Auditory neuropathy

Ten patients presented as children or young adults with hearing impairments that, by behavioural and physiological testing, were compatible with a disorder of the auditory portion of the VIII cranial nerve. Evidence of normal cochlear outer hair cell function was provided by preservation of otoacoustic emissions and cochlear microphonics in all of the patients. Auditory brainstem potentials showed evidence of abnormal auditory pathway function beginning with the VIII nerve: the potentials were absent in nine patients and severely distorted in one patient. Auditory brainstem reflexes (middle ear muscles; crossed suppression of otoacoustic emissions) were absent in all of the tested patients. Behavioural audiometric testing showed a mild to moderate elevation of pure tone threshold in nine patients. The extent of the hearing loss, if due to cochlear receptor damage, should not have resulted in the loss of auditory brainstem potentials. The shape of the pure tone loss varied, being predominantly low frequency in five patients, flat across all frequencies in three patients and predominantly high frequency in two patients. Speech intelligibility was tested in eight patients, and in six was affected out of proportion to what would have been expected if the pure tone loss were of cochlear origin. The patients were otherwise neurologically normal when the hearing impairment was first manifest. Subsequently, eight of these patients developed evidence for a peripheral neuropathy. The neuropathy was hereditary in three and sporadic in five. We suggest that this type of hearing impairment is due to a disorder of auditory nerve function and may have, as one of its causes, a neuropathy of the auditory nerve, occurring either in isolation or as part of a generalized neuropathic process.

Surgical treatment of trigeminal schwannomas

A total of 27 patients with trigeminal schwannoma were treated between 1982 and 1992 at the Neurosurgery Department of Nordstadt Hospital. Twelve cases of solitary schwannoma without any family history or physical stigmata of neurofibromatosis were included and form the basis of this study. There were four women and eight men (mean age 44 years) in this series. Duration of symptoms ranged from 2 months to 6 years. The most frequent symptoms were either pain or numbness of the ipsilateral hemiface. The surgical approach was chosen depending on the tumor type. Tumors that belonged to Type A (five cases), which were predominantly in the middle fossa, were approached using a transsylvian method; Type B (one case), which presented predominantly in the cerebellopontine angle, was operated on via a retrosigmoid suboccipital craniectomy; Type C (five cases), which were dumbbell-shaped extending into both the middle and posterior fossa, were removed via a combined temporal craniotomy-presigmoidal method; and in Type D (one case), in which tumor was primarily extracranial with intracranial extension, an infratemporal extradural approach was undertaken. There was no operative mortality or long-term disability in this series. The follow-up period ranged from 12 to 60 months; during that time magnetic resonance imaging revealed tumor recurrence in two cases after 12 and 48 months, respectively, and these were excised again. An additional 178 cases collected from the world literature are also reviewed and analyzed.

The varieties of auditory neuropathy

Auditory neuropathy (AN) was initially described as impairment of auditory neural function, with preserved cochlear hair cell function. In this report, 67 patients with audiological and neurophysiological criteria for hearing loss due to auditory neuropathy are described. Reviewing this large body of patients, AN appears to consist of a number of varieties, with different etiologies and sites affected. All varieties share a relatively spared receptor function, and an impaired neural response, with diminished ability to follow fast temporal changes in the stimulus, but different varieties in this general scheme can be distinguished. Analyses of the clinical features indicate that auditory neuropathies vary in several measures including age of onset, presence of peripheral neuropathy, etiology, and behavioral and physiological measures of auditory function. The sites affected along the peripheral auditory pathway may include dysfunction of the outer hair cells, the synapse between hair cell and auditory nerve, and the auditory nerve fibers, with myelin as well as axonal impairments contributing to the disorder.

The neuronal architecture of the anteroventral cochlear nucleus of the cat in the region of the cochlear nerve root: horseradish peroxidase labelling of identified cell types

Golgi impregnations of the posterior part of the cat's anteroventral cochlear nucleus have revealed two types of neurons, bushy cells with short bush-like dendrites and stellate cells with long, tapered processes; Nissl stains have revealed globular and multipolar cell bodies with dispersed and clumped ribosomal patterns, respectively. In the present study, we injected horseradish peroxidase into the trapezoid body. Ipsilaterally, retrograde, diffuse labelling of neurons, presumably through damaged fibers, yielded Golgi-like profiles of numerous bushy cells with typical dendrites and with thick axons projecting toward the trapezoid body. Stellate cells were almost never labelled in this way. Anterograde diffuse labelling of thick axons demonstrated calyx endings in the contralateral medial nucleus of the trapezoid body. In the electron-microscope, the perikarya of diffusely-filled bushy neurons were found to have the dispersed ribosomal pattern and the kinds of synaptic endings typical of globular cells, including large profiles of end-bulbs from cochlear nerve axons. After injections restricted to the medial trapezoid nucleus, granularly-labelled cells in the cochlear nucleus were almost completely confined to the contralateral side; Nissl counterstaining showed them to be globular cells in the posterior part of the anteroventral cochlear nucleus. After larger injections, involving surrounding regions of the superior olivary complex, granular labelling occurred throughout the ventral cochlear nucleus on both sides. There is also evidence that stellate cells in Golgi impregnations correspond to multipolar cell bodies in Nissl stains. We conclude that bushy cells typically correspond to globular cells, which receive end-bulbs from the cochlea and send thick axons to the contralateral medial trapezoid nucleus, where they form calyces on principal cells. Principal cells, in turn, are known to project to the lateral superior olive and to one of the nuclei of origin of the crossed olivo-cochlear bundle, which feeds back to the cochlea. In this circuit, correlations between synaptic patterns and particular physiological signal transfer characteristics can be suggested. These could be related to binaural intensity interactions in the lateral superior olive and to a regulatory loop involving the olivo-cochlear bundles.

Consequences of neural asynchrony: a case of auditory neuropathy

The neural representation of sensory events depends upon neural synchrony. Auditory neuropathy, a disorder of stimulus-timing-related neural synchrony, provides a model for studying the role of synchrony in auditory perception. This article presents electrophysiological and behavioral data from a rare case of auditory neuropathy in a woman with normal hearing thresholds, making it possible to separate audibility from neuropathy. The experimental results, which encompass a wide range of auditory perceptual abilities and neurophysiologic responses to sound, provide new information linking neural synchrony with auditory perception. Findings illustrate that optimal eighth nerve and auditory brainstem synchrony do not appear to be essential for understanding speech in quiet listening situations. However, synchrony is critical for understanding speech in the presence of noise.

Long-term complications following gamma knife radiosurgery of vestibular schwannomas

Since its inception in 1969, Gamma Knife radiosurgery (GKR) for vestibular schwannomas has been documented as an efficient and safe procedure based on more than 8,000 treatments worldwide. The author's personal experience comprises 669 treatments for patients with vestibular schwannoma between 1969-1997. This experience demonstrates long-term growth control, usually with shrinkage, in 95% of unilateral tumors. In the mid-1970s, early facial weakness occurred in 38% and facial numbness in 33%. This has gradually decreased to less than 2% in the 1990s. Preservation of hearing (unchanged or almost unchanged) is currently achieved in 65 to 70%. Tinnitus is rarely changed by the treatment. The risks of intracranial bleeding, infection and CSF leak are avoided because of the noninvasive nature of the treatment. Hydrocephalus directly induced by the tumor occurred in 9.2% of patients. On the other hand, a treatment%related peritumoral reaction sufficient to block the CSF circulation and require shunt insertion was seen in only 1.4%. Based on experiences worldwide, the incidence of secondary neoplasia seems to be 0.1%. The effectiveness of GKR together with its low complication rate makes it a suitable treatment for anyone, regardless of age and general health. With few exceptions, schwannomas with an intracranial size of up to approximately 3 cm are suitable for GKR.

Submicroscopic changes of the synapse after nerve section in the acoustic ganglion of the guinea pig; an electron microscope study

The degenerative changes of the synaptic regions after nerve section have been studied with the electron microscope in the interneuronal synapse of the ventral ganglion of the acoustic nerve of the guinea pig. Fixation with buffered osmic tetroxide was carried out 22, 44, and 48 hours after destruction of the cochlea on one side; the contralateral ganglion being used as control. The submicroscopic organization of normal axosomatic and axodendritic synapses is described. In the synaptic ending four morphological components are recognized: the membrane, the mitochondria, the synaptic vesicles (19, 20), and the cytoplasmic matrix. The intimate contact of glial processes with the endings and with the surface of the nerve cell is described. At the level of the synaptic junction there is a direct contact of the limiting membranes of the ending and of the cell body or dendrite. Both contacting membranes constitute the synaptic one with a total thickness of about 250 A. This membrane has regions of higher electron density where the synaptic vesicles come into intimate contact and fuse with it. Definite degenerative submicroscopic changes in the nerve endings were observed after 22 hours of destruction of the cochlea and were much more conspicuous after 44 and 48 hours. After 22 hours there is swelling of the ending and decreased electron density of the matrix. Most synaptic vesicles have disappeared or seem to undergo a process of clumping and dissolution. Some mitochondria also show signs of degeneration. After 44 hours the synaptic vesicles have practically disappeared; mitochondria are in different stages of lysis; the membrane of the ending becomes irregular in shape, and there is shrinkage and in some cases detachment of the ending. No changes in the postsynaptic cytoplasm were observed. These observations and particularly the rapid lysis of the synaptic vesicles are discussed in correlation with data from the literature indicating the early alteration of synaptic function and the biochemical changes occurring after section of the afferent nerve. The hypothesis that the synaptic vesicles may be carriers of acetylcholine or other active substances (19, 20) and that they may act as biochemical units in synaptic transmission is also discussed.(2)

Cochlear Implants in Five Cases of Auditory Neuropathy: Postoperative Findings and Progress

OBJECTIVES

To review our experiences with some of the preoperative and postoperative findings in five children who were diagnosed with auditory neuropathy and were provided with cochlear implants. We describe changes in auditory function, which enabled these children to have significant improvement in their hearing and communication skills.

STUDY DESIGN

Pre- and postoperatively, these children received complete medical examinations at Mayo Clinic, including related consultations in audiology, pediatrics, neurology, medical genetics, otolaryngology, psychology, speech pathology, and radiology.

METHODS

These children typically had additional medical and audiological examinations at more than one medical center. The hearing assessments of these children included appropriate behavioral audiometric techniques, objective measures of middle ear function, acoustic reflex studies, transient (TOAE) or distortion product (DPOAE) otoacoustic emissions, auditory brainstem responses (ABR), and, in some cases, transtympanic electrocochleography (ECoG). After placement of the internal cochlear implant devices (Nucleus CI24), intraoperatively we measured electrode impedances, visually detected electrical stapedius reflexes (VESR) and neural response telemetry (NRT). These intraoperative objective measures were used to help program the speech processor for each child. Postoperatively, each child has had regular follow-up to assure complete healing of the surgical incision, to assess their general medical conditions, and for speech processor programming. Their hearing and communication skills have been assessed on a regular basis. Postoperatively, we have also repeated electrode impedance measurements, NRT measurements, otoacoustic emissions, and electrical auditory brainstem responses (EABR). We now have 1 year or more follow-up information on the five children.

RESULTS

The five children implanted at Mayo Clinic Rochester have not had any postoperative medical or cochlear implant device complications. All of the children have shown significant improvements in their sound detection, speech perception abilities and communication skills. All of the children have shown evidence of good NRT results. All but case D (who was not tested) showed evidence of good postoperative EABR results. Otoacoustic emissions typically remained in the non-operated ear but, as expected, they are now absent in the operated ear.

CONCLUSION

Our experiences with cochlear implantation for children diagnosed with auditory neuropathy have been very positive. The five children we have implanted have not had any complications postoperatively, and each child has shown improved listening and communication skills that have enabled each child to take advantage of different communication and educational options.

Technical and instrumental improvements in the surgical treatment of acoustic neurinomas

Microsurgical removal of large acoustic neurinomas, more than 3 cm in diameter, has been performed by the lateral suboccipital transmeatal approach with the patient in the lateral position in 68 cases in the past 5 years. sixty-two patients (92%) returned to their former occupations and two died: one in the immediate postoperative period and the other 16 months later. The postoperative follow-up examination showed satisfactory facial nerve function in 70% of the patients. Hearing was preserved in six of 14 patients who had preoperatively retained their auditory function. The authors emphasize the usefulness of bipolar forceps for intraoperative stimulation of the facial nerve and for facial muscle monitoring. The value of the four-pronged hook and the multipurpose head-frame in this procedure is also discussed.