Benoit Godey

Improvement of cognitive function after cochlear implantation in elderly patients

IMPORTANCE The association between hearing impairment and cognitive decline has been established; however, the effect of cochlear implantation on cognition in profoundly deaf elderly patients is not known. OBJECTIVE To analyze the relationship between cognitive function and hearing restoration with a cochlear implant in elderly patients. DESIGN, SETTING, AND PARTICIPANTS Prospective longitudinal study performed in 10 tertiary referral centers between September 1, 2006, and June 30, 2009. The participants included 94 patients aged 65 to 85 years with profound, postlingual hearing loss who were evaluated before, 6 months after, and 12 months after cochlear implantation. INTERVENTIONS Cochlear implantation and aural rehabilitation program. MAIN OUTCOMES AND MEASURES Speech perception was measured using disyllabic word recognition tests in quiet and in noise settings. Cognitive function was assessed using a battery of 6 tests evaluating attention, memory, orientation, executive function, mental flexibility, and fluency (Mini-Mental State Examination, 5-word test, clock-drawing test, verbal fluency test, d2 test of attention, and Trail Making test parts A and B). Quality of life and depression were evaluated using the Nijmegen Cochlear Implant Questionnaire and the Geriatric Depression Scale-4. RESULTS Cochlear implantation led to improvements in speech perception in quiet and in noise (at 6 months: in quiet, 42% score increase [95% CI, 35%-49%; P < .001]; in noise, at signal to noise ratio [SNR] +15 dB, 44% [95% CI, 36%-52%, P < .001], at SNR +10 dB, 37% [95% CI 30%-44%; P < .001], and at SNR +5 dB, 27% [95% CI, 20%-33%; P < .001]), quality of life, and Geriatric Depression Scale-4 scores (76% of patients gave responses indicating no depression at 12 months after implantation vs 59% before implantation; P = .02). Before cochlear implantation, 44% of the patients (40 of 91) had abnormal scores on 2 or 3 of 6 cognition tests. One year after implant, 81% of the subgroup (30 of 37) showed improved global cognitive function (no or 1 abnormal test score). Improved mean scores in all cognitive domains were observed as early as 6 months after cochlear implantation. Cognitive performance remained stable in the remaining 19% of the participants (7 of 37). Among patients with the best cognitive performance before implantation (ie, no or 1 abnormal cognitive test score), 24% (12 of 50) displayed a slight decline in cognitive performance. Multivariate analysis to examine the association between cognitive abilities before implantation and the variability in cochlear implant outcomes demonstrated a significant effect only between long-term memory and speech perception in noise at 12 months (SNR +15 dB, P = .01; SNR +10 dB, P < .001; and SNR +5 dB, P = .02). CONCLUSIONS AND RELEVANCE Rehabilitation of hearing communication through cochlear implantation in elderly patients results in improvements in speech perception and cognitive abilities and positively influences their social activity and quality of life. Further research is needed to assess the long-term effect of cochlear implantation on cognitive decline.

Speech Performance and Sound Localization in a Complex Noisy Environment in Bilaterally Implanted Adult Patients

Objective: To evaluate speech performance, in quiet and noise, and localization ability in adult patients who had undergone bilateral and simultaneous implantation. Study Design: Prospective multi-center study. Methods: Twenty-seven adult patients with profound or total hearing loss were bilaterally implanted in a single-stage procedure, and simultaneously activated (Med-El, Combi 40/40+). Subjects were assessed before implantation and at 3, 6 and 12 months after switch-on. Speech perception tests in monaural and binaural conditions were performed in quiet and in noise using disyllabic words, with speech coming from the front and a cocktail party background noise coming from 5 loudspeakers. Sound localization measurements were also performed in background noise coming from 5 loudspeakers positioned from –90° to +90° azimuth in the horizontal plane, and using a speech stimulus. Results: There was a bilateral advantage at 12 months in quiet (77 ± 5.0% in bilateral condition, 67 ± 5.3% for the better ear, p < 0.005) and in noise (signal-to-noise ratio +15 dB: 63 ± 5.9% in bilateral condition, 55 ± 6.9% for the better ear, p < 0.05). Considering unilateral speech scores recorded in quiet at 12 months, subjects were categorized as ‘good performers’ (speech comprehension score ≥60% for the better ear, n = 19) and ‘poor performers’ (n = 8). Subjects were also categorized as ‘asymmetrical’ (difference between their 2 unilateral speech scores ≥20%, n = 11) or ‘symmetrical’ (n = 16). The largest advantage (bilateral compared to the better ear) was obtained in poor performers: +19% compared to +7% in good performers (p < 0.05). In the group of good performers, there was a bilateral advantage only in cases of symmetrical results between the 2 ears (n = 10). In the group of poor performers, the bilateral advantage was shown in both patients with symmetrical (n = 6) and asymmetrical results (n = 2). In bilateral conditions, the sound localization ability in noise was improved compared to monaural conditions in patients with symmetrical and asymmetrical performance between the 2 ears. No preoperative factor (age, duration of deafness, use of hearing aids, etiology, etc.) could predict the asymmetrical performance, nor which ear would be the best. Conclusion: This study demonstrates a bilateral advantage (at 12 months after the implantation) in speech intelligibility and sound localization in a complex noisy environment. In quiet, this bilateral advantage is shown in cases of poor performance of both ears, and in cases of good performance with symmetrical results between the 2 ears. No preoperative factor can predict the best candidates for a simultaneous bilateral implantation.

Inflammatory pseudotumour of the nasal cavity and sinuses.

The term inflammatory pseudotumour encompasses a very diverse group of conditions, with different sites, whose only common feature is the absence of a specific histological diagnosis. The histopathological and aetiopathogenic data have been derived from experience in the thoracic, orbital and abdominal forms, which are much more frequent than disease affecting the nasal cavities and sinuses. However, there is no evidence that these data are applicable to sino-nasal pseudotumour. We present a case of inflammatory pseudotumour of the nasal cavity and a review of the literature (19 cases in 30 years) with respect to the clinical and radiological findings, the natural history and the specific management of disease at these sites. Surgery seems to be the best option for this localization. Corticosteroids and radiotherapy may be of value in cases of residual tumour after the histological confirmation of the diagnosis and the exclusion of neoplasia.

Sensitivity of Auditory Brainstem Response in Acoustic Neuroma Screening

Auditory brainstem response (ABR) is the reference screening technique for acoustic neuromas, but because of a few false negatives and the increasing performance of magnetic resonance imaging (MRI), its role as the standard method has been questioned. We assessed sensitivity of screening tests in 89 patients with surgically proven acoustic neuromas. Sensitivity of ABR was 92%; 94% for extracanalicular neuromas and 77% for intracanalicular neuromas. For stapedius reflex (SR), sensitivity was 84% and for caloric vestibular response (CVR) 86%. The combined sensitivity of ABR + SR was 97% and of ABR + RS + CVR 98%. For false negatives, the greatest diameter including the intracanalicular portion was always less than 18 mm, with a mean of 15 mm, and none of these tumours reached the brainstem. For patients with unilateral cochleo-vestibular deficit, we propose ABR and SR as first-line screening tests. These tests are repeated at 6 months and at 1 year in the case of normal results. MRI is ordered for patients whose auditory threshold is too low and for those whose ABR or SR results favour retrocochlear disease.

Primary Aspergillosis of the Larynx and Squamous Cell Carcinoma

Primary laryngeal aspergillosis is exceptionally rare, and only five cases have been reported in the literature. We present here two cases of invasive laryngeal aspergillosis without tracheobronchopulmonary extension and without any generalized immune deficit. Aspergillosis developed after local radiotherapy for a squamous cell carcinoma and preceded a recurrence of the tumor. The relationships between the clinical features, the histopathology, and the etiology of laryngeal aspergillosis and squamous cell carcinoma are discussed. We recommend that following treatment of laryngeal aspergillosis, these rare patients should systematically be investigated for a squamous cell carcinoma or a recurrence thereof.

Beware of dogs licking ears.

A patient with right-sided chronic purulent otorrhoea developed meningitis due to Pasteurella multocida transmitted by a dog that frequently licked his ear. We suggest that patients with a perforated tympanic membrane should avoid being licked on their ears by animals.

Pituitary adenomas with infra-sellar extension into the nasopharynx

Three cases of pituitary adenomas with infra-sellar extension into the nasopharynx and the nasal cavities are reported. The clinical signs were epistaxis, nasal obstruction, painful sinuses and purulent rhinorrhoea. The initial diagnostic hypothesis was that of a carcinoma of the nasopharynx or the sinuses in all three cases. The diagnosis was made by histological examination and measurement of plasma hormone levels. These cases highlight the difficulty in the diagnosis of such tumours due to their misleading clinical, radiological and histological features.

Predictive Factors of Cochlear Implant Outcomes in the Elderly

Objective: To analyze predictive factors of cochlear implant outcomes and postoperative complications in the elderly. Study Design: Prospective, longitudinal study performed in 10 tertiary referral centers. Methods: Ninety-four patients aged 65-85 years with a profound, postlingual hearing loss were evaluated before implantation, at time of activation, and 6 and 12 months after cochlear implantation. Speech perception and lipreading were measured using disyllabic word recognition in quiet and noise, and lipreading using disyllabic words and sentences. The influence of preoperative factors on speech perception in quiet and noise at 12 months was tested in a multivariate analysis. Complications, presence of tinnitus and of vestibular symptoms were collected at each evaluation. Results: The effect of age was observed only in difficult noisy conditions at SNR 0 dB. Lipreading ability for words and sentences was negatively correlated with speech perception in quiet and noise. Better speech perception scores were observed in patients with shorter duration of hearing deprivation, persistence of residual hearing for the low frequencies, the use of a hearing aid before implantation, the absence of cardiovascular risk factors, and in those with implantation in the right ear. General and surgical complications were very rare, and the percentage of vestibular symptoms remained stable over time. Conclusion:This study demonstrates that cochlear implantation in the elderly is a well-tolerated procedure and an effective method to improve communication ability. Advanced age has a low effect on cochlear implant outcome. Analyses of predictive factors in this population provide a convincing argument to recommend treatment with cochlear implantation as early as possible in elderly patients with confirmed diagnosis of a severe-to-profound hearing loss and with only limited benefit from hearing aid use in one ear.

Évidement cervical dans les carcinomes de la cavité orale classes N0

Objectifs La prise en charge des patients porteurs de carcinomes classes N0 reste controversee. Le but de cette etude a ete d’evaluer l’efficacite de l’evidement selectif dans le traitement des patients porteurs de carcinomes de la cavite orale classes N0. Materiel et methodes Une analyse retrospective de 77 patients ayant presente un carcinome epidermoide de la cavite orale entre 1988 et 2001 a ete realisee. Le traitement ganglionnaire a ete une surveillance dans 7 cas, un evidement cervical dans 56 cas, une radiotherapie seule dans 14 cas. 77 evidements cervicaux dont 62 selectifs et 15 radicaux modifies ont ete realises. Resultats Le nombre moyen de ganglions examines par evidement a ete de 10,7. Le taux de metastases occultes (cN0pN+) a ete de 32,5 %. Une rupture capsulaire a ete detectee dans 7,8 % des cas. Le suivi moyen a ete de 43 mois. Le taux global de controle ganglionnaire parmi les patients sans recidive locale a ete de 2,4 %. Une recidive ganglionnaire est survenue dans 2,9 % des cous cN0pN0. L’efficacite globale de l’evidement cervical a ete de 94 %. Aucun des 11 patients traites par evidement selectif sans radiotherapie postoperatoire n’a recidive. Parmi les T1T2pN0 il n’y a pas eu de difference en termes de survie ou de recidive, qu’il y ait eu de la radiotherapie postoperatoire ou pas. La radiotherapie a pu etre evitee chez 27 % des patients traites par evidement cervical. La survie globale a 1, 3 et 5 ans a ete de 89,3 %, 77,7 % et 63.2 %. Conclusions L’evidement selectif est un moyen efficace de diagnostic de l’envahissement et de traitement ganglionnaire des tumeurs de la cavite orale classees N0.

Nontraumatic arteriovenous fistula of the superficial temporal artery

Acquired arteriovenous fistulas (AVF) of the scalp are generally a result of trauma. Because of its long and relatively exposed course in the scalp, the superficial temporal artery (STA) is particularly vulnerable to trauma.1 In 1935, Winslow and Edwards2 reviewed the literature on this subject and found 15 cases of AVF of the STA, all of which were traumatic in origin. Today, fewer than 60 cases have been reported in the literature. To the best of our knowledge, a nontraumatic acquired case of AVF of the STA has only been described once.3 We report a second case of nontraumatic AVF of the STA and discuss pathogenesis, clinical features, and management of such an unusual lesion.