Ben I. Nageris

Asymmetry in noise-induced hearing loss: relevance of acoustic reflex and left or right handedness.

Objective: Noise-induced hearing loss (NIHL) is more severe in the left ear than the right ear. The aim of this study was to examine the possible association of handedness and acoustic reflex parameters on right or left NIHL predominance. Study Design: Retrospective case review and prospective series. Setting: Tertiary center. Patients: Three samples were studied: 1) the files of 4,277 army personnel with NIHL were reviewed to analyze the relation between the side affected and age, sex, duration of noise exposure, and acoustic damage; 2) an additional 119 army personnel with NIHL were evaluated for the possible association of handedness and NIHL asymmetry; and 3) fifty-one normal-hearing subjects were tested for threshold and latency of acoustic reflex by handedness. Intervention: None. Main Outcome Measure: Differences in NIHL asymmetry by background and noise-related variables and handedness. Results: NIHL was more pronounced in the left ear, regardless of demographic characteristics, noise exposure parameters, acoustic reflex measures, or handedness. Conclusion: The asymmetry in hearing loss severity may be attributed to the cortical pathways, specifically to the more pronounced efferent auditory system on the right side, which reduces the susceptibility of the right ear to cochlear insult.

Predicting outcome of malignant external otitis.

Objective: Malignant external otitis (MEO) continues to pose a diagnostic and therapeutic challenge. The lack of a diagnostic study since 1987 combined with recent findings of quinolone-resistant MEO prompted the present analysis of MEO outcome in a major tertiary medical center. Methods: Seventy-five consecutive patients hospitalized for suspected MEO between 1990 and 2003 were divided into 2 diagnostic groups: MEO Type 1, presence of all obligatory clinical and radiologic criteria and most of the occasional criteria of Cohen and Friedman or absence of 1 obligatory criterion with failure of intensive treatment, and MEO Type 2, absence of one of the obligatory criteria with treatment response within 1 week. The groups were compared for demographic data, underlying diseases, ear parameters, culture findings, length of hospitalization, and treatment before hospitalization, obtained from the charts. Results: Both types of MEO affected mostly diabetic patients and were characterized by granulations and discharge in the external ear, severe prolonged pain, soft tissue involvement and bone destruction on computed tomographic scan, and growth of Pseudomonas aeruginosa in culture. However, Type 1 MEO was associated with a significantly older patient age at presentation, higher rate of oral antidiabetic treatment, history of diabetic (vascular) complications, computed tomographic findings of nasopharyngeal involvement (soft tissue swelling, soft tissue asymmetry, or abscess formation), bone destruction, and temporomandibular joint involvement-all of which led to significantly longer treatment and shorter survival. Conclusion: The worse prognosis of Type 1 MEO compared with Type 2 should alert clinicians to establish earlier diagnosis and treatment.

Complications of Mastoiditis in Children at the Onset of a New Millennium

The aim of the present study was to review our recent experience in the diagnosis and treatment of acute mastoiditis and its complications in a single tertiary-care, university-affiliated pediatric center. Ninety-eight children with 101 episodes of acute mastoiditis were included in the study. The mean interval from onset of illness to mastoiditis was 4.5 days. Ear cultures most often grew Streptococcus pneumoniae and Pseudomonas aeruginosa (23.7% each). Complications occurred in 15.8% of episodes. The only factor differentiating children with and without complications was white blood cell count. These findings indicate that acute mastoiditis not only is a complication of prolonged infection of the middle ear, but may also present as an acute infection of the mastoid bone that can progress within 48 hours. The complication rate remains high, and antibiotic treatment at the onset of symptoms does not prevent complications. A high white blood cell count on admission may serve as a predictive factor of complicated cases.

Magnesium Treatment for Sudden Hearing Loss

Magnesium treatment has been repeatedly shown to reduce the incidence of both temporary and permanent noise-induced hearing loss. We hypothesized that it might also improve the permanent threshold shift in patients with acute-onset hearing loss. In a prospective, randomized, double-blind, placebo-controlled trial, 28 patients with idiopathic sudden sensorineural hearing loss were treated with either steroids and oral magnesium (study group) or steroids and a placebo (control group). Compared to the controls, the magnesium-treated group had a significantly higher proportion of patients with improved hearing (>10 dB hearing level) across all frequencies tested, and a significantly greater mean improvement in all frequencies. Analysis of the individual data confirmed that more patients treated with magnesium experienced hearing improvement, and at a larger magnitude, than control subjects. Magnesium is a relatively safe and convenient adjunct to steroid treatment for enhancing the improvement in hearing, especially in the low-tone range, in patients with sudden sensorineural hearing loss.

Otologic and Audiologic Lesions Due to Blast Injury

AIM To evaluate the effect of blast injury on the otologic and hearing state over time. SETTING Otology unit of a tertiary referral center. METHODS Seventy-three patients aged 16 to 73 years who sustained physical trauma from an explosion underwent otologic and audiologic examination 3-4 months and one year later. RESULTS At the first examination, high-frequency sensorineural hearing loss was detected in 57 patients (78%), mixed hearing loss in 13 (19%), and low-tone conductive hearing loss in two (3%). Conductive hearing loss had improved by one year, while the cochlear hearing loss, in most cases, did not. Only 7% of the patients with tinnitus reported improvement after one year. CONCLUSIONS The permanent otologic damage caused by blast injury cannot be determined before one year after the traumatic event.

Test-retest tinnitus characteristics in patients with noise-induced hearing loss

PURPOSE The purpose of the study was to examine the test-retest value of tinnitus pitch and loudness in patients with tinnitus and noise-induced hearing loss (NIHL). MATERIALS AND METHODS The study sample consisted of 30 patients of mean age 35 +/- 6.7 years with long-standing tinnitus and hearing loss due to exposure to noise during military service. Ten patients had unilateral tinnitus, and 20 had bilateral tinnitus. All presented with a typical NIHL audiogram on the affected side(s). None of the patients was receiving drug therapy. RESULTS There was no statistically significant difference in tinnitus pitch or loudness between the 2 tests for the whole group and separately in patients with unilateral or bilateral tinnitus. CONCLUSION Subjective testing of pitch and loudness of tinnitus secondary to NIHL is accurate and reproducible, making it a valuable tool for diagnosis and follow-up. The lack of differences between patients with unilateral or bilateral tinnitus indicates that both types may be managed in a similar manner.

Malignant external otitis: analysis of severe cases.

Objective. To study the effect of specific clinical, laboratory, and imaging parameters on the course of severe (type 1) malignant external otitis (MEO). Study Design. Case series with chart review. Setting. Tertiary, university-affiliated medical center. Subjects and Methods. Fifty-seven patients hospitalized with severe MEO were followed for disease course and survival in a tertiary center between 1990 and 2008. Results. In 20% of patients, disease was persistent and/or aggressive despite prolonged and extensive treatment. Of this subgroup, 45% died of the disease. Prognostic factors of persistent/aggressive disease were facial nerve paralysis, bilateral disease, and significant major computed tomography findings (temporomandibular joint destruction, infratemporal fossa or nasopharyngeal soft tissue involvement). Cultures grew fungi in 5 patients, and follow-up imaging revealed disease progression. The overall 5-year survival was 55% for patients with short-term disease and 40% for patients with persistent/ aggressive disease (P = .086). By age, 5-year survival was 75% in patients younger than 70 years old and 44% in older patients (P = .029). Conclusions. A significant subset of patients with MEO has a prolonged, aggressive, and highly fatal disease that needs to be identified early. These patients more frequently have bilateral disease, cranial nerve paralysis, and positive computed tomography findings. Their follow-up should routinely include imaging studies to evaluate disease progression, and every effort should be made to identify and treat underlying fungal infection.

Cochlear third window in the scala vestibuli: an animal model.

Background: Pathologic third window has been investigated in both animals and humans, with a third window located in the vestibular apparatus, specifically, dehiscence of the superior semicircular canal, serving as the clinical model. Hypothesis: The present study sought to examine the effect of a cochlear third window in the scala vestibuli on the auditory thresholds in fat sand rats that have a unique anatomy of the inner ear that allows for easy surgical access. Methods: The experiment included 7 healthy 6-month-old fat sand rats (a total of 10 ears). A pathologic third window was induced by drilling a hole in the bony labyrinth over the scala vestibuli, with preservation of the membranous labyrinth. Auditory brainstem responses to high- and low-frequency acoustic stimuli delivered via air and bone conduction were recorded before and after the procedure. Results: In the preoperative auditory brainstem response recordings, air-conduction thresholds (ACTs) to clicks and tone bursts averaged 9 and 10 dB, respectively, and bone-conduction thresholds averaged 4.5 and 2.9 dB, respectively. Postfenestration ACTs averaged 41 and 42.2 dB, and bone-conduction thresholds averaged 1.1 and 4.3 dB. The change in ACT was statistically significant (p < 0.01). Conclusion: The presence of a cochlear third window in the scala vestibuli affects auditory thresholds by causing a decrease in sensitivity to air-conducted sound stimuli. These findings agree with the theoretical model and clinical findings.

Histologic and immunohistochemical characterization of tumor and inflammatory infiltrates in oral squamous cell carcinomas treated with local multikine immunotherapy: the macrophage at the front line

Squamous cell carcinomas of the head and neck (SCCHN) are excellent candidates for local immunotherapy owing to their accessibility and their infiltration by mononuclear cells that are susceptible to immunomodulation. A response rate of 25–60% has been reported for treatment with natural IL-2 or a mixture of natural lymphokines. In the present study, biopsies and posttreatment excision specimens from nine patients with operable SCCHN treated systemically with a variety of immunomodulators and locally with natural lymphokines (multikine, CelSci) were analyzed in an attempt to correlate clinical response to histopathological and immunohistochemical changes. Formalin-fixed, paraffin-embedded tissues were stained with antibodies against lymphocytes (CD45, CD3, CD4, CD8, CD20), macrophages (CD68) including dendritic cells (S-100), markers for lymphocyte activation (CD30, HLA-DR), natural killer cells (CD56 and CD57), beta-2-microglobulin and keratin. One patient showed a complete response to treatment and two a partial response. Tumor size was significantly smaller after therapy. Clinical and pathological regression were more prominent in the smaller tumors. Numerous macrophages, both mononucleated and multinucleated, were present along the tumor-stroma interface in the posttreatment specimens of seven patients, most prominently in the three patients with tumor regression. The increase in the number of CD68+ and S-100+ macrophages after treatment was statistically significant. Lymphocytic infiltrates, which showed some increase following treatment, were composed of a mixture of T and B lymphocytes, the former mostly in contact with the tumor and the latter placed more peripherally. CD8+ lymphocytes extended into the tumors, whereas CD4+ lymphocytes showed minimal extension. Intensity of beta-2-microglobulin staining in tumors was significantly higher following therapy and associated with a better outcome. The marked increase in macrophages following treatment may indicate that the macrophage plays a major role in tumor recognition, destruction and clearance. An increase in the number of macrophages in a posttreatment specimen may indicate immunoresponsiveness.

Spontaneous pneumocephalus in the posterior fossa in a patient with a ventriculoperitoneal shunt: case report.

OBJECTIVE AND IMPORTANCE: A unique case of spontaneous pneumocephalus is described. It appeared a few years after the uneventful introduction of a cerebrospinal fluid shunt and was probably attributable to a defect of the posterior mastoid plate. CLINICAL PRESENTATION: A 65‐year‐old man presented with a subacute onset of vertigo, vomiting, and atactic gait instability. The patient had undergone a ventriculoperitoneal shunt implantation 2 years previously for communicating hydrocephalus. A computed tomographic scan revealed a posterior fossa pneumatocele without hydrocephalus. INTERVENTION: A simple mastoidectomy was performed. Detection of the area of the bone defect was followed by mastoid obliteration with abdominal fat. CONCLUSION: Clinicians should be aware that pneumocephalus can occur spontaneously, with or without obvious shunt problems. Treatment should be directed toward the area through which air penetrated the posterior fossa. (Neurosurgery 46:1002‐1004, 2000)