Sudden onset hearing loss--causes, investigations and management

BACKGROUND

Sudden onset hearing loss (SOHL) has a number of causes, ranging from the simple and reversible to the profound and permanent. The sequelae of a sudden loss of hearing can be significant.

OBJECTIVE

This article seeks to address the various aetiologies of SOHL, how they can be diagnosed at the earliest opportunity, and outlines the methods of investigation and management.

DISCUSSION

SOHL causes great concern for the patient. It is when there is a 30 dB or greater hearing loss over less than 72 hours. History and examination, with discerning use of investigations, can identify whether the hearing loss is of conductive or sensorineural origin; and those individuals who have a potentially reversible hearing loss that can be addressed quickly and in an appropriate fashion. However, in the majority of cases of sudden sensorineural hearing loss (SSNHL), no cause is identified and it is considered idiopathic SSNHL. In these patients, high dose oral prednisolone may improve hearing outcome, particularly if started early.

Wideband energy reflectance measurements: effects of negative middle ear pressure and application of a pressure compensation procedure

The wideband energy reflectance (ER) technique has become popular as a tool for evaluating middle ear function. Negative middle ear pressure (MEP) is a prevalent form of middle ear dysfunction, which may impact application of ER measurements in differential diagnosis. A negative MEP may be countervailed by application of an equivalent negative ear canal pressure. The present study examined ER in the same ears under normal and experimentally induced negative MEP conditions. Thirty-five subjects produced at least one negative MEP each (-40 to -225 daPa). Negative MEP significantly altered ER in a frequency-specific manner that varied with MEP magnitude. ER increased for low- to mid-frequencies with the largest change (~0.20 to 0.40) occurring between 1 and 1.5 kHz. ER decreased for frequencies above 3 kHz with the largest change (~-0.10 to -0.25) observed between 4.5 and 5.5 kHz. Magnitude of changes increased as MEP became more negative, as did the frequencies at which maximum changes occurred, and the frequency at which enhancement transitioned to reduction. Ear canal pressure compensation restored ER to near baseline values. This suggests that the compensation procedure adequately mitigates the effects of negative MEP on ER. Theoretical issues and clinical implications are discussed.

Otologic and audiologic characteristics of children with skeletal dysplasia in central China

CONCLUSION

Otologic and audiologic abnormalities are both highly prevalent in Chinese children with skeletal dysplasias. Audiologic and otologic evaluations with medical intervention are recommended for these children.

OBJECTIVE

Children with skeletal dysplasia have a number of otolaryngologic issues including hearing loss. This study aimed to investigate the otologic and audiologic features of Chinese children with skeletal dysplasia in central China.

METHODS

Otologic evaluations and pure tone audiometry were performed in children with skeletal dysplasias. To explore the potential associations with hearing loss, we studied various craniofacial anomalies.

RESULTS

A total of 125 children (mean age 9.2 years, range 5-18 years) with skeletal dysplasia were enrolled, and otoscopic examination identified eardrum abnormalities in 45.6% of the children. Audiologic analysis revealed 14 cases (11.2%) with conductive hearing loss (CHL) and 22 cases (17.6%) with sensorineural hearing loss (SNHL).

Idiopathic incus necrosis: Analysis of 4 cases

We evaluated ossicular chain reconstruction in patients with idiopathic incus necrosis who have conductive hearing loss and an intact ear drum. The study included four patients (3 women and 1 man; the ages of the patients were 22, 31, 35, and 56 years, respectively) with unilateral conductive hearing loss, no history of chronic serous otitis media, an intact ear drum, normal middle ear mucosa, and necrosis of the long processes of the incus. On preoperative pure tone audiometry, air-bone gaps were 24, 25, 38, and 33 dB. Bilateral tympanometry and temporal bone computed tomography results were normal. All 4 patients underwent an exploratory tympanotomy. During the operation, the mucosa of the middle ear was normal, with a mobile stapes foot plate and malleus. No evidence of any granulation tissue was found; however, necrosis of the incus long processes was seen. For ossicular reconstruction, we used tragal cartilage between the incus and the stapes in 1 patient; in the other 3 patients, glass ionomer bone cement was used (an interposition cartilage graft also was used in the patients who received the glass ionomer bone cement). In all patients, air-bone gaps under 20 dB were established in the first year after surgery. In the ossicular disorders within the middle ear, the incus is the most commonly affected ossicle. While, the most common cause of these disorders is chronic otitis media, it may be idiopathic rarely. Several ossicular reconstruction techniques have been used to repair incudostapedial discontinuity.

Anophthalmia-plus syndrome with unusual findings. A clinical report and review of the literature

We present a male child at 3 years old with Anophthalmia-Plus Syndrome (APS). He has asymmetry of the face and head, left choanal atresia, a sunken facial appearance, microphthalmia in the right eye, severe microphthalmia in the left eye, bilateral low-set ears, scarring from cleft palate surgery. Magnetic resonance imaging (MRI) sections revealed decreased right globe volume, an undeveloped left globe, decreased left optical nerve thickness, Chiari type 2 malformation, left choanal atresia and cleft palate. Echocardiography and abdominal ultrasonography were normal. The patient has a 45 dB conductive hearing loss in the left ear. Repeated thyroid function tests were evaluated as compatible with central hypothyroidism. We report a Fryns Anophthalmia-Plus Syndrome in a child with unusual findings including central hypothyroidism, chiari type 2 malformation, conductive hearing loss and developmental regression. Summary of the features reported in the present case and all 14 previous cases that might be defined as APS.

Middle ear implant in conductive and mixed congenital hearing loss in children

PURPOSE

Active middle ear implant can be used in children and adolescents with congenital hearing loss. The authors report their experience with the semi implantable Medel Vibrant Soundbridge(®) (VSB) in the audiologic rehabilitation of such patients.

METHODS

In this retrospective study, audiological and surgical data of 10 children (10.5±4 years) implanted with 12 VSB in 2 tertiary cares ENT Departments were analysed.

RESULTS

Two children with bilateral external auditory canal (EAC) atresia and mixed hearing loss (mean air conduction (AC) thresholds=65dB HL) were bilaterally implanted. Eight children presented with microtia associated with EAC atresia bilaterally (n=3) and unilaterally (n=5). All of them had a conductive hearing loss in the implanted ear (mean (AC) thresholds were 58.75dB HL preoperatively). The Floating Mass Transducer was crimped on the long process of the incus (n=8) or on the suprastructure of the stapes (n=4). There were no intra- or postoperative surgical complications. All the children wore their implants after 5 weeks. Postoperative mean bone conduction (BC) thresholds were unchanged. The mean aided thresholds with VSB (four frequencies warble tones at 0.5, 1, 2 and 4 kHz) were 28dB HL (± 10). Word discrimination threshold in quiet conditions in free field with the VSB unilaterally activated was 50% at 38dB SPL (± 9).

CONCLUSION

The results indicate that satisfaction of the children and their parents is very encouraging but surgeons should be cautious with this new approach in relation to the pinna reconstruction and to possible risks to inner ear and facial nerve.

Wideband aural acoustic absorbance predicts conductive hearing loss in children

OBJECTIVE

This study tested the hypothesis that wideband aural absorbance predicts conductive hearing loss (CHL) in children medically classified as having otitis media with effusion.

DESIGN

Absorbance was measured in the ear canal over frequencies from 0.25 to 8 kHz at ambient pressure or as a swept tympanogram. CHL was defined using criterion air-bone gaps of 20, 25, and 30 dB at octaves from 0.25 to 4 kHz. A likelihood-ratio predictor of CHL was constructed across frequency for ambient absorbance, and across frequency and pressure for absorbance tympanometry. Performance was evaluated at individual frequencies and for any frequency at which a CHL was present.

STUDY SAMPLE

Absorbance and conventional 0.226-kHz tympanograms were measured in children of age three to eight years with CHL and with normal hearing.

RESULTS

Absorbance was smaller at frequencies above 0.7 kHz in the CHL group than the control group. Based on the area under the receiver operating characteristic curve, wideband absorbance in ambient and tympanometric tests were significantly better predictors of CHL than tympanometric width, the best 0.226-kHz predictor. Accuracies of ambient and tympanometric wideband absorbance did not differ.

CONCLUSIONS

Absorbance accurately predicted CHL in children and was more accurate than conventional 0.226-kHz tympanometry.

Round window vibroplasty: long-term results

CONCLUSIONS

The round window (RW) approach in the use of the Vibrant Soundbridge(®) (VSB) is a safe and effective treatment of conductive and mixed hearing losses for a period of more than 3 years of device use.

OBJECTIVE

To investigate the long-term safety and efficacy as well as user satisfaction of patients with conductive and mixed hearing losses implanted with the VSB using RW vibroplasty.

METHODS

Twelve patients with conductive and mixed hearing losses were evaluated after 40 months of daily VSB use. Safety was assessed by evaluating reports of postoperative medical and surgical complications as well as by changes in bone conduction hearing thresholds. Efficacy outcome measures included aided and unaided hearing thresholds, speech recognition in quiet and in noise and subjective benefit questionnaires.

RESULTS

The safety results revealed no significant medical complications. One subject experienced sudden hearing loss after 18-24 months of device use, but still continues to wear the device to her satisfaction. With regard to efficacy, there were no significant changes from short- to long-term results in aided word understanding, functional gain or speech recognition threshold, suggesting that the outcomes are stable over time. Subjective questionnaires revealed either the same or better results compared with the short-term data.

Aberrant internal carotid artery causing objective pulsatile tinnitus and conductive hearing loss

Aberrant internal carotid artery (ICA) in the middle ear is a rare, dangerous vascular anomaly and conservative follow-up was usually adopted in most reported cases. Here we report the case of an 8-year-old girl with symptoms of objective pulsatile tinnitus and conductive hearing loss in the right ear. Otoscopic examination, computed tomography, and conventional angiography were performed. An aberrant ICA combined with a 'third mobile window' was suspected preoperatively and confirmed at exploratory surgery of the middle ear. The aberrant ICA was treated, and the pulsatile tinnitus disappeared and hearing recovered after the surgery. This case suggests that surgery is practical to relieve troublesome tinnitus and hearing loss in appropriate cases with aberrant ICA.

Aging and the 4-kHz air-bone gap

PURPOSE

In this study, the authors assessed age- and sex-related patterns in the prevalence and 10-year incidence of 4-kHz air-bone gaps and associated factors.

METHOD

Data were obtained as part of the longitudinal, population-based Epidemiology of Hearing Loss Study (Cruickshanks et al., 1998). An air-bone gap at 4 kHz was defined as an air-conduction threshold ≥ 15 dB higher than the bone-conduction threshold in the right ear.

RESULTS

Among 3,553 participants ages 48-92 years at baseline (1993-1995), 3.4% had a 4-kHz air-bone gap in the right ear. The prevalence increased with age. Among the 120 participants with an air-bone gap, 60.0% did not have a flat tympanogram or an air-bone gap at 0.5 kHz. Ten years later, the authors assessed 2,093 participants who did not have a 4-kHz air-bone gap at baseline; 9.2% had developed a 4-kHz air-bone gap in the right ear. The incidence increased with age. Among the 192 participants who had developed an air-bone gap, 60.9% did not have a flat tympanogram or air-bone gaps at other frequencies.

CONCLUSION

These results suggest that a finding of a 4-kHz air-bone gap may reflect a combination of aging and other factors and not necessarily exclusively abnormal middle-ear function.

Skull base plasmacytoma with conductive hearing loss and an external auditory canal mass

Skull base plasmacytomas are rare and difficult to differentiate clinically and radiologically from other tumors of the head and neck. Because of the risk of progression to multiple myeloma, early diagnosis is essential. We report the case of a 65-year-old woman who presented with left-sided conductive hearing loss and an external auditory canal mass. The tumor was removed along with much of the tympanic membrane, and it was found to be a plasmacytoma. The patient was subsequently diagnosed with multiple myeloma and treated with chemoradiation before being lost to follow-up.

Diagnosis and treatment of giant cell granuloma of the temporal bone: Report of eight cases

Abstract Conclusions: It is impossible to make a diagnosis of temporal giant cell granuloma (GCG) before operation because of nonspecific clinical and imaging feature. Surgery is the first-line choice of treatment.

OBJECTIVE

To evaluate the diagnosis and treatment of temporal GCG.

METHODS

Eight patients with GCG receiving treatment in the Chinese PLA General Hospital between 2001 and 2010 were recruited for the study. These patients' clinical features, imaging and histopathological findings, types of surgery, and results of follow-up evaluations were noted.

RESULTS

The group was made up of four males and four females, with a median age of 37 years (range 21-50 years). Four patients had a granuloma on the left side and four on the right of the head. The median duration of the disease was 21 months (range 5-60 months). All patients, except one referred to us for recurring disease, were managed in our hospital. The main symptoms were: hearing loss (n = 5), tinnitus (n = 4), otalgia (n = 3), dizziness (n = 2), and local masses (n = 2). Radiological examination of the masses revealed erosion of the temporal bone and base of the skull. There was no definitive diagnosis in any of the patients before surgery. All patients had surgical treatment, six of them by middle cranial fossa approach and two by combined cranio-auricular approach. Surgical complications included partial facial paralysis (three cases) and cerebral edema (one case) but they resolved soon after surgery. One patient was lost to follow-up, but the other seven were followed up over a mean period of 24 months; none has reported a recurrence.

Open-type congenital cholesteatoma: differential diagnosis for conductive hearing loss with a normal tympanic membrane

CONCLUSION

In patients with progressive conductive hearing loss and a normal tympanic membrane (TM), and with soft tissue density in the middle ear cavity (MEC) on temporal bone computed tomography (TBCT) scan, open-type congenital cholesteatoma (OCC) should be highly suspected and a proper surgical plan that includes mastoid exploration and second-stage operation is required.

OBJECTIVE

The clinical presentation of OCC is very similar to congenital ossicular anomaly (COA) presenting with a conductive hearing loss with intact TM. Therefore, it is challenging to make a correct preoperative diagnosis in patients with OCC. We evaluated the clinical characteristics of OCC compared with those of COA to find diagnostic clues useful in diagnosis of OCC.

METHODS

The medical records of 12 patients with surgically proven OCC and 14 patients with surgically proven COA were reviewed for demographic data, otologic history, preoperative TBCT findings, intraoperative findings, and pre- and postoperative audiologic data.

RESULTS

There was no difference between OCC and COA based on demographic data, preoperative hearing, and ossicular status on TBCT. However, the presence of progressive hearing loss, soft tissue density in the MEC on TBCT scan, and the need for mastoid surgery and second-stage operation were significantly more frequent in OCC patients.

Atresia and sudden sensorineural hearing loss

This case study summarizes findings in an adult male, aged 57, who presented to the Adult Audiology Clinic with aural atresia in the right ear resulting in a conductive hearing loss and a sudden sensorineural hearing loss in the left ear. Treatment options included reconstruction surgery in the right ear, bone anchored hearing aid in the right ear to overcome the conductive hearing loss, bone anchored hearing aid in the left ear for single sided deafness, and intratympanic steroid injections in the left ear to salvage hearing. This case study highlights that when a patient is educated on all available options the patient is then able to make a decision comfortable to him and to help improve his hearing.

Functional and structural evaluation of hearing in acromegaly

CONTEXT

The impact of acromegaly on the auditory system remains unknown.

OBJECTIVE

This study aimed to examine audiological symptoms and the structure and function of the auditory system in patients with acromegaly. DESIGN/SETTING AND PATIENTS:  The study included 44 patients with acromegaly. Pure tone audiometry, speech audiometry, tympanometry, otoacoustic emissions testing, computerized tomography of the temporal bone and magnetic resonance imaging of the ear were performed in all patients. The study also included 36 age- and sex-matched healthy controls. The patients with acromegaly were divided into three subgroups, as follows: controlled disease (n=13); partially controlled disease (n=16); uncontrolled disease (n = 15).

RESULTS

  In all, 43% of the patients with acromegaly had hearing loss, and 20% had had an episode of otitis in at least one ear. Median pure tone average (PTA) in the patients with acromegaly was 12.5 dB (range: 2-72 dB), vs 8.3 dB (range: 0-20 dB) in the control group (P < 0.001). PTA did not differ significantly between the three patient subgroups. Audiometric tests showed various degrees of hearing loss in at least one ear in 21 patients (48%). Conductive, sensorineural and mixed type hearing loss in at least one ear was noted in 9%, 30% and 18% of the patients, respectively. Auditory imaging showed that 50% of the patients had temporomandibular joint degeneration (TMJD).

CONCLUSIONS

  Hearing loss is quite common in patients with acromegaly. Contrary to common belief, in this study, conductive hearing loss did not occur more frequently than other types. Based on PTA findings in the controls and patients with acromegaly, acromegaly caused hearing loss, but the level of disease activity had no effect on hearing. Middle ear pressure problems might be caused by increased perilymph because of growth hormone (GH)-related volume overload.

The morphological findings of malleus and incus in a case of Marfan's syndrome

In Marfan's syndrome, which is a connective tissue disorder of hereditary origin, collagenous tissue development and bone synthesis are generally altered in addition to the occurrence of many systemic deformities. External ear, stapes, and vestibular aqueduct pathologies are reported as some of the otological deformities. However, the malleus and incus pathologies of the ear are not reported in any study. In the morphometric measurements carried out, the distance between the malleus head and manubrium was found to be 9.8 mm. When similar measurements were carried out for the incus, the distance between the upper part of the incus body and tip of the long process was found to be 6.9 mm. All of these measurements were detected to be greater than in normal people. It can be concluded from this study that in Marfan's syndrome, in addition to the musculoskeletal alterations particularly in bone synthesis, the ossicular chain in the middle ear is also affected.

[The differential approach to the treatment of exudative otitis media with the use of mucosal immunocorrection]

The objective of the present study was to improve the efficacy of the treatment of the patients suffering from exudtaive otitis media (EOM). A total of 75 patients presenting with EOM were allocated to 2 groups. In one of them (n=36) the patients were treated using conventional therapeutic modalities, in the other one (n=39) with the use of a local immunomodulator (a 0.04% synthetic tetradecapeptide solution). The local application of the immunocorrective agent has demonstrated its normalizing action on the parameters of both local and systemic immunity. It is concluded that the adequate and timely treatment with the use of synthetic tetradecapeptide reduces the probability of relapse and chronization of the pathological process which not infrequently allows the surgical intervention to be avoided.

Congenital incudostapedial anomalies in adult stapes surgery: a case-series review

OBJECTIVES

The management of developmental anomalies of the ossicular chain and otic capsule in stapes surgery tests the otologist's diagnostic skills and flexibility in technique and prosthesis choice. We review our experience in managing various incudostapedial developmental anomalies discovered during middle ear exploration for suspected otosclerosis in adult patients.

DESIGN

A retrospective case-series review was used.

SETTING

The study was set at a military tertiary referral center.

PATIENTS AND OTHER PARTICIPANTS

A review of 185 stapes procedures yielded 8 cases of identified congenital anomalies of the stapes or incudostapedial complex including congenital absence of the oval window with malformed incus and stapes, columellar-type stapes with promontory fixation, stapes superstructure fixation to the fallopian canal, and malformed incus with stapes superstructure fixation to the promontory.

INTERVENTIONS

The developmental anatomy and surgical technique in each case were reviewed. The surgical technique used in each case varied depending on the specific ossicular abnormality found and whether both the stapes and incus were affected.

MAIN OUTCOME MEASURES

Comparison of preoperative and postoperative audiometric testing results was performed.

RESULTS

All 8 ears (7 patients) that underwent a stapes procedure for either an isolated congenital stapes anomaly or a combined incudostapedial anomaly had a favorable hearing outcome, with 7 ears improving to within 10-dB and 1 ear to within 13-dB air-bone gap on postoperative audiometry.

CONCLUSIONS

Despite unanticipated findings of congenital anomalies of the stapes and incus during middle ear exploration for conductive hearing loss, a flexible management approach can lead to successful hearing outcomes.

Otologic and audiologic manifestations of Hutchinson-Gilford progeria syndrome

OBJECTIVES/HYPOTHESIS

To define the audiologic and otologic phenotype of Hutchinson-Gilford progeria syndrome (HGPS).

STUDY DESIGN

Prospective case series.

METHODS

Fifteen patients with HGPS were enrolled in a prospective natural history study; 14 were evaluated in the neurotology clinic, and 11 received audiologic evaluations. The physical exam and audiologic findings of these patients were reviewed to define an otologic and audiologic phenotype for HGPS in the largest series of subjects in the literature.

RESULTS

All patients were noted to have stiff auricular cartilages, small or absent lobules, and hypoplasia of the lateral soft-tissue portion of the external ear canal leading to a shortened canal. Ten of 14 patients (71%) had dry cerumen impaction, and four of 14 patients (29%) reported a history of recurrent otitis media. Nineteen of 22 ears (86.4%) demonstrated low-frequency conductive hearing loss in the 250 to 500 Hz range. Sixteen of 22 ears (73%) had type A tympanograms; three of 22 ears (14%) displayed bimodal or "W" peaked tympanograms; two of 22 ears (9%) had type B tympanograms; one of 22 ears (4%) had a type C tympanogram. Nine of 10 patients had distortion product otoacoustic emissions consistent with normal peripheral hearing sensitivity.

CONCLUSIONS

HGPS is caused by a mutation in the LMNA gene resulting in the production of an abnormal nuclear protein; this in turn affects nuclear structure and function. Patients with HGPS have characteristic otologic features due to cartilaginous and subcutaneous tissue abnormalities and typically demonstrate low-frequency conductive hearing loss despite largely normal tympanometry. It is important to be aware of these conditions in managing these patients.

Automated hearing tests: applying the otogram to patients who are difficult to test

OBJECTIVE

The Otogram is an automated audiometer capable of determining air and bone conduction thresholds with masking when appropriate. The manufacturer claims that testing can be done in a quiet physician's consultation room without a sound-treated booth. We aimed to test the validity of the Otogram on "difficult-to-test" patients, all of whom require masking.

METHODS

Twenty-eight difficult-to-test patients underwent three audiograms: two by an audiologist and one by the Otogram. First, audiograms performed by the audiologists were compared, establishing test-retest reliability. Second, audiograms performed by the Otogram were compared to those of the audiologists. We calculated the percentage of pure-tone thresholds that were in agreement by 10 dB. Weighted kappa statistical analyses demonstrated levels of agreement.

RESULTS

Comparisons between audiologists demonstrated a very high degree of agreement. More than 90% of air and bone conduction thresholds fell within 10 dB of each other. Comparisons between audiologists and the Otogram also demonstrated a high degree of agreement.

CONCLUSIONS

The Otogram has the capability to accurately ascertain air and bone conduction thresholds. It appropriately used masking when indicated. The Otogram has great potential as a diagnostic tool to improve access to health care, especially where hearing test facilities are limited or unavailable.

Cochlin-tomoprotein (CTP) detection test identifies traumatic perilymphatic fistula due to penetrating middle ear injury

CONCLUSIONS

The cochlin-tomoprotein (CTP) detection test can be used to make a definite, objective diagnosis of traumatic perilymphatic fistula (PLF), and therefore offers valuable information on patient selection for surgical treatment.

OBJECTIVES

Penetrating middle ear injury can cause traumatic PLF, which is a surgically treatable otologic emergency. Recently, we have reported on CTP, a novel perilymph-specific protein. The purpose of this study was to determine if the CTP detection test is useful for the diagnosis of traumatic PLF.

METHODS

This was a prospective study of CTP detection in penetrating middle ear injury cases with tympanic membrane perforation and hearing loss.

RESULTS

A total of seven individuals were included in this study. CTP was detected in three of four cases with posterosuperior quadrant perforation of the tympanic membrane. In one of these three cases, even though the high resolution CT scan was not suggestive of PLF and the perilymph leakage could not be visualized intraoperatively, the CTP detection test was able to detect PLF. In two cases, the preoperative positive test results enabled us to make a diagnosis of PLF and a decision for surgical treatment. CTP was not detected in the cases with anterior or inferior tympanic membrane perforation.