Eyal Raveh

Adenoidectomy: Long-term Follow-Up

OBJECTIVE: To assess the long-term (3-5 years) success of adenoidectomy and reasons for unsatisfactory results. STUDY DESIGN AND SETTING: The parents of all children who underwent adenoidectomy alone at a major tertiary center from 1998 to 2000 were asked to complete a questionnaire assessing their childs well-being and symptomatology 3-5 years after surgery; some were invited for follow-up. Symptom improvement, persistent symptoms, and adenoid regrowth were evaluated. RESULTS: Among the 206 parents who complied, 74%-87% reported improvement in all main symptoms: nasal obstruction, snoring, chronic rhinorrhea, hyponasal speech, and obstructive sleep disorder. At follow-up (n = 36), the symptomatic patients had significantly more anatomic nasal abnormalities (P = 0.01) and a higher rate of significant adenoid enlargement (P = 0.08), 3 patients (19%) vs none (0%). CONCLUSIONS AND SIGNIFICANCE: Adenoidectomy alone is satisfactory treatment for nasal obstruction and obstructive sleep apnea in selected children. Though some adenoid regrowth is not rare, clinically significant adenoid regrowth is infrequent. Persistent or recurrent symptoms are attributable mainly to nasal pathology.

Multiple auditory steady-state responses in children and adults with normal hearing, sensorineural hearing loss, or auditory neuropathy.

Objectives: We tested the clinical effectiveness of multiple auditory steady-state responses (ASSRs) for the objective assessment of hearing thresholds in patients with and without hearing loss, candidates for cochlear implants, and children with auditory neuropathy. Methods: The study sample included 29 subjects with sensorineural hearing loss (SNHL), 18 candidates for cochlear implants, 11 subjects with auditory neuropathy, and 18 subjects with normal hearing thresholds. Behavioral hearing thresholds and ASSRs to carrier frequencies of 0.5, 1, 2, and 4 kHz were obtained. Special care was taken to minimize possible aliasing and high-intensity multiple stimulation effects. Differences and correlations between the ASSRs and the behavioral thresholds were determined. Results: The ASSR estimation of behavioral thresholds in the normal-hearing group was elevated, whereas very close predictions were found for the SNHL group. The correlations between the Two measures ranged from 0.86 at 0.5 kHz carrier frequency to 0.94 at 2 kHz. In the cochlear implant candidates and the auditory neuropathy group, the ASSR thresholds generally overestimated the behavioral audiogram. In these groups the number of detected ASSRs was higher than the number of behavioral responses, especially for the high-frequency carrier stimuli. Conclusions: Multiple ASSRs may reliably predict the behavioral threshold in subjects with SNHL and may serve as a valuable objective measure for assessing the hearing threshold across different frequencies in candidates for cochlear implants and children with auditory neuropathy.

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.

Prothrombotic factors in children with otitis media and sinus thrombosis.

Objective Venous sinus thrombosis (VST) is the second most common intracranial complication of acute otitis media (AOM). There is some evidence that hereditary and acquired prothrombotic disorders are risk factors for VST. The aim of the present study was to evaluate whether children with AOM complicated VST have a prothrombotic tendency, which might have important therapeutic and preventive implications.

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.

Well-differentiated thyroid carcinoma

PURPOSE This study presents our experience with 728 patients treated in our department for well-differentiated thyroid carcinoma between 1954-1994. MATERIALS AND METHODS The retrospective evaluation of the prognostic implications of the clinical and pathological findings was performed. Age, sex, histological variants, tumor size, and locoregional and distant spread were evaluated as risk factors in relation to the prognosis. RESULTS During follow-up, which ranged from 1 to 31 years, 125 locoregional and/or distant metastases developed (17.2% of the patients), 87 of which occurred in the first 10 years after initial therapy. Thirty-two patients with papillary cancer and 20 with follicular cancer died of causes related to malignancy of the thyroid. CONCLUSION The experience gained in our department has led us to adopt an aggressive approach in the treatment of patients with well-differentiated carcinoma of the thyroid gland.

Treatment of lymphatic malformations: a more conservative approach

BACKGROUND/PURPOSE Lymphatic malformation is a benign disfiguring lesion of the neck and face in children. This study investigated the application and outcome of different modes of treatment. METHODS The medical files of all children with lymphatic malformation of the head and neck attending a tertiary medical center in 1999 to 2010 were reviewed. Findings were compared by treatment: surgery, OK-432 sclerotherapy, or observation. RESULTS The study group included 46 patients, most (65%) with macrocystic disease. Twenty were treated by OK-432 sclerotherapy, and 15, by surgery; 11 (with minor disfigurement) were observed only. Mean follow-up time was 2.4 years. Complete removal or complete response to treatment was achieved in 67% of the surgery group and 45% of the OK-432 group; fair results (>50% reduction in swelling) were achieved in 20% and 50%, respectively. Sclerotherapy failure did not interfere with subsequent surgery. Complete spontaneous regression occurred in 5 patients under observation only. CONCLUSIONS OK-432 sclerotherapy is associated with good aesthetic results in children with lymphatic malformation. Observation alone is sometimes sufficient. Surgery should be reserved for cases requiring a histologic diagnosis, microcystic disease, patients with an urgent clinical problem (eg, airway obstruction), and sclerotherapy failures.

A Comparative Study of Hearing Loss in Two Microdeletion Syndromes: Velocardiofacial (22q11.2 Deletion) and Williams (7q11.23 Deletion) Syndromes

OBJECTIVE To comprehensively assess auditory impairments in velocardiofacial syndrome (VCFS) and Williams syndrome (WS). STUDY DESIGN Audiologic measurements were conducted with 62 subjects with VCFS and 44 subjects with WS, as well as two control groups consisting of 22 subjects with idiopathic developmental disability and 23 typically developing controls. An association between severity of hearing loss in VCFS and the (158)Val/Met polymorphism of the catechol-O-methyltransferase gene (COMT) was explored. RESULTS Hearing was significantly more impaired in the VCFS and WS groups compared with the developmental disability and typically developing groups. Audiologic abnormalities identified in both the VCFS and WS groups included high-tone hearing loss (predominantly sensorineural or mixed type), loss of acoustic reflex, and middle ear pathologies. In both the VCFS and WS groups, hearing loss severity was positively correlated with age. In the VCFS group, hearing loss was more severe in the subgroup carrying the COMT Val allele compared with the subgroup carrying the COMT Met allele. CONCLUSIONS Hearing impairments, including sensorineural hearing loss and acoustic reflex dysfunction, are very common in both VCFS and WS. Hearing loss is less severe in subjects with the COMT Met allele, possibly due to the protective effect of dopamine on the hearing system.