John Xenellis

Intratympanic steroid treatment in idiopathic sudden sensorineural hearing loss: A control study

BACKGROUND AND OBJECTIVE: Although systemic steroids in sudden sensorineural hearing loss (SSHL) appears to be the most effective and the most widely accepted treatment today, a significant number of patients do not respond to steroid treatment or they cannot receive steroids for medical reasons. Intratympanic (IT) administration of steroids appears to be an alternative or additional method of management without the side effects of intravenous steroids. The aim of this study is to investigate the effectiveness and safeness of IT administration of steroids in patients who had not responded to IV treatment and to compare treatment efficacy with controls. STUDY DESIGN AND SETTING: Our study consisted of 37 patients with SSHL who, at the end of 10 days of therapy with intravenous steroids as a 1st line treatment, had pure-tone 4-frequency (0.5, 1, 2, and 4 kHz) average (PTA) of worse than 30 dB or worse than 10 dB from the contralateral ear (defined as failed intravenous treatment). They were randomized into 2 groups, treatment and control. The 19 patients of the treatment group received approximately 0.5 mL sterile aqueous suspension of methylprednisolone acetate in a concentration of 80 mg/2 mL by direct injection. The procedure was carried out 4 times within a 15-day period. An audiogram was performed before each injection and approximately 1.5 months after the last session. RESULTS: All patients tolerated the procedure well. No perforation or infection was noticed in any of the patients at their last visit. With regard to the 19 patients who received intratympanic treatment, in 9 patients, the PTA threshold improved more than 10 db, in 10 patients there was no change greater than 10 db, and no patients deteriorated more than 10 db. In the control group, none of the patients showed any change greater than 10 db. The difference was statistically significant (P = 0.002). The treatment group showed an improvement in mean PTA of 14.9 dB, whereas the control group showed a deterioration of 0.8 dB, and this difference also was statistically significant (P = 0.0005). IT treatment (P = 0.0001), better post-IV PTA (P = 0.0008), and absence of vertigo (P = 0.02) were good predictors of the outcome. In contrast, sex, age, affected ear, days to admission, and pattern of the initial audiogram showed no significant influence on the outcome. CONCLUSION AND SIGNIFICANCE: IT steroid administration after failed intravenous steroids is a safe and effective treatment in sudden sensorineural hearing loss.

Idiopathic sudden sensorineural hearing loss: prognostic factors

OBJECTIVES Sudden sensorineural hearing loss (SSHL) remains a challenge for the clinician. In the majority of cases, no definite cause can be found and the prognosis is variable. METHODS The present study assessed 114 patients suffering from idiopathic SSHL, with regard to the prognostic value of demographic, epidemiologic, neurotologic and audiometric factors. In addition, the relationship between the identification of wave V in auditory brainstem responses and the final hearing outcome was investigated. All patients received 75 mg/day intravenous prednisolone, divided into three daily doses, for 10 days, with gradual tapering of the dose over the next 10 days. RESULTS The results (after one year follow up) revealed the following factors to be related to a better hearing outcome: younger age; male sex; less time elapsed between the onset of hearing loss and the beginning of treatment; and an upward-sloping or cupeloid audiogram contour. The detection of wave V early in recovery and within the first month of medical treatment might also constitute a significant favourable factor in respect to hearing recovery. CONCLUSIONS The present study revealed that there are certain factors that affect prognosis in idiopathic SSHL. This is very important in counselling patients and may affect current clinical practice.

Surgical anatomy of the external branch of the superior laryngeal nerve and its clinical significance in head and neck surgery

Injury of the external branch of the superior laryngeal nerve (EBSLN) increases the morbidity following a variety of neck procedures and can have catastrophic consequences in people who use their voice professionally. Identification and preservation of the EBSLN are thus important in thyroidectomy, parathyroidectomy, carotid endarterectomy, and anterior cervical spine procedures, where the nerve is at risk. There are large variations in the anatomical course of the EBSLN, which makes the intraoperative identification of the nerve challenging. The topographic relationship of the EBSLN to the superior thyroid artery and the upper pole of the thyroid gland are considered by many authors to be the key point for identifying the nerve during surgery of the neck. The classifications by Cernea et al. ([ 1992a ] Head Neck 14:380–383; [ 1992b ] Am. J. Surg. 164:634–639) and by Kierner et al. ([ 1998 ] Arch. Otolaryngol. Head Neck Surg. 124:301–303), as well as clinically important connections are discussed in detail. Along with sound anatomical knowledge, neuromonitoring is helpful in identifying the EBSLN during neck procedures. The clinical signs of EBSLN injury include hoarseness, decreased voice projection, decreased pitch range, and fatigue after extensive voice use. Videostroboscopy, electromyography, voice analysis, and electroglottography can provide crucial information on the function of the EBSLN following neck surgery. Clin. Anat. 21:99–105, 2008.

Treatment of the horizontal semicircular canal canalithiasis: pros and cons of the repositioning maneuvers in a clinical study and critical review of the literature.

Objective: Several repositioning maneuvers have been proposed for the treatment of benign paroxysmal positional vertigo (BPPV) due to canalithiasis of the horizontal semicircular canal (HSC). However, comparisons between these canalith repositioning procedures as well as a generally accepted algorithm for the management of HSC canalithiasis are currently lacking. The aim of this study was to compare the efficacy of 3 different treatment proposals and review the relevant literature. Study Design: Prospective clinical study. Setting: Tertiary neurotology department. Patients: Sixty patients diagnosed with HSC canalithiasis. Interventions: A single application of Balohs maneuver (n = 13), Vannucchis forced prolonged position (n = 29), or Asprella-Gufoni maneuver (n = 18). Main Outcome Measures: Bilateral geotropic nystagmus. Results: The first application of the Balohs maneuver seemed to be significantly less effective than both Vannucchis forced prolonged position (p = 0.035) and the Asprella-Gufoni maneuver (p = 0.006). No significant difference was detected in the efficiency of Vannucchis forced prolonged position and the Asprella-Gufoni maneuver for this population (p = 0.4). Conclusion: The Asprella-Gufoni maneuver and Vannucchis forced prolonged position both seem to be significantly more effective than the Balohs maneuver in the treatment of HSC canalithiasis. The important pros of the Asprella-Gufoni maneuver versus Vannucchis forced prolonged position are patients convenience and maximal use of gravitational and angular acceleration forces. Controlled clinical studies are needed to conclude to an evidence-based proposal for the therapeutical steps that should be followed after the diagnosis of HSC canalithiasis.

Screening for hearing loss and middle-ear effusion in school-age children, using transient evoked otoacoustic emissions: a feasibility study.

INTRODUCTION The characteristics of otoacoustic emissions that make them ideally suited for universal newborn hearing loss screening could potentially be useful for the screening of older children. This study was performed in order to assess the role of otoacoustic emissions in a screening programme for middle-ear disorders and hearing loss in school-age children. METHODS Cross-sectional, preliminary screening study. SETTING Primary schools of Argolida municipality, south-east Greece, between December 2004 and March 2005. PATIENT SELECTION AND RECRUITMENT: All the primary school students of Argolida were invited, by press releases and individually by their teachers, to attend a session of otological and audiological screening. RESULTS One hundred and ninety-six children were evaluated using transient evoked otoacoustic emissions. Twenty per cent failed in both ears, while in 32 per cent otoacoustic emissions could not be produced in at least one ear. Younger children had higher rates of absent transient evoked otoacoustic emissions. The absence of otoacoustic emissions was highly correlated with tympanic membrane changes seen on otoscopy and the presence of a type B tympanogram. As a single screening modality, otoacoustic emissions had a 100 per cent sensitivity in diagnosing hearing loss worse than 30 dB, and a 90 per cent sensitivity and 64 per cent specificity in diagnosing hearing loss worse than 25 dB, which did not improve by adding tympanometry to the screening protocol. CONCLUSION These results strongly suggest the potential usefulness of otoacoustic emission testing in screening school-age children for hearing loss. Further studies, taking into account cost-effectiveness issues, are indicated.

GSTT1 , GSTM1 , GSTM3 and NAT2 polymorphisms in laryngeal squamous cell carcinoma in a Greek population

OBJECTIVE It is well known that laryngeal squamous cell carcinoma is strongly related to tobacco and alcohol consumption. Accumulating evidence suggests that alterations of detoxification enzymes, such as glutathione S-transferases and N-acetyltransferases, influence the risk of cancers associated with tobacco smoke and alcohol. METHODS This was a retrospective case-control study. The study group consisted of 88 Greek patients with laryngeal squamous cell carcinoma; there were also 102 control subjects. Frequencies of the genotypes GSTT1, GSTM1, GSTM3 and NAT2 were evaluated by polymerase chain reaction restriction fragment polymorphism. RESULTS The distribution of overall genotypes was 55.68 per cent rapid acetylator and 44.32 per cent slow acetylator in patients, and 36.27 per cent rapid acetylator and 63.72 per cent slow acetylator in controls. The odds ratio for rapid acetylator status in cases versus controls was 2.207 (95 per cent confidence interval 1.23-3.95, p = 0.0087). CONCLUSION This study demonstrated a significant relationship between rapid acetylator genotypes and laryngeal squamous cell carcinoma in a Greek population.

Cochlear implantation in atelectasis and chronic otitis media: long-term follow-up.

Objective: To report the long-term results of cochlear implantation in cases with chronic otitis media or atelectasis using a single surgical technique performed in a single cochlear implant center. Patients: Nine patients who were implanted using the blind-pit closure of the external ear canal technique (4 patients with adhesive otitis media and 5 with radical mastoid cavities). Follow-up ranged from 18 months to 12 years (mean, 7.05 yr). Intervention: The surgical procedure was performed in 2 stages. The first stage included canal wall down or lowering any high facial ridge in previous mastoidectomies, removal of all skin, and blind-pit closure of the external ear canal without mastoid cavity obliteration or eustachian tube obliteration. Cochlear implantation was performed 6 months after the first surgical procedure. Results: All operations were uneventful, and during cochlear implantation, as a second stage, no epithelia or other problems were encountered. No serious complications were encountered during the follow-up period. One case had a minor disruption of the external canal closure that was reclosed successfully under local anesthesia. All patients were using the device at the last follow-up interval with no device problems. Conclusion: Blind-sac closure of the external ear canal without obliteration is a rather safe surgical procedure in cases with chronic otitis media or atelectasis. Meticulous surgical technique and proper patient selection are of paramount importance. However, a 2-stage procedure may not always be necessary andmight best be confined to those patients who have active inflammatory disease at the primary procedure.

Primary lymphoma of the internal auditory canal. Case report and review of the literature.

We report a rare case of a primary intracranial B cell lymphoma originating in the internal auditory canal. The clinical manifestations were indistinguishable from those of other, more common tumors of the same region. We achieved total gross tumor removal with preservation of the facial nerve. A detailed histologic examination and a systemic workup confirmed the primary nature of this tumor. To our knowledge, this is the second case reported in the literature of a primary malignant lymphoma originating in the internal auditory canal. This is the first instance that includes immunohistochemical and cytometric studies of fresh tissue. We discuss the management of primary lymphomas of the central nervous system, with special emphasis on their association with acquired immunodeficiency syndrome and other immune system diseases. Awareness of primary central nervous system lymphomas is important, since a greater occurrence of these rare tumors in the cerebellopontine angle is probable in the future.

Aural Symptoms in Patients With Temporomandibular Joint Disorders: Multiple Frequency Tympanometry Provides Objective Evidence of Changes in Middle Ear Impedance

Objective: The association of temporomandibular joint (TMJ) disorders with aural symptoms, such as tinnitus, otic fullness, and subjective decrease of hearing acuity, is a well-established clinical observation. Although several hypotheses have been made about the otic-conductive origin of these complaints, conventional 226-Hz tympanometry has failed to demonstrate any middle ear abnormalities. The aim of this study was to evaluate patients with TMJ disorders with multiple frequency tympanometry (MFT). Study Design: Prospective clinical study. Setting: Outpatient clinic. Patients: The population of this study consisted of 40 patients with unilateral TMJ disorders diagnosed for longer than 1 month. Interventions: After verifying that there were no abnormal otoscopic findings, 226-Hz tympanometry, conventional pure-tone audiometry, brainstem auditory evoked potentials, and MFT were performed. Main Outcome Measure: Resonant frequency (RF) values. Results: With the exception of MFT, no abnormal audiologic findings were revealed. The ear ipsilateral to the lesion demonstrated significantly higher (p = 0.002) RF values in comparison to the contralateral ear. The difference in RF values was more obvious in patients aged 45 years or younger. Conclusion: The results of this study imply an increase in the stiffness of the middle ear, which has not been detected by conventional tympanometry. This represents the first concrete documentation of minor alterations in the conductive properties of the middle ear and seems to support the various hypotheses on the middle-ear origin of aural complaints in patients with TMJ disorders. Further studies are needed before a clear insight on the presumably multifactorial pathophysiology of these complaints can finally be reached.

Temporal bone study of development of the organ of Corti: correlation between auditory function and anatomical structure

OBJECTIVE To study the development of the organ of Corti in the human cochlea, and to correlate our findings with the onset of auditory function. MATERIAL AND METHODS Step sections of 81 human fetal temporal bones were studied, from eight weeks of gestation to full term. RESULTS By the end of the 10th week, the tectorial membrane primordium could be traced even in the most apical turns. Individual hair cells became identifiable at the basal turn at 14 weeks. At the same time, a small but well formed oval space was observed between the inner and outer hair cells in the basal turn. This does not correspond to the tunnel of Corti, as is erroneously quoted in the literature, as the individual pillar cells develop at later stages. Between 14 and 15 weeks, Hensens cells were recognised for the first time. Individual pillar cells were identifiable at 17 weeks and the tunnel of Corti opened at 20 weeks. By 25 weeks, the cochlea had reached its adult size, but continued to develop until full term. DISCUSSION AND CONCLUSIONS A temporal coincidence of different developmental events is responsible for early fetal audition at 20 weeks, including growth of pillar cells, opening of the tunnel of Corti and regression of Kollickers organ, with the subsequent formation of the inner spiral sulcus and then separation of the tectorial membrane. The fine structures of the organ of Corti continue to develop well after the 25th week, and this may well alter the mechanical properties of the vibrating parts of the cochlea, which may in turn account for the frequency shift observed in preterm infants. These changes will have to be taken into account in the development of prenatal hearing screening tests.