David Ulanovski

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.

Pattern of hearing loss following cochlear implantation.

Cochlear implantation is associated with deterioration in hearing. Despite the fact that the damage is presumed to be of sensory origin, residual hearing is usually assessed by air-conduction thresholds alone. This study sought to determine if surgery may cause changes in air- and bone-conduction thresholds producing a mixed-type hearing loss. The sample included 18 patients (mean age 37xa0years) with an air–bone gap of 10xa0dB over three consecutive frequencies and measurable masked and reliable bone-conduction thresholds of operated and non-operated ears who underwent cochlear implant surgery. All underwent comprehensive audiologic and otologic assessment and imaging before and after surgery. The air–bone gap in the treated ears was 17–41xa0dB preoperatively and 13–59xa0dB postoperatively over 250–4,000xa0Hz. Air-conduction thresholds in the treated ears significantly deteriorated after surgery, by a mean of 10–21xa0dB. Bone-conduction levels deteriorated nonsignificantly by 0.8–7.5xa0dB. The findings indicate that the increase in air-conduction threshold after cochlear implantation accounts for most of the postoperative increase in the air–bone gap. Changes in the mechanics of the inner ear may play an important role. Further studies in larger samples including objective measures of inner ear mechanics may add information on the source of the air–bone gap.

Pediatric otogenic sigmoid sinus thrombosis: 12-Year experience.

OBJECTIVESnOtogenic sigmoid sinus thrombosis is a rare complication of acute otitis media. Treatment remains controversial particularly regarding extent of surgical intervention. The aim of the study was to review the 12-year experience of a major medical center with the treatment of sigmoid sinus thrombosis in children.nnnMETHODSnRetrospective case series identified by database review in a tertiary university-affiliated pediatric medical center. Twenty-four children aged 7-155 months were treated for sigmoid sinus thrombosis from 2000 through 2011.nnnRESULTSnThe transverse sinus was also involved in 10 patients, and the jugular vein, in 4. Acute otitis media with mastoiditis was the causative factor in all cases. Subperiosteal abscess was diagnosed in 21 patients, 11 with epidural involvement. Treatment in all cases consisted of broad-spectrum antibiotics and ventilation tube insertion. Twenty-one children (87.5%) underwent mastoidectomy with removal of bone covering the sigmoid sinus to drain pus and remove granulations from the epidural cavity, without aspiration or sinus drainage. Twenty-two patients received low-molecular-weight heparin for 3-6 months postoperatively. Children infected with Fusobacterium necrophorum had a longer and more severe course with coexisting osteomyelitis. There were no neurologic sequelae or hematologic complications. Follow-up imaging, performed in 15 children, revealed partial or full recanalization in 87%.nnnCONCLUSIONSnRelatively conservative surgical intervention appears to yield good results in children with sigmoid sinus thrombosis consequent to acute otitis media. Anticoagulants are safe if correctly administered and may prevent extension of the thrombus.

Sinusitis in pilots of different aircraft types: is allergic rhinitis a predisposing factor?

Background Despite the high association of allergic rhinitis and acute sinusitis, their exact relationship remains unclear, especially in pilots. The purpose of this study was to analyze the possible relationship of a history of allergic rhinitis with the occurrence of acute sinusitis in Israeli air force pilots. A comparative case series was conducted. Methods Events of acute sinusitis were compared between Israeli air force pilots with (n = 54) and without (n = 82) allergic rhinitis who presented for their annual physical examination. Results Previous episodes of acute sinusitis were noted in 33% of the pilots with allergic rhinitis and 21% of the control group (p = 0.09). A separate analysis of young pilots (<26 years old) yielded corresponding rates of 57% versus 29% (p < 0.001). When the groups were divided by type of pilot, the results showed that 54% of the transport pilots, 34% of the fighter pilots, and 13% of the helicopter pilots with rhinitis also suffered from acute sinusitis, as opposed to 28, 15, and 15%, respectively, of the control group. Conclusion Despite careful selection, allergic rhinitis is still a very common disease in pilots and may pose a risk of acute sinusitis. The lower prevalence of acute sinusitis in combat than in transport pilots with rhinitis may be explained by vasoconstriction due to psychological and physiological stress during flight missions.

Air-bone gap component of inner-ear origin in audiograms of cochlear implant candidates.

Background Experimental studies have shown that creating a window in the bony cover of the cochlea and vestibular parts of the inner ear, with preservation of membranous and middle-ear functions, induces an air-bone gap (ABG). This study sought to determine if a similar mechanism explains the ABG frequently observed in audiograms of cochlear implant candidates. Method The study group included 47 candidates for a cochlear implant (94 ears) attending a university-affiliated tertiary medical center who had an ABG component in the audiogram in the absence of external or middle-ear abnormalities. Air- and bone-conduction thresholds on pure-tone audiometry were analyzed for 250 to 8,000 Hz and 250 to 4,000 Hz, respectively. In the 25 patients operated on during the study period, differences in the ABG and in cerebrospinal fluid (CSF) leak were compared between those with and without anomalies on computed tomography. Results Imaging revealed an abnormal inner-ear structure in 46% of cases, mostly a large vestibular aqueduct, alone or combined with other cochlear or vestibular malformations. ABG was evident over high and low frequencies and was significantly larger at low frequencies and in ears with structural anomalies. A high rate of CSF leak was observed in patients with an ABG and structural anomalies imaging as well as in those with an ABG and normal imaging findings. Conclusion In cochlear implant candidates, the presence of a third window could cause an ABG because of stapes motion–induced shunting of acoustic energy outside the cochlear duct in response to air-conducted stimuli while bone conduction is preserved.

Acute mastoiditis in children with a cochlear implant

OBJECTIVESnCochlear implantation is performed at a young age, when children are prone to acute otitis media. Acute mastoiditis is the most common complication of otitis media, but data on its management in the presence of a cochlear implant are sparse. The objective of this study was to assess the characteristics, treatment, and outcome of acute mastoiditis in children with a cochlear implant.nnnMETHODSnThe medical files of all children who underwent cochlear implantation at a pediatric tertiary medical center in 2000-2014 were retrospectively reviewed. Those diagnosed with acute mastoiditis after implantation were identified, and data were collected on demographics, history, presentation, method of treatment, complications, association with untreated otitis media with effusion, and long-term middle-ear sequelae.nnnRESULTSnOf the 370 children (490 ears) who underwent cochlear implantation, 13 (3.5%) were treated for acute mastoiditis (median age at acute mastoiditis, 32 months). Nine had a pre-implantation history of chronic secretory or acute recurrent otitis media, and 5 had been previously treated with ventilation tubes. In all 9 children who had unilateral cochlear implant, the acute mastoiditis episode occurred in the implanted ear. The time from implantation to mastoiditis was 5-61 months. The same treatment protocol as for normal-hearing children was followed, with special attention to the risk of central nervous system complications. Primary treatment consisted of myringotomy with intravenous administration of wide-spectrum antibiotics. Surgical drainage was performed in 8 out of 13 patients, with (n=7) or without (n=1) ventilation-tube insertion, to treat subperiosteal abscess or because of lack of symptomatic improvement. There were no cases of intracranial complications or implant involvement or need for a wider surgical approach. No middle-ear pathology was documented during the average 3.8-year follow-up.nnnCONCLUSIONSnThe relatively high rate of acute mastoiditis and subperiosteal abscess in children with a cochlear implant, predominantly involving the implanted ear, supports the suggestion that recent mastoidectomy may be a risk factor for these complications. Despite the frequent need for drainage, more extensive surgery is usually unnecessary, and recovery is complete and rapid. As infections can occur even years after cochlear implantation, children with otitis media should be closely followed, with possible re-introduction of ventilation tubes.

Pediatric Cochlear implant soft failure

PURPOSEnHard cochlear implant failures are diagnosed by objective tests whereas soft failures are suspected on the basis of clinical signs and symptoms. This study reviews our experience with children in tertiary pediatric medical center who underwent revision cochlear implantation, with emphasis on soft failures.nnnMATERIALS AND METHODSnChildren (age<18years) who underwent revision cochlear implantation from 2000 to 2012 were identified by database search. Pre- and post-explantation data were collected.nnnRESULTSnTwenty-six revision surgeries were performed, accounting for 7.4% of all cochlear implant surgeries at our center during the study period. The pre-explantation diagnosis was hard failure in 7 cases (27%), soft failure in 12 (46%), and medical failure in 7 (27%). On post-explantation analysis, 7/12 devices from the soft-failure group with a normal integrity test had abnormal findings, yielding a 63% false-negative rate (12/19) for the integrity test. All children regained their initial performance. Compared to hard failures, soft failures were associated with a shorter median time from first implantation to symptom onset (8 vs 25months) but a significantly longer time from symptom onset to revision surgery (17.5 vs 3months; P=0.004).nnnCONCLUSIONSnSoft cochlear implant failure in young patients poses a diagnostic challenge. A high index of suspicion is important because a delayed diagnosis may have severe consequences for language development. A normal integrity test does not unequivocally exclude device failure and is unrelated to functional outcome after revision surgery. Better education of parents and rehabilitation teams is needed in addition to more accurate diagnostic tests.