David S. Haynes

Intratympanic Dexamethasone for Sudden Sensorineural Hearing Loss After Failure of Systemic Therapy

Objective: Intratympanic steroids are increasingly used in the treatment of inner ear disorders, especially in patients with sudden sensorineural hearing loss (SNHL) who have failed systemic therapy. We reviewed our experience with intratympanic steroids in the treatment of patients with sudden SNHL to determine overall success, morbidity, and prognostic factors.

Clinical practice guideline: Tympanostomy tubes in children

Objective Insertion of tympanostomy tubes is the most common ambulatory surgery performed on children in the United States. Tympanostomy tubes are most often inserted because of persistent middle ear fluid, frequent ear infections, or ear infections that persist after antibiotic therapy. Despite the frequency of tympanostomy tube insertion, there are currently no clinical practice guidelines in the United States that address specific indications for surgery. This guideline is intended for any clinician involved in managing children, aged 6 months to 12 years, with tympanostomy tubes or being considered for tympanostomy tubes in any care setting, as an intervention for otitis media of any type. Purpose The primary purpose of this clinical practice guideline is to provide clinicians with evidence-based recommendations on patient selection and surgical indications for and management of tympanostomy tubes in children. The development group broadly discussed indications for tube placement, perioperative management, care of children with indwelling tubes, and outcomes of tympanostomy tube surgery. Given the lack of current published guidance on surgical indications, the group focused on situations in which tube insertion would be optional, recommended, or not recommended. Additional emphasis was placed on opportunities for quality improvement, particularly regarding shared decision making and care of children with existing tubes. Action Statements The development group made a strong recommendation that clinicians should prescribe topical antibiotic eardrops only, without oral antibiotics, for children with uncomplicated acute tympanostomy tube otorrhea. The panel made recommendations that (1) clinicians should not perform tympanostomy tube insertion in children with a single episode of otitis media with effusion (OME) of less than 3 months’ duration; (2) clinicians should obtain an age-appropriate hearing test if OME persists for 3 months or longer (chronic OME) or prior to surgery when a child becomes a candidate for tympanostomy tube insertion; (3) clinicians should offer bilateral tympanostomy tube insertion to children with bilateral OME for 3 months or longer (chronic OME) and documented hearing difficulties; (4) clinicians should reevaluate, at 3- to 6-month intervals, children with chronic OME who did not receive tympanostomy tubes until the effusion is no longer present, significant hearing loss is detected, or structural abnormalities of the tympanic membrane or middle ear are suspected; (5) clinicians should not perform tympanostomy tube insertion in children with recurrent acute otitis media (AOM) who do not have middle ear effusion in either ear at the time of assessment for tube candidacy; (6) clinicians should offer bilateral tympanostomy tube insertion to children with recurrent AOM who have unilateral or bilateral middle ear effusion at the time of assessment for tube candidacy; (7) clinicians should determine if a child with recurrent AOM or with OME of any duration is at increased risk for speech, language, or learning problems from otitis media because of baseline sensory, physical, cognitive, or behavioral factors; (8) in the perioperative period, clinicians should educate caregivers of children with tympanostomy tubes regarding the expected duration of tube function, recommended follow-up schedule, and detection of complications; (9) clinicians should not encourage routine, prophylactic water precautions (use of earplugs, headbands; avoidance of swimming or water sports) for children with tympanostomy tubes. The development group provided the following options: (1) clinicians may perform tympanostomy tube insertion in children with unilateral or bilateral OME for 3 months or longer (chronic OME) and symptoms that are likely attributable to OME including, but not limited to, vestibular problems, poor school performance, behavioral problems, ear discomfort, or reduced quality of life and (2) clinicians may perform tympanostomy tube insertion in at-risk children with unilateral or bilateral OME that is unlikely to resolve quickly as reflected by a type B (flat) tympanogram or persistence of effusion for 3 months or longer (chronic OME).

Horizontal-Plane Localization of Noise and Speech Signals by Postlingually Deafened Adults Fitted With Bilateral Cochlear Implants *

Objectives: The main purpose of the study was to assess the ability of adults with bilateral cochlear implants to localize noise and speech signals in the horizontal plane. A second objective was to measure the change in localization performance in these adults between approximately 5 and 15 mo after activation. A third objective was to evaluate the relative roles of interaural level difference (ILD) and interaural temporal difference (ITD) cues in localization by these subjects. Design: Twenty-two adults, all postlingually deafened and all bilaterally fitted with MED-EL COMBI 40+ cochlear implants, were tested in a modified source identification task. Subjects were tested individually in an anechoic chamber, which contained an array of 43 numbered loudspeakers extending from –90° to +90° azimuth. On each trial, a 200-msec signal (either a noise burst or a speech sample) was presented from one of 17 active loudspeakers (span: ±80°), and the subject had to identify which source from the 43 loudspeakers in the array produced the signal. Subjects were tested in three conditions: left device only active, right device only active, and both devices active. Twelve of the 22 subjects were retested approximately 10 mo after their first test. In Experiment 2, the spectral content and rise-decay time of the noise stimulus were manipulated. Results: The relationship between source azimuth and response azimuth was characterized in terms of the adjusted constant error (Ĉ). (1) With both devices active, Ĉ for the noise stimulus varied from 8.1° to 43.4° (mean: 24.1°). By comparison, Ĉ for a group of listeners with normal hearing ranged from 3.5° to 7.8° (mean: 5.6°). When subjects listened in unilateral mode (with one device turned off), Ĉ was at or near chance (50.5°) in all cases. However, when considering unilateral performance on each subjects better side, average Ĉ for the speech stimulus was 47.9°, which was significantly (but only slightly) better than chance. (2) When listening bilaterally, error score was significantly lower for the speech stimulus (mean Ĉ = 21.5°) than for the noise stimulus (mean Ĉ = 24.1°). (3) As a group, the 12 subjects who were retested 10 mo after their first visit showed no significant improvement in localization performance during the intervening time. However, two subjects who performed very poorly during their first visit showed dramatic improvement (error scores were halved) over the intervening time. In Experiment 2, removing the high-frequency content of noise signals resulted in significantly poorer performance, but removing the low-frequency content or increasing the rise-decay time did not have an effect. Conclusions: In agreement with previously reported data, subjects with bilateral cochlear implants localized sounds in the horizontal plane remarkably well when using both of their devices, but they generally could not localize sounds when either device was deactivated. They could localize the speech signal with slightly, but significantly better accuracy than the noise, possibly due to spectral differences in the signals, to the availability of envelope ITD cues with the speech but not the noise signal, or to more central factors related to the social salience of speech signals. For most subjects the remarkable ability to localize sounds has stabilized by 5 mo after activation. However, for some subjects who perform poorly initially, there can be substantial improvement past 5 mo. Results from Experiment 2 suggest that ILD cues underlie localization ability for noise signals, and that ITD cues do not contribute.

The natural history of untreated acoustic neuromas

The emergence of magnetic resonance imaging with gadolinium has dramatically enhanced our ability to accurately detect the presence of acoustic tumors as small as 2 mm in diameter. Early diagnosis and improved surgical techniques continue to reduce the morbidity associated with surgical removal of these lesions. There exists, however, a select group of patients in whom no treatment may be the most appropriate management. Since 1979, a total of 51 patients with radiographic evidence of an acoustic neuroma have been prospectively followed for tumor growth and progression of symptoms. Patients were chosen for this conservative approach on the basis of age, medical condition, tumor size, audiometric data, and patient preference. This study reveals that a significant number of patients with acoustic tumors can be safely followed with regular imaging studies and may never require treatment. Discussed are tumor growth rates, epidemiology, and the impact of these factors on patient management.

Interaural time and level difference thresholds for acoustically presented signals in post-lingually deafened adults fitted with bilateral cochlear implants using CIS+ processing.

Objectives: The main purpose of the study was to measure thresholds for interaural time differences (ITDs) and interaural level differences (ILDs) for acoustically presented noise signals in adults with bilateral cochlear implants (CIs). A secondary purpose was to assess the correlation between the ILD and ITD thresholds and error scores in a horizontal-plane localization task, to test the hypothesis that localization by individuals with bilateral implants is mediated by the processing of ILD cues. Design: Eleven adults, all postlingually deafened and all bilaterally fitted with MED-EL COMBI 40+ CIs, were tested in ITD and ILD discrimination tasks in which signals were presented acoustically through headphones that fit over their two devices. The stimulus was a 200-msec burst of Gaussian noise bandpass filtered from 100 to 4000 Hz. A two-interval forced-choice adaptive procedure was used in which the subject had to respond on each trial whether the lateral positions of the two sound images (with the interaural difference favoring the left and right sides in the two intervals) moved from left-to-right or right-to-left. Results: In agreement with previously reported data, ITD thresholds for the subjects with bilateral implants were poor. The best threshold was ∼400 &mgr;sec, and only five of 11 subjects tested achieved thresholds <1000 &mgr;sec. In contrast, ILD thresholds were relatively good; mean threshold was 3.8 dB with the initial compression circuit on the implant devices activated and 1.9 dB with the compression deactivated. The ILD and ITD thresholds were higher than previously reported thresholds obtained with direct electrical stimulation (generally, <1.0 dB and 100 to 200 &mgr;sec, respectively). When the data from two outlying subjects were omitted, ILD thresholds were highly correlated with total error score in a horizontal-plane localization task, computed for sources near midline (r = 0.87, p < 0.01). Conclusions: The higher ILD and ITD thresholds obtained in this study with acoustically presented signals (when compared with prior data with direct electrical stimulation) can be attributed—at least partially—to the signal processing carried out by the CI in the former case. The processing strategy effectively leaves only envelope information as a basis for ITD discrimination, which, for the acoustically presented noise stimuli, is mainly coded in the onset information. The operation of the compression circuit reduces the ILDs in the signal, leading to elevated ILD thresholds for the acoustically presented signals in this condition. The large magnitude of the ITD thresholds indicates that ITDs could not have contributed to the performance in the horizontal-plane localization task. Overall, the results suggest that for subjects using bilateral implants, localization of noise signals is mediated entirely by ILD cues, with little or no contribution from ITD information.

Multicenter U.S. bilateral MED-EL cochlear implantation study: Speech perception over the first year of use

Objective: Binaural hearing has been shown to support better speech perception in normal-hearing listeners than can be achieved with monaural stimulus presentation, particularly under noisy listening conditions. The purpose of this study was to evaluate whether bilateral electrical stimulation could confer similar benefits for cochlear implant listeners. Design: A total of 26 postlingually deafened adult patients with short duration of deafness were implanted at five centers and followed up for 1 yr. Subjects received MED-EL COMBI 40+ devices bilaterally; in all but one case, implantation was performed in a single-stage surgery. Speech perception testing included CNC words in quiet and CUNY sentences in noise. Target speech was presented at the midline (0 degrees), and masking noise, when present, was presented at one of three simulated source locations along the azimuth (−90, 0, and +90 degrees). Results: Benefits of bilateral electrical stimulation were observed under conditions in which the speech and masker were spatially coincident and conditions in which they were spatially separated. Both the “head shadow” and “summation” effects were evident from the outset. Benefits consistent with “binaural squelch” were not reliably observed until 1 yr after implantation. Conclusions: These results support a growing consensus that bilateral implantation provides functional benefits beyond those of unilateral implantation. Longitudinal data suggest that some aspects of binaural processing continue to develop up to 1 yr after implantation. The squelch effect, often reported as absent or rare in previous studies of bilateral cochlear implantation, was present for most subjects at the 1 yr measurement interval.

Treatment of benign positional vertigo using the semont maneuver: efficacy in patients presenting without nystagmus.

Objective To evaluate and compare the efficacy of the Semont liberatory maneuver on “objective” benign paroxysmal positional vertigo (BPPV) defined as vertigo with geotropic nystagmus in Dix‐Hallpike positioning versus “subjective” BPPV defined as vertigo without nystagmus in Dix‐Hallpike positioning.

Impact of electrode design and surgical approach on scalar location and cochlear implant outcomes

Three surgical approaches: cochleostomy (C), round window (RW), and extended round window (ERW); and two electrodes types: lateral wall (LW) and perimodiolar (PM), account for the vast majority of cochlear implantations. The goal of this study was to analyze the relationship between surgical approach and electrode type with final intracochlear position of the electrode array and subsequent hearing outcomes.

Sudden hearing loss.

Sudden sensorineural hearing loss is a medical emergency in search of an appropriate treatment. Almost all aspects of this disease process are disputed in the literature. The natural course of the disease process has not been well defined, although spontaneous recovery in a percentage of patients appears well accepted. Little scientific data exist to develop an evidence-based treatment protocol. The more common elements of treatment in the United States include oral steroid therapy, transtympanic steroid therapy, and potentially oral antiviral therapy. Other therapies are used with great frequency, and their potential should not be discounted.

Twenty-five years of experience with stapedectomy.

The purpose of this report is to review the outcomes of patients undergoing stapes surgery by the senior author during the past 25 years, and to compare these results with those obtained in other series.