Christopher D. Bauch

Patient Outcomes After Vestibular Schwannoma Management: a Prospective Comparison of Microsurgical Resection and Stereotactic Radiosurgery

OBJECTIVE The best management for patients with small- to medium-sized vestibular schwannomas (VS) is controversial. METHODS : A prospective cohort study of 82 patients with unilateral, unoperated VS less than 3 cm undergoing surgical resection (n = 36) or radiosurgery (n = 46). Patients undergoing resection were younger (48.2 yr versus 53.9 yr, P = 0.03). The groups were similar with regard to hearing loss, associated symptoms, and tumor size. The mean follow-up period was 42 months (range, 12-62 mo). RESULTS Normal facial movement and preservation of serviceable hearing was more frequent in the radiosurgical group at 3 months (P < 0.001), 1 year (P < 0.001), and at the last follow-up examination (P < 0.01) compared with the surgical resection group. Patients undergoing surgical resection had a significant decline in the following subscales of the Health Status Questionnaire 3 months after surgery: physical functioning (P = 0.006), role-physical (P < 0.001), energy/fatigue (P = 0.02), and overall physical component (P = 0.004). Patients in the surgical resection group continued to have a significant decline in the physical functioning (P = 0.04) and bodily pain (P = 0.04) subscales at 1 year and in bodily pain (P = 0.02) at the last follow-up examination. The radiosurgical group had no decline on any component of the Health Status Questionnaire after the procedure. The radiosurgical group had lower mean Dizziness Handicap Inventory scores (16.5 versus 8.4, P = 0.02) at the last follow-up examination. There was no difference in tumor control (100 versus 96%, P = 0.50). CONCLUSION Early outcomes were better for VS patients undergoing stereotactic radiosurgery compared with surgical resection (Level 2 evidence). Unless long-term follow-up evaluation shows frequent tumor progression at currently used radiation doses, radiosurgery should be considered the best management strategy for the majority of VS patients.

Intratympanic steroid treatment: A review

Objective: To review published literature regarding the use of intratympanic steroids in the treatment of Ménière’s disease and sudden sensorineural hearing loss and to make recommendations regarding their use based on the literature review. Data Sources: Literature review from 1996 to 2003, PubMed, Medline Plus, and Web of Science. Study Selection: Retrospective case series and uncontrolled prospective cohort studies were the only types of studies available for review. Conclusion: On the basis of the available literature, a weak recommendation is made to use intratympanic steroid treatment of sudden hearing loss if oral steroid therapy fails or is con-traindicated. The available studies regarding intratympanic steroid treatment of Ménière’s disease and tinnitus are inadequate to answer the question of the efficacy of this treatment for these conditions. Higher quality studies are needed.

Management of Eustachian Tube Dysfunction With Nasal Steroid Spray: A Prospective, Randomized, Placebo-Controlled Trial

OBJECTIVE To determine the efficacy of intranasal aqueous triamcinolone acetonide in treating the tympanometric signs and symptoms of eustachian tube dysfunction, such as otitis media with effusion and negative middle ear pressure. DESIGN Randomized, placebo-controlled, double-blind prospective clinical trial. SETTING Tertiary referral clinic. PATIENTS Adults (≥18 years) and children (6-17 years) presenting with otitis media with effusion, negative middle ear pressure, or both. INTERVENTIONS The 2 treatment arms consisted of aqueous triamcinolone or matching placebo administered once daily intranasally for 6 weeks. All subjects underwent tympanometry, otologic examination, and completion of a symptom questionnaire before and after treatment. MAIN OUTCOME MEASURES Resolution of abnormal tympanometry and change in symptom scores (severity and frequency). RESULTS Ninety-one patients presenting from September 1, 2005, through December 31, 2008, with otitis media with effusion or with negative middle ear pressure were enrolled and randomly assigned to treatment or placebo in a double-blind manner. No statistically significant difference in normalization of abnormal tympanometric signs was demonstrated with the active treatment arm compared with placebo on either a per-patient basis (19% vs 32%; P = .18) or a per-ear basis (22% vs 35%; P = .15). There was also no significant difference in the overall poststudy symptom score between the 2 treatment arms, after adjusting for the prestudy overall symptom score in an analysis of covariance model (P = .27). CONCLUSION These findings do not support the use of intranasal steroid sprays to treat the manifestations of eustachian tube dysfunction. Trial Registration clinicaltrials.gov Identifier: NCT00279916.

Hearing Loss in Rheumatoid Arthritis

Objective: The objective of this study was to evaluate whether patients with rheumatoid arthritis (RA) are more likely to have subclinical hearing loss compared with persons without RA.

Psychologic profile of tinnitus patients using the SCL-90-R and Tinnitus Handicap Inventory.

Objective To correlate the Tinnitus Handicap Inventory and the Symptom Checklist-90-R results on a group of tinnitus patients and to compare the average scores of the Tinnitus Handicap Inventory and SCL-90-R for help-seeking and non–help-seeking patients with tinnitus. Study Design A prospective study in which tinnitus patients were administered the Tinnitus Handicap Inventory and the Symptom Checklist-90-R. Setting Tertiary referral center. Patients Patients with tinnitus seeking audiological services. Interventions Rehabilitative. Main Outcome Measures Results of Tinnitus Handicap Inventory and Symptom Checklist-90-R. Results Fifty-three consecutive patients having tinnitus were administered the Tinnitus Handicap Inventory and the Symptom Checklist-90-R. There was a significant correlation between the Symptom Checklist-90-R and the Tinnitus Handicap Inventory (rs = 0.43). Furthermore, 25% of these patients scored abnormally high on the Symptom Checklist-90-R, which is substantially more than the general medical population of patients. Conclusions Based on this sample of 53 patients, the Symptom Checklist-90-R does seem to be a useful tool in identifying distress among tinnitus patients. The Global Severity Index of the Symptom Checklist-90-R has a defined cutoff score indicating significant distress levels, which makes it a useful screening tool for identifying those who would benefit from psychologic or psychiatric intervention.

The Effect of 2000-4000 Hz Hearing Sensitivity on ABR Results

Pure-tone hearing sensitivity at 2000, 3000, and 4000 Hz and ABR results were reviewed for 458 patients with cochlear hearing loss. Wave V latency and waveform morphology data from the 916 ears yielded percentages of abnormal ABR results as a function of degree and slope of hearing loss. Threshold sensitivity at all three frequencies influenced ABR latency or waveform. A higher incidence of abnormal ABR results was observed when 3000 Hz thresholds were elevated than when 4000 Hz thresholds were elevated to the same levels. ABR results for various audiometric configurations are reported.

Auditory brain stem response results from 255 patients with suspected retrocochlear involvement.

Auditory brain stem response (ABR) evaluations were conducted on 255 patients with suspected retrocochlear involvement. Twenty-six patients (10%) had surgically confirmed tumors, and ABRs were abnormal in 25 (96%) of these cases. The remaining 229 patients had nontumor medical diagnoses, but 25% of these were found to have abnormalities in ABR recordings. The most common ABR abnormality in the nontumor patients was large wave V interaural latency difference, followed by no response or poor waveform resolution and delayed absolute wave V latency. Peripheral hearing loss, including decreased sensitivity at 2000 and 4000 Hz, appears to have influenced waveform morphology and component latency.

Comparison of ABR amplitudes with TIPtrode and mastoid electrodes.

ABR evaluations were completed for 36 adults (18 males, 18 females) having normal hearing sensitivity and for 91 adult patients having various degrees of sensorineural hearing loss. Amplitudes of waves I and V were compared for ear canal (TIPtrode) electrode and mastoid electrode recordings. Interpeak intervals (I-III, III-V, and I-V) were determined and upper 95% confidence limits defined for normative data. In general, amplitude of wave I was larger when TIPtrodes were used. Wave V amplitude was nearly identical for the two electrodes. Wave I was identified more frequently for TIPtrode than for mastoid recordings of ABR waveforms for the sensorineural hearing loss subjects.

Brainstem Responses to Tone Pip and Click Stimuli

Brainstem auditory-evoked responses to tone pips at 1000, 2000, and 4000 Hz and clicks were evaluated for 17 normal-hearing adults. Wave V Consistently emerged as the best indicator of auditory sensitivity, whereas waves II, III, and IV generally were not identifiable at lower intensities. An inverse relationship existed between wave V latency and intensity and between wave V latency and stimulus frequency. Large ranges were noted for the levels at which the various components became identifiable. Even though some frequency specificity may have occurred, the range of wave V latencies for 1000- and 4000-Hz tone pips demonstrated considerable overlap.

Auditory Brainstem Responses as a Function of Average Hearing Sensitivity for 2 000-4 000 Hz

Average hearing thresholds for 2,000, 3,000 and 4,000 Hz and ABR results were analyzed for 290 patients having some degree of cochlear hearing loss. As average hearing sensitivity in the 2,000- to 4,000-Hz range became poorer, the incidence of abnormal auditory brainstem responses (ABR) increased. When the 2,000-Hz threshold sensitivity was 0-40 dB and the three-frequency average hearing loss was less than 50 dB, nearly 80% of ABR tracings were normal. Steeply sloping audiograms above 2,000 Hz increased the percent of abnormal ABR results.