Barbara M. Heinze

Auditory and otological manifestations in adults with HIV/AIDS

Abstract Objectives: This study describes the prevalence and nature of auditory and otological manifestations in adults with HIV/AIDS through clinical examinations and self-reported symptoms across stages of disease progression. Design: Descriptive cross-sectional group design. Study sample: Two hundred HIV positive adult patients (56.5% male; 43.5% female; mean age: 37.99 ± 6.66 years) attending the Infectious Disease Clinic of a tertiary referral hospital in Pretoria, South Africa were included. Patients were interviewed, medical files were reviewed, and clinical examinations, including otoscopy, tympanometry, pure-tone audiometry, and distortion product otoacoustic emissions, were conducted. A matched HIV negative control group was used to compare hearing loss prevalence. Results: Tinnitus (26%), vertigo (25%) hearing loss (27.5%), otalgia (19%), and ear canal pruritis (38%) were prevalent self-reported symptoms. Abnormalities in otoscopy, tympanometry, and otoacoustic emissions were evident in 55%, 41%, and 44% of patients respectively. Pure-tone average (PTA) hearing loss > 25 dBHL was evident in 14% of patients and 39% for hearing loss > 15 dBHL (PTA). Significant differences across average thresholds in the HIV positive and HIV negative control group was present. An increase in self reported vertigo, self reported hearing loss, OAE abnormalities, and hearing loss (PTA > 15 dBHL and PTA > 25 dBHL) was seen with disease progression but was not statistically significant. A significant increase (p <.05) in sensorineural hearing loss was however evident with disease progression. Conclusions: Auditory and otological symptoms are more common in patients with HIV with a general increase of symptoms, especially sensorineural hearing loss, towards advanced stages of disease progression.

Systematic review of vestibular disorders related to human immunodeficiency virus and acquired immunodeficiency syndrome.

INTRODUCTION Disorders of the auditory and vestibular system are often associated with human immunodeficiency virus infection and acquired immunodeficiency syndrome. However, the extent and nature of these vestibular manifestations are unclear. OBJECTIVE To systematically review the current peer-reviewed literature on vestibular manifestations and pathology related to human immunodeficiency virus and acquired immunodeficiency syndrome. METHOD Systematic review of peer-reviewed articles related to vestibular findings in individuals with human immunodeficiency virus infection and acquired immunodeficiency syndrome. Several electronic databases were searched. RESULTS We identified 442 records, reduced to 210 after excluding duplicates and reviews. These were reviewed for relevance to the scope of the study. DISCUSSION We identified only 13 reports investigating vestibular functioning and pathology in individuals affected by human immunodeficiency virus and acquired immunodeficiency syndrome. This condition can affect both the peripheral and central vestibular system, irrespective of age and viral disease stage. Peripheral vestibular involvement may affect up to 50 per cent of patients, and central vestibular involvement may be even more prevalent. Post-mortem studies suggest direct involvement of the entire vestibular system, while opportunistic infections such as oto- and neurosyphilis and encephalitis cause secondary vestibular dysfunction resulting in vertigo, dizziness and imbalance. CONCLUSION Patients with human immunodeficiency virus and acquired immunodeficiency syndrome should routinely be monitored for vestibular involvement, to minimise functional limitations of quality of life.

Vestibular involvement in adults with HIV/AIDS

OBJECTIVE HIV/AIDS is responsible for widespread clinical manifestations involving the head, and neck. The prevalence and nature of vestibular involvement is still largely unknown. This study, aimed to describe and compare the occurrence and nature of vestibular involvement among a group of, adults infected with HIV compared to a control group. It also aimed to compare the vestibular function, of symptomatic and asymptomatic HIV positive adults who receive antiretroviral (ARV) therapies to, subjects not receiving ARV. METHODS A cross-sectional study was conducted on 53 adults (29 male, 24 female, aged 23-49 years, mean=38.5, SD=4.4) infected with HIV, compared to a control group of 38 HIV negative adults (18, male, 20 female, aged 20-49 years, mean=36.9, SD=8.2). A structured interview probed the subjective, perception of vestibular symptoms. Medical records were reviewed for CD4+ cell counts and the use of, ARV medication. An otologic assessment and a comprehensive vestibular assessment (bedside, assessments, vestibular evoked myogenic potentials, ocular motor and positional tests and bithermal, caloric irrigation) were conducted. RESULTS Vestibular involvement occurred in 79.2% of subjects with HIV in all categories of disease, progression, compared to 18.4% in those without HIV. Vestibular involvement increased from 18.9% in CDC category 1 to 30.2% in category 2. Vestibular involvement was 30.1% in category 3. There were, vestibular involvement in 35.9% of symptomatic HIV positive subjects, and 41.5% in asymptomatic, HIV positive subjects. There was no significant difference in the occurrence of vestibular involvement, in subjects receiving ARV therapies compared to those not receiving ARV therapies (p=.914; chi-square, test). The odds ratio indicates that individuals with HIV have a 16.61 times higher risk of developing, vestibular involvement during their lifetime of living with the disease and that it may occur despite, being asymptomatic. CONCLUSION Vestibular involvement was significantly more common in subjects with HIV. Primary health care providers could screen HIV positive patients to ascertain if there are symptoms of vestibular involvement. If there are any, then they may consider further vestibular assessments and subsequent vestibular rehabilitation therapy.

Monitoring Hearing in an Infectious Disease Clinic with mHealth Technologies

BACKGROUND Decentralized detection and monitoring of hearing loss can be supported by new mobile health technologies using automated testing that can be facilitated by minimally trained persons. These may prove particularly useful in an infectious disease (ID) clinic setting where the risk of hearing loss is high. PURPOSE To evaluate the clinical utility of mobile and automated audiometry hearing health technology in an ID clinic setting. RESEARCH DESIGN Smartphone-automated pure-tone audiometry (PTA) (hearTest™) and speech-in-noise testing (SA English digits-in-noise [DIN] test) were compared with manual audiometry (2, 4, and 8 kHz). Smartphone-automated PTA and the DIN test were repeated to determine the test-retest reliability. STUDY SAMPLE Two hundred subjects (73% female and 27% male) were enrolled. Fifty participants were retested with the smartphone applications. Participants ranged from an age of 18 to 55 years with a mean age of 44.4 (8.7 standard deviation). DATA ANALYSIS Threshold comparisons were made between smartphone audiometry testing and manual audiometry. Smartphone-automated PTA, manual audiometry, and test-retest measures were compared (Wilcoxon signed ranked test). Spearman rank correlation test was used to determine the relationship between the smartphone applications and manual audiometry, as well as for test-retest reliability. RESULTS Within all participants, 88.2% of thresholds corresponded within 10 dB or less between smartphone audiometry and manual audiometry. There was a significant difference (p < 0.05) between the right ear at 4 and 8 kHz and in the left ear at 2 and 4 kHz between smartphone and manual audiometry, respectively. No significant difference was noted (p < 0.05) between test and retest measures of smartphone technology. CONCLUSIONS Smartphone audiometry with calibrated headphones provides reliable results in an ID clinic setting and can be used as a baseline and monitoring tool at ID clinics.

A Cross-sectional Survey and Cross-sectional Clinical Trial to Determine the Prevalence and Management of Eye Movement Disorders and Vestibular Dysfunction in Post-Stroke Patients in the Sub-Acute Phase: Protocol

Introduction Visual impairment, specifically eye movement disorders and vestibular dysfunction may have a negative influence on the functional recovery in post-stroke patients. This type of sensory dysfunction may further be associated with poor functional outcome in patients’ post-stroke. Methods In phase 1, a cross-sectional survey (n = 100) will be conducted to determine the prevalence of eye movement disorders and vestibular dysfunction in patients who sustained a stroke. A cross-sectional clinical trial (n = 60) will be conducted during phase 2 of the study to determine the effect of the combination of vestibular rehabilitation therapy (VRT) and visual scanning exercises (VSE) (experimental group) integrated with task-specific activities compared with the effect of task-specific activities as an intervention (control group) on patients who present with eye movement impairment and central vestibular dysfunction post-stroke. An audiologist will assess (a) visual acuity (static and dynamic), (b) nystagmus, (c) saccadic eye movements, (d) smooth pursuit eye movements, (e) vestibulo-ocular reflex, and (f) saccular, utricular, and vestibular nerve function. An independent physiotherapist will assess (1) cognitive function, (2) residual oculomotor visual performance, (3) visual–perceptual system, (4) functional balance, (5) gait, (6) functional ability, (7) presence of anxiety and/or depression, and (8) level of participation in physical activity. Ethics and dissemination Ethics approval has been obtained from the Ethics Committee of the Faculty of Health Sciences at the University of Pretoria (UP) (374/2015). The study will be submitted as fulfillment for the PhD degree at UP. Dissemination will include submission to peer-reviewed professional journals and presentation at congresses. Training of rehabilitation team members on the integration of VSE and VRT into task-specific activities in rehabilitation will be done if the outcome of the experimental group’s functional performance is clinically and statistically significantly better than the control group on the Barthel Index. Trial Registration Pan African Clinical Trials Registry (PACTR201509001223262).

Standard vs. nose electrode placement for measuring oVEMPs : test-retest reliability and preliminary patient results

Introduction: Loss of hypocretin (HCRT) neurons has been linked to narcolepsy. These neurons project widely throughout brain, but it is not known which projection to which target site produces what symptom. We showed that HCRT receptors are present in brainstem areas implicated in REM sleep Begin superscript 1 End superscript. Since abnormal REM sleep triggering characterizes narcolepsy, we used HCRT2-saporin (HCRT2SAP), a toxin that selectively lesions HCRT receptor bearing cells, to assess the effects of such lesions on sleep. We also used α-DBH-sap to specifically destroy NA-LC neurons, which are the major brainstem targets of HCRT neurons. Methods: Twenty-three male Sprague-Dawley rats (350-620 g) instrumented for sleep recordings were given a single bilateral microinjection of either saline (n=11), or α-DBH-sap (n=5; 100 ng), or HCRT2-SAP (n=6; 46 ng). All injections were stereotaxically aimed to dorsolateral pons (A=-0.7; L=±1.4-1.6;V=+3.0). Then 24 h sleep recordings were done on 3rd, 6th, 9th, 12th and 18th days post-injections (12:12h lights on/off). Scoring was made visually on a computer (Icelus software) in 12s epochs for waking, slow wave sleep (SWS) and REM sleep (REMS) by one technician blind to treatment. ANOVA and t-test were used to compare changes in sleep parameters. Then brain were fixed, removed and sectioned for immunohistochemistry against DBH (1:50K;Chemicon) TH (1:12K; Chemicon) and NeuN (1:1K;Chemicon) proteins. Histochemistry for NADPH was made as well. A technician blind to treatment counted DBH-ir and NADPH+ cells in a 1:5 sections across the mesopontine tegmentum. Results: α-DBH-sap lesioned DBH-ir cells in the locus coeruleus (LC) region but did not affect the number of NADPH+ cells (cholinergic) in the LDTg (Fig 1). In addition α-DBH-sap produced a major loss in DBH fibers-ir among several LC-projection sites. TH and NeuN-ir neurons were not evident in the LC after α-DBH-sap either. Despite all these major degenerative signs observed in the LC after α-DBHsap, sleep parameters over the long-term were not different from saline-injected rats. In contrast rats lesioned with HCRT2-SAP showed a significant increase in nighttime sleep time across three weeks after injections (Table 1). Nighttime SWS+REMS time percent increased by 44% in HCRT2-SAP lesioned rats (P<0.01). The nighttime increase in sleep was associated with a significant increase in SWS and REMS bouts (P<0.05) but not with any change in bout duration. Daytime sleep was not affected by HCRT2-SAP. This toxin lesioned NADPH+ neurons in LDTg as well as NeuN-ir neurons in the parabrachial nucleus although DBH-ir cells were spared in the LC. Figure 1

cVEMPs : a systematic review and meta-analysis

Abstract Objective: A systematic literature review and meta-analysis was performed to determine the effect of stimulus type, SCM muscle activation method, transducer type, and method to control SCM muscle EMG level on response parameter values for 0.1-ms click-evoked and 500-Hz tone burst cVEMPs. A description of normative response values was attempted. Design: An electronic systematic literature review was performed to obtain normative cVEMP response data. Subsequently a meta-analysis was conducted to determine significant effects on cVEMP response parameters and to obtain norms. Study sample: Scopus was used to identify reports containing normative data. Reports were selected based on inclusion and exclusion criteria determined beforehand. Weighted means were calculated and compared to identify significant effects and normative data. Results: Sixty-six reports were included in the systematic review. Stimulus type, SCM muscle activation method, transducer type, and method to control SCM muscle EMG level had significant effects on all response parameters. Conclusions: Optimal stimulus and recording parameters suggested by previous research are confirmed by the current systematic review and meta-analysis and are suggested for clinical use. Response parameter values are influenced by variations in stimulus and recording parameters and normative response values are suggested as guideline for cVEMP interpretation.