objectives:

Facial nerve (FN) injuries are functionally, psychologically, and financially debilitating. Facial nerve autograft repairs produce significant donor nerve morbidity and functional results that rarely exceed House-Brackmann (HB) grade III over VI. In this study we sought to enhance FN regeneration via collagen conduit entubulation.

Methods:

Five control cats underwent right (“cut-side”) FN transection and immediate microsurgical anastomosis repair. Five experimental cats underwent identical repairs plus collagen conduit entubulation of each anastomosis.

Results:

Postoperative behavioral observations revealed gradual FN functional recovery in all cats, who attained adapted HB grades of II to III over VI after 6 weeks. Electromyographic latencies and amplitudes from the bilateral orbicularis oculi and orbicularis oris muscles indicated restoration of FN continuity in all 10 cats. In comparison with FN repairs without conduits, repairs with conduits significantly enhanced recovery of amplitude in cut-side orbicularis oculi muscles (p = .037) and latency in cut-side orbicularis oris muscles (p = .048). In comparison with intact left (“uncut-side”) FN latencies and amplitudes, more statistically significant differences in cut-side FN function were observed in repairs without conduits than in repairs with conduits. Conduits therefore facilitated a more complete return of electrophysiological function. Histologic analyses confirmed FN continuity and revealed more organized FN regenerative architecture in conduit-implanted repairs.

Conclusions:

The overall results support enhanced FN regeneration with collagen conduit entubulation.

Quantitative Proteomics of Vestibular Schwannoma Cerebrospinal Fluid

This pilot study aimed to identify candidate proteins for future study that are differentially expressed in vestibular schwannoma (VS) cerebrospinal fluid (CSF) and to compare such proteins with those previously identified in perilymph and specimen secretions. CSF was collected intraoperatively prior to removal of untreated sporadic VS (3 translabyrinthine, 3 middle cranial fossa approaches) and compared with reference CSF samples. After proteolytic digestion and iTRAQ labeling, tandem mass spectrometry with ProteinPilot was used to identify candidate proteins. Of the 237 proteins detected, 13 were dysregulated in ≥3 of the 6 VS patients versus controls, and 13 were dysregulated (12 up, 1 down) in samples from patients with class D versus class B hearing. Four perilymph proteins of interest were dysregulated in ≥1 VS CSF samples. Thus, 26 candidate VS CSF biomarkers were identified that should be considered in future VS biomarker and tumor pathophysiology investigations.

Single-Stage Tympanosotomy Tube Insertion: Design Issues on a New Surgical Approach

Objectives:

Multiple efforts are under way to develop methodologies to allow tympanostomy tube (TT) placement in young children under conscious sedation where there can be significant head motion. This practice modification would provide an option for TT placement without the risk of general anesthesia and the potential for procedures being performed in an office.

Methods:

Investigators evaluated a tool designed to perform a quick, single pass tube delivery across the tympanic membrane with a downward force of motion in a moving child under conscious sedation. Training required bench evaluation and the use of general anesthesia before performing conscious sedation cases.

Results:

A total of 176 TTs were performed in 89 children at 3 institutions. Ninety-one TTs in 46 children used general anesthesia, and 85 TTs in 43 children used conscious sedation. Conscious sedation included nitrous oxide in 35 children and midazolam plus nitrous oxide in 8 patients. All cases used phenol as a topical anesthetic. Twelve children were converted to general anesthesia for over-insertions, design challenges, anatomy, or movement. The major complication encountered was delivery of the TT into the middle ear space. Multiple tubes were used, but a beveled medial flange tube with a lateral visualization tab to provide depth feedback proved most effective for attenuating patient movement without TT over-insertion (64 children).

Conclusions:

Early results show that TT placement in children may be done safely under conscious sedation. Additional clinical experience is required to optimize the tool and the training to prevent complications of TT placement with a single-pass device.

Symptom timeline preceding cochlear implant failure: an institutional experience

OBJECTIVE

Review cochlear explants and determine the incidence of device and medical failures and develop a pattern of symptoms indicating probable implant failure.

STUDY DESIGN

Case series with chart review.

SETTING

Tertiary referral center.

SUBJECTS AND METHODS

Subjects were selected if they underwent cochlear explantation. Data were reviewed to determine initial symptom and symptom timeline preceding implant failure.

RESULTS

A total of 847 implants were performed from 1988 to 2008, with 128 devices explanted. Of total implants, 72% were Advanced Bionic devices, and 28% were Cochlear Nucleus devices. Overall failure rate was 128 of 847 (15%), with 51 (6%) medical failures and 77 (9%) device failures. Patients with Advanced Bionic devices underwent 102 explants (16.7% failure rate), with 35% medical failures and 65% device failures. Patients with Nucleus devices underwent 26 explants (11% failure rate), with 58% medical failures and 42% device failures. Medical failures included infected devices and wound dehiscence, with the pattern averaging 4.5 months to explantation. Hard device failures included sudden malfunction and slow decline in function, with pattern of failure over 4.2 months. Soft failures included tinnitus and discomfort, with failure over 8 months.

CONCLUSIONS

There were common patterns when evaluating both medical and device failures. By recognizing patterns of symptoms that may indicate probable implant failure, otolaryngologists can better counsel patients on what to expect with their implants when they present with certain symptoms.

The first new otologic disorder in a century: superior canal dehiscence syndrome

Superior canal dehiscence syndrome is a recently described vestibular and hearing condition caused by an absence of bone over the arc of the superior semicircular canal. Patients with the condition present with a variety of perplexing symptoms including conductive hearing loss, hyperacusis, vertigo, autophony, and eye movement in response to sound. This article presents the case of a patient with the condition, discusses how it is distinct from other vestibular and hearing disorders, and describes how patients with this disorder can be diagnosed and treated.

Long-term Outcomes and Reliability of Jahn Ventilating Tube

Objective: The Jahn ventilating tube (JVT) is an osseointegrated middle ear ventilating tube that is used internationally in the treatment of Eustachian tube dysfunction (ETD). Little long-term data exists quantifying the functions and complications of this device. This study aims to assess the long-term outcomes with use of the JVT.

Method: Retrospective chart review of 22 patients (24 ears) with ETD managed with JVT (1994-2008) with at least 3 years of follow-up, or documented JVT failure at any time point. Main outcome measures were duration of patency, time to extrusion, middle ear aeration, audiogram, Sade score, and complication rate.

Results: Twelve out of 24 JVTs were patent at last follow-up. Mean duration of retention of a patent tube was 6 years. Aeration of the middle ear with a patent JVT was excellent, with mean Sade score at last visit of 1.08. Mean improvement in air bone gap between the preoperative and last visit was 3 dB. Twelve out of 24 JVTs extruded during the study period. The mean time to extrusion was 21 months. There was no difference in age at insertion between the 2 groups ( P = .113). Two complications were identified, which were persistent tympanic membrane perforations.

Conclusion: JVTs are a safe alternative to traditional pressure equalization tubes. When successful, they can establish a well-aerated middle ear for extended periods of time. However, early extrusion undermines reliability.

Limiting Hazardous Noise Exposure from Noisy Toys

Objective: 1) Assess the decibel (dB) level of toys from the Sight & Hearing Association 2010 Noisy Toys List. 2) Evaluate the change in dB level of these toys after covering the speakers with tape or glue.

Method: Sight & Hearing Association 2010 Noisy Toys List (n = 18) toys were tested at a distance of 0 cm and 25 cm from the sound source in a soundproof booth using a digital sound-level meter. Toys with speakers (n = 16) were tested before and after covering the speakers with packing tape or non-toxic glue.

Results: Mean dB level for nontaped toys at 0 cm and 25 cm was 107.6 dB (SD 8.5) and 82.5 dB (SD 8.8), respectively. With tape, there was a statistically significant decrease in loudness at 0 cm and 25 cm: 84.2 dB and 68.2 dB Mean dB level for non-taped toys at 0 cm and 25 cm was 107.6 dB (SD 8.5) and 82.5 dB (SD 8.8), respectively. With tape, there was a statistically significant decrease in loudness at 0 cm and 25 cm: 84.2 dB and 68.2 dB ( P <.001). With glue, there was a statistically significant decrease in loudness at 0cm and 25 cm ( P < .001). The average duration of sound produced was 9.2 seconds.

Conclusion: Adding tape or glue to cover the speakers of noisy toys can significantly limit the dB level of these toys. These are simple measures that parents can perform to limit hazardous noise exposure from noisy toys.

Symptom Timeline Preceding Cochlear Implant Failure

Objective: 1) Review cochlear explants and determine the incidence of device and medical failures. 2) Develop a pattern of symptoms indicating probable implant failure.

Method: This is a retrospective chart review at a tertiary referral center. Subjects were selected if they underwent cochlear explantation. A total of 847 implants were performed from 1988 to 2008, with 128 devices explanted. Data were reviewed to determine initial symptom and symptom timeline preceding implant failure.

Results: Of total implants, 72% were Advanced Bionic devices, 28% were Nucleus. Overall failure rate was 128 out of 847 (15%). Patients with Advanced Bionic devices underwent 102 explants (16.7% failure rate), with 35% medical failures and 65% device failures. Patients with Nucleus devices underwent 26 explants (11% failure rate), with 58% medical failures and 42% device failures. Medical failures included infected devices and wound dehiscence, the pattern averaging 4.5 months to explantation. Hard device failures included sudden malfunction and slow decline in function, with pattern of failure over 4.2 months. Soft failures included tinnitus and discomfort, with failure over 8 months.

Conclusion: There were common patterns when evaluating both medical and device failures. By recognizing patterns of symptoms that may indicate probable implant failure, otolaryngologists can better counsel patients on what to expect with their implants when they present with certain symptoms.

Hearing preservation after acoustic neuroma surgery

Acoustic neuromas (AN) are benign tumors that arise from the vestibular nerve within the internal auditory canal, where hearing loss is the most common symptom. This retrospective study was done to determine the results of hearing preservation in patients operated for AN at the University of Minnesota, as well as the factors affecting them. One hundred-eighty patients with AN were operated between 1988 and 1998, of whom 91 (50.5%) underwent hearing preservation surgery by either the middle fossa (MF) or the suboccipital (SO) approach. Preoperative and postoperative pure-tone averages (1, 2, and 4 K), speech discrimination scores (SDS), and acoustic reflex thresholds (ART) were noted and classified according to the Shelton's and the Gardner's classifications. The overall rate of hearing preservation was 23.1%. The outcome of hearing results was better with the MF approach compared with the SO approach. Small tumor size and better preoperative hearing levels favored a better postoperative hearing result. The rate of hearing improvement over time was better for the MF patients. Patients for whom intraoperative auditory monitoring was performed seemed to have better hearing outcomes.

Infectious complications in pediatric cochlear implants

OBJECTIVES

Infectious complications may cause significant delay in cochlear implant device initiation and programming and be a source of additional morbidity. We reviewed our experience with infectious complications in the pediatric age group to determine specific sources that may not be seen in adults.

STUDY DESIGN

A retrospective analysis from a single implant center.

METHODS

Cases of pediatric cochlear implants were reviewed for data on infectious complications. Complications were identified as "major" or "minor," "early" or "delayed." Information was gathered regarding any comorbid, chronic health condition. Data related to the causative organism(s) were collected.

RESULTS

Two hundred sixty-eight cases of pediatric implants were reviewed. Twenty-two cases were identified (an infection rate of 8.2%), all classified as "major." The majority, 12, were classified as "delayed" complications. Twenty-one cases required explantation with 14 successfully reimplanted. Five cases (in 4 patients) or 23% were associated with a specific chronic pediatric condition including two children with tracheostomies. Among implanted children who had chronic health conditions, 42% developed implant-related infections. Among otherwise healthy implanted children, only 6.6% developed implant-related infections. Resistant bacterial infections were not identified.

CONCLUSIONS

Health conditions in the pediatric age group were associated with 23% of our complications, a risk factor not previously identified in the literature. These children, demonstrating seven times the infection rate of healthy children, should be carefully observed postoperatively. Overall, cochlear implantation in children continues to be associated with a low risk of infectious complications.

Reconstruction of complicated skull base defects utilizing free tissue transfer

We managed five patients with large skull base defects complicated by complex infections with microvascular free tissue transfer. The first patient developed an infection, cerebrospinal fluid (CSF) leak, and meningitis after undergoing a translabyrinthine resection of an acoustic neuroma. The second patient had a history of a gunshot wound to the temporal bone, with a large defect and an infected cholesteatoma that caused several episodes of meningitis. The third through the fifth patients had persistent CSF leakage and infection refractory to conventional therapy. In all cases prior attempts of closure with fat grafts or regional flaps had failed. Rectus abdominis myofascial free flap, radial forearm free flap or a gracilis muscle free flap was used after debridement of the infected cavities. The CSF leaks, local infections, and meningitis were controlled within a week. In our experience, microvascular free tissue provides the necessary bulk of viable, well-vascularized tissue, which not only assures a mechanical seal but also helps clear the local infection.

Sarcoidosis presenting with hearing loss and granulomatous interstitial nephritis in an adolescent

Granulomatous interstitial nephritis is an uncommon finding in a kidney biopsy. The differential diagnosis is broad and includes infections, drug exposure, and sarcoidosis. Sarcoidosis, a systemic disorder of unknown etiology characterized by the presence of noncaseating granulomata in affected organs, is rare in children. We discuss an adolescent boy with the unusual presentation of granulomatous interstitial nephritis and acute deafness. Sarcoidosis should be considered as part of the differential diagnosis for children and adolescents with hearing loss and kidney disease.

Predictors for Resident Success in Otolaryngology

BACKGROUND

This study aimed to determine predictors for otolaryngology resident success using data available at the time candidates are interviewed (eg, medical school attended, letters of recommendation, test scores) and data that emerge during residency.

STUDY DESIGN

We performed a retrospective cohort study of 36 residents who entered our program between 1983 and 1993.

RESULTS

Seventy percent of Alpha Omega Alpha (AOA) members and 13% of nonmembers were in the highest tertile based on faculty ranking (p<0.01), and candidates with an exceptional trait were more likely than those without an exceptional trait to rank in the highest tertile (57% versus 10%, p<0.01). AOA membership was also related to current academic appointment (p=0.02). Significant correlations included United States Medical Licensing Examination (USMLE) I score, year 2 in-training score (0.48, p=0.03), and years 3 and 4 in-training score and faculty ranking (minus 0.39, minus 0.50, respectively, p<or=0.01). Having more than one peer-reviewed publication was associated with higher USMLE I scores and being favored for selection by >50% of the interviewers (p<0.05 for both).

CONCLUSIONS

In our program designed to train academic otolaryngologists, postresident success was strongly predicted by having an exceptional trait and AOA membership. Success during residency was predicted by interviewer's impression of the candidate and a USMLE I score>570. Knowledge of these factors at the time of the resident interview could increase the likelihood of selecting the most appropriate candidates for academic otolaryngology. Resident success is a complex outcome, and other unmeasured and unexamined characteristics can provide additional insight into choosing successful residents.

Cochlear implantation in severe traumatic brain-injury and paranoid schizophrenia: two case studies

In view of the demanding instruction and training requirements associated with cochlear implantation;,patients with cognitive impairments have typically been considered to be poor candidates for this procedure. This presumption persists in part because experience and research in this area are limited. We describe our experience with implanting cochlear devices in 2 patients who had significant psychological impairments; 1 patient had experienced a severe brain injury, and the other had paranoid schizophrenia. Nevertheless, both patients were able to follow the implant training program, and they experienced different degrees of improvement in their hearing. We discuss our preoperative evaluations of these patients and the key factors that led to our decision to proceed with surgery.

Cochlear Implantation in Severe Traumatic Brain Injury and Paranoid Schizophrenia: Two Case Studies

In view of the demanding instruction and training requirements associated with cochlear implantation, patients with cognitive impairments have typically been considered to be poor candidates for this procedure. This presumption persists in part because experience and research in this area are limited. We describe our experience with implanting cochlear devices in 2 patients who had significant psychological impairments; 1 patient had experienced a severe brain injury, and the other had paranoid schizophrenia. Nevertheless, both patients were able to follow the implant training program, and they experienced different degrees of improvement in their hearing. We discuss our preoperative evaluations of these patients and the key factors that led to our decision to proceed with surgery.

Chronic and recurrent otitis media: a genome scan for susceptibility loci

Otitis media (OM) is the most common childhood disease. Almost all children experience at least one episode, but morbidity is greatest in children who experience chronic/recurrent OM (COME/ROM). There is mounting evidence that COME/ROM clusters in families and exhibits substantial heritability. Subjects who had tympanostomy tube surgery for COME/ROM (probands) and their families were recruited for the present study, and an ear examination was performed, without knowledge of the subject's history, to determine presence of OM sequelae. In addition, tympanometric testing was performed at three frequencies (226, 630 or 710, and 1,400 Hz) to detect abnormal middle-ear mechanics, and hearing was screened at 20 dB for the speech frequencies. Of these families, 121 had at least two individuals who had received the diagnosis of COME/ROM (364 affected and genotyped individuals), of whom 238 affected and informative relative pairs were used for analyses. Single-point nonparametric linkage analysis provided evidence of linkage of COME/ROM to chromosome 10q at marker D10S212 (LOD 3.78; P=3.0 x 10(-5)) and to chromosome 19q at marker D19S254 (LOD 2.61; P=5.3 x 10(-4)). Analyses conditional on support for linkage at chromosomes 10q and 19q resulted in a significant increase in LOD score support on chromosome 3p (between markers D3S4545 and D3S1259). These results suggest that risk of COME/ROM is determined by interactions between genes that reside in several candidate regions of the genome and are probably modulated by other environmental risk factors.

Complications of otitis media before placement of tympanostomy tubes in children

OBJECTIVES

To report the incidence of short-term complications from otitis media in children before placement of tympanostomy tubes (TTs) and to compare children treated according to the Agency for Health Care Policy and Research guidelines with those who were treated earlier or later than recommended.

DESIGN

Retrospective outcomes review.

PATIENTS

Subjects were children aged 10 or younger who had TTs inserted at a tertiary care county hospital from January 1, 1999, to December 31, 2000. Exclusion criteria included prior TT placement, any concurrent head and neck procedure, and craniofacial defects.

INTERVENTION

Tympanostomy tube placement.

MAIN OUTCOME MEASURES

Any occurrences of otorrhea, tympanic membrane perforation, tinnitus, antibiotic reactions, speech or language delay, febrile seizures, or meningitis before placement of TTs documented in the county hospital records were recorded as complications. Hearing loss was considered separately.

RESULTS

Of 147 children who met our criteria, 81 (55.1%) had 1 or more complications from otitis media before placement of TTs. Fifty-five (37.4%) had 2 to 6 complications documented. Adverse reactions to antibiotics were the most common complication, reported in 34 (23.1%).

CONCLUSIONS

Most children in this county hospital experienced short-term complications of otitis media before receiving TTs. Even the children treated "on time" according to the guidelines from the Agency for Health Care Policy and Research experienced complications; however, adherence to the guidelines had no significant effect on complications.

Chordomas of the skull base: manifestations and management

PURPOSE OF REVIEW

Chordomas are rare congenital tumors of the midline skull base. They are slow-growing and usually cause symptoms only when they compress a cranial nerve.

RECENT FINDINGS

The MRI will show the lesion with irregular uptake of gadolinium. The only way to define the diagnosis is with tissue, and there are two primary pathologic forms of the disease. Resection approaches vary with extent of disease, surgeon preference, and critical structures involved.

SUMMARY

There is building evidence that proton beam therapy improves survival and duration of a disease-free state.

Resolution of Facial Stimulation in Otosclerotic Cochlear Implants

OBJECTIVES: We examined the incidence of facial nerve stimulation in a population of patients with otosclerosis implanted with the Nucleus 22, Clarion 1.2, or Clarion High Focus (CHF) device.

STUDY DESIGN AND SETTING: A retrospective chart review was used for 147 patients who had been implanted with electronic cochlear devices at the University of Minnesota between June 1986 and February 2001. Seventy-four patients were implanted with the Nucleus 22, 41 patients were implanted with the Clarion 1.2 (without a positioner), and 32 patients were implanted with the CHF I or II.

RESULTS: Eleven (14.9%) of the 74 patients implanted with the Nucleus 22 device had facial stimulation. There were 9 patients with otosclerosis. Seven (78%) of the 9 patients with otosclerosis had facial stimulation. One (2.4%) of the 41 patients implanted with the Clarion 1.2 device (without a positioner) had facial stimulation and that 1 (100%) patient in the group had otosclerosis. There were 4 patients in the CHF group with otosclerosis. One patient experienced stimulation, but it was possible to decrease maximum current levels and still use the electrode pair.

CONCLUSION: Facial stimulation appears to be less problematic in patients with otosclerosis implanted with the CHF devices.

High-resolution magnetic resonance imaging of human cochlea

OBJECTIVES

High-resolution MRI (MRI) of human inner ear structures provides several advantages over other imaging modalities. High-resolution visualization of inner ear ultrastructure in a noninvasive manner may provide important information about inner ear disease that is not obtainable in other ways. The study was performed to demonstrate the capabilities of MRI at high resolution on the human cochlea, vestibular structures, and facial nerve. Comparative analyses of MRI anatomy with that seen on histological dissection were made. The aim of the study was to define the anatomy of human cadaveric cochlea using a 9.4-Tesla magnetic resonance scanner, currently the most powerful magnetic resonance magnet available.

STUDY DESIGN

Experimental pilot study of cadaveric human cochleae.

METHODS

Serial scanning using a 9.4-Tesla magnetic resonance imager on normal preserved and fresh cadaveric inner ears was performed in different planes.

RESULTS

The images revealed detailed anatomy of the modiolus, utricle, saccule, semicircular canals, and facial nerve. Specifically, identifiable structures within the cochlea included the osseous spiral lamina, Reissner's membrane, membranous spiral lamina, spiral ligament, and others.

CONCLUSIONS

Data established through the acquisition of images from cadaver cochlea, facial nerve, and vestibular complex provide a foundation for developing steps for testing temporal bones and, eventually, patients with Meniere's disease and other inner ear disease. The present ongoing project will provide information on baseline images of the inner ear using high-resolution MRI.

Cochlear implantation in the elderly: results and quality-of-life assessment

To assess the efficacy, quality of life, and complication rate of cochlear implantation in patients over 60 years of age, we performed a retrospective chart review of 31 cochlear implant patients more than 60 years old at the time of surgery (mean, 70 years; range, 62 to 86 years). All patients had improvement in their audiological test results after operation. Twenty-eight patients (93%) are regular implant users at a median follow-up of 12 months. Major complications occurred in 2 patients (6%). We conclude that cochlear implantation in the elderly population has excellent results, with a complication rate similar to that in patients less than 60 years old, and yields an improved quality of life.

Effects of the Clarion Electrode Positioning System on auditory thresholds and comfortable loudness levels in pediatric patients with cochlear implants

OBJECTIVE

To evaluate the effects of using the Electrode Positioning System on psychophysical auditory thresholds, most comfortable loudness levels, and electric auditory brainstem response (EABR) thresholds in children with the Clarion version 1.2 cochlear implant.

DESIGN

Retrospective analysis.

SETTING

Academic tertiary care center.

PATIENTS AND METHODS

Clinical records of a series of 25 children who received the Clarion version 1.2 cochlear implant at the University of Minnesota, Minneapolis, between January 1997 and August 1999 were examined. Measures evaluated were psychophysical thresholds (T-levels) and most comfortable loudness levels (M-levels) obtained at the 3-month posthookup audiologic evaluation and EABR thresholds obtained during implant surgery. Relevant threshold measures were available for 24 patients, 11 of whom had received the Clarion spiral electrode and electrode positioner (EP group) and 13 of whom had received the spiral electrode without positioner (non-EP group). The 3 measures (T-levels, M-levels, and EABR thresholds) were compared across groups. In addition, EABR thresholds were compared with T-levels and M-levels within groups.

RESULTS

Mean T-levels and M-levels were significantly lower for the EP group than for the non-EP group, and interpatient variability for these measures was considerably smaller in the EP group. Electric auditory brainstem response thresholds were not significantly different for EP vs non-EP patients; however, EABR data were available for only a few non-EP patients.

CONCLUSIONS

Use of the electrode positioner results in lower T-levels and M-levels in children with the Clarion version 1.2 cochlear implant, consistent with results of previous studies in adults, and reduces across-patient variability for these measures. It is unclear from the present data whether use of the electrode positioner systematically reduces intraoperative EABR thresholds.

Securing cochlear implants to the skull: Two alternate methods

In view of the various problems encountered with the traditional methods of securing cochlear implants—including dural tear and suture dissolution following infection—we devised two alternate methods of performing this procedure. We use a titanium mesh or a Gore-Tex patch secured with two 4-mm screws to fix the receiver to the skull. No patient who has undergone either of these procedures at our institution has experienced any of the complications that are associated with the older silk, nylon, and Dacron sutures. Moreover, our two alternate methods are less technically difficult and can be performed in a shorter period of time.

Securing cochlear implants to the skull: two alternate methods

In view of the various problems encountered with the traditional methods of securing cochlear implants--including dural tear and suture dissolution following infection--we devised two alternate methods of performing this procedure. We use a titanium mesh or a Gore-Tex patch secured with two 4-mm screws to fix the receiver to the skull. No patient who has undergone either of these procedures at our institution has experienced any of the complications that are associated with the older silk, nylon, and Dacron sutures. Moreover, our two alternate methods are less technically difficult and can be performed in a shorter period of time.

Carotid stenting and "extarterectomy" in the management of head and neck cancer involving the internal carotid artery: technical case report

OBJECTIVE AND IMPORTANCE

Head and neck cancer that invades the internal carotid artery (ICA) represents a significant management challenge. We describe a novel technique that allows for aggressive tumor removal without disrupting blood flow through the affected ICA.

CLINICAL PRESENTATION

A 62-year-old man was referred to our institution for management of a neck malignancy involving the ICA. Cerebral angiography suggested that there was good collateral flow from the opposite hemisphere, but the patient reported visual loss in the ipsilateral eye during balloon test occlusion of the ICA.

INTERVENTION

A self-expanding stent was deployed in the ICA; it spanned the entire length of the artery involved by tumor. One month later, the patient underwent tumor resection. During surgery, a long ICA arteriotomy was performed directly down to the mesh of the stent. A neoendothelium had formed within the stent, which prevented arterial bleeding. The carotid wall was dissected from the stent without difficulty and removed en bloc with the surrounding tumor. The exposed stent was wrapped circumferentially with a synthetic patch material. The patient tolerated the procedure well, and postoperative angiography demonstrated normal filling of the ICA.

CONCLUSION

We describe a novel approach to a patient with head and neck cancer involving the cervical ICA. Preliminary stenting, which allows time for endothelialization before surgery, may permit aggressive tumor resection without interrupting flow through the ICA. This technique obviates the need for complicated carotid reconstruction procedures and avoids the risk of delayed ischemia from carotid sacrifice.

What do infants know about continuous quantity?

We investigated infants' sensitivity to amount of continuous quantity and to change in amount of continuous quantity. Using a habituation procedure, Experiment 1 examined whether 6-month-old infants can distinguish between different amounts of liquid in a container. Infants looked significantly longer at a novel quantity than at the familiar quantity. Using a violation-of-expectation paradigm, Experiment 2 examined whether 9-month-old infants expect a change in amount when liquid is added to a hidden container which is already one-fourth full of liquid. Infants looked significantly longer at the impossible event than at the possible event. These findings indicate that infants are sensitive to amount, calling into question claims that infants have a quantitative mechanism which is exclusive to number.

Safety and clinical performance of acoustic reflex tests

OBJECTIVE

Safety and effectiveness of acoustic reflex tests are important issues because these tests are widely applied to screen for retrocochlear pathology. Previous studies have reported moderately high sensitivity and specificity for detection of acoustic neuroma. However, there have been reports of possible iatrogenic hearing loss resulting from acoustic reflex threshold (ART) and decay (ARD) tests. This study assessed safety and clinical performance of ART tests for detection of acoustic neuroma.

DESIGN

We report a case in which ARD testing resulted in a significant bilateral permanent threshold shift. This case was the impetus for us to investigate the clinical utility of ART and ARD tests. We analyzed sensitivity and specificity of ART, as well as asymmetry in pure-tone thresholds (PTT) for detection of acoustic neuroma in 56 tumor and 108 non-tumor ears.

RESULTS AND CONCLUSIONS

Sensitivity and specificity were higher for PTT asymmetry than for ART. Ipsilateral ART at 1000 Hz had poor sensitivity and specificity for detection of acoustic neuroma, and involves some potential risk to residual hearing for presentation levels higher than 115 dB SPL. Approximately half of the acoustic neuroma group had ipsilateral ARTs that would require administration of ARD tests at levels exceeding 115 dB SPL. Therefore, we conclude that PTT asymmetry is a more effective test for detection of acoustic neuroma, and involves no risk to residual hearing. Future studies of contralateral reflex threshold and ARD in combination with PTT asymmetry are recommended.

Prospective study of tympanic membrane retraction, hearing loss, and multifrequency tympanometry

Tympanic membrane retraction is a significant sequela of OME and has been linked clinically to atelectasis, ossicular erosion, and cholesteatoma. We investigated important factors for prediction of tympanic membrane retraction in a prospective study of 112 children. After 4 to 6 years of follow-up, 12% of ears had pars tensa retraction without atrophy, and 28% had various degrees of retraction with atrophy. Mild pars flaccida retraction was present in 23%, and severe pars flaccida retraction was present in 12%. Retraction severity was related to hearing level and multifrequency tympanometry. Three factors were significantly related to retraction severity: type of tube, male sex, and percent of visits in the second year with abnormal tympanograms. This study shows that type of tube was the most important factor in long-term outcome after tympanostomy tube treatment of OME.

Early sex differences in spatial skill

This study investigated sex differences in young children's spatial skill. The authors developed a spatial transformation task, which showed a substantial male advantage by age 4 years 6 months. The size of this advantage was no more robust for rotation items than for translation items. This finding contrasts with studies of older children and adults, which report that sex differences are largest on mental rotation tasks. Comparable performance of boys and girls on a vocabulary task indicated that the male advantage on the spatial task was not attributable to an overall intellectual advantage of boys in the sample.

Early sex differences in spatial skill

This study investigated sex differences in young children's spatial skill. The authors developed a spatial transformation task, which showed a substantial male advantage by age 4 years 6 months. The size of this advantage was no more robust for rotation items than for translation items. This finding contrasts with studies of older children and adults, which report that sex differences are largest on mental rotation tasks. Comparable performance of boys and girls on a vocabulary task indicated that the male advantage on the spatial task was not attributable to an overall intellectual advantage of boys in the sample.

Physiologic identification of eighth nerve subdivisions: direct recordings with bipolar and monopolar electrodes

The purpose of this study was to determine stimulation and recording parameters that maximize differences in evoked responses recorded between the cochlear nerve and the surrounding tissues. Click-evoked potentials were obtained using monopolar and bipolar recording electrodes placed directly on the exposed eighth nerve of anesthetized cats. Responses were compared as stimulus intensity, electrode location, and bipolar electrode orientation and interelectrode spacing were systematically varied. Wave amplitudes increased monotonically with intensity for both monopolar and bipolar configurations, but bipolar configurations exhibited greater selectivity in differentiating cochlear from vestibular subdivisions. The optimal stimulus intensity was 70 to 80 dB peak sound pressure level (pSPL). Monopolar recordings were often confounded by activity originating at remote sites, typically the cochlear nucleus and (for recording sites on the vestibular nerve) the cochlear nerve. Bipolar response amplitudes increased with interelectrode spacing and were largest when electrodes were oriented parallel to the long axis of the nerve. Extrapolation of empirical data indicated that amplitudes of bipolar responses would be maximal at an electrode separation of 7.5 mm. Cochlear nerve conduction velocity, calculated from wave latencies at each of the two monopolar electrodes, was 11.6 +/- 1.6 m/sec.

A review of type 3 tympanoplasty

With the introduction of newer technologies, the advent of antibiotics, and improved surgical methods; the past 25 years have seen a great revolution, refinement, and improvement of tympanoplastic procedures. Furthermore, the methods of classification have been modified. The introduction of ossicular reconstruction with biocompatible implants greatly enhanced the success of type 3 tympanoplasty. This article reviews the classification, indications, surgical techniques, biomechanical properties, and expected hearing results of type 3 tympanoplasty.

Early fraction calculation ability

Three- to 7-year-olds' ability to calculate with whole-number, fraction, and mixed-number amounts was tested using a nonverbal task in which an amount was displayed and then hidden (J. Huttenlocher, N. C. Jordan, & S. C. Levine, 1994). Next, an amount was added to or subtracted from the hidden amount. The child's task was to determine the hidden amount that resulted from the transformation. Although fraction problems were more difficult than whole-number problems, competence on all problem types emerged in the early childhood period. Furthermore, there were striking parallels between the development of whole-number and fraction calculation. This is inconsistent with the hypothesis that early representations of quantity promote learning about whole numbers but interfere with learning about fractions (e.g., R. Gelman, 1991; K. Wynn, 1995, 1997).

Early fraction calculation ability

Three- to 7-year-olds' ability to calculate with whole-number, fraction, and mixed-number amounts was tested using a nonverbal task in which an amount was displayed and then hidden (J. Huttenlocher, N. C. Jordan, & S. C. Levine, 1994). Next, an amount was added to or subtracted from the hidden amount. The child's task was to determine the hidden amount that resulted from the transformation. Although fraction problems were more difficult than whole-number problems, competence on all problem types emerged in the early childhood period. Furthermore, there were striking parallels between the development of whole-number and fraction calculation. This is inconsistent with the hypothesis that early representations of quantity promote learning about whole numbers but interfere with learning about fractions (e.g., R. Gelman, 1991; K. Wynn, 1995, 1997).

Relationships between otitis media sequelae and age

OBJECTIVES

To explore relationships between age and sequelae in two groups of children treated with tympanostomy tubes for chronic otitis media with effusion (OME).

STUDY DESIGN

Cross-sectional study of sequelae among children, adolescents, and adults at 4 years and 9 to 23 years after tympanostomy tube treatment.

METHODS

Group I was examined with otomicroscopy, tympanometry, and audiometry two to four times a year as part of a prospective study, and they were evaluated 4 years after initial tube treatment for this study. Group II received tubes while participating in a chronic OME study, but participants were not followed prospectively after treatment. Nine to 23 years after tube treatment, they were examined with otomicroscopy, tympanometry, and hearing screening.

RESULTS

Among the 5- to 28- year-old subjects, cholesteatoma (< or = 1%) and perforation (< or = 2%) were rare. In Group I, tympanosclerosis increased with age (P < .01), and OME (flat tympanograms) decreased with age in Group II (P < .01). The older cohort was more likely to have severe retractions (18% vs. 4%, P = .02), hearing loss (21% vs. 10%, P < .01), and severe atrophy (24% vs. 0%, P < .01) than the younger cohort, but they were less likely to have flat tympanograms (2% vs. 12%, P < .01).

CONCLUSIONS

Although OME became less prevalent with age, important sequelae (severe atrophy, severe tympanic membrane retraction, hearing loss, cholesteatoma, and chronic perforation) may develop in children with chronic OME as they become adolescents and young adults. Long-term prospective studies are important in defining the progression of sequelae in these children.

Management of otitis media using Agency for Health Care Policy and Research guidelines. The Agency for Health Care Policy and Research

Increased costs of managing otitis media and its complications may result from delays in diagnosis and treatment. The Agency for Health Care Policy and Research developed guidelines to assist in the management of chronic otitis media with effusion. We examined the medical care adherence to Agency for Health Care Policy and Research guidelines in 59 consecutive patients referred because of chronic otitis media with effusion and recurrent acute otitis media. Patient history and examination data were collected prospectively. In the group with chronic otitis media with effusion, the rate of adherence to Agency for Health Care Policy and Research guidelines was 0%; in those with recurrent acute otitis media, adherence was 5%. Delayed referral occurred in 34% of patients; 25% of patients were referred early. The average duration of effusion in patients with chronic otitis media with effusion was 5.2 months; the duration of recurrent acute otitis media immediately before referral was 9.3 months. Eighteen patients (47%) in the chronic otitis media with effusion group had a history of recurrent chronic otitis media with effusion spanning an average of 22.7 months. On referral, hearing loss was discovered in 92% of all patients, and in 69% the tympanogram was flat. The complication and sequelae rate was 49.1%, and speech delay was the most frequent at 16.9%. We conclude that in our study patients there is a significant referral delay, long history of chronic otitis media with effusion in patients before referral, high rate of hearing loss, and high complication rate. Continued efforts should be directed toward improving education of all clinicians so that diagnostic tools and timely otolaryngologic referral are better used.

Menstrual cycle phase and mood effects on perceptual asymmetry

Several studies have reported shifts in perceptual asymmetry during the menstrual cycle, but the potential confounding effect of mood changes has been largely ignored. In this study, 24 female subjects completed four visual laterality tasks and a mood questionnaire at three phases of the cycle. Results indicate no overall effect of cycle phase on any of the asymmetry or mood scores. However, results revealed significant associations between affect and perceptual asymmetry on a face perception task. Implications for mood effects on perceptual asymmetry and future research on cycle-related shifts in asymmetry are discussed.